CORRECTION

References
Breech delivery in ALARM ( Advance Labour And Risk Management ) International by PIT HOGSI 2013

PRETERM BREECH DELIVERY

VAGINAL DELIVERY VS. CAESAREAN SECTION

Breech the buttocks of the fetus enter the pelvis before the head The incidence of breech early pregnancy 40% at 20 weeks, 25% at 32 weeks, and only 3-4% by term Preterm birth < 37 completed weeks of pregnancy

Preterm breech perinatal mortality 2 to 4 fold the mode of delivery

Fetal malformations, prematurity, and intrauterine fetal death common causes of perinatal mortality.

(Hannah et al) obstetricians preterm breech delivery as a highrisk situation, dealt with by primary CS

risk of surgery to the mother from CS delivery of an early preterm breech fetus include the need for a vertical uterine incision, risk of haemorrhage, bladder injury, and uterine tears.

There are also risks in subsequent pregnancies : uterine rupture, placenta previa and placenta acreta.

Therefore the optimal route for delivery of preterm breech presenting fetuses remains a clinical dilemma.Grene R 1998.

IDENTITY
Name Age MR No. Date : Mrs. SD : 32 years old : 82 64 59 : April 27th 2013

Chief Complain:
A 32 years old patient was admitted to the Delivery Room of Dr. M. Djamil Central General Hospital on April 27th, 2013 at 12.40 pm referred by midwife with diagnose preterm pregnancy + Breech presentation.

Present Illness History

Feeling of pain from waist region which referred to the groin felt more frequent and getting stronger since 10 hours ago. Bloody show from the vagina was felt since 10 hours ago Fluid leakage from the vagina was absent No massive vaginal bleeding. Amenorrhea since 8 months ago. First date of last menstrual period was on September 1st 2012 Estimation date of delivery was on June 8th 2013 Fetal movement was felt since 3 months ago. No complain of nausea, vomiting and vaginal bleeding neither during early pregnancy nor late pregnancy. Prenatal care with midwife in primary health care every month since the age of pregnancy was 4 months, fetal and mother in a good condition. Menstruation History : menarche at 12 years old, regular cycle, once a month which last for 5 to 7 days each cycle with the amount of 2-3 times pad change/day without menstrual pain.

Previous Illness History

There was not previous history of heart, liver, kidney, DM and hypertension. There is no history of allergy

Family Illness History :

There was not history of hereditary disease, contagious and psychological illness in the family.

Occupation, Socioeconomics, Psychiatry, and Habitual History :

Marriage history: once in 2012 History of pregnancy/abortion/delivery: 1/0/0 Present History of family planning: (-) History of immunization: TT 2x on 3 and 4 month of pregnancy History of education : Senior High School graduated History of occupation : Housewife History of habit : Smoking (-), Alcohol (-), Drug abuse (-)

Physical Examination
GA Cons BP PR RR 20x/i T 370C

Body Height : 155 cms Mdt CMC 120/80mmHg 90x/i Body Weight before pregnancy : 52 kgs Body Weight after pregnancy : 65 kgs Body Mass Index : 22,73 kg/m2 Upper Arm Cirfumference : 24 cms Nutrition State : Normoweight Eyes : Conjunctiva anemic (-), sclera icteric (-) Neck : JVP 5-2 cmH2O, tyroid gland no enlarge Chest : H/L normal Abdoment : OR Genitalia : OR Extremity : Edema -/-, Physiological Reflex +/+, Pathological Reflex -/-

Obstetric Record:

Abdomen Inspection Enlargement in accordance with preterm pregnancy, median line hyperpigmentation, striae gravidarum (+), cicatrix (-) Palpation L1: Uterine fundal height was palpable 4 fingers below xiphoideus processus. A hard mass was palpable

L2: Greatest resistance was palpable on the left side. Numerous small, irregular structure were felt on the right side
L3 : A large nodular mass was palpable, not fixed L4 : not performed Uterine Fundal Height : 28 cm Estimated fetal body weight : 2015 gr Uterine contraction : 3x/40/strong Percution Tympani Auscultation Peristaltic sound was normal, Fetal heart sound: 142-150x/i

Genitalia

Inspection Inspeculo :

V/U normal , vaginal bleeding (-) Vagina Portio tumor (-), laceration (-), fluxus (-) tumor (-), laceration (-), fluxus (-), OUE was opened 4 cm

VT

4-5 cm Amnionic sac (+) Breech presentation H I

Pelvic inlet and pelvic outlet:

Inner pelvic examination:

Promontorium cant be reached Inominate line palpable 1/3-1/3 Sacrum os : concave Side walls : straight Ischial spine : protrude < 0.5 cms Coccygeus os : moveable Pubic arch : > 90

