Presented by:
Ahmad mukhtar
MD.,M.B.B.Ch., M.Sc Obstetrics and Gynecology Consultant and Lecturer of Obstetrics and Gynecology, Faculty of
MEDICINE, Zagazig University.
Andheri East ) Call Girls in Mumbai Phone No 9004268417 Elite Escort Service ...
Breech presentation
1. MALPRESENTATIONMALPRESENTATION
And CORD PROLAPSEAnd CORD PROLAPSE
Presented by:Presented by:
Ahmad mukhtarAhmad mukhtar
MD.,M.B.B.Ch., M.Sc Obstetrics and GynecologyMD.,M.B.B.Ch., M.Sc Obstetrics and Gynecology
Consultant and Lecturer of Obstetrics and Gynecology,Consultant and Lecturer of Obstetrics and Gynecology,
Faculty ofFaculty of
MEDICINE, Zagazig University.MEDICINE, Zagazig University.
9.
IntroductionIntroduction
Breech presentation occurs inBreech presentation occurs in 3-4% of all deliveries.3-4% of all deliveries.
The occurrence of breech presentation decreases withThe occurrence of breech presentation decreases with
advancing gestational age. Breech presentation occursadvancing gestational age. Breech presentation occurs
in 25% of births that occur before 28 weeks’ gestation, inin 25% of births that occur before 28 weeks’ gestation, in
7% of births that occur at 32 weeks, and 1-3% of births7% of births that occur at 32 weeks, and 1-3% of births
that occur at term.that occur at term.
..
Perinatal mortality is increased 2- to 4-fold with breechPerinatal mortality is increased 2- to 4-fold with breech
presentation, regardless of the mode of delivery. Deathspresentation, regardless of the mode of delivery. Deaths
most often are associated with malformations,most often are associated with malformations,
11. Perinatal mortality isPerinatal mortality is
increased 2- to 4-fold withincreased 2- to 4-fold with
breech presentation,breech presentation,
regardless of the mode ofregardless of the mode of
delivery.delivery.
Congenital malformation 6%Congenital malformation 6%
12. Types of breechesTypes of breeches
Frank breech (50-70%) - Hips flexed,Frank breech (50-70%) - Hips flexed,
knees extendedknees extended
Complete breech (5-10%) - HipsComplete breech (5-10%) - Hips
flexed, knees flexedflexed, knees flexed
Footling or incomplete (10-30%) -Footling or incomplete (10-30%) -
One or both hips extended, footOne or both hips extended, foot
presentingpresenting
25. Criteria for VD orCSCriteria for VD orCS
VDVD
FrankFrank
GA>34wGA>34w
FW=2000-3500grFW=2000-3500gr
Adequate pelvisAdequate pelvis
Flexed headFlexed head
Nonviable fetusNonviable fetus
No indicationNo indication
Good progress laborGood progress labor
CSCS
FW<1500or>FW<1500or>
3500gr3500gr
FootlingFootling
Small pelvisSmall pelvis
Deflexed headDeflexed head
Arrest of laborArrest of labor
GA24-34wGA24-34w
Elderly PGElderly PG
Inf or poor historyInf or poor history
Fetal distressFetal distress
27. :: Once the feet have delivered, thereOnce the feet have delivered, there
may be temptation to pull on themay be temptation to pull on the
feet. However, this should neverfeet. However, this should never
be done with a singletonbe done with a singleton
gestation because it maygestation because it may
precipitate an entrapped head inprecipitate an entrapped head in
an incompletely dilated cervix or itan incompletely dilated cervix or it
may precipitate nuchal arms. Asmay precipitate nuchal arms. As
long as the fetal heart rate islong as the fetal heart rate is
stable and no physical evidencestable and no physical evidence
of a prolapsed cord exists,of a prolapsed cord exists,
expectant management may beexpectant management may be
followed, awaiting full cervicalfollowed, awaiting full cervical
Footling breech presentationFootling breech presentation
28. Assisted vaginal breech deliveryAssisted vaginal breech delivery
Thick meconium passageThick meconium passage
is common as the breechis common as the breech
is squeezed through theis squeezed through the
birth canal. This usually isbirth canal. This usually is
not associated withnot associated with
meconium aspirationmeconium aspiration
because the meconiumbecause the meconium
passes out of the vaginapasses out of the vagina
and does not mix with theand does not mix with the
amniotic fluid.amniotic fluid.
