Malposition - Breech Presentation.pptx
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Breech Presentation
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PRESENTED BY,
Dr. (Mrs). S. Anuchithra,
Vice Principal Cum HOD OBG Nursing,
P.D.Bharatesh College of Nursing,
Halaga, Belgaum.
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Meaning
An unusual presentationNot to be considered abnormal - fetus lies
longitudinally with the buttocks in the lowerpole of the uterus.
Presenting diameter is the bitrochanteric
(10cm)
Denominator the sacrum.
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Breech presentation
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Breech presentation
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Breech presentation
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It is the commonest malpresentation
Reassure mother for normal labour and birth.
Ensuring informed consent - that not all
breech babies can or should be born vaginally.
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IncidenceBreech Presentation
1 in 5 at 28th week
5% at 34th week - 3 out of 4, spontaneous
correction in to vertex
In mid-trimester frequency is much higher -
greater proportion of amniotic fluid facilitatesfree movement of the fetus.
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The incidence in all pregnancies is about 3-4%.
Advancing gestational age - % of breech
deliveries decreases
25% of births prior to 28 weeks' gestation
7% of births at 32 weeks' gestation
1-3% of births at term.
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Fetal abnormalities are observed in
17% of pre-term breech deliveries and
In 9% of term breech deliveries.
Cord prolapse occurs in 7.5% of all breeches.
This incidence varies with the type of breech:0-2% with frank breech,
5-10% with complete breech, and
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10-25% with footling breech.
Cord prolapse occurs twice as often in women
who have had previous pregnancy (or
multiparas) (6%) than in the first time
pregnancy (or primigravidas) (3%).
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Nuchal arms(one or both
arms are wrapped around
the back of the neck)
present in 0-5% of
vaginal breech deliveries
and in 9% of breech
extractions.
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Fetal head entrapment - result from an
incompletely dilated cervix and head that lacks
time to mould to the maternal pelvis - occurs
in 0-8.5% of vaginal breech deliveries.
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Types or VarietiesComplete
Incomplete
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Complete Breech Normal attitude of full flexion
is maintained.
The thighs are flexed at the
hips and the legs at the knees.
The presenting part consists of
two buttocks, external
genitalia and two feet.
Commonly present in
multipara.
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Incomplete Breech
Due to varying degrees of
extension of thighs or legs
at the podalic pole.
Three varieties are possible
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Incomplete Breech
Breech withExtended Legs
Footling
Presentation
Knee
Presentation
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Breech with Extended Legs
Thighs are flexed on the trunk and
the legs are extended at the knee
joints.
The presenting part - the two
buttocks and external genitalia only.
Common in primigravida 70% -
tight abdominal wall, good uterine
tone and early engagement of
breech.
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Footling Breech
Both the thighs and the
legs are partially
extended bringing the
legs to present at the
brim.
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Knee presentation
Thighs are extended but
the knees are flexed,
bringing the knees down
to present at the brim.
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Clinical varieties
Uncomplicated Defined as one where
there is no other
associated obstetric
complications apart
from the breech,prematurity being
excluded.
ComplicatedWhen the presentation is
associated with
conditions which
adversely influence the
prognosis - prematurity,twins, contracted pelvis,
placenta praevia etc.
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Six positions - Breech Presentation
RSP LSP RSL LSL
RSA LSA
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EtiologyCause remains obscure.
Prematurity
Factors preventing spontaneous versionFavourable adaptation
Undue mobility of the fetusFetal abnormality
Recurrent or habitual breech
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Diagnosis
I. Antenatal diagnosis
a.Abdominal examination,
b. Ultrasound examination,c. X-ray examination
II. Diagnosis during laboura. Abdominal examination,
b. Vaginal examination
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I. Antenatal diagnosis
a. Abdominal examination 1. Listen to the mother,
2. Palpation and
3. Auscultation
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I. Antenatal diagnosis
2. Palpation
Primigravida difficult to diagnose - firm
abdominal muscles.
Lie is longitudinal with a soft presentation-
easily felt using pawliks grip
Head felt in the fundus - round hard mass.
