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PATIENS IDENTITY
Name
: Mrs. S
Age
: 33 years old
Address : Tarogong Kidul
Graduate : Junior High School
Occ
: Housewife
No. Medical Record : 883xxx
Date of Admission : 21 August
2016
MAIN COMPLAINT
Uterine
Contraction
GESTATIONAL HISTORY
Kehamilan
Tempat
Penolong
Cara Kehamilan
Cara Persalinan
BB Lahir
Jenis Kelamin
Usia
Keadaan :
Hidup /
Mati
Rumah Bidan
Bidan
Aterm
Spontan
4000
RS
Dr.SpOG
Aterm
SC
2900
ADDITION INFORMATION
First marriage
25 years, junior high school, housewife
25 years, senior high school, self employed
HPHT : 20 November 2015
TP : 27 August 2016
UK : 439-40 weeks
Mestrual history
Cycle : Regularly, 7 days
Blood : usual
Pain
: No
Menarche
: 12 years old
Last Contraception :
PILLS
Acceptor contraception since 2011
until 2012
Reason for stop the contraception:
menstruation irregularity
Prenatal Care
Midwife, 9 times
Last PNC 1 week ago
Complaints during pregnancy : Past medical history
:-
PHYSICAL EXAMINATION
General condition : Compos Mentis
Blood pressure : 120 / 70 mmHg
Pulse rate
: 80 x/mnt
Respiratory rate : 20 x/mnt
Temperature
: AF 0C
Head
: Conjuctiva: anemis -/- Sklera: ikterik -/ Neck
: no abnormalities.
KGB = no abnormalities
Thoraks
: heart : S I & S II reguler, G(-), M(-)
lung : VBS left = right, Rh(-), Wh(-)
Abdomen
: soft, distended, tenderness (-), DM (-)
Liver
: no abnormalities
Lien
: no abnormalities
Ekstremities
: Edema: - Varises: -
OBSTETRIC STATUS
EXTERNAL EXAMINATION
Symphycial fundal height
: 37 cm
Abdominal circumference
: 105 cm
Fetal Position
: breech, back on left side, 2/5
Number of contraction : three times per 10 minutes for 20
seconds
Fetal heart rate
: 138x/minute
EBW
: 3780
SPECULUM EXAMINATION
not performed
VAGINAL EXAMINATION
Vulva
: No Abnormality
Vagina
: No Abnormality
Portio
: Thick Soft
Dilataion
: 2-3cm
Amnion Fluid
: positif
Presentation
: breech
Factor
PARITY
GESTATIO
NAL
AGES
(WEEKS)
39
36
37
TBBA
3500
30003500
< 3000
BREECH
LABOR
Never
2 or more
DILATATI
ON
STATION
-3
-2
-1
SCORE
PLANNING MANAGEMENT
DIAGNOSIS
PROBLEM
This is her third pregnancy, she has given birth two times and she
never miscarriage . G3P2A0
There is 2-3cm dilatation parturien
HPHT 20 November 2015, TP 27 Agustus 2016, date of admission
21 Agustus 2016 39-40 weeks
Leopold 1-4 : breech
Has a SC Hystory SC history
Patient :
Observation of GS, VS, His, FHR
Infusion of RL 500cc 20 gtt
Check hematology Routine
Induction was not done because she had SC History, but because of
her EBW is more than normal and her zatuchni andros score is 3
so she has the indication for SC
Add 0 Points
Add 1 Point
Add 2 Points
39+
38
<37
EFW (lb)
7-8
<7
Previous breech
Dilatation
Station
-3
-2
-1
Parity
Gestational age
(wk)
LABORATORY INVESTIGATION
Date 21-08-2016 time 19:56
Hematology
Routine blood
1. Hemoglobin : 11,7 g/dl ( n 12.0 - 16.0 )
2. Hematocryte : 35 %
( n 35 - 47)
3. leukocyte : 32.760 /mm3
( n 3.800 10.600 )
4. Trombosit : 292.000 /mm3 ( n 150.000 440.000 )
5. Erytrocyte : 3.53 juta/mm3 ( n 3,6 5,8 )
Intruction
P/ Th :
Obs KU, TTV
Inf Rl 500
cc 20 tpm
Inj
Cefotaxim 2
x 1 gr iv
Mefenamat
Ac 3 x 500
mg iv
Kaltrofen
Supp 2x1
Aff DC
Mobilization
FOLLOW UP-DAY 2
Date, time
23/08/2016 S/ Cough
O/ GS
POD II
Blood pressure
Respiratory rate
Pulse rate
Temp
Eye
Breast Milk
Abdomen
DM (-)
SFH
Surgical wound
Bleeding
Bowel/urine output
Notes
