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At the end of the learning session, the student should be able to: 1. define breech presentation 2. define the types of breech presentation 3. explain the predisposing factors of breech presentation 4. describe the diagnosis of breech presentation 5. explain the management of mother with breech presentation 5.1 antenatal 5.2 in labour

6. explain the types of breech delivery 7. state the complications of breech delivery 8. demonstrate the mechanism of breech delivery by simulation breech delivery

DEFINISI
Janin dalam baringan memanjang dan bahagian buttock di bahagian lower segment uterus ( presentation ). Presenting part adalah anterior buttock presenting diameter bitrochantric adalah 10cm. Denominator adalah sacrum Breech presentation is one which the fetal buttocks, with or without the feet, lie lower most at the lower uterine segment.
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Types of breech presentation Frank breech means the buttocks are presenting and the legs are up along the fetal chest (hips flexed, knees extended). The fetal feet are next to the fetal face. This is the safest arrangement for breech delivery.

Frank breech
Bahagian hip dan thigh adalah tinggi Betis ( leg ) extended di lutut ( knee ) dan berada sepanjang badan Kaki berdekatan dengan kepala Selalu berlaku pada primigravida disebabkan uterine muscle tone menghalang flexion betis dan fetus tidak dapat bergerak bebas
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Footling breech means either one foot ("Single Footling") or both feet ("Double Footling") is presenting. This is also known as an incomplete breech.

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Complete breech means the fetal legs are flexed along the fetal abdomen, but the fetal chins and feet are tucked under the legs. The buttocks is presenting first, but the feet are very close. Sometimes during labor, a complete breech will shift to an incomplete breech if one or both of the feet extend below the fetal buttocks.

Complete breech
Attitude fetus adalah complete flexion Bahagian thigh dan knee flexed dan kaki rapat dengan punggong Biasanya dalam multigravida

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Predisposing factors of breech presentation


Interference of adaptation of the presenting part to the pelvic brim which may be:

Fetal causes Maternal causes

Fetal causes
Malpresentations. Prematurity. Multiple pregnancy. Size of the fetus (not too small and not too large) Polyhydramnios. Anatomical malformation of the fetus

Maternal causes:
Contracted pelvis. Pelvis tumours. Size of the maternal pelvis Abnormal shape of the pelvis, uterus, or abdominal wall,

Previous vaginal breeches

explain the predisposing factors of breech presentation

CAUSES OF BREECH PRESENTATION


1. Spontaneous cephalic version. Kalau leg extended akan splinting belakang extended leg 2. Preterm labour 3. Multiple pregnancy 4. Polyhydramnious 5. Hydrocephaly 6. Uterine anomalies
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POSITION BREECH
1. 2. 3. 4. 5. 6. Terdapat 6 position breech RSA RSP LSA LSP RSL LSL
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Knee presentation
Satu atau kedua dua knee dibawah buttock dengan satu atau kedua dua leg extended dan knee flexed

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Placenta praevia Primigravida Oligohydramnious Grandmultipara Fetal death Decrease fetal activity due to compromised fetus Impaired fetal growth Short umbilical cord
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Describe the diagnosis of breech presentation


1 During pregnancy Inspection:
A transverse groove may be seen above the umbilicus in sacro-anterior corresponds to the neck. If the patient is thin, the head may be seen as a localised bulge in one hypochondrium.

Palpation:
Fundal palpation: the head is felt as a smooth, hard, round ballottable mass which is often tender. Lateral palpation: the back is identified and a depression corresponds to the neck may be felt. Pelvic palpation: the breech is felt as a smooth, soft mass continuous with the back. Trial to do ballottement to the breech shows that the movement is transmitted to the whole trunk.

Auscultation:
FHS is heard above the level of the umbilicus. However in frank breech it may be heard at or below the level of the umbilicus.

Ultrasonography:
It is used for the following:
To confirm the diagnosis. Fig To detect the type of breech.

2. During Labour In addition to the previous findings, vaginal examination reveals; The 3 bony landmarks of breech namely 2 ischial tuberosities and tip of the sacrum. The feet are felt beside the buttocks in complete breech. Fresh meconium may be found on the examining fingers. Male genitalia may be felt.

explain the management of mother with breech presentation

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Antenatally
Tagging high risk pregnancy If the midwife suspects or detects a breech presentation at 36 weeks gestation or later, she should refer the woman to a doctor. All breech presentations require ultrasound assessment to confirm dates, exclude abnormalities and for placental localization.
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All breech presentations must be delivered in hospital. All breech presentations should have a planned caesarean section or external cephalic version (ECV). Seek the opinion of a specialist. External Cephalic Version can be done after 36 weeks of gestation with or without using tocolytics.
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Contraindications to ECV: engaged breech multiple breech past history of LSCS / myomectomy hypertensive, pre-eclamptic patient antepartum haemorrhage abnormality in liquor volume (polyhydramnios, oligohydramnios) abnormal fetus

Planned caesarean delivery at 38 weeks for breech presentation should be emphasized.


