Chapter 28 (Breech Delivery) Flashcards
Type of breech in wherein the lower extremities are flexed at the hips and extended at the knees, and thus the feet lie close to the head
FRANK BREECH
Type of breech wherein both hips ate flexed and one or both knees are also flexed
COMPLETE BREECH
Type of incomplete breech wherein one or both feet are below the breech
FOOTLING BREECH
Mode of delivery for breech fetuses with hyperextended neck (Stargazing fetus)
CESAREAN DELIVERY
Risk factors predisposing to breech presentation EXCEPT: A. Multifetal gestation B. Hydrocephaly C. Anencephaly D. Structural uterine anomalies E. Placenta previa F. Pelvic tumors G. Prior breech delivery H. Extremes of amniotic fluid I. None of the ahove
I. NONE OF THE ABOVE
Following one breech delivery, the recurrence rate for a second breech presentation was __% and for a subsequent third breech is __%
10%
28%
The fetal _______ is used to establish fetal position
SACRUM
True or False
Fetal weight is more important than gestational age in considering whether to do vaginal breech delivery or not
TRUE
Vaginal breech delivery is reasonable when the estimated fetal weight is
> 2500 grams <3800 to 4000
Factors favoring cesarean delivery of the breech fetus include the following EXCEPT:
A. Lack of operator experience B. Maternal request for CS C. EFW > 3800 grams D. Severe fetal growth restriction E. NOTA
E. NOTA
Factors favoring cesarean delivery of the breech fetus include the following EXCEPT:
A. Fetal anomaly incompatible with vaginal delivery
B. Prior perinatal death or neonatal death trauma
C. Incomplete or footling breech presentation
D. Hyperextended head
E. NOTA
E. NOTA
Vaginal delivery method by which the fetus is expelled entirely without any traction or manipulation other than support of the newborn
SPONTANEOUS BREECH DELIVERY
Vaginal delivery method by which the fetus is delivered spontaneously as far as the umbilicus, but the remainder of the body is delivered by the provider
PARTIAL BREECH EXTRACTION
Vaginal delivery method by which the fetus’s entire body is extracted by the provider
TOTAL BREECH EXTRACTION
Imaging technique which provides the best confirmation on type pr breech, and degree of neck flexion or extension
SONOGRAPHY
Although variable, some suggests specific measurements to permit a planned vaginal delivery
Inlet AP diameter: >=__ cm
Inlet transverse diameter: >=__ cm
Midpelvic interspinous distance: >=__ cm
Inlet AP diameter: >=10.5 cm
Inlet transverse diameter: >= 12.0 cm
Midpelvic interspinous distance: >=10.0cm
(assessed through CT scan)
Cardinal movements with breech delivery
Engagement Descent Internal rotation Flexion External rotation Expulsion
E-D-Ir-F-Er-E
Episiotomy preferred for vaginal breech delivery
MEDIOLATERAL
Maneuver performed wherein:
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 same hand and forearm (straddled). Two fingers of the other had are placed over the fetal neck and grasp the shoulders. Downward traction is applied until suboccipital region appears. Gentle suprapubic pressure is applied by an assistant. Body is then slightly elevated toward the maternal abdomen.
MAURICEAU MANEUVER
Specialized forceps for the delivery of the aftercoming head
PIPER FORCEPS
Maneuver done in which two fingers of one hand grasp the shoulders of the back down fetus from below while the other hand draws the feet up and over the maternal abdomen
Modified Prague Maneuver
Remember that this is used to deliver the after coming head in an occiput posterior position. (nakaharap si baby)
Incision in the cervix in cases of head entrapment during vaginal breech delivery
Dührssen incision
Dührssen incision is done at:
2 o’clock
then
10 o’clock
then
6 o’clock (infrequently)
Symphisiotomy widens the symphysis pubis by how many centimeters? What are the complications?
