9 Introduction Breech presentation occurs in 3-4% of all deliveries Introduction Breech presentation occurs in 3-4% of all deliveries. The occurrence of breech presentation decreases with advancing gestational age. Breech presentation occurs in 25% of births that occur before 28 weeks’ gestation, in 7% of births that occur at 32 weeks, and 1-3% of births that occur at term. . Perinatal mortality is increased 2- to 4-fold with breech presentation, regardless of the mode of delivery. Deaths most often are associated with malformations, prematurity, and intrauterine fetal demise.
25 Criteria for VD orCS VD CS Frank FW<1500or> 3500gr GA>34w FW= grAdequate pelvisFlexed headNonviable fetusNo indicationGood progress laborCSFW<1500or> 3500grFootlingSmall pelvisDeflexed headArrest of laborGA24-34wElderly PGInf or poor historyFetal distress
26 VAGINAL BREECH DELIVERY Three types of vaginal breech deliveries:Spontaneous breech deliveryAssisted breech deliveryTotal breech extraction
27 Footling breech presentation : Once the feet have delivered, there may be temptation to pull on the feet. However, this should never be done with a singleton gestation because it may precipitate an entrapped head in an incompletely dilated cervix or it may precipitate nuchal arms. As long as the fetal heart rate is stable and no physical evidence of a prolapsed cord exists, expectant management may be followed, awaiting full cervical dilatation..
28 Assisted vaginal breech delivery Thick meconium passage is common as the breech is squeezed through the birth canal. This usually is not associated with meconium aspiration because the meconium passes out of the vagina and does not mix with the amniotic fluid.
29 Picture 3. Assisted vaginal breech delivery: The Ritgen maneuver is applied to take pressure off the perineum during vaginal delivery. Episiotomies often are cut for assisted vaginal breech deliveries, even in multiparous women, to prevent soft-tissue dystocia.
30 Picture 4. Assisted vaginal breech delivery: No downward or outward traction is applied to the fetus until the umbilicus has been reached.
31 Picture 5. Assisted vaginal breech delivery: With a towel wrapped around the fetal hips, gentle downward and outward traction is applied in conjunction with maternal expulsive efforts until the scapula is reached. An assistant should be applying gentle fundal pressure to keep the fetal head flexed.
32 Picture 6. Assisted vaginal breech delivery: After the scapula is reached, the fetus should be rotated 90° in order to delivery the anterior arm.
33 Picture 7. Assisted vaginal breech delivery: The anterior arm is followed to the elbow, and the arm is swept out of the vagina.
34 Picture 8. Assisted vaginal breech delivery: The fetus is rotated 180°, and the contralateral arm is delivered in a similar manner as the first. The infant is then rotated 90° to the back-up position in preparation for delivery of the head.
35 Picture 9. Assisted vaginal breech delivery: The fetal head is maintained in a flexed position by using the Mauriceau-Smellie-Veit maneuver, which is performed by placing the index and middle fingers over the maxillary prominence on either side of the nose. The fetal body is supported in a neutral position with care to not overextend the neck.
36 Picture 10. Piper forceps application: Pipers are specialized forceps used only for the aftercoming head of a breech presentation. They are used to keep the head flexed during extraction of the fetal head. An assistant is needed to hold the infant while the operator gets on one knee to apply the forceps from below.
37 Picture 11. Assisted vaginal breech delivery: Low 1-minute Apgar scores are not uncommon after a vaginal breech delivery. A pediatrician should be present for the delivery in the event that neonatal resuscitation is needed.
