Vaginal Breech Delivery

Vaginal Breech Delivery

Vaginal Breech Delivery

Objectives
Incidence and Significance
Selection
Management
-Intrapartum
-Delivery

Vaginal Breech Delivery

Definition
longitudinal lie
breech or lower
extremity presenting
cephalic pole in the
uterine fundus

Types
1. frank
- flexed hips,
extended knees
2. complete
- flexed
hips, flexed knees

Vaginal Breech Delivery

Types of Breech

Complete

Footling

Frank

Vaginal Breech Delivery

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

Etiology of
Breech
Presentatio
n
idiopathic
prematurity
(head to trunk
size)
uterine or
pelvic

Vaginal Breech Delivery

Diagnosis
maternal perception of
movement
Leopolds maneuvers
FH auscultated above
umbilicus
vaginal exam
ultrasound
X-ray

Vaginal Breech Delivery

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*

Vaginal Breech Delivery

Selection Criteria for Trial of Labour

frank or complete breech
fetal head not hyperextended
estimated fetal weight 2500 to 4000g

Vaginal Breech Delivery

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

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

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

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

Entering the Pelvis

Obstetrics - Normal and Problem Pregnancies, 2nd Edition

Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

Vaginal Breech Delivery

Descent of the Breech

Obstetrics - Normal and Problem Pregnancies, 2nd Edition

Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

Vaginal Breech Delivery

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

Vaginal Breech Delivery

Hurry up & Wait!

DONT PULL!
traction
deflexes the
fetal head
may cause
nuchal arm

Obstetrics - Normal and Problem Pregnancies, 2nd Edition

Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

Vaginal Breech Delivery

Deliver Legs by lateral rotation of thighs and

flexion of knees - keep sacrum anterior

Obstetrics - Normal and Problem Pregnancies, 2nd Edition

Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

Vaginal Breech
Delivery

Deli
ver
y of
Ar
ms
good maternal
pushing
deliver when winging
of scapulae seen
rotate arm to anterior
sweep humerus across
the chest and deliver

Vaginal Breech Delivery

Avoid Over-extension

Obstetrics - Normal and Problem Pregnancies,2nd Edition

Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

Vaginal Breech Delivery

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

Delivery of the head

Obstetrics - Normal and Problem Pregnancies, 2nd Edition

Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

Vaginal Breech Delivery

Delivery of the head

Forceps
assistant
elevating babe
direct
application

Obstetrics - Normal and Problem Pregnancies, 2nd Edition

Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

Vaginal Breech Delivery

Vaginal Breech Delivery

Piper forceps for delivery of the

aftercoming head

A. The fetal body is elevated

using a warm towel and the left
blade of the forceps is
applied to the aftercoming
head.
B. The right blade is applied
with the body still elevated.
C. Forceps delivery of
the aftercoming head
(Copyright The McGraw-Hili Companies, Inc. Breech
presentation and delivery. In: Cunningham FG et al. Williams
obstetrics. 22nd ed.1)

Vaginal Breech Delivery

Vaginal Breech Delivery

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

TIMING OF ECV
It is currently felt that the ideal time to carry
out ECV is after 36 weeks gestation.
Under certain circumstances, it can be offered
in labour.

Vaginal Breech Delivery

TIMING OF ECV
Why more than 36 weeks?
Spontaneous cephalic version often occurs
before 36 weeks.
Spontaneous podalic version after the
procedure is rare after 36 weeks.
Infant will usually be matufe if complications
of ECV necessitate immediate delivery.

Vaginal Breech Delivery

PREREQUISITES
1. Singleton pregnancy
2. No contraindication to labour
3. Fetal well-being established prior
to procedure
4. Assessment of amniotic fluid
volume
5. Position of fetus known prior to
procedure
6. Facilities for immediate delivery

Vaginal Breech Delivery

CONTRAINDICATIONS
ABSOLUTE
1. Any contraindications to labour, e.g., placenta previa, nonreassuring fetal heart rate (FHR), compromised fetus .
RELATIVE
1. Severe oligohydramnios
2. Hyperextension of the fetal head
3. Two or more previous Caesarean sections
4. Morbid obesity
5. Active labour
External version is safe after one Caesarean section with a low
transverse uterine incision

Vaginal Breech Delivery

RISKS
1. Intrauterine death is rare but may occur
secondary to cord accident, maternal-fetal
hemorrhage, or may be unexplained
2. Abruption
3. Rupture of the membranes
4. Labour
5. Fetal bradycardia necessitating a
Caesarean
delivery (less than 1%)
6. Alloimmunization

