BREECH PRESENTATION.

GROUP 4.

introduction.

• is unsual presentation and should not be considered abnormal.

• the fetus lie longitudinally with the buttocks in the lower pole of the uterus.

• bitrocanteric is the presenting diameter with he sacrum as the denominator.

• occurs in 3% of pregnancies at term.

types and positions

• their are 6 positions.

1. right and left sacroposterior.

2. right or left sacrolateral

position

• 3. right and left sacroanterior

positions

types.

• has 4 types.

1. frank breech• hips are flexed with

legs extended on the abdomen.

• comprises 70%• common in primi

2. footling breech.• its rare.• one or both feet

present cz neither hips nor knees are fully flexed.

• feet normally lower than buttocks

3. complete breech

-fetal attitude is one of complete flexion with hips and bones flexed and feet tucked in beside the buttocks.

4. knee presentation.

-rare.

-one or both hips are normally extended with knees flexed.

causes.

1.extended knees- inhibit cephalic version2.preterm labour-occurs b4 34wks.3.placenta previa.4.hydrocephally- big head readily

accomodated in the fundus.5.polyhydramnios-distention hence breech6.multiple pg-limit space for fetus to turn7.uterine abnormalities- distortion of uterine

cavity by a septum or fibroid.

diagnosis

1.abdominal examination

-palpation where you will feel the head at the fudus as a round mass

-auscultation if the fetus has not passed though pelvic brim then the fetal heart rate is heard clearly above the umbilicus.

2. ultrasound examination.

3. x-ray• durind labour

diagnosis can be done by doing a vaginal examination and abdominal examination.

antenatal management.

• if breech has bn detected at 36wks then she should be refered to a doctor.

• the presentation is confirmed by doing an ultrasound.

• the following are ways through which it can be managed.

a)External ceophalic version (ECV)

• use of external manipulation on the mothers abdomen to convert a breech presentation to cephalic one.

• should be done by a skilled personal and at term and in a unit where there are equipments for emergency delivery.

• succes depends on position and engagement of the fetus liquir volume and maternal parity.

• its known to reduce breech by 2/3 at term reducing chances for a c-section.

procedure of doing ECV.

ultrasound done to localize the placenta and confrim position and fetus presentation.

a canula should be sited to allow venus acces if the procedure is to be done under tocolysis

a 30 min cardiotocography is perfomed to establish the fetus compromised. record maternal bp and pulse.

ask the woman to empty her bladder then assist her into a comfortable supine position.

elevate the foot of the bed to help free the breech from the pelvic brim.

dust the abdomen with talcum powder to prevent pinching of the womans skin.

displace the breech from the pelvic brim toward the iliac fosa.

force is then used with one hand on each pole and make the fetus perfome a forward somersault.

if this is not possible then backward somersault is done.

abandone if the the fetus is not turning easly and try again later.

complications of ECV.

1.rupture of membranes.

2.separation of the placenta.

3.knotting of the umblical cord.

4.relative contraindications- uterine scar

contraindictions

1.pre-eclampsia

2.multiple pregnancy

3.oligohydramios-

4.ruptured membranes

5.any condition that would require delivery by c-section.

cautions

1.do not sedate the mother

2.do not use excess force.

3.give anti-D 100ug IM to serum negative mothers

4.exclude contraindications

5.use hexoprenaline 10ug or salbutol 0.1-0.2 mg IV to relax the uterus.

PERSISTANT BREECH PRESENTATION.

• In case of unsucesfull ECV at 37 wks then discussion of available options shoild be made btwn the mother and practioner.

• this should be whether to perfome a c-section or vaginal birth.

• this should be formulated and recorded.• a c-section at term reduces the perinatal

and neonatal mortality and morbidity but there is increased risk of maternal morbidlity.

assesment for a vaginal birth

• any doubt as to the capacity of the pelvis to accomodate the fetal head must be resolved before the buttocks are born and the head attempts to enter the pelvic brim

• this is so because the fetus begins to be deprived of oxygen and a c-section decision may be late.

• abdominal palpation can be done to acces the fetal size.• pelvic capacity can be judged on a vaginal examination

which will show the shape of the sacrum and give accurate measurement of the anteposterior diameters of the pelvic brim, capacity and outlet.

mechanism of left sacroanterior position.

• the lie is longitudinal• attitude is one of complete flexion• presentation is breech• position is left sacroanterior• sacrum is the denominator• presenting part is anterior(left) buttock.• bitrochanteric diameter enters the pelvis in the

left oblique diameter of the brim• sacrum points to the left iliopectineal eminence

• compaction- descent takes place with increasing flexion of the limbs.

