Management of Breech Presentation

By Dr Dambo

Introduction
• The management of breech presentation is an area of intense controversy. • A variety of committed opinions have been expressed on every aspect of management from the mode of delivery (once a breech always a cesarean section) to the place of external cephalic version in modern management. • The most fundamental shift in opinion over the last 10-15 years has been the realization that breech presentation may well be a bad prognostic variable of itself hence caution.

• Management involves:-History taking -Physical examination -Laboratory investigations -Treatment

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 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 buttocks, ischial tuberosities, the sacrum and the anus are felt, if cervix is dilated and membrane ruptured, feet felt alone or close to buttocks, cord may also be felt.

INVESTIGATIONS: • Pelvic u/scan: confirm breech presentation - R/o PDF (fetal cong. Abn, p.praevia, multiple preg) - Estimate fetal weight • Pelvimetric assessment: clinical pelvimetary, x-ray pelvimetary (plain abdo x-ray, CTScan, MRI) – Role in the management of breech is controversial:- has not changed the incidence of c/s

MODE OF DELIVERY: The management of breech presentation remains controversial due to the associated high perinatal morbidity and mortality following breech deliveries. Options employed to reduce the perinatal mortality and improve the maternal and fetal outcome include:-Caesarean section -vaginal breech delivery -External cephalic version (E.C.V)

E.C.V is a manipulative transabdominal conversion of an abnormal presentation to cephalic presentation. Arguments: Those in favour of E.C.V say it has reduced the incidence and therefore the risk factors associated with vaginal breech delivery or caesarean section.

While those against E.C.V say its complications outweigh its benefits - prelabour rupture of fetal membranes -cord prolapse -premature labour, - prematurity -fetal heart rate abnormalities -abruptio placenta -cord entanglements -uterine rupture

when E.C.V is considered it is carried out only at term and after exclusion of contraindications such as; placenta praevia, multiple pregnancy, PROM, APH, PIH, Previous c/s, prematurity and contraindications to vaginal delivery. STEPS: E.C.V to be done in labour ward unit or theatre. 1. Obtain consent after explaining procedure to the woman 2. u/scan to R/O contraindications. 3. Maternal B.P measurement. 4. Fetal heart rate measurement (b/4 and after procedure):- non stress test (CTG) 5. Tocolytics (eg salbutamol, ritodrine) for uterine relaxation. 6. Mother placed in a steep lateral position with her back supported with a cushion or in a supine position and comfortable. 7. Breech disengaged from pelvic inlet using both hands, E.C.V carried out when breech is above the inlet. 8. One hand on lower pole, other on upper pole, manipulate in the direction which increases flexion of the fetus and makes it do a forward somersault, bringing the head to the lower uterine pole.

9. On completion of version the fetus is steadied by lateral pressure while the mother is transferred to the supine or semi-recumbent position. 10. Check fetal heart rate after procedure. N/B: If procedure fails or becomes difficult, it is abandoned. it is easier to perform ECV in multiparous women due to laxity of uterus and abdominal wall. No place for E.C.V in preterm – high failure rate. E.C.V at term is what is recommended - to allow for spontaneous version (reversion less likely, if successful), delivery of term baby in case of spontaneous labour or complications that require C/S, other unidentified P.D.F would have become obvious, associated with higher success rate, ECV success rate is between 25-97% of breech presentation.

Factors influencing success of E.C.V Maternal: parity - higher in multiparity Race - higher in black women due to late engagement

Fetal:

type of breech - flexed>frank descent of presenting part

CAESAREAN SECTION: Due to the high perinatal mortality and morbidity associated with breech presentation, the global trend now for breech delivery is C/S Recent randomised controlled trial (Mary Hannah in Canada) has shown that planned c/s is better than V.B.D, however in our society where there is an aversion for c/s, and where women with previous c/s attempt vaginal delivery to avoid repeat c/s outside the hospital with the possible risk of uterine rupture, liberal c/s for breech delivery is not justified.

