BREECH BIRTH

BACKGROUND
Pregnancy is an enjoyable and expected state for every mother as well as for entire family in our
society. Even though pregnancy is a natural outcome of a congenial marriage, it is biologically,
physiologically and psychologically stressful. Having borne this stress during the pregnancy, both
the mother and fetus are exposed to their greatest danger at childbirth. This may be fatal for either
or both or may lead to prolonged disability if any complication arises. To avert these potential
adverse outcomes, pre-natal, natal, and post-natal care are aimed at identification, assessment
and management of women whose pregnancies are at risk because of existing or potential
complication.
The World Health Organization (WHO) defines all pregnancies as HIGH RISK due to the inherent
dangers the mother and the fetus are exposed to at the time of delivery in the absence of trained
help. Therefore, maternal and infant mortalities are high amongst those with poor access to trained
obstetrical help, as in the developing countries. In Nepal, on an average, twelve women die daily
either due to complication of pregnancy or childbirth. In order to standardize the documentation of
impact of health delivery system on maternal health, the WHO has introduced the Maternal
Mortality Rate (MMR). Maternal mortality has been defined by the WHO as THE DEATH OF A
WOMAN WHILE PREGNANT OR WITHIN FOURTY-TWO DAYS OF TERMINATION OF
PREGNANCY, IRRESOECTIVE OF THE DURATION AND SITE OF PREGNANCY,FROM ANY
CAUSE RELATED TO OR ITS MANAGEMRENT BUT NOT FRIM ACCIDENTAL OR INCIDENTAL
CAUSES. Maternal mortality rate measures the risk of a women dying from puerperal causes
and is defined as the maternal mortality per 100,000 live births in a given area and year. The
National survey conducted in 2006AD estimated the Maternal Mortality as 281/100,000 live births
that means everyday 6 and every year approximately 2066 mother die of pregnancy. Among total
maternal mortality 90% occurs in rural area. According to the Nepal Maternal Mortality and
Morbidity Study of 1998AD, 62% mother die after the birth of the baby, 28% die during pregnancy,
10% die during labour. According to the Nepal Family Health Survey of 1996AD, approximately
40% of all pregnancies fall into the high risk category, emphasizing the necessity of accessible
trained obstetrical care in the community.
The determinants of maternal mortality are categorized into direct, indirect and contributory
causes, to understand and locate resources to address the prevalence of high maternal mortality.
A direct obstetric death result from complication of pregnancy, labor or puerperium, and is closely
equated to true maternal death. The important causes of direct maternal death are ante and postpartum hemorrhage, obstructed labor, eclampsia, puerperal sepsis and complication of abortion.
These, collectively account for more than 70% of maternal deaths. Indirect obstetric death occurs
because of pregnancy, in presence of pre-existing disease state (e.g. heart valve disease, collagen
vascular disorder etc.) or due to development of a new disease in presence, pregnancy (e.g.
hepatitis, anemia etc.).
Contributory causes to maternal mortality include socio-economic status, maternal illiteracy,
traditional factors and unavailable health services.

INTRODUCTION

A case study is an important learning technique with specific educational objectives. A case study
provides the chance to integrate theoretical knowledge with clinical practice with focus on a
specific or a set of problems. As the basic concept of case study can be applied to many situations
and is popular amongst many disciplines as a modality of imparting knowledge. As a student of
Bachelor of Nursing, we are required to undertake a study on high risk pregnancy as an emphasis
on the national policy to improve the maternal and child health.

About fifty years ago it was not uncommon to know of someone who had died during child birth. At
that time, every young women about to become a mother was practically concerned about her
wellbeing. A healthy baby was considered an extra dividend. From the obstetrical viewpoint,
maternal survival was of primary importance and in some instances, even the living fetus was
sometimes sacrificed for the mother safety.

The focus of obstetric care has changed during the past years because of advances in the
management of disorders that have an adverse effect on the pregnant women. However, there has
been a less significant reduction in perinatal mortality and morbidity. In many ways, morbidity
exerts a more profound economic effect than mortality.

Since the fetus in any pregnancy is now at greater risk than the mother is, the concept of AT RISK
applies to both maternal and fetal outcome. A HIGH RISK pregnancy is one in which THE
MOTHER OR FETUS HAS A SIGNIFICANTLY INCREASED CHANCE OF DEATH OR
DISABILITY WHEN COMPARED WITH A LOW RISK PREGNANCY IN WHICH AN OPTIMAL
OUTCOME IS EXPECTED FOR BOTH.

The aim of obstetric care is to concentrate resources on improving peri-natal outcome. It is thus
important to identify those at risk and then to provide the specific care required to prevent death or
disability.

OBJECTIVE OF HIGH RISK CASE STUDY

GENERAL OBJECTIVE

The purpose of high risk case study is to provide an exercise for the student to promote knowledge
and skill in obstetric care, so that she becomes aware of the hazards of supposedly normal
pregnancies in the community. This will provide an impetus to detect pregnancies at risk once the
trained nurse returns to her community.

SPECIFIC OBJECTIVE

1.
2.
3.
4.

Identify high risk pregnancies.

Elucidate the history and reveal the reason(s) why the pregnancy is high risk.
Learn to perform systemic and obstetrical examination methodically and correctly.
Identify abnormalities, anticipate problems, plan and take appropriate action during labour
and post-natal period to avoid mortality and morbidity.
5. Plan and implement comprehensive care of the client, using the knowledge gained from
basic science and nursing theory.
6. Formulate nursing diagnosis and priorities nursing care plan according to patients needs.
7. Provide holistic nursing care to the client and visitors using the nursing process.
8. Provide emotional and physical support to mother during the conduct of delivery and in the
peri-natal period.
9. Help mother in establishing parent infant relationship.
10. Observe and evaluate the care given to the baby by mother and provide comprehensive
guidance.
11. Identify needs and post-natal complication in mother and infant by interview and physical
examination.
12. Alleviate pain and discomfort in the patient by applying nursing measures and
administering analgesics as per prescription.
13. Teach mother and family about hygiene, self care and baby care for promotion of health
and prevention of disease.
14. Work together with client, family members and other health worker to plan the discharge
and follow up care of the mother and the baby.
15. Acquaint one-self with the equipments, procedures and facilities used in the management
of high risk pregnancies.
16. To study, document and present a high risk pregnancy case report.

HIGH RISK PREGNANCY: IMPLICATIONS

High risk pregnancy is defined as a pregnancy in which the result is found to be poor for the
mother and the foetus; before, during and after delivery. Thus in High risk Pregnancy the mother
and the foetus are at a higher risk for morbidity and mortality due to problems that arise during
pregnancy either due to conception or due to other health problems which are pre-existent or

newly acquired during the pregnancy. Having mentioned the definition of high risk pregnancy, we
should not equally forget that every pregnancy is potentially at risk.

The incidence of high risk pregnancies in the developed countries is 25% while in the developing
countries the value is about 45%. This group of patients is responsible for 70%-80% of perinatal
morbidity and mortality. Thus in order to reduce the maternal and perinatal mortality rate and
improve on the obstetrical result, we must identify this group and provide appropriate supervision
and facility for successful delivery.

DEFINITIONS & CONCEPTS

RISK FACTORS:

A risk factor is a link in a chain of associations leading to an illness. The risk factor may itself be an
indicator of disease. Thus in pregnancy, parity, age, height, Birth canal condition, birth interval and
presence of disease become some of the determinants of health of the mother and the newborn
around childbirth. Thus, the risk factor may be already present or introduced early in pregnancy or
be introduced early in the pregnancy or be introduced late during the process of labour.

RISK RATIO:

Risk ratio is the ratio between the prevalence of disease condition among exposed population to
that among the unexposed. This index is used in the assessing the likelihood that an association
represents a casual relationship.

RISK APPROACH:

This concept is promoted by the WHO to identify the group at risk or the target group e.g. at the
risk mothers, infants, families; chronically ill; handicapped; elderly etc. in a defined population as
per certain distinctive criteria and then direct appropriate resources to them first. This management
concept is known as the Risk Approach. This is summed up as something for all, but more for
those in need in proportion to the need. The risk approach is a managerial device for increasing
the efficacy of health care services within the limits of existing resources.

The risk approach implies identification of high risk case at an ealy stage and makes available
skilled care from the point of identification. The main aim of risk approach is to improve the
efficiency and objectiveness of the maternal and child health services through maximum utilization
of available resources including nursing care.

CATEGORIES OF HIGH RISK PREGNANCY

MATERNAL AND PARIETY FACTORS:

i.
ii.
iii.
iv.
v.
vi.
vii.

Maternal age of sixteen years and under.

Nullipara at thirty-five years or over.
Multipara at forty years or over.
Interval of eight years of more since last pregnancy.
High parity (five or more children).
Pregnancy occurring three years or less since last delivery.
Non-marital pregnancy.

PREGNANCY INDUCED HYPERTENSION, KIDNEY DISEASE:

a)
b)
c)
d)
e)

Pre-eclampsia with hospitalization before labour.

Eclampsia.
Kidney disease: Pyelonephritis, Nephrotic syndrome etc.
Severe chronic hypertension (160/100mmHg).
Blood pressure of 140/100mmHg or more on two different occasions.

ANAEMIA AND HAEMORRHAGE:

a.
b.
c.
d.

Haematocrit (PCV) of 30% or less in pregnancy.

Severe hemorrhage in previous pregnancy requiring transfusion.
Hemorrhage in the present pregnancy ( Ante-partum hemorrhage)
Anemia (Hb: 10gm %) for which treatment other than iron supplement was
required.
e. Sickle cell disease and trait.
f. History of bleeding or clotting disorder.

