KELAINAN PRESENTASI

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

Bag. / SMF Obstetri Ginekologi

FK.UNCEN / RSUD Jayapura
JAYAPURA

Vaginal Breech
Delivery

Lois Jovanovic, MD
The Norbert Freinkel Lecture: Glucose mediated
macrosomia: the over-fed fetus and the future. Program
and abstracts of the 61st Scientific Sessions of the
American Diabetes Association; June 22-26, 2001;
Philadelphia,
The Norbert Pennsylvania.
Freinkel Lecture,
an annual invited event at the
Scientific Sessions of the American Diabetes Association
since 1991, is awarded to a speaker selected for outstanding
contributions in the field of diabetes and pregnancy. I am
honored to be selected as this year's speaker[1] and to
provide tribute to Professor Freinkel for his role as a mentor,
scientist, and motivator of a generation of researchers. The
lifetime clinical and laboratory research work of Professor
Freinkel was dedicated to the enhancement of our
understanding of the metabolic abnormalities of
pregnancies complicated by diabetes. He was the first to
introduce the concepts of "accelerated starvation" and
"facilitated anabolism" in the fasting and fed states during
pregnancy. In addition, he modified Pedersen's hypothesis
of maternal hyperglycemia as a basic cause of aberrant fetal
development, and viewed pregnancy complicated by
diabetes as a disorder of fuel metabolism. In fact, he coined
the term to describe this abnormal metabolic state as "fuelmediated teratogenesis."

Objectives
Incidence and
Significance
Selection
Management

Intrapartum
Delivery

Definition
longitudinal lie
breech or lower extremity
presenting
cephalic pole in the uterine fundus

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

Types of Breech

Complete

Footling

Frank

Incidence
3 to 4% of all pregnancies
increases with decreasing
gestational age

7 to 10% at 32 weeks
25 to 35% at < 28 weeks

Etiology of Breech Presentation

idiopathic
prematurity (head to trunk
size)
uterine or pelvic structural
abnormality
uterine fibroid
fetal anomaly or abnormality
polyhydramnios
multiple gestation

Diagnosis
maternal perception of
movement
Leopolds maneuvers
FH auscultated above umbilicus
vaginal exam
ultrasound
X-ray

Recommendations for Breech Delivery

recommend trial of labour at 36
weeks or when estimated weight is
2500 to 4000 grams
offer trial of labour at 31 to 35 weeks
gestation or when estimated weight
is 1500 to 2500 grams
offer caesasean section at 30
weeks gestation or when estimated
weight is < 1500 grams*
no recommendation for when
estimated weight is > 4000 grams*

* acknowledged lack of evidence for recommendation

Selection Criteria for Trial of Labour

frank or complete breech
fetal head not hyperextended
estimated fetal weight 2500 to
4000g

WILLIAMS OBST 2005

Methods of vaginal delivery:
1. Spontaneous breech delivery
entirely spontaneously
without any traction or manipulation
other than support of the infant
2. Partial breech delivery
3.Total breech delivery

HANNAH ET AL 2000
MORTALITAS MORBIDITAS

SC

3/ 1000

1,3 %

PERVAGINAM

3/ 1000

3,8 %

INDIKASI SC
1.
2.
3.
4.
5.
6.
7.
8.

JANIN BESAR
PSR
HIPEREKSTENSI
ADA INDIKASI
PARTUS LAMA
DISFUNGSI RAHIM
INCOMPL OR
FOOTLING
BREECH
PRETERM
IUGR BERAT

9. ROJ
10. MOW
11. TIDAK ADA
YANG
BERPENGALAMA
N

Ultrasound Assessment
confirm lie and type of breech
assess head position
obtain estimate of fetal weight
assess for IUGR and congenital
anomalies
assess amniotic fluid volume
confirm placental localization

Contraindications to Trial of Labour

fetal or maternal contraindication
to labour
footling breech
hyperextension of the fetal head
absence of informed consent
absence of experienced maternity
health care giver

Management in Labour
planned delivery in hospital
admission in early labour or with
ROM
appropriate fetal surveillance
epidural and ARM for usual
indications
immediate vaginal exam at ROM to
rule out cord prolapse
good progress in labour ( 0.5 cm/h
after 3 cm)
induction and augmentation
permissible

Management at Delivery
experienced newborn resuscitator
present
empty maternal bladder
maternity attendant with
experience in breech delivery
forceps if available, may be helpful

Entering the Pelvis

Obstetrics - Normal and Problem Pregnancies, 2nd Edition

Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

Descent of the Breech

Obstetrics - Normal and Problem Pregnancies, 2nd Edition

Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

Spontaneous Expulsion

spontaneous
expulsion to the
umbilicus
the sacrum should
be gently guided
anteriorly
singleton breech
extraction is
contraindicated
C/S is indicated
for failure of
descent or

Obstetrics - Normal and Problem Pregnancies, 2nd Edition

Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

Hurry up & Wait!