Previous caesarean section is generally considered to be an unfavourable factor for vaginal breech birth Study had suggested improved perinatal outcome for vaginal breech delivery in women with computed tomography confirmed adequate pelvimetry

Mother In labour Review general care principles and start an IV infusion.

First Stage Labour: as other malpresentations.


Basic care during first stage labour is the same as in normal labour with additional specific care as below:

Psychological care - provide emotional support and encouragement. Physical care Maternal monitoring

Fetal monitoring Continuous electronic fetal heart rate monitoring should be offered to women with a breech presentation in labour Bladder care Progress of labour prevent prolonged labour Vaginal examination is performed to exclude risk of cord prolapsed as soon as the membranes ruptured

Pain relief - Epidural analgesic should not routinely advised - Women should have a choice of analgsia during breech labour and birth to inhibit the urge to push prematurely Prevention of infection Emergency caesarean section should be planned if os is < 5 cm dilated Record and report abnormalities

Second stage labour Management of Vaginal Breech Delivery Vaginal delivery should be presented to the woman as the norm for breech delivery, the fetus may be delivered by complete breech or extended breech if admitted in advanced labour.

Full dilatation of the cervix should always be confirmed by vaginal examination before the woman commences active pushing Active pushing is not commenced until the buttocks are distending the vulva Inform obstetrician when os is fully dilated to conduct delivery, and Paediatric team standby for resuscitation

Placed mother in lithotomy position to facilitate vaginal breech delivery Episiotomy should be performed when indicated to facilitate delivery Caesarean section should be considered if there is delay in the descent on to the perineum in the second stage despite good contractions Failure of the presenting part to descent may be a sign of relative feto -pelvic disproportion. Caesarean section should be considered. Perform all manoeuvres gently without undue force.

Third stage Suction the babys mouth and nose Clamp and cut the cord Active management of third stage Give IM Oxytocin 10 units within 1 minute of delivery Conduct delivery of placenta & membranes by apply CCT Uterine massage if uterus not contracted Examine the woman carefully and repair any tears to the cervix or vagina or repair episiotomy

Types of breech delivery


Spontaneous breech delivery:
This is rarely occurs in multipara with adequate pelvis, strong uterine contractions and small sized baby. The baby is delivered spontaneously with little assistance from the attendant.

"Keep your hands off" for complete / well flexed breech.

DELIVERY OF THE BUTTOCKS


Once the buttocks have entered the vagina and the cervix is fully dilated, tell the woman she can bear down with the contractions. perform an episiotomy when the buttock distending the perinuem the mother is encouraged to push with the contractions the buttocks are delivered spontaneously

Delivery of the legs and body


if the legs are flexed, the feet disengage at the vulva and the baby is born as far as the umbilicus A loop of cord is gently pulled down to avoid traction on the umbilicus The fetus covered with warm towel to prevent hypothermia and premature stimulation of respiration

DELIVERY OF THE ARMS


The midwife should feel for the elbows, which are usually on the chest. ARMS ARE FELT ON CHEST If so, the arms will escape with the next contraction. Allow the arms to disengage spontaneously one by one. Only assist if necessary. After spontaneous delivery of the first arm, lift the buttocks towards the mothers abdomen to enable the second arm to deliver spontaneously.

DELIVERY OF THE SHOULDERS


The uterine contractions and the weight of the body will bring the shoulders down on to the pelvic floor where there are in the antero-posterior diameter of the outlet The midwife now grasps the baby by the iliac crests with her thumbs held parallel over his sacrum and tilts the baby towards the maternal sacrum in

When the anterior shoulder has escaped, the buttocks are lifted towards the mothers abdomen to enable the posterior shoulder and arm to pass over the perineum.

DELIVERY OF THE HEAD


As the shoulders are born the head enters the pelvic brim and descends through the pelvic with the sagittal suture in the transverse diameter. Hold the baby by the hips and turn half a circle, keeping the back uppermost

Then allow the baby to hang for 1 or 2 minutes

Gradually the neck elongates, the hair-line appears and the suboccipital region can be felt Controlled delivery of the head is vital to avoid any sudden change in intracranial pressure and subsequent cerebral haemorrhage There are 3 methods used
Forceps delivery Burns Marshall Method Mauriceau-Smellie-Veit manoeuvre

Assisted breech delivery:


This is the method of delivery in the minority of cases. The buttocks are born spontaneously but some assistance is necessary for delivery of extended legs or arms and the head.

