Breech Presentation Quiz

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Questions and Answers

What is the most common type of mal-presentation during delivery?

Breech presentation.

What is the incidence of breech presentation at term?

2-3%.

Name two predisposing factors for breech presentation.

Pre-term fetus and polyhydramnios.

What are the three types of breech presentation?

Frank breech, complete breech, and incomplete breech. Signup and view all the answers

How is breech presentation diagnosed through abdominal examination?

No head is felt at the lower end, and a hard rounded knob is ballotable at the upper end of the uterus. Signup and view all the answers

What is the role of external cephalic version (ECV) in the management of breech presentation?

ECV is attempted to turn the fetus to a cephalic position around 37 weeks of gestation. Signup and view all the answers

What should be administered to an Rh-negative mother after a successful ECV?

Anti-D immunoglobulin. Signup and view all the answers

What is a potential treatment option if breech presentation is confirmed but ECV fails?

Elective cesarean section. Signup and view all the answers

What are some reasons for the failure of external cephalic version (ECV)?

Reasons include a deeply engaged breech, tense uterus, fetal abnormalities, undiagnosed twins, and a tense abdominal wall. Signup and view all the answers

List at least three contraindications for performing an ECV.

Contraindications include placenta previa, hypertension, and planned cesarean section. Signup and view all the answers

What complications can arise from performing an ECV?

Complications may include placental abruption, premature rupture of membranes, and fetal bradycardia. Signup and view all the answers

In the event of ECV failure, what should be discussed with the woman regarding delivery options?

There should be a discussion on the pros and cons of vaginal breech delivery versus cesarean section. Signup and view all the answers

What assessments should be done for primiparous patients before considering vaginal breech delivery?

A standing lateral CT scan should be performed to assess pelvis size, and an ultrasound to estimate fetal weight. Signup and view all the answers

What are some positive factors that favor vaginal breech delivery?

Positive factors include a flexed breech position, normal fetal size, good pelvimetry, and the presence of a supportive healthcare team. Signup and view all the answers

Identify at least two adverse factors that indicate a cesarean section may be preferable for breech delivery.

Large estimated fetal weight (>3.8 kg) and fetal head positioning issues are adverse factors. Signup and view all the answers

What significant risk is associated with breech delivery compared to normal delivery?

Perinatal mortality is 2-3 times more common in breech deliveries. Signup and view all the answers

Study Notes

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)

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Description

This quiz explores the topic of breech presentation in obstetrics, covering its incidence, etiology, and types. Learn about the factors contributing to this common malpresentation and the different classifications of breech. Perfect for medical students or those interested in maternal-fetal medicine.