1. OPERATIVE OBSTETRICS

2. BREECH : Definition,Incidence & Significance fetal buttocks or feet enter maternal pelvis before the baby’s head Breech presentation affects 3 – 4 % of all pregnant women reaching term associated with increased perinatal morbidity, due to PREMATURITY, CONG. ANOMALIES, BIRTH TRAUMA, ASPHYXIA

3. Varieties of breech presentation (relationship bet.lower extremities & buttocks/hips determines the variety) 1) FRANK BREECH lower extremities flexed at the hips & extended at the knees  extended legs are against the trunk, baby’s feet lie close to its head & against its face most common breech pres. at term

4. 2) COMPLETE BREECH -Lower extremities flexed at the hips; both knees are also flexed. Buttocks & knees are then at same level; feet also alongside buttocks in front of abdomen 3)INCOMPLETE BREECH - One or both hips are extended so that one or both feet &/or knees lie are below the breech/buttocks, and may be prolapsed into the mother’s vagina

5. Diagnosis of Non-Vertex Pres. Fundal grip Umbilical grip Pawlick’s grip Pelvic grip Auscultation of FHT with Pinard fetoscope Digital vaginal exam / IE Sonology (other info. here are AFI, placental localization, cord posn., pres. of fetal abnies)

7. hyperextended head, mother’s abd. x-ray

8. Etiologic & Predisposing Factors In majority of breeches, no etiology is identifiable Predisposing to & associated w/ breech: - prematurity - uterine abnormalities & pelvic tumors - abnormal AFV - multiple gestations - placenta previa - fetal anomalies

9. It is very important to rule out serious fetal congenital anomalies prior to Cesarean Section delivery for breech.

10. Management remains controversial Planned CS for term breech delivery, based on Term Breech Trial (Hannah et.al., 2000). This multicentric RCT & a meta-analysis of all breech trials have shown that one neonatal death is prevented for every 112 planned CS ; maternal long-term risks not yet addressed Planned vaginal term breech delivery

11. RECOMMENDATIONS FOR DELIVERY CAESAREAN DELIVERY:  a large fetus more than 3.6kg.  any degree of contraction or unfavorable shape of the pelvis (may do x-ray, CT or MRI)  a hyper-extended head, or BPD above 10cm  no labor, & with additive maternal/fetal indication for delivery (e.g. HPn, ruptured membranes for 12 hrs. or more)

12.  Uterine dysfunction  Footling presentation or incomplete breech  Apparently healthy yet preterm fetus of 26 wks AOG or more, or w/ 1-2kg wt. & mother in active labor or in imminent delivery  Severe IUGR or chronic fetal distress  Previous hx of perinatal death, or children suffering from birth trauma;hx of difficult del.  Request for sterilization

13. VAGINAL DELIVERY - for a frank or complete breech presentation 36 weeks or more and with:  Adequate maternal pelvis  EFW < 3600 gms. or between 2.5-3.6kg.  Normal labor course w/ good cervical dilatation and effacement  Competent and available OB, Anes, Pedia

14. Planned vaginal birth for breech Can also be offered for either frank or complete breech at 31-35 wks. gestation, and/or when estimated BW is 1.5-2.5 kg. The woman’s wishes, in collaboration with the attending healthcare providers’ judgment, should determine which delivery method (abd. or vag.) is most appropriate.

15. MANAGEMENT OF LABOR & DELIVERY Admission to del.facility in early labor, or after sROM Appropriate fetal monitoring Epidural anesthesia for usual indications Amniotomy for same indications Immediate IE at membrane rupture TO RULE OUT CORD PROLAPSE! Assess labor progress & expect same progress as in vertex presentation Mother’s bladder should be emptied prior to delivery Selective episiotomy preferable to routine episiotomy Experienced healthcare team Ö

16. Types of VAGINAL BREECH DELIVERY a. Spontaneous breech delivery - infant is entirely expelled by natural forces of the mother, unassisted except for support of the baby as it is born - infrequent; usually in multiparas, with rapid expulsion of fetus

17. b.Assisted Breech Delivery 1) Partial breech extraction - infant is delivered by natural forces up to navel/umbilicus; then the rest of the body & after-coming head are extracted - the best method of vaginal breech delivery

18. 2) Total or complete breech delivery - fetus is delivered entirely by extraction - in second of twins (second twin must not be much bigger than first); done by experienced OB, under anesthesia

19. Delivery of aftercoming head a. Mauriceau -Smellie-Veit Maneuver: index & middle fingers of one hand over maxilla to flex head, while fetal body rests upon palm and forearm of obstetrician

20. b. Prague maneuver – Kiwisch of Prague (1846) ; two fingers grasp shoulders of back-down fetus while other hand draws feet up over abdomen of mother

21. c. Bracht Maneuver - breech delivers up to umbilicus; fetal body held but not pressed against maternal symphysis, only allow gravity to work ; uterine contractions + supra-pubic pressure  spontaneous delivery

22. d. Forceps (Piper’s) - should be applied only when the head is well within pelvic cavity - assistant may wrap baby’s body in towel to keep the arms out of the way (Savaj maneuver)

23. e. Entrapped head (rare; greater frequency w/ preterm breech) - Duhrssen incisions at 2, 6, 10 o’clock of cx; cervix should be fully effaced and at least 7 cms dilated ; - Symphysiotomy

24. f. Abdominal Rescue - for entrapped head  stat CS - DON’T PANIC!

