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Obstetric illustrated
TB of obstetric DC Dutta
e-medicine:
occurs in 3-4% of all deliveries Incidence decreases with advancing gestational age: 20% at 20wks to 3-4% at term Definition
The lie is longitudinal Podalic pole presents at the pelvic brim
malpresentation.
Types
A) Complete (flexed
breech) -The limbs and body wil be in flexed attitude -Presenting part consists of: -buttocks -external genitalia -2 feet
B) Frank breech -thighs flexed, legs are extended at the knee joints. -presenting part consists of the buttocks and external genitalia only.
c) Footling or Incomplete breech -both the thighs and the legs are partially extended. -legs are present at the brim.
Aetiology:
1)Prematurity 2)Factors preventing spontaneous version:
i. Twins (multiple fetus) ii. oligohydramnios iii. breeeech with extended legs iv. short cord v. congenital malformation of the uterus vi. intrauterine death of the fetus
Diagnosis
Clinically per abdomen,
-head: smooth,hard, round, ballotable mass is felt during fundal grip -back to one side & irregular limbs to the other - soft,broad, round mass of buttock -the fetal heart is best heard at the level of the umbilicus or above
tip of sacrum feet beside the buttocks in complete breech Fresh meconium on examining fingers Male genitalia may be felt
Ultrasound 1.confirms the clinical diagnosis 2.detect fetal abnormalities & congenital anomalies of the uterus 3.measures biparietal diameter, gestational age, and approximate weight of the fetus 4.localises the placenta 5.assessment of the liquor volume 6.attitude of the head, eg flexed or hyperextension
Management of breech
1. External cephalic version
2. Vaginal delivery 3. Caesarean section
any time thereafter upto early labour) Success rate : ~69% Causes of failure - large fetus, oligo/polyhydramnios, short umbilical cord, uterine anomalies, irritable uterus, obesity, rigid abdominal wall, frank breech extended legs
- antepartum hemorrhage -fetal causes:cong.anomalies, dead fetus, hyperextensio. Of head - multiple pregnancy -ruptured membranes - previous caesarean: risk of scar rupture -uterine abnormalities
Technique of ECV
In a delivery unit set-up where facilities are
available for emergency CS Supine with legs & abdomen relaxed Patient should empty bladder prior to version Anesthesia contraindicated pain is a safeguard against rough manipulation 1 hand on lower pole of fetus (breech) 1 hand on upper pole (head)
Technique of ECV
When uterus is relaxed
of pelvis laterally toward iliac fossa Head pushed toward pelvis in opposite direction
Technique of ECV
Procedure complete when fetal head
overlies the pelvic brim Patient is observed for one hour & CTG performed Note fetal heart rate, fetal movements, abdominal pain, vaginal bleeding Seen again 3-7 days Seen immediately if symptoms develop
- placental separation - rupture of membranes - preterm labour - fetal distress - cord presentation/prolapse - entanglement of cord around fetal parts - fetomaternal hemorrhage
- frank breech - estimated fetal weight 2.0 - 3.8 kg - flexed head - adequate pelvis - normal progress of labour - uncomplicated pregnancy - multiparas - intrauterine fetal death - an experienced obstetrician
Unfavourable if:
Footling breech
Large baby
Small baby Hyperextended neck
Previous CS
Inadequate pelvis
Placenta previa
Pre-eclampsia
- minimal support - multigravida/precipitate labor/ antenatal fetal death 2. Assisted breech delivery - assistance indicated for delivery of shoulders & after-coming head - delivery up to umbilicus spontaneously 3. Breech extraction
- patient asked to bear down during uterine contractions & relax in between until perineum is distended by buttocks - an episiotomy done - the legs are hooked out but without traction
- when umbilicus appears, a loop of cord is hooked(min. compression) & detect its pulsation - fetus is covered with warm towel
- gentle steady downward traction applied over the fundus during uterine contraction - gradual rotation of fetus to bring shoulders in AP diameter of pelvis - anterior scapula appear below symphysis - both arms delivered by hooking the index finger at elbow & sweep forearm across fetal chest - the back is rotated anteriorly
1) Burns-Marshalls method 2) Jaw flexion shoulder traction (Mauriceau- Smellie-Veit technique) 3) Forceps delivery
Breech extraction
Indications - maternal/fetal distress
- prolonged 2nd stage - to shorten 2nd stage in maternal respiratory & heart diseases - prolapsed pulsating cord with fully dilated cervix Contraindication - grand multipara - post-caesarean pregnancy - incompletely dilated cervix
pressure to deliver breech & trunk After-coming head delivered by jaw flexion shoulder traction / forceps
- inefficient uterine contractions - contracted pelvis - large-sized baby Arrest of buttock at pelvic outlet - inefficient uterine contractions - contracted outlet - rigid perineum - extended legs (frank breech)
- extension of arms due to traction on breech before full dilatation of cervix - nuchal position of arm (forearm displaced behind the neck due to rotation of trunk in wrong direction)
(a) Faults in head - large head - hydrocephalus - extended head - posterior rotation of occiput (b) Faults in passages - contracted pelvis - rigid perineum - incomplete dilated cvx
Lovesets manoeurve:
Caesarean section
Indications (contraindication of vaginal del.)
- large fetus - preterm fetus weight > 1.25kg - footling/complete breech-risk of cord prolapse - hyperextended head - contracted pelvis - uterine dysfunction - breech in primigravida
Caesarean section
-complicated pregnancy with : hypertension DM placenta previa PROM > 12 hours post-term IUGR placental insufficiency
Thank you!!