Delivery of the buttocks:


Once the buttocks have entered the vagina and the cervix is fully dilated, tell the mother to bear down with the contractions until the perineum is distended by the buttocks Perform an episiotomy especially in primigravida to avoid much lateral flexion of the spines, perineal lacerations and intracranial haemorrhage due to sudden compression and decompression of the after - coming head.
The woman is encouraged to push with the contraction and the buttocks are delivered spontaneously

The woman is encouraged to push with the contraction and the buttocks are delivered spontaneously

Delivery of the extended legs


Assistance is usually required to deliver the extended legs When the popliteal fossae appear at the vulva, the extended legs are delivered by apply pressure to the popliteal space to flex the knee

2 fingers are placed along the length of one thigh with the fingertips in the fossa Then, splint the thigh and the leg is swept to the side of the abdomen (abducting the hips) and the knee is flexed by the pressure on its under the surface This process should be repeated in order to deliver the second leg

Delivery of the body


When the umbilicus appears, track down a loop of the cord to prevent traction or compression of the cord and detect its pulsation. The fetus is covered with warm towel to prevent hypothermia & premature stimulation of respiratio

Delivery of the shoulders & extended arms:


Midwife should feel for the elbows If the arms are not felt on the chest after the umbilicus is born, they are extended. Delivery of the extended arms may be dealt with by using the Lovset manoeuvre

Lovset manoeuvre
this is a combination of rotation and downward traction that may be employed to deliver the arms the direction of rotation must always bring the back uppermost and the arms are delivered from under the pubic arch When the umbilicus is born and the shoulders are in the anteroposterior diameter, the baby is grasped by the iliac crests with the thumbs over the sacrum

Downward traction is applied until the axilla is visible

Use the Lovsets manoeuvre


Hold the baby by the hips and turn half a circle (180), keeping the back uppermost and applying downward traction at the same time, so that the arm that was posterior becomes anterior and can be delivered under the pubic arch.

Assist delivery of the arm by placing one or two fingers on the upper part of the arm (by splint the humerus). Draw the arm down over the chest as the elbow is flexed, and sweeping the forearm across the face and chest of the fetus

To deliver the second arm, the body is now rotated back in the opposite direction and delivered in a similar way under the pubic arch.

Delivery of the after-coming head:


Mauriceau-Smellie-Veit method (Jaw flexion- shoulder traction) Burns - Marshalls method

Mauriceau-Smellie-Veit method (Jaw flexion- shoulder traction):


This is mainly used when there is delay in descent of the head because of extension (Extended head). When the body has been allowed to hang, the neck and hair-line are not visible; it is probable that the head is extended.

Use the dominant hand


to lay the babys face down with the length of its body over your hand and arm the baby is laid astride the arm with the palm supporting the chest Two fingers (the index and the ring finger) on the malar eminencies (the maxillae) to avoid dislocation of the jaw while the middle finger in the babys mouth to pull the jaw down and increase flexion of the head.

Use the other hand to grasp the babys shoulder The index and ring finger of the left hand are placed on each shoulder while the middle finger is pressing against the occiput towards the chest to promote flexion and act as a splint for the neck, preventing hyperextension and hence cervical spine injury. Then bring the babys head down until the hairline is visible Then allow the occiput pivot under the symphysis pubis

Occiput pivot under symphysis pubis

Traction is commenced downwards and backwards till the nape of the fetus appears The baby is lifted towards the mothers abdomen gently, still astride the arm
the chin, face and sinciput are permitted to sweep the perineum and, the occiput to escape under the symphysis pubis

MECHANISMA LABOR LSA


Lie longitudinal Attitude- complete breech Presentation - breech Denominator - sacrum Position left sacro anterior Presenting part left anterior buttock The bitrochantric diameter 10 cm memasuki ruang pelvic melalui left oblique diameter of the brim 8. Sacrum mengarah ke iliopectineal eminence 1. 2. 3. 4. 5. 6. 7.
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Engage dengan bitrochantric diameter 10cm descend kepelvic brim dalam kiri / kanan pectineal emiinence Compaction Decsend berlaku dan bertambahnya compaction disebabkan bertambah flexion pada limp Internal rotation buttock Anterior buttock bertemu dengan pelvic floor dan berpusing kehadapan 1/8 a circle sepanjang sebelah kanan pelvis dan bitrochanric diameter dalam kedudukan anterior posterior pelvic outlet dan berada dibawah symphysis pubis
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Lateral flexion of the buttock Anterior buttock melepasi bawah symphysis pubis dan posterior buttock menyapu perineum. Buttock dilahirkan dengan pergerakan lateral flexion Restitution of the buttock Anterior buttock pusing sedikit ke arah kanan ibu untuk selari dengan fetal back

