1. dr. Udin Sabarudin Department of Obstetrics & Gynecology Medicine School of Padjadjaran University Bandung MECHANISM OF LABOR IN BREECH PRESENTATION

2. Frank (65%) : Hips are flexed, knees are extended. Complete (10%) : The hips and knees are flexed Incomplete (25%): The feet or knees are the lowermost presenting part. o Single footling : one of the lower extremities is lowermost. o Double footling : Both of the lower extremities are lowermost THE 3 TYPES OF BREECH PRESENTATION

3. Figure 21-2. Breech presentations. A: Right sacrum posterior (RSP) position. B: Left sacrum anterior (LSA) position. (Redrawn and reproduced, with permission, from Bumm E: Grundiss zum Studium der Geburtshilfe. Bergmann, 1922)

4. PREDISPOSING FACTORS :  Prematurity  Uterine abnormalities :-Malformation; -Fibroids  Fetal abnormalities :-CNS Malformations; -Neck Masses  Multiple gestations  Previous breech delivery

5. Gestational age and frequency of breech birth Gestational age in weeks% Breech 21-2433 25-2828 29-3214 33-369 37-407

6. DIAGNOSIS :  Palpation and ballottement  Ultrasound  Pelvic examination  X-Ray studies

7. Leopold Maneuver

8. External Cephalic Version TTTT

9. MANAGEMENT DURING LABOR Type of Delivery  Vaginal delivery:  Spontaneous  Partial breech extraction  Total breech extraction  Cesarean of delivery

10. Management

11. Three types of vaginal breech delivery exist  Spontaneous 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 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.

12. Conditions are unfavorable for breech delivery  Fetus weight more than 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 pelvis  Hyperextension 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 fetus

13. MORTALITY/MORBIDITY  Increased 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 restriction  Incidence of prolapsed umbilical cord depends on type of breech presentation : Footling 17%, Complete 5%, Frank 0,5%

14. Mechanism of Labor in Breech Delivery

15. Assisted Delivery of Frank Breech

22. Mechanism of Labor in Breech Delivery Figure 21-5. Maneuver for delivery of the head. 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. (Modified and reproduced, with permission, from Benson RC: Handbook of Obstetrics & Gynecology, 8 th ed. Lange, 1983)

23. Mauriceau Maneuver

24. Delivery of the Aftercoming Head  Piper forceps  Modified prague maneuver

25. Mechanism of Labor in Breech Delivery Figure 21-12. 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. (Reproduced, with permission, from Benson RC: Handbook of Obstetrics & Gynecology, 8 th ed. Lange, 1983)

26. Forceps to Aftercoming Head

27. Modified Prague Maneuver

28. Complete or Incomplete Breech Extraction

32. Breech Extraction

33. C-Section Indication o A large fetus ( > 3.500 gr ) o A Hyperextended fetus o Uterine dysfunction o Footling presentation o Any degree of contraction or unfavorable shape restriction o Previous perinatal death or children suffering from birth trauma

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