Week 6: Breech Presentation & Delivery PDF

WEEK 6 : BREECH PRESENTATION & DELIVERY BATANGAS STATE UNIVERSITY - TNEU COLLEGE OF MEDICINE PATHOLOGIC OBSTETRICS DRA. RENA CRI...

WEEK 6 : BREECH PRESENTATION & DELIVERY BATANGAS STATE UNIVERSITY - TNEU COLLEGE OF MEDICINE PATHOLOGIC OBSTETRICS DRA. RENA CRISTINA KOA-MALAYA SEPTEMBER 18, 2024 OBJECTIVES Classify the different types of breech presentation. Properly recognize and diagnose breech presentation. Describe the labor and delivery and other management of the breech. Demonstrate proper techniques of vaginal breech delivery. BREECH Fetal buttocks or legs enter pelvis At term - 2-5% or singletons 📚 Of singleton term breech fetuses, the neck may be extremely hyperextended in perhaps 5 percent, and the term stargazing fetus is used. With transverse lie and similar hyperextension of the fetal neck, the term flying fetus is applied. With these, fetal or uterine anomalies may be more prevalent and are sought if not previously identified. With hyperextension, vaginal delivery can injure the cervical spinal cord. Thus, if identified at term, cesarean delivery is indicated. However, cats of spinal cord injury have been reported following uneventful cesarean delivery of breech fetuses. Here, the flexion itself may be implicated. CLASSIFICATION FRANK BREECH COMPLETE BREECH INCOMPLETE BREECH Lower extremities are flexed at the With a complete breech, both hips are One or both hips are extended hips and extended at the knees, and flexed, and one or both knees are also One or both feet or knees lie 🩺 thus the feet lie close to the head flexed below the breech, and thus a foot On internal examination of frank parang ninja (hindi nakataas yung paa) or knee is lowermost in the birth breech, no feet are appreciated, but canal. the fetal ischial tuberosities, sacrum, A footling breech is an incomplete 🩺⭐️ and anus are usually palpable yung paa halos nasa mukha 📑 below the breech ⭐️ breech with one or both feet may tinatawag daw na “single at na nahihiya double footling”. Pag isang paa lang bumaba = single footling. Pag dalawa paa edi double footling. AUTHOR: CLEOFE, DEL ROSARIO, MENDOZA  WEEK 6 : BREECH PRESENTATION & DELIVERY 2 PATHOPHYSIOLOGY most common type of the breech : FRANK BREECH (65%) RISK FACTORS 🩺 🩺 Preterm ( paikot ikot pa) Multifetal gestation ( sikip) 📑 (SPEAKER NOTES) Understanding the clinical settings that predisposed to breech Extremes of amnionic fluid volume presentation can aid early recognition. This fetal lie is more 🩺 Fetal anomalies common remote from term, as earlier in pregnancy each fetal Structural uterine abnormalities ( heart shape uterus) pole has similar bulk. Multifetal gestation is another. with Placenta previa singletons, Other factors include extremes of amniotic fluid Nulliparity volume, fetal anomalies, Structural uterine abnormalities, Increased maternal age placenta previa, nulliparity, increased maternal age, female Female fetal gender fetal gender, prior breech delivery, & size that is small for Prior breech delivery gestational age. Small for gestational age EXAMINATION ⭐️⭐️⭐️ LM1 - hard, round fetal head occupies the fundus 📑 (SPEAKER NOTES) Leopold maneuvers to a certain fetal presentation is done. With the first maneuver, the hard, round fetal head occupies LM2 - identifies the hard broad back to be on one side of the fundus. the abdomen and the knobby small parts on the other. Second maneuver identifies the heart roadblock to be on one side of the abdomen and the knobby small parts on the other. LM3 - if not engaged, the softer breech is movable above With the third maneuver, if not engaged, the softer breech is the pelvic inlet. movable above the pelvic inlet. After engagement, the 4th maneuver shows the