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May be made to move independently - with one
or both hands.
Extended legs & feet prevents nodding.
When the breech is anterior and the fetus well
flexed - may be difficult to locate the head - but
use of the combined grip (upper and lower
poles) may aid diagnosis.
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I. Antenatal diagnosis
3. Auscultation
FHS clear above umbilicus - If breech has not
passed through the pelvic brim.
FHS heard at a lower level - when legs are
extended & breech descends into the pelvis.
I A t t l di i
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I. Antenatal diagnosisb. Ultrasound examination
Used to demonstrate a breech presentation.
(1) Confirms the clinical diagnosis
(2) Can detect fetal congenital abnormality
(3)Measures biparietal diameter, GA and approximate
weight of the fetus.
(4) Locates the placenta.
(5) Assessment of liquor volume (important for ecv).
(6) attitude of the head
I A l di i
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I. Antenatal diagnosis
c. X-ray examinationAdded advantage - allowing pelvimetry to beperformed
A straight x-ray is rarely done:
(1) To confirm the clinical diagnosis.
(2)To exclude bony congenital malformation
(hydrocephalus).(3) To note the size of the baby.
(4) To note the position of the limbs and the head.
II Di i d i l b
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II. Diagnosis during labour
a. Abdominal examinationExamination Complete breech Frank breech
Per
abdomen
Fundal grip
Head suggested
by hard and
globular mass.
Head is ballotable.
Head irregular small parts
of the feet may be felt by the
side of the head.
Head is non-ballotable due
to splinting action of the legs
on the trunk
Examination Complete breech Frank breech
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Examination Complete breech Frank breech
Lateral grip Fetal back is to one side
and the irregular limbs to
the other.
Irregular parts are less
felt on the side
Pelvic grip Breech suggested by
soft, broad and irregular
mass.Breech usually not
engaged during
re nanc .
Small hard and conical
mass is felt
The breech is usuallyengaged
Examination Complete breech Frank breech
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Examination Complete breech Frank breech
FHS Usually above
the umbilicus
Located in lower level in the
midline due to early
engagement of the breech
Per vaginal
During
pregnancy
Soft, irregular
parts are felt
through the
fornix
Hard feel of sacrum is felt,
often mistaken for the head.
Palpation of ischial
tuberosities, anal opening and
sacrum only.
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II. Diagnosis during labour
b. Vaginal ExaminationThe breech feels soft and irregular with no
sutures palpable,
Occasionally the sacrum may be mistaken for a
hard head and the buttocks mistaken for caputsuccedaneum.
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The anus may be felt and fresh meconium on
the examining finger is usually diagnostic.
If the legs are extended - external genitalia are
very evident (become edematous).
An edematous vulva may be mistaken for a
scrotum.
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If a foot is felt - differentiate it from the hand.
Toes are all the same length,
shorter than fingers and the big toe cannot be
opposed to other toes.
The foot is at right angles to the leg, and
the heel has no equivalent in the hand.
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No feet felt; the legs are extended.Feet felt; complete breech presentation
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Antenatal Management
Identification of the complicating factors
External cephalic version
Formulation of the line of management
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Identification of the
complicating factorsClinical examination,
Sonography- useful to detect
Congenital malformations of the fetus,
The precise location of the placental site and
Congenital anomalies of the uterus.
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External cephalic version
Definition: External cephalic version (ECV) is
the use of external manipulation on themothers abdomen to convert a breech to a
cephalic presentation.
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The success rate of version is about 60%
Successful version reduces the risk of
caesarean section significantly.
Prior Sonography should be a routine.
Cardiotocography should ideally be done
before and after the procedure.
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Time of version:
At 35-37 weeks but can be attempted at any
time thereafter up to early labour.
Version in the early weeks is easy but chance of
reversion is more.
Late version may be difficult - increasing size ofthe fetus and diminishing volume of liquor
amnii tocolysis makes less difficult.
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Time of version:
Routine version at 35 to 37 weeks may have
advantages.
It minimises chance of reversion and
Developed fetal complications can be
effectively tackled by caesarean section.Hypertonus or irritable uterus can be
overcome with the use of tocolytic drugs.
