vaginal breech delivery international vaginal breech delivery

25
Vaginal Breech Delivery Internatio nal Vaginal Breech Delivery

Upload: brook-shaw

Post on 30-Dec-2015

269 views

Category:

Documents


1 download

TRANSCRIPT

Page 1: Vaginal Breech Delivery International Vaginal Breech Delivery

Vaginal Breech DeliveryInternational

Vaginal Breech Delivery

Page 2: Vaginal Breech Delivery International Vaginal Breech Delivery

Vaginal Breech DeliveryInternational

Objectives

• Incidence and Significance• Selection• Management

–Intrapartum–Delivery

Page 3: Vaginal Breech Delivery International Vaginal Breech Delivery

Vaginal Breech DeliveryInternational

Definition• longitudinal lie• breech or lower extremity presenting• cephalic pole in the uterine fundus

Types• frank - flexed hips, extended knees• complete - flexed hips, flexed knees• footling - extended hip(s)

Page 4: Vaginal Breech Delivery International Vaginal Breech Delivery

Vaginal Breech DeliveryInternational

Types of Breech

Complete Footling Frank

Page 5: Vaginal Breech Delivery International Vaginal Breech Delivery

Vaginal Breech DeliveryInternational

Incidence

• 3 to 4% of all pregnancies

• increases with decreasing gestational age– 7 to 10% at 32 weeks– 25 to 35% at < 28 weeks

Page 6: Vaginal Breech Delivery International Vaginal Breech Delivery

Vaginal Breech DeliveryInternational

Etiology of Breech Presentation

• idiopathic• prematurity (head to trunk size)• uterine or pelvic structural abnormality• uterine fibroid• fetal anomaly or abnormality• polyhydramnios• multiple gestation

Page 7: Vaginal Breech Delivery International Vaginal Breech Delivery

Vaginal Breech DeliveryInternational

Diagnosis • maternal perception of movement

• Leopold’s maneuvers

• FH auscultated above umbilicus

• vaginal exam

• ultrasound

• X-ray

Page 8: Vaginal Breech Delivery International Vaginal Breech Delivery

Vaginal Breech DeliveryInternational

Recommendations for Breech Delivery• recommend trial of labour at 36 weeks or when

estimated weight is 2500 to 4000 grams

• offer trial of labour at 31 to 35 weeks gestation or when estimated weight is 1500 to 2500 grams

• offer caesasean section at 30 weeks gestation or when estimated weight is < 1500 grams*

• no recommendation for when estimated weight is > 4000 grams*

* acknowledged lack of evidence for recommendation

Page 9: Vaginal Breech Delivery International Vaginal Breech Delivery

Vaginal Breech DeliveryInternational

Selection Criteria for Trial of Labour

• frank or complete breech

• fetal head not hyperextended

• estimated fetal weight 2500 to 4000g

Page 10: Vaginal Breech Delivery International Vaginal Breech Delivery

Vaginal Breech DeliveryInternational

Ultrasound Assessment

• confirm lie and type of breech

• assess head position

• obtain estimate of fetal weight

• assess for IUGR and congenital anomalies

• assess amniotic fluid volume

• confirm placental localization

Page 11: Vaginal Breech Delivery International Vaginal Breech Delivery

Vaginal Breech DeliveryInternational

Contraindications to Trial of Labour

• fetal or maternal contraindication to labour

• footling breech

• hyperextension of the fetal head

• absence of informed consent

• absence of experienced maternity health care

giver

Page 12: Vaginal Breech Delivery International Vaginal Breech Delivery

Vaginal Breech DeliveryInternational

Management in Labour

• planned delivery in hospital

• admission in early labour or with ROM

• appropriate fetal surveillance

• epidural and ARM for usual indications

• immediate vaginal exam at ROM to rule out cord prolapse

• good progress in labour ( 0.5 cm/h after 3 cm)

• induction and augmentation permissible

Page 13: Vaginal Breech Delivery International Vaginal Breech Delivery

Vaginal Breech DeliveryInternational

Management at Delivery

• experienced newborn resuscitator present

• empty maternal bladder

• maternity attendant with experience in breech

delivery

• forceps if available, may be helpful

Page 14: Vaginal Breech Delivery International Vaginal Breech Delivery

Vaginal Breech DeliveryInternational

Entering the Pelvis

Obstetrics - Normal and Problem Pregnancies, 2nd EditionEdited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

Page 15: Vaginal Breech Delivery International Vaginal Breech Delivery

Vaginal Breech DeliveryInternational

Descent of the Breech

Obstetrics - Normal and Problem Pregnancies, 2nd EditionEdited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

Page 16: Vaginal Breech Delivery International Vaginal Breech Delivery

Vaginal Breech DeliveryInternational

Spontaneous Expulsion

Obstetrics - Normal and Problem Pregnancies, 2nd EditionEdited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

• spontaneous expulsion to the umbilicus

• the sacrum should be gently guided anteriorly

• singleton breech extraction is contraindicated

• C/S is indicated for failure of descent or expulsion

Page 17: Vaginal Breech Delivery International Vaginal Breech Delivery

Vaginal Breech DeliveryInternational

Hurry up & Wait!

• DON’T PULL!

• traction deflexes the fetal head

• may cause nuchal arm

Obstetrics - Normal and Problem Pregnancies, 2nd EditionEdited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

Page 18: Vaginal Breech Delivery International Vaginal Breech Delivery

Vaginal Breech DeliveryInternational

Deliver Legs by lateral rotation of thighs and flexion of knees - keep sacrum anterior

Obstetrics - Normal and Problem Pregnancies, 2nd EditionEdited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

Page 19: Vaginal Breech Delivery International Vaginal Breech Delivery

Vaginal Breech DeliveryInternational

Delivery of Arms• good maternal pushing• deliver when winging of

scapulae seen• rotate arm to anterior• sweep humerus across the

chest and deliver• rotate other arm anterior

and repeat to deliver

Obstetrics - Normal and Problem Pregnancies, 2nd EditionEdited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

Page 20: Vaginal Breech Delivery International Vaginal Breech Delivery

Vaginal Breech DeliveryInternational

Avoid Over-extension

Obstetrics - Normal and Problem Pregnancies,2nd EditionEdited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

Page 21: Vaginal Breech Delivery International Vaginal Breech Delivery

Vaginal Breech DeliveryInternational

Delivery of the head

• Mauriceau - Smellie - Veit manoeuvre to deliver the head in flexion

• The body should be supported in a horizontal position

Page 22: Vaginal Breech Delivery International Vaginal Breech Delivery

Vaginal Breech DeliveryInternational

Delivery of the head

Obstetrics - Normal and Problem Pregnancies, 2nd EditionEdited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

Page 23: Vaginal Breech Delivery International Vaginal Breech Delivery

Vaginal Breech DeliveryInternational

Delivery of the head• Forceps

• assistant elevating babe

• direct application

Obstetrics - Normal and Problem Pregnancies, 2nd EditionEdited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

Page 24: Vaginal Breech Delivery International Vaginal Breech Delivery

Vaginal Breech DeliveryInternational

Prevention of Breech• consider external cephalic version at 36 weeks

gestation for eligible candidates

• success rate 30 - 70% depending on experience

• results in lower cesarean section rate

Page 25: Vaginal Breech Delivery International Vaginal Breech Delivery

Vaginal Breech DeliveryInternational

Conclusions

• proper selection of patients• thorough explanation and informed consent• good progress in labour ( 0.5 cm/h after 3 cm)• induction and augmentation permissible• experienced attendants• standard fetal monitoring• assisted delivery - DON’T PULL - stay cool!