Breech Delivery PDF

Breech Delivery Updated June 2021 Jacaranda Health Presentation v1 20170606 1 Learning objectives Define Breech malposition Review predisposing factors for breech Discuss different types of breech presentation Review management of babies in breech position Review complic...

Breech Delivery Updated June 2021 Jacaranda Health Presentation v1 20170606 1 Learning objectives Define Breech malposition Review predisposing factors for breech Discuss different types of breech presentation Review management of babies in breech position Review complications of Breech/breech delivery Jacaranda Health Presentation v1 20170606 2  Pre-test #1. What percentage of full term pregnancies result in breech presentation?: a..5-1% b. 3-4% c. 10-15% d. 20-25% Jacaranda Health Presentation v1 20170606 3  Pre-test #2. Frank breech is defined as: a. one leg folded up, one leg extending down into the birth canal b. hips flexed, legs extended c. hips flexed, legs flexed d. hips extended, legs flexed Jacaranda Health Presentation v1 20170606 4  Pre-test #3. Which of the following is NOT a risk factor for breech presentation?: a. prematurity b. septate uterus c. placenta previa d. oligohydramnios Jacaranda Health Presentation v1 20170606 5  Pre-test #4. Which of the following is NOT true regarding external cephalic version?: a. it needs to be performed by an EXPERIENCED provider b. The membranes NEED to be in tact for this procedure c. needs to be performed in a facility equipped with emergency CS services d. Should be performed at 39-40 weeks gestation Jacaranda Health Presentation v1 20170606 6  Pre-test #5. Which of the following methods of delivery is deemed safest for a pregnancy in breech position?: a. Caesarian section b. External cephalic version then normal delivery c. Vaginal breech extraction Jacaranda Health Presentation v1 20170606 7  The facts 3-4% of all pregnancies will result in a baby being breech at term Jacaranda Health Presentation v1 20170606 8 Definitions Breech presentation is when the buttocks and /or feet of the foetus are the presenting part It is the most common malpresentation Breech presentation is more common in preterm labour Jacaranda Health Presentation v1 20170606 9 Different types of breech There are 3 different types of breech presentation: Frank breech: the hips are flexed, legs extended (*most common type) Complete breech: the hips are flexed, legs also flexed Footling breech: one leg folded up, one leg extending down into the birth canal (this is more likely in preterm babies) FRANK COMPLETE BREECH FOOTLING BREECH BREECH Jacaranda Health Presentation v1 20170606 10 Predisposing factors to breech presentation Prematurity Multiple pregnancy Abnormalities of the uterus (ex. Fibroids, septate uterus) Foetal abnormalities Placenta previa Mulitparity Polyhydramnios Jacaranda Health Presentation v1 20170606 11 Diagnosis of breech presentation The majority of breech babies are discovered before labour via palpation of the mother’s abdomen The head will be felt in the upper abdomen and the breech in the pelvic brim Foetal heart tones are usually heard higher in the maternal abdomen Confirmation via ultrasound is typically performed Approximately 1/3 of breech babies are discovered during labour during vaginal exam It is important to have a high index of suspicion for any woman in labour Thick meconium often present in babies that are breech Jacaranda Health Presentation v1 20170606 12 The chances of a baby turning on its own - If a primiparous patient has a breech baby at 36 weeks, the chance of the baby turning itself naturally before labour is about 1 in 8 - If a multiparous patient has a breech baby at 36, the chances of the baby turning naturally is about 1 in 3 Jacaranda Health Presentation v1 20170606 13  Management of Breech There are 3 different options for a woman with a breech baby at term: External cephalic version Vaginal assisted breech delivery Caesarean section Jacaranda Health Presentation v1 20170606 14 External cephalic version This procedure may be attempted if: It is being performed by an EXPERIENCED healthcare provider The gestation is at or after 37 weeks There are no contraindications for vaginal delivery Membranes are intact Amniotic fluid volume is adequate It is being done in a facility that can accommodate an emergency caesarean section Jacaranda Health Presentation v1 20170606 15 External cephalic version - complications Placental abruption **NOTE: This procedure is best Foetal bradycardia or performed under ultrasound distress guidance. It is rarely performed in Knotted or entangled cord Kenya at this time Amniotic fluid embolism Foetal or maternal death Jacaranda Health Presentation v1 20170606 16 Vaginal assisted breech delivery This procedure may be attempted if: It is being performed by an EXPERIENCED health provider it is a complete or frank breech (cannot attempt in footling breech!) Estimated foetal weight is between 2500- 3500 (do not attempt in preterm, IUGR or macrosomic babies) There is adequate pelvic pelvimetry The head is well flexed There is no history of previous C/S or myomectomy There are no foetal anomalies identified NOTE: only approximately 50% women aiming for vaginal delivery will achieve this. Jacaranda Health Presentation v1 20170606 17 Vaginal assisted breech delivery - complications Cord prolapse Birth trauma (damage to abdominal organs, fractures, dystocia) Asphyxia Trapped foetal head Stillbirth NOTE: the Second stage of labor is the most concerning part of a vaginal breech birth because this is the time the umbilical cord gets compressed and acidosis may ensue (especially in a small fetus). NOTE: Perinatal outcomes are affected if the second stage of labor lasts longer than 60 minutes. Jacaranda Health Presentation v1 20170606 18 Caesarean section breech delivery This procedure is the safest method of breech delivery CS should ALWAYS be performed in cases of breech