Nuha AL yousfi

DEFINITION Breech presentation is the entrance of the fetal buttocks or lower extremities into the maternal pelvic inlet. It is the commonest form of malpresentation. The term breech was derived from the word Britches which is a cloth used to cover the loins and thighs.

 The incidence of breech varies with gestational age It is 30%-40% at 20-25 weeks of gestation 25% at 28-30 weeks 15% at 32 weeks 2% - 3% at term

Aetiology
Cause is unknown: Fetal
Prematurity It is the commonest cause twins Fetal abnormalities e.g. hydrocephalus, anencephaly, neck masses & aneuploidy

 Maternal
Multiparity Polyhydramnios or oligohydramnios Pelvic tumours Congenital uterine anomalies e.g. bicornuate or septate uterus

Placental
Placenta praevia Cornual implantation of placental Drugs anticonvulsant - phenytoin

TYPES OF BREECH PRESENTATIONS

Frank breech : flexed at hips and extended at knees Complete breech : flexed at hips and flexed at knees Incomplete breech : one or both hips are not flex and one or both feet or knees lie below the breech

Contd

DIAGNOSIS:
Based on clinical presentation, usually an incidental finding on abdominal examination. Palpation:- soft, globular, non ballotable fetal part at the lower uterine pole and a hard, rounded and ballotable part felt above the umbilicus (uterine fundus). Difficulties in making a diagnosis by palpation arise when the anterior abdominal wall is obese, extended legs obscure ballotment of the fetal head with the fetus in dorso-anterior position and polyhydramnios present.

Auscultation:- the area of greatest intensity of the fetal heart sounds is above the level of the maternal umbilicus although if the legs are extended, the sounds tend to be heard at a lower level. Vaginal examination:- fetal buttock is felt, if cervix is dilated and membrane ruptured, natal cleft is felt, feet felt alone or close to buttocks, cord may also be felt.

INVESTIGATIONS:
ULTRASONOGRAPHY FOR CONFIRMATION

DIAGNOSIS OF HYPEREXTENSION
ESTIMATION OF WEIGHT DIAGNOSIS OF MAJOR CONGENITAL MALFORMATIONS

METHODS OF VAGINAL DELIVERY

There are three general methods of breech delivery through the vagina: Spontaneous breech delivery. The infant is expelled entirely spontaneously without any traction or manipulation other than support of the infant. assisted breech delivery. The infant is delivered spontaneously as far as the umbilicus, but the remainder of the body is extracted/delivered with operator traction and assisted maneuvers with or without maternal expulsive efforts. Total breech extraction. The entire body of the infant is extracted by the obstetrician.

MECHANISM OF LABOR IN BREECH PRESENTATION

In breech presentation there are three mechanisms of labor. Delivery of the buttocks and lower limbs Delivery of the shoulders and arm Delivery of the head

MECHANISM OF LABOR buttocks and lower limb

Engagement and descent with compaction Engagement occurs when the bitrochanteric diameter has passed through the pelvic inlet. The bistrochanteric diameter is 10cm. Descent is slow as the breech is a less efficient dilator. Compaction means that every part becomes a little bit more flexed.

Delivery of the buttocks and lower limb

Internal rotationIn case of RSA or LSA bitrochanteric diameter rotates 45 degrees from the oblique diameter The sacrum turns away from the midline from anterior quadrant to the transverse plane.

Delivery of the buttocks and lower limb

Birth of buttocks by lateral flexionThe anterior hip impinges under the pubic symphysis, lateral flexion occurs and the posterior hip raises and is born over the perineum. Then the anterior hip slips out under the pubic symphysis.

Delivery of shoulders and arms

Engagement Occurs in the oblique diameter of the pelvis. Internal rotation of the shouldersThe bisacromial diameter turns 45 degrees from the oblique to the anteroposterior diameter of the outlet. The bisacromial diameter is 12cm. Birth of the shoulders by lateral flexionAnterior shoulder impinges under pubic syphysis and the posterior shoulder and arm are born followed by anterior shoulder.

Delivery of after coming head

Descent and engagementHead enters the pelvis in the opposite oblique diameter . Flexion Internal rotation The occiput comes under the pubic symphysis. Birth of the head by flexionThe nape of the neck pivots under the symphysis pubis and the chin, mouth, nose, forehead, bregma, and occiput are born by movement of flexion.

ASSISTED DELIVERY OF BREECH

The frank breech should ideally be allowed to deliver without assistance to at least the level of the umbilicus. Unless there is considerable relaxation of the perineum, an episiotomy should be made.

