BREECH

PRESENTATION
AND DELIVERY
Karlina Dahlianingrum
1410221051

BACKGROUND
Breech presentation : a condition
when the buttocks of the fetus enter
the pelvis before the head
Presentage of breech presentation in
pregnancy :
> 37 weeks : 5 7 %
29 32 weeks : 14 %
21 24 weeks : 33 %

 Type of breech presentation:

frank breech : 50 75 % the lower
extremities are flexed at the hips and
extended at the knees, and thus the feet
lie in close proximity to the head
complete breech : 5 10 %, differs in
that one or both knees are flexed
footling breech : 20 24 % an
incomplete breech presentation with one
or booth feet below the breech

 Only 3 4 % incidents of breech

presentation in pregnancy of single
fetus
The mortality rising up to 2-4 times
in every pregnancy

CASE ILLUSTRATION

Identitas Pasien

Name
:Mrs. Sunarti
Age
: 42 yrs old
Address
: East Jakarta
Medical Recod: 02.25.64.22

Anamnesa
A
woman
G4P3A0
from
Jatinegara
community
health
center
came
to
Persahabatan Hospital with 41 weeks
gestation of breech presentation ( 9th July
2016, 5.45 PM)

Main Complaint:
Patiens came with water broke for 6
hours before admission to the
hospital. (9/07/16)

Keluhan Tambahan:
Patiens also felt the contraction for
12 hours before admission (9/07/16)

Riwayat Penyakit Sekarang :

Patients suffered with water broke for

6 hours before admission. The color
of the water was clear and didnt
smell. Before the water broke, she
felt the contraction for about 12
hours before the admission. She felt
it for about 10-15 minutes, and the
contraction was gone. Then she felt it
again with the same intensity.

 Patiens admitted this was her fourth

of pregnancy.It was 9 months of
pregnancy. Her first day of the last
period was on 25th of October 2015.
She didnt know the estimate time of
the labor day but she thought that, it
should be happen this July. She also
admitted that the fetus had a active
movement in the womb.

 During the pregnancy, patients did

the ANC at midwife clinic, regularly.
She never had an USG examination
before. She denied suffering for fluor
albus during pregnancy.

 She denied the history of high blood

pressure, diabetes, fever, cough, flulike
syndrome,
pain
during
mixturation,
allergies
during
pregnancy. She admitted to have
teeth cavity in the right side of
molar, but during the pregnancy she
never felt pain in the molar area.

Family history
None of hipertention, diabetes,
asthma, heart disease, allergies
History of Menarche :
First Menarche 12 yrs old,
regularly, 7 days, she changed 3
times of tampons a day, she denied
suffering for dysmenorrhea.

History of Marriage
She married 2 times:
First marriage happened in 1993-2003.
she was 20 years old and the husband
was 27 years old.
Second marriage happened in 2004. She
was 31 years old and the husband was
36 years old. She is a housewife and the
husband is a freelance labor.

History of obstetrics
G4P3A0 :
Baby boy, spontaneus delivery, aterm,
2800 gr, in shaman
Baby boy, spontaneus delivery, aterm,
2600 gr, in shaman
Baby boy, spontaneus delivery, aterm,
2700 gr, at midwife clinic
Latest pregnancy

History of contraception
Using Pil since 2005
History of medicine
Vitamin for latest pregnancy from the
midwife

Physical Examination
Blood pressure:
140/90
Pulse: 84
times/minutes
Respiratory rate: 20
times/minutes
Temperature: 36,5o C
Compos Mentis
Weight: 65 kg, (before
pregnancy 60 kg)
Generelazid status
Within normal limits

Obstetrics status
Height of fundus: 30 cm
Back is in the right area,
breech presentation, FHR
156, HIS: 4x/10/50
Inspection : v/u within
normal limits, bleeding (-)
Inspekulo : didnt do this
examnation
VT : complete cervical
dilatation, anterior
sacrum, sacrum H-IV,
mekonium +

 Ultrasonografi I (17.50)
Fetus in breech presentation, single
term life, placental in fundus, fhr:
146. there is none abnormality in
toraco-abdominal section

Working diagnose
Second stage of labor on G4P3 with 41 weeks of
pregnancy, breech presentation dd/ preeklampsia

Plan of support examination

bloodtest, UL, blood sugar test, ALT, AST, Ur/Cr
Plan of assessment
Spontaneus delivery
Control and monitoring blood pressure

Delivery report
(06.05 PM)
Patient in litotomi position, mother led to
strain
accordance
arrival
of
the
contraction. Breech expelled spontaneusly.
Then using bracht maneuver we delivered
the baby, chin and face came in a row.
Born baby girl, weight 3100 g, length of
the body is 50 cm, Apgars score 8/9. We
clamped the cord and cut it. Then we
injected the mother with oxitocyn.

