Lecture 6 BREACH PRESENTATION TRANSVERSAL OBLIQUE LIE Prof

Lecture 6 BREACH PRESENTATION TRANSVERSAL & OBLIQUE LIE Prof. Vlad TICA, M. D. , Ph. D.

TYPES OF BREECH PRESENTATION • Frank (65%): Hips are flexed, knees are extended • Complete (10%): The hips and knees are flexed • Incomplete (25%): The feet or knees are the lowermost presenting part: • Single footling: one of the lower extremities is lowermost. • Double footling: Both of the lower extremities are lowermost

Breech presentations: A: Right sacrum posterior (RSP) position B: Left sacrum anterior (LSA) position

TYPES OF BREECH PRESENTATION • Frank (65%): Hips are flexed, knees are extended • Complete (10%): The hips and knees are flexed • Incomplete (25%): The feet or knees are the lowermost presenting part: • Single footling: one of the lower extremities is lowermost. • Double footling: Both of the lower extremities are lowermost

BREECH PRESENTATION PREDISPOSING FACTORS • Prematurity • Uterine abnormalities • Malformation • Fibroids • Fetal abnormalities • CNS Malformations • Neck Masses • Multiple gestations • Previous breech delivery

BREECH PRESENTATION Gestational age in weeks % Breech 21 -24 33 25 -28 28 29 -32 14 33 -36 9 37 -40 7

BREECH PRESENTATION DIAGNOSIS • Palpation and ballottement • Ultrasound • Pelvic examination • X-Ray studies

BREECH PRESENTATION Leopold Maneuver

EXTERNAL CEPHALIC VERSION

MANAGEMENT

MANAGEMENT TYPE OF DELIVERY • Vaginal delivery: • Spontaneous • Partial breech extraction • Total breech extraction • Cesarean delivery

TYPES OF VAGINAL BREECH DELIVERY • Spontaneous breech (rare): No manipulation of the infant necessary, other than supporting the infant • Partial breech extraction: Fetus descend spontaneously t where umbilicus is at the vaginal introitus; then, the fetus extracted completely • Total breech extraction: The entire body is extracted. This indicated only if there is evidence of fetal distress unresponsive to routine maneuvers and a cesarean delive not possible.

CONDITIONS ARE UNFAVORABLE FOR BREECH DELIVERY • Fetus weight > 3500 g • Unfavorable pelvis – Breech delivery does not allow suff time for molding of the fetal head; thus, a platypelloid or android pelvis decreases ability fetal head to navigate ma pelvis • Hyperextension of the head – increases risk of cervical sp injury • Footlings- incidence of umbilical cord prolapse increases coiling of the umbilical cord around the legs of the fetus

MORTALITY/MORBIDITY • Increased birth trauma: As duration of umbilical cord compression increases → deliver the infant more rapidly increasing birth trauma • Decreased birth weight may result from preterm delivery/growth restriction • Incidence of prolapsed umbilical cord depends on type of breech presentation : Footling 17%, Complete 5%, Frank

MECHANISM OF LABOR IN BREECH DELIVERY

ASSISTED DELIVERY OF FRANK BREECH

ASSISTED DELIVERY OF FRANK BREECH

ASSISTED DELIVERY OF FRANK BREECH

ASSISTED DELIVERY OF FRANK BREECH Maneuver for delivery of the head: • The fingers of the left hand are inserted into the infant’s mouth of over mandible; • The right hand exerts pressure on the head from above

MAURICEAU MANEUVER

MECHANISM OF LABOR IN BREECH DELIVERY • Piper forceps • Modified Prague maneuver

DELIVERY OF THE AFTERCOMING HEAD Application of Piper forceps, employing towel sling support. The forceps are introduced from below, left blade first. Aiming directly and intended positions on sides of the head

DELIVERY OF THE AFTERCOMING HEAD

MODIFIED PRAGUE MANEUVER

COMPLETE OR INCOMPLETE BREECH EXTRACTION

COMPLETE OR INCOMPLETE BREECH EXTRACTION

BREECH EXTRACTION

C-SECTION INDICATION • A large fetus ( > 3. 500 grams) • A hyperextended fetus • Uterine dysfunction • Footling presentation • Any degree of contraction or unfavorable shape restrictio • Previous perinatal death or children suffering from birth trauma

COMPLICATIONS 1. Perinatal morbidity and mortality from difficult delivery 2. Low birthweight from preterm delivery, growth restriction, bot 3. Prolapsed cord 4. Placenta praevia 5. Fetal, neonatal, and infant anomalies 6. Uterine anomalies and tumors 7. Multiple fetuses 8. Operative intervention, especially cesarean delivery

