Lecture 6 BREACH PRESENTATION TRANSVERSAL & OBLIQUE LIE Prof. Vlad TICA, M.D., Ph. D.

Frank (65%): Hips are flexed, knees are extendedFrank (65%): Hips are flexed, knees are extended Complete (10%): The hips and knees are flexedComplete (10%): The hips and knees are flexed Incomplete (25%): The feet or knees are the lowermost presenting part:Incomplete (25%): The feet or knees are the lowermost presenting part: Single footling: one of the lower extremities is lowermost.Single footling: one of the lower extremities is lowermost. Double footling: Both of the lower extremities are lowermostDouble footling: Both of the lower extremities are lowermost TYPES OF BREECH PRESENTATION

Breech presentations: A: Right sacrum posterior (RSP) position B: Left sacrum anterior (LSA) position

Frank (65%): Hips are flexed, knees are extendedFrank (65%): Hips are flexed, knees are extended Complete (10%): The hips and knees are flexedComplete (10%): The hips and knees are flexed Incomplete (25%): The feet or knees are the lowermost presenting part:Incomplete (25%): The feet or knees are the lowermost presenting part: Single footling: one of the lower extremities is lowermost.Single footling: one of the lower extremities is lowermost. Double footling: Both of the lower extremities are lowermostDouble footling: Both of the lower extremities are lowermost TYPES OF BREECH PRESENTATION

PREDISPOSING FACTORS PrematurityPrematurity Uterine abnormalitiesUterine abnormalities MalformationMalformation FibroidsFibroids Fetal abnormalitiesFetal abnormalities CNS MalformationsCNS Malformations Neck MassesNeck Masses Multiple gestationsMultiple gestations Previous breech deliveryPrevious breech delivery BREECH PRESENTATION

Gestational age in weeks % Breech BREECH PRESENTATION

DIAGNOSIS Palpation and ballottementPalpation and ballottement UltrasoundUltrasound Pelvic examinationPelvic examination X-Ray studiesX-Ray studies BREECH PRESENTATION

Leopold Maneuver BREECH PRESENTATION

EXTERNAL CEPHALIC VERSION

MANAGEMENT

MANAGEMENT TYPE OF DELIVERY Vaginal delivery:Vaginal delivery: SpontaneousSpontaneous Partial breech extractionPartial breech extraction Total breech extractionTotal breech extraction Cesarean deliveryCesarean delivery

TYPES OF VAGINAL BREECH DELIVERY Spontaneous breech (rare): No manipulation of the infant is necessary, other than supporting the infantSpontaneous breech (rare): No manipulation of the infant is necessary, other than supporting the infant Partial breech extraction: Fetus descend spontaneously to where umbilicus is at the vaginal introitus; then, the fetus is extracted completelyPartial breech extraction: Fetus descend spontaneously to where umbilicus is at the vaginal introitus; then, the fetus is extracted completely Total breech extraction: The entire body is extracted. This is indicated only if there is evidence of fetal distress unresponsive to routine maneuvers and a cesarean delivery is not possible.Total breech extraction: The entire body is extracted. This is indicated only if there is evidence of fetal distress unresponsive to routine maneuvers and a cesarean delivery is not possible.

CONDITIONS ARE UNFAVORABLE FOR BREECH DELIVERY Fetus weight > 3500 gFetus weight > 3500 g Unfavorable pelvis – Breech delivery does not allow sufficient time for molding of the fetal head; thus, a platypelloid or android pelvis decreases ability fetal head to navigate maternal pelvisUnfavorable pelvis – Breech delivery does not allow sufficient time for molding of the fetal head; thus, a platypelloid or android pelvis decreases ability fetal head to navigate maternal pelvis Hyperextension of the head – increases risk of cervical spine injuryHyperextension of the head – increases risk of cervical spine injury Footlings- incidence of umbilical cord prolapse increases with coiling of the umbilical cord around the legs of the fetusFootlings- incidence of umbilical cord prolapse increases with coiling of the umbilical cord around the legs of the fetus

MORTALITY/MORBIDITY Increased birth trauma: As duration of umbilical cord compression increases → deliver the infant more rapidly → increasing birth traumaIncreased birth trauma: As duration of umbilical cord compression increases → deliver the infant more rapidly → increasing birth trauma Decreased birth weight may result from preterm delivery/growth restrictionDecreased birth weight may result from preterm delivery/growth restriction Incidence of prolapsed umbilical cord depends on type of breech presentation : Footling 17%, Complete 5%, Frank 0,5%Incidence of prolapsed umbilical cord depends on type of breech presentation : Footling 17%, Complete 5%, Frank 0,5%

