BREECH PRESENTATION

JI RAPACON

GENERAL DATA

L.A.
22 year old
Female
Married
Roman catholic
Filipino
Brgy. Lanit, Jaro Iloilo City
Feb. 28, 2015

Chief Complaint

Labor Pains

PAST MEDICAL HISTORY

(+) allergy to crustaceans
(-) hypertension
(-) diabetes mellitus
(-) bronchial asthma

FAMILY HISTORY

(-) hypertension
(-) diabetes mellitus
(-) bronchial asthma
(-) cancer

PERSONAL HISTORY

o Housewife
o Non-smoker
o Non-alcoholic beverage drinker

OB GYN HISTORY
G1 - present pregnancy
o LMP: June 06, 2014
o AOG: 37 3/7 weeks AOG
o EDC: March 18, 2015

HISTORY OF PRESENT CONDITION

15 weeks
AOG

Started prenatal check up

Patient experienced amenorrhea
(+) Urine pregnancy test
Folic Acid 1 cap OD was started

HISTORY OF PRESENT CONDITION

15 WEEKS
AOG

Baseline Laboratories
were requested:
CBC
FBS
HBS Ag and RPR
Blood typing
Urinalysis
UTZ

URINALYSIS

10/3/14

HEMOGLOBIN
COLOR

Straw 117 g/L

CBC

HEMATOCRIT

TRANSPARENCY
RBC

REACTION
WBC

0.34 L/L
3.62 /L

6.5 ( ACIDIC)
8.80 /L

SEGMRNTE NEUTROPHILS

0.70

LYMPHOCYTES

0.30

Negative

SUGAR
EOSINOPHILS

Negative0.00
0.00

WBC PUS CELLS

6-10/HPF (1+)

RBC
RED CELLS
PLATELET

2-4 (OCCASIONAL)
ADEQUATE

BASOPHILS

- VDRL/RPR: NON- REACTIVE

- HBS Antigen (Quali) : NEGATIVE

1.009

ALBUMIN

MONOCYTES

10/3/14

CEFALEXIN 500 mg/cap every 6 hours for 7 days

DIFFERENTIAL COUNT

SPECIFIC GRAVITY

Hazy

10/3/15

0.00

- S. GLUCOSE: 4.80 mmol/L

- BLOOD TYPING: O, Rh positive

HISTORY OF PRESENT CONDITION

Repeat Urinalysis
10/18/14

COLOR

STRAW

TRANSPARENCY

SLIGHTLY HAZY

REACTION

6.5 (ACIDIC)

SPECIFIC
GRAVITY

1.012

ALBUMIN

NEGATIVE

SUGAR

NEGATIVE

WBC PUS CELLS

0-2/HPF
(OCCASIONAL)

RBC RED CELLS

3-6/ HPF (1+)

HISTORY OF PRESENT CONDITION

Pregnancy Uterine, 14 weeks 4 days by
sonar age (EDD = 3-26-15), cephalic, live
and singleton. ANTERIOR LOW
PLACENTAL IMPLANTATION (margin of
the os). Adequate amniotic fluid. No
adnexal mass.

UTZ report
09/29/14
( PALMARES)
15 5/7 weeks AOG

HISTORY OF PRESENT CONDITION

UTZ Feb 11, 2015 35 weeks AOG
(CONTRVEDA)
Pregnancy uterine, 34 weeks and 2
days by sonar age, FRANK
Repeat Pelvic UTZ for
35 weeks AOG
BREECH, live singleton. High lying
Placental Localization
anterior placenta.
Normohydramnios
SEFW=2175-2233 g. female fetus

HISTORY OF PRESENT CONDITION

37 3/7
weeks
AOG
-(+) irregular uterine
contraction
- Internal exam:
3cm cervical dilatation
50 % efface
Station -2
Intact BOW

Scheduled for Stat Cesarean

Section

ADMITTED

PHYSICAL EXAMINATION
Came in wheelchair-borne, conscious, coherent, and not in cardiopulmonary distress
Weight: 53.7 kg
Vital signs:
BP= 110/70 mmHg
CR= 84 bpm
Temp = 36.9C
RR = 19 cpm