TRANSVERSE OR OBLIQUE PRESENTATION 1. DEFINITION At the end of pregnancy or during of labor, champ of pelvic inlet is not fetal head or fetal breech 2. VARIETY - shoulder right in dorso-anterior - shoulder left in dorso-anterior - shoulder right in dorso-posterior - shoulder left in dorso-posterior

TRANSVERSE OR OBLIQUE PRESENTATION 3. ETIOLOGY • Mistake of accommodation: the grand cause of transverse position is multipara (relax of uterine wall) • Other cause can hydramnios, previa tumor, shortness umbilical cord • Uterine malformation

TRANSVERSE OR OBLIQUE PRESENTATION 4. CLINICAL • Inspection • The uterus is developing transverse or oblique • Palpation • Hands explored base part of uterus on of pelvic inlet can not contact fetal pole • At middle of uterus fundus have no fetal pole

TRANSVERSE OR OBLIQUE PRESENTATION • At lateral face of uterus (right or left) can contact with fetal pole or breech • Multipara are rare on same plan of transverse • Uterus malformation, the two poles can contact at same higher at uterine body (back in anterior) • In dorso-posterior, abdominal wall perception fetal limps

TRANSVERSE OR OBLIQUE PRESENTATION

TRANSVERSE OR OBLIQUE PRESENTATION • Auscultation: • the fetal cardiac sound can receive a bite under umbilical at cephalic side • Digital exam: • during pregnancy: the excavation is empty (fingers are not contact the presentation)

TRANSVERSE OR OBLIQUE PRESENTATION • During labor: if membranes are not rupture, the sac amniotic fluid is big volume (can not evaluation the presentation) • After rupture of membranes, the fingers are perception: . Shoulder and acromial protrusion. Axillary furrow

TRANSVERSE OR OBLIQUE PRESENTATION • At profound permit contact: . Costal. Scapula • In some cases, superior limp fall down in excavation, vaginal, vulva with character cyanosis and edema • The thumb turn to thigh of mother same name with of shoulder that present

TRANSVERSE OR OBLIQUE PRESENTATION • Diagnostic of variety: must to know head, breech, back, shoulder (right or left) situate at pelvic inlet • When the hand is out side of vulva, sign of thumb confirm the diagnosi • X-ray: necessary in all cases, it confirme diagnostic • Ultrasound: same of x-ray and position of placenta

TRANSVERSE OR OBLIQUE PRESENTATION 5. DELIVERY A. Ovular phenomenon: The precocity of membranes rupture is favorable by character of amniotic fluid sac (big volume in cervical canal) Uterus is empty of amniotic fluid and cord prolapses

TRANSVERSE OR OBLIQUE PRESENTATION

TRANSVERSE OR OBLIQUE PRESENTATION B. Mechanic phenomenon: • First time: weakness, head orient opposite trunk (vertical). The shoulder is in center of basin. Superficial exam, the presentation return longitudinal • Second time: engage of shoulder • Third time: stop of progression (enclave).

TRANSVERSE OR OBLIQUE PRESENTATION C. Plastic phenomenon: • is at region of shoulder, neck, back D. Physiologic phenomenon: • the dilatation of cervix is trouble: cause of dynamic abnormal and ovular infection • The cervix is edema, thick • Lower segment still thick not contact with presentation

TRANSVERSE OR OBLIQUE PRESENTATION • The uterine contraction is the trouble: the contraction is normal until rupture of membrane but the progression of presentation is stopped • First irregular, then inertia or hypertonia with hypercinesis • The consequence of retraction is: • Death of the fetus: the retraction provoke diminution of blood fluid trans placenta and infection

TRANSVERSE OR OBLIQUE PRESENTATION • Uterine rupture: • the retraction of the myometrium of uterine body provoke lower segment stretch (lower segment rupture)

TRANSVERSE OR OBLIQUE PRESENTATION 6. TREATMENT: A. During of pregnancy: - the surveillance of presentation is every days - it can external version for cephalic presentation or breech presentation at pelvic inlet (multipara) - primipara: cesarean section at the end of pregnancy

TRANSVERSE OR OBLIQUE PRESENTATION

TRANSVERSE OR OBLIQUE PRESENTATION

TRANSVERSE OR OBLIQUE PRESENTATION B. During of labor: • Primipara: • cesarean section • Multipara: • The membrane is intact: • Complete dilatation of cervix: artificial rupture of membrane and internal version • Dilatation is incomplete: conservation of membrane until complete dilatation

TRANSVERSE OR OBLIQUE PRESENTATION • The membranes are ruptured: • Uterus is soft (not retracted) & fetus is alive: • cesarean section if incomplete dilatation • internal version if complete dilatation • Uterus is retracted: • Fetus is alive: cesarean section • Fetus is dead: embryotomy

TRANSVERSE OR OBLIQUE PRESENTATION • Uterus is ruptured: • after laparotomy and extraction of fetal mort and placenta, the operation must suture of rupture or hysterectomy