2.5 cm
pelvic or urinary tract injury
Maneuver:
• After the arms are delivered, the infant is grasped by the hips and lifted with two hands toward the mother’s stomach, without any traction, the neck pivoting around the symphysis.
• Having an assistant apply suprapubic pressure facilitates delivery of the aftercoming head.
Bracht’s maneuver
Maneuver
Hold the baby by the hips and turn half a circle, keeping the back uppermost and applying downward traction at the same time, so that the arm that was posterior becomes anterior and can be delivered under the pubic arch.
Assist delivery of the arm by placing one or two fingers on the upper part of the arm. Draw the arm down over the chest as the elbow is flexed, with the hand sweeping over the face.
To deliver the second arm, turn the baby back half a circle, keeping the back uppermost and applying downward traction, and deliver the second arm in the same way under the pubic arch.
Loveset Maneuver
Breech decomposition is accomplished by this maneuver. It aids in bringing the fetal feet within reach of the operator. Two fingers are carried up along one extremity to the knee to push it away from the midline. Spontaneous flexion usually follows and the foot of the fetus is felt to impinge on the back of the hand. The fetal foot then may be grasped and brought down.
Pinnard maneuver
Neonatal upper extremity nerve injury which involves the C8-T1 roots leading to a claw-like deformity which can result fro traumatic vaginal breech delivery
Klumpke paralysis
Neonatal upper extremity nerve injury involving C5-C6 leading to paralysis of one arm
Erb paralysis:
arm adducted and internally rotated
forearm pronated
wrist flexed
paralysis of the deltoid, biceps and brachial muscles
involvement of the axillary, musculocutaenous and suprascapular nerves
Name the study/trial:
Planned CS was associated with lower risk of perinatal morbidity and “serious” neonatal morbidity.
Term Breech Trial or Hannah Trial
Name the study/trial:
No difference in corrected neonatal mortality rates and neonatal outcomes according to delivery mode
PREMODA
Presentation et Mode d’accouchement
Name the study/trial:
No excessive morbidity among term breech delivered vaginally provided strict fetal biometric and maternal pelvimetry parameters are applied
Lille Breech Study
Mode of delivery for:
24-28 weeks
32-37 weeks
consider CS for periviable fetuses beginning 23 weeks
CS recommended starting 25 weeks
For 32-37 weeks, consider EFW rather than AOG. May deliver vaginally if EFW => 2500g.
True or False:
Fetal trauma is seen more in vaginal breech deliveries than CS
True.
But trauma may also occur during CS.
Traumatic injuries include: fracture to humerus, clavicle, femur severed or injured spinal cord Sternocleidomastoid hematoma genital injury brachial plexus injury and paralysis
True or false. Hip dysplasia is more inherent to the mode of delivery rather than the breech position.
False. Development of hip dysplasia is more common among breech fetuses than cephalic.
True or False. The head of a breech-presenting fetus does not undergo appreciable molding during labor.
True.
True or False. The accuracy of fetal weight estimation by sonography is affected by breech presentation.
False. Not affected.
Vaginal breech delivery is reasonable when the BPD is
<90 to 100mm
EVENTS DURING SPONTANEOUS BREECH DELIVERY
ENGAGEMENT AND DESCENT
bitrochanteric diameter is in the oblique diameters of the pelvis
**Anterior hip usually descends more rapidly than the posterior
—-Upon meeting the resistance of the pelvic floor—-
If anterior hip comes first: there will be a 45-deg INTERNAL ROTATION, ant hip is brought toward the pubic arch –>bitrochanteric diamter occupies the anteroposterior diameter of the maternal pelvis
If posterior extremity is prolapsed, it rotates to the pubic symphysis, not the anterior hip.
**if the breech descends transversely, internal rotation is through an arc of 90 deg not 45
FURTHER DESCENT
Anterior hip appears at the vulva.
Lateral flexion of body–> posterior hip forced over the perineum.
Fetus will straighten out once anterior hip is born.