29.
Picture 3. AssistedPicture 3. Assisted
vaginal breech delivery:vaginal breech delivery:
The Ritgen maneuver isThe Ritgen maneuver is
applied to take pressureapplied to take pressure
off the perineum duringoff the perineum during
vaginal delivery.vaginal delivery.
Episiotomies often are cutEpisiotomies often are cut
for assisted vaginalfor assisted vaginal
breech deliveries, even inbreech deliveries, even in
multiparous women, tomultiparous women, to
prevent soft-tissueprevent soft-tissue
dystocia.dystocia.
30. Picture 4. Assisted vaginal breechPicture 4. Assisted vaginal breech
delivery: No downward or outward tractiondelivery: No downward or outward traction
is applied to the fetus until the umbilicusis applied to the fetus until the umbilicus
has been reached.has been reached.
31. Picture 5. Assisted vaginal breech delivery: With aPicture 5. Assisted vaginal breech delivery: With a
towel wrapped around the fetal hips, gentletowel wrapped around the fetal hips, gentle
downward and outward traction is applied indownward and outward traction is applied in
conjunction with maternal expulsive efforts until theconjunction with maternal expulsive efforts until the
scapula is reached. An assistant should be applyingscapula is reached. An assistant should be applying
gentle fundal pressure to keep the fetal head flexed.gentle fundal pressure to keep the fetal head flexed.
32. Picture 6. Assisted vaginal breech delivery: AfterPicture 6. Assisted vaginal breech delivery: After
the scapula is reached, the fetus should be rotatedthe scapula is reached, the fetus should be rotated
90° in order to delivery the anterior arm.90° in order to delivery the anterior arm.
33. Picture 7. Assisted vaginal breech delivery: The anteriorPicture 7. Assisted vaginal breech delivery: The anterior
arm is followed to the elbow, and the arm is swept out ofarm is followed to the elbow, and the arm is swept out of
the vagina.the vagina.
34. Picture 8. Assisted vaginal breech delivery: The fetus isPicture 8. Assisted vaginal breech delivery: The fetus is
rotated 180°, and the contralateral arm is delivered in arotated 180°, and the contralateral arm is delivered in a
similar manner as the first. The infant is then rotated 90°similar manner as the first. The infant is then rotated 90°
to the back-up position in preparation for delivery of theto the back-up position in preparation for delivery of the
head.head.
35. Picture 9. Assisted vaginal breech delivery: The fetal head isPicture 9. Assisted vaginal breech delivery: The fetal head is
maintained in a flexed position by using the Mauriceau-Smellie-maintained in a flexed position by using the Mauriceau-Smellie-
Veit maneuver, which is performed by placing the index andVeit maneuver, which is performed by placing the index and
middle fingers over the maxillary prominence on either side of themiddle fingers over the maxillary prominence on either side of the
nose. The fetal body is supported in a neutral position with carenose. The fetal body is supported in a neutral position with care
to not overextend the neck.to not overextend the neck.
36. Picture 10. Piper forceps application: Pipers arePicture 10. Piper forceps application: Pipers are
specialized forceps used only for the aftercoming head ofspecialized forceps used only for the aftercoming head of
a breech presentation. They are used to keep the heada breech presentation. They are used to keep the head
flexed during extraction of the fetal head. An assistant isflexed during extraction of the fetal head. An assistant is
needed to hold the infant while the operator gets on oneneeded to hold the infant while the operator gets on one
knee to apply the forceps from below.knee to apply the forceps from below.
