Breech presentation

Dr Ayman Shehata

Definition

Breech presentation is the presentation in which the fetus is in longitudinal lie and its buttock is the lower most part .

Incidence

28 weeks…25% Term 2-3% 1/3 are undiagnosed in labour

classifications

Frank breech (65%): where the hips are flexed and legs extended

Complete breech (25%): where the hips and knees are flexed and the feet are not below the level of the fetal buttocks

Footling breech: where one or both feet are presenting as the lowest part of the fetus

Kneeling: kneesare the lowermost presenting part

Kneeling presentation

Positions

the denominate is the sacrum: First position;left sacro-anterior (back anterior and to left). Second position; right sacro-anterior (back anterior and to right). Third position; right sacro-posterior (back posterior and to

right). Fourth position; left sacro-posterior (back posterior and to left).

Etiology

Maternal factors

Polyhydraminos Oligohydramnios Uterine anomalies (bicornuate, septate) Space occupying lesions (e.g fibroids) Placental abnormalities (praevia,

cornual) Multiparity (in particular grand

multiparas) Contracted pelvis

Fetal factors

Prematurity Fetal anomalies (e.g neurological,

hydrocephalus, anenecephaly) Multiple pregnancy Fetal death Short umbilical cord Extended legs; because they splint the

trunk, and so interfere with spontaneous cephalic version.

Mechanism of delivery

Engagement Descent Internal rotation Lateral flexion External rotation Birth : breech then body then head

Diagnosis of Breech

Clinical examination:

abdominal vaginal

Radiological examination:

x-ray

ultrasound scan

CT

MRI

Clinical Diagnosis

Abdominal examination Palpation 1. Fundal grips; the head is felt with its

characters. 2. Pelvic grip; the breech is felt, with its

characters. AuscultationThe fetal heart sounds are head just at, or

above the level of the umbilicus.

Vaginal examination

1. Slow dilatation of cervix, sausage-chapel bag of fore-waters, and liability to premature rupture of the membrane and prolapse of the cord.

2. After rupture of the membranes, the presenting part is felt, that is , the two buttocks with the anus in between , the genitalia on one side and the sacral spines on the opposite side.

3. In case of complete breech, the feet are felt on the same level as the buttocks.

4. In case of breech with extended legs, the buttocks only are felt. In case of footling presentation, the feet are at a lower level than the buttocks. In case of knee presentation, the knees are a lower level than the buttocks.

Imaging Techniques

Ultrasound CT MRI

US breech

Management of Breech

BREECH PRESENTATIONManagement during pregnancy

After 36 weeks

Spontaneous version

External cephalic version

Management of breech

Management During Pregnancy:

If persisted till 34 weeks…. Then ultrasound scan to exclude; abnormality, Ployhydramnios, placenta praevia.

By completed 37 weeks External Cephalic Version:

Version

External cephalic version Internal podalic version

External Cephalic Version

In delivery room

NPO and ready for c/s

CTG & USS

Tocolytic

Head down position

Dislodge breech then

gently turn around

US and CTG after procedure.

Internal podalic version

Risks of External Cephalic Version

Placental abruption Premature rupture of the membranes Cord accident Transplacental haemorrhage(remember

anti-D aministration in Rhesus-negative women)

Fetal bradycardia

Contraindications of External Cephalic Version

Absolute contraindication: Previous scar on the uterus Placenta praevia Unexplained APH Pre-eclampsia Multiple pregnancy

Relative contraindications: Rhesus isoimmunisation Elderly primigravida IUGR Oligohydramnios Polyhydramnios

Management during labour

Cesarean sectionVaginal delivery

Spontaneous breech delivery

Assisted breech deliveryTotal breech extraction

Indications of vaginal deliverya) Frank or complete breech presentation

b) Gestational age > 36 weeks

c) Estimated foetal weight b/n 2.5-3.5 kg

d) Foetal head must be flexed

e) Adequate maternal pelvis, x-ray or ct pelvimetry

f) No other obstetric complications.

Management during labour

During labour:1. If there is contracted pelvic, and fetus

is living and good; do caesarean section.

2. First stage Rest in bed and avoid repeated vaginal

examination to prevent premature rupture of the membranes. But vaginal examination is done after rupture of membranes to exclude cord prolapse.

Partial breech extraction or Assisted breech delivery

Second stage :Delivery of the aftercoming head

Burns Marshall method Mauriceau-Smellie-veit maneuver Prague maneuver Piper forceps

Burns Marshall Method

Mauriceau-Smellie-Veit Maneuver

Prague maneuver

The back of the fetus fail to rotate to the anterior

Piper Forceps

Total breech extraction

Indication1. Prolonged second stage of labor2. Twins3. Maternal disease4. Prolapsed cord5. Fetal distress

Total Breech Extraction

Cesarean section

Indications: Large fetus Contraction or unfavorable shape of

pelvis Hyperextended head(Star gazing) Uterine dysfunction Incomplete or footling presentation Primigravida

Indications of Cs in Breech

Healthy preterm Severe fetal growth restriction Previous perinatal death or newborn complication of birth trauma Lack of an experienced operator

Complications of Breech Delivery Maternal complications Risk of Operative intervention Risk of infection due to

Manipulations Intrauterine maneuvers : Rupture of

the uterus +/- lacerations of Cx Extensions of the episiotomy Uterine atony , Postpartum

hemorrhage

Complications cont.

Fetal complications Preterm delivery & low birth weight & IUGR Prolapse cord Birth aphyxia Fetal Injuries

Fx of humerous and clavicle Fx of femur Hematomas of sternocleidomastoid Separation of epiphyses of scapular,humerus or femur Brachial plexus Avulsion of upper C-spine Skull Fx , intracerebral injury

THANK YOU