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Delivery in improper fetal position (Breech (Diagnosis (Differentiation in…

- - - - 1
        
        Engagement of breech into the bony canal  and passage to the pelvic outlet
        
        The intertrochanteric diameter pass the inlet  with the intertrochanteric diameter  into the transverse diameter of the bony pelvis
        
        After the 2nd rotation one of the buttocks is called  „anterior” and the other one „posterior”
      - 2
        
        After passage of the vaginal canal curve,  buttocks turn to set the intertrochanteric diameter into the a-p diameter of the vaginal canal
        
        The lateral flexion of the fetal vertebral column up to the pubic symphysis
        
        Buttocks present themselves between vulvar labias
      - 3
        
        Delivery of the trunk:
        With lateral flexion of the vertebral column
        Both limbs fall out free
        Shoulders become engaged in the „inlet”  – their transverse diameter in the transverse pelvis diameter
      - 4
        
        Shoulders delivery:
        Turn to the a-p pelvis diameter
        The „anterior” shoulder presents first
        The „posterior” shoulder afterwards
      - 5
        
        Delivery of the head:
        When lower angles of scapulas can be seen, the head becomes engaged in „inlet”
        Its a-p diameter in the transverse pelvic diameter
        Internal rotation
        Head delivery after it touches the pubic symphysis
  - - - Breech is smaller than head
        Rigid and elastic parts of breech
        Are not oval
        Heart beat auscultated above umbilicus of pregnant woman
    - - the presenting part is smaller than head  without sutures and fontanellae
        palpable sacral vertebrae
        palpable fisssura between buttocks
        no characteristic plane cranial bones
  - - - Perineum disinfection, Urinary bladder emptying, Local anaesthesia;
        Intravenous fluid infusion into which Oxytocine is added during delivery or at least during delivery of shoulders;
        Pressure on uterus above pubic symphysis to facilitate  the engagement of fetal head to the „inlet”
        When the fetus is delivered up to the lower brims of scapulas the medical assistance is applied: Bracht manouver, Classical manouver, Lövset manouver, Müller manouver, Veit-Smellie manouver, Wiegand-Martin-Winckel manouver
      - Classical manouver
        
        Right fetal hand is liberated by the right obstetrician’s hand  and left fetal hand by the left obstetrician’s hand;
        
        The „posterior” hand is liberated first;
        
        Fetal legs are grasped by the hand corresponding to fetal abdomen and pulled to the opposite side of the liberated hand;
        
        The liberated hand is pulled down by sweeping it in front of fetal face
        
        Rotation of fetus to make the „anterior” hand the „posterior” one like in Lövset manouver
        
        Any traction is forbidden during rotation
- - - - Can be performed before rupture of membranes  or when membranes are just ruptured;
        
        If membranes are intact - they have to be broken before hand insertion;
        
        Obstetrician’s hand inserted into the vagina and uterus;
        
        Fetal „anterior” foot (only one) has to be found, grasped and pulled down;
        
        Then the fetal manual extraction has to be performed;
        
        The assisting person can exert some force above pubic symphysis to facilitate the engagement of fetal head  to the pelvic inlet.
- - - - Parietal
        
        anterior fontanellum – „leading point”
        
        head circumference – 34 cm
        
        delivery possible if:
        improper „second rotation”, small fetus, fetus dead, huge pelvic diameters, in multiparas, second twin
        
        3rd rotation – the rotation point – forehead-hair border
        
        huge flexion
        
        occipital part delivered first
        
        deflexion
        
        delivery of face
      - Frontal
        
        leading point – space between nose and greater fontanellum
        
        the greatest head circumference – 35-36 cm
        
        delayed or absent second rotation
        
        delivery possible if:
        improper „second rotation”, small fetus, fetus dead, huge pelvic diameters, in multiparas, second twin
        
        3rd rotation – the rotation point – nose or zygomatic bone
        
        huge flexion
        
        face & chick delivered first
        
        flexion – delivery of face
        
        slight deflexion – delivery of cheek
      - Face
        
        leading point – nose and chick
        
        the greatest head circumference – 34 cm.
        
        deflexion increases during head advancement
        
        sequence of delivery:
        cheek, mouth, nose, eyes
        
        delivery may become impossible
        if „proper” 2nd rotation – chick to the back – delivery impossible
        
        3rd rotation – the rotation point – space under chick
        flexion, forehead delivered first