37. Picture 11. Assisted vaginal breech delivery: Low 1-minute Apgar scores are notPicture 11. Assisted vaginal breech delivery: Low 1-minute Apgar scores are not
uncommon after a vaginal breech delivery. A pediatrician should be present for theuncommon after a vaginal breech delivery. A pediatrician should be present for the
delivery in the event that neonatal resuscitation is needed.delivery in the event that neonatal resuscitation is needed.
38. Picture 12. Assisted vaginalPicture 12. Assisted vaginal
breech delivery - The neonatebreech delivery - The neonate
after birthafter birth
53. Definition:Definition:
Shoulder dystocia (Sh. D) isShoulder dystocia (Sh. D) is
the inability to deliver thethe inability to deliver the
fetal shoulders after deliveryfetal shoulders after delivery
of the head, without the aidof the head, without the aid
of specific maneuvers (ie.of specific maneuvers (ie.
other than gentle downwardother than gentle downward
traction on the head) .traction on the head) .
55. PATHOPHYSIOLOGYPATHOPHYSIOLOGY
Shoulder dystocia results fromShoulder dystocia results from
a size discrepancy between thea size discrepancy between the
fetal shoulders and the pelvic inletfetal shoulders and the pelvic inlet
when:when:
1.1. The bisacromial diameter is largeThe bisacromial diameter is large
relative to the biparietal diameterrelative to the biparietal diameter
2.2. Pelvic prim is flat ratherPelvic prim is flat rather
than gynecoidthan gynecoid
.
61. Brachial plexus injuries,Brachial plexus injuries,
Fractures of the humerus, andFractures of the humerus, and
Fractures of the clavicleFractures of the clavicle
are the most commonly reportedare the most commonly reported
injuries associated with shoulderinjuries associated with shoulder
dystociadystocia
Fetal Complications of Sh DFetal Complications of Sh D
62. Traction combined withTraction combined with
fundal pressure has beenfundal pressure has been
associated with a high rateassociated with a high rate
of brachial plexus injuriesof brachial plexus injuries
and fracturesand fractures
Fetal Complications of Sh DFetal Complications of Sh D
63. Fewer than 10% ofFewer than 10% of
deliveries complicated bydeliveries complicated by
shoulder dystociashoulder dystocia will resultwill result
in brachialin brachial
plexus injury.plexus injury.
Fetal Complications of Sh DFetal Complications of Sh D
a persistenta persistent
64. Release techniquesRelease techniques
Head –shoulder interval > 7min.Head –shoulder interval > 7min.
Brain injuryBrain injury
With hypoxic fetus it is much shorterWith hypoxic fetus it is much shorter
Fetal ComplicationsFetal Complications
(sensitivity & specificity :70 %)
67. RISK FACTORS FORRISK FACTORS FOR
SHOULDER DYSTOCIASHOULDER DYSTOCIA
Antenatal:Antenatal:
Excessive maternal weight gainExcessive maternal weight gain
MacrosomiaMacrosomia
G. diabetesG. diabetes
Short statureShort stature
Post termPost term
68. RISK FACTORS FOR SHOULDERRISK FACTORS FOR SHOULDER
DYSTOCIADYSTOCIA
Intrapartum:Intrapartum:
1.1. Protracted or arrested active phaseProtracted or arrested active phase
2.2. Protracted or failure of descent ofProtracted or failure of descent of
headhead
3.3. Need for midpelvic assisted deliveryNeed for midpelvic assisted delivery
69. RISK FACTORS FORRISK FACTORS FOR
SHOULDER DYSTOCIASHOULDER DYSTOCIA
Most of the prenatal and antenatal risk
factor are interrelated with fetal
macrosomia. So the main risk factor is:
Fetal
Macrosomia
73. ACOG Issues GuidelinesACOG Issues Guidelines
Recommendation 1991Recommendation 1991
.
5-The Mc Roberts
manoeuvre
(Exaggerated hyper
flexion of the thighs
upon the abdomen.)