DONT PULL!
traction
deflexes the
fetal head
may cause
nuchal arm

Obstetrics - Normal and Problem Pregnancies, 2nd Edition

Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

Deliver Legs by lateral rotation of thighs and

flexion of knees - keep sacrum anterior

Obstetrics - Normal and Problem Pregnancies, 2nd Edition

Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

Delivery of Arms
good maternal
pushing
deliver when winging
of scapulae seen
rotate arm to
anterior
sweep humerus
across the chest and
deliver
rotate other arm
anterior and repeat
to deliver

Obstetrics - Normal and Problem Pregnancies, 2nd Edition

Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

Avoid Over-extension

Obstetrics - Normal and Problem Pregnancies,2nd Edition

Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

Delivery of the head

Mauriceau - Smellie - Veit

manoeuvre to deliver the head in
flexion
The body should be supported
in a horizontal position

Delivery of the head

Obstetrics - Normal and Problem Pregnancies, 2nd Edition

Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

Delivery of the head

Forceps
assistant elevating
babe
direct application

Obstetrics - Normal and Problem Pregnancies, 2nd Edition

Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

Prevention of Breech
consider external cephalic version at
36 weeks gestation for eligible
candidates
success rate 30 - 70% depending on
experience
results in lower cesarean section rate

Conclusions
proper selection of patients
thorough explanation and informed
consent
good progress in labour ( 0.5 cm/h after
3 cm)
induction and augmentation permissible
experienced attendants
standard fetal monitoring
assisted delivery - DONT PULL - stay cool!

LABOR AND DELIVERY PROBLEMS

BREECH PRESENTATION AT TERM

Management
option
Version in
prenatal period

Fetal assessment

Labor and
delivery

Quality of
evidence

Strength of
recommendation

References

Evidence for reduced breech presentation at

delivery and in cesarean section rate with external
cephalic version (ECV) at term

Ia

Tocolysis is associated with fewer ECV failures

Ia

Fetal vibroacoustic stimulation in medicine fetal

position is associated with fewer ECV failure

Ia

Need for fetal heart rate monitoring before and after

ECV

III

Apparent safety in women with a previous cesarean

section

IIa

No evidence to support postural management to

encourage spontaneous version

Ia

Confirm diagnosis and determine placental side

Confirm normality as association of breech

presentation with congenital anomaly

III

Assess fetal attitude-hyperextension of fetal head is

associated with spinal cord injury during vaginal
delivery

III

Evidence that planned cesarean section for breech

at term as preferred method of delivery significantly
reduced perinatal mortality and morbidity

Ia

PRETERM BREECH PRESENTATION

Management
option

Quality of
evidence

Strength of
recommendatio
n

References

Prenatal

Evidence that external cephalic version

is not useful in preterm breech
presentation

Ia

Labor and
deliverygeneral

Infant outcome worse with breech

presentation than vertex

III

2,3

Routine cesarean section would cause

iatrogenic prematurity

Ib

Preterm
breech
presenting in
labor

Confirm in labor, including vaginal

examination

Confirm normality

Confirm type of breech

No strong evidence of benefit but

probably cesarean section preferred,
especially for 1000-1500 g

III

5-9

For babies less than 1000 g no evidence

of benefit from either mode of delivery

III

9,10

PROLONGED PREGNANCY
Management
option
Prenatal:
general

Prenatal: at 41
weeks

Quality of
evidence

Strength of
recommendation

References

Establish accurate gestational age as early as

possible

III

Menstrual dates overestimate gestation. Routine

early scan of value in preventing induction for post
dates

Ia

Breast stimulation does not reduce incidence of

postterm pregnancy

Ia

Sweeping membranes at term reduces chance of

pregnancy going beyond 41 weeks

Ia

Reevaluated for possible risk factors

Routine induction of labor reduce perinatal

mortality

Ia

Ib
Ia

A
A

4
2

Ib

III

IIa

Ia

Active management:
Cervical ripening reduce risk of failed induction
Labor induction does not increase rate of cesarean
section or operative vaginal delivery if cervix made
favorable first
Expectant management :
Routine fatal movement counts alone have not
been shown to be of value in reducing perinatal
deaths-but no
Maternal perception of sound-provoked fetal
movements may be of value where facilities for
frequent nonstress testing (NST) are not available
Serial NST twice weekly at least helpful in
monitoring fetal wellbeing in postterm pregnancies
Fetal acoustic stimulation test may be of value in
those with a nonreactive NST

Quality of
evidence

Strength of
recommenda
tion

Ib

IIb

III

III

Manage as high-risk pregnancy

If umbilical cord compression from oligohydramnions

amnionfusion is useful

Ia

Be vigilant for shoulder dystocia

III

Managemen
t option
Perinatal: at
41 weeks

Labor and
delivery

Expectant management:
Assessment of amniotic fluid index versus vertical pockets
of amniotic fluid increases obstetric intervention
Biophysical profile twice weekly may be helpful for
monitoring fetal wellbeing but is time-consuming
Combination of just amniotic fluid volume and fetal
acoustic stimulation test may be acceptable
Umbilical artery Doppler has not been shown to be any
better than NST

RINGKASAN