vaginal breech delivery international vaginal breech delivery
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Vaginal Breech DeliveryInternational
Vaginal Breech Delivery
Vaginal Breech DeliveryInternational
Objectives
• Incidence and Significance• Selection• Management
–Intrapartum–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)
Vaginal Breech DeliveryInternational
Types of Breech
Complete Footling Frank
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
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
Vaginal Breech DeliveryInternational
Diagnosis • maternal perception of movement
• Leopold’s maneuvers
• FH auscultated above umbilicus
• vaginal exam
• ultrasound
• X-ray
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
Vaginal Breech DeliveryInternational
Selection Criteria for Trial of Labour
• frank or complete breech
• fetal head not hyperextended
• estimated fetal weight 2500 to 4000g
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
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
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
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
Vaginal Breech DeliveryInternational
Entering the Pelvis
Obstetrics - Normal and Problem Pregnancies, 2nd EditionEdited by SG Gabbe, JR Niebyl, JL Simpson. (1991)
Vaginal Breech DeliveryInternational
Descent of the Breech
Obstetrics - Normal and Problem Pregnancies, 2nd EditionEdited by SG Gabbe, JR Niebyl, JL Simpson. (1991)
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
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)
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)
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)
Vaginal Breech DeliveryInternational
Avoid Over-extension
Obstetrics - Normal and Problem Pregnancies,2nd EditionEdited by SG Gabbe, JR Niebyl, JL Simpson. (1991)
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
Vaginal Breech DeliveryInternational
Delivery of the head
Obstetrics - Normal and Problem Pregnancies, 2nd EditionEdited by SG Gabbe, JR Niebyl, JL Simpson. (1991)
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)
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
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!