BREECH

 Name : Fathima
 Age : 26 years
 Occupation : House wife
 Address : Manjaly
 Blood group : A+
 Husbands Blood group : A+
 Socioeconomic status : Middle class
 Obstetric score : G3 P1 L1 A1
 First day of LMP : 3rd February 2020, previous 3 cycles regular
 Expected date of delivery : 10 November 2020
 Gestational age : 37 weeks

PRESENTING COMPLAINT

 She came for regular antenatal checkup

HISTORY OF PRESENT PREGNANCY

 Pregnancy was confirmed by UPT,1 week after missing her periods.she then visited a
hospital and booked her pregnancy
 FIRST TRIMESTER
 Nausea,vomiting present
 Blood and urine investigations were done and was found to be normal
 No history of bleeding or discharge per vagina
 No history of fever with rash, abdominal pain
 Scan was done at 6th and 11th weeks and was normal
 No exposure to radiation
 Folic acid supplements were taken
 No other drugs taken

 SECOND TRIMESTER
 Quickening felt in the 5th month
 Iron,folic acid and calcium tablets were taken
  2 doses of Td was taken
 Scan was done at 18th week and found to be normal
 OGTT was done at 18th week and was found to be normal
 No history of bleeding or discharge per vagina
 No history of pedal Edema, headache, increased frequency of micturition, increased
thirst, increased appetite, hypertension
 No history of UTI
 No history of hospital admission

 THIRD TRIMESTER
 Regular fetal movements were perceived
 Had history of discharge per vagina which was treated medically
 Blood glucose level was estimated and was found to be elevated and is on insulin and
Metformin
 History of UTI present 2-3 weeks back and was treated medically
 Scan was done at 32 weeks and showed podalic presentation
 No history of bleeding per vagina or abdominal pain

MENSTRUAL HISTORY

 Menarche at the age of 13 years

 Regular 28 day cycle
 Bleeding for 5 days
 No history of dysmenorrhoea or passage of clots
 LMP -3rd Feb 2020,previous 3 cycles regular

MARITAL HISTORY

 Married at the age of 21 years, Non consanguineous marriage, Spontaneous conception

 No history of any contraceptive use or infertility treatment

OBSTETRIC HISTORY
  Obstetric score : G3 P1 L1 A1

FIRST PREGNANCY

 At the age of 21 years

 History of spotting in the 2nd month
 Missed abortion confirmed
 Dilatation and curettage done

SECOND PREGNANCY

 At the age of 22 years

 Regular antenatal check up done
 History of elevated BP recorded during 2nd trimester and was managed conservatively
 No complications like GDM,PPH
 Full term vaginal delivery
 Healthy female child weighing 3.2kg
 Breast fed for 1.5 years,child immunised for age
 Puerperium normal

PAST MEDICAL AND SURGICAL HISTORY

 History of Laparoscopic appendicectomy done at the age of 15 years

 No history of DM, HTN, TB, asthma, thyroid disease, epilepsy and drug allergy

PERSONAL HISTORY

 She is on medical nutritional therapy

 Normal sleep and appetite
 Normal bowel and bladder habits
 No history of addictions

FAMILY HISTORY

 Mother and father have DM and HTN

  No history of TB, multiple pregnancy, congenital anomalies or any psychological illness
in family

EXAMINATION

GENERAL EXAMINATION

 Patient conscious,cooperative and well oriented

 Moderately built and nourished
 Height = 162 cm
 Weight = 75.6 kg
 BMI = 23.59 kg/ m² (using prepregnant weight =63 kg)
 No pallor, icterus, cyanosis, clubbing, lymphadenopathy or edema
 VITALS
 Pulse : 74 bpm, normal rhythm, character, volume, no radio-radial or radio-femoral
delay
 BP : 100/70 mm of Hg, right arm, sitting position
 Respiratory rate : 16/min ,thoracoabdominal
 Temperature : 38.6°c
 Thyroid examination normal
 Breast examination : No retracted nipple,no palpable lump
 Spine and gait normal

SYSTEMIC EXAMINATION

 Respiratory system : Normal vesicular breath sounds heard

 CVS : S1, S2- normally heard ,No murmur
 CNS : No focal neurological deficit

OBSTETRIC EXAMINATION

 INSPECTION
 Abdomen longitudinally distended
 Linea nigra and Stria gravidarum present
 Umbilicus central and everted
 No visible scars, Engorged veins, sinus
 Hernial orifices intact
  PALPATION
 Symphysiofundal height is 36 cm ,which corresponds to 37 weeks of gestation
 Abdominal girth - 110 cm

Fundal grip

 Hard, round, compact, ballotable mass indicating cephalic pole of fetus

Umbilical grip

 Hard, uniform resistance on maternal left side indicating back of fetus

 Irregular nodules felt on right side indicating limbs

First pelvic grip

 Soft, broad, boggy, non ballotable mass indicating podalic pole of fetus

No second pelvic grip in breech

 AUSCULTATION
 Fetal heart sound heard at left upper lateral quadrant with a fetal heart rate of 140
beats/min

SUMMARY

26 year old patient with obstetric score G3 P1 L1 A1, gestational age 37 weeks , LMP-3rd Feb
2020 , EDD - 10th Nov 2020 , came to OPD for regular antenatal checkup.Has history of GDM,
h/o abortion in first pregnancy and gestational hypertension in 2nd pregnancy. Family history of
diabetes and hypertension .No history of any blood transfusion.