FOETAL FACTORS:

a. Two or more previous premature deliveries. (Delivery of twins is considered a single

b.
c.
d.
e.
f.
g.

delivery.)
Two or more consecutive spontaneous abortions.
One or more still-births at term.
One or more births with gross congenital anomaly.
ABO or RH incompatibility or iso-immunization.
History of previous birth defects e.g. cerebral palsy, brain damage.
History of large baby weighing more than nine pounds.

MOTHERS SURGICAL CONDITION:

a.Pelvic floor restoration or any pelvic surgery.

b.Previous surgery of uterus (e.g.myomectomy)
c.
Surgery of ectopic pregnancy.

CEPHALO-PELVIC DISPROPORTION & DYSTOCIA:

a.
b.
c.
d.
e.

Cephalo-pelvic disproportion
Two or more deliveries
Multiple pregnancies in the present pregnancy (twins, triplets etc.)
Previous operative deliveries (caesarean section, mid-cavity forceps delivery etc.)
History of prolonged labour (> 18 hours for primigravida & > 12 hours for multigravida)
f. Previously diagnosed abnormality of the maternal pelvis and genital tract
g. Short stature of the mother (Height:140cm).
h. Malposition and Malpresentation (Breech presentation)

a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.

CONCURRENT ILLNESS IN THE MOTHER:

Diabetes Mellitus. Gestational Diabetes
Hyper emesis gravidarum
Thyroid dysfunction: Hypothyroidism/Hyperthyroidism
Malnutrition or extreme obesity
Organic heart disease
Syphilis & TORCH infections
Tuberculosis or other pulmonary pathologies
Malignant, pre-malignant & locally invasive tumors (including H.Mole)
Alcoholism & drug addiction
Psychiatric disease or epilepsy
Mental retardation

MISCELLANEOUS:
a. Those with history of late registration
b. Those with poor clinical attendance

c. Those with weak family support

FACTORS THAT PLACE THE PREGNANCY AND FOETUS IN

HIGH RISK
FIRST TRIMESTER

CATEGORY

RISK FACTOR

Gross foetal chromosomal abnormality

Hydatidiform mole
Poor trophoblast

Multiple pregnancies

2. PSYCHOLOGICAL

Psychological shock
Hyperemesisgravidarum

3. THERAPEUTIC

Abortion
Drug therapy
Radiotherapy / X- ray

4. INFECTION

Viral infection

5. GENETIC

Sporadic Mutation, Sex- linked recessive

chromosomal disorders

6. ENVIRONMENT

Poverty
Malnourishment
Tobacco, Alcohol, Drug abuse

1. PHYSIOLOGIC

SECOND TRIMESTER

CATEGORY

RISK FACTOR

1. ANATOMIC

Maternal uterine abnormality

Incompetent cervical os
Gross foetal abnormality
Acute hydraminous
Multiple pregnancies
Poor implantation

2. MATERNAL
FACTORS

Rh incompatibility
Hypertension

Renal disease
Urinary tract infection
Heart disease
Accidents
Anoxia of eclampsia or epilepsy

3. INFECTION

4. INVESTIGATIVE
PROCEDURE
5. ENVIRONMENTAL

Polio, Syphilis, Hepatitis (esp. HEV),

HIV/AIDS, other viral infection
Amniocentesis

6. IDIOPATHIC

Poverty, Malnourishment, Tobacco, Alcohol,

Drug abuse etc.
-

THIRD TRIMESTER
CATEGORY

RISK FACTOR

1. ANATOMIC

Mal-presentation
Cord complications
Placenta previa

2. MATERNAL

Rh incompatibility
Hypertensive disease
Diabetes
Thyrotoxicosis

3. INFECTION

Viral infection
Pneumonia
Other inter-current infection
Anti-thyroid drugs
Steroids
Anti-convulsants
Anti-coagulants

Protein-Energy Malnutrition
Iron deficiency
Premature rupture of membrane
Preterm labour
Post-maturity
Hydramnious or oligohydramnious
Multiple gestations

Poverty, Tobacco, Alcohol, Drug abuse

Inadequate nutrition

4. DRUGS

5. NUTRITIONAL
6. FOETAL
COMPLICATIONS

7. ENVIRONMENTAL

NURSES ROLE IN MANAGEMENT OF HIGH RISK

PREGNANCY

1. Detect, categorize and place the patient in the high risk category during antenatal period
2. Identify the risk factor(s) early in the antenatal period and report them promptly to the
treating obstetrician.
3. Educate the patient and family members regarding the risk factor(s), the need for regular
antenatal check-ups and the necessity for hospital delivery rather than home delivery.
4. Be vigilante and anticipate complications during labour; take necessary precautionary steps
and report them to the treating obstetrician.
5. Motivate the parents to adopt suitable family planning method, or adopt puerperal
sterilization if the family is complete.

BIOGRAPHICAL DATA : MOTHER

NAME

: ANITA GURUNG

AGE

: TWENTY SEVEN (27 YEARS)

EDUCATION

: TEN (10 CLASS)

ADDRESS

: VYAS 1, DAMAULI

ETHNIC GROUP

: GURUNG

RELIGION

: HINDU

OCCUPATION

: HOUSEWIFE

DURATION OF MARRIAGE

: EIGHT (8 YEARS)

HUSBANDS NAME

: SHYAM DHOJ GURUNG

AGE

: THIRTY SIX (36 YEARS)

EDUCATION

: SLC

OCCUPATION

: ABROAD

NAME OF HOSPITAL

: WESTERN REGIONAL HOSPITAL

WARD

: MATERNITY WARD

BED NUMBER

: 10 (ANC)

IN PATIENT NUMBER

: 1016482

BLOOD GROUP OF MOTHER

: A POSITIVE

DATE OF ADMISSION

: 2068/03/21

DATE OF DISCHARGE

: 2068/03/22

DURATION OF STAY IN HOSPITA

: ONE (1 DAY)

PROVISIONAL DIAGNOSIS

: G2P1 @ 38+4 WEEKS OF PREGNANCY WITH

BREECH PRESENTATION WITH LEAKING

ATTENDING DOCTOR

HISTORY TAKING

: DELLA SINGH JOSHI

History taking is a very important component in the treatment of a patient. Histories regarding the
main complaints direct the care giver to the site of the pathology/altered anatomy & help to reach a
diagnosis. History taking also starts the patient-caregiver rapport, which is essential for effective
care & patient satisfaction.

Mrs. GURUNG was booked case of Western regional hospital. She had total five ANC visit. Her
last ANC visit was at approximately37 +2 week. She came for admission on 21th of Aahar at 9:30am.
She felt leaking of amniotic fluid since 2068/03/20 at 4am.

Chief complaint:

Amenorrhea since nine (9) months.

Leaking of amniotic fluid since 2068/03/20 at 4am

History of Present illness:

History of amenorrhea since nine months.

Feeling of quickening at 16+ weeks of pregnancy. Normal fetal movement at the
time of admission.
On regular antenatal check-up at the department of obstetrics, since tenth weeks of
amenorrhea.
No history of fever, drug/medication use, trauma bleeding per vagina, hypertension
etc.
History of mild morning sickness for first four month.
Mild edema present in lower limbs

Menstrual History:

Age at menarche
Menstrual cycle
Duration of menses
Interval in between menstruation
Amount of flow
History of mild dysmenorrheal

Marital History:

Duration of marriage : Eight years

: Twelve years (12 yrs)

: Regular
: Five-six days (5-6 days)
: Twenty-eight to thirty days (28-30 days)
: Normal

Mrs. Anita Gurung got married at the age of nineteen years (19 yrs.). Her marriage is within same
cast. She and her husband have a delightful married life, with a loving husband-wife relationship.
They have been using mechanical method (condom) as the contraceptive for family planning.

Family History:

Mrs. Anita Gurung lives in a joint family with her husband. Her husband is third child in
his family among three siblings. Her sister-in-laws are already married and settled
elsewhere. Mrs. Anita herself is elder child among the two siblings. No any significant
history in her family. Within her husbands family, her fatherin-law is a chronic
alcoholic and smoker and her mother-in-law is under the medication of Asthma. Out of
this, there is no any other significant history in her family.

Family Tree
Anitas
Family

Anitas
Husbands
Family

Key

Male

female
Patients
husband
Patient
Newbor
n
Personal history:

Mrs. Gurung is an educated housewife. She is a non-vegetarian and her diet consists of rice,
pulses, beans, green vegetables, meat and fish. Her diet consists of rice with ghee, jaulo, juanoko-jhol, meat and soup after she delivers. She has a good appetite. Her bowel and bladder habit is
normal.
There is no any significant history of drug allergy. She has good personal hygiene. She neither
smoke nor drink alcohol.

Socio-economic Status:

Mrs. Anita Gurungs family belongs to middle class Nepali family. Her family depends on pension
and her husbands job(abroad). She herself is unemployed.

Past Medical History:

The past medical history provides an idea regarding the general wellbeing of the patient. There are
certain medical and surgical conditions, when present, can affect the mother and fetus.

she has no history of:

Heart disease
Hypertension
Renal disease
Infection: Hepatitis, HIV/AIDS, Leprosy etc.
Diabetes
Drug allergies
Seizure disorders
Injury/deformity of the pelvis.

Past obstetric History:

She has a seven (7) years old son. She had antenatal check up at the health post of
Damauli but for the delivery she came to Western Regional Hospital. She delivered a male baby
weighing 2.5kg on 2061/03/06. She had a normal vaginal delivery and there were no any
significant problem to her as well as her baby during delivery and during the post natal period.

