By :

Shandi Franswer
Triana Purwoningsih
Nurul aulia S. Putri

Supervisor

dr. Fadjrir M.ked (OG)

Breech Presentation
Definiti
on
Breech presentation is the
presentation in which the fetus is
longitudinal lie and its buttock is
the lower most part
Incidence 2-3% of term singleton
deliveries and about 25% of
cases before 30 weeks of
gestation.
 Classifications
Frank Breech (60-70%) : where the
hips are flexed and legs extended
Complete breech (10%) : where
the hips and knees are flexed and
the feet are not below the level of
the fetal buttocks
Footling breech : where one or
both feet are presenting as the
lowest part of the fetus
Kneeling : knees are the lowermost
 Etiology
Materna :
Polyhydramnios
Oligohydramnios Fetal
Uterine anomalies Fetal anomalies
Placental Mutiple pragnancy
abnormalies Shorth umbilical
cord
 Diagnosis
Abdominal Examination
 Diagnosing a breech
Palpation
The fetal head can be palapated at
uterine fundus
Auscultation
The fetal heart sound may be heard
above umbilicus
 Vaginal examination
Extended (frank) presentation
The ischial tuberosities, sacrum anus
and/or genitals may be palpated. In
addition, there may be meconium
staining of the examiners fingers
Complete presentation
The feet of the fetus may be palpated
with the buttocks
Ultrasonograph :
To confirm the diagnosis
To detect the type of breech
To detect gestational age and foetal
age
To exclude hyperextension of the
head
To exclude congenital anomalies
Breech index ( Zatuchni dan Andros)
 Zatuchni and Andros using "breech
index" to assessed several clinical
parameters of a case: When the
value 3: recommended to do a
Caesarean because if do the vaginal
delivery, it would improve perinatal
morbidity and mortality. Value 4: do
reevaluation estimated fetal weight
and observe to do a vaginal delivery.
Value 5: Safe enough for vaginal
 Indication
Vaginal delivery Sectio caesar

Presentation frank breech and complete EFW 3500 g or <1500 g

breech. Panggul sempit atau ukuran dalam nilai
Gastasional age 34 weeks borderline

EFW 2500-3800 gram Head defleksion or hiperekstension

Head flexion Premature membranes ruptured

Adequat pelvic (depend on x-ray pelvimetry) The lower part of foetus un-engaged

No indication of section Caesar on mother Late delivery

and feotus Primitua

Preterm (gestasional age 25-34 weeks)

Footling
 Mechanism of delivery
Engagement
Descent
Internal rotation
Lateral flexion
External rotation
Birth : breech then body then head
 Management during labour
Vaginal delivery
Spontaneous breech delivery
Assisted breech delivery/ manual aid
Total breech extraction
Cesarean section
 Indications of vaginal
delivery
1. Frank or complete breech
presentation
2. Gestational age > 36 weeks
3. Estimated foetal weight 2.5-3.5 kg
4. Foetal head must be flexed
5. Adequate maternal pelvis, x-ray or
ct pelvimetry
6. No other obstetric complications
 Management during labour
First stage :
Rest in bed avoid repeated vaginal examination to
prevent premature rupture of the membranes. But
vaginal examination is done after rupture of membranes
to exclude cord prolaps.
Second stage :
The cervix should be fully dilated and the fetal anus
visible on the perineum for active second stage
The women should be in lithotomy position
Delivery of the breech should be hands off
Legs and abdomen are born spontaneously.
Delivery of the aftercoming head :
Mauriceau Smellie Veit Maneuver
Burn Marshall Method
Mauriceau Smellie
Veit Maneuver

Burn Marshall Method

 Complication of breech
delivery
Maternal complication
Risk of operative
Fetal complications
intervention
Preterm delivery
Risk of infection due
to manipulations
and low birth
weight
Rupture of the uterus
Extentions of the
Prolaps cord
episiotomy Birth aphyxia
Post partum Fetal injury
hemorrhage
 Case report
Name :Mrs. E
Age :38 years old
Occupation :housewife
Religion :Islam
Ethnic group :Javanese
Address :st. Jemadi 1 Blok C No. 21
Date of entry :15 march 2017 (13.30 pm )
No.MR :74.19.79
Parity:G5P4A0
 ANAMNESIS
A patient mrs. E, 38 yo, G5P4A0, Javanese, Islam, SHS,
housewife, Mr. As wife, 45 yo, javanese, Islam, D3,
enterpreneur. 15 march 2017, came to pirngadi
general hospital at 02.00 am, with :
Main complaints : uterine contraction
Study : it is experienced by the patient since March
13th 2017 at 02:00 pm, history of vaginal bleeding
since March 14th 2017 10:00 pm, history of water
breaking (+).Micturition and defecation with in normal.
Previous Medical History: -
History of previous medication : -
Menstrual history :
LMP : ?/6/2016
EDD: ?/3/2017
ANC : -
Pregnancy History :
Male , aterm, 2900 gr, VB, midwife, clinic, 18 yo,
healthy.
Male , aterm, 2700 gr, VB, midwife, clinic, 13 yo,
healthy.
Female , aterm, 3000 gr, VB, SpOG, H, 8 yo, Healthy.
Male, aterm, 2700 gr, VB, SpOG, H, 1 yo, healthy.
Current pregnancy.
 Physical examination
Status presens Status Obtetricus
Sensorium :Compos Inspeksi
Mentis Abdomen : enlarged
BP :130/80 mmHg asimetricaly
RR :18 x/i Fundal Height : 3 fingers
HR :80 x/i below proc. Xypoideus
Temp :36,5C Unrestrained : left
Anemic :- Bottom : Buttocks
Jaundice :- Fetal movement : (+)
Uterine Contraction:
Syanosis :-
(3x30/10)
Dyspnoe :-
FHR : 120x/i
Edema:-
Status gynecology
VT : Cx anterior, diameter 9 cm, eff 100%, amniotic
membrane (-), sacrum at 5 oclock
Gloves : Blood Mucus (+), Amniotic Fluid (+)
USG :
BPO 91,8 mm
Fl 61,3 mm
AC 304,8 mm
Placenta korpus anterior
EFW 2730
Result : IUP (36-37) week + BP + LF
 LABORATORY
VALUE NORMAL VALUE
WBC 8,28 4,0-11,0
RBC 3,79 4,0-5,40
HB 8,5 12-16
PLT 329.000 150-400
DIAGNOSIS
MG + IUP (36-37) weeks + Breech
presentation+ Live Fetus + Inpartu (Active
phase)