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Internal rotation of the shoulder Shoulder memasuki ruang pelvis dengan oblique diameter brim . Anterior shoulder bertemu dengan pelvic floor dan berpusing 1/8 pusingan kearah kanan pelvic ibu. Anterior shoulder berada dibawah symphysis pubis dan melepasinya , posterior shoulder menyapu perineum dan shoulder dilahirkan

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Internal rotation of the head Kepala memasuki ruang pelvis dengan saggital suture dalam transverse diameter of pelvic brim. Occiput bertemu dengan resistent dan berpusing kedepan kearah kiri dan sub occipital region ( the nab of the neck )impinges ( menyelinap ) dibawah surfase of symphysis pubis External rotation of the body Pada masa yang sama badan bayi akan berpusing supaya belakang berada diatas ( uppermost )
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Kelahiran kepala janin Chin,muka, sinciput menyapu perineum dan kepala dilahirkan dalam flexed atitude

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JENIS JENIS KELAHIRAN BREECH


Spontaneous breech delivery Kelahiran erlaku dengan sedikit sahaja pertolongan dari staff Assissted breech delivery Buttock dilahirkan secara spontaneous , bantuan diperlukan untuk kelahiran extended leg atau tangan dan kepala Breech extraction Dalam bentuk emergency, manipulative deliveryoleh obstetrician
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PENGENDALIAN KELAHIRAN BREECH


1. apabila buttock menekan perineum - Barigkan ibu dalam lithotomy position - Swab vulva dan drapped dengan kain yang strile - Kosongkan bladder, catheterize - Apabila breech meregang perineum , infiltrate dan lakukan episiotomy - Minta ibu untuk push setiap contraction - Buttock akan dilahirkan secara spontaneous jika leg nya flex dan feet akan keluar luar vulva
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- Bayi dilahirkan sehingga umbilicus - Cord di tarik ( tract ) kebawah secara gently untuk elak dari traction ( spasm of the cord vessel boleh berlaku disebabkan manipulating cord atau regang ) rasa untuk pulsation( optional ) - Cord kebawah belakang dan kesebelah pubic bone - Apabila axillary region ( scapula ) kelihatan rasakan elbow dengan 2 jari biasa di chest
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- Jika elbow boleh dirasai tiada extended arm dan arm akan keluar dengan satu lagi contraction - Jika elbow tidak dirasai extended arm
2. Kelahiran shoulder - Uterine contraction dan berat badan bayi akan menyebabkan shoulder turun kebawah ke pelvic floor - Bertemu dengan resisten akan berpusing 1/8 ke anterior posterior diameter outlet
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- Balutkan babys hip dengan kain( untuk kepanasan dan elak licin ) - Pegang bayi di illias crest dan kedua dua ibu jari selari di sacrum - Tilt kan baby kearah maternal sacrum untuk mengeluarkan anterior shoulder - Apabila anterior shoulder telah keluar , angkatkan buttock keatas kearah symphysis pubis ibu untuk membolehkan posterior shoulder dan tangan melepasi perineum
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- Apabila shoulder dilahirkan kepala memasuki pelvic brim - Kepala descend melalui pelvis dengan saggital suture di transverse diameter brim, semasa ini bahagian belakang masih dalam kedudukan lateral ( jika belakang terlalu cepat keuppermost anterior posterior diameter kepala akan memasuki posterior diameter brim dan kepala menjadi extended dan shoulder akan impacted di outlet
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3. Kelahiran kepala - Apabila belakang bayi di uppermost bayi dibiarkan tergantung divulva tanpa di ampu - Berat badan bayi membawa kepala ke pelvic floor dan occiput akan berpusing kedepan dan saggital suture di anterior posterior diameter - Jika kepala gagal untuk rotate letakkan 2 jari dimalar bone dan rotate kepala - Gantungkan bayi untuk 1-2 minute, perlahan lahan neck akan elongated dan hair line akan kelihatan dan suboccipital region boleh dirasai - Kelahiran kepala penting untuk elak perubahan intracranial pressure secara mendadak dan cerebral haemorrhage berlaku
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CARA KELAHIRAN KEPALA


