Prepared by;

Muhammad Nzar Supervised by; Dr. Sheelan

Breech presentation
Breech presentation is defined as a fetus in a

longitudinal lie with the buttocks or feet closest to the cervix. It is the most common type of malpresentations The dominator is the sacrum , the position is sacroanterior . occurs in 3-4% of all deliveries.
Gestational age in weeks prior to 28 32 37-42 % of Breech 22 7 1-3

Types

Preterm Uterine fibroid Increased maternal parity Multiple gestation Polyhydramnios Oligohydramnios Placenta previa Fetal malformation Previous breech deliveries Placental cornual-fundal implantation Maternal smoking Maternal diabetes

 Usually presented in the last trimester

Subcostal tenderness Feeling of a hard mass in epigastric area

Ballootable head in fundal area fundal grip

Soft irregular mass in the pelvis pelvic grip Lie is longitudinal

Auscultation; fetal heart sound can be heard above the

umbilicus

 Vaginal examination; In frank presentations, the ischial tuberosities, sacrum, anus, and/or genitals may be palpated. In addition, meconium staining of the examiner's digit may occur. In complete presentations, the feet of the fetus may be palpated with the buttocks. In incomplete presentations, one or both of the feet/knees may be palpated.

Diagnosis

History and clinical features

X-Ray

Ultrasound

External cephalic version

Moxibustion

Caesarean section

Vaginal delivery

External cephalic version ECV

Is trans abdominal manual rotation of the fetus into cephalic presentation. It relatively straightforward safe technique and

has been shown to reduce the number of C/S due to breech presentation. Should be offered at 36-37 weeks in selected women. Success rate ranges from 35%-86%.

External cephalic version ECV

Carried out by senior obstetrician. Under U/S guidance the baby is gently manipulated into cephalic version. A fetal heart trace must be performed before and after the procedure Tocolytics or epidural anesthesia.

External cephalic version ECV

Factors associated with success
multiparity adequate liquor volume station above the pelvic brim

Factors associated with failure

obesity uterine fibroid oligohydramnios deep engagement of the presenting part fetal back posterior nulliparity

Contraindications to ECV
Placenta previa
Oligohydramnios or polyhydramnios History of antepartum hemorrhage

Previous Cesarean or myomectomy scar on the uterus

Multiple gestation Pre-eclampsia or hypertension

Plan to deliver by Cesarean section anyway

Risks of ECV
Placental abruption
Premature rupture of membranes Cord Transplacental accident hemorrhage Fetal bradycardia

Moxibustion
Application of heat from burning the herb

Mugwort Is a non-invasive and safe method to help turn breech baby Success rate in studies from China is 80% The best results are often gained before week 36/37 Is applied to only one point on the body Bladder 67

Moxibustion
Using a moxa stick, the heat is applied

daily for 15 min for 7 days The heat increases the effect of gravity Its even more effective if the patient does knee to chest position

Caesarean section
Factors favor C/S; Large or small baby (>3.5 or < 2.5 kg) Small pelvis on pelvimetry Primigravid Previous Cesarean section Extended neck Poor obstetric history Any obstetric problem; placenta previa, gestational diabetes, PIH and pre-eclampsia History of infertility and assisted conception

Vaginal delivery
Factors favor vaginal delivery Normal size baby (2.5-3.5kg) Good pelvimetry Flexed neck Multiparous Breech deeply engaged Extended and flexed breech No fetal congenital abnormality Positive mental attitude of woman and partner Obstetric unit and staff familiar with breech delivery

Vaginal delivery Vaginal delivery

Continuous fetal monitoring is recommended and fetal

blood sampling from the buttocks allows accurate assessment of the acid-base status
Epidural anaesthetic avoids pushing before full dilation The maxim is "hands off the breech". Avoid beginning

extraction of the fetus prior to complete descent - the cervix must be fully dilated and effaced with the infant's umbilicus at the vaginal introitus

Vaginal delivery
Pinard maneuver,

pressure is exerted in the popliteal space of the knee, flexion of the knee follows, and the lower leg is swept medially and out of the vagina

 When the scapulas

appear, fingers should be placed over the shoulders from the back. The humerus should be followed down, and each arm rotated across the chest and out (Loveset's maneuver). To deliver the right arm, the fetus is turned in a counterclockwise direction; to deliver the left arm, the fetus is turned in a clockwise direction

Vaginal delivery

The fetal head should be maintained in a flexed position to allow delivery of its smallest diameter. This can be accomplished by;
Mauriceau-Smellie-Veit

maneuver( with fetus resting on hand and forearm, operator's index and middle fingers lift up the fetal maxillary prominences and an assistant applies suprapubic pressure

Vaginal delivery

Forceps delivery

 Mortality Cord prolapse; depends on type of breech presentation

Footling, 15% Complete, 5%

Frank, 0.5%

Asphyxia Birth trauma Intracranial haemorrhage Spinal cord injuries Genital tract injury (maternal)

 Johns Hopkins manual of gynecology and

obstetrics 3rd edition 2007 Obstetrics by ten teachers www.patient.co.uk www.emedicine.medscape.com www.taoofwellness.com Lecture on breech presentation by dr. Shahla