August 12, 2016 OBSTETRICS

 Look at the picture, left side of the quadrant of the pelvic cavity is being
BREECH - NER occupied by the occiput more toward the area between 12 o’clock and 3
REVIEW: o’clock  Left occiput anterior (LOA)
 Point of reference: OCCIPUT in cephalic presentation
Fetal Lie – refers to the relation of the long axis of fetus (back) to the long axis  When the mother is in lithotomy position and you do internal examination,
of the mother. the sacrum (breech) was on the left side of the mother posteriorly. (LOP).
a. Oblique Lie It is between 6 o’clock and 9 o’clock.
b. Longitudinal Lie
c. Transverse Lie Fetal Attitude – the degree of flexion a fetus assumes during labor or the
Longitudinal Lie we can have 2 possibilities: relation of the fetal parts to each other.
1. Cephalic presentation or Vertex Presentation - It is very important to determine what type of breech presentation it
2. Breech presentation will be.
Transverse Lie -------End of review-----
- Shoulder Presentation: you can feel the scapula and acromion
CLASSIFICATION OF BREECH PRESENTATIONS
Fetal Presentation – Designates fetal part over the pelvic inlet:
• Cephalic
• Breech
• Transverse
• Compound
• Face
• Brow
Diagnosis of Fetal Presentation
 abdominal palpation  Frank Breech Presentation – lower extremities are flexed at the
o Leopold’s maneuver hips and extended at the knees, and thus the feet lie in close
 vaginal examination proximity to the head.
 auscultation  Complete Breech – one or both knees are flexed.
 sonography o Preterm
 Incomplete Breech – one or both hips are not flexed or one or both
*Doing Internal Examination in a cephalic presentation: knees lie below the breech, such that a foot or knee is lowermost in
 Vertex Presentation the birth canal.
- Common presentation  Footling breech - is an incomplete breech with one or both feet
- Head is flexed sharply so that the chin is in contact with below the breech.
the thorax Another important thing in internal examination, you can palpate anus, sex
 Face Presentation / Mentum organ and ischial tuberosity.
- Fetal neck may be sharply extended so that the occiput In complete breech, you can feel the anus, genitalia, ischial tuberosity and
and back come in contact sometimes the toe or the foot on the lateral side.
 Sinciput Presentation If incomplete breech (footling), ang una mong makakapa ay yung paa.
- Partially flexed head  Preterm babies have higher possibility of breech presentation.
- Anterior or Large Fontanel or Bregma is presented  In Term pregnancy, it is more common on cephalic presentation.
 Brow Presentation
- Partially extended head 5 % of term breech fetuses, the head may be in extreme hyperextension.
- Can lead to dystocia These presentations have been referred as stargazer fetus or flying fetus.
With such hyperextension, vaginal delivery may result in injury to the cervical
*The linear area where the baby will be coming spinal cord. Thus if present, this indicate for cesarean delivery.
out will be a position will be on the right side or
left side of the mother. (Anterior or Posterior DIAGNOSIS
quadrant of the pelvic cavity.)
*It is a dilemma, most of the time reading the
nomenclature of a transverse position. We should Risk Factors precipitated to a Breech Presentation:
take note where the scapula or acromion then 1. Oligohydramnios
checks if it is on the anterior or posterior area. 2. Hydrocephaly
(nakahiga or nakadapa si baby sa loob). 3. Multifetal gestation
*By doing an internal examination, we can 4. Anencephaly
come up with a diagnosis whether it is a 5. Uterine anomalies – Mullerian duct development
dorsoanterior or dorsoposterior lie) 6. Placenta previa – located at the lower segment
 Determining points in various presentations: 7. Fundal placental implantation
 Vertex – Occiput 8. Pelvic tumors – tumors at the lower segment of uterus
 Face – Chin (mentum) 9. High parity with uterine relaxation
 Breech – Sacrum 10. History of Cesarean Section s/t breech delivery
 Shoulder - Acromion 11. Women who smokes

