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Breech presentataion

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presented by dr Thenmolee …

presented by dr Thenmolee
ref:RCOG

Published in: Health & Medicine

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  • 1. Breech presentation by DR THENMOLEE SUBRAMONIE
  • 2. • The definition of breech presentation is when the buttocks, foot or feet are presenting instead of the head
  • 3. classifications • Frank breech where the hips are flexed and legs extended • Complete breech where the hips and knees are flexed and the feet are not below the level of the fetal buttocks • Footling breech where one or both feet are presenting as the lowest part of the fetus
  • 4. Associations and Causes
  • 5. Maternal factors • Polyhydraminos • Uterine anomalies (bicornuate, septate) • Space occupying lesions (e.g fibroids) • Placental abnormalities (praevia, cornual) • Multiparity (in particular grand multips)
  • 6. Fetal factors • Prematurity • Fetal anomalies (e.g neurological, hydrocephalus, anenecephaly) • Multiple pregnancy • Fetal death • Short umbilical cord
  • 7. • The incidence of breech presentation decreases from about 20% at 28 weeks of gestation to 3–4% at term, as most babies turn spontaneously to the cephalic presentation
  • 8. What information should be given to women with breech presentation regarding mode of delivery?
  • 9. Term Breech Trial 2000 • trials with 2396 participant • Caesarean delivery 1060/1169 (91%) of those women allocated to planned caesarean section • 550/1227 (45%) of allocated to a vaginal delivery protocol
  • 10. • Perinatal or neonatal death(excluding fatal anomalies) or short-term neonatal morbidity was reduced with a policy of planned CS(RR 0.33, 95% CI 0.19–0.56) and perinatal or neonatal death alone (excluding fatal anomalies) was reduced with a policy of planned caesarean section (RR 0.29, 95% CI 0.10–0.86)
  • 11. • After excluding ,perinatal mortality, neonatal mortality or serious neonatal morbidity with planned caesarean section compared with planned vaginal birth was 16/1006 (1.6%) compared with 23/704 (3.3%) (RR 0.49; CI 0.26–0.91); P = 0.02).
  • 12. adverse perinatal outcome was lowest with prelabour caesarean section and increased with caesarean section in labour
  • 13. • In the latter study, of the 2526 women with planned vaginal deliveries, 1796 delivered vaginally (71%) • The rate of neonatal morbidity or death was considerably lower than the 5% in the Term Breech Trial (1.60%; 95% CI 1.14–2.17), and not significantly different from the planned caesarean section group
  • 14. • death or neurodevelopmental delayat age 2 years, was similar between the two groups.
  • 15. Summary of TBT • lower rates of perinatal and neonatal death • lower rates of short term neonatal morbidity or perinatal death • fewer 5 minutes Apgar scores <7 • lower risk of adverse perinatal outcomes • small increase in the short term maternal morbidity
  • 16. What factors affect the safety of vaginal breech delivery should be assessed carefully before selection for vaginal breech birth
  • 17. unfavourable for vaginal breech birth • ● other contraindications to vaginal birth (e.g. placenta praevia, compromised fetal condition) • ● clinically inadequate pelvis • ● footling or kneeling breech presentation • ● large baby (usually defined as larger than 3800 g) • ● growth-restricted baby (usually defined as smaller than 2000 g) • ● Hyperextended fetal neck in labour (diagnosed with ultrasound or X-ray where ultrasound is not available) • ● lack of presence of a clinician trained in vaginal breech delivery • ● previous caesarean section.
  • 18. Intrapartum management • should take place in a hospital with facilities for emergency caesarean section • Labour induction for breech presentation may be considered if individual circumstances are favourable • Labour augmentation is not recommended
  • 19. • Epidural analgesia should not be routinely advised; women should have a choice of analgesia during breech labour and birth.
  • 20. • Continous electronic fetal heart rate monitoring should be offered to women with a breech presentation in labour. • Fetal blood sampling from the buttocks during labour is not advised.
  • 21. • Caesarean section should be considered if there is delay in the descent of the breech at any stage in the second stage of labour. • Episiotomy should be performed when indicated to facilitate delivery.
  • 22. • Three types of vaginal breech deliveries Spontaneous breech delivery Assisted breech delivery Total breech extraction
  • 23. Total breech extraction • only with 2nd non vextex twin delivery • procedure in which the infant's feet are grasped by the operator and the fetus is extracted from the uterine cavity through the vagina.
  • 24. ECV • External cephalic version (ECV) is the transabdominal manual rotation of the fetus into a cephalic presentation. • after ECV successful rate 35-86% • breech presentation at term, after ECV 1 - 1.5% • indications for urgent caesarean after ECV 1 - 3% • The risk of intrauterine death of foetus after ECV is about 0.0001%
  • 25. contraindication to ECV • preterm • Multiple pregnancy • significant third trimester bleeding • IUGR, • oligohydramnion • PROM • PIH • nonreassuring foetal monitoring patterns • all contraindications to vaginal birth are concerned to execute ECV
  • 26. Risk of ECV • umbilical cord entanglement • abruptio placenta • premature rupture of the membranes (PROM) • severe maternal discomfort
  • 27. THANK YOU