KELAINAN PRESENTASI

DAN LETAK

Dr.David Randel Christanto, SpOG., M.Kes

Bag. / SMF Obstetri – Ginekologi

FK.UNCEN / RSUD Jayapura
JAYAPURA
Vaginal Breech Delivery
Lois Jovanovic, MD
The Norbert Freinkel Lecture: Glucose mediated macrosomia: the over-fed
fetus and the future. Program and abstracts of the 61st Scientific Sessions of
the American Diabetes Association; June 22-26, 2001; Philadelphia,
Pennsylvania.

The Norbert Freinkel Lecture, an annual invited event at

the Scientific Sessions of the American Diabetes
Association since 1991, is awarded to a speaker
selected for outstanding contributions in the field of
diabetes and pregnancy. I am honored to be selected as
this year's speaker[1] and to provide tribute to Professor
Freinkel for his role as a mentor, scientist, and motivator
of a generation of researchers. The lifetime clinical and
laboratory research work of Professor Freinkel was
dedicated to the enhancement of our understanding of
the metabolic abnormalities of pregnancies complicated
by diabetes. He was the first to introduce the concepts
of "accelerated starvation" and "facilitated anabolism"
in the fasting and fed states during pregnancy. In
addition, he modified Pedersen's hypothesis of maternal
hyperglycemia as a basic cause of aberrant fetal
development, and viewed pregnancy complicated by
diabetes as a disorder of fuel metabolism. In fact, he
coined the term to describe this abnormal metabolic
state as "fuel-mediated teratogenesis."
Objectives
Incidence and
Significance
Selection
Management
– Intrapartum
– Delivery
 Definition
longitudinal lie
breech or lower extremity presenting
cephalic pole in the uterine fundus

Types
frank - flexed hips, extended
knees
complete - flexed hips, flexed knees
footling - extended hip(s)
 Types of Breech

Complete Footling Frank

Incidence
3 to 4% of all pregnancies
increases with decreasing gestational
age
– 7 to 10% at 32 weeks
– 25 to 35% at < 28 weeks
Etiology of Breech Presentation
idiopathic
prematurity (head to trunk size)
uterine or pelvic structural abnormality
uterine fibroid
fetal anomaly or abnormality
polyhydramnios
multiple gestation
Diagnosis
maternal perception of
movement
Leopold’s maneuvers
FH auscultated above umbilicus
vaginal exam
ultrasound
X-ray
 Recommendations for Breech
Delivery
recommend trial of labour at  36 weeks or
when estimated weight is 2500 to 4000
grams
offer trial of labour at 31 to 35 weeks
gestation or when estimated weight is 1500
to 2500 grams
offer caesasean section at  30 weeks
gestation or when estimated weight is < 1500
grams*
no recommendation for when estimated
weight is > 4000 grams*
* acknowledged lack of evidence for recommendation
 Selection Criteria for Trial of
Labour
frank or complete breech
fetal head not hyperextended
estimated fetal weight 2500 to 4000g
WILLIAMS OBST 2005
Methods of vaginal delivery:
1. Spontaneous breech delivery
entirely spontaneously
without any traction or manipulation
other than support of the infant
2. Partial breech delivery
3.Total breech delivery
HANNAH ET AL 2000
MORTALITAS MORBIDITAS

SC 3/ 1000 1,3 %

PERVAGINAM 3/ 1000 3,8 %

 INDIKASI SC
1. JANIN BESAR 9. ROJ
2. PSR 10. MOW
3. HIPEREKSTENSI 11. TIDAK ADA
4. ADA INDIKASI YANG
PARTUS LAMA BERPENGALAMA
5. DISFUNGSI N
RAHIM
6. INCOMPL OR
FOOTLING
BREECH
7. PRETERM
8. IUGR BERAT
Ultrasound Assessment
confirm lie and type of breech
assess head position
obtain estimate of fetal weight
assess for IUGR and congenital anomalies
assess amniotic fluid volume
confirm placental localization
 Contraindications to Trial of
Labour
fetal or maternal contraindication to labour
footling breech
hyperextension of the fetal head
absence of informed consent
absence of experienced maternity health care
giver
Management in Labour
planned delivery in hospital
admission in early labour or with ROM
appropriate fetal surveillance
epidural and ARM for usual indications
immediate vaginal exam at ROM to rule
out cord prolapse
good progress in labour ( 0.5 cm/h after
3 cm)
induction and augmentation permissible
Management at Delivery
experienced newborn resuscitator
present
empty maternal bladder
maternity attendant with experience in
breech delivery
forceps if available, may be helpful
Entering the Pelvis

Obstetrics - Normal and Problem Pregnancies, 2nd Edition

Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)
Descent of the Breech

Obstetrics - Normal and Problem Pregnancies, 2nd Edition

Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)
 Spontaneous
Expulsion
• spontaneous expulsion
to the umbilicus
• the sacrum should be
gently guided anteriorly
• singleton breech
extraction is
contraindicated
• C/S is indicated for
failure of descent or
expulsion
Obstetrics - Normal and Problem Pregnancies, 2nd Edition
Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)
 Hurry up &
Wait!
DON’T PULL!
traction deflexes the
fetal head
may cause nuchal
arm