Present Obstetric History:

Last Menstrual Period (LMP)

: 2067/06/24

Expected Date of Delivery (EDD)

: 2068/03/31

Gravid

: G2

Parity

: P1+0

Gestational Age

: 38+4 weeks

Mrs. Gurung confirmed her pregnancy by doing urine for pregnancy test in Western Regional
Hospital as doctors advice. She had done the test three weeks after missing her regular cycle.
She had only mild degree of morning sickness and did not need to take any medications. Her
trimesters were eventful with regular ANCs at the department of OBG, Western Regional Hospital.
The antenatal record is given below:

ANTENATAL RECORD

Urine:

Blood

P.O.G.

Fundal

(Kg)

Oedema

Alb/glu

Pressure

(Weeks)

Height

-/-

nil

90/70

7+2

USG to
detect
blighted
ovum

-/-

nil

90/60

16+2

14

54

-/-

nil

90/70

21+2

20

RBS report,
USG

068/02/16

53

T.T1st
dose,contin
ue iron
calcium

57

-/-

nil

90/70

34+2

35

140

Confirm
breech
presentation by USG,
f/u 3 weeks

068/03/06

067/10/10

52

F.H.S

Remarks

Date

Pallor/

067/11/16

067/08/13

Wt.

58

-/-

nil

90/70

37+2

TS

134

f/u after 3
weeks or
SOS

OTHER INVESTIGATIONS:

Hb

: 11.6 gm%

Random blood sugar

: 90 mg/dl

Platelet

: 148,000

VDRL

: Non reactive

HBsAg

: Negative

HIV

: Negative

Blood group

: O positive

Ultrasound: Obstetric Scan:

Date of USG: 2067/11/16

Single live fetus in the uterine cavity, with regular cardiac activity and normal fetal activity
The placenta is situated at the anterior and upper uterine
The gestational age by the BPD.FI and HC corresponds to 19-20 weeks.
Presentation is breech
No gross congenital anomaly is detected.

The liquor volume is adequate.

Date of USG: 2061/01/12

Single life fetus in the uterine cavity, with regular cardiac activity and normal fetal activity
The placenta is situated at the anterior and upper uterine clear of internal os
The gestational age by the BPD.FI and HC corresponds to 34 weeks.
Presentation is breech
No gross congenital anomaly is detected.
The liquor volume is adequate AFI 7

PHYSICAL EXAMINATION

Physical examination follows history taking, and is done in a systemic manner with special
emphasis on the site of pathology. The physical examination data correlated with subjective data of
history taking aids to reach a working diagnosis direct the investigation and formulate a treatment.

The following are the steps of physical examination:

Inspection
Palpation
Percussion
Auscultation

Her general physical examination carried out on the day of admission revealed:

Pallor

: No any

Icterus

: No any

Clubbing

: No any

Oedema

: No any

JVD

: No any

Lymph nodes

: No any

Vital Signs:

Blood pressure
: 90/60 mm of Hg
Pulse
: 72/min regular, good volume
Respiratory rate
: 18/min
Temperature
: 98.6F
Weight
: 51 Kg
Height
: 150cm

General Physical Examination:

General physical examination is done in cephalo-caudal approach that is head to toe.

General Appearance:
Her general condition is good, though she looked a bit apprehensive. She had a slightly
uncomfortable gait due to the gravid uterus and leaking. Her personal hygiene was maintained.

Head & neck:

Examination of the head revealed well groomed black hair, healthy scalp without infestation
or infection.
Her ears are symmetrical with well formed auricles. There were no signs of infection and
her hearing was good.
Her eyes are symmetrical; the pupils are bilaterally equal and reacting to light. The extraocular muscle movements are coordinated. There are no sign of infection.
Her nose is normally shaped and without deformity.
The examination of the mouth and the oral cavity revealed adequate oral hygiene.
The examination of the neck did not reveal any mass or gland enlargement.

Chest:

No obvious deformity of the chest evident.

Examination of the respiratory system revealed adequate air entry bilaterally with clear
lung fields.
Examination of the cardiac area revealed the apex to be at left fifth intercostals space in
the mid-clavicular line. The first and second heart sounds heard in all four cardiac
auscultatory areas were normal.
Examination of breasts revealed well-developed, symmetrical breasts with central, normal,
hyperpigmentated nipple surrounded by the areola. No obvious mass was palpable in the
breast matrix. No cracks on the nipple are evident.

Spine & Extremities:

No spinal deformity evident on physical examination.

The extremities are symmetrical and functionally normal.

Obstetrical Examination:

The obstetrical examination consists of abdominal and pelvic examinations. The obstetrical
examination is continuous process of assessment, especially around the time of labour when the
status of both the mother and the fetus are changing dynamically.
The purpose of the pre-natal examination is to:

Determine the size of the uterus & correlate with the gestational age. This helps to
anticipate complications if any e.g. twins, SGA babies, polyhydramnious, oligihydramious
etc.
Assess the state of previous caesarean scar if present.
Determine the lie & presentation of the fetus. Assess the progression of labour.
Detect any maternal or fetal abnormality and take corrective steps to prevent any
complication.

Abdominal Examination:
(Finding at the time of admission at 9:30am):

Inspection
- The abdomen was uniformly distended and ovoid in shape.
- Striae gravidera & linea nigra were present.

Palpation:
- Fundal height: 38 weeks of gestation. (chronological age of gestation: 38+4 weeks )
- Fetal movement appreciated.
- Lie
: Longitudinal
- Presentation
: Breech
- Presenting part
: Not engaged.
- Uterine contraction is present

Auscultation:
- Fetal Heart Sound (FHS) heard on the right side of the abdomen, at the umbilicus
level.
- Fetal Heart Rate : 130/minute regular

Percussion
- Not applicable

Pelvic examination:

No swelling or varicose vein of the external genitalia

Not any discharge
Per Vaginal (P/V) Examination
Os
: 4 cm
Effacement

: 30%

Membrane

: Absent

Presenting part: High up

Clinical impression: G2P1+0 38+4 weeks with breech presentation with

Leaking in active stage of labor.

Plan: VAGINAL DELIVERY

BREECH PRESENTATION

INTRODUCTION:

It is the commonest malpresentation.in breech presentation the lie is

longitudinal, podalic pole present in pelvic brim, presenting diameter is bitrochantric and the
denominator is sacrum.
A breech birth is the birth of a baby from a breech presentation. In the breech presentation the
baby enters the birth canal with the buttock or feet first as opposed to the normal head first
presentation.

INCIDENCE:
The incidence is about 1 in 5 at 28 th week and drops to 5% at 34 th week and to
3% in term. Thus in 3 out of 4 spontaneous correction into vertex presentation occurs by 34 th week
because the greater proportion of amniotic fluid facilitate free movement of fetus. The incidence is
expected to be low in hospital where high parity birth are minimal and routine external cephalic
version is done in antenatal period.

TYPES:

Complete
Incomplete

Complete
The normal attitude of full flexion is maintained. The thigh are flexed at the hips and
the legs at the knee. The presentating part consists of two buttock, external genitalia and two feet.
It commonly present in multipara (10%).

Incomplete
This is due to varying degree of extension of thighs or legs at the podalic pole. Three
varieties are possible (25%).

Breech with extended legs(frank breech)

In this condition, the thigh are flexed on the trunk and legs are extended knee joint. The
presenting part consists of the two buttocks and external genitalia only. It is commonly present in
primigravida, about 70%. The increase prevalence in primi gravida is due to a tight uterine tone
and early engagement of breech that inhibits flexion of the legs and free turning of the fetus.

Footling Breech

Both the thigh and the legs are partially extended bringing the legs to present at the brim.
This is rare condition.

Knee presentation
Thighs are extended but the knee are flexed, bringing the knees down to present at the
brim. This is very rare.

In addition to the above, breech births in which the sacrum is the fetal denominator can be
classified by the position of a fetus. Thus sacro-anterior, sacro-transverse and sacro-posterior
positions all exist, of which sacro-anterior indicates an easier delivery.

Clinical varieties:
In an attempt to find out the dangers inherent to breech, breech presentstion is clinically
classified as:

Uncomplicated:
It is defined as one where there is no other associated obstetric apart from the breech,
prenaturity being exeluded.

Complicated:
When the presentation is associated with condition which adversely influence the
prognosis such as prematurity, twins, contracted pelvis, placenta previa etc. it is called complicated
breech. Extended legs extended arms, cord prolapse or difficulty encountered during breech
delivery should no be called complicated breech but are called complicated or abnormal breech.

Epidemiology:
Frequency

United States
Incidence is correlated to gestational age (see Table 1 below). However, the overall
frequency is 3-4% at delivery.

Table 1: Gestational age and frequency of breech birth

Gestational Age, Weeks

Breech, %

21-24

33

25-28

28

29-32

14

33-36

37-40

Mortality/Morbidity:

Many complications can result from breech presentation. They are generally related to
complications of the fetal abnormalities that may be the primary reason for the breech
presentation and those related to umbilical cord compression resultant from abnormal
progression through the maternal pelvis.

Increased birth trauma: As the duration of umbilical cord compression increases, the
practitioner tries to deliver the infant more rapidly than advisable, thus increasing the
incidence of birth trauma.

Incidence of prolapsed umbilical cord depends on type of breech presentation.

Footling, 17% incidence

Complete, 5% incidence

Frank, 0.5% incidence

Umbilical cord abnormalities: Cord length may be reduced, and, in footlings, there is an
increased risk of the cord coiling around the legs of the fetus.