Legs and feet follow.
SLIGHT EXTERNAL ROTATION
Back turns anteriorly, shoulders now in oblique diameters of maternal pelvis.
Shoulders descend rapidly.
INTERNAL ROTATION OF THE SHOULDERS
bisacromial diameter occupies anteroposterior diameter of maternal pelvis
—–Flexed head enters pelvis through the oblique diameters
HEAD ROTATES
Posterior portion of the neck brought to the symphysis pubis
Head is born in flexion
EXTRA INFO (not in WIlliams)
Name the maneuver:
Pull the infant downward: insert one hand along the back to look for the anterior arm. With the operator thumb in the infant armpit and middle finger along the arm, bring down the arm (Figure 6.4a). Lift infant upward by the feet in order to deliver the posterior shoulder
Suzor Maneuver
During the delivery of the shoulders, you detect a right nuchal arm. What should you do?
Rotate the body COUNTERCLOCKWISE (180 deg) to direct the fetal back to the maternal RIGHT. The created friction from the birth canal will cause the arm to move in the direction of the chest or toward the face.
(mahahawi yung arm pafront)
During the delivery of the shoulders, you detect a left nuchal arm. What should you do?
Rotate the body CLOCKWISE (180 deg) to direct the fetal back to the maternal LEFT.
During delivery of the right nuchal arm, counterclockwise rotation of the body fails. What should you do next?
Pushing the fetus back up the birth canal to a roomier portion of the pelvis in order to disengage the shoulders and arms above the pelvic brim.
During delivery of the right nuchal arm, counterclockwise rotation failed. Pushing the fetus back up also failed. What to do next?
Extract the nuchal arm by hooking a finger over it and forcing the arm over the shoulder down to the ventral part of the body.
Fracture of the humerus or clavicle is common.
How to apply Piper Forceps
The head should have been:
- brought into the pelvis by gentle traction and suprapubic pressure
- engaged
Body should be suspended by warm towel. (Keeps fetus up, and the arms and cord out of the way)
You may choose to apply the forceps while on a one-knee position.
Blade to be placed on maternal left, should be held by the left hand, with the right hand sliding between the fetal head and left maternal vaginal sidewall.
Mirror with the right.
Articulate the blades. Fetal body should rest across the shanks.
Delivery the head through a gentle outward motion, slightly raising the handle simultaneously. Head and body should move in unison.
Maneuvers which could be done for cases of CPD or arrest of the after coming head or head entrapment
- cervix may be manually slipped over the occiput
- Duhrssen incision; general anesthesia may aid LUS relaxation
- Zavanelli then CS
- Symphysiotomy (with local analgesia), if CS is not possible
One or both of the hips are extended, and thus one of both feet or knees are lower than the breech
Incomplete breech
Manipulation through the abdominal wall that yields a cephalic presentation
external cephalic version
manipulation accomplished inside the uterine cavity that yield a breech presentation
internal podalic version
reserved for delivery of second twin
In general when should external cephalic version be attempted
before labor at 37 weeks
-if done too early, may revert back to breech, or may correct spontaneously
Contraindications to ECV (absolute and relative)
Absolute:
vaginal delivery is not an option (eg. previa)
multifetal gestation
Relative: known nuchal cord early labor oligohydramnios structure uterine abnormalities FGR prior abruption prior CS
What factors can improve the attempt to do ECV?
multigravid uterus abundant AF nonobese patient unengaged presenting part non anterior placenta
How is ECV done
mother is placed in left lateral tilt (for uteroplacental perfusion) and trendelendburg (to aid breech elevation)
forward roll is attempted first:
fetal buttocks elevated from maternal pelvis and displaced laterally, guided towards fundus
one hand is on the head, directed downward to the pelvis
if unsuccessful, backward flip is done
When is ECV abandoned?
excessive discomfort
persistently abnormal FHR
multiple failed attempts