PHYSICAL EXAMINATION
Skin: no active skin lesion, (-) pallor, (-) jaundice
HEENT: anicteric sclerae, pink conjunctivae, no neck vein
engorgement
Chest, Heart, Lungs: symmetrical chest expansion, clear breath
sounds, (-) rales, (-) wheeze, Adynamic precordium, regular cardiac
rate and rhythm, (-) murmur

PHYSICAL EXAMINATION

Abdomen:
- globular, (+) linea nigra, (+) striae gravidarum, (+) irregular uterine contraction
EXTREMITIES:
Grossly Normal Extremities, (-) Edema
- Fundic
height = 30 cm
- Fetal heart tone: 150s at left upper quadrant

Leopolds 1: cephalic
Leopolds 2: fetal back, left
Leopolds 3: floating
Leopolds 4: breech

Pelvic Exam

Grossly normal external genitalia

IE/Bimanual:
Introitus admits 2 fingers
with ease
Cervical dilatation: 3 cm
Cervical effacement: 50%
Presentation: breech
Station: - 2
intact BOW

ADMITTING IMPRESSION
G1
Intrauterine Pregnancy 37 3/7 Weeks AOG, Breech In
Labor

ON ADMISSION
o
o
o
o
o
o

Venoclysis: PLRS 1L x 30 qtts/min

NPO
Laboratories:
Patient was scheduled for stat Cesarean Section
IV antibiotics was prescribed
1 unit FWB/PRBC

o Primary LSTCS done

- Delivery of live, baby girl in frank
breech presentation with:

Intraoperative findings:
o Gravid uterus appropriate for age
of gestation

o Lower uterine segment well

formed
o Amniotic fluid-clear and
adequate
o Placenta implanted at the
posterofundal area.
o Bilateral ovaries and
follopian tubes are grossly
normal

POST-OP MEDICATIONS

o Post Op IV antibiotics
o Post Op IV pain meds

Complete Blood Count

Post- op

Hemoglobin (g/L)

102

Hematocrit (L/L)

0.31

RBC (x1012/L

3.19

WBC (x109/L)

9.05

Different Count
Segmenters

0.61

Lymphocytes

0.24

Eosinophils

0.09

Monocytes

0.06

MCH (pg)

32.10

MCV (fl)

96.60

MCHC (g/dl)

33.20

PLATELET COUNT
INCREASED

INCREASED

1ST POST OP DAY

(+) flatus
Soft abdomen
(+) minimal pain on incision site
(+) Minimal vaginal bleeding
(-) bowel movement
(-) abdominal pain
Stable vital signs
Adequate urine output

G1P1 (1001)
Pregnancy uterine delivered
term, cephalic, live baby girl
by primary LSTCS under
spinal anesthesia for frank
breech presentation.

 May have general liquids; soft diet if with flatus and full
diet if with several flatus
Foley catheter was removed
May turn to sides
Encourage breathing exercises

2ND POST OP DAY

(+) flatus
Soft abdomen
(+) dry and coaptated wound
(+) minimal pain on incision site
(+) Minimal vaginal bleeding
(-) bowel movement
(-) abdominal pain
Stable vital signs
Adequate urine output

G1P1 (1001)
Pregnancy uterine
delivered term, cephalic,
live baby girl by primary
LSTCS under spinal
anesthesia for frank
breech presentation.

3RD POST-OP DAY

Patient was discharged
Home medications
o Cefuroxime 500 mg/tab, 1 tab BID x 5 days
o Celecoxib 200 mg/tab, 1 tab BID to complete for 3 days
o Multivitamins 1 tab OD x 1 month
o Ascorbic Acid 500 mg/tab, 1 tab OD x 1 month

Final Diagnosis
G1P1 (1001)
Pregnacy uterine delivered, term, live, Baby Girl, Birth
weight 2450g,APGAR score 8 and 9, Pediatric Aging
37-38 weeks, via Primary Low Segment Transverse
Ceasarean Section under Spinal Anesthesia for Frank
Breech Presentation

NAME OF OPERATION
Primary Low Segment Transverse Ceasarean Section

CASE DISCUSSION

Breech Presentation & Delivery

 Presentation the portion of the body of the fetus that

is either foremost within the birth canal or in closest
proximity to it

RISK FACTORS
Early gestational age
Abnormal amniotic fluid
volume
Multifetal gestation
Hydrocephaly
Anencephaly
Uterine anomalies

Placenta previa
Fundal placental
implantation
Pelvic tumors
High parity with uterine
relaxation
Prior breech delivery

 Relations between the lower extremities and buttocks

form the categories of breech presentation.

