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.
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.

Management of Breech Presentation
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.
Management of Breech Presentation
Version is difficult after 37th weeks due to:
* Larger foetal size.
* Relatively less liquor.
* More irritability of the uterus.
Management of Breech Presentation
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
Causes
Management
Inefficient
uterine
contractions
Oxytocin drip, if contraindicated do caesarean
section Breech extraction - if cervix is fully
dilated
Contracted
pelvis
Caesarean section
Large - sized
baby
Caesarean section
Arrest of the buttocks at the pelvic brim
Arrest of the buttocks at the pelvic outlet
Causes
Management
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


DEMONSTRATION OF MECHANISM FOR
BREECH DELIVERY


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