• internal rotation of the buttocks-anterior buttock reaches pelvic floor first and rotates forwords 1/8 of a circle along the right side of the pelvis to lie underneath the symphisis pubis. bitrochanteric diameter is now in the anterioposterior diameter of the outlet.

• lateral body flexion- anterior buttock escape under pubis symphysis pubis as the posterior one sweeps the perinium making the buttocks to be born.

• restitution of the buttocks- anterior buttock turns slightly to the mothers right side.

• internal rotation of the shoulders- anterior shouler rotates1/8 along right sied and escape under symphisis pubis.posterior shoulder sweeps the perineum and they are born

• internal head rotation- enters the pelvis with sagital suture in transverse diameter of the brim.occiput rotates forwords along left side and suboccipital region impinges on the undersurface of the symphysis pubis.

• external rotation of the body-the body turns so that the back is uppermost

• birth of the head-the chin,face and sinciput sweep the perineum and head is born in a flexed attitude.

management of labour.

• first stage.

• encourage upright position to aid decsent

• an analgesia may be given if the breech inhibits urge to push prematurely.

• with complete breech its less fiting on presenting part and membranes tend rapture hence a vaginal exam should be done to exclude cord prolapse.

• second stage.• corfim full cx dilation before she statrs

active pushing.• she may adopt a supported squart position

to utilize gravity at this stage.• active pushing is discouraged untill

buttocks are distending the vulve.• need for a c-section should be made when

breech fails to descend onto perineum in this stage despite good contractions.

types of birth.

1.spontaneous- birth with little assistance

2.assisted breech- buttocks born spontanously but sm assistance is necessary foe delivery of extended legs or arm and head

3.breech extraction-manipulation delivery done to hasten the birth in an emergrncy situation.

management of birth birth of shoulder.• uterine contractions and weight of the body will bring the

shoulders down on the pelvic floor where they will rotate into anteroposterior diameter of the outlet.

• wrap a small towel around the babys hip to preserve warmth and improve grip

• grab the baby by the iliac crest and tilt towards the maternal sacrum in order to free the anterior shoulder.

• when the shoulder has escaped the buttocks are tilted towards the mothers abdomen to enable the posterior shoulder and arm to pass over the perineum.

• as they are born the head enters the pelvic brim and descend through the pelvis with sagital suture in the transverse diameter.

bith of the head.• when the back has been turned the

infant is allowed to hand from the vulva without support.

• the baby brings the head onto the pelvic floor on which the occiput rotates forward.

• the sagital suture now is in anteroposterior diameter of the outlet.

• two fingers should be on the malar bones and the head rotated if it fails to rotate.

• the neck will gradualy elongate and hair line will appear and the subocipital region will be felt.

• delivery of the head is normally vital to avoid changes in itracranial pressure.

• three methods are normally used1. forceps delivery2. burns marshall method3. mauriceau-smellie-vietmanouvre.

delivery of extended legs.

• frank breech descends more rapidly during first stage.• cx dilates quickly and thier is risk of cord becoming

compressed btn legs and head.• delay may occur at the outlet because the legs splint the

body and impede lateral flexion of the spine.• assistance is usually given when the baby presents with

extended extended legs• when the popliteal fosa appears two fingers are placed

along the length of the thigh with finertips on the fosa.• the leg is swept to the side of the abdomen with the knee

flexed .this will cause lower part of the leg to emerge.

• the process should be repeated for birth of the second leg.

• the leg should not be pulled forward to avoid causing injury.

delivery of extended arms.

• diagnosed when elbows are not felt on the chest after umbilicus is born.

• delivery is done by lǿvset manoeuvre which is a combination of rotation and downward traction.

• shoulders are in anterior posterior position when umbilicus is born.

• grab the baby by the iliac crest with the thumbs over the sacrum

• downward traction is applied till axilla is visible.

• maintain downward traction throughout and rotate the baby half a circle by turning the back uppermost.

• the friction produced by posterior arm on pubic bone sweeps the arm in front of the face allowing the shoulders to enter the pelvis in transeverse diameter.

• the anterior arm is then delivered.• splint the humerus by two fingers of the hand placed on

the babys back.• draw the baby down over the chest as the elbow is

flexed.• the baby is rotated on the opposite side and the other

arm is born.

complication

1.impacted breech

2.cord prolapse

3.birth injury

4.intracranial haemorrhage

5.fetal hypoxia'

6.premature separation of placenta

7.maternal trauma.