Breech Presentation PDF

Prepared by Dr. Eman Yousif  Breech presentation It is the most common type of mal-presentation in which the fetal buttocks occupy the lower part of the uterus. Incidence At term 2-3%, more in preterm deliveries. The percentage of breech deliveries decreases with advancing gestational...

Prepared by Dr. Eman Yousif  Breech presentation It is the most common type of mal-presentation in which the fetal buttocks occupy the lower part of the uterus. Incidence At term 2-3%, more in preterm deliveries. The percentage of breech deliveries decreases with advancing gestational age: from 25% of births prior to 28 weeks' gestation to 7% of births at 32 weeks' gestation to 2-3% of births at term. Etiology(predisposing factors) Pre-term fetus. Polyhydramnios and oligohydramnios. Multiple pregnancy. Placenta previa Abnormality in the uterus e.g. bicornate uterus fibroid , & uterine surgery. Fetal malformations eg. Hydrocephaly & anencephaly. Abnormal fetal attitude e.g. extended fetal legs. Unknown cause. Types According to knees & hips flexion & extension: 1.Frank breech or extended breech. extended both knees joints and flexed both hip joints. Commonest. 2.Complete breech or flexed breech. Both knees and hips are flexed. 3.Incomplete breech or Footling; one or both of the hips are extended ,so that the fetal lower extremityis entering the pelvis before the fetal buttocks.often occur with very small babies. On vaginal examination, the breech presentation in labour Is described according to the relation of the fetal sacrum to the maternal pelvis. Diagnosis Abd exam. No head is felt at the lower end , and a hard rounded knob is ballotable at the upper end of the uterus. Fetal heart sounds heard above the umblicus. Pelvic exam. Confirms there is no head in the pelvis & instead gluteal clefts and anus are felt on palpation. Investigation U/s confirms the presentation & also to diagnose any fetal abnormality or undiagnosed twin.  Management 1.Management in pregnancy. 2.Management in labour. Options of treatment External cephalic version. Trial of breech vaginal delivery. Elective cesarean section. Management in pregnancy: 1.External cephalic version ECV From about 37 weeks onwards is worthwhile trying under U/S vision without general anesthesia. If the mother is Rh-negative, anti-D immunoglobulin should be given after the first attempt. Tocolytics, such as terbutaline 0.25 mg IM ,can be used before ECV to help relax the uterus.  Precisions It is difficult to perform in overweight women , in case of deeply engaged breech & oligohydramnios. Listen to the fetal heart immediately before and after the procedure. If it works, the women should be seen weekly to ensure the fetus stays as a cephalic presentation.  If failed o If it fails, the women should be counseled about the route of delivery. Reasons of failure of ECV: a.Too deeply engaged breech in pelvis. b.Too tense a uterus. c.Too tense an abdominal wall. d.Fetal abnormality. e.Undiagnosed twin.  Contraindications to doing ECV: 1.Placenta previa or history of APH. 2.Hypertension. 3.Planned delivery by cesarean section anyway. 4.Ruptured membranes. 5.Multiple pregnancy. 6.Previous scar of cesarean section or myomectomy. 7.Active labour. 8.Fetal causes ;IUGR, cong.anomalies, non- reassuring NST.  Complications of ECV Placental abrution. Premature rupture of the membranes. Transplacental hemorrhage. Cord accident. Fetal bradycardia. 2.If ECV does not succeed then the women should be advised about the pros and cons of vaginal breech delivery compared with cesarean section.: A standing lateral CT scan of the pelvis should be done for all primiparous patients and any multiparous women who have delivered a baby more than 3.5 kg in the past , this is to know whether the head will fit the prlvis or not? And an U/S of the fetus to establish its estimated weight. Because in cephalic delivery the descending head acts as a pelvimeter whereas in breech it does not. Positive factors in favour of vaginal breech delivery (or indications of it) : 1. Flexed or extended breech. 2. Normal size baby. 3. Good pelvimetry. 4. Flexed neck. 5. Multiparous. 6. Breech deeply engaged. 7. Positive mental attitude of woman & husband. 8. Presence of obstetric unit with staff familiar with breech delivery. Ccomplications & risks of breech delivery: Perinatal mortality is 2-3 times more. 1. Cord prolapse ;is common in footling & to lesser extent in flexed breech causing fetal hypoxia. 2. Difficulty in delivering the shoulders; causing brachial plexus & liver damage. 3. Difficulty in delivering the head; causing intracranial damage, subdural and intracranial hemorrhage. 4. Birth asphyxia due to slow delivery of the head & prolonged cord compression. 3.If there is any other variation from normal , many obstetricians will deliver the baby by elective cesarean section at 38-39 weeks. Adverse factors against vaginal breech delivery (or indications of CS):- 1-Large or small baby (U/S estimated weight >3.8kg or