Breech Presentation www.freelivedoctor.com BREECH PRESENTATION • Definition-It is a longitudinal lie in which the buttocks is the presenting part with or without the lower limbs. • Incidence-3.5% of term singleton deliveries and about 25% of cases before 30 weeks of gestation as most cases undergo spontaneous cephalic version up to term. www.freelivedoctor.com Aetiology • In general, the foetus is adapted to the pyriform shape of the uterus with the larger buttock in the fundus and smaller head in the lower uterine segment. • Any factor that interferes with this adaptation, allows free mobility or prevents spontaneous version, can be considered a cause for breech presentation as: www.freelivedoctor.com Aetiology *Prematurity: > relatively small foetal size, > relatively excess amniotic fluid, and >more globular shape of the uterus. * Multiple pregnancy: one or both will present by the breech to adapt with the relatively small room. www.freelivedoctor.com Aetiology * Poly-and oligohydramnios. * Hydrocephalus. * Intrauterine foetal death. * Bicornuate and septate uterus. * Uterine and pelvic tumours. * Placenta praevia. www.freelivedoctor.com Types • Complete breech: > The feet present beside the buttocks as both knees and hips are flexed. >More common in multipara. www.freelivedoctor.com Types . Incomplete breech a.Frank breech: >It is breech with extended legs where the knees are extended while the hips are flexed. >More common in primigravida b.Footling presentation: >The hip and knee joints are extended on one or both sides. >More common in preterm singleton breeches. www.freelivedoctor.com Types . Incomplete breech:c.Knee presentation: >The hip is partially extended and the knee is flexed on one or both sides. www.freelivedoctor.com Positions * Left sacro-anterior. * Right sacro-anterior. * Right sacro-posterior. * Left sacro-posterior. * Left and right sacro- transverse (lateral). * Direct sacro-anterior and posterior. www.freelivedoctor.com • Sacro-anterior positions are more common than sacro-posterior as in the first the concavity of the foetal front fits into the convexity of the maternal spines. www.freelivedoctor.com Diagnosis • During pregnancy • Inspection * Inspection: >A transverse groove may be seen above the umbilicus in sacro-anterior corresponds to the neck. > If the patient is thin, the head may be seen as a localised bulge in one hypochondrium. www.freelivedoctor.com Diagnosis * Palpation: > Fundal grip: the head is felt as a smooth, hard, round ballottable mass which is often tender. > Umbilical grip: the back is identified and a depression corresponds to the neck may be felt. > First pelvic grip: the breech is felt as a smooth, soft mass continuous with the back. Trial to do ballottement to the breech shows that the movement is transmitted to the whole trunk. www.freelivedoctor.com Diagnosis * Auscultation: > FHS is heard above the level of the umbilicus. However in frank breech it may be heard at or below the level of the umbilicus. www.freelivedoctor.com Diagnosis Ultrasonography: > It is used for the following: > To confirm the diagnosis. > To detect the type of breech. > To detect gestational age and foetal weight: Different measures can be taken to determine the foetal weight as the biparietal diameter with chest or abdominal circumference using a special equation. > To exclude hyperextension of the head. > To exclude congenital anomalies. > Diagnosis of unsuspected twins. www.freelivedoctor.com Diagnosis • During Labour • In addition to the previous findings, vaginal examination reveals: * The 3 bony landmarks of breech namely 2 ischial tuberosities and tip of the sacrum. * The feet are felt beside the buttocks in complete breech. * Fresh meconium may be found on the examining fingers. * Male genitalia may be felt. www.freelivedoctor.com Mechanism of Labour • Delivery of the buttocks * The engagement diameter is the bitrochanteric diameter 10 cm which enters the pelvis in one of the oblique diameters. * The anterior buttock meets the pelvic floor first so it rotates 1/8 circle anteriorly. * The anterior buttock hinges below the symphysis and the posterior buttock is delivered first by lateral flexion of the spines followed by the anterior buttock. * External rotation occurs so that the sacrum comes anteriorly. www.freelivedoctor.com Mechanism of Labour • Delivery of the shoulders * The shoulders enter the same oblique diameter with the biacromial diameter 12 cm (between the acromial processes of the scapulae). * The anterior shoulder meets the pelvic floor first, rotates 1/8 circle anteriorly, hinges under the symphysis, then the posterior shoulder is delivered first followed by the anterior shoulder. www.freelivedoctor.com Mechanism of Labour * The head enters the pelvis in the opposite oblique diameter. * The occiput rotates 1/8 circle