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Benefits of ECV are
Reduction in the incidence of breech
presentation at term,
Reduction in the incidence of breech delivery
and the associated complications,
Reduction in the incidence of caesarean
delivery by 5%.
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Successful version is likely in cases of:
Complete breech,
Non-engaged breech sacroanterior position,
Adequate liquor
Non obese patient.
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Causes of failure of version:
Breech with extended legs- difficult to
disimpact because of early engagement and
difficult to flex the trunk because of splinting
action of the limbs,
Scanty liquor
Big size baby.
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Causes of failure of version:
Mechanical
Obesity,
Increased tone of the abdominal muscles and
Irritable uterus.
Short cord - either relative or absolute,
Uterine malformations- septate or bicornuate.
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Method
An ultrasound scan
To localize the placenta
To confirm the position and
Presentation of the fetus.
If tocolysis site a cannula to allow venous
access.
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Method
A 30min CTG
To confirm no fetal compromise
Maternal blood pressure and
Pulse.
Ask woman to empty her bladder.
Provide a comfortable supine position.
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Method
Elevate the foot of the bed - help free the
breech from the pelvic brim.
Dust the abdomen with talcum powder - to
prevent pinching of the mothers skin during
the procedure.
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Method
ECV - uncomfortable but it should not bepainful.
The breech is displaced from the pelvic brimtowards an iliac fossa.
Simultaneous force is then used as with one
hand on each pole the operator makes the fetus
perform a forward somersault (Fig).
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Pressure is exerted on head and breech
simultaneously until the head is lying at the pelvic
brim.
Flexion is continued. The left hand brings thehead downwards. The right hand pushes the
breech upwards.
The right hand lifts the breech out of thepelvis. The left hand makes the head follow
the nose. Flexion of head and back is
maintained throughout.
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Method
If this is not successful then a backward
somersault can be attempted.
If fetus does not turn easily, then the procedure
is abandoned but may be tried again a few days
later.
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Repeat CTG following the procedure.
Rhesus negative woman an injection of anti-D
immunoglobulin - prophylaxis against
isoimmunization caused by any placental
separation.
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If the version is performed immediately
prior to the onset of labour, this can be
delay Injection - until after birth when the
blood group of the baby is known.
In this case if anti-D is needed, it must be
given within 72hrs of the version.
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Dangers of version
Premature onset of labour,
Premature rupture of the membranes,
Placental separation and bleeding,
Entanglement of the cord - round the fetal part
or formation of a true knot - impairment of
fetal circulation and fetal death and,
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Dangers of version
Increased chance of feto-maternal bleed and
Amniotic fluid embolism.
Immunoprophylaxis with anti-D gamma
globulin for non-immunized Rh- negative
mother.
Management if version fails or is
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Management-if version fails or is
contraindicated
Continue pregnancy - usual check up and possible
unexpected spontaneous version
But if the breech persists case assessment to bedone
Age of the mother especially in primigravida
Size of the baby and,
Pelvic capacity.
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Clinical assessment of the pelvis - all
primigravida
CT or MRI is a better alternative.
Ultrasonographic examination - gold standard for
decision making.
Two methods of delivery can be planned.
Elective caesarean section.
To allow spontaneous labour to start and vaginal
breech delivery to occur.
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Elective Caesarean section
Tendency to liberalize the caesarean section -risk involved in vaginal breech delivery
The indications of C.S. In breech areBig baby fetal weight >3.5kg
Hyperextension of the head
Footling presentation.
Any associated complication
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The overall incidence of CS in breech range
from 15-50%, out of which about 80% is
elective.
Delivery of preterm breech by caesarean
section is commonly done but in selected
centers, equipped with intensive neonatal
care unit.
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Vaginal breech delivery
Considered in cases with
Adequate pelvis,
Average fetal weight flexed head and
Without any other complications.
Frank breech is preferred - ensure closemonitoring of labour and facilities for
immediate caesarean delivery.