Obstetrics - Normal and Problem Pregnancies, 2nd Edition

Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)
 Deliver Legs by lateral rotation of thighs
and flexion of knees - keep sacrum anterior

Obstetrics - Normal and Problem Pregnancies, 2nd Edition

Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)
Delivery of Arms
good maternal pushing
deliver when winging
of scapulae seen
rotate arm to anterior
sweep humerus across
the chest and deliver
rotate other arm
anterior and repeat to
deliver

Obstetrics - Normal and Problem Pregnancies, 2nd Edition

Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)
Avoid Over-extension

Obstetrics - Normal and Problem Pregnancies,2nd Edition

Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)
Delivery of the head
• Mauriceau - Smellie - Veit manoeuvre
to deliver the head in flexion
• The body should be supported in a
horizontal position
Delivery of the head

Obstetrics - Normal and Problem Pregnancies, 2nd Edition

Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)
 Delivery of the head
Forceps
assistant elevating
babe
direct application

Obstetrics - Normal and Problem Pregnancies, 2nd Edition

Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)
Prevention of Breech
consider external cephalic version at  36
weeks gestation for eligible candidates
success rate 30 - 70% depending on
experience
results in lower cesarean section rate
Conclusions
proper selection of patients
thorough explanation and informed consent
good progress in labour ( 0.5 cm/h after 3 cm)
induction and augmentation permissible
experienced attendants
standard fetal monitoring
assisted delivery - DON’T PULL - stay cool!
LABOR AND DELIVERY PROBLEMS
 BREECH PRESENTATION AT TERM

Management Quality of Strength of References

option evidence recommendation
Version in Evidence for reduced breech presentation at delivery Ia A 1
prenatal period and in cesarean section rate with external cephalic
version (ECV) at term
Tocolysis is associated with fewer ECV failures Ia A 2

Fetal vibroacoustic stimulation in medicine fetal Ia A 2

position is associated with fewer ECV failure
Need for fetal heart rate monitoring before and after III B 3
ECV
Apparent safety in women with a previous cesarean IIa B 4
section
No evidence to support postural management to Ia A 5
encourage spontaneous version
Fetal assessment Confirm diagnosis and determine placental side -  -

Confirm normality as association of breech III B 6

presentation with congenital anomaly

Assess fetal attitude-hyperextension of fetal head is III B 7

associated with spinal cord injury during vaginal
delivery
Labor and Evidence that planned cesarean section for breech at Ia A 8
delivery term as preferred method of delivery significantly
reduced perinatal mortality and morbidity
PRETERM BREECH PRESENTATION

Management Quality of Strength of References

option evidence recommendatio
n
Prenatal Evidence that external cephalic version Ia A 1
is not useful in preterm breech
presentation
Labor and Infant outcome worse with breech III B 2,3
delivery- presentation than vertex
general
Routine cesarean section would cause Ib A 4
iatrogenic prematurity
Preterm Confirm in labor, including vaginal -  -
breech examination
presenting in
Confirm normality -  -
labor
Confirm type of breech -  -

No strong evidence of benefit but III B 5-9

probably cesarean section preferred,
especially for 1000-1500 g
For babies less than 1000 g no evidence III B 9,10
of benefit from either mode of delivery
 PROLONGED PREGNANCY
Management Quality of Strength of References
option evidence recommendation
Prenatal: general Establish accurate gestational age as early as III B 1
possible
Menstrual dates overestimate gestation. Routine Ia A 2
early scan of value in preventing induction for “post
dates”
Breast stimulation does not reduce incidence of Ia A 2
postterm pregnancy
Sweeping membranes at term reduces chance of Ia A 5
pregnancy going beyond 41 weeks
Prenatal: at 41 Reevaluated for possible risk factors -  -
weeks
Routine induction of labor reduce perinatal Ia A 2
mortality
Active management:
Cervical ripening reduce risk of failed induction Ib A 4
Labor induction does not increase rate of cesarean Ia A 2
section or operative vaginal delivery if cervix made
favorable first
Expectant management :
Routine fatal movement counts alone have not Ib A 5
been shown to be of value in reducing perinatal
deaths-but no
Maternal perception of sound-provoked fetal III B 6
movements may be of value where facilities for
frequent nonstress testing (NST) are not available
Serial NST twice weekly at least helpful in
monitoring fetal wellbeing in postterm pregnancies IIa B 7
Fetal acoustic stimulation test may be of value in
those with a nonreactive NST Ia B 8
Managemen Quality of Strength of
evidence recommenda
t option tion

Perinatal: at Expectant management:

41 weeks Ib A
Assessment of amniotic fluid index versus vertical pockets
of amniotic fluid increases obstetric intervention
Biophysical profile twice weekly may be helpful for IIb B
monitoring fetal wellbeing but is time-consuming
Combination of just amniotic fluid volume and fetal acoustic
stimulation test may be acceptable III B

Umbilical artery Doppler has not been shown to be any

III B
better than NST
Labor and Manage as high-risk pregnancy - 
delivery
If umbilical cord compression from oligohydramnions – Ia A
amnionfusion is useful
Be vigilant for shoulder dystocia III B
RINGKASAN