Etiology:

1.Prematurity: it is the commonest cause of breech

2.Factors preventing spontaneous version:
Breech with extended legs
Twins
Oligohydraminos
Congenital malformation of the uterus such as septste or bicorunated
Short cord ,relative or absolute
Intrauterine death of the fetus
3.Favorable adaptation:

Hydrocephalus- big head can be well accommodated in the wide fundus

Placenta previa
Contrcted pelvis
Cornufundal attachment of the placenta- minimizes the space of the fudus where the
smaller head can placed comfortably
Undue mobility of fetus:
Hydraminos
Multipara with lax abdominal wall
4.Fetal abnormality:

Trisomies 13, 18 21 and myotonicdystrophy due to alteration of fetal muscular tone and
mobility
5.Recuurent or habitual:

On occasion, the breech presentation recurs in successive pregnancies. When it recurs in

three or more consecutive pregnancy, it is called habitual or recurrent breech. The probable
causes are congenital malformation of the uterus or bicorunated, and repeated cornufundal
attachment of the placenta.

Diagnosis

Ultrasonography: It is most informative

1. It confirm the clinical diagnosis- especially in primigravida with engaged frank breech or
with tense abdominal wall and irritable uterus.
2. It can detect fetal congenital abnormality and also congenital anomalies of the uterus.
3. It measure biparietal diameter, gestational age and approximate weight of the fetus.
4. It also localized the placenta.
5. Assessment of liquor volume (important for ECV)
6. Attitude of the head- flexion or hypertension.
Radiology: A straight X-ray rarely done
1.
2.
3.
4.

To confirm the clinical diagnosis

To exclude bony congenital malformation (hydrocephalus)
To note the size of the baby
To note the position of the limbs and the head

Clinical: the diagnostic feature of a complete breech and a frank breech are given below in the
tabulated form.

Clinical Diagnosis of Breech Presentation

Complete breech

Frank breech

Per abdomen
Fundal grip

Head suggested
globular mass

by

hard

Head is ballottable

Head- irregular small pars of the

feet may be felt by head the side
of the head.
Head is non ballottable due to
splinting action of the legs on the
trunk
Irregular parts are less felt on the
side

Lateral grip

Fetal back is to one side and the

irregular limbs to the other
Breech suggested by soft,
broad and irregular mass

Pelvic grip

Small hard conical mass is felt.

The breech is usually engaged

Breech is usually not engaged

during pregnancy
Usually located at a higher level
round about the umbilicus

Located at a lower level in the

midline due to early engagement
of the breech

Fetal heart sound

Per vagina
During pregnancy

Soft and irregular parts are felt

through the fronix

Hard feel of the sacrumis felt, often

mistaken for the head.

Palpation of ischial tuberosities,

sacrum and the feet by the side
of buttocks.

Palpation of ischial tuberosities,

anal opening and sacrum only

During labour

The foot is identified by the

prominence of the heel and
lesser mobility or the great toe

Position: The sacrum is the denominator of the breech and there are four positions. In anterior
position, the sacrum is directed towards the iliopubic eminences and in posterior position, the
sacrum is directed to the sacro iliac joints. The positions are
Left sacro anterior (LSA)
Right sacro anterior (RSA)
Left sacro posterior (LSP)
Right sacro posterior (RSP)

Antenatal management

Identification of the complicating factors related with breech presentation

External cephalic version

External version is a non-surgical method in which a doctor can help move the baby
within the uterus. A medication to help relax the uterus might be given as well as an
ultrasound exam, to better check the position of the baby, the location of the
placenta, and the amount of amniotic fluid in the uterus. Gentle pushing on the
lower abdomen can turn the baby into the head-down position. Throughout the
external version, the baby's heartbeat will be checked closely so that if any
problems should occur, the health care provider will stop turning immediately. Most
attempts at external version are successful; however, as the due date gets closer
this procedure is more difficult.

Time of version: 35-37 weeks but can be attempted at any time there after up to early
stage of labour.

Contraindication of external cephalic version:

1. Antepartum haemorrhage (placenta previa or abription) _risk of placenta separation
2. Fetal causes- congenital anomalies(major), dead fetus, hyperextentionof the head, fetal
compromise(IUGR)
3. Multiple pregnancy
4. Rupture membrane- with drainage of liquor
5. Known congenital malformation of the uterus
6. Contracted pelvis
7. Previous cesarean delivery risk of scar rupture.
8. Obstetric complication- severe pre- eclampsia, obesity, elderly primigravida, bad obesteric
history.
Danger of external cephalic version:
1.
2.
3.
4.

Premature rupture of membrane

Premature rupture of membrane
Placental separation and bleeding
Entanglemen of the cord rou8nd the fetal part or formation of a true knot leading to
impairment of fetal circulation and fetal death
5. Increase the chance of feto-maternal bleed
6. Amniotic fluid embolism
Management, if version fail or contraindicated: two method of delivery can be planned

To perform an elective cesarean section

To allow spontaneous labour to start and vaginal breech delivery to occur

Vaginal Breech delivery

Vaginal breech delivery is considered in cases with adequate pelvis, average fetal weight(between
1.5 and 3.5kg), flexed head and without any other complication. Frank breech is preferred. In all
such cases one must ensure close monitering of labour and facilities for immediate cesarean
delivery should necessity arises.

Management of Vaginal Breech Delivery

First stage of labour

The management protocol is similar to that mentioned in normal labour. The fallowing are the
important consideration. Spontaneous onset labour increases the chance of successful vaginal
delivery.
1.
2.
3.
4.

Vaginal examination is indicated

At the onset of labour
Soon after rupture of membrane to exclude cord porolapse
An intravenous line is sited with ringer,s solution, oral intake is avoided, blood is sent for
group and crossmatching (considering the chance of cesarean section)
5. Adequate analgesic is given, epidural is preferred
6. Fetal status and progress of labour are monitered
7. Oxytocin infusion may be used for augumentation of labour
Second stage of labour: there are three method of vaginal delivery
1. Spontaneous: expulsion of the fetus occurs with very little assistance. This is not preffered.
2. Assisted breech: the delivery of the fetus is by assistance from the beginning to the end.
This method is employed in all cases
3. Breech extraction: when the entire body of the fetus is extracted by the obstetrician. It is
rarely done these days as it produces trauma to the fetus and the mother. Indications are:
Delivery of the second twins after internal podalic version
Cord prolapse
Extended legs arrested at the cavity or at the outlet
Mechanism of labour
Sacro- anterior position (being the commonest)

Buttocks

The diameter of engagement of the buttocks is one of the oblique diameters of the inlet.
The engaging diameter is bitrochantric (10cm) with the sacrum directed towards the ilio
pubic eminence. When the diameter passes through the pelvic brim, the breech is engaged
Descent of the buttocks occurs until the anterior buttocks touches the pelvic floor.

Internal rotation of the anterior buttock occurs through 1/8 th of a circle placing it behind the
symphasis pubis.
Further descent with lateral flexion of the trunk occurs until the anterior hip hinges under
the symphasis pubis which is released first fallowed by the posterior hip
Delivery of the trunk and lower limb fallow
Restitution occurs so that the buttocks occupy the original position as during engagement
in oblique diameter.
Shoulder

Bisacromial diameter (12cm) engages in the same oblique diameter as that occupied by
the buttocks at the brim soon after the delivery of the breech.
Descent occurs with the internal rotation of the shoulder bringing the shoulders to lie in the
antero- posterior diameter of the pelvic outlet. The trunk simultaneously rotates externally
through 1/8th of a circle.
Delivery of the posterior shoulder fallowed by the anterior one is completed by anterior
flexion of the delivered trunk.
Restitution and external rotation: untwisting of the trunk occur putting the anterior shoulder
towards the right thigh in LSA and left thigh in RSA. External rotation of the occiput through
1/8th of a circle anteriorly. The frank trunk is now posiioned as dorso anterior

Head

Engagement occurs either through the opposite oblique diameter as that occupied by the
buttocks or through the transverse diameter. The engaging diameter of the head is
suboccipio- frontal (10cm)
Descent with increasing flexion occurs.
Internal rotation of the occiput occurs anteriorly, through 1/8 th or 2/8th of the circle placing
the occiput behind the symphysis pubis.
The head is born by flexion- the chin, mouth, nose,forehead, vertex and occiput appearing
successively. The expulsion of the head from the pelvic depends entirely upon the bearing
down efforts and not at all on uterine contraction.

Prognosis

Maternal:
Labour is usually not prolonged but because of operative delivery including cesarean section, the
morbidity is increased. The risk include trauma to the genital tract, operative vaginal delivery
(episiotomy, forcep), cesarean section, sepsis and anesthetic complication. As a consequence
maternal mobidity is a slightly raised.