Instruction
P/ Th :
Aff Infus
: CM
: 100/60 mmHg
: 20x/mnt
: 108 x/mnt
: AF 0C
Cefadroxil
2 x 500
mg po
Metronida
zol 3 x
500 mg
po
As.Mefena
mat 3 x
500 mg
op
Change
bandage
Mobilizati
on
FOLLOW UP-DAY 3
Date, times
24/08/2016
POD III
Notes
S/ O/ GS
: CM
Blood pressure: 100/60 mmHg
Respiratory rate : 20 x/mnt
Pulse rate
: 80 x/mnt
Temp
: AF 0C
Eye
: Ca -/- Si -/Abdomen
: soft, tenderness(-), DM
(-)
Breast milk
: +/+
SFH
: 3 finger under
umbilicus
Lochia
: + rubra
Surgical wound: dry
Bleeding
:Bowel/urine output : - / A/ P3A0 Partus matures with SC + IUD
insertin a.c breech with EBW > 3500
gr + SC History
Intruction
P/ Th :
Cefadroxil 2 x 500
mg po
Metronidazol 3 x
500 mg po
As. Mefenamat 3
x 500 mg op
Changed bandage
FINAL DIAGNOSIS
A/ P3A0 Partus maturus with SC + IUD insertion
e.c breech presentation with EBW > 3500 gr +
SC History
THEORY
BREECH PRESENTATION
Breech presentation is defined as a fetus in a longitudinal lie with
the buttocks or feet closest to the cervix.
This occurs in 3-4% of all deliveries.
CLASSIFICATION
PREDISPOSING FACTORS
PATHOPHYSIOLOGY
Fetal and uterine size can influence breech presentation. Preterm
infants are more likely to change their in utero position due to the
smaller size. Larger fetuses may be forced into a cephalic
presentation in late pregnancy due to space or alignment
constraints within the uterus.
Leopold
Vaginal
examination
USG
LEOPOLD MANEUVERS
Leopold I
Leopold III
Leopold II
Lepold IV
VAGINAL EXAMINATION
Frank Breech
o No feet are palpable, but the fetal ischial tuberosities, sacrum, and anus are
usually palpable.
o After further fetal descedance, the external genitalia may also be
distinguished.
o Especially when labor is prolonged, the fetal buttocks may become markedly
swollen, rendering differentiation of a face and breech is difficult.
Complete Breech
The feet may be felt alongside the buttocks.
Footling Presentations
One or both feet are inferior to the buttocks.
TREATMENT
Contraindication of
ECV
1. Hipertention
2. narrow pelvic
External cephalic version
Knee
chest
position
(if there
is no contraindication
3. Oligohydramnion
4. gemelli
5. antepartum
haemorrhage
DELIVERY
Vaginal delivery
Caesarean
delivery
VAGINAL DELIVERY
Terms of vaginal delivery in breech position :
Complete or frank breech
Clinical adequate
The fetus is not too large
No history of caecarean with indication of CPD (Cephalo-Pelvic
Disproportion)
Head flexion
MANUAL AID
Step one
breech birth
until the navel is
born with his
own mother's
strength and
power
Step two
birth the
shoulders and
arms with the
helper
(classic
(Deventer),
Mueller, Lovset,
Bickenbach)
Step Three
The birth of
head
Mauriceau ( Veit
- Smellie ),
Najouks, Wigand
Martin
Winckel,Parague
reversed,
cunam piper)
STEP TWO
CLASSIC (DEVENTER)
LOVSET
MUELLER
BICKHENBACH
Mauriceau
(Veit
Smellie)
Najouks
Parague
reversed
cunam
piper
No downward or outward
traction is applied to the
fetus until the umbilicus has
been reached.
T H E A N T E R I OR A R M I S F OLLOW E D T O
T H E E L BO W , A N D T H E A R M I S S W E P T
O U T O F T H E VAG I N A.
T H E F E T U S I S R O TAT E D 1 8 0 , A N D T H E
C O N T RA L AT E RA L A R M I S D E L I V E R E D I N A
S I M I L A R M A N N E R A S T H E F I R S T. T H E I N FA N T
I S T H E N R O TAT E D 9 0 T O T H E B A C K- U P
P O S I T I O N I N P R E PA RAT I O N F O R D E L I V E RY O F
THE HEAD.