38 Picture 12. Assisted vaginal breech delivery - The neonate after birth
39 Risks Lower Apgar scors An entrapped head Nuchal arms Cervical spine injuryCord prolapse,
41 If the score is 0-4, cesarean delivery is recommended Table 1. Zatuchni-Andros Breech ScoringAdd 0 PointsAdd 1 PointAdd 2 PointsParity12Gestational age (wk)39+38<37EFW (lb)87-8<7Previous breechDilatation34Station-3-2-1If the score is 0-4, cesarean delivery is recommended
50 Shoulder dystocia will still the obstetric nightmare
51 Definition:Shoulder dystocia (Sh. D) is the inability to deliver the fetal shoulders after delivery of the head, without the aid of specific maneuvers (ie. other than gentle downward traction on the head) .
52 Objective definition : Mean head-to-body delivery time > 60 seconds
53 PATHOPHYSIOLOGYShoulder dystocia results from a size discrepancy between the fetal shoulders and the pelvic inlet when:The bisacromial diameter is large relative to the biparietal diameterPelvic prim is flat ratherthan gynecoid.
54 SHOULDER DYSTOCIA%,Risk factor;macrosomia,diabetes,history of SD,prolonged2th stage of labor,maternal obesity,multiparity,postterm.50%SDnorisk factorSono
69 Management 1-Suprapubic pressure 2-McRobert manoeuver 3- Woods corkscrew .4-Rubens manoeuver5-Delivery of P. shoulder6-Zavanelli7-All fours8-Cleidotomy9-symphysiotomy
70 ACOG Issues Guidelines Recommendation 1991 1-Call for help: assistants, anesthesiologist2-Initial gentle attempt of traction.3-Generous episiotomy.4-Suprapubic pressure.
71 ACOG Issues Guidelines Recommendation 1991 5-The Mc Roberts manoeuvre (Exaggerated hyper flexion of the thighs upon the abdomen.) & Suprapubic pressure in the direction of the Foetal face.
72 McRoberts manoeuvre: X ray pelvimetry study No increase in pelvic dimensions.Decrease in the angle of pelvic inclination P=0.001Straightening of the sacrum P= 0.04%Tends to free the impacted anterior shoulderGherman et al Obstet Gynecol 95:43 ,2000
73 ACOG Issues Guidelines Recommendation 1991 If Mc Roberts failed:6-Woods manoeuvre:The hand is placedbehind the posteriorshoulder of the fetus.The shoulder is rotated progressively 180 d in a corkscrew manner so that the impacted anterior shoulder is released..
74 ACOG Issues Guidelines Recommendation 1991 7-Delivery of the posterior arm :.
75 delivery over the perineum By inserting a hand into the posterior vagina and ventrally rotating the arm at the shoulderdelivery over the perineum
79 Umbilical Cord Prolapse Etiology1-275 deliveriesClassificationComplete: cord is seen or palpated ahead of presenting part (OB Emergency)Fundic: cord felt through intact membranes ahead of presenting partOccult: hidden or not visible at any time during course of laborDefinition: umbilical cord that lies below/beside presenting part
80 Umbilical Cord Prolapse Precipitating factors:Long umbilical cordAbnormal location on placentaSmall or preterm infantPolyhydramniosMultiple gestationPrecipitating factors:Amniotomy before fetal head is engagedIUPC placementExternal cephalic version
81 Umbilical Cord Prolapse Clinical Manifestations:Cord observed or palpatedBradycardia following ROMRepetitive, variable decelerations that do not respond to medical intervention (e.g. amnioinfusion)Prolonged decelerations (>15 bpm lasting 2 mins or longer yet <10 mins)
82 Umbilical Cord Prolapse Nursing interventions:Assess fetal viabilityCall for assistanceRelieve pressure from cord (usually presenting part)Continuous manual relief of pressure from presenting partAvoid excessive manipulation of cordRe-position client: Trendelenburg, modified Sim’s, or knee-chestPrepare for emergency deliveryAdminister oxygen by mask L/minFill maternal bladder with cc NSContinuous fetal monitoringPossible neonatal resuscitation (notify neonatal team per hospital protocol)
83 Umbilical Cord Prolapse Aim of Medical management:Immediate delivery of viable infantHallmark treatment: C-section