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Complications
Knotting of the umbilical cord
Separation of the placenta
Rupture of the membranes
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Relative contraindications
The presence of a uterine scar
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Contraindications
Pre-eclampsia or hypertension
Multiple pregnancy
Oligohydramnios
Ruptured membranes
Any condition that would require delivery by
caesarean section.
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Persistent breech presentation
Mechanism of left sacroanterior
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Mechanism of left sacroanterior
position
Description of fetus The lie is longitudinal
The attitude is one of complete flexion
The presentation is breech
The position is left sacroanterior
The denominator is the sacrum
The presenting part is the anterior (left) buttock
The bitrochanteric diameter, 10cm, enters the pelvis in the left oblique
diameter of the brim
The sacrum points to the left iliopectineal eminence.
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Main Movements of LSA
Compaction
Internal rotation of the buttocks
Lateral flexion of the body Restitution of the buttocks
Internal rotation of the shoulders
Internal rotation of the head
External rotation of the body
Birth of the head
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Management of vaginal breech
deliveryFirst stage
The management protocol is similar in normallabour.
Spontaneous onset labour increases thechance of successful vaginal delivery.
First stage
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First stageVaginal examination is indicated
Onset of labour - pelvic assessment.
Soon after ROM to exclude cord prolapse.
An intravenous line is sited
Ringers solution,
NPO
Blood is sent for group and cross matching
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First stage
Adequate analgesia - preferred epidural.
Monitor Fetal status and progress of labour
Oxytocin infusion - augmentation of labour.
di i f i
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Indication of Caesarean Section
(C.S.)Cases seen for the first time in labour with
presence of complications.
Arrest in the progress of labour.
Non-reassuring fhr pattern (fetal distress).
Cord presentation or prolapse.
I l b
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IV fluidsKeep fastingGive anti acidPartogramContinuous fetal monitoring
AnalgesiaInform neonatologistKeep theater staff and the anesthetistInformed
In labor
1st stage of labor :
Proper historyReview of the A.N c. RecordsInvestigation
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Early Care In First Stage of Labour
Cleanliness and Comfort
i) Bowel Preparation
ii) Perineal Shaveiii) Bath or Shower
iv) Clothing
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Early Care In First Stage of Labour
Analgesia
Records
Drug Records
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SECOND STAGE
There are three methods of vaginal breechdelivery
Spontaneous (10%) very little assistanceAssisted breech Assistance from beginning to
end
Breech extraction - entire body of the fetus is
extracted by the obstetrician
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SECOND STAGE
Breech extraction
Indications are:
Delivery of the second twin
Cord prolapsed
Extended legs arrested at the cavity or at
the outlet.
ASSISTED BREECH DELIVERY
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ASSISTED BREECH DELIVERY
Conducted by a skilled obstetrician.
The following are to be kept ready
beforehand in addition
Anaesthetist
An assistant
ASSISTED BREECH DELIVERY
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ASSISTED BREECH DELIVERY
Instrument and suture materials forepisiotomy
A pair of obstetric forceps - after cominghead
Appliances for revival of the Baby-Asphyxiated
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Principles in conduction
Never to rush,
Never to pull from below but push from
above,
Always keep the fetus with the back
anteriorly.
Steps
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Steps
Woman brought to the table - anterior buttock
and fetal anus are visible - place in lithotomy
position when the posterior buttock distends
the perineum.
Woman is tilted laterally using wedge under
the back - to avoid aortocaval compression.
Steps
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Steps
Antiseptic cleaning,
Bladder is emptied with catheterization.
Pudendal block with perineal infiltration orepidural
Episiotomy - best time - the perineum is
distended and thinned by the breech.
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The patient is encouraged to bear - ensure
flexion of the fetal head and safe descent.
Policy adopted - no touch - until the buttocks
are delivered along with the legs in flexed
breech and the trunk slips up to the umbilicus.
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Soon after the trunk up to the umbilicus is
born. The Following are to be done:
The extended legs
The umbilical cord
If the back remains posteriorly
The baby is wrapped
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Delivery of the arms
Assistants gives steady fundal pressure during
uterine contractions to prevent Extension of the
arms.
Soon, the anterior scapula is visible - position of
the arm should be noted.
