Breech Presentation Quiz

Breech Presentation

• Breech presentation is the most common type of mal-presentation, where the fetal buttocks occupy the lower part of the uterus.
• Incidence of breech presentation at term is 2-3%, higher in preterm deliveries.
• The percentage of breech deliveries decreases as gestational age advances. It is 25% of births prior to 28 weeks, 7% at 32 weeks, and 2-3% at term.

Etiology (Predisposing Factors)

• Pre-term fetus
• Polyhydramnios and oligohydramnios
• Multiple pregnancy
• Placenta previa
• Uterine abnormalities (e.g., bicornate uterus, fibroids)
• Uterine surgery
• Fetal malformations (e.g., hydrocephaly, anencephaly)
• Abnormal fetal attitude (e.g., extended legs)
• Unknown cause

Types of Breech Presentation

• Frank breech: Extended both knees and flexed both hips. Commonest type.
• Complete breech: Both hips and knees are flexed
• Incomplete breech (Footling): One or both hips are extended, allowing the fetal lower extremity to enter the pelvis before the buttocks. Often seen in smaller babies.

Variations of Breech Presentation

• Diagrams showing the different types of breech presentation (complete, frank, incomplete/footling).

Diagnosis

• Abdominal exam: No head felt at the lower end, hard, rounded knob at the upper end, fetal heart sounds above the umbilicus.
• Pelvic exam: No head in the pelvis. Gluteal clefts and anus are felt.
• Investigation: Ultrasound (U/S) confirms the presentation, and screens for fetal abnormalities or undiagnosed twins.

Management

• Management in pregnancy:
  • External Cephalic Version (ECV).
  • Trial of vaginal breech delivery.
  • Elective cesarean section.
• Management in labor:
  • First Stage: Increased risk of early rupture of membranes; cord prolapse needs assessment.
  • Second Stage: Delivery of buttocks, legs, shoulders, and head. Possible maneuvers: -Loveset's maneuver
    • Mauriceau-Smellie-Veit maneuver
    • Forceps if maneuvers fail.
  • Third Stage: Syntometrine (oxytocin, ergotamine) given for prevention of postpartum hemorrhage (PPH). Placenta delivered spontaneously or via controlled cord traction.
• Emergency cesarean section: Used if vaginal delivery is deemed unsafe due to mild pelvic contractions, wrong fetal position, failure to progress, etc.

Complications of ECV

• Placental abruption
• Premature rupture of membranes
• Transplacental hemorrhage
• Cord accident
• Fetal bradycardia

Contraindications to ECV

• Placenta previa or history of antepartum hemorrhage (APH)
• Hypertension
• Planned cesarean delivery
• Ruptured membranes
• Multiple pregnancy
• Previous cesarean scar or myomectomy
• Active labor
• Fetal issues (e.g., IUGR, congenital anomalies, non-reassuring NST)

Positive Factors for Vaginal Breech Delivery

• Flexed or extended breech
• Normal size baby
• Good pelvimetry
• Multiparous women
• Breech deeply engaged
• Positive mental attitude/support
• Adequate obstetric unit/staff with breech delivery experience

Complications and Risks of Breech Delivery

• Increased perinatal mortality (2-3 times higher compared to cephalic)
• Umbilical cord prolapse is common in footling breech
• Shoulder dystocia (difficulty in delivering shoulders) can cause brachial plexus injuries, clavicular fracture
• Difficulty with head delivery can cause intracranial damage.
• Birth asphyxia if delivery is slow, and/or protracted.

Adverse Factors Against Vaginal Breech Delivery

• Large or small baby (estimated weight >3.8kg or <2.5kg)
• Small pelvis
• Primigravida
• Previous cesarean section
• Poor obstetric history
• Long history of infertility/assisted conception
• Extended neck

Shoulder Dystocia

• Maternal complications: Postpartum Hemorrhage (PPH)
• Fetal complications: Brachial plexus injuries, clavicular fracture
• Risk factors: Obesity, multiparity, diabetes mellitus.
• Management: Various maneuvers (e.g., Suprapubic pressure, McRoberts maneuver, Woodscrew maneuver, etc)
• Management Steps: Ask for Help & subsequent maneuvers/assistance

More Drastic Maneuvers

• Zavanelli's maneuver: Pushes baby's head back in, and may involve Cesarean section.
• Intentional clavicular fracture
• Maternal symphysiotomy (to widen the birth canal)