Fetal:
The fetal risk in term of perinatal mortality is considerable in vaginal breech delivery. It is difficult to
assess the magnitude of the real risk, because the complicating factors such ad prematurity, birth
trauma, congenital malformation of the fetus that contribute significantly to the fetal hazards. The

corrected (excluding fetal abnormality) perinatal mortality ranges from 5-35per 1000 birth. The
overall perinatal mortality in breech still remains 9-25% compared with 1-2% for non breech
delivery. Perinatal death is 3 to 5 times higher than the non breech presentation. The fetal mortality
is least in frank breech and maximum in footling presentation, where the chance of cord prolapse
is more. Gynaecoid and anthropoid pelvis are favorable for the aftercoming head. The fetal risk in
multipara is no less than that of primigravida. Thos is because of increased chance of cord
prolapsed associated with flexed breech. The factorswhich significantly influences the fetal risk
are:

Skill of the obstetrician

Weight of the baby
Position of the legs
The type of the pelvis

The fetal danger

The fetal dangers in vaginal delivery are as fallow:

Intracranial hemorrhage:-compression fallowed by decompression during delivery of the

unmoulded aftercoming head results in tear of the tentorium cerebelli and haemorrhage in
the subaracnoid space. The risk is more with preterm babies.
Asphyxia: it is due to
Cord compressions soon after the buttocks are delivered and also when the head enters
into the pelvis. A period of more than 10 minutes will produce asphyxia of varying degree
Retraction of the placental site
Premature attempt at respiration while the head is still inside
Delay delivery of the head
Cord prolapse
Injuries: the fallowing injuries are inflicted during manipulative deliveries
Haematoma- over the sternomastoid or over the thighs.
Fracture- the commonest sites are femur, humerus, clavical, odontoid process.
There may be dislocation of the hip joint, mandible or 5 th and 6th cervical vertebrae
and epiphyseal separation.
Visceral injuries include rupture of liver, kidneys, suprarenal glands, lungs and
haemorrhage in the testicles.
Nerve- medullary coining, spinal cord injury, starching of the brachial plexus to
cause either Erbs palasy or klumpke palasy
Some of the injuries may prove fatal and contribute to perinatal mortality. Long term(neurological)
mobidity of the surviving infants should not be underestimated.

SCHEME FOR MANAGEMENT OF BREECH DELIVERY

ANTENATAL ASSESSMENT

Fetal wellbeing, weight, attitude

Maternal health(obstetric and medical)
Maternal pelvis

Elective cesarean section

(>38weeks)

External cephalic version

Around 36 weeks or
after
In the labour suite
With tocolytic if needed
Fetal monitering
(CTG)before and after
procedure

Successful

Estimated fetal weight

Hyperextended head
Associated complication
(obstetric and medical)
Pelvic inadequancy

Fail

Delivery as
vertex
Vaginal breech
delivery

Assisted breech
delivery

Elective cesarean delivery

Average fetal
weight
Frank breech
Flexed head
Adequate
pelvis
Cesarean section
Arrest of progress
Fetal distress (Non-reassuring FHR)

Leaking of Amniotic Fluid

Amniotic Fluid is the watery liquid that surrounds the baby / fetus within the uterus. This Amniotic
Fluid allows the baby / fetus to move about freely without the hindrance caused by the uterus walls
being too tight around it. At the same time, this fluid helps provide a cushioning within the uterus
and gives the fetus buoyancy.
This Amniotic Fluid begins to fill up the Amniotic Sac from about 2 weeks of fertilization. Another 10
weeks later, the fluid contains different proteins, carbohydrates, electrolytes, lipids, phospholipids
and even urea, which provide nutrition to the fetus. Towards the later stages of pregnancy, the
amniotic fluid also begins to contain fetal urine. It has also been recently discovered that the
amniotic fluid also contains non-embryonic stem cells.
Leaking of Amniotic Fluid
Normally, when the pregnancy completes the full term, the membranes of the amniotic sac burst
and the amniotic fluid begins to leak out via the vagina. This is called Spontaneous Rupture Of
Membranes or SROM. In common parlance, this is also termed as the time when a womans
Water Breaks.
However, there are times, when the amniotic sac may develop a tear or may rupture causing the
amniotic fluid to leak before term. When this occurs 37 38 weeks before term, it is referred to as
Premature Rupture Of Membrane or PROM.
When either of these cases occurs, the fluid may just gush out or may just leak out in a continuous
trickle like a discharge.
When the premature rupture of amniotic sac occurs, it is necessary to determine the cause of the
leaking amniotic fluid. Normally, the leaking is caused by a bacterial infection or by a defect in the
structure of the amniotic sac or the uterus or the cervix. The mother-to-be is advised not to douche
or have intercourse when the water breaks.
This leakage may lead to further complications for the growth of the fetus, as it may hamper the
growth of the fetus and may cause bacterial infection to spread from the vagina to the uterus and
consequently to the fetus.
Sometimes when there is a small tear in the amniotic sac, it may heal itself over a period of time
and the leaking may simply stop of its own accord.
However, if the leaking amniotic fluid is a result of a severe rupture of the membranes of the
amniotic sac, then labor may begin within 48 hours. When this happens, the mother-to-be must
receive treatment in order to avoid causing an infection to the fetus.
Often what is thought of as leaking amniotic fluid can just turn out to be the urine. Therefore, in
such cases, the mother-to-be must ascertain if the fluid is urine or not. It is advised to wear a
sanitary napkin and observe the color of the liquid. The amniotic fluid is colorless. The mother-tobe must never use a tampon during pregnancy.

If the leaking amniotic fluid is brownish-yellow, green, or any other color, the mother-to-be is
advised show it to her physician and go to the hospital right away. The mother-to-be is also
advised to note down the color of the fluid and the time when the leaking began and tell her doctor
about these details.
In such cases, most physicians will usually deliver the baby within 24 hours in order to avoid
infection risk.
Nowadays, many over the counter products are available to test whether the fluid is urine or
amniotic fluid. It is always recommended that one avail of these tests to ensure the health of the
baby.

COURSE OF EVENTS AT THE HOSPITAL

Mother sent to labor room (first stage) from admission room for Normal Vaginal Delivery

Management in the first stage of labor:

Mother was kept in the comfortable position.

Assessment of physical and mental status: a complete physical examination was
done to find out any abnormalities including general condition of the patient, Vital
signs, FHS.
Psychological preparation: Emotional support was given to the patient and
explained about the procedure.
Ordered investigations were sent like RBS, CBC and Urine R/E and reports were
also collected.
Half hourly monitoring of Fetal Heart Sound and correct recording and reporting
was done.
Augmentation with injection oxitocin was started according to doctors order.
Partograph was filled to monitor the progress of labour.
Intake and output was monitored.
Mother was encouraged for adequate fluid intake like black tea, hot soups etc. to
prevent dehydration.
Cervix was fully dilated at 7:30 pm and mother was taken to second stage of labour.
Equipments/ materials required for the normal vaginal vaginal delivery was kept
ready.
Management in the second stage of labor:

Mother was shifted to the second stage (delivery room) and kept comfortably on the
delivery bed with the head elevated 450.
Mothers Vital signs and Fetal Heart Sound was also monitored and recorded.

She was encouraged to push during strong contraction.

Strict aseptic technique was maintained during delivery.
She delivered a live female baby at 08:00 pm weighing 2250 gm.
Kangaroo mother care was provided to the baby.
Babys sex was shown to the mother.

Management of the third stage of labour:

As soon as the baby was delivered injection Syntocin 10 units I/M was given.
Post delivery Vital signs were taken and recorded.
Placenta was delivered using Control Cord Traction and placenta was observed;
which was complete and normal.
Vagina was carefully observed and cleaned.
Wet dress of the mother was changed.
She was encouraged to massage the uterus every 15 minutes for 5 minutes.
Teaching about breast feeding, perineal hygine, cord care was given.
Mother was transferred to the post natal ward.

MANAGEMENT OF THE NEWBORN BABY

Immediately after the baby was born, she was received in dry, clean wrapper and
transferred to the warmer, which had already been prepared to receive the baby.
After placing the baby under the warmer, the nose and oral cavities were suctioned free of
secretions with sterile ET suction catheter. The babys APGAR was scored.
The heel of the baby was flicked to stimulate him to cry/breath.
Umbilical cord was clamped with sterile thread and its redundant length trimmed.
The baby was cleaned around the eyes, mouth and nose with clean paraffin soaked
gauze. The baby was then cleaned from head to toe.
The baby was weighed: 2250 gm
The baby was checked for maturity and presence of any obvious congenital birth defect.
APGAR: Rapid assessment tool to assess cardio-respiratory and neurological status of the
newborn. It is determined by the level of oxygenation.
1.
2.
3.
4.
5.

A: Appearance
: Pink or blue
P: Pulse
: Heart rate
G: Grimace
: Reflex immutability
A: Activity
: Muscle tone: Normal or flaccid.
R: Respiration : Normal, laboured, shallow or apnoeic

APGAR score of the baby born to the patient under study:

Parameters

APGAR 1 minute

APGAR 5 minutes

Heart Rate

Respiratory Rate

Muscle Tone

Reflex Immutability

Colour

Total

IMMEDIATE NURSING CARE OF THE NEONATE

The newborn is in complete dependence of it caretakers. The nurse has to ensure the baby does
not aspirate the amniotic fluid and that the baby maintains hoemeostatis. Thus the main objectives
of taking care of newborn are to:

Establish and maintain a patent airway

Maintain normal body temperature
Promote mother infant bonding
Provide optimal nutrition
Protection from infection and injury

Maintain a patent airway:

The oropharynx and nostrils are suctioned with bulb-suction once the head is delivered. The
mouth is suctioned first to avoid amniotic fluid or mucous aspiration.
Once the baby is delivered, the baby is placed in a lateral decubitus, 15 head down position
to facilitate drainage of secretions under a radiant warmer or on the mothers abdomen.
The oropharynx and nostrils are suctioned to ensure clearance of secretions.
Maintain stable body temperature:
Dry the baby with a soft warm towel
Wrap the baby in a pre warmed blanket
Place the baby under a radiant warmer
Avoid unnecessary exposure
Check the babys temperature every 15 min for the first hour if required
Promote mother infant bonding:

 Show the baby to the mother/ parents as soon as is possible, and reveal the sex of the baby.
Place the baby close to the face of the parents so that bonding/attachment can be initiated.
Initiation of breast feeding:
Put the baby to the mothers breast as soon as it is feasible.
Teach the mother about on demand feeding.
Teach the mother to burp the baby after every feed to prevent regurgitation/ vomiting.
Protection from Infection and Injury:
Wash hands or use sterile gloves when handling newborns.
Divide the umbilical cord with sterile scissors and apply sterile disposable umbilical cord
clamp to the babys end of to umbilical cord stump.
Wipe the eyes of the baby with sponge towel wet with pre-boiled water.
Sponges bathe the baby with warm water.
Mother must be taught to maintain good personal hygiene. She must keep her nail short to
prevent injury to the newborn
Avoid unnecessary handling of the baby

ASSESSMENT OF THE NEONATE

OBJECTIVE:

We all expect our newborn to be normal, kike us, not realizing that there are others for no fault of
theirs are born with horrendous defects which could snuff the existence or worse still, leave a
person maimed forever. Thus, the objective of assessing the newborn is to detect any congenital
anomalies, injury, infection that could require intervention in any way. The other main objective is to
help the baby maintain homeostasis in the face of adverse environment. To list the objective:

Detect congenital anomalies and plan out treatment where relevant.