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COMPLICATIONS:
EXAMINATION - Genital tract lacerations
- Intrauterine maneuvers
 Leopold maneuvers to ascertain fetal presentation. o Lacerations up to the anal area can be contaminated by the
a. First maneuver, the hard, round, ballotable fetal head may be stool and there will be healing problem resulting to fistula or
found to occupy the fundus. gaping of the wound.
(Cephalic: Ballotable structures; Breech: Irregular structures) o Death due to uterine atony profuse bleedingpost-partum
b. Second maneuver, back to be on one side of the abdomen hemorrhage
and the small parts on the other. Perinatal morbidity and mortality
c. Third maneuver, if not engaged, the breech is movable above  Major contributors to perinatal loss
the pelvic inlet. - Preterm delivery
(Breech: Rounded structure/ Head occupied in the fundus) - Congenital anomalies
d. After engagement, the Fourth maneuver shows the firm breech - Birth trauma
to be beneath the symphysis.  Fetal injuries
- Position of the examiner is facing the mother’s legs. - Associated with vaginal breech deliveries
*If suspected with breech presentation or any presentation other - Fracture of the humerus and clavicle
than cephalic – sonographic evaluation is indicated. - Fracture of the femur
- Neonatal perineal tears
Another diagnostic way to identify cephalic or breech presentation, is to identify - Hematomas of the sternocleidomastoid muscles disappear
the location of fetal heart tone and then correlate it to the umbilical area of the spontaneously
mother. - Separation of the epiphyses of the scapula, humerus, or femur
- If the FHT is more prominent in the upper quadrant it is breech - Upper extremity paralysis
presentation. o Pressure on the brachial plexus (paglabas ng bata halos
 Ultrasound di nya mamove yung kanyang upper extremities)
 CT scan, MRI or X-ray o Overstretching the neck while freeing the arms
 Vaginal Examination - Avulsion of the upper cervical spine roots
- Take note: where is the anus, tuberosities, genitalia area. - Spoon-shaped depressions skull
- Actual fractures of the skull
Breech presentation Face presentation - Spinal cord injury or vertebral fracture
Anus, ischial tuberosities Mouth, malar prominence - Umbilical cord prolapse
Fingers encounters muscular resistance Firmness, less yielding jaws felt firmly - Testicular injury (Anorchia)
with anus
Upon removal from the anus, maybe (-) staining on removal of finger IMAGING TECHNIQUES
stains In breech presentation, especially the preterm. The breech is
with meconium smaller than the after coming head. The head of a breech
Ischial tuberosity and anus lie in Mouth and malar prominence form a presenting fetus does not undergo appreciable molding during labor.
STRAIGHT LINE TRIANGULR SHAPE
To avoid head entrapment following delivery of the breech, pelvic
Complete Breech - the feet may be felt alongside the buttocks. dimensions should be assessed before vaginal delivery.
Footling Presentation – one or both feet are inferior to the buttocks To make sure that the inlet, outlet and the midpelvis is just adequate for the
Fetal positions designations: fetus to come out since it is breech presentation. We must do radiological
1. Left sacrum anterior (LSA) Pelvimetry.
2. right sacrum anterior (RSA) If there is a deficiency on the pelvic diameter it will end up with
3. left sacrum posterior (LSP) dystocia. (Macrosomic or the small passages.)
4. right sacrum posterior (RSP) Can able to identify whether it is frank breech, incomplete or
5. sacrum transverse (ST) complete breech.
Type of breech and degree of neck flexion or extension should be
ROUTE OF DELIVERY identified.
Review:
In Clinical Pelvimetry all we do is “kapa kapa”. We try to measure the inlet by trying to
Deciding Factor: do the measurement from the sacrum to the symphysis pubis
1. Fetal characteristics and we will get the diagonal conjugate.
2. Pelvic dimension – if there is pelvic contraction  head entrapment The anterior posterior diameter of the pelvic inlet will be made
3. Coexistent pregnancy complication up of 3 diameters: diagonal, obstetrical, true conjugate.
4. Operator experience Always remember if you are having problem in AP diameter of
5. Patient preference the inlet, measuring clinically it is always diagonal conjugate!
6. Hospital capabilities “D” stands for down (diagonal conjugate) this is the only
thing you can measure. From the promontory to the lower
edge of the symphysis pubis.
DELIVERY COMPLICATIONS You need to do minus 1 or minus 2 because of the inclination
of the symphysis pubis.
Maternal morbidity Diagonal: 11.5 cm
- Greater frequency of operative delivery Obstetrical: 10cm (shortest)
True conjugate: 13cm