&
Suprapubic pressure
in the direction of the
Foetal face
74. No increase in pelvic dimensions.
Decrease in the angle of pelvic inclination P=0.001
Straightening of the sacrum P= 0.04%
Tends to free the impacted anterior shoulder
Gherman et al Obstet Gynecol 95:43 ,2000
McRoberts manoeuvre: X ray pelvimetry study
75. ACOG Issues GuidelinesACOG Issues Guidelines
Recommendation 1991Recommendation 1991
.
If Mc Roberts failed:If Mc Roberts failed:
6-Woods manoeuvre6-Woods manoeuvre::
•The hand is placed
behind the posterior
shoulder of the fetus.
•The shoulder is
rotated progressively 180 d in a corkscrew manner so
that the impacted anterior shoulder is released.
76. ACOG Issues GuidelinesACOG Issues Guidelines
Recommendation 1991Recommendation 1991
.
7-Delivery of the
posterior arm :
77. By inserting a hand
into the posterior
vagina and ventrally
rotating the arm at
the shoulder
delivery
over the
perineum
81. Umbilical Cord ProlapseUmbilical Cord Prolapse
EtiologyEtiology
– 1-275 deliveries1-275 deliveries
ClassificationClassification
– Complete: cord is seen or palpated ahead ofComplete: cord is seen or palpated ahead of
presenting part (OB Emergency)presenting part (OB Emergency)
– Fundic: cord felt through intact membranes ahead ofFundic: cord felt through intact membranes ahead of
presenting partpresenting part
– Occult: hidden or not visible at any time during courseOccult: hidden or not visible at any time during course
of laborof labor
Definition: umbilical cord that lies below/besideDefinition: umbilical cord that lies below/beside
presenting partpresenting part
82. Umbilical Cord ProlapseUmbilical Cord Prolapse
Precipitating factors:Precipitating factors:
– Long umbilical cordLong umbilical cord
– Abnormal location onAbnormal location on
placentaplacenta
– Small or preterm infantSmall or preterm infant
– PolyhydramniosPolyhydramnios
– Multiple gestationMultiple gestation
Precipitating factors:Precipitating factors:
– Amniotomy beforeAmniotomy before
fetal head is engagedfetal head is engaged
– IUPC placementIUPC placement
– External cephalicExternal cephalic
versionversion
83. Umbilical Cord ProlapseUmbilical Cord Prolapse
Clinical Manifestations:Clinical Manifestations:
– Cord observed or palpatedCord observed or palpated
– Bradycardia following ROMBradycardia following ROM
– Repetitive, variable decelerations that do notRepetitive, variable decelerations that do not
respond to medical intervention (e.g.respond to medical intervention (e.g.
amnioinfusion)amnioinfusion)
– Prolonged decelerations (>15 bpm lasting 2Prolonged decelerations (>15 bpm lasting 2
mins or longer yet <10 mins)mins or longer yet <10 mins)
84. Umbilical Cord ProlapseUmbilical Cord Prolapse
Nursing interventions:Nursing interventions:
– Assess fetal viabilityAssess fetal viability
– Call for assistanceCall for assistance
– Relieve pressure from cord (usually presenting part)Relieve pressure from cord (usually presenting part)
Continuous manual relief of pressure from presenting partContinuous manual relief of pressure from presenting part
Avoid excessive manipulation of cordAvoid excessive manipulation of cord
Re-position client: Trendelenburg, modified Sim’s, or knee-Re-position client: Trendelenburg, modified Sim’s, or knee-
chestchest
Prepare for emergency deliveryPrepare for emergency delivery
Administer oxygen by mask 10-12 L/minAdminister oxygen by mask 10-12 L/min
Fill maternal bladder with 500-700 cc NSFill maternal bladder with 500-700 cc NS
Continuous fetal monitoringContinuous fetal monitoring
Possible neonatal resuscitation (notify neonatal team perPossible neonatal resuscitation (notify neonatal team per
hospital protocol)hospital protocol)
85. Umbilical Cord ProlapseUmbilical Cord Prolapse
Aim of Medical management:Aim of Medical management:
– Immediate delivery of viable infantImmediate delivery of viable infant
– Hallmark treatment: C-sectionHallmark treatment: C-section