Detect birth injury any other acquired illness.
Record the vital statistics of the baby.
Maintain homeostasis.

Measurement:

Parameters:

Measured value

Reference value

Head circumference

31.2 cm

31-35 cm

Chest circumference

30.4 cm

30.54-33.00 cm

Vertex to heel length

47.6 cm

48-53 cm

Body weight

2250 gm

2700-4000 gm

Vital signs

Temperature

Pulse

Respiratory Rate

98.0 F

146/min

44/min

GENERAL PHYSICAL EXAMINATION OF THE NEONATE

Appearance:

General:
The face, Chest, tongue & lips were pink. The extremities (hands & feet) were mildly cyanotic.
The head was flexed and resting on the on the chest, the arms were flexed on the chest while the
thighs were flexed up on the abdomen.

Skin:
Skin was pinkish and slightly puffy and smooth.
Vernix caseosa and lanugo hair were present.
The face, legs, feet and dorsa of the hands were puffy.
Head
No caput present.
Anterior fontanelle: diamond shaped
Posterior fontanelle: triangular shaped
No deformity present around the scalp.
Eyes
Closed eyes, Oedematous eyelids.
Absence of tears.
Ears
The top 1/3 rd of the ear crosses the imaginary line joining the outer canthus of the eye to the
external occipital protuberance.
No deformity of the ear. No discharge.

 Nose
No deformity involving the nose.
No discharge from the nostrils.
Mouth and throat:
Sucking and rooting reflexes present.
No cleft or palate.
No oral thrush or dribbling of saliva.
Neck
There was short & thick skin fold around the neck.
No webbing of the neck or masses.

Chest
Normal in shape and appearance.
Antero-posterior and lateral diameters were equal.
Bilateral nipples were present and symmetrical.
Respiratory system
Respiratory rate was 44/min. The pattern was abdominal-thoracic.
No cough reflex.
Heart
Heart rate: 146/min, regular
S1 S2 heard. No murmur.
Abdomen
Rounded, soft.
No infection or bleeding at the umbilical cord stump.

External Genitalia and perineum:

Well developed female external genitalia.
The labia majora was covered by the labia minora.
The hymen and clitoris were disproportionately large.
The back:
The spine was flexed, the spinous processes were complete.
No pit, tuft of hair, melanoma or mass at the lower spine.
Extremities:
The neonate had two upper and two lower extremities, w hich were well developed.
No missing, extra or fused digits.

Nail beds: pink

Normal range of motion at all extremities.
Ortolanis and Barlows tests were negative.
Neuro-muscular system:
Normal tone of muscles on passive flexion and extension.
The extremities were held in flexion.
The baby was able to turn the head from side to side when placed in prone position.
The baby was able to hold the head horizontal with the back when held horizontal.

Neonatal reflexes:
All neonatal reflexes appropriate for his developmental age were present i.e.: sucking, rooting,
swallowing, Moros and grasp reflex.
Cry:
The baby and a very strong and healthy cry.
Sleeping pattern:
Normal.

ESTABLISHMENT OF MOTHER-INFANT BONDING

Bonding is a psychological state of belonging and reciprocation. Mother-infant bonding is essential

for proper nurture of the newborn. The bonding starts even before the birth of the child, but needs
to be reinforced at birth because of the trauma of birth the mother undergoes. Thus, the crucial
period of bonding is during the first few hours after birth. It is noted that the close physical contact
between the mother and the child sets into motion and intricate set of reciprocal actions, whereby
each stimulates and rewards the other. It is postulated that hormonal stimulations may contribute
to the attachment, but social and cultural components play a very influential role.

Bonding is strengthened by the babys interaction with the parents. The passive infant probably
receives less attention and stimulation than an active alert tone.

One of the key components to strengthening the mother-infant bonding is breast-feeding. For my
patient, I initiated breast feeding once the mother was shifted to the post natal room. During that
time, I discussed about the expectations of the mother and reiterated the measures to strengthen
the mother-child bonding.
I also discussed about:

Eye contact whenever possible and specially during breast feeding

Process of attachment and its importance in parent-infant bonding.
Importance of physical contact like touching, picking up the child and holding, hugging.
Correct position of the infant during breast-feeds.
Importance of burping the child after each feed.
Sleeping the child with the mother versus sleeping the child on the cot.

Mrs Gurung has a healthy newborn baby. It was not difficult to educate her about mother-infant
relation and breast feeding. For my patient, mother-infant bonding was easy to establish and
maintain. She was avid learner and was ready to adopt measures required for good infant nursing.

POST-NATAL CARE AND HEALTH EDUCATION

The Puerperium:

The puerperium covers the period from the expulsion of the placenta till six weeks of postpartum.
During this time the intra-abdominal reproductive organ return to the non-pregnant state while a
number of physiological and psychological changes occur.
Objective of post-natal care:

To provide care for rapid restoration to optimum health of the mother.

To prevent complication in the postnatal period.
To ensure adequate nourishment of the neonate through breast feeding.
To teach about family planning methods and make available family planning services.
To provide basic health education to mother and rest of family.
To ensure good communication between the mother, rest of family and health workers.

Management objective:
Immediate attention and care to the newborn and mother.
Rest and ambulation of the mother.
Adequate sleep.
Adequate and nourishing diet.
Care of bladder and bowl.
Care of breast and breast feeding.
Examination of mother and baby.
Health education:

Eye care:
The eyes were cleaned with boiled cotton and mother was advised to clean the
eyes of the baby with boiled cotton.
The mother was advised not to get the milk into babys eyes while breast feeding.
Cord care:
The umbilical cord stump was cleaned with boiled cotton and dried with dry sterile
gauze swab.

The mother was advised to clean the babys umbilical stump with boiled cotton,
even at home.
The mother was instructed not to apply anything on the umbilical cord stump and to
keep it clean.
Inform the mother that the cord stump falls off in 5-10 days.
Instruct the mother to watch for any discharge, bleeding or infection.
Nose & mouth care:
The mother was advised to keep the nose and mouth clean with soft tissue paper.
Skin care
Sponge bath the baby after 24 hours of birth.
Keep the baby clean. Bathe the child every 2-3 days once the cord falls off.
Do not use the soap on the babys face.
Apply oil all over the body everyday.
Recovery from the physiological jaundice
Exclusive breast feeding.
Keep the baby in the morning sunlight.
If jaundice should prolong, then obtain medical check up.
Napkin care:
Teach the mother the correct method of putting on the napkin.
Ask the mother to change the napkin as soon as it is wet.

DAILY ASSESSMENT OF POSTNATAL MOTHER:

Mrs. Gurung delivered a healthy baby on 2068/03/21 and she was discharged on 2068/03/22. So,
her assessment on 2068/03/22 are as follows:

S.NO
1.

Parameters

Findings

Vital Signs:
Temperature
Pulse
Blood Pressure
Respiratory Rate

98.80 F
78 beats/minute
90/60 mm of Hg
16 breaths/minute

2.

Uterine height

14cm

3.

Lochia

Rubra (healthy)

4.

Abdomen

Mild tenderness

5.

Breast

Nipple everted, adequate milk flow

6.

Appetite

Normal, no nausea and vomiting

7.

Sleep

Disturbed sleep

8.
S.
No

Elimination
Nursing
Diagnosis

Nursing
Goal

Passed urine, not stool.

Plan of action
Nursing Intervention

Nursing Care Plan For Mother

1)

S.
No

Anxiety &fear
related to
hospital
environment as
evidenced by
perspiration.

Nursing
Diagnosis

Minimizing
anxiety
of
hospital
admission

Nursing
Goal

Develop a
therapeutic
relationship with
patient & family.
Orient the patient
to the hospital,
its rules &
facilities
available.
Reassure the
patient that she
is in safe, good
hands & not
alone.
Assist in anxiety
reducing
maneuvers:
relaxation, deep
breathing and
oral intake of
warm fluids.

Plan Of Action

Therapeutic
relationship with
patient & family
was developed.
The patient was
oriented to the
hospital its rules
& facilities
available.
The patient was
reassured that
she is in safe
hands and not
alone.
Assisted in
anxiety reducing
maneuvers:
relaxation, deep
breathing and
oral intake of
warm fluids.