that are: Footling or double footling breech Small or malformed foetus Very large foetus Previous C/S or myomectomy Hyper extended / deflexed head Jacaranda Health Presentation v1 20170606 19 How to conduct a vaginal breech birth Step 1. Delivery of buttocks and Legs: Once buttocks have entered the vagina/cervix is fully dilated, tell woman to push with contractions Let the buttocks deliver until the lower back and then the shoulder blades are seen Wrap fetal body in dry towel and gently hold the buttocks in one hand, but do not pull If the legs do not deliver spontaneously, deliver one leg at a time using Pinard Maneuver Jacaranda Health Presentation v1 20170606 20 Pinard maneuver Sweeping/external rotation of each thigh combined with rotating the pelvis in the opposite direction resulting in the flexion of the knee and the delivery of each leg Jacaranda Health Presentation v1 20170606 21 How to conduct a vaginal breech birth Step 2. Delivery of arms: Allow the arms to disengage spontaneously one by one Assist if necessary using Lovset’s maneuver Jacaranda Health Presentation v1 20170606 22 Lovset’s maneuver With thumbs on the infant's sacrum, take hold of the hips and pelvis with the other fingers Turn infant 90° to bring the anterior shoulder underneath the symphysis and engage the arm Deliver the anterior arm Then do a 180° counter-rotation to engage the posterior arm, which is then delivered Jacaranda Health Presentation v1 20170606 23 How to conduct a vaginal breech birth Step 3. Delivery of the head Lay the baby face down with the length of its body over your hand and arm. Use Smellie Veit maneuver to delivery head ** Note: Ask an assistant to push above the mother’s pubic bone as the head delivers. This helps to keep the baby’s head flexed. Jacaranda Health Presentation v1 20170606 24 Smellie Veit maneuver Lay baby face down with the length of its body over your hand and arm Place index and middle fingers of this hand on the baby’s maxilla (bone behind upper lip) to bring the neck into moderate flexion Use the other hand to grasp the baby’s shoulders Gently flex the baby’s head towards the chest, while applying downward pressure on the jaw to bring the baby’s head down until the hairline is visible Pull gently to deliver the head Jacaranda Health Presentation v1 20170606 25 How to conduct a vaginal breech birth Step 4: Post delivery care: Place infant on mom’s abdomen Proceed with routing post delivery care Jacaranda Health Presentation v1 20170606 26  Vaginal Breech Extraction Breech presentation identified Identify which type of breech: Footling Breech Complete or Frank breech: consider options, consent mother for either O OR Initiate emergency CS R Vaginal breech extraction Step 1. Delivery of buttocks and Legs: - Once buttocks have entered the **Pinard Maneuver: vagina/cervix is fully dilated, tell sweeping/external rotation of each woman to push with contractions thigh combined with - Let the buttocks deliver until the rotating the pelvis in the opposite lower back and then the shoulder direction resulting in the flexion of blades are seen the knee and the delivery of each leg - Wrap fetal body in dry towel and gently hold the buttocks in one hand, but do not pull. - If the legs do not deliver spontaneously, deliver one leg at a time using Pinard Maneuver** **Lovset’s Maneuver: - With thumbs on the infant's sacrum, take hold of the hips and pelvis with the other fingers - Turn infant 90° to bring the anterior shoulder underneath the Step 2. Delivery of arms: symphysis and engage the arm - Allow the arms to disengage Deliver the anterior arm spontaneously one by one - Then do a 180° counter-rotation - Assist if necessary using Lovset’s to engage the posterior arm, maneuver** which is then delivered Step 3. Delivery of the head **Smellie Veit Maneuver: - Lay the baby face down with - Lay baby face down with the the length of its body over length of its body over your hand your hand and arm. and arm - Use Smellie Veit** maneuver - Place index and middle fingers of to delivery head this hand on the baby’s maxilla ** Note: Ask an assistant (bone behind upper lip) to bring to push above the the neck into moderate flexion mother’s pubic bone as - Use the other hand to grasp the the head delivers. This baby’s shoulders helps to keep the baby’s - Gently flex the baby’s head head flexed. towards the chest, while applying downward pressure on the jaw to bring the baby’s head down until Step 4. Post delivery care: the hairline is visible - Place infant on mom’s abdomen - Pull gently to deliver the head - Proceed with routing post delivery care QUESTIONS?? Jacaranda Health Presentation v1 20170606 28  Post-test #1. Which of the following is a known complication of external cephalic version? a. head entrapment b. intracranial haemorrhage c. placental abruption d. cord prolapse Jacaranda Health Presentation v1 20170606 29  Post-test #2. A vaginal breech delivery should NOT be attempted with which of the following scenarios?: a. The foetal head is well flexed b. Estimated fetal weight is 2kg c. Primiparous patient d. The foetus is in frank breech position Jacaranda Health Presentation v1 20170606 30  Post-test #3. When attempting a vaginal breech delivery, perinatal outcomes are significantly affected if the second stage lasts longer than: a. 20 minutes b. 30 minutes c. 60 minutes d. 2 hours Jacaranda Health Presentation v1 20170606 31  Post-test #4. In a vaginal breech delivery, the Lovset maneuver is used to assist delivery of the: a. Foetal buttock b. Foetal legs c. Foetal arms d. Foetal head Jacaranda Health Presentation v1 20170606 32  Post-test #5. Sweeping/external rotation of each thigh combined with rotating the pelvis in the opposite direction resulting in flexion of the knee and delivery of each leg is called: a. Pinard Maneuver b. Lovset Maneuver c. Smellie Veit Maneuver d. Zavanelli Maneuver Jacaranda Health Presentation v1 20170606 33