Breech Presentation

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.

Etiology
• In general, the fetus 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:
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www. * Multiple pregnancy: one or both will present by the breech to adapt with the relatively small room.freelivedoctor. > relatively excess amniotic fluid.com . and >more globular shape of the uterus.Etiology *Prematurity: > relatively small fetal size.

* Uterine and pelvic tumours.com . * Bicornuate and septate uterus. www. * Hydrocephalus. * Placenta praevia.Etiology * Poly-and oligohydramnios. * Intrauterine foetal death.freelivedoctor.

www.com .freelivedoctor. >More common in multipara.Types • Complete breech: > The feet present beside the buttocks as both knees and hips are flexed.

>More common in primigravida b. >More common in preterm singleton breeches.Footling presentation: >The hip and knee joints are extended on one or both sides.Frank breech: >It is breech with extended legs where the knees are extended while the hips are flexed. www.com .freelivedoctor.Types . Incomplete breech a.

Knee presentation: >The hip is partially extended and the knee is flexed on one or both sides.freelivedoctor. Incomplete breech:c. www.com .Types .

com . * Left sacro-posterior.freelivedoctor. * Right sacro-posterior.transverse (lateral).Positions * Left sacro-anterior. * Right sacro-anterior. www. * Direct sacro-anterior and posterior. * Left and right sacro.

• 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.com . www.freelivedoctor.

freelivedoctor.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. www.com . the head may be seen as a localised bulge in one hypochondrium.

> Umbilical grip: the back is identified and a depression corresponds to the neck may be felt.Diagnosis * Palpation: > Fundal grip: the head is felt as a smooth.freelivedoctor. soft mass continuous with the back. > First pelvic grip: the breech is felt as a smooth. round ballottable mass which is often tender. www. Trial to do ballottement to the breech shows that the movement is transmitted to the whole trunk.com . hard.

However in frank breech it may be heard at or below the level of the umbilicus. www.com .Diagnosis * Auscultation: > FHS is heard above the level of the umbilicus.freelivedoctor.

www. > To exclude hyperextension of the head. > To exclude congenital anomalies.freelivedoctor.com . > 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.Diagnosis Ultrasonography: > It is used for the following: > To confirm the diagnosis. > Diagnosis of unsuspected twins.

* The feet are felt beside the buttocks in complete breech. vaginal examination reveals: * The 3 bony landmarks of breech namely 2 ischial tuberosities and tip of the sacrum.Diagnosis • During Labour • In addition to the previous findings. www.freelivedoctor. * Male genitalia may be felt. * Fresh meconium may be found on the examining fingers.com .

• Delivery of the buttocks * The engagement diameter is the bitrochanteric diameter 10 cm which enters the pelvis in one of the oblique diameters.com Mechanism of Labour . * External rotation occurs so that the sacrum comes anteriorly. * The anterior buttock meets the pelvic floor first so it rotates 1/8 circle anteriorly. www. * 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.freelivedoctor.

com . then the posterior shoulder is delivered first followed by the anterior shoulder. rotates 1/8 circle 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). www.freelivedoctor. * The anterior shoulder meets the pelvic floor first. hinges under the symphysis.

the occiput rotates posteriorly and this should be prevented by the obstetrician.com . in case of sacro. * Rarely.posterior position. www.Mechanism of Labour * The head enters the pelvis in the opposite oblique diameter.freelivedoctor. * The occiput rotates 1/8 circle anteriorly.anterior position and 3/8 circle anteriorly in case of sacro.

* Face mento-anterior.The head is delivered by movement of flexion in: * Direct occipito-posterior (face to pubis).com . www. * The after coming head in breech presentation.freelivedoctor.

www.freelivedoctor. • 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.Management of Breech Presentation • External Cephalic Version • It regains its importance after increased rate of caesarean sections nowadays.com .

www.Management of Breech Presentation • Version is not done earlier because: * Spontaneous version is liable to occur.com .freelivedoctor. * Return to breech presentation is liable to occur. * If labour occurs the foetus will have a lesser chance for survival.

Management of Breech Presentation Version is difficult after 37th weeks due to: * Larger foetal size. * Relatively less liquor.com . * More irritability of the uterus.freelivedoctor. www.

or polyhydramnios. Tocolytic drugs may be started 15 minutes before the procedure to overcome this. www. * Frank breech because the legs act as a splint. *Obesity * Rigid abdominal wall. * Irritable uterus.com . * Short umbilical cord.Management of Breech Presentation • Causes of failure * Large sized foetus. * Uterine anomalies as bicornuate or septate uterus.freelivedoctor. * Oligo.

> Susceptibility to cord prolapse.75 kg estimated by ultrasound. www.freelivedoctor.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.com . > Early bearing down as the foot passes through partially dilated cervix and reaches the perineum. Large foetus i.Caesarean Section • Indications: a. b.25 kg. > 3.Preterm foetus but estimated weight is still more than 1.e. c.

e.com .Caesarean Section • Indications d.freelivedoctor. f. www. Contracted pelvis: of any degree. Hyperextended head: diagnosed by ultrasound or X-ray. Uterine dysfunction.

> Intrauterine growth retardation.freelivedoctor. > Pre . > Placenta praevia.Complicated pregnancy with: > Hypertension. > Diabetes mellitus.Caesarean Section • Indications: g. www. > Placental insufficiency.com .labour rupture of membranes for = 12 hours. > Post-term.

com .freelivedoctor.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. www.

* Uncomplicated pregnancy. www.com . * Adequate pelvis. * An experienced obstetrician.75 kg.Vaginal Delivery • Prerequisites: * Frank breech. * In case of intrauterine foetal death. * Gestational age: 36-42 weeks. * Multiparas. * Estimated foetal weight not more than 3.freelivedoctor. * Flexed head. * Normal progress of labour by using the partogram.

caesarean section should only be done if the premature foetus has a reasonable chance of post . However. 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. prematures are more susceptible to: * hypoxia. www. * trauma.Vaginal Delivery • During vaginal delivery.com .freelivedoctor.natal survival.

Assisted breech delivery c.Breech extraction www.freelivedoctor.Spontaneous breech delivery b. • Second stage: The foetus may be delivered by one of the following methods: a.Management of Vaginal Breech Delivery • First stage: as other malpresentations.com .

com .freelivedoctor.Complicated Breech Delivery www.

Arrest of the buttocks at the pelvic brim Causes Inefficient uterine contractions Management Oxytocin drip.if cervix is fully dilated Contracted pelvis Large . if contraindicated do caesarean section Breech extraction .com .freelivedoctor.sized baby Caesarean section Caesarean section www.

Rigid perineum Extended legs (frank breech) Caesarean section Episiotomy Breech deeply impacted: Groin traction www.com .freelivedoctor.Arrest of the buttocks at the pelvic outlet Causes Management Inefficient uterine contractions Breech extraction Contracted outlet.

www.freelivedoctor.com .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. > Puerperal sepsis. >Postpartum haemorrhage due to prolonged labour and lacerations.

Intracranial haemorrhage b.Complications of Breech Delivery FoetalComplications: • Foetal mortality due to a.com . Fracture dislocation of the cervical spines c.freelivedoctor. Asphyxia www.

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