Therapy
O2 2-3 l/m nasal canul
Observe progression of the labor

Plan
manual aid

 Manual aid Report

Born baby girl, BW 2700 gram, L
48 cm, AS 3/5, anus (+)
Mother laid on the gynaecology table with an iv line
seattled. The bladder was emptied. With adequate uterine
contraction, breech moves forward and backward in the
vaginal introitus and then confirmed to performed
mediolateral episiotomy. Buttocks is delivered first followed
by right foot-left foot to the umblical. Hold baby pelvis
firmly, provide traction rotation 180 back upwards. Causes
arm to sweep in front of face. Release arm by reachingover
shoulder, supporting humerus, press into cubital fossa to
flex arm. Sweep down over face and chest. Repeat in
opposite direction. Later, head is delivered with left index
and middle finger is placed on the malar bones, while the
right index and ring fingers are placed on the respective
shoulders and the middle finger on the sub occipital region.
To achieve flexion, traction is now given in downward
and backward direction and simultaneous suprapubic
pressure is maintained by the assitant until the nape of
the neck is visible. Thereafter, the baby is pulled in
upward and forward direction so that the face is born
and by depressing the trunk the head is born. Borned
Baby girl, BW 2700 gr, BL 48 cm, AS 6/7, Anus (+). The
umbilical cord clamped between two places and incised
while waiting 5-10 minutes. Plasenta is delivered
spontaneously complete. Evaluated the birth canal
found episiotomy wounds. Anatomic catgut No 2.0
repair is done. General condition of mother post partum
is good.
LABORATORY POST LABOR
VALUE NORMAL VALUE
WBC 12,87 4,0-11,0
RBC 12,87 4,0-5,40
HB 10,3 12-16
PLT 323.000 150-400
FOLLOW UP
 Date 15 March 2017 (07.00 am) 16 March 2017 (07.00 am)

Main complain Post oparated wound pain Post oparated wound pain
Status Present Sens: CM Sens: CM
TD : 110/80mmHg TD : 130/80 mmHg
HR : 76x/i HR :82x/i
RR : 16x/i RR : 20x/i
Temp: 36,8 C Temp: 36,7 C
Anemis : - Anemis :-
Sianosis : - Sianosis : -
Ikterik : - Ikterik : -
Dypsnoe : - Dypsnoe : -
Oedema : - Oedema : -

Status L,ocalisata Abdomen : Abdomen :

Soepel, peristaltik (+) normal
Fundal height : 1 finger below navel
P/V : (-), lochia rubra (+)
BAK : (+)
BAB : (+)
Soepel, peristaltik (+) normal
TFU: 3 fingers under umbilical
P/V : (-), lochia rubra (+)
BAK : (+)
BAB : (+)

Diagnosis Post Manual Aid a/i breech presentation + NH1 Post Manual Aid a/i breech presentation + NH2

Therapi IVFD Ringer Laktat + Oxytocin 10 cc 20 IVFD Ringer Laktat + Oxytocin 10 cc 20

gtt/i gtt/iI
Cefadroxil tab 2 x 500 mg Cefadroxil tab 2 x 500 mg
Mefenamic acidtab 3 x 500 mg Mefenamic acidtab 3 x 500 mg
Vit B Complex 2 x 1 tab Vit B Complex 2 x 1 tab

Rencana - --Aff Infus

-mobilistion
 Cases analisa
Teori Kasus

Definition In these patients breech presentation is found on

Breech presentation is the presentation in which the leopolds examination and ultrasound
fetus is longitudinal lie and its buttock is the lower
most part
Vaginal delivery This is the 5th pregnancy with history vaginal delivery.
Presentation frank breech The gestasional age is 36-37 weeks.
Gastasional age 34 weeks Enable to manual aid in clinically
EFW 2500-3800 gram
Head flexion
Pelvic adequate (depend on x-ray pelvimetry)
No indication of section Caesar on mother or feotus

Zathucni andros breech index In case :

Multiparity
Clinical parameters such as parity, gestational age,
Gestasional age 36-37 weeks
estimated fetal weight, history of breech delivery, EFW 2700
Cervical dilatation >4cm
cervical dilatation, decreased buttocks. Values> 5 do
Decreased buttocks : low
the vaginal delivery No history of breech delivery
Breech index >5, vaginal delivery
Mortality increased on frank breech and maximum on In case, frank presentation and there is no cord
footling breech, where frequent possibility cord
 Problems
What is the underline of the vaginal
delivery of this case?
How we handle the case until the
patient referenced to the proper
hospital as a general practitioners ?
TERIMA KASIH