Implementation

C
i
t

O
a
s
p
a
P
t
h
r

U
r
s
e
p
p
&

2)

Knowledge
deficit & fear
related to
breech
pregnancy and
leaking.

She will
know about
the breech
pregnancy
and leaking.

Explain the
process of breech
delivery and
management of
leaking.

The process of
breech delivery and
management of
leaking was
explained.

Assist & teach her

how to maintain
position during
delivery.

She was assisted &

taught to maintain
position during
delivery.

Encourage her to
maintain patience
during delivery.

She was
encouraged to
maintain patience
during delivery.

S.
No

Nursing
Diagnosis

Nursing
Goal

Plan of Action

3)

Altered fluid
&electrolyte
balance related
to loss of body
fluids during
delivery as
evidenced by
dry lips.

Maintain fluid
& electrolyte
balance
during &after
delivery.

Assess the fluid

and electrolyte
status.
Monitor vitals,
Intake/output.
Monitor dryness of
mucous
membrane.
Replace I/V fluid
as needed.

Implementation

Fluid and electrolyte

status was
assessed.
Vitals and
intake/output were
monitored.
Dryness of mucous
membrane were
monitored.
I/V fluid was
administered as

 Provide oral fluids

like water, black
tea, soups etc.

S.
No

Nursing
Diagnosis

4)

Altered
sleeping
pattern related
to new
environment
and
hospitalization
as evidenced
by frequent
awakening.

Nursing
Goal
Patient will
be able to
sleep
properly.

Plan of Action

needed.

Oral fluids like

water, black tea and
hot soups were
provided.

Implementation

To assess the
sleep and rest
pattern.
To provide quiet
and peaceful
environment.

Sleep and rest

pattern was
assessed.
Quiet and peaceful
environment was
provided.

To encourage
patient to sleep in
regular time daily.

Patient was
encouraged to
sleep in regular
time.

Encourage patient
to drink warm milk
at bed time.
To encourage the
patient to talk and
ventilate her
feeling at bed
time.
To provide
comfortable
bedding and
pillow.

Patient was
encouraged to drink
warm milk.
Patient was
encouraged to
express her
feelings and
concern.
Comfortable
bedding and pillow
were provided.

I
b

I
u
s
p
R
r
a
s
p
M
i

I
a

A
d
t
d
p

S.
No
5)

Nursing
Diagnosis

Risk of infection
related to leaking
of the amniotic
fluid and altered
primary
defenses in the
post-partum
period.

Prevent
infection to
mother and
child during
the hospital
stay

Nursing
Goal

Plan of Action

Implementatio

Maintain standard
precautions and
hand washing
technique while
providing care.
Maintain aseptic
technique while
doing P/V
examination and
conducting delivery.
Advice to maintain
perineal hygiene
after each urination
and stool.
Monitor vital signs.

Standard precautions
and proper hand
washing technique
was maintained while
providing care.
Aseptic technique
was maintained
during P/V
examination and
delivery.
Adviced to maintain
perineal hygiene after
each urination and
stool.
Vital signs were
monitored.

Monitor malaise,
chills, loss of
appetite, fatigue &
pallor.
Give antibiotics as
prescribed.

Malaise, chills, loss of

appetite, fatigue and
pallor were
monitored.
Prescribed antibiotics
(cefotaxime 1gm)
intravenous stat was
given.

CARE PLAN FOR BABY

S.
No
1)

Nursing
Diagnosis

Nursing
Goal

Ineffective
airway clearance
due to excessive
oropharyngeal
secretion.

Clear the
babys airway
so that the
baby can
breathe
comfortably.

Plan of Action

Wipe the babys

mouth and nose
with soft gauze as
soon as the head is
delivered.
Keep the head
slightly lower than

Implementation

Babys mouth and

nose was wiped as
soon as the head was
delivered.

The head was kept

slightly lower than

body & turned

laterally.
Gentle suction as
necessary.
Demonstrate
routine care & have
mother & family
members return the
demonstration.
Call the pediatrician
before delivery.

S.
N
o

Nursing
Diagnosis

Nursing
Goal

2)

Ineffective
thermoregulatio
n due to
exposure to the
environment
immediately
after birth.

The
newborns
body
temperature
will be
maintained
at normal
body
temperature.

Plan of Action

body and turned

laterally.
Gentle suctioning was
done.
Routine care was
demonstrated and
return demonstration
was also done by
mother & family
members too.
Pediatrician was
called before delivery.

Implementation

Wrap the baby in

warm/ dry blanket
and place
beneath a radiant
warmer.
Dry the baby
immediately.

The baby was

Remove the wet

sheet and
monitor the
temperature.

Wet sheet was

removed and
temperature was
monitored.

M
l
e
P
l
d
h

Maintain the
temperature of
the room.

Temperature of the
room was
maintained.

T
h
c

wrapped in a warm
and dry blanket
and beneath a
radiant warmer.
The baby was dried
immediately.

P
l
w

S.
No

Nursing
Diagnosis

Nursing
Goal

3)

Risk of
developing
hypoglycemia
due to
ineffective
breast feeding.

The newborn
will not
develop
hypoglycemia
.

Plan of Action

Implementation

Breast feed the

baby immediate
after delivery and
every 2 hours or
when baby
demands.

The baby was

breast feed
immediately after
and every 2 hours
or when baby
demands.

H
m
l
h

Encourage

The mother was

encouraged to
breast feed the
baby as demanded
by baby and taught
her the importance
of breast milk.

B
c
n
p
f

mother to breast
feed the baby as
demanded by
baby & teach her
importance of
breast milk.

MEDICINE USED IN MY PATIENT

The following medications were administered to Mrs. Anita Gurung during her admission:

Injection Syntocin
Injection Cefotaxime

Injection Oxytocin (Syntocin) :

Oxytocin is a peptide hormone secreted by the posterior pituitary that elicits milk injection in
lactating women. In pharmacologic doses, Oxytocin can be used to induce uterine contractions
in a gravid uterus and maintain labour.
Uses:
oDiagnostic uses: Oxytocin challenge test near term provides information on
adequacy of placental reserve and the need for intervention in the presence of an abnormal
test.
oTherapeutic uses: Oxytocin is used to induce labour and augument dysfunctional
labour.
Indication:
oInduction of labour
oUterine inertia
oIncomplete abortion
oPost partum haemorrhage
Dosage:
oInduction of Labour: Oxytocin is administered via micro-drip, infusion or syringe
pumps at a rate of 1mU/min and gradually increased every 15-30 minutes to 5-20mU/min
till a physiologic contraction pattern is established.
oPost partum haemorrhage: 5-20 units is added to 500 ml 5% dextrose, And the dose
is titrated to control uterine atony.
oProphylaxis: Single intramuscular dose of 5 units is given to prevent postpartum
haemorrhage and augument uterine contraction after delivery of the baby.
Precaution:
Contraindications:
oGrand multipara
oContracted pelvis with CPD, obstructed labour
oPrevious history of caesarean section or hysterotomy
oMalpresentation
oInco-ordinated uterine contraction
oHypovolemic state
oCardiac disease
Dangers:
oUterine rupture
oHypotension

oAnti-diuretic effect
oPituitary shock: Myocardial infarction due to coronary spasm caused by non-purified
preparation of posterior pituitary is now seen only with very high doses of Oxytocin.
oFoetal distress/death: Encountered in presence of already compromised foetus, and
is due to diminished placental circulation brought on by strong and sustained uterine
contraction
Injection Cefotaxime :
Cefotaxime is a third-generation cephalosporin antibiotic. Like other third-generation
cephalosporins, it has broad spectrum activity against Gram positive and Gram negative
bacteria. In most cases, it is considered to be equivalent to ceftriaxone in terms of safety and
efficacy.
Mechanism of action
Inhibits bacterial cell wall synthesis by binding to one or more of the penicillin-binding proteins
(PBPs) which in turn inhibits the final transpeptidation step of peptidoglycan synthesis in
bacterial cell walls, thus inhibiting cell wall biosynthesis. Bacteria eventually lyse due to ongoing
activity of cell wall autolytic enzymes (autolysins and murein hydrolases) while cell wall
assembly is arrested.
Cefotaxime, like other -lactam antibiotics does not only block the division of bacteria,
including cyanobacteria, but also the division of cyanelles, the photosynthetic organelles of
the Glaucophytes, and the division of chloroplasts of bryophytes. In contrast, it has no effect on
the plastids of the highly developed vascular plants. This is supporting the endosymbiotic
theory and indicates an evolution of plastid division in land plants
Clinical use
Cefotaxime is used for infections of the respiratory tract, skin, bones, joints, urogenital
system, meningitis, and septicemia. It generally has good coverage against most Gramnegative bacteria, with the notable exception of Pseudomonas. It is also effective against
most Gram-positive cocci except for Enterococcus. It is active against penicillin-resistant strains
of Streptococcus pneumoniae. It has modest activity against the anaerobic Bacterides fragilis.
Chemistry
The syn-configuration of the methoxyimino moiety confers stability to -lactamase enzymes
produced by many Gram-negative bacteria. Such stability to -lactamases increases the activity
of cefotaxime against otherwise resistant Gram-negative organisms.
Dosage

Adult: 1-2 gm BD
Child 1month-12 years: 50-180mg/kg/day divided QID
Severe infections
Adult: 2 gm q4hr, not to exceed 12 g/day
Child1month-12 years: 50-180 mg/kg/day in 4-6 divided doses
Side effects:
CNS: Headache, dizziness, weakness, paresthesia, fever, chills, seizures, dyskinesia.
CV: Heart failure, syncope
GI: Nausea, vomiting, diarrhea, anorexia, pain, glossitis, bleeding increased AST, ALT, bilirubin,
LDH, alk.phosphate, abdominal pain, pseudomembramous colitis; cholestasis.
GU: Proteinuria, vaginitis, pruritis, candidiasis, increased BUN, nephrotoxicity, renal failure
Haem: Leukopenia, thrombocytopenia, agranulocytosis,anaemia, neutropenia, lymphocytosis,
eosinophilia, pancytopenia, haemolytic anaemia
Integ: Rash, urtcaria, dermatitis
Respiratory: Dyspnea
Syst: Anaphylaxis, serum sickness, Steven-Johnson Syndrome, toxic epidermal necrolysis
Contraindications:

Hypersensitivity to cephalosporins
Infants <1 month

Precautions:
Pregnancy, breast feeding, children, hypersensitivity to penicillins, GI/renal disease

WHY MY CASE IS A HIGH RISK PREGNANCY?

