In The Name of Allah Ar-rahman Ar-Raheem

Management of Complicated Breech Delivery

1) Arrest of the breech
A. Arrest of the breech at the pelvic brim Causes 1. Powers: uterine inertia Management Oxytocin drip if there is no contraindications

2. Passages: a. Contracted Pelvis b. Pelvic tumor c. Pendulous abdomen

Cesarean section Cesarean section If no disproportion :bring down the anterior leg first, followed by breech extraction

3. Passenger: large fetus

Cesarean section

B. Arrest of the breech at the pelvic outlet 1. Powers: Uterine inertia Oxytocin drip, groin traction during pains, if fails: foot should be drawn down and traction on the legs 2. Passages a. Pelvic outlet contraction Cesarean section b. Rigid perineum Pudendal block and episiotomy 3. Passenger Bring down the legs, is the i. Frank Breech is the most safest and the surest important cause, method, because, if traction fails to deliver, the fetus becomes firmly impacted in the pelvis (impacted breech) and the subsequent bringing down of the legs becomes much more difficult ii. Large fetus Cesarean section

Techniques of bring down a leg Condition

If the legs are flexed (Complete breech)

Techniques
The hand is introduced along the ventral aspect of the breech, a foot is gently drawn down in a direction, that the thigh is adducted across the body. Pinard's maneuver (1889) The hand is passed into the uterus along the ventral aspect of the fetus and the fingers follow the thigh with the finger-tips on the popliteal region. The fingers then press the thigh against the trunk and outwards ,as a result the leg becomes partially flexed and the foot comes lower and it is drawn downward. Bring down the anterior leg first to avoid overriding of the anterior buttock on the symphisis pubis.

If the legs are extended

Cases of impacted breech in which attempts of bringing down a limb have failed are treated like a failed forceps by CS.

Groin Traction Done under general anesthesia, Episiotomy is necessary The index finger is put in the anterior groin, gentle traction towards the trunk side to avoid fracture of the femur. Traction is done during uterine contraction and it is helped by Kristellers maneuver. When the posterior groin appear, apply traction by the other index finger in it (combined traction). Direction of traction: At first, downwards and backwards until the anterior buttock appears under the symphysis pubis Then traction is directed upwards to deliver the posterior buttock. If the fetus is dead, Groin traction can be done by groin hook.

2) Arrest of the shoulder

1. Extension of The Arms Causes Rarely: it may be a primary condition. Commonly secondary due to: Pulling on the fetus, with incompletely dilated cervix without fundal pressure. Contracted pelvis Arms are absent in the front of the chest wall 1. Classical Method Under General anesthesia. Bring the posterior arm through (Bringing Down the the sacral hollow (roomy space) Posterior Arm) first, then bring the anterior arm either anteriorly or after rotating it to become posterior

Diagnosis Management

2. Lovset's Maneuver

Bring down the arms by means of rotation of the fetal trunk without introducing a hand inside the uterus. Based on inclination of the pelvic brim Rotate the trunk (180) until the posterior shoulder becomes anterior and deliver the arm. Rotation of the trunk in the opposite direction to deliver the other shoulder and arm. It is done without anesthesia.

2. Nuchal Position of The Arm

Due to rotation of the trunk in the wrong direction. Diagnosis : the forearm lies behind the nape of the neck Treatment: Rotation of the trunk in the direction of the finger tips of the displaced hand.

3) Arrest of the after coming head

Definition Causes If Kristeller's maneuver fails to deliver the head, the head is considered arrested. Causes in the Head Extension of the head (deflexion of the head) Posterior rotation of the occiput Large sized head Hydrocephalus Contracted Pelvis. Incompletely dilated cervix. Rigid perineum.

Causes in the passages

Site of arrest (causes & managem ent)

1. Arrest Above The Brim

Contracted pelvis Incompletely dilated Cervix

Extension of the head Hydro cephalus II.Entrapment of The After Coming Head Of A Premature Living Fetus -

Symphysiotomy: if the fetus is living Craniotomy: if the fetus is dead If the fetus is dead :wait till full cervical dilatation. If the fetus is living : do cervical incisions at 5 and 7 Oclock (Duhressens incisions). Do jaw flexion-shoulder traction

III. Head Arrest In Pelvic Cavity

Do perforation of the head through the spinal cord due to associated spina bifida or roof of the mouth). Gentle downwards traction on the shoulders combined with fundal pressure. If fails : repeat under general anesthesia (halothane). If fails and the fetus is living do cervical incisions (Duhressen's incision) at 5 and 7 Oclock ( not at 3 or 9 Oclock to avoid extension to the uterine vessels). Jaw flexion- shoulder traction. Forceps delivery.

Posterior Rotation of The Occiput (Management)

Anterior Rotation of the Back

If fails the management depends on the attitude of the head

Deep anesthesia and cease all traction. Dislodge the chin from the symphysis pubis and do anterior rotation of the shoulder and the head. - Effect engagement by supra pubic pressure. - Deliver the after coming head If the fetus is living : Prague's - The fetus is grasped from its feet and its Maneuver: body is flexed on the mothers abdomen and the fingers forked over the shoulders from behind. - Traction from behind aided by suprapubic pressure will flex the head within the birth canal and results in delivery of the occiput over the perineum. If the fetus is dead do perforation.

Cesarean Section in Breech Presentation 1. 2. Incidence: 90% in breech delivery in USA Indications for CS in Breech Causes in passenger 1-Breech with extended legs in primigravida. 2-Footling presentation. 3-Hyperextension of the fetal head (star-gazing look) to avoid fracture of the cervical spine during vaginal delivery. 4-Large fetus (>3.6 Kg). 5-Prematurity to avoid intracranial he 6-prolapsed pulsating cord with undilated cervix 7-fetal distress 8-prolonged PROM 1. Contracted pelvis (any degree). Causes in the 2. Cervical rigidity passages Maternal 1. Elderly primigravida. causes 2. Associated conditions and diseases: - Diabetes mellitus - Previous still birth - Heart disease - Severe PET (pre-eclamptic toxaemia) Transverse lower segment incision. For premature fetus do low vertical incision Maternal Risks Genital tract laceration. Postpartum hemorrhage. Infection: puerperal sepsis. Fetal Mortality: 3 times than that of cephalic presentation. Intracranial Hemorrhage Fetal Asphyxia Fetal Birth Injuries

Indications for CS in Breech

Type of The CS Incision Complications of breech delivery

Fetal Risks