anteriorly, in case of sacro- anterior position and 3/8 circle anteriorly in case of sacro- posterior position. * Rarely, the occiput rotates posteriorly and this should be prevented by the obstetrician. www.freelivedoctor.com The head is delivered by movement of flexion in: * Direct occipito-posterior (face to pubis). * Face mento-anterior. * The after coming head in breech presentation. www.freelivedoctor.com Management of Breech Presentation • External Cephalic Version • It regains its importance after increased rate of caesarean sections nowadays. • Timing: After the 32nd weeks up to the 37th week and some authors extend it to the early labour as long as the membranes are intact and there is no contraindications. www.freelivedoctor.com Management of Breech Presentation • Version is not done earlier because: * Spontaneous version is liable to occur. * Return to breech presentation is liable to occur. * If labour occurs the foetus will have a lesser chance for survival. www.freelivedoctor.com Management of Breech Presentation Version is difficult after 37th weeks due to: * Larger foetal size. * Relatively less liquor. * More irritability of the uterus. www.freelivedoctor.com Management of Breech Presentation • Causes of failure * Large sized foetus. * Oligo- or polyhydramnios. * Short umbilical cord. * Uterine anomalies as bicornuate or septate uterus. * Irritable uterus. Tocolytic drugs may be started 15 minutes before the procedure to overcome this. *Obesity * Rigid abdominal wall. * Frank breech because the legs act as a splint. www.freelivedoctor.com Caesarean Section • Indications: a. Large foetus i.e. > 3.75 kg estimated by ultrasound. b.Preterm foetus but estimated weight is still more than 1.25 kg. c.Footling or complete breech: as the presenting irregular part is not well fitting with the lower uterine segment leading to; > Less reflex stimulation of uterine contractions. > Susceptibility to cord prolapse. > Early bearing down as the foot passes through partially dilated cervix and reaches the perineum. www.freelivedoctor.com Caesarean Section • Indications d. Hyperextended head: diagnosed by ultrasound or X-ray. e. Contracted pelvis: of any degree. f. Uterine dysfunction. www.freelivedoctor.com Caesarean Section • Indications: g.Complicated pregnancy with: > Hypertension. > Diabetes mellitus. > Placenta praevia. > Pre - labour rupture of membranes for = 12 hours. > Post-term. > Intrauterine growth retardation. > Placental insufficiency. www.freelivedoctor.com Caesarean Section • Indications h. Primigravidas: breech in primigravida equals caesarean section in opinion of most obstetricians as the maternal passages were not tested for delivery before. www.freelivedoctor.com Vaginal Delivery • Prerequisites: * Frank breech. * Estimated foetal weight not more than 3.75 kg. * Gestational age: 36-42 weeks. * Flexed head. * Adequate pelvis. * Normal progress of labour by using the partogram. * Uncomplicated pregnancy. * Multiparas. * An experienced obstetrician. * In case of intrauterine foetal death. www.freelivedoctor.com Vaginal Delivery • During vaginal delivery, prematures are more susceptible to: * hypoxia, * trauma, and • retained after-coming head as the partially dilated cervix allows the passage of the body but the less compressible relatively larger head will be retained. However, caesarean section should only be done if the premature foetus has a reasonable chance of post - natal survival. www.freelivedoctor.com Management of Vaginal Breech Delivery • First stage: as other malpresentations. • Second stage: The foetus may be delivered by one of the following methods: a.Spontaneous breech delivery b.Assisted breech delivery c.Breech extraction www.freelivedoctor.com Complicated Breech Delivery www.freelivedoctor.com Arrest of the buttocks at the pelvic brim Causes Management Inefficient uterine contractions Contracted pelvis Oxytocin drip, if contraindicated do caesarean section Breech extraction - if cervix is fully dilated Caesarean section Large - sized baby Caesarean section www.freelivedoctor.com Arrest of the buttocks at the pelvic outlet Management Causes Inefficient uterine contractions Breech extraction Contracted outlet. Caesarean section Rigid perineum Episiotomy Extended legs (frank breech) Breech deeply impacted: Groin traction www.freelivedoctor.com Complications of Breech Delivery • Maternal: >Prolonged labour with maternal distress > Obstructed labour with its sequelae may occur as in impacted breech with extended legs. > Laceration especially perineal. >Postpartum haemorrhage due to prolonged labour and lacerations. > Puerperal sepsis. www.freelivedoctor.com Complications of Breech Delivery FoetalComplications: • Foetal mortality due to a.Intracranial haemorrhage b. Fracture dislocation of the cervical spines c. Asphyxia www.freelivedoctor.com