Outer pelvic examination

Inter tuberous distance could be passed through by normal adult fist (>10.5 cm)

Impression

: Not contracted pelvic

Laboratory Evaluation:
Result Normal Limit 3rd Trimester

Urinalyze Protein : (-) : (-) : 0-1/lpb : 0-1/lpb : (-) : (-) : (+) gepeng : (-) : (+) Glucose

Routine Blood Count

Haemoglobine Leucocyte Hematocryte Trombocyte Eritrocyte MCV MCH MCHC 11 14.100 32 339.000 4.200.000 83 27,5 32,1 9.515 g/dl 5.916.9/mm3 28.040.0% 146429/mm3 2.714.43/mm3 8292 m3 2731 pg 32-36 g/dl

Leukocyte Eritrocyte Silinder Kristal Epitel Bilirubin Urobilinogen

Baseline : 140-150 dpm Variability : 5-10 dpm Acceleration : (+) Deceleration : (-) Impressed : Reactive CTG

Fetal alive, singleton, intra uterine, head presentation Fetal Movement activity was good Biometri : BPD : 85,8 mm

FL : 65,3 mm

USG

Amnionic Fluid enough Fetal weight 2279 gr :

AC : 295 mm

Placenta in corpus anterior grade I-II

Impression : preterm pregnancy, Fetal alive

Plan
CS

Management Diagnose
G1P0A0 L0 preterm pregnancy 34-35 weeks first stage of active phase + labor in progress observation Fetal alive, singleton, intra uterine, breech presentation at HI Control GA, VS, FHS, Uterine Contraction CBC, urinalysis Antibiotic skin test Consult anesthesia Consult OR Informed consent

At 01.40 pm

At 01.45 pm
A Male baby was born by TPPCS

Diagnose
P1 A0 L1 post TPPCS on indication Preterm pregnancy + breech presentation + IUD acceptor

Action

TPPCS was performed

FW FH A/S

: : :

2200 gr 44 cm 8/9

Monitoring post surgery

Placenta was delivered by small traction, complete, 16 x 15 x 2 cm in size, 400 gr in weight, umbilical cords length 45 cm, insertion paracentralis. IUD Insertion was performed.

Mother-child were in care

Blood loss during operation 200 cc

LITERATURE REVIEW
Breech presentation when the buttocks of the fetus enter the pelvis before the head.

The incidence

Conditions predisposing contracted pelvis uterine anomaly fibroid uterus placenta previa multiple pregnancies polyhydramnios oligohydramnios fetal spina bifida (baby cannot kick well) fetal goiter (baby cannot flex its head) a hydrocephalic baby (the lower segment is too small).

The frank breech

Complete breech

Footling breech

Different kinds of breech presentations

CARDINAL MOVEMENTS WITH BREECH DELIVERY

Engagement and descent of the breech the bitrochanteric diameter in one of the oblique pelvic diameters.

The anterior hip usually descends more rapidly than the posterior hip when the resistance of the pelvic floor is met, internal rotation of 45 degrees usually follows, bringing the anterior hip toward the pubic arch and allowing the bitrochanteric diameter to occupy the anteroposterior diameter of the pelvic outlet. Descent continues until the perineum is distended by the advancing breech, and the anterior hip appears at the vulva. By lateral flexion of the fetal body, the posterior hip then is forced over the perineum, which retracts over the buttocks, thus allowing the infant to straighten out when the anterior hip is born. The legs and feet follow the breech and may be born spontaneously or require aid.

After the birth of the breech, there is slight external rotation, with the back turning anteriorly as the shoulders are brought into relation with one of the oblique diameters of the pelvis.

The shoulders then descend rapidly and undergo internal rotation, with the bisacromial diameter occupying the anteroposterior plane. Immediately following the shoulders, the head, which is 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. The head is then born in flexion

Anamnesis

Abdominal examination Leopold maneuver I,II,III,IV The fetal heart is best heard at the level of the umbilicus or above.

Vaginal examination Frank breech, Complete breech, footling breech

an ultrasound examination EFW, Fetal biometry, type of breech, head hyperexten sion star gazing

D I A G N O S E

The mother may complain of pain under the ribs.

PLANNING THE MODE OF DELIVERY

Vaginal delivery CS

METHODS OF VAGINAL DELIVERY :

1.Spontaneous breech delivery 2.Partial breech delivery 3.Total breech delivery

Reducing the incidence of breech presentations

External cephalic version (ECV) breech to vertex can be offered after 36 weeks. Cardiotocography should be done prior to ECV.