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When the arms are flexed-vertebral border of
the scapula - parallel to the vertebral column
and when extended - winging of the scapula.
The arms are delivered one after the other only
when one axilla is visible-hooking down each
elbow with a finger.
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Breech delivery. Delivering the buttocks (A); feeling for the arms for deliveryone at a time (B); the hairline over the nape of the neck is visible (C); lifting
the legs slowly over the mothers abdomen (D).
Delivery of the after coming head
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Delivery of the after-coming head
Most crucial stage of the delivery.The time between the delivery of umbilicus to
delivery of mouth should preferably be 5 to 10minutes.
There are various methods of delivery for the
after- coming head.
Delivery of the after coming head
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Delivery of the after-coming head
Each one is quite safeEffective in the hands of an expert,
conversant with that particular technique.
Employed common methods are:
Burns Marshall Method
Forceps delivery
Malar flexion and shoulder traction
Burns Marshall Method
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Burns Marshall MethodThe baby is allowed to hang by its own weight.
Assistant - gives suprapubic pressure with the
flat of hand in a downward and backward
direction-more towards the sinciput - aim is
to promote flexion of the head so favourable
diameter is presented to the pelvic cavity. Not
> 1-2 minutes are required to achieve the
objective
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When the nape of the neck is visible under
the pubic arch, the baby is grasped by the
ankles with a finger in between the two.
Maintaining a steady traction and forming a
wide arc of a circle, the trunk is swung in
upward and forward direction.
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Meanwhile, with the left hand to guard the
perineum, slipping the perineum off
successively the face and brow. When the
mouth is cleared off the vulva, there should
be no hurry. Mucus of the mouth and
pharynx is cleared by mucus sucker.
The trunk is depressed to deliver rest of the
head
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Burns Marshall Method
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Burns Marshall Method
(A)The baby is grasped by the feet and held on the stretch.(B) The
mouth and nose are free. The vault of the head is
delivered slowly.
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Forceps delivery
Malar flexion and shoulder
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Malar flexion and shoulder
traction
MauriceauSmellieVeit
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manoeuvre (jaw flexion and
shoulder traction)
MauriceauSmellieVeit manoeuvre for delivering the aftercoming head of breech presentation
(A) The hands are in position before the body is lifted. (B) Extraction of the head.
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Resuscitation of the baby: The baby may be
asphyxiated and need to be resuscitated.
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THIRD STAGE
Usually uneventful.
The placenta is usually expelled out soon afterdelivery of the head.
Prophylactic ergometrine- administered
intravenously with the crowing of the head.
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Preterm breech
ECV with preterm breech presentation is
not recommended.
Cs - fetal weight is
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BREECH DELIVERY
Delay in Descent of the breech
Frank Breech Extraction
Extended Arms - Lovsets ManeuverNuchal displacement of arm
Arrest of the After coming head
Delivery of the head through an incompletely
dilated cervix
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Delay in Descent of the breech
The breech may be arrested:
At the outlet
In the cavity
At the brim
Arrest At the outlet
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Arrest At the outlet
Causes areBig size baby with extended legs
(commonest)Weak uterine contractions
Rigid perineum and
Outlet contraction.
Management
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g
Caesarean section: outlet is contracted, baby
is big.
In the absence of outlet contraction and
fetopelvic disproportion
Liberal episiotomy and fundal pressure
Arrest of the breech at or above
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Arrest of the breech at or above
the level of ischial spines
The causes of arrest are-contracted pelvis,
weak uterine contractions, big baby.
Management:
Best treatment - delivery by ceasarean
section.
Frank Breech Extraction
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Frank Breech Extraction
Intrauterine manipulation to convert a frankbreech to a footling breech.
Possible - membranes have ruptured recently.
Frank Breech Extraction
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Frank Breech Extraction
In pinards maneuver - the middle and theindex fingers are carried up to the popliteal
fossa. It is then presses and abducted so that thefetal leg is flexed. The fetal foot is then grasped
at the ankle and breech extraction is
accomplished.
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Pinards maneuver
Extended Arms
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Extended Arms
One or both the arms are fully stretched along
the side of the head or lie behind the neck.