 Maternal expulsive efforts are used in conjunction with continued gentle downward operator rotational traction to effect delivery of the fetus. Gentle downward traction is combined with simultaneous 180 degree rotation of the fetal pelvis from either left to right sacrum transverse or from right to left

Principles of assisted breech delivery

Dont rush: aggressive and hasty pull may cause entrapment of after coming head through the incompletely dilated cervix Always keep the fetus with the back anteriorly Delivery of after coming head (dont pull from below but suprapubic pressure can be applied

 The no touch of the fetus policy is adapted until the buttock are delivered along with the legs in flexed breech & the trunk slips up to the umbilicus

 When the trunk has been delivered upto the level of the umbilicus.
The extended legs in frank breech are to be delivered by the pressure on the knees (popliteal fossa) in the manner of abduction and the flexion of the thighs. Further flexion can be obtained by gradually reaching for the ankle, grasped and eased out the foot.

Umbilical cord is then freed to avoid tension on it The baby is wrapped with a sterile towel to prevent slipping when held by the hands and to facilitate manipulation, if required

Delivery of the arm A steady traction is applied at the hips till the ant. Scapula is visible, the position of the arm should be noted The Flexed arm delivered one after the other by simply hooking down elbow with a finger across the face

 Extended arm
If the arms are extended adduction and flexion of the shoulder followed by extension at the elbow helps to bring down the forearm and hand. Lovset maneuver

Arrest of the shoulders and arms

NUCHAL ARMS Here the hand is behind the occiput. Diagnosis is made when the medial border of the scapula is not parallel to the spine. Managed by rotating the baby in the direction in which fingers are pointing

Delivery of the after coming head

This is the most crucial stage of the delivery The time between delivery of the umbilicus to delivery of mouth should preferably be 5 10 min. Various methods of delivery.
Mauriceau-smellie-veit maneuvre Burn-Marshall method Forceps delivery

Burn-Marshall method
The procedure here is to gently sweep the babys limbs and truck over the mothers abdomen

Forceps delivery

PRAGUE MANEUVER. Rarely, the back of the fetus fails to rotate to the anterior. When this occurs, rotation of the back to the anterior may be achieved by using stronger traction on the fetal legs or bony pelvis. If the back still remains posteriorly, extraction may be accomplished using the Mauriceau maneuver and delivering the fetus back down. If this is impossible, the fetus still may be delivered using the modified Prague maneuver. two fingers of one hand grasping the shoulders of the back-down fetus, from below, while the other hand draws the feet up over the maternal abdomen

Complications with Vaginal Delivery for Breech

Maternal injuries 1. Uterine rupture 2. Lacerations of the birth canal 3. Extension of the episiotomy 4. Deep perineal tears Infection Atonic PPH

FETAL INJURIES Intracranial hemorrahge Cord prolapse Fetal acidosis Skeletal injuries Brachial plexus injury paralysis of the arm Testicular injury Perinatal loss

MANAGEMENT OF BREECH PRESENTATION AT TERM

Management options
(1) external cephalic version(antenatally) (2) elective caesarean section (3) trial of vaginal delivery

Total breech extraction

VERSION
Version is a procedure in which the presentation of the fetus is altered artificially, either substituting one pole of a longitudinal presentation for the other, or converting an oblique or transverse lie into a longitudinal presentation. According to whether the head or breech is made the presenting part, the operation is designated cephalic or podalic version, respectively. In external version, the manipulations are performed exclusively through the abdominal wall; whereas in internal version, the entire hand is introduced into the uterine cavity.

 External cephalic version is successful in 65 percent of cases. FACTORS ASSOCIATED WITH SUCCESSFUL VERSION. external version using tocolysis is more likely to be successful if: 1. The presenting part has not descended into the pelvis. 2. There is a normal amount of amnionic fluid. 3. The fetal back is not positioned posteriorly.

4. The woman is not obese.

Absolute Contraindications
Multiple gestation IUGR, major anomaly Hyperextension of fetal head PROM Oligohydramnios Ante partum bleeding Placenta previa PIH, preeclampsia Maternal cardiac disease Uterine scar Uterine malformation CPD

Relative Contraindications
Macrosomia Excess maternal obesity Active labor

Zatuchni-Andros Breech Scoring

Add 0 Points
Parity Gestational age (wk) EFW (lb) 0 39+ 8

Add 1 Point
1 38 7-8

Add 2 Points
2 <37 <7

Previous breech
Dilatation Station

0
2 -3

1
3 -2

2
4 -1

If the score is 0-4, cesarean delivery is recommended

Indications for caesarean section

Elective LSCS
Elderly primi History of infertility Bad obstetric history Contracted pelvis IUGR PROM Placenta previa Footling breech Hyperextension of the fetal head Breech score of <3 Large baby-EFW >3800 gms Premature infant

Emergency LSCS IN 1ST STAGEcord prolapse fetal distress In 2nd stage non progress of labor fetal distress

THANK YOU