(06.15 PM)
The placental expelled spontaneusly.
Message the mothers fundus. Good
contraction. We did the hemostatis
stitch exploration Bleeding in thirdfourth stage delivery was 100 cc

Letak Sungsang

LITERATURE REVIEW

DEFINITION
Breech presentation : a condition
when the buttocks of the fetus enter
the pelvis before the head
Presentage of breech presentation in
pregnancy :
> 37 weeks : 5 7 %
29 32 weeks : 14 %
21 24 weeks : 33 %

 Type of breech presentation:

frank breech : 50 75 % the lower
extremities are flexed at the hips and
extended at the knees, and thus the feet
lie in close proximity to the head
complete breech : 5 10 %, differs in
that one or both knees are flexed
footling breech : 20 24 % an
incomplete breech presentation with one
or booth feet below the breech

 Only 3 4 % incidents of breech

presentation in pregnancy of single
fetus
The mortality rising up to 2-4 times
in every pregnancy

ETHIOLOGY
Presentation of fetus depends on fetal
adaptation with the room cavity in the
uterus
First-mid trimester enough amount of
amniotic fluid the fetal make any
position as its possible
Last trimester the amount of amniotic
fluid is decreasing the biggest section of
the fetal is placed in the largest area of the
uterus (fundus)

Risk Factor of Breech

Presentation
multiparitas,
Double term,
hidramnion,
hidrosefalus,
anensefalus,
History of breech
presentation in
pregnancy
CPD

Abnormality of uterus,
Pelvic tumor, plasenta
previa
Plasental position in
the cornu of uteri
(lateral position near
the peak of the
fundus). This could be
reduce the area in the
fundus

DIAGNOSIS
Leopold
Leopold I : hard, round, readily ballottable fetal
head may be foun to occupy the fundus
Leopold II : indicates the back to be on one
side of the abdomen and the small parts on the
other
Leopold III : if not enggaged, the breech is
movable above the pelvic inlet.
Leopold IV :
After the engagement, the fourth maneuver
shows the firm breech ti be beneath the
symphisis

Pemeriksaan dalam
After the membran of amniotic fluid
is ruptured, sacrum, tuber osiis iskii
and anus could be palpated in
internal examination

Delivery Scor
Tabel 1. Skor Zatchni-Andros

ilai :
persalinan perabdomen
evaluasi kembali secara cermat, khususnya berat badan janin bila nilainya tetap
t dilahirkan pervaginam
dilahirkan pervaginam

Methods of Vaginal
Delivery
Spontaneus breech delivery the fetus is
expelled entirely spontaneusly without any
traction or manipulation other than support of
the newborn
Partial breech extraction the fetus is
delivered spontaneusly as far as the umblicus,
but the remainder of the body is extracted or
delivered with operator traction and assisted
maneuver, with or without expulsive efforts
Total breech extraction the entire body of the
fetus is extracted by the obstetrician

Spontaneus Breech Delivery

BRACHT
Persiapan ibu, janin, penolong dan peralatan

Ibu posisi litotomi, penolong berada di depan vulva,

saat bokong mulai membuka vulva suntik 2-5
unit oksitosin IM.
Lakukan episiotomi

Segera setelah bokong lahir, bokong dicengkram

dengan cara Bracht
(kedua ibu jari penolong sejajar sumbu panjang
paha, sedangkan jari-jari lain memegang panggul)

Saat tali pusat lahir dan tampak teregang

kendorkan tali pusat

Penolong lakukan hiperlordosis badan janin

(punggung janin didekatkan ke perut ibu, gerakan
disesuaikan gerak berat badan janin)

Jaga kepala janin tetap dalam posisi fleksi

(hindari ruang kosong antara fundus uterus dan kepala
janin, sehingga tidak teradi lengan menjungkit)

Berturut-turut lahir pusar, perut, bahu,

lengan, dagu, mulut dan akhirnya seluruh
kepala.

Janin yang baru lahir diletakkan diperut ibu.

Burn-Marshall Technique

Tidak ada traksi yang perlu dilakukan pada bayi hingga

bagian umbilikus melewati perineum, dimana usaha

mengejan ibu diperlukan dalam penurunan

bayi.

Traksi ke bawah dilakukan sampai scapula dan aksila

bayi terlihat. Gunakan handuk kering pada bagian pinggul (bukan
perut) bayi untuk membantu traksi bayi secara lembut.

Ketika scapula telah terlihat, putar bayi 90o dan secara

lembut sapukan bagian lengan anterior keluar dari
vagina dengan menekan bagian dalam lengan atau
siku.

