Breechpresentation 100515015714 Phpapp01

Breech Presentation
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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.
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:
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.
Aetiology
*
*
*
*
*
*
Poly-and oligohydramnios.
Hydrocephalus.
Intrauterine foetal death.
Bicornuate and septate uterus.
Uterine and pelvic tumours.
Placenta praevia.
TYPES
Types
Complete breech:
> The feet present beside the
buttocks as both knees and hips are
flexed.
>More common in multipara.
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.
Types
Incomplete breech:c.Knee
presentation:
>The hip is partially extended and the
knee is flexed on one or both sides.
Positions
*
*
*
*
*
Left sacro-anterior.
Right sacro-anterior.
Right sacro-posterior.
Left sacro-posterior.
Left and right sacro- transverse
(lateral).
* Direct sacro-anterior and posterior.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.

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.

Version is difficult after 37th weeks
due to:
* Larger foetal size.
* Relatively less liquor.
* More irritability of the uterus.

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.
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.
Caesarean Section
Indications
d. Hyperextended head: diagnosed by
ultrasound or X-ray.
e. Contracted pelvis: of any degree.
f. Uterine dysfunction.
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.
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.
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.
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.
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
Complicated Breech
Delivery
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 Caesarean section

baby
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
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.
Complications of Breech Delivery

FoetalComplications:
Foetal mortality due to
a.Intracranial haemorrhage
b. Fracture dislocation of the cervical
spines
c. Asphyxia

Breechpresentation 100515015714 Phpapp01

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Copyright:

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Breech Presentation

Sacro-anterior positions are more

The head is delivered by movement of

Management of Breech Presentation

Management of Breech Presentation

Management of Breech Presentation

Management of Breech Presentation

During vaginal delivery, prematures are

Management of Vaginal Breech

Arrest of the buttocks at the pelvic

Oxytocin drip, if contraindicated do

Large - sized Caesarean section

Arrest of the buttocks at the pelvic

Extended legs (frank

Breech deeply impacted:

Complications of Breech Delivery

Complications of Breech Delivery

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