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Sonography
- Part of prenatal care (mandatory)
- Gross fetal abnormalities such as hydrocephaly or anencephaly can
be rapidly ascertained.
- Can identify many fetuses not suitable for vaginal delivery and will
help to ensure that as CS delivery is not performed under
emergency conditions for an anomalous fetus with no chance of
survival.
- Head flexion can usually also be determined sonographically and for
vaginal delivery the fetal head should not be extended. (If it is still
difficult to see on UTZ, you can use X-ray machine). 2 most
important: UTZ and X-Ray machine.
- For the checking of fetal weight. If you have a large baby for
gestational age >3800 to 4000g or breeches small for gestational
age that is a candidate for CS delivery.
Pelvimetry (Radiologic Pelvimetry)
- This assessment of the bony pelvis before vaginal delivery may be
completed with one- view computed tomography (CT), MRI or plain
film radiographs. (If you would like a less exposure of the fetus to
radiation then you could use MRI)
- If may magtanong na mother sayo “Doc, pag na expose ba ang
baby sa loob will it be a problem being exposed to radiation? The
answer is NO! If the radiation is just before the time of delivery BUT
if you exposed the baby on the first 8 weeks of gestation
(embryogenesis) there is a chance magkakaroon ng fetal anomalies
for example gonadal problem. If a male baby, he can have
azoospermia or testicular problem. If female, she will have
unovulatory or infertility in the future.
CT Pelvimetry
- More favored due to its accuracy, low radiation dose and
widespread availability.
- Can assess the critical dimensions of the pelvis.
Specific measurements to permit a planned vaginal delivery:
 Inlet anteroposterior diameter > 105mm (10.5cm)
 Inlet transverse diameter > 120mm (12cm)
 Midpelvis interspinous diameter > 100mm (10cm)
Can also measure biparietal diameter
 Sum of the inlet obstetrical conjugate minus the fetal BPD is >15
mm
 Inlet transverse diameter minus the BPD is >25mm
 The Midpelvis interspinous diameter minus the BPD >0mm
MANAGEMENT OF LABOR AND DELIVERY
On the type of deliveries, there are some guidelines that we should follow.
1. Fetal characteristic
2. Pelvic Dimensions
3. Complication related to pregnancy
Before doing a Cesarean Delivery (abdominal delivery), try to assess first
before suggesting it is for CS delivery baka kasi pwede naman thru
vaginal delivery.  If all the parameters ay abnormal then do CS
delivery.
Studies shows that if you deliver the term or preterm baby via CS there is
a less chance of maternal and fetal complication and less mortality rate.
Indication that will inhibit you in doing abdominal delivery:
1. Imminent delivery (fully dilated cervix, the baby is almost coming out, there
is no chance for anesthetic prep, to deliver to the operation)
2. Extreme premature – the baby might survive < 48hours
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3. Diabetic mother
4. Allergic to anesthesia
Methods of Vaginal Delivery
Cephalic Presentation – once the head is delivered, the rest of the
body typically follows without difficulty.
Breech Presentation – successively larger and less compressible
parts are born.
Spontaneous complete expulsion of the fetus that presents as a
breech – is seldom accomplished successfully.
As a rule, vaginal delivery requires skilled participation for a favorable
outcome.
 If you are taking time in deliver the fetal head the cervix starts to decrease its
diameter.
 <10cm cervix and it starts to close you might have fetal head entrapment.
 If you don’t enough skill in performing breech vaginal delivery then perform
CS delivery.
 Remember, ok lang mag induce ng labor if beyond term but once
the patient was in active phase of labor (>4cm) dilated, regular
contraction NEVER TO OPEN.
Three General Methods of Breech Delivery through the Vagina:
1. Spontaneous Delivery – The fetus is expelled entirely
spontaneously without any traction or manipulation other than
support of the newborn.
2. Partial Breech Extraction – The fetus is delivered spontaneously
as far as the umbilicus, but the remainder of the body is extracted or
delivered with operator traction and assisted maneuvers, with or
without maternal expulsive efforts.
3. Total Breech Extraction – The entire body of the fetus is extracted
by the obstetrician.
o CS delivery, when you open the uterus the next thing you
will do is to insert your hand inside the uterus and then
get the extremities out of the body.
o Multifetal Cephalic Breech (2nd of twins)
 Internal Podalic Version - maneuver to
deliver the fetus by inserting a hand into the
uterine cavity, grasping one or both feet, and
drawing them through the cervix (cephalic to
breech to deliver the 2nd of twin as fast as
possible)
If you will do an assessment as what type of breech presentation,