breech to be beneath the symphysis. LM4 - After engagement, shows the breech to be beneath The accuracy of this palpation varies. Thus if unclear the symphysis presentation sonographic examination is indicated. CLINICAL EXAMINATION Frank breech – fetal ischial tuberosities, sacrum, & anus 📑 (SPEAKER NOTES) No feet appreciated on cervical examination but the fetal After fetal descent, external genitalia may be ischial tuberosities, sacrum, and animals are usually palpable. distinguished After fetal descent, the external genitalia may also be Markedly swollen buttocks may be mistaken for the mouth distinguished. When they grace belonged the fetal buttocks and ischial tuberosities for the malar eminences may become markedly swollen, rendering digital differentiation of a face and breech difficult. In some cases the unless may be mistaken for the mouth and the ischial tuberosities for the other eminences. AUTHOR: CLEOFE, DEL ROSARIO, MENDOZA  WEEK 6 : BREECH PRESENTATION & DELIVERY 3 POSITION OF SACRUM (view from above) 📚 The fecal sacrum is palpated to establish position. As with cephalic presentations, fetal position is designated to reflect the relations of the fecal sacrum to the maternal pelvis. 📑 Thus, with left sacrum anterior (LSA), the fetus's back is up and its sacrum occupies the left upper (ventral) quadrant of Pag diretso si baby = transverse the mother's pelvis. Other positions are right sacrum anterior pag nakaharap si baby = posterior (RSA), right or left sacrum posterior (RSP or LSP), and right pag nakatalikod/ nakadapa si baby = anterior or left sacrum transverse (RST or LST). INTERNAL EXAMINATION Fetal sacrum is palpated to establish position, in relation to maternal pelvis 📑 (SPEAKER NOTES) The fetal sacrum is palpated to establish position. As with cephalic presentations, fetal position is designated to reflect the relations of the fetal sacrum to the maternal pelvis. Thus, with left sacrum anterior (LSA), the fetus’s back is up and its sacrum occupies the left upper (ventral) quadrant of the mother’s pelvis. Other positions are right sacrum anterior (RSA), right or left sacrum posterior (RSP or LSP), and right or left sacrum transverse (RST or LST). VIEW FROM CERVICAL OR INTERNAL EXAMINATION FACE BREECH 🩺 face- triangle: bibig tapos may matigas breech -dalawang matigas tapos anus, minsan may meconium 📚 With careful examination, however, the finger encounters muscular resistance with the anus, whereas the bony, less yielding jaws and palate are felt through the mouth. The finger, upon removal from the anus, may be stained with meconium. The mouth and malar eminences form a triangular shape, whereas the ischial tuberosities and anus lie in a straight line. With a complete breech, the feet may be felt alongside the buttocks. In footling presentations, one or both feet are inferior to the buttocks. AUTHOR: CLEOFE, DEL ROSARIO, MENDOZA  WEEK 6 : BREECH PRESENTATION & DELIVERY 4 IDENTIFY POSITION LEFT SACRUM ANTERIOR LEFT SACRUM TRANSVERSE ⭐FACTORS FAVORING CESAREAN DELIVERY OF THE BREECH FETUS⭐ ⭐⭐⭐MEMORIZE Clinical characteristics Lack of operator experience - 🩺 if there is no midwife or Maternal characteristics 🩺🩺 Pelvic contraction or unfavorable pelvic shape determined entrapment in vaginal breech ⭐ OB who knows vaginal breech delivery; possible head Patient request for cesarean delivery clinically or with pelvimetry Prior cesarean delivery mabutas cephalopelvic disproportion upon manipulation baka Prior perinatal death or neonatal birth trauma Sonographic fetal characteristics Large fetus: >3800 to 4000 g Incomplete breech presentation - 🩺footling g- 🩺 Severe fetal-growth restriction; term weight 90 to 100 mm – excluded for vaginal delivery FETAL complications Some recommend: pelvimetry to assess the maternal Prematurity bony pelvis if adequate 📑(SPEAKER NOTES) Higher rates of congenital anomaly Umbilical cord prolapse – 0.5% frank breech, 5% complete breech, 15% footling The accuracy of fetal weight estimation by sonography is not Humeral or clavicular fracture, brachial plexus injury, SCM altered by breech presentation (McNamara, 2012). For muscle trauma planned vaginal delivery at term, thresholds in table 28-1 guide care. Others monitor the steady progression of fetal descent and cervical dilation to reflect adequate pelvic capacity LABOR INDUCTION OR AUGMENTATION Labor induction is not recommended 🩺 Controversial Labor induction - hindi naglalabor but magbibigay ka ng Induction: higher rates of NICU admission (3% higher) gamot para maglabor Labor proceeds slower than cephalic Augmentation - habang naglalabor, binibigyan mo ng pampahilab para bumilis ang labor leads to higher NICU admission Example G4 px (you decide for vaginal delivery) - ang pwede lang i labor ay frank breech or complete breech and labor should proceed slower VAGINAL DELIVERY METHODS ⭐ SPONTANEOUS BREECH DELIVERY TOTAL BREECH EXTRACTION 🩺 📚🩺 📚 no manipulation, mag abang ka lang the entire fetal body is extracted by the provider. With spontaneous breech delivery, the fetus is expelled entirely without any traction or manipulation other than You only do this during CS support of the newborn. Second twin/ Undiagnosed twins Cardinal Movements: Engagement - & descent Grasp the feet and then deliver Internal rotation of 45 degrees – brings anterior hip toward pubic arch allowing bitrochanteric diameter to occupy the AP diameter of the pelvic outlet Descent – continues til perineum is distended & hip appears at the vulva Lateral flexion – of the fetal body, the posterior hip is forced over the perineum, which retracts over fetal buttocks allowing the fetus to straighten out when the anterior hip is born. Legs & feet follow the breech & born spontaneously. External rotation – back turning anteriorly Internal rotation AUTHOR: CLEOFE, DEL ROSARIO, MENDOZA  WEEK 6 : BREECH PRESENTATION & DELIVERY 6 ⭐PARTIAL BREECH EXTRACTION⭐ ⭐HOW TO DELIVER A BABY IN BREECH PRESENTATION⭐ 🩺you allow the delivery up to the umbilicus then you will do the maneuvers https://youtu.be/nbz_WKgfhj0?si=MSDSNRETkyxuCjAX 📚 The fetus is delivered spontaneously as far as the umbilicus, but the remainder of the body is delivered by provider traction and assisted maneuvers, with or without maternal expulsive efforts. The legs are sequentially delivered by The fetal bony pelvis is grasped with Two methods are suitable for delivery. splinting the femur with the operator’s both hands. The fingers should rest on 1st Method: With the scapulas visible, fingers positioned parallel to the long the trunk is rotated either clockwise or ⭐ the anterior superior iliac crests and axis of the femur. This helps avoid counterclockwise to bring the anterior the thumbs on the sacrum. femoral fracture. Pressure is exerted shoulder and arm into view (Fig. 28-5). upward and laterally to sweep each leg away from the midline (Fig. 28-3). Steady, gentle, downward traction until The body of the fetus is then rotated 180 the lower halves of the scapulas are degrees in the reverse direction to bring The thigh is then slightly abducted and delivered. the other shoulder and arm into position popliteal fossa ⭐ pressure from the fingertips in the should induce knee flexion and bring the foot within reach. 🩺 wag na wag hahawakan ang tiyan or delivery. 