MECHANISM OF LABOR IN BREECH DELIVERY

ASSISTED DELIVERY OF FRANK BREECH

Maneuver for delivery of the head: The fingers of the left hand are inserted into the infant’s mouth of over mandible; The fingers of the left hand are inserted into the infant’s mouth of over mandible; The right hand exerts pressure on the head from above The right hand exerts pressure on the head from above

MAURICEAU MANEUVER

MECHANISM OF LABOR IN BREECH DELIVERY Piper forceps Piper forceps Modified Prague maneuver Modified Prague maneuver

DELIVERY OF THE AFTERCOMING HEAD Application of Piper forceps, employing towel sling support. The forceps are introduced from below, left blade first. Aiming directly and intended positions on sides of the head

DELIVERY OF THE AFTERCOMING HEAD

MODIFIED PRAGUE MANEUVER

COMPLETE OR INCOMPLETE BREECH EXTRACTION

BREECH EXTRACTION

C-SECTION INDICATION A large fetus ( > grams)A large fetus ( > grams) A hyperextended fetusA hyperextended fetus Uterine dysfunctionUterine dysfunction Footling presentationFootling presentation Any degree of contraction or unfavorable shape restrictionAny degree of contraction or unfavorable shape restriction Previous perinatal death or children suffering from birth traumaPrevious perinatal death or children suffering from birth trauma

COMPLICATIONS 1.Perinatal morbidity and mortality from difficult delivery 2. Low birthweight from preterm delivery, growth restriction, or bot 3. Prolapsed cord 4. Placenta praevia 5. Fetal, neonatal, and infant anomalies 6. Uterine anomalies and tumors 7. Multiple fetuses 8. Operative intervention, especially cesarean delivery

TRANSVERSE OR OBLIQUE PRESENTATION 1.DEFINITION At the end of pregnancy or during of labor, champ of pelvic inlet is not fetal head or fetal breech At the end of pregnancy or during of labor, champ of pelvic inlet is not fetal head or fetal breech 2. VARIETY - shoulder right in dorso-anterior - shoulder right in dorso-anterior - shoulder left in dorso-anterior - shoulder left in dorso-anterior - shoulder right in dorso-posterior - shoulder right in dorso-posterior - shoulder left in dorso-posterior - shoulder left in dorso-posterior

3. ETIOLOGY Mistake of accommodation: the grand cause of transverse position is multipara (relax of uterine wall)Mistake of accommodation: the grand cause of transverse position is multipara (relax of uterine wall) Other cause can hydramnios, previa tumor, shortness umbilical cordOther cause can hydramnios, previa tumor, shortness umbilical cord Uterine malformationUterine malformation TRANSVERSE OR OBLIQUE PRESENTATION

4. CLINICAL InspectionInspection The uterus is developing transverse or obliqueThe uterus is developing transverse or oblique PalpationPalpation Hands explored base part of uterus on of pelvic inlet can not contact fetal poleHands explored base part of uterus on of pelvic inlet can not contact fetal pole At middle of uterus fundus have no fetal poleAt middle of uterus fundus have no fetal pole TRANSVERSE OR OBLIQUE PRESENTATION

At lateral face of uterus (right or left) can contact with fetal pole or breechAt lateral face of uterus (right or left) can contact with fetal pole or breech Multipara are rare on same plan of transverseMultipara are rare on same plan of transverse Uterus malformation, the two poles can contact at same higher at uterine body (back in anterior)Uterus malformation, the two poles can contact at same higher at uterine body (back in anterior) In dorso-posterior, abdominal wall perception fetal limpsIn dorso-posterior, abdominal wall perception fetal limps TRANSVERSE OR OBLIQUE PRESENTATION

Auscultation:Auscultation: the fetal cardiac sound can receive a bite under umbilical at cephalic sidethe fetal cardiac sound can receive a bite under umbilical at cephalic side Digital exam:Digital exam: during pregnancy: the excavation is empty (fingers are not contact the presentation)during pregnancy: the excavation is empty (fingers are not contact the presentation) TRANSVERSE OR OBLIQUE PRESENTATION

During labor: if membranes are not rupture, the sac amniotic fluid is big volume (can not evaluation the presentation)During labor: if membranes are not rupture, the sac amniotic fluid is big volume (can not evaluation the presentation) After rupture of membranes, the fingers are perception:After rupture of membranes, the fingers are perception:. Shoulder and acromial protrusion. Shoulder and acromial protrusion. Axillary furrow. Axillary furrow TRANSVERSE OR OBLIQUE PRESENTATION

At profound permit contact:At profound permit contact:. Costal. Scapula In some cases, superior limp fall down in excavation, vaginal, vulva with character cyanosis and edemaIn some cases, superior limp fall down in excavation, vaginal, vulva with character cyanosis and edema The thumb turn to thigh of mother same name with of shoulder that presentThe thumb turn to thigh of mother same name with of shoulder that present TRANSVERSE OR OBLIQUE PRESENTATION