you will not be doing it once that baby was coming out. You always
assess it BEFORE that presenting part will come out.
MANAGEMENT OF LABOR
On arrival, rapid assessment should be made to establish the status
of the membranes, labor, and fetal condition.
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Surveillance of fetal heart rate and uterine contractions begins at
admission
Immediate recruitment o necessary staff should include:
a. Obstetrician skilled in the art of breech extraction
b. Associate to assist with the delivery
c. Anesthesia personnel who can ensure adequate
analgesia or anesthesia when needed
d. Individual trained in newborn resuscitation
(pediatrician)
For the mother, an intravenous catheter is inserted and crystalloid
infusion begun. Emergency induction of anesthesia or maternal
resuscitation following hemorrhage from lacerations or from uterine
atony are but two of many reasons that may require immediate
intravenous access.
Assessment of cervical dilatation and effacement and the station of
the presenting part are essential for planning the route of delivery.
If labor is too far advanced, there may not be sufficient time to
obtain pelvimetry. (You will do clinical pelvimetry and monitor the baby
continuously prior to vaginal delivery. Dapat yung fetal monitoring machine
laging nakahook!)
When membranes are ruptured, either spontaneously or artificially,
the cord prolapse risk is appreciable and is increased when the
fetus is small or when the breech is not frank.
Therefore, a vaginal examination should be performed following
rupture to exclude prolapse, and special attention should be directed
to the fetal heart rate for the first 5 to 10 mins following membrane
rupture.
 Remember, monitoring is important, position the mother in lithotomy
position, and one of the greater risk is the cord traction LET IT GO! Just
remain to support, as much as possible you will do less total breech
extraction if you will perform vaginally. Avoid TBE in order to decrease the
mortality and moribidity.
 Control and slow the delivery of aftercoming head.
 Mauriceau Maneuver - to make sure the fetal head will be pull up. That
the head will stay at the flexed position.
 Modified Prague Maneuver- consist of two fingers of one hand grasping
the shoulder of the back – down fetus from below while the other hand
draws the feet up and over the maternal abdomen.
CARDINAL MOVEMENTS WITH BREECH DELIVERY
 Engagement and descent:
- Take place with the bitrochanteric diameter in one of the oblique
pelvic diameters
- Anterior hip usually descends more rapidly than the posterior hip
 Internal rotation
- 45 ° follows when the resistance of the pelvic floor is met
- Anterior hip toward the pubic arch
- Allowing the bitrochanteric diameter to occupy the anteroposterior
diameter of the pelvic outlet
Note: if posterior extremity is prolapsed  rotates to the symphysis pubis
 Descent continues
- Until the perineum is distended by the advancing breech
- Anterior hip appears at the vulva
 Lateral flexion of the fetal body
- Posterior hip then is forced over the perineum  retracts over the
buttocks  allowing the infant to straighten out when the anterior
hip is born
- Legs and feet follow the breech and may be born spontaneously or
require aid
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 After birth of the breech
- Slight external rotation
- Back turning anteriorly as the shoulders are brought into relation
with one of the oblique diameters of the pelvis
 Descent and internal rotation:
- The shoulders then decend rapidly and undergo internal rotation 
bisacromial diameter occupying the anteroposterior plane
Head:
- Normally sharply flexed upon the thorax
- Enters the pelvis in one of the oblique diameters and then rotates in
such a manner as to bring the posterior portion of the neck under
the symphysis pubis HEAD IS THEN BORN IN FLEXION
Breech engagement
 May engage in the transverse diameter of the pelvis with the sacrum
directed anteriorly or posteriorly.
Mechanism of labor in the transverse position
Difference:
 Internal rotation through an arc of 90° rather than 45°
- Rotation occurs in such a manner that the back of the fetus is
directed posteriorly instead of anteriorly. (Should be prevented if possible)
 Although the head may be delivered by allowing the chin and face to pass
beneath the symphysis.
 Slightest traction on the body may cause extension of the head, which
increases the diameter of the head that must pass through the pelvis
Partial breech extraction
- Delivery is easier  morbidity and mortality rates are probably
lower, when the breech is allowed to deliver spontaneously to the
umbilicus
- Draws the umbilicus and attached cord into the pelvis 
compresses the cord
- Breech pass beyond the introitus, the abdomen, thorax, arms, and
head  delivered promptly