TERDAPAT 3 CARA 1. Secara menggunakan forsep- after coming head 2. Burns Marshall method - Posisi jururawat sebelah kanan ibu - Tangan kiri memegang ankle bayi dari belakang dimana fore finger diantaranya - Bayi diluruskan dengan traction yang berpatutan untuk elak neck dari bend kebelakang dan menyebabkan kepatahan
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- Suboccipital region ( bukannya neck )pivot apex of pubic arch ( jika tidak spinal cord akan crushed ) - Kaki diangkat 180 darjah sehingga mulut dan hidung melepasi vulva swab mulut hidung dan lakukan suction - Tangan kanan guard perineum untuk mengelak kepala keluar secara mendadak - Suck dan bayi akan bernafas - Minta ibu bernafas secara biasa dan vault akan perlahan lahan dikeluarkan mengambil masa 2-3 minit
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- Jika terdapat delay dalam descend disebabkan extension kepala mauriceus smellie veit manoeuvre dilakukan . Jika traction di bahu berlebihan menyebabkan erbs palsy

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Maureceau smellie-veit method


Jaw flexion and shoulder traction digunakan apabila delay dalam descend disebabkan head extension - bayi diletakkan astride diatas right arm , tapak tangan ampu chest bayi - Masukkan 1 jari dalam mulut bayi untuk menarik jaw kebawah dan flexkan kepala, 2 jari diletakkan dimalar bone jari tengah dalam mulut
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- 2 jari ditangan kiri hooked diatas bahu jari tengah di occiput untuk membantu flexion kepala - Lakukan traction untuk keluarkan kepala dari vagina. - Apabila suboccipital region kelihatan , angkat badan dan kepala pivot di symphysis pubis - Apabila muka keluar suction dilakukan - Lahirkan vault perlahan lahan
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Kelahiran extended leg


Frank breech akan descend lebih cepat semasa 1st stage, cervix dilate lebih cepat dan risiko mendapat cord compression diantara kaki dan badan. Kelewatan berlaku dioutlet kerana leg splint the body dan akan mengurangkan lateral flexion spine - Tunggu sehingga popleteal fossae divulva 2 jari diletakkan sepanjang panjang paha dengan fingertip di fossa.
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Kelambatan kelahiran kepala


Hair line tidak kelihatan extended head boleh gunakan McRobert manoeuvre ( position untuk memudahkan kelahiran kepala Gunakan Mauriceus- Smellie- veit method Guna forcep

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- Leg menyapu kearah tepi abdomen ( abducting the hip ) flexed knee dengan pressure diatas permukaannya. - Dengan pergerakan ini lower part leg akan emerge dari vagina

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Posterior rotation of the occiput ( malrotation )


- Untuk melahirkan kepala - dagu dan muka memasuki dibawah symphysis pubis sehingga root of the nose. - Baby akan diangkat keatas kearah abdomen ibu untuk membenarkan occiput menyapu perineum

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Kelahiran extended arm


Jika elbow tidak dapat dirasai didada selepas umbilicus dilahirkan. Ini boleh menyebabkan kelambatan dalam kelahiran dan menyebabkan fetal hypoxia Kombinasi antara rotation dan downward traction . Arah rotation ialah back mistilah uppermost dan arm dilahirkan dibawah pubic arch
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- umbilical dilahirkan dan shoulder dalam anterior posterior diameter - Pegang anak diiliac creast dan kedua dua ibu jari disacrum - Lakukan downward traction sehingga axilla kelihatan - Jaga ( maintain) downward traction. rotate kan badan bayi bulatan 180 darjah , mulakan dengan bahagian belakang uppermost
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- Posterior arm akan bersandar dipubic bone apabila shoulder `menjadi anterior ( posterior ke anterior )akan menyapu arm kehadapan muka - Pergerakan ini memberi laluan shoulder untuk memasuki pelvic dalam transverse diameter - Arm dibahagian anterior dilahirkan dengan menggunakan dua jari splint humerus tangan bawa keluar menyapu chest disebabkan elbow flexed
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- Rotate kembali badan seperti sebelumnya untuk lahirkan arm kedua - ( tindakannya adalah sama )

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Komplikasi breech presentation


Ibu Laceration perineum PPH Risiko instrumental delivery forcep Risiko LSCS

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Fetus Intracranial bleeding Asphyxia Fracture humerus Erbs palsy Ruptured liver disebabkan manipulasi Fractured spinal cord Hip dislocation

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