🩺 Sa antecubital fossa ⭐ ang hawak The foot is then grasped to gently deliver Body delivery: fingers on the ASIS, the entire leg outside the vagina. A thumbs on sacrum; gentle downward similar procedure is followed on the traction until one axilla is visible right. Leg delivery: lateral pressure to sweep each leg away from the midline 2nd Method: With this, the posterior shoulder is delivered first. For this, the feet are grasped in one hand and drawn upward over the inner thigh of the During delivery, one or both fetal arms occasionally may lie across the back of the mother (Fig. 28-6). The operator's hand neck and become trapped at the pelvic inlet. With such a nuchal arm, delivery is enters over the fetal shoulder, fingers more difficult and can be aided by rotating the fetus through a half circle in such a are aligned parallel to the long axis of direction that the friction exerted by the birth canal will draw the elbow toward the the fetal humerus, and the fetal arm is face (Fig. 28-7). With a right nuchal arm, the body should be rotated swept upward. The posterior shoulder counterclockwise, which rotates the fetal back toward the maternal right. With a left nuchal arm, the rotation is clockwise, which rotates the fetal back toward the slides out over the perineal margin and maternal left AUTHOR: CLEOFE, DEL ROSARIO, MENDOZA  WEEK 6 : BREECH PRESENTATION & DELIVERY 7 is usually followed by the arm and hand. DELIVERY OF AFTERCOMING HEAD 📚 The head of the fetus is normally extracted with one of the three maneuvers. With any of these, hyperextension of the fetal neck is avoided MAURICEAU-SMELLIE-VEIT MANEUVER ⭐️ MODIFIED PRAGUE MANEUVER The index and middle finger of one hand are applied over the maxilla, to flex the head, while the fetal body rests on the palm of the same hand and forearm. Two fingers on the other hand hook over and grasp the 🩺 shoulders The 3 fingers of the other hand is in the head to keep it flexed. Downward traction is concurrently applied until the suboccipital region appears under the symphysis. Gentle 📑 In some cases, the back of the fetus fails to rotate to the symphysis. The fetus still may be delivered using the modified suprapubic pressure simultaneously applied by an Prague maneuver. With this, two fingers on one hand grasp assistant helps keep the head flexed. the shoulders of the back-down fetus from below while the other hand draws the feet up and over the maternal abdomen USING PIPER’S FORCEPS 📑 Piper forceps, or Laue-Piper forceps may be applied selectively or when the Mauriceau maneuver cannot be accomplished easily. The blades of the forceps are not applied to the aftercoming head until it has been brought into the pelvis by gentle traction, combined with suprapubic pressure, and is engaged. Suspension of the body of the fetus in a towel effectively holds the fetus up and helps keep the arms and cord out of the way as the forceps blades are applied. AUTHOR: CLEOFE, DEL ROSARIO, MENDOZA  WEEK 6 : BREECH PRESENTATION & DELIVERY 8 HEAD ENTRAPMENT TOTAL BREECH EXTRACTION Etiology: Incompletely dilated cervix – constricts around Complete extraction of frank breech fetal neck or CPD (Cephalopelvic Disproportion) True emergency Once the breech is pulled through the introitus Management: General anesthesia w/ halogenated agents Extreme measure: Zavanelli Maneuver – replacement of The steps are similar for partial breech the fetus higher in the vagina & uterus followed by Symphysiotomy - 📑 cesarean section delivery Surgical division of the symphysis pubis to widen the pelvis for vaginal delivery. ⭐️ DÜrhrssen incision being cut at 2 o’clock, which is followed by a second incision if needed at 10 o’clock. Infrequently, an additional incision is required at 6 o’clock. The incisions are so placed as to minimize bleeding from the laterally located cervical branches of the uterine artery. After delivery, the incisions are repaired. 