 Episiotomy should be made and is an important adjunct to any type of
breech delivery
 Posterior hip will deliver, usually from the 6 o'clock position
 With sufficient pressure  passage of thick meconium
 Anterior hip then delivers followed by external rotation to a sacrum
anterior position
 Mother continue to push
 cord drawn into the birth canal and likely is being compressed or stretched
 fetal bradycardia
 The hips of the frank breech are delivering over the perineum. The
anterior hip usually delivered first.
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 As the fetus continues to descend Forceps
- The legs by sequentially delivered by splinting the medial aspect of A. Piper forceps
femur with the operator's fingers positioned parallel to each femur, - Fetal body is held elevated using a warm towel and the left blade of
lateral pressure to sweep each leg away from the midline forceps applied to the aftercoming head
 Fetal bony pelvis is grasped with both hands, using a cloth towel - Right blade is applied with the body still elevated
moistened with warm water - Forceps delivery of aftercoming head
 Fingers should rest on the ASIS and the thumbs on the sacrum B. Laufe forceps
minimizing the chance of fetal abdominal soft tissue injury
 Maternal expulsion efforts are used in conjunction with downward traction Entrapment of the aftercoming head
to effect delivery  If you have a problem in the delivery of the neck:
 Dührssen incision
Cardinal rule - Cut at 2 o'clock position of the cervix, which is followed by a
Employ steady, gentle, downward rotational traction until the lower halves of second incision at 10 o'clock of the cervix
the scapulas are delivered, making no attempt at delivery of the shoulders and - Incisions are so placed as to minimize bleeding from the laterally
arms until one axilla becomes visible located cervical branches of the uterine cavity
- DO NOT CUT ON THE 3 o’clock or 9 o’clock position because the
Nuchal arm blood supply of the cervix. It may cause severe bleeding.
- One or both arms
occasionally may be  Zavanelli maneuver
found around the back of - Last resort
the neck Replacement of the fetus higher into the vagina and uterus followed
 Rotating the fetus through half a by CS delivery can be used to rescue an entrapped breech fetus
circle in such a direction that the that cannot be delivered vaginally. (Push the head back)
friction exerted by the birth canal - This maneuver described for the protruding head with intractable
will serve to draw the elbow shoulder dystocia.
toward the face
 Fail to free the nuchal arm:  Symphysiotomy
- Push the fetus upward in an attempt to release it - Used to aid delivery of an entrapped aftercoming head.
 Rotation is still unsuccessful: - Using local analgesic, this operation surgically divides the
- Nuchal arm often is extracted by hooking a finger(s) over it and intervening symphyseal cartilage and much of its ligament support
forcing the arm over the shoulder, and down the ventral surface for to widen the symphysis pubis up to 2.5cm
delivery of the arm
o Fracture of the humerus or clavicle is very common Total breech extraction
A. Complete or incomplete breech extraction
Delivery of aftercoming head Method:
1. Mauriceau maneuver Hand is introduced through the vagina and both feet of the fetus are grasped
- Index and middle finger of Ankles are held with the second finger lying between them and with gentle
one hand are applied over traction, the feet are brought through the vulva.
the maxilla, to flex the 1st
head, while the fetal body - One foot should be drawn into the vagina but not through the introitus
rests on the palm of the 2nd
hand and forearm - Other foot advanced in a similar fashion
Method:
 As the fetal head is being delivered, flexion of the head is B. Frank breech extraction
maintained by suprapubic pressure provided by an assistant Extraction of a frank breech may be required and can be accomplished by
 Pressure on the maxilla is applied simultaneously by the operator as moderate traction exerted by a finger in each groin and aided by a generous
upward and outward traction is exerted episiotomy
Method:
2. Modified Prague maneuver Extraction of frank breech using fingers in groins
- Rarely, the back of the fetus fails to Once the hips are delivered, each hip and knee is flexed to deliver them from
rotate to the anterior. the vagina
- Consists of 2 fingers of 1 hand Pinard maneuver:
grasping the shoulders of the back- Frank breech decomposition
down fetus from below while the other - Aids in bringing the fetal feet within reach of the operator
hand draws the feet up over the 2 fingers are inserted along one extremity to the knee, which is then pushed
maternal abdomen away from the midline after spontaneous flexion
- Indication: FETAL BACK DOWN Traction is used to deliver a foot into the vagina

