Breech delivery + other labor Flashcards
What is the percentage of breech presentation?
What is the most common type of breech?
3-4%
Frank breech - accounts for 50%
Complete breech is when both of the baby’s knees are bent and his feet and bottom are closest to the birth canal.
Frank breech is when the baby’s legs are folded flat up against his head and his bottom is closest to the birth canal.
There is also footling breech where one or both feet are presenting.
How do you counsel a patient about perinatal and neonatal morbidity with breech delivery?
Planned cesarean delivery associated with lower risk of perinatal mortality compared with planned vaginal delivery (3 per 1000 vs 13 per 1000). C-section also associated with lower risk of serious neonatal morbidity (1.4 vs 3.8%).
Genital tract laceration, with cesarean delivery added stretching of LUS by forceps or poorly molded fetal head can extend hysterotomy incisions, episiotomy (can create deep perineal tears and increase infection risks), anesthesia required for uterine relaxation during vaginal delivery can cause uterine atony and PPH
What are risk factors for breech presentation?
Uterine (multiparity, uterine anomalies, myoma, placenta previa, prior breech)
Fetal (prematurity, polyhydramnios, congenital anomaly like anencephaly, multiple gestation)
After 1 prior breech presentation, what is the risk of subsequent breech delivery?
10%
What is perinatal morbidity/mortality for a breech delivery?
Injuries to humerus, clavicle and femur
Traction can separate scalupular, humeral or femoral epiphyses
Neonatal tears from fetal scalp electrodes
Upper extremity paralysis (Erb or Duchenne) from brachial plexus stretching
Fractures of skull from contracted maternal pelvis
Spinal cord or vertebral injuries from lot of force
Hematoma of sternocleiodomastoid
Umbilical cord prolapse
Development of hip dysplasia more common in breech (unaffected by delivery mode)
What are the criteria for safe breech vaginal delivery?
MATERNAL
spontaneous labor
GA > 37wks
No prior CD
Adequate maternal pelvis, normal AFI
FETAL
Lack of uterine or fetal anomalies
EFW between 2500-4000g
Frank or complete (NOT footling breech)
OB
OB w/ appropriate training and experience
Who is NOT a good candidate for a breech delivery?
Lack of OB experience
Large fetus >3800g
Preterm fetus
Severe FGR
Fetal anomaly incompatible with vaginal delivery
Incomplete or footling breech
Pelvic contraction or unfavorable pelvic shape
Prior cesarean delivery
How to manage breech delivery in active labor?
Rapid assessment of mother (cervical exam, fetal condition, recruit additional staff)
Trained obstetrician and associate to assist
Anesthesia
NICU or someone trained in newborn resuscitation
IVF for mother
How is partial breech extraction done?
Consider episiotomy unless considerable relation of perineum
- Breech allowed to delivery spontaneous to umbilicus. Once breech has passed beyond the introitus, the abdomen, thorax arms should be delivered promptly. The posterior hip delivers first. Continue to have mom push. Legs deliver sequentially by splinting medial aspect of each femur with fingers and exert pressure laterally to sweep each leg away from the midline.
After delivery of the legs, use both hands to grasp bony pelvis w/ cloth towel. Place fingers on anterior superior iliac crest and thumb on sacrum to minimize abdominal soft tissue injury. Maternal expulsive effects used in conjunction with downward traction to effect delivery.
Once scapulas are visible: rotate trunk so that anterior shoulder/arm appear at vulva can be delivered. Rotate fetus 180 degrees in reverse direction to deliver the other shoulder and arm.
How do manage a nuchal arm?
Rotate fetus counterclockwise so that friction of birth canal draws the elbow towards the face.
How do you deliver the head in breech extraction?
Mauriceau maneuver: index and middle finger of one hand applied to maxilla to flex the head while fetal body rests on the palm of hand/forearm. The two fingers of the other head are hooked over the fetal neck and grasping shoulders, downward traction applied until suboccipital region appears under the symphysis.
Other methods: Piper forceps if maureiceau maneuver cannot be accomplished easily. Don’t apply forceps until head is in pelvis and engaged. Fetal body held elevated w/ warm towel and apply blades directly at 3 and 9 o’clock to fetal head.
How do you manage head entrapment?
PERFORM CERVICAL EXAM TO ASSESS FOR CERVICAL DILATION
See if cervix can be manually slipped over the occiput. If unsuccessful:
- Duhrssen incisions (at 2 o’clock and 10 o’clock, placed to avoid bleeding from cervical branches of uterine artery)
- IV nitroglycerin (100 ug) for relaxation or general anesthesia with halogenated agents.
Last resort: Zavanelli maneuver: replace fetus higher into vagina/uterus and then do c-section.
Last option: symphysiotomy: use local anesthesthetic and surgically divide cartilage to widen the symphysis pubis.
How do you manage obstructed shoulders?
Lovset’s maneuever: with thumbs on infant’s sacrum, hold the hips and pelvis with other fingers. Turn infant 90 degrees to bring anterior shoulder underneath symphysis and engage the arm. Deliver anterior arm then do 180 degree rotation to deliver posterior arm.
Suzor’s maneuever: use if lovset’s manuever failed. Turn infant 90 degrees (have its back to right or left). Pull infant downward to deliver the anterior arm. Lift infant upward by the feet in order to deliver posterior shoulder.
Bracht maneuever: after arms delivered, infant grasped by hips and lifted towards mother’s stomach. Have assistant apply suprapubic pressure to help delivery of head.
What are the steps of a breech delivery?
Examine pt to determine type of breech and position
If back down try to rotate back up with rotational forces
Counsel pt about breech delivery
Call for help, alert NICU and anestehsia, other OB providers, have nursing obtain IV. Call for piper forceps and towels.
Rely on maternal pushing. Maternal expulsive efforts should delivery the fetal umbilicus to the perineum.
- avoid assisting delivery until maternal efforts result in expulsion of fetus to level of umbilicus.
- Deliver legs w/ Pinard’s maneuever (pressure in popliteal fossa)
- Wrap body in towel
- Rotate 180 degrees to deliver 1st shoulder/arm, then opposite direction to deliver the other one.
What is the Pinard maneuver?
Pressure in popliteal space of knee - helps to deliver the legs. Once both elgs delivered, fetus should be in prone position. Dry towel wrapped around fetal pelvis. Only place hands on bony parts.
What is the delivery of fetus after delivery of scapulae?
Once scapulae passed through introitus, deliver arms one at a time by Lovset maneuver (TO DELIVER BODY AND SHOULDER): slide hand onto anterior humorous and sweep arm downward across fetal chest. Then rotate fetus 180 degrees to deliver other arm.
LEARN Piper’s forceps! Swing legs upward above the horizontal. Have assistant move fetal body to maternal right so I can apply the left blade. Ease toe of blade into vagina direct upward at 45 degree below horizontal and over infant’s right ear. Left hadn gradually move handle downward toward midline while right hand protects vaginal sidewall. Assitant moves fetus to left and similar procedure performed. Handles then lock into place and elevate handles and provide mild traction to ensure flexion/extraction of fetal head.