Vaginal Breech Delivery

ECV PROCEDURE
Obtain informed consent. The patient should be
informed that:
a policy of offering ECV after 36 weeks will
reduce the chance of a Caesarean section
success is approximately 30% - 50%
sedation and tocolysis may be used

Vaginal Breech Delivery

ECV Procedure
In the initial ECV attempt direction of rotation should be so that the baby "follows
its nose" (i :e., a forward roll) .
1. Dislodge the buttocks from the pelvis, pushing upwards and then laterally
2. Grasp the head and direct it downwards .
3. Slowly rotate the baby by pushing upwards and to the side of the fetal back
with the hand holding the buttocks, at the same time guiding the head
downwards and to the opposite side
4. When the head reaches a lower level than the buttocks, manoeuvre the head
over the pelvic inlet
5. If the forward roll attempt fails , a backward flip (i.e., the opposite direction)
may be attempted
Fetal vibroacoustic stimulation may facilitate fetal rotation (There are insufficient
trials to evaluate the benefit of this tool to date)
Administer Rh immunoglobulin 300 flg to unsensitized Rh-negative women

Vaginal Breech Delivery

Vaginal Breech Delivery

ECV Procedure
Stop the procedure if the patient is too uncomfortable or the fetal
heart rate is non-reassuring . Most nonreassuring FHR patterns
will resolve. If the FHR doesn't recover with intrauterine
resuscitation, an emergency Caesarean section must be done.
Fetal surveillance is continued for a minimum of 20 minutes after
an attempted ECV, whether or not it is successful.
If version was successful, the woman should continue to receive
antenatal care and await labour.
If version was not successful, then discuss appropriate
arrangements for her ongoing care and choice of delivery
method.

Vaginal Breech Delivery

Postural Management

Vaginal Breech Delivery

Moxibustion and/or acupuncture

Moxibus(onisaformoftradi(onalChinesemedicinethatusesheat
generatedbyburningherbs,mosto9en Artemisiavulgaris

(magwort),tos3mulatetheacupuncturepointBL 67(Zhiyinin
Chinese).insu cie ntevidencetoassessiftheuseofmoxibus(on
signi ca ntlyconvertsabreechtoacephalicpresenta(on.
Therearedierencesininterven(ons(e.g.moxibus(onaloneorwith
acupuncture),makingitinappropriatetoperformasa(sfactory
meta
analysis.Moxibus(onmayreducetheneedforECVby53%,the
incidenceofnonvertexpresenta(onattermby3570%,but

Vaginal Breech Delivery

Versi Luar < 37 Minggu

Vaginal Breech Delivery

Versi Luar 37 minggu

Vaginal Breech Delivery

Versi Luar dgn tokolitik

Vaginal Breech Delivery

Suggested
managementof
breechpresenta(on.
(AdaptedfromACOG)

Vaginal Breech Delivery

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 - DONT PULL - stay cool!

Vaginal Breech Delivery

Vaginal Breech Delivery

Biometri dengan Disporposi

Fetopelvik
Sugijanto (1998), cross
sectional, n=50 :
CT scan panggul-biometri
neonatus
Rerata Lingkar Kepala (HC)
BBL neonatus
4000-4500 g 36,2 1,0 cm
Rerata Lingkar Perut (AC) BBL 4000-4499
g 34 2,4 cm

Vaginal Breech
Delivery

Biometri
dengan
Disporpo
si
Fetopelvik
Sugijanto (1998), cross
sectional :
Rerata PAP 36,2 cm
Rerata PT 33,8 cm
Rumus Morgan Thurnau,
1991 :

Vaginal Breech Delivery

Biometri dengan Risiko Distosia

Susilawati ID (2004), kohort, n=60 :
USG Lingkar kepala (HC) 35 cm RR
12,0
Se 80%, Sp 93%

Vaginal Breech Delivery

Rumus Morgan-Thurnau
Bila 2 dari nilai di bawah ini >0 (Positif)
1. Lingkar Kepala-Lingkar PAP
2. Lingkar Kepala-Lingkar PT
3. Lingkar Perut-Lingkar PAP
4. Lingkar Perut-Lingkar PT
Terdapat disporposi fetopelvik

Vaginal Breech Delivery

TERIMA KASIH

Vaginal Breech Delivery

Vaginal Breech Delivery

Vaginal Breech Delivery

Vaginal Breech Delivery