Any deviation from normal process in pregnancy is high risk. In my case Breech
presentation is mal presentation and leaking is also present which increases risk of infection.
o
In vaginal breech delivery many risk of baby being injured and asphyxia. Different
data show asphyxia is a 2nd leading cause of neonatal death.
o
In this way breech presentation is risk for both mother and baby. So it is high risk
o

pregnancy.

DISCHARGE PLANNING & SUMMARY

The mother was discharged on 2068/03/22. There was no any complain of discomfort. The baby
was well and breast feeding actively. The baby was active and had a good cry.
Discharge Note:
Patients name

Mrs. Anita Gurung

Husbands name:

Mr. Shyam Dhoj Gurung

Age of patient :

27 years

Inpatient number :

1016482

Birth certificate number :

58925

Address :

Vyas - 1, Damauli

Date of admission :

2068/03/21

Date of delivery (time) :

2068/03/21at 08:00 pm

Date of discharge :

2068/03/22

Mothers blood group :

O positive

Babys sex :

Female

Birth weight :

2.25 kg

Gestational age at delivery :

38+4 weeks

Type of delivery :

Vaginal breech delivery

Puerperium :

Uneventful

Medication :

Consultant :
Follow up :

1. Cap. Calcium OD x 45 days

2. Tab. Iron OD x 45 days
3. Cap. Megapan 500mg QID x 5 days
4. Tab. Metron 1 tab TDS P/O x 5 days
5. Tab. Aciloc 150mg BD PO x 3 days
6. Tab. Flexon 500mg TDS x 3 days
Dr. Della Singh Joshi
One week after discharge(Sunday or
Thursday) and SOS

DISCHARGE TEACHING
Health teaching is an important part of holistic patient care. It begins from the time of admission
till the patient is discharged and is reinforced in the subsequent follow ups at the OPD. Health
teaching tries to ensure that appropriate care is given to the patient even after discharge. This is
especially relevant to the context of care for new born babies and post partum mothers, where
cultural and traditional practices form an integral part, but do not always have a rational base.
Health teaching tries to integrate the traditional with the rational.
The following topics were covered during the health teaching:
1. Nutrition for baby & mother
2. Breast care and breast feeding
3. Personal hygiene including pericare
4. Rest and resumption of activities
5. Care of the baby
6. Oil massage
7. Immunization
8. Weaning
9. Family planning
10. Follow up visits
11. Medications
1.

Nutrition:

Post natal mothers require a balanced diet to recuperate from the stress of parturition, meet the
caloric requirements of breast feeding and return to normal daily activities.
The diet of the post natal mother should contain green leafy vegetables, plenty of liquids,
cereals, pulses and meat. A post natal mother should take at least four meals a day. Culturally
influenced diet high on calorie like ghee, Chakku, sweets etc are allowed. This ensures that the
baby acquires adequate calories through the mothers milk.

2. Breast care and Breast feeding:

Care of the breast commences from the ante-natal period. This not only ensures that the nipple
is not retracted when the breast feeding commences, but also raises the awareness of the
advantages of the breast feeding as opposed to commercial preparation. Unnecessary
manipulation of the breast is avoided during late pregnancy, as this may precipitate early labour.
The mother is encouraged to feed the baby soon after birth.
The mother is taught the proper technique of breast feeding the baby. This includes the
following:

On demand feeds
Proper positioning of the baby during feeds
Burping the baby after feeds
Maintenance of personal hygiene.

3. Rest and activities:

The mother needs rest during the puerperium to recuperate from the stress of labour and
immediate post natal period. The mother requires about 9 hours of sleep a day, and she needs
about 2 months of period to recover from pregnant state to non-pregnant state after delivery.
The above statement does not mean that the mother is bed bound, but that she is gradually
helped to return to normal daily activities. The mother is not allowed to undertake heavy or
labourious tasks during the puerperium, as it predisposes to uterine prolapse.
The mother is taught about the pelvic floor exercises to tone up the musculature.

4. Care of the baby:

The baby must be cleaned and cared daily. The eyes, face and body must be wiped with a clean
cloth soaked with clean luke-warm water.
The umbilical cord stump must be cleaned daily till it naturally drops off.
The babys diapers must be checked and changed regularly. The perineum must be kept clean
and dry to prevent rashes.

5. Oil massage:
Massaging the baby ensures good skin circulation and prevention of pressure sores. The
massage with stretching of the joints ensures suppleness and strengthens the muscle tone.
Oil massage is a traditional practice amongst the Nepali community and is encourages both for
the mother and the baby.

6. Immunizations:
Active immunization against various bacterial and viral childhood diseases is part of the
extended program for immunization in Nepal. The parents had a good knowledge of the
immunization schedule.

7. Weaning food:
The baby requires dietary supplement from 6 months of age as the baby grows and the calories
obtained from the breast milk becomes inadequate.
The parents knowledge of weaning foods was reinforced when I discussed the weaning
techniques. They had a good idea of home made preparations as well as proprietary products.

8. Personal hygiene and pericare:

Good personal hygiene is a prerequisite for good health.

Encourage the mother to bathe and change clothes daily.

Pericare must be done after every urination and defecation.
The mother is educated about the types of lochia, its odour and character. The mother is
advised to obtain consultation or any abnormality in lochia, especially if she develops fever.

9. Medicines:
My patient was prescribed antibiotics, analgesics and she was further prescribed hematinics
and calcium supplements by the doctor.
I explained the justification for taking the prescribed medications for the mentioned durations.

10. Follow up Visits:

The parents were advised to return with the baby after a week from the date of discharge.
The parents were advised to visit the Pediatrician at the next visit for the babys first
immunization shot of BCG.
They were further advised to seek consultation in case of any difficulty.

FOLLOW UP CARE
Follow up care and home visits are modalities to make certain that the patient who had required
in hospital treatment in recuperating well in the domestic environment. It is to ensure that the
patient is compliant with the prescribed therapy and has not developed any complication that
would require immediate medical attention. Thus in case of new born, community base follow up
is essential for early detection of congenital illness and infection or complication in the mother.
The follow-up fulfils the following details:

Evaluation of health status of baby and mother.

Detection of deviation from normal, the health of the baby and mother at home.
Detection of complications early
Assessment of uterine involution
Solve problems faced by the mother or baby.

On the follow up visit, the baby and the mother were well and did not suffer from any
complication. In Nepal there is no facility of home visiting doctors/nurses for follow-up after
discharge from the hospital. The patients are therefore encouraged to attend at the OPD of the
local hospital which is certainly stressful for the recuperating patient but on the other hand
solves the difficulty of shortage of physicians and community nurses available in our country.

CONCLUSION
Case studies are a modality of learning patient management in a clinical setting. The patient is
followed through from the time of admission till discharge and the first follow up. The case study
provides a holistic approach to patient care and updates the knowledge of the nurse regarding
the disease process, possible complication and how to handle this situation as a team player.
No pregnancy is simple and the uneventful second stage can suddenly turn critical at the next
stage or an apparently healthy baby may suddenly be fighting for its life. Thus high risk
pregnancy case study brings home the message that every pregnancy is a potential at risk
pregnancy and the only way to ensure safety for the mother and child is to provide a thorough
care.

My patient had already delivered one male baby in normal mode of delivery however she had
anxiety because of breech pregnancy with leaking. Her anxiety level was decrease because of
continuous reassurance. She was discharged from hospital without any complication.she was
happy on discharge day due to continuous contact with care provider(me).

I WISH GOOD HEALTH OF THE MOTHER AND HER BABY AND WISH
HER A WONDERFUL LIFE AHEAD

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Dutta D.C. (2001). Text book of Obstetrics, 5th edition, 400 416.
Fraser Diare M., Cooper Margaret A. (2003). Myles Textbook for Midwives, 14 th
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Govoni Laura E., Mayers Janice E. Drugs and Nursing Implications, 4 th edition,
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Gulanick & Myers. (2003). Mosbys Nursing care plans, Nursing diagnosis &
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Howkins and Bourne. (1999). Shaws textbook of Gynecology, 12th Edition

Joshi Mohan P., Adhikari Ramesh Kumar. (1996). Manual of Drugs and
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Subedi Durga, Gautam Saraswoti. (2010). Midwifery Nursing Part II, 1 st edition,
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Subedi Durga, Gautam Saraswoti. (2011). Midwifery Nursing Part III, 1 st
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http://emedicine.medscape.com/article/797690-overview
http://www.americanpregnancy.org/labornbirth/breechpresentation.html
http://www.buzzle.com/articles/leaking-amniotic-fluid.html

http://en.wikipedia.org/wiki/Breech_birth