DIAGNOSIS: ABDOMINAL EXAM: LEOPOLDS MANEUVER

 Vaginal exam
Frank ischial tuberousities, sacrum, anus are palpable
Complete feet felt alongside the buttocks
Footling foot identified as R or L based on great toe

 Imaging techniques
UTZ confirm
CT pelvic measurement & configuration at low radiation dose
MRI reliable information about pelvic capacity & architecture

COMPLICATIONS
Maternal
o Vaginal wall or cervical
laceration
o Perineal lacerations

PERINATAL

Preterm delivery
Head entrapment
Birth trauma
Testicular injury
Upper extremity paralysis
Umbilical cord prolapse
Birth asphysia

FACTORS FAVORING CESAREAN DELIVERY OF THE BREECH

FETUS
Fetal anomaly incompatible with

Lack of operator experience

Patient request for cesarean

delivery

Large fetus: > 3800 to 4000 g

Apparently healthy and viable

preterm fetus either with active
labor or with indicated delivery

Severe fetal-growth restriction

vaginal delivery
Prior perinatal death or neonatal
birth trauma
Incomplete or footling breech
presentation
Hyperextended head
Pelvic contraction or unfavorable
pelvic shape determined
clinically or with pelvimetry
Prior cesarean delivery

GUIDELINES FOR VAGINAL DELIVERY OF THE BREECH

INFANT

A. Sonagraphic (or x-ray) confimation of

1.

Frank breech

B. Clinical evaluation for:

2.

flexed attitude

3.

no nuchal arms

1. adequate pelvis

4.

estimated fetal weight of 1250 and

3750 grams

5.

estimated gestational age of 36-42

weeks

6.

immature fetus ( < 24 weeks or < 599

grams)

7.

Intrauterine fetal death

2. progress of labor (friedman curve)

3. absence of fetal distress
C. Second Twin

MANAGEMENT OF LABOR AND DELIVERY

MANAGEMENT OF LABOR

METHODS OF VAGINAL DELIVERY

A. Spontaneous breech delivery

Infant is expelled entirely spontaneously without any
traction or manipulation other than support of the infant

B. Partial breech extraction

Infant is delivered spontaneously as far as the umbilicus

The remainder of the body is extracted or delivered w/

operator traction & assisted maneuvers, w/ or w/o
maternal expulsive efforts

C. Total breech extraction

The entire body of the infant is extracted by the

obstetrician

B. PARTIAL BREECH EXTRACTION: OPERATIVE TECHNIQUE

Consent
Adequate analgesia/anesthesia
Episiotomy when anterior buttocks and anus are crowning
Allow expulsion up to the level of the umbilicus, keeping the fetus
sacrum anterior position
If legs do not deliver spontaneously, perform the Pinard maneuver
Support the baby around the hips and have the mother push until
the scapulae are visible

 A cardinal rule in successful

breech extraction is to
employ steady, gentle,
downward traction until the
lower halves of the
scapulas are delivered,
making no attempt at
delivery of the shoulders
and arms until one axilla
becomes visible.

 Rotate the body anteriorly and deliver the arms when winging of
the scapulae are seen by sweeping the arm across the face and
chest and deliver Loveset maneuver
Support the body in horizontal position or allow to hang until the
nape of the neck appears at the introitus

 Avoid overextension of the head by applying

suprapubic pressure
Deliver the head by Mauriceau-Smellie-Veit
Maneuvere:
Inspect for injuries
Document

C. TOTALBREECH EXTRACTION

1. FRANK BREECH EXTRACTION

moderate traction exerted by a finger in
each groin and aided by a generous
episiotomy
manipulation within the birth canal to
convert the frank breech into a footling
breech

Once the hips are delivered,

each hip and knee is flexed to
deliver them from the vagina

 Frank breech decomposition

using the Pinard maneuver
Two fingers are inserted along
one extremity to the knee, which
is then pushed away from the
midline after spontaneous flexion.
Traction is used to deliver a foot
into the vagina.