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*If you encounter a prolapse umbilical cord DO EMERGENCY CS
ANALGESIA AND ANESTHESIA DELIVERY!

 Continuous epidural analgesia

 2nd stage  prolonged significantly in women whose fetuses
weighed more than 2500 g
 Advantages:
1. Better pain relief
2. Increased pelvic relaxation

VERSION

 Procedure in which the fetal presentation is altered by physical

manipulation by:
 Substituting one pole of a longitudinal presentation for the
other
 Converting an oblique or transverse lie into a longitudinal
presentation
 External version
 Manipulations are performed exclusively through the
abdominal wall
 Internal version
 Accomplished inside the uterine cavity
1. External cephalic version
 Indications
 Breech presentation is recognized prior to labor in a woman who has
reached 36 weeks' gestation  external cephalic version should be
considered
 Contraindicated
1. Vaginal delivery is not an option
2. Placenta previa
3. Nonreassuring fetal status
4. Rupture of membrane
5. Known uterine malformation
6. Multifetal gestation
7. Recent uterine bleeding
 Relative contraindication
1. Prior uterine incision
 Complications
1. Placental abruption, uterine rupture, fetomaternal hemorrhage,
isoimmunization, preterm labor, fetal compromise, and even death
2. Maternal death due to amnionic fluid embolism

2. Internal podalic version

 Used only for delivery of a second twin
 With the membranes preferably still intact, a hand is inserted
into the uterine cavity to turn the fetus manually.
 Operator seizes one or both feet and draws them through the
fully dilated cervix while using the other hand transabdominally
to push the upper portion of the fetal body in the opposite
direction
 Followed by breech extraction

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