INDICATIONS FOR C/S IN BREECH PRESENTATION: 1. Previous c/s 2. P.I.H 3. B.O.HX 4. Previous infertility 5. Contracted pelvis 6. Primigravida breech with inadequate pelvis 7. Elderly primigravida 8. Preterm breech, 9. Footling breech

Vaginal Breech Delivery
• 3 options -Spontaneous vaginal breech delivery -Assisted breech delivery -Total breech extraction

Vaginal breech delivery
In modern obstetric practise there is no place for S.V.B.D A.V.B.D is the choice of delivery but in well selected cases (women properly assessed:R/O P.D.F, C/I to V.D) Scoring index for A.V.B.D:- Zatuchni-Andros breech Scoring index Parameters of index:- Parity, cervical dilatation, Previous V.B.D, gestational age, estimated fetal weight, and station of the presenting part.

STEPS IN A.V.B.D:• Transfer to 2nd stage room when fully dilated • Place in lithotomy position and cleanse lower abdomen, vulva, vagina and thighs with swabs soaked in hibitane soln. • Apply sterile drapes to isolate the vulva 4. Empty bladder with a plastic catheter and repeat V.E to confirm full cervical dilatation. 5. With each contraction she is encouraged to bear down while the descent of the breech is observed without interference 6.The perineum is infiltrated with 10mls of 1% xylocaine

7. A left mediolateral episiotomy is given as the breech distends the perineum, the descent of the baby allowed to continue until the umbilicus and popliteal fossa become visible 8. Each extended lower limb is delivered by the pinard’s manoeuvre (pressure applied with two fingers to the popliteal fossa to flex the knee and gently abduct and flex the thigh)

9. Mother encouraged to bear down until the trunk, up to the scapula becomes visible, cord pulsation checked and a loop of cord pulled down to prevent cord compression 10. Baby gently held by the groin and trunk rotated 90o in one direction with a downward traction applied and the back facing upwards to deliver the anterior shoulder (lovset maneouvre for extended arms) 11. Procedure repeated in the opposite direction, with a rotation of 1800 to deliver the posterior shoulder.

12. Mother further encouraged to bear down until the hair lines is visible (the nape of the neck become visible) under the pubic symphysis 13. The aftercoming head is delivered by one of the following methods: - Mauriceau-Smellie-Veit manoeuvre (jaw flexion and shoulder traction) - Burns Marshall - Obstetric forceps (piper’s) The most important aspect of V.B.D is delivery of the aftercoming head

Zatuchni Andros scoring index(1965)
parameter parity Gestational age (weeks) Previous vag breech delivery Estimated fetal weight (kg) Cervical os dilatation (cm) Station of presenting part • • Score 0 0 39+ 0 > 4.0 2 -3 Score 1 1 38 1 3.5-4.0 3 -2 Score 2 >2 < 37 2 < 3.5 >4 -1

Score 0-4 - Caesarean delivery recommended Score > 5 – allow vaginal breech delivery

• At times in preterm breech presentation the incompletely dilated cervix may cause aftercoming head to be entrapped. -Gentle downward traction on the shoulders combined with fundal pressure by an assistant may effect delivery. -If this fails Duhrssen`s incisions is considered, which is incision made at 6 o`clock on the cervix with addition if necessary at 2 and 10 o`clock.

BREECH EXTRACTION: No maternal effort in V.B.D (breech extraction) Mother under general or regional anaesthesia INDICATIONS: - Retained 2nd twin with breech presentation - Transverse lie (do prior internal podalic version, then breech extraction) - I.U.F.D with breech presentation COMPLICATIONS OF A.V.B.D - Trauma to fetal head (I.C.H) - Fractured limbs (clavicular #, humerus #, shoulder dislocation) - Dislocation of the neck

Other methods of achieving spontaneous version
• Mousi Burston manouvre used by the chinese – where they burn a herb on the patient feet to achieve version. • Elkin’s manouvre – patient is advised to be in repeated knee-chest position to encourage spontaneous version

Conclusion
• Vaginal breech delivery requires an experienced obstetrician and careful counseling for the parent(s). • Patients must be informed about potential risks and benefits to the mother and neonate for both vaginal breech delivery and cesarean delivery. The likelihood is high that the trend will continue toward 100% cesarean delivery for breeches and that vaginal breech deliveries will no longer be performed.

Conclusion Contd
• ECV is a safe alternative to vaginal breech delivery or cesarean delivery, reducing the cesarean delivery rate for breech by 50%. Consider adjuncts such as tocolysis, regional anesthesia, and acoustic stimulation to improve ECV success rates. Before performing a delivery or ECV on a mother whose fetus is in a breech presentation, evaluate why the fetus is breech. The position may represent a marker for an underlying fetal anomaly.

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