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Breech presentation
Dr
Ayman Shehata
Definition
Breech presentation is
the presentation in which
the fetus is in longitudinal
lie and its buttock is the
lower...
Incidence
 28 weeks…25%
 Term 2-3%
 1/3 are undiagnosed in labour
classifications
 Frank breech (65%): where the hips are
flexed and legs extended
 Complete breech (25%): where the hips ...
Kneeling presentation
Positions
the denominate is the sacrum:
 First position;
left sacro-anterior (back anterior and to left).
 Second positi...
Etiology
Maternal factors
 Polyhydraminos
 Oligohydramnios
 Uterine anomalies (bicornuate, septate)
 Space occupying lesions (e...
Fetal factors
 Prematurity
 Fetal anomalies (e.g neurological,
hydrocephalus, anenecephaly)
 Multiple pregnancy
 Fetal...
Mechanism of delivery
 Engagement
 Descent
 Internal rotation
 Lateral flexion
 External rotation
 Birth : breech th...
Diagnosis of Breech
 Clinical examination:
 abdominal
 vaginal
 Radiological examination:
 x-ray
 ultrasound scan
 ...
Clinical Diagnosis
Abdominal examination
 Palpation
1. Fundal grips; the head is felt with its
characters.
2. Pelvic grip...
Vaginal examination
1. Slow dilatation of cervix, sausage-chapel bag of fore-
waters, and liability to premature rupture o...
Imaging Techniques
 Ultrasound
 CT
 MRI
US breech
Management of Breech
BREECH PRESENTATION
Management during pregnancy
After 36 weeks
Spontaneous version External cephalic version
Management of breech
 Management During Pregnancy:
 If persisted till 34 weeks…. Then ultrasound
scan to exclude; abnorm...
Version
 External cephalic version
 Internal podalic version
External Cephalic Version
In delivery room
NPO and ready for c/s
CTG & USS
Tocolytic
Head down position
Dislodge breech then
gently turn arou...
Internal podalic version
Risks of External Cephalic Version
 Placental abruption
 Premature rupture of the membranes
 Cord accident
 Transplace...
Contraindications of External Cephalic
Version
 Absolute
contraindication:
 Previous scar on the
uterus
 Placenta praev...
Management during