Use of tocolysis and regional anesthesia should be considered

Contraindications to ECV placenta previa, multiple pregnancy, antepartum hemorrhage, small-for-dates babies, and mothers with uterine scars, preeclampsia, or hypertension (risk of abruption is increased) Theoretical risks of ECV include placental separation (abruption), cord entanglement, premature rupture of the membranes, precipitation of labor

PLANNING THE MODE OF DELIVERY

According to ALARM recommendation for breech delivery:ALARM, 2013 It recommend for trial labor in breech presentation when gestational age 36 weeks or more or when estimated birth weight 2500 gram 4000 gram. It offered for trial labor when gestasional age 31-35 weeks or estimated birth weight 1500-2500 gram It offered for CS when gestasional age 30 weeks or less or when estimated birth weight less then 1500 gram. It not recommended for vaginal delivery when estimated birth weight more then 4000 gram.

If the score is 0-4, cesarean delivery is recommended If the score > 4 , vaginal delivery is recomended

VAGINAL BREECH DELIVERY

Preterm birth

is defined as delivery before 37 completed weeks of pregnancy.

Preterm birth is a concern because babies who are born too early may not be fully developed. They may be born with serious health problems.

The incidence of preterm birth in USA 8-10 % and in Indonesia, 16-18 % of all live birth

Academy of Pediatrics and the American College of Obstetricians and Gynecologists (1997) had earlier proposed the following criteria to document preterm labor:
Cunningham,2010

Contractions of four in 20 minutes or eight in 60 minutes plus progressive change in the cervix

Cervical dilatation greater than 1 cm

Cervical effacement of 80 percent or greater.

There are signs and symptoms of preterm labor : ACOG,2013

Change in type of vaginal discharge ( watery, mucus or bloody ) Increase in amount of discharge Pelvic or lower abdominal pressure Constant low, dull backache Mild abdominal cramps, with or without diarrhea Regular or frequent contractions or uterine tightening, often painless Ruptured membranes ( your water breaks with a gush or trickle of fluid )

Recommended Management of Preterm Labor : Cunningham,2003

Confirmation of preterm labor as detailed in Diagnosis For pregnancies less than 34 weeks in women with no maternal or fetal indications for delivery, close observation with monitoring of uterine contractions and fetal heart rate is appropriate. Serial examinations are done to assess cervical changes For pregnancies less than 34 weeks, corticosteroids are given for enhancement of fetal lung maturation

Consideration is given for maternal magnesium sulfate infusion for 12 to 24 hours to afford fetal neuroprotection For pregnancies less than 34 weeks in women who are not in advanced labor, some practitioners believe it is reasonable to attempt inhibition of contractions to delay delivery while the women are given corticosteroid therapy and group B streptococcal prophylaxis. Although tocolytic drugs are not used at Parkland Hospital, they are given at University of Alabama at Birmingham Hospital

For pregnancies at 34 weeks or beyond, women with preterm labor are monitored for labor progression and fetal well-being

For active labor, an antimicrobial is given for prevention of neonatal group B streptococcal infection.

Prevention of Neonatal Intracranial Hemorrhage

DISCUSSION
It has been reported a case of a 32 years old patient was admitted to the Emergency Room of Obstetrics and Gynecology Department of Dr. M. Djamil General Hospital on April 27th , 2013 at 12.40 pm referred by midwife with preterm pregnancy + breech presentation. After undergone few examination, the patient diagnosed with G1P0A0L0 preterm pregnancy 34-35 weeks first stage of active phase, fetal alive singleton intrauterine breech presentation HI. Then the patient undergo for Trans Peritoneal Profunda Caesarean Section. As a guide to the discussion on target academically comprehensive scientific then we will discuss some of the reference question are as follows : Whether the diagnose of this patient was right? Whether the management of this patient was appropriate? What the cause of preterm breech presentation in this patient?

WHETHER THE DIAGNOSE OF THIS PATIENT WAS RIGHT?

The diagnose of this patient was determined according to anamnesis, physical examination and supportive examination. From the anamnesis this patient was primigravida, and according to last menstrual period this is preterm pregnancy appropriate with 34-35 weeks with right assumption of the last 3 months menstruation regular cycle without contraception before and she was in labor.
Physical examination showed normal vital sign, and from Leopold, the impression was singleton pregnancy, breech presentation and the baby was alive. Through the vaginal examination,the impression was that she was in labor in first stage of active phase, breech presentation HI. From the ultrasound examination, we got impression preterm breech pregnancy. From first date of last menstrual period, gestational age is 34-35 weeks, with the uterine fundal was palpable 4 finger below processus xypoideus. As well as biometry result from ultrasound ( BPD 85,5 mm, FL 65,3 mm, AC 295 mm and estimated fetal body weight 2279 gr ) showed preterm pregnancy. From all of the ananmnesis, physical examination and supportive examination had appropriate to establish the diagnosis and we can conclude that the diagnosis of this patient was correct.