🩺 cut in areas where there is no vessels’ Vessels are in 3 o’clock & 9 o’clock position letter Y EXTERNAL CEPHALIC VERSION (ECV) Manipulations performed through the abdominal that yields a cephalic presentation INDICATIONS CONTRAINDICATIONS Transverse or breech Absolute ○ Same contraindication to vaginal delivery Done at 37 weeks Relative: ○ Early labor ○ Oligohydramnios (low amniotic fluid) ○ Ruptured Bag of Waters (BOW) ○ Nuchal cord (umbilical cord around the neck) ○ Uterine anomalies ○ Fetal Growth Restriction (FGR) ○ Multifetal gestation ○ Prior abruptio placentae AUTHOR: CLEOFE, DEL ROSARIO, MENDOZA  WEEK 6 : BREECH PRESENTATION & DELIVERY 9 REQUIREMENTS TECHNIQUE Facility has ready access to emergency Cesarean section Woman in left lateral tilt / Trendelenburg (CS) Fetal heart tone continuously monitored (sonographically) Intravenous (IV) access A forward roll of the fetus is attempted first NPO (nothing by mouth) for 6 hours 1 or 2 providers may participate Sonographic Examination done to: Fetal buttocks are then elevated from the maternal pelvis ○ Confirm non-vertex fetal position and displaced laterally ○ Document amniotic fluid volume These are then gently guided toward the fundus, while the ○ Assess placental location head is simultaneously directed toward the pelvis. ○ Exclude fetal anomalies If the forward roll is unsuccessful, a backward flip is ○ Evaluate spinal position attempted. Additional Care: ECV attempts are discontinued for: ○ Anti-D Immunoglobulin (Ig) administered to ○ (1)excessive discomfort, RhD-negative mothers ○ (2)persistently abnormal fetal heart rate, ○ Or after (3)multiple failed attempts. If ECV is successful, a nonstress test is repeated until a normal test result is obtained. 📑 Failure is not always absolute. Ben-Meir and colleagues (2007) reported a spontaneous version rate of 7 percent among 226 failed versions—2 percent among nulliparous and 13 percent among multipara If ECV is successful, a nonstress test is repeated until a normal test result is obtained COMPLICATIONS SUMMARY Fetal heart rate aberrations Emergency CS Placental abruptio TOCOLYSIS Betamimetics: ○ Terbutaline – 52% higher success rate compared to without treatment -250 μ g subcutaneously Isoxuprine, Ritodrine CONDUCTION ANALGESIA Epidural Analgesia MOXIBUSTION Traditional Chinese medicine technique ○ Involves burning a cigarette-shaped stick made of ground Artemisia vulgaris (mugwort) or Japanese “moxa.” ○ Typically performed between 33 to 36 weeks of gestation. AUTHOR: CLEOFE, DEL ROSARIO, MENDOZA  WEEK 6 : BREECH PRESENTATION & DELIVERY 10 ⭐️⭐️STEP BY STEP VAGINAL BREECH DELIVERY⭐️⭐️ 1. Consent should be secured 2. Ask for help 3. Adequate analgesia/ anesthesia (epidural, saddle block, pudendal block) 4. Allow is spontaneous expulsion to umbilicus keeping fetus in sacrum anterior, wait: DO NOT PULL 5. Episiotomy may be considered when anterior buttock and anus are “crowning” 6. Deliver legs by pressure on the popliteal fossa, lateral rotation of thighs & flexion of knees, grasp foot & deliver –Pinard’s maneuver 7. Deliver arms a. Deliver when wing of scapula seen b. Rotate arm to anterior c. Splint & Sweep humerus across the chest & deliver – Loveset maneuver d. Rotate other arm anterior and repeat to deliver 8. Support body in horizontal position or allow to hang until the nape of neck appears at the introitus 9. Avoid over extension of head by applying suprapubic pressure 10. Delivery of the head – Mauriceau- Smellie-Veit maneuver a. Apply pressure over maxilla to promote head flexion b. 2 fingers over nape c. Piper’s forceps 11. 11. Inspect for injuries/ lacerations 12. Documentation NOTE: ⭐️⭐️⭐️ Umbilicus – Pinard’s Wing of scapula – LOVESET Nape of Neck – MAURICEAU-SMELLIE-VEIT AUTHOR: CLEOFE, DEL ROSARIO, MENDOZA