Vaginal Breech Delivery International Vaginal Breech Delivery

Vaginal Breech Delivery International Objectives • Incidence and Significance • Selection • Management – Intrapartum – Delivery

Vaginal Breech Delivery International Definition • longitudinal lie • breech or lower extremity presenting • cephalic pole in the uterine fundus Types • frank • complete • footling - flexed hips, extended knees - flexed hips, flexed knees - extended hip(s)

Vaginal Breech Delivery International Types of Breech Complete Footling Frank

Vaginal Breech Delivery International 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 Delivery International 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 Delivery International Diagnosis • • • maternal perception of movement Leopold’s maneuvers FH auscultated above umbilicus vaginal exam ultrasound X-ray

Vaginal Breech Delivery International 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 Delivery International Selection Criteria for Trial of Labour • frank or complete breech • fetal head not hyperextended • estimated fetal weight 2500 to 4000 g

Vaginal Breech Delivery International 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 Delivery International 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 Delivery International 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 Delivery International 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 Delivery International Entering the Pelvis Obstetrics - Normal and Problem Pregnancies, 2 nd Edition Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

Vaginal Breech Delivery International Descent of the Breech Obstetrics - Normal and Problem Pregnancies, 2 nd Edition Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

Vaginal Breech Delivery International Spontaneous Expulsion • 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 Obstetrics - Normal and Problem Pregnancies, 2 nd Edition Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

Vaginal Breech Delivery International Hurry up & Wait! • DON’T PULL! • traction deflexes the fetal head • may cause nuchal arm Obstetrics - Normal and Problem Pregnancies, 2 nd Edition Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

Vaginal Breech Delivery International Deliver Legs by lateral rotation of thighs and flexion of knees - keep sacrum anterior Obstetrics - Normal and Problem Pregnancies, 2 nd Edition Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

Vaginal Breech Delivery International 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, 2 nd Edition Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

Vaginal Breech Delivery International Avoid Over-extension Obstetrics - Normal and Problem Pregnancies, 2 nd Edition Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

Vaginal Breech Delivery International 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 Delivery International Delivery of the head Obstetrics - Normal and Problem Pregnancies, 2 nd Edition Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

Vaginal Breech Delivery International Delivery of the head • Forceps • assistant elevating babe • direct application Obstetrics - Normal and Problem Pregnancies, 2 nd Edition Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

Vaginal Breech Delivery International 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 Delivery International 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!