preterm breech

7/28/2019 Preterm Breech

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CORRECTION

References

Breech delivery in ALARM ( Advance Labour And Risk Management ) Internatio

PIT HOGSI 2013


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PRETERM BREEC

DELIVERY

VAGINAL DELIVERY VS. CAESAREAN SE


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Breech the buttocks of the fetusenter the pelvis before the head

The incidence of breech earlypregnancy 40% at 20 weeks, 25%at 32 weeks, and only 3-4% by term

Preterm birth < 37 completedweeks of pregnancy

Preterm breech perinatal

mortality 2 to 4 fold the mode of

delivery

Fetalmalformations,

prematurity, andintrauterine fetal

death commoncauses of

perinatal mortality.

(Hannah et al)obstetricianspreterm breech

delivery as a high-risk situation, dealtwith by primary CS

risk of surgery tothe mother from CSdelivery of an early

preterm breechfetus include the

need for a verticaluterine incision,

risk ofhaemorrhage,

bladder injury, anduterine tears.

There are also risks in subsequent

pregnancies :uterine rupture,

placenta previa andplacenta acreta.


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IDENTITY

Name : Mrs. SD

Age : 32 years old

MR No. : 82 64 59

Date : April 27th 2013

Chief Complain:

A 32 years old patient was aDelivery Room of Dr. M. DjamGeneral Hospital on April 27pm referred by midwife with

preterm pregnancy + Breech


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Present Illness History

Feeling of pain from waist region which referred to the groin felt more frequestronger 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 p

late pregnancy.

Prenatal care with midwife in primary health care every month since the agewas 4 months, fetal and mother in a good condition.

Menstruation History : menarche at 12 years old, regular cycle, once a month to 7 days each cycle with the amount of 2-3 times pad change/day without m


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Previous Illness History

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

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 (-)


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Physical Examination

Body Height : 155 cms

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

GA Cons BP

Mdt CMC 120/80mmHg 9


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Obstetric

Record:

Abdomen

Inspection

Enlargement in accordance with preterm pregnancy, median line hyperpigmentation, striae grav

Palpation

L1: Uterine fundal height was palpable 4 fingers below xiphoideus processus. A hard mass was p

L2: Greatest resistance was palpable on the left side. Numerous small, irregular structure were fe

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


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Genitalia

Inspection V/U normal , vaginal bleeding (-)

Inspeculo : Vagina tumor (-), lace

Portio tumor (-), laceopened 4 cm

VT : 4-5 cm

Amnionic sac (+)

Breech presentation H I

Pelvic inlet and pelvic outlet: Inner pelvic examination: Promontorium

Inominate lin

Sacrum os : co

Side walls : st

Ischial spine :

Coccygeus os

Pubic arch : >

Outer pelvic examination Inter tuberouthrough by no

Impression : Not contracted pelvic


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Laboratory Evaluation:

Result Normal Limit 3rd Trimester

Routine Blood Count

Haemoglobine 11 9.515 g/dl

Leucocyte 14.100 5.916.9/mm3

Hematocryte 32 28.040.0%

Trombocyte 339.000 146429/mm3

Eritrocyte 4.200.000 2.714.43/mm3

MCV 83 8292 m3

MCH 27,5 2731 pg

MCHC 32,1 32-36 g/dl

Urina

Protein : (-)

Glucose : (-)

Leukocyte : 0-1/lpb

Eritrocyte : 0-1/lpb

Silinder : (-)

Kristal : (-)

Epitel : (+) gepeng

Bilirubin : (-)

Urobilinogen : (+)


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Baseline : 140-150 dpm

Variability : 5-10 dpm

Acceleration : (+)

Deceleration : (-)

Impressed : Reactive CTG


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USG

Fetal alive, singleton, intra uterine, hpresentation

Fetal Movementactivity was good

Biometri :

BPD :

FL : 6

AC : Amnionic Fluid

enough

Fetal weight :2279 gr

Placenta in corpus anterior grade I-II

Impression : preterm pregnancy, Fe

alive


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Diagnose

G1P0A0 L0 preterm pregnancy34-35 weeks first stage of

active phase + labor inprogress observation

Fetal alive, singleton, intrauterine, breech presentationat HI

Management

Control GA, VS, FHS, UterineContraction

CBC, urinalysis

Antibiotic skin test

Consult anesthesia

Consult OR

Informed consent

Plan

CS


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At 01.40 pm

TPPCS was performed

At 01.45 pm

A Male baby was born byTPPCS

FW : 2200 gr

FH : 44 cm

A/S : 8/9

Placenta was delivered bysmall traction, complete, 16 x

15 x 2 cm in size, 400 gr inweight, umbilical cordslength 45 cm, insertion

paracentralis.