T H E F E TA L H E A D I S M A I N TA I N E D I N A F L E X E D
P O S I T I O N BY U S I N G T H E M A U R I C E A U - S M E L L I E VEIT MANEUVER, WHICH IS PERFORMED
BY
PL ACING THE INDEX AND MIDDLE FINGERS OVER
T H E M A X I L L A RY P R O M I N E N C E O N E I T H E R S I D E O F
T H E N O S E . T H E F E TA L B O DY I S S U P P O RT E D I N A
N E U T RA L
POSITION
WITH
CARE
TO
NOT
OVEREXTEND THE NECK.
MAURICEAU MANEUVER
D E L I V E RY O F T H E A F T E RC O M I N G H E A D U S I N G
T H E M A U R I C E A U M A N E U V E R. N O T E T H AT A S T H E
F E TA L H E A D I S B E I N G D E L I V E R E D , F L E X I O N O F
THE
HEAD
IS
M A I N TA I N E D
BY
S U P RA P U B I C
P R E S S U R E P R O V I D E D BY A N A S S I S TA N T.
P I P E R S A R E S P E C I A L I Z E D F O RC E P S U S E D O N LY F O R
T H E A F T E RC O M I N G H E A D O F A B R E E C H P R E S E N TAT I O N .
THEY ARE USED TO KEEP THE HEAD FLEXED DURING
E X T R A C T I O N O F T H E F E TA L H E A D . A N A S S I S TA N T I S
N E E D E D T O H O L D T H E I N FA N T W H I L E T H E O P E R AT O R
G E T S O N O N E K N E E T O A P P LY T H E F O RC E P S F R O M
B E L O W.
LO W 1 - M IN U T E A P G A R S C O R E S A R E N O T U N C O M M O N
A F T E R A VA G I N A L B R E E C H D E L I V E RY. A P E D I AT R I C I A N
S H O U L D B E P R E S E N T F O R T H E D E L I V E RY I N T H E
E V E N T T H AT N E O N ATA L R E S U S C I TAT I O N I S N E E D E D .
EXTRACTION BREECH
Total
breech
extraction
For frank
breech
Foot
extractio
n
Breech
extractio
n
CAESAREAN DELIVERY
IF :
1. Vaginal Childbirth estimated difficult and dangerous (Feto Pelvic Disproportion
or scor Zachtucni Andros 3 )
2. Umbilical cord prolapse in primi/multigravida
3. Obstained Dystonia
4. Age of Pregnancy
5. The value of children (only consideration)
6. History of labor : a history of poor labor, fetal high social value.
Factor
PARITY
GESTATIO
NAL
AGES
(WEEKS)
39
36
37
TBBA
3500
30003500
< 3000
BREECH
LABOR
Never
2 or more
DILATATI
ON
STATION
-3
-2
-1
SCORE
Information :
3 : labor
perabdominal .
4 : reevaluation
carefully , especially
BBJ , if the value can still
be born vaginally
5 : born vaginally
Persalinan Pervaginam
Seksio Sesaria
gr
- Ukuran pelvis yang sempit atau
perbatasan
- Presentasi kaki
COMPLICATION
MOTHER :
1.Bleeding because trauma of the
birth canal, atonic uterus,
retained placenta.
2.Infection occurs because
ascendens trought trauma
(endometritis)
3.Labor trauma such as trauma of
the birth canal, symphisidiolisis
Infants factors :
bleeding , such as intracranial hemorrhage ,
intracranial edema , hemorrhage vital tools intra
-abdominal .
Infections due to manipulation
Trauma labor such as
dislocation / fracture extremities ,
joints neck
rupture vital tools intra -abdominal ,
damage to the brachial plexus and the facial
damage to the central vital in the medulla
oblongata
direct trauma to vital tools ( eyes , ears , mouth
asphyxia
stillbirth
PROGNOSIS
With rapid recourse to
cesarean section, use of
banked blood, and expertly
administered anesthesia, the
overall maternal mortality
has fallen to less than 1 in
1000.
VBAC, SC HISTORY
Risk for the fetus
Still Birth (1,3 per 1000 in
15.515 deliveries, Smith, dkk
(2012))
Hipoxyc Ischemic
Encephalopaty
THANK YOUU