Diagnostic of variety: must to know head, breech, back, shoulder (right or left) situate at pelvic inletDiagnostic of variety: must to know head, breech, back, shoulder (right or left) situate at pelvic inlet When the hand is out side of vulva, sign of thumb confirm the diagnosiWhen the hand is out side of vulva, sign of thumb confirm the diagnosi X-ray: necessary in all cases, it confirme diagnosticX-ray: necessary in all cases, it confirme diagnostic Ultrasound: same of x-ray and position of placentaUltrasound: same of x-ray and position of placenta TRANSVERSE OR OBLIQUE PRESENTATION

5. DELIVERY A. Ovular phenomenon: A. Ovular phenomenon: The precocity of membranes rupture is favorable by character of amniotic fluid sac (big volume in cervical canal) The precocity of membranes rupture is favorable by character of amniotic fluid sac (big volume in cervical canal) Uterus is empty of amniotic fluid and cord prolapses TRANSVERSE OR OBLIQUE PRESENTATION

B. Mechanic phenomenon: B. Mechanic phenomenon: First time: weakness, head orient opposite trunk (vertical). The shoulder is in center of basin. Superficial exam, the presentation return longitudinalFirst time: weakness, head orient opposite trunk (vertical). The shoulder is in center of basin. Superficial exam, the presentation return longitudinal Second time: engage of shoulderSecond time: engage of shoulder Third time: stop of progression (enclave).Third time: stop of progression (enclave). TRANSVERSE OR OBLIQUE PRESENTATION

C. Plastic phenomenon: C. Plastic phenomenon: is at region of shoulder, neck, backis at region of shoulder, neck, back D. Physiologic phenomenon: D. Physiologic phenomenon: the dilatation of cervix is trouble: cause of dynamic abnormal and ovular infectionthe dilatation of cervix is trouble: cause of dynamic abnormal and ovular infection The cervix is edema, thickThe cervix is edema, thick Lower segment still thick not contact with presentationLower segment still thick not contact with presentation TRANSVERSE OR OBLIQUE PRESENTATION

The uterine contraction is the trouble: the contraction is normal until rupture of membrane but the progression of presentation is stoppedThe uterine contraction is the trouble: the contraction is normal until rupture of membrane but the progression of presentation is stopped First irregular, then inertia or hypertonia with hypercinesisFirst irregular, then inertia or hypertonia with hypercinesis The consequence of retraction is:The consequence of retraction is: Death of the fetus: the retraction provoke diminution of blood fluid trans placenta and infectionDeath of the fetus: the retraction provoke diminution of blood fluid trans placenta and infection TRANSVERSE OR OBLIQUE PRESENTATION

Uterine rupture:Uterine rupture: the retraction of the myometrium of uterine body provoke lower segment stretch (lower segment rupture)the retraction of the myometrium of uterine body provoke lower segment stretch (lower segment rupture) TRANSVERSE OR OBLIQUE PRESENTATION

6. TREATMENT: A. During of pregnancy: A. During of pregnancy: - the surveillance of presentation is every days - the surveillance of presentation is every days - it can external version for cephalic presentation or breech presentation at pelvic inlet (multipara) - it can external version for cephalic presentation or breech presentation at pelvic inlet (multipara) - primipara: cesarean section at the end of pregnancy - primipara: cesarean section at the end of pregnancy TRANSVERSE OR OBLIQUE PRESENTATION

B. During of labor: B. During of labor: Primipara:Primipara: cesarean sectioncesarean section Multipara:Multipara: The membrane is intact:The membrane is intact: Complete dilatation of cervix: artificial rupture of membrane and internal versionComplete dilatation of cervix: artificial rupture of membrane and internal version Dilatation is incomplete: conservation of membrane until complete dilatationDilatation is incomplete: conservation of membrane until complete dilatation TRANSVERSE OR OBLIQUE PRESENTATION

The membranes are ruptured:The membranes are ruptured: Uterus is soft (not retracted) & fetus is alive:Uterus is soft (not retracted) & fetus is alive: cesarean section if incomplete dilatationcesarean section if incomplete dilatation internal version if complete dilatationinternal version if complete dilatation Uterus is retracted:Uterus is retracted: Fetus is alive: cesarean sectionFetus is alive: cesarean section Fetus is dead: embryotomyFetus is dead: embryotomy TRANSVERSE OR OBLIQUE PRESENTATION

Uterus is ruptured:Uterus is ruptured: after laparotomy and extraction of fetal mort and placenta, the operation must suture of rupture or hysterectomyafter laparotomy and extraction of fetal mort and placenta, the operation must suture of rupture or hysterectomy TRANSVERSE OR OBLIQUE PRESENTATION