IUD Insertion was performed.

Blood loss during operation200 cc

Diagnose

P1 A0 L1 post TPPCS onindication Pretermpregnancy + breechpresentation + IUD

acceptor

Mother-child were incare

M

LITERATURE REVIEW


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LITERATURE REVIEW

Breech presentation

when the buttocks ofthe fetus enter thepelvis before thehead.

The incidence Conditions

contracted

uterine ano

fibroid uter

placenta pr

multiple pre

polyhydram

oligohydram

fetal spina bcannot kick

fetal goiter flex its head

a hydrocephlower segmsmall).


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The frank breech Complete breech Footl

Different kinds of breech presentations


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Engagement and descent of the breech the bitrochanteric diameter in one of the

The anterior hip usually descends more rapidly than the posterior hip when the refloor is met, internal rotation of 45 degrees usually follows, bringing the anterior hipand allowing the bitrochanteric diameter to occupy the anteroposterior diameter of

Descent continues until the perineum is distended by the advancing breech, and thethe vulva. By lateral flexion of the fetal body, the posterior hip then is forced over theretracts over the buttocks, thus allowing the infant to straighten out when the anteriand 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 ashoulders are brought into relation with one of the oblique diameters of the pelvis.

The shoulders then descend rapidly and undergo internal rotation, with the bisacromthe anteroposterior plane. Immediately following the shoulders, the head, which is nupon the thorax, enters the pelvis in one of the oblique diameters and then rotates ibring the posterior portion of the neck under the symphysis pubis. The head is then

CARDINAL MOVEMENTS WITH BREECH DELIVERY

Abdominal Vaginal an ultrasound


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Anamnesis

The mothermaycomplain ofpain underthe ribs.

Abdominalexamination

Leopoldmaneuver I,II,III,IV

The fetal

heart isbest heardat the levelof theumbilicus orabove.

Vaginalexamination

Frankbreech,Completebreech,footlingbreech

an ultrasoundexamination

EFW, Fetalbiometry,type ofbreech,headhyperextensionstargazing

D

I

AG

N

O

S

E


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PLANNING THE MODE OF DELIVERY

Vaginaldelivery

CS

METHODS OF


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METHODS OF

VAGINAL

DELIVERY :

1.Spontaneous breech

delivery

2.Partial breech

delivery3.Total breech

delivery


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Reducing theincidence ofbreechpresentations

External cephalic version (ECV) breech to vertex canafter 36 weeks.

Cardiotocography should be done prior to ECV.

Use of tocolysis and regional anesthesia should be co

Contraindications to ECV placenta previa, multiple pantepartum hemorrhage, small-for-dates babies, and

uterine scars, preeclampsia, or hypertension (risk of aincreased)

Theoretical risks of ECV include placental separation (cord entanglement, premature rupture of the membrprecipitation of labor



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According to ALARM recommendation for

breech delivery:ALARM, 2013

It recommend for trial labor in breech

presentation when gestational age 36weeks 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 30weeks 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

If the score > 4 , vaginal delivery is r

VAGINAL BREECH DELIVERY


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VAGINAL BREECH DELIVERY


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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 bproblems.

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

Academy of Pediatrics andthe American College ofObstetricians andGynecologists (1997) hadearlier proposed thefollowing criteria todocument 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 andsymptoms of pretermlabor : 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 )


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Recommended Management of Preterm Labor : Cunningh

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 uterinand 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 in

contractions to delay delivery while the women are given corticosteroid therapy and group B streptococcal prophylaxis. Although tocolyticused 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


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DISCUSSION

It has been reported a case of a 32 years old patient was adm

Emergency Room of Obstetrics and Gynecology Departmen

Djamil General Hospital on April 27th , 2013 at 12.40 pm

midwife with preterm pregnancy + breech presentation. Aftefew examination, the patient diagnosed with G1P0A0

pregnancy 34-35 weeks first stage of active phase, fetal aliv

intrauterine breech presentation HI. Then the patient underg

Peritoneal Profunda Caesarean Section. As a guide to the d

target academically comprehensive scientific then we will discthe 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?


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The diagnose of this patient was determined according to anamnesis, physical examexamination. From the anamnesis this patient was primigravida, and according to lais preterm pregnancy appropriate with 34-35 weeks with right assumption of the last

regular cycle without contraception before and she was in labo

Physical examination showed normal vital sign, and from Leopold, the impression was sinpresentation and the baby was alive. Through the vaginal examination,the impression wa

first stage of active phase, breech presentation HI.