General examination - Normal

Systemic examination - Normal

On examination - Fundal height corresponds to 37 weeks, single live intrauterine pregnancy,

longitudinal lie, podalic presentation, Left sacroanterior position,FHR :140 bpm.
DIAGNOSIS

26 year old patient with obstetric score G3 P1 L1 A1 , gestational age 37 weeks , LMP - 3rd Feb
2020 ,EDD - 10th Nov 2020 ,with single live intrauterine pregnancy , longitudinal lie , podalic
presentation ,LSA position ,complicated with GDM.

CASE DISCUSSION

1.Types of breech ?

 Extended or Frank breech

 Flexed or complete breech
 Incomplete breech - footling presentation , knee presentation

2.Aetiology of breech presentation?

 Maternal factors - prematurity( most important), multiparity, uterine obliquity,

placenta praevia, fibroids in lower segment, uterine anomalies (septate, bicornuate),
cornuofundal placenta
 Fetal factors - multiple pregnancy, polyhydramnios, oligohydramnios, Extended legs,
congenital anomalies(hydrocephaly, anencephaly, myelomeningocele, pracder willi
syndrome), neuromuscular disorders( myotonic dystrophy), trisomies(13, 18, 21)

3.key facts

 Denominator - sacrum
 Attitude - flexion in complete breech and partial extension in extended breech
 Positions - LSA,RSA,LSP,RSP
 Engaging diameters - Bitrochanteric (9.5cm) , Bisacromial (12cm) , suboccipitofrontal
(10.5 cm)
4.Diagnosis ?

Abdominal examination

 Head of the fetus is felt in the Fundal grip

 Breech is felt in the first pelvic grip
 Fetal heart is heard above the umbilicus

Vaginal examination

 Conical bag of membranes

 Presenting part is high up
 In flexed breech - ischial tuberosities ,anus, sacrum , buttocks , and feet are palpated
 In extended breech - only the buttocks are felt

Ultrasound

5.complications of breech ?

 Maternal : increased chance of operative delivery and anaesthesia

 Fetal : Birth asphyxia ( cord prolapse ,entrapment of after coming head) , Birth trauma

6.Management of breech ?

Antenatal assessment

 Fetal : well being, weight, attitude

 Maternal : health and maternal pelvis

A.Elective caesarean section

 Planned procedure -at 39 weeks of gestation

 Indications : complicated breech, contracted pelvis, severe FGR, footling presentation,
previous caesarean section

B.External cephalic version

 Performed at 36 - 37 weeks

C.Assisted breech delivery

 Ideal cases : Averaged sized fetus, normal pelvis, no indication for caesarean section
 Zatuchini - Andros prognostic scoring system : To asses prognosis for vaginal delivery
First stage

 Vaginal examination
 Nil per oral
 Parenteral fluids
 Epidural anaesthesia
 CTG monitoring
 Partogram
 Maintain intact membrane until compleate cervical dilatation

Second stage

 Delivery of breech : usually breech is delivered on its own up to the umbilicus

 Delivery of shoulders : Lovset manoeuvre
 Delivery of after coming head : Burns Marshall manoeuvre, Mauriceau smellie viet
manoeuvre, Piper forceps

Third stage

 Active management of third stage of labour.

D.Emergency caesarean section

 Indications - cord prolapse, failure to progress, maternal or fetal distress, impacted

breech

E.Breech Extraction :

 performed when cervix is fully dilated and immediate breech delivery is warranted as
in cases of fetal distress, maternal distress or cord prolapse

6.Relevance of ballotable head ?

 Flexed breech is ballotable

 Extended breech -less ballotable due to the extended legs splinting the head

7.How hydrocephalus causes breech?

 Bulky head cannot occupy narrow lower pole, so it occupy fundus

8.worries about breech presentation?

 Cord prolapse
 Head entrapment
 Risk of c-section
9.percentage of cord prolapse in breech presentation?

 Flexed breech - 6%
 Extended breech -0.5%
 Footling presentation - 12%

10.Incidence of breech?

 At 28 weeks - 25%
 At 32 weeks -16%
 At delivery - 3-4%

11.Mechanism of labour in breech presentation?

 Most common position - LSA

Delivery of breech

 Engagement
 Descent with increasing compaction
 Internal rotation
 Lateral flexion
 Delivery
 Restitution

Delivery of the shoulders

 Engagement
 Internal rotation
 Birth by lateral flexion
 Restitution

Delivery of the head

 Engagement
 Descent with increasing flexion
 Internal rotation
 Birth by flexion