2. COMPLETE OR INCOMPLETE BREECH EXTRACTION

Hand is introduced into

vagina & both fetal feet is
grasped.
Ankles are held by second
finger.
Both feet are grasped &
pulled to the vulva
simultaneously

 As legs begin to emerge,

through the vulva, downward
gentle traction is continued.
As buttocks emerge, the back
of the infant usually rotates to
the anterior.

THANK YOU

TECHNIQUES FOR BREECH DELIVERY

DELIVERY OF AFTERCOMING
HEAD

MAURICEAU 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 hand and
forearm
Two fingers of the other hand then are
hooked over the fetal neck, and
grasping the shoulders, downward
traction is concurrently applied
until the suboccipital region appears
under the symphysis.

MAURICEAU MANEUVERT
Gentle suprapubic pressure
simultaneously applied by
an assistant helps keep the
head flexed.

PRAGUE MANEUVER
while the other hand
draws the feet up over the
maternal abdomen

Two fingers of one hand

grasping the shoulders of the
backdown fetus from below

Use of Pipers forceps by wrapping the fetal body in a towel and

elevate it Savage maneuvere

The fetal body is held elevated using a

warm towel and the left blade of forceps
is applied to the aftercoming head.

THE RIGHT BLADE IS APPLIED

WITH THE BODY STILL ELEVATED.

Forceps delivery of the aftercoming

head.

ENTRAPMENT OF THE AFTERCOMING HEAD

Duhrssen incision being cut at 2
oclock, which is followed by a second
incision at 10
oclock. Infrequently, an additional
incision is required at 6 oclock
. The incisions are so placed as to
minimize bleeding from the laterally
located cervical branches of the
uterine artery.

ZAVANELLI MANEUVER
last resort
replacement of the fetus higher into the vagina and
uterus, followed by cesarean delivery

SYMPHYSIOTOMY
This operation surgically divides the intervening
symphyseal cartilage and much of its ligamentous
support to widen the symphysis pubis up to 2.5 cm

THANK YOU

SOURCES:
Williams obstetrics 24 th editions
Textbook of Obstetrics 3 rd ed

If legs do not deliver spontaneously,

perform the Pinard maneuver
Deliver legs by inserting 2 fingers
along one extremity to the knee and
applying pressure on the popliteal
fossa. This will cause lateral rotation
of the thighs and flexion of the knee.
Grasp the foot and deliver.
Repeat procedure on the other leg.

The appearance of one axilla indicates that the time has arrived for
shoulder delivery.

WITH THE SCAPULAS VISIBLE, THE TRUNK IS ROTATED IN SUCH

A WAY THAT THE ANTERIOR SHOULDER AND ARM APPEAR AT
THE VULVA AND CAN EASILY BE RELEASED AND DELIVERED
FIRST

 The body of the fetus is

then rotated 180 degrees
in the reverse direction to
deliver the other shoulder
and arm.

The second method is employed if

trunk rotation is unsuccessful.
The posterior shoulder is delivered
first.
The feet are grasped in one hand
and drawn upward over the inner
thigh of the mother, toward which the
ventral surface of the fetus is directed
Leverage is exerted on the posterior
shoulder, which slides out over the
perineal margin,
Usually followed by the arm and
hand.

NUCHAL ARM
One or both fetal arms
occasionally may be found
around the back of the neck
and impacted at the pelvic
inlet
REDUCTION OF NUCHAL ARM BEING ACCOMPLISHED BY
ROTATING THE FETUS THROUGH HALF A CIRCLE
COUNTERCLOCKWISE SO THAT THE FRICTION EXERTED
BY THE BIRTH CANAL WILL DRAW THE ELBOW TOWARD
THE FACE.

Complete Blood Count

Pre-op

Hemoglobin (g/L)

116

Hematocrit (L/L)

0.34

RBC (x1012/L

3.46

WBC (x109/L)

14.69

Different Count
Segmenters

0.84

Lymphocytes

0.12

Eosinophils
Monocytes

0.04
MCH (pg)

33.50

MCV (fl)

97.30

MCHC (g/dl)

34.40

PLATELET COUNT INCREASED