Putar bayi 180o ke arah sebaliknya, dan sapukan

tangan yang lain keluar dari vagina.

1
2

3
4

Delivering shoulder of the

fetus
Principal
delivering posterior
arm first and then
the anterior arm
will come
afterwards below
the arcus pubic
Classic Maneuver

Loevsett maneuver
Grasp hip of the fetus
Than we turn the body
of the fetus, until the
back is at anterior area
While doing the twist,
do traction downwards,
so that the posterior
arm turns into the
anterior arm
Rotate in the opposite
position while we do
traction downward.

Mueller
Delivering the shoulder
of the fetus with the
anterior of the arm
below the simphisis
through the extraction
Then continuesly
deliver the posterior of
the arm
This methode is
chosed if the shoulder
trap in the lower pelvic

 Manuver Mueller

Tarik janin vertikal kebawah, lalu dilahirkan bahu

dan lengan depan

Cara melahirkan bahu lengan depan dapat

spontan atau dikait dengan satu jari menyapu
wajah

Lahirkan bahu belakang dengan menarik kaki

keatas lalu bahu- lengan belakang dikait menyapu
kepala.

Deliver the Head

Head should stay in flexi positition
Manuver Mauriceau :
The operator lift the prominens of
maxilaris, whie assistantas perform
suprapubic pressure

 Manuver Wigand Martin

The left hand enter to the birth canal
with one of the finger enter to the fetus
Indeks finger and thumb in the mandible
another hand pressed over the
symphisis or fundus area

 Prague Manuever consists of two

fingers of one hand grasping the
shoulders of the back down fetus
from below while the other hand
draws the feet up over the maternal
abdomen

 Piper Methode used when the

maurice maneuver cannot be
accomplished easily. The blades of
the forceps should not be applied to
the aftercoming head until it has
been brought into the pelvis by
gentle traction, combined with
suprapubic pressure, and is
enggaged. Suspension of the body of
the fetus in a towel effectively holds

 Pinard Manuever aims at bringing down the

foot in cases where the fetal leg is extended
frank breech
Pressure is exerted against the inner aspect
of the knee (popliteal fossa), with help of the
middle and indeks fingers of the clinician. As
the pressure is applied, the knee gets flexed
and abducted. This causes the lower leg to
move downward, which is then swept
medially and gently pulled out of the vagina

 Resiko persalinan pervaginam :

head entrapment in aftercoming head
due to the occurrence of molasses head,
or the opening of the cervix incomplete
This risk could reduce by maintaining
flexi position with pressed the external
suprapubic and not do the extraction.

Persalinan
Perabdominam

Tata Cara SC
Insisi abdominal
Insisi garis tengah vertikal
Insisi transversal suprapubik.

Insisi lapisan subkutan

Insisi fasia
Insisi muskulus rektus abdominis
Insisi segmen bawah uterus
Bayi dilahirkan (manuver sama dengan
persalinan pervaginam)

Komplikasi
Morbidity and mortality from delivery
difficulty
Low weight of the baby, IUGR
Cord prolaps
Plasenta previa
Anomali fetus, neonatus, dan infantil
Anomali dan tumor uterus
Low APGAR Score
Head entrapment especially in preterm
pregnancy

Assessment
Indication of external cephalic version
If the gestational week is 37 weeks or more
Possibility of vaginal delivery
The amount of amniotic fluid is enough
There is No sign of complication or
contraindication

Contraindication
CPD, antepartum hemorhage, hipertension,
gemelli, IUGR, history of ceacarian, fetal
abnormal

DISCUSSION

Diagnose
A woman 42 years old diagnosed with second
stage of labor on G4P3 with 41 weeks of
pregnancy, breech presentation dd/ preeclampsia
Gestational week first day on the last period
Breech maneuver Leopold examination, fetal
heart rate in the upper of umbilical (anterior
sacrum palpated at H-IV), and the last of
ultrasonography.
Second stage of labor came with full dilatation
of the cervix

Assessment
Zatuchni Andros Paritas :
Multi
:1
Gestational weeks : 38 - 39 wk: 0
Estimated fetal weight : < 3176 : 2
History of breech presentation: No: 0
Cervical dilatation : 4 cm
:1
Station : H IV
:2
6 pervaginam

Penyebab Letak
Sungsang
Multipara the most favorable
factor
The position of the plasenta didnt
make breech presentation for this
pregnancy
There is No abnormality of fetus
Overdistention of the uters and
pelvic obstruction is not discovered

CONCLUSION

 The examination, diagnose, and the

assessment of this case depends on
anamnesa, physical examination,
and support examination.
This case assessed with vaginal
delivery
Prediposing factor multipara

THANK YOU