WHETHER THE MANAGEMENT OF THIS PATIENT WAS APPROPRIATE?

According to RCOG green top guideline

The routine caesarean section for the delivery of preterm breech presentation should not be advised.

recommendation for breech delivery, it still offer for trial labor when gestational age 31-35 weeks or estimated birth weight 1500-2500 g. This patient with gestational age 34-35 weeks and estimated birth weight 2015 g, According to so there was still a place for vaginal delivery than CS as a mode of delivery for ALARM this patient.

According to ZA Breech Scoring

ZA score for this patient is 6. It means vaginal delivery is recommended.

ACCORDING TO CUNNINGHAM
Malloy and co-workers (1991) studies of 437 very-low-birth weight breech newborns After adjusting for several variables, the risk of intraventricular hemorrhage and death was not significantly affected by the mode of delivery for fetuses weighing less than 1500 g.
It also said in breech presentation cesarean delivery is commonly, but not exclusively, used in the following circumstances: a large fetus, any degree of contraction or unfavorable shape of the pelvis determined clinically or with CT pelvimetry, a hyperextended head, when delivery is indicated in the absence of spontaneous labor, uterine dysfunctionsome would use oxytocin augmentation, incomplete or footling breech presentation, IUGR, previous perinatal death or children suffering from birth trauma, a request for sterilization, lack of an experienced operation

France, Kayem and co-workers (2008) described neonatal outcomes in 169 breech deliveries from 26 to 30 weeksThe neonatal death risk11 versus 7 percentwas similar in infants undergoing planned vaginal versus planned cesarean delivery.
Doe to all of circumstances for caesarean section above, when we compare with the condition of this patient as follow : the estimated fetal weight from USG only 2239 g, the patient came in labor ( in first stage of active phase ), type of breech is frank breech presentation, and there is no contracted pelvic clinically, but there is no data the absent of a hyperextended head. As a conclusion in this patient there was no contraindication for vaginal delivery.

According to Alarab, M Reyan, 2004, the diameter of bisacromial of the fetus is 11 cm , the diameter bitrochanterika of the fetus is 10 cm, the oblique diameter of the pelvic brim is 12 cm, and the transverse diameter of outlet pelvic is 11 cm. Based on all of the size above in breech presentation the sacrum of the fetus ( bitrachanterica diameter 10 cm ) enter the pelvic birm in the left sacro anterior position ( oblique diameter of the pelvic brim 12 cm ) while the shoulder ( diameter of bisacromial 11 cm ) enter and occupied the diameter transverse of the outlet pelvic ( 11 cm ). This mean the difficulty in delivering the shoulder will not happen, especially in this patient with the estimated birth weight only 2015g. However, it likely to be difficult in delivering the head, because in preterm fetus the head circumferential greater than abdominal circumferential. However, the differences of head and abdominal circumferential in 34-35 weeks pregnancy is only 0,7 1 cm, so the possibility of difficulties in delivering the head in this patient is small. Therefore in this patient we can offer trial for pervaginam delivery.

ACCORDING TO SEVERAL STUDIES THAT NOT SUPPORTING CAESAREAN SECTION IN PRETERM BREECH PRESENTATION

The authors concluded that operative delivery of a fetus in breech presentation in early preterm cases was not associated with increased survival without disability or handicap Wolf H et al, and that routine caesarean section is therefore not recommended.Wolf H et al,199
1999

Evidently, the route of delivery did not significantly influence outcome among complete and frank breeches, while abdominal delivery might offer some benefit for footling Cibilis LA et breeches.Cibilis LA et al, 1994
al, 1994

Thus, caesarean section was apparently associated with higher maternal morbidity and no neonatal benefits. Sthol HE et al, 2011 Sthol HE et
al, 2011

Based on several data above , choosing mode of delivery for this case a preterm breech with gestational age 34-35 weeks and birth weight < 2500 gram, there is still a place for vaginal delivery. Finally I can conclude that the management of this patient by performed cesarean section as a mode of delivery is less precise, but not incorrect.

WHAT THE CAUSE OF BREECH PRESENTATION IN THIS PATIENT?

Based on anamneses, physical examination and supportive examination of this patient we can exclude the causes as fhas been mentioned previously . This patient is primiparous with gestational age 3435 weeks and estimated birth weight 2015 gr. The cause of breech presentation in this patient is because preterm gestational age., at 34-35 weeks pregnancy amnionic fluid still in great quantities, and doe to the fetal weight small so that the fetus can freely move.Cunningham,2003 It could be the factor that caused breech presentation for this patient

CONCLUSION

The diagnosis in this patient was correct

Management in this patient was less appropriate

The possibility cause of breech presentation for this patient is due to preterm gestational age.