25. Some Variations in Partial Breech Delivery: If the fetal sacrum rotates backwards after delivery of the breech, this must be manually corrected so that head does not enter pelvis in posterior position.

26. Extraction of Frank Breech - delivered by moderate traction exerted by a finger in each groin - breech decomposition (to convert frank to footling breech); Pinard maneuver pushes fetal knee from midline (abduct) in backward outward direction  flexion

27. For extended arm/nuchal arm: Arms are normally folded across chest and freed after shoulder delivery. Especially in preterm infants the arm may be pulled and may become extended over the head. OB manipulates this by rotating the baby’s body in order to induce flexion of arms. For nuchal arm, rotate fetus to release arm. Or, do LOVESET maneuver.

28. Partial Breech Extraction: No intervention is done until after body is born up to umbilicus of the baby. Bearing down by mother is encouraged & may be aided by an assistant who exerts supra-pubic pressure. Premature traction/pulling can cause de-flection of head and extension of arms above or behind the neck.

29. The moment the umbilicus comes out, the rest of the delivery should be accomplished within 3-5 minutes. *Time becomes an important factor!

30. Cardinal rule in delivery of shoulders: Do not attempt delivery of shoulders and arms until downward traction makes one axilla visible. Do not panic! AVOID PULLING ON THE BREECH !!!

31. -A Competent Team: skillful obstetrician assistants, medical & nursing anesthesiologist pediatrician

32. COMPLICATIONS OF BREECH DELIVERY MATERNAL 1. Infection 2. Uterine rupture 3. Cervical lacerations 4. Uterine atony However, prognosis for mother is better in vaginal breech delivery than in C.Section.

33. FETAL Complications – poorer fetal/neonatal prognosis in vaginal delivery 1.Tentorial tears, intra-cerebral bleed 2.Cord prolapse 3.Fracture of clavicle, humerus 4.Paralysis of arm 5.Broken neck 6.Testicular injury

34. VERSION -An operation in which the presentation of the fetus is altered artificially a. Substitute one pole of a longitudinal presentation for the other b. Converting an oblique or transverse lie into a longitudinal lie (cephalic or podalic)

35. External version – manipulations done through abdominal wall (ECV) Internal version– hand introduced into uterine cavity (internal podalic version)

36. External Cephalic Version  Usually with tocolysis  Hook to fetal monitor  Each hand grasps a fetal pole  the preferred presenting part is gently stroked to the pelvic inlet  Have OR ready

37. Internal Podalic Version  Feet grasped and drawn through cervix while body is pushed abdominally in opposite direction  For delivery of second of twin

38. Cesarean Section (CS) defined: Delivery of a fetus through an abdominal incision (laparotomy), followed by incision of the uterus (hysterotomy). Definition does not include removal of the fetus from the abdominal cavity after uterine rupture or in an abdominal pregnancy. CS Hysterectomy is removal of uterus in conjunction w/ a CS or abdominal delivery.

39. Reasons for increasing CS rates: 1.Safety of the operation 2.Delivery of breech by CS 3.Fear of uterine rupture after previous CS 4.Fetal distress/nonreassuring FHR pattern as indic.+ increased use of electronic fetal monitor 5. More preference to CS than operative vaginal deliveries, particularly mid-forceps or difficult vaginal operative deliveries

40. Reasons for increasing CS rates: 6.Increasing age of marriage and childbearing; hence, more elderly primis today ? 7. Use of technology like USG & E.F. monitoring 8. Emphasis on patient’s rights and autonomy (CDMR)

41. CS Indications Medical: maternal cardiac dse (unstable coronary artery disease), pulmo/resp. dse (Guillain-Barre syndrome), conditions associated w/ ICP Mechanical: tumor previa; obstruction of the vulva (massive condylomata) Fetal : FHR, malpresentation/malposition Maternal-Fetal: dystocia due to CPD, placenta abruptio or previa

42. Phil./ Local Indications for CS: 1.Obstructed labor 2.Hemorrhagic complications 3.Abnormal patterns of labor 4.Fetal distress 5.Previous CS (more than 30%) 6.Cord complications 7.Obstetric problems

43. Maternal mortality from CS is due to underlying diseases rather than surgery itself, except those cases complicated by infection. Perinatal fetal morbidity is related to age of gestation and prior status of baby.

44. Some Maternal Complications of CS 1.Injury to neighboring organs: urinary bladder, ureters, bowels, blood vessels in broad ligaments and uterine blood vessels; 2. More risk of postpartum hemorrhage 3. More risk of pulmonary embolism, 4. Paralytic ileus 5. Infection – wound infection, UTI 6. Placenta previa accreta

45. PLACENTA ACCRETA is reported to be the most frequent indication for postcesarean hysterectomy, while uterine ATONY is the most common reason for hysterectomy after a vaginal delivery. A sub-total hysterectomy is preferred when faster surgery is required, or dissection of cervix is difficult.

46. Vaginal Birth After Cesarean (VBAC)  one way to lower CS rates  Limited to cases where uterine incision is low transverse and no extension of the wound (previous CS of one low-segment incision), after excluding inadequate pelvis.

47. Advantages of VBAC 1.Vaginal births are associated with lower rate of infection and blood loss compared to CS. 2. Babies born vaginally undergo a natural squeeze to expel fluid from esophagus, nose and lungs. 3. Recovery time is faster after vaginal birth. 4. Hospital stay is shorter.