From the ultrasound examination, we got impression preterm breech pregnancyof last menstrual period, gestational age is 34-35 weeks, with the uterine funda

finger below processus xypoideus. As well as biometry result from ultrasound (FL 65,3 mm, AC 295 mm and estimated fetal body weight 2279 gr ) showed pret

From all of the ananmnesis, physical examination and supportive examination hto establish the diagnosis and we can conclude that the diagnosis of this patien

WHETHER THE MANAGEMENT OF THIS PATIENT WAS A


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WHETHER THE MANAGEMENT OF THIS PATIENT WAS A

According toRCOG green top

guideline

The routine caesarean section for the delivery of ppresentation should not be advised.

According toALARM

recommendation for breech delivery, it still offer for trial lagestational age 31-35 weeks or estimated birth weight 1500patient with gestational age 34-35 weeks and estimated birso there was still a place for vaginal delivery than CS as a mthis patient.

According toZA Breech

Scoring

ZA score for this patient is 6. It means vaginrecommended.

ACCORDING TO CUNNINGHAM


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ACCORDING TO CUNNINGHAM

Malloy and co-workers (1991) studies of 437very-low-birth weight breech newborns

After adjusting for several variables, the risk ofintraventricular hemorrhage and death was

not significantly affected by the mode ofdelivery for fetuses weighing less than 1500 g.

France, Kayem and co-described neonatal ou

breech deliveries frweeksThe neonatalversus 7 percentwas

undergoing planned planned cesarean

It also said in breech presentation cesarean delivery is

commonly, but not exclusively, used in the followingcircumstances: a large fetus, any degree of contraction orunfavorable shape of the pelvis determined clinically or with CTpelvimetry, a hyperextended head, when delivery is indicated inthe absence of spontaneous labor, uterine dysfunctionsome

would use oxytocin augmentation, incomplete or footling breechpresentation, IUGR, previous perinatal death or children

suffering from birth trauma, a request for sterilization, lack of anexperienced operation

Doe to all of circumstances f

above, when we compare witpatient as follow : the estimaUSG only 2239 g, the patient

stage of active phase ), typbreech presentation, and th

pelvic clinically, but there is nhyperextended head. As a conthere was no contraindicatio

According to Alarab, M Reyan, 2004,


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g , y , ,

the diameter of bisacromial of the fetus is 11 cm , the diameter bitroch

fetus is 10 cm, the oblique diameter of the pelvic brim is 12 cm, and

diameter of outlet pelvic is 11 cm.

Based on all of the size above in breech presentation the sacrum o

bitrachanterica diameter 10 cm ) enter the pelvic birm in the left sacro an( oblique diameter of the pelvic brim 12 cm ) while the shoulder

bisacromial 11 cm ) enter and occupied the diameter transverse of the ou

cm ).

This mean the difficulty in delivering the shoulder will not happen, esp

patient with the estimated birth weight only 2015g.

However, it likely to be difficult in delivering the head, because in prehead circumferential greater than abdominal circumferential.

However, the differences of head and abdominal circumferential in

pregnancy is only 0,7 1 cm, so the possibility of difficulties in deliverin

this patient is small.

Therefore in this patient we can offer trial for pervaginam delivery.

ACCORDING TO SEVERAL STUDIES THAT NOT SUPPORTING CAESAREA


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ACCORDING TO SEVERAL STUDIES THAT NOT SUPPORTING CAESAREA

PRETERM BREECH PRESENTATION

Wolf H et al,

1999

The authors concluded that operative delivery of a fetus in breech prespreterm cases was not associated with increased survival without disaband that routine caesarean section is therefore not recommended.Wolf H

Cibilis LA etal, 1994

Evidently, the route of delivery did not significantly influence outcome aand frank breeches, while abdominal delivery might offer some benefitbreeches.Cibilis LA et al, 1994

Sthol HE etal, 2011

Thus, caesarean section was apparently associated with higher maternano neonatal benefits. Sthol HE et al, 2011


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Based on several data above , choosing mode of delivery forpreterm breech with gestational age 34-35 weeks and birth

2500 gram, there is still a place for vaginal delivery. Finally I cathat the management of this patient by performed cesarean s

mode of delivery is less precise, but not incorrect.

WHAT THE CAUSE OF BREECH PRESENTATIIN THIS PATIENT?


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IN THIS PATIENT?

Based on anamneses, physical examination and

supportive examination of this patient we canexclude the causes as fhas been mentionedpreviously .

This patient is primiparous with gestational age 34-35 weeks and estimated birth weight 2015 gr.

The cause of breech presentation in this patient is

because preterm gestational age., at 34-35 weekspregnancy amnionic fluid still in great quantities,and doe to the fetal weight small so that the fetuscan freely move.Cunningham,2003 It could be the factorthat caused breech presentation for this patient


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CONCLUSION

The diagnosis in thispatient was correct

Management in thispatient was less

appropriate

The possibilityof breech

presentation fpatient is du

preterm gestaage.

preterm breech

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