The cause - faulty technique in delivery- usingunnecessary traction, forgetting the principle
of never pull but push from above.
Extended Arms
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Arrest - delivery of the trunk up to the costal
margins.
Diagnosis - by noting the winging of the
scapula and absence of the flexed limbs in front
of the chest.
M t
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Management
Urgent delivery of the arms - first the
posterior and then the anterior one.
Any one of the following methods: classical,
lovset.
Management - Classical
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Same principle - lovsets maneuver.
Addition - intra uterine manipulation with
patient is in GA.
First - posterior arm is delivered followed by
the anterior arm.
L f h d i i d d l h f h
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Left hand is introduced along the curve of the
sacrum while the baby is pulled slightlyupwards.
With firm pressure over the humerus, theposterior arm is pushed over the babys face.
The extended anterior arm is in the same
manner, while the babys trunk is depressed
towards the perineum.
Management - Lovsets Maneuver
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Widely practiced
Advantages
Wider applicability
Intrauterine manipulation is nil,
A single manipulation is effective
General anesthesia is usually not needed.
Management - Lovsets Maneuver
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Principles:
Because of curved birth canal, when the anterior
shoulder remains above the symphysis pubis, the
posterior shoulder will be below the sacralpromontory.
If the fetal trunk is rotated keeping the back
anterior and maintaining a downward traction,
the posterior shoulder will appear below the
symphysis pubis.
Procedure
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The baby is grasped, using both hands by
femoropelvis grip keeping the thumbs parallel
to the vertebral column.
Start only when the inferior angle of the
anterior scapula is visible underneath the
pubic arch.
Procedure
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Step-1:
Lift baby slightly to cause lateral flexion.
The trunk is rotated through 180 keeping the
back anterior and maintaining a downward
traction.
Posterior arm to emerge under the pubic arch -
hooked out.
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Procedure
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Step-2:
Rotate the trunk in the reverse direction
keeping the back anterior to deliver the
erstwhile anterior shoulder under the
symphysis pubis.
Nuchal Displacement of Arm
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p
Arm is flexed at the elbow and extracted at theelbow and extended at the shoulder and lies
behind the fetal head.
Lovsetts maneuver.
If this fails, the arm is forcibly extracted by
hooking - fracture almost always follows
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Arrest of the Aftercoming head
At
Brim
Cavity
Outlet
Arrest of the Aftercoming head
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at Brim
The causesdeflexed head, contracted pelvis
and, hydrocephalus.
Management:
If the arrest by a deflexed head - completed by
malar flexion and shoulder tractionalong with
suprapubic pressure by the assistant.
Arrest of the Aftercoming head
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g
at Brim
The head is to be negotiated though the brim in
the transverse diameter and rotated in the cavity.
Forceps should not be applied in high head.
If the arrest of the head - contracted pelvis or
hydrocephalus, perforation of head is to be done.
Arrest of the Aftercoming head In
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g
the cavity
Causes - deflexed head and, contracted pelvis.
The best management is delivery of the
head by forceps which is effective in both the
circumstances.
Malar flexion and shoulder traction - only in
deflexed head.
Arrest of the Aftercoming head
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g
At the outlet
The causes - rigid perineum and, deflexed
head.
Episiotomy followed by forceps application or
Malar flexion and shoulder traction is quite
effective.
Delivery of the head through an
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incompletely dilated cervix
Causes premature baby, macerated baby, and
footling presentation and, hasty delivery of
breech before the cervix is fully dilated.
Delivery of the head through anincompletely dilated cervix
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incompletely dilated cervix
Management:
If the baby is living- push up the cervix, malar
flexion and shoulder traction (Shoe- HornMethod).
If necessary, Duhrssens incision can be madeat 2 and 10 Oclockposition on the cervix.
Occipito- posterior position of thehead
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headUsually occurs in spontaneous breech delivery.
The fetal trunk and the head are rotated to
bring them anteriorly.
For rotation, the fetal trunk and the head are
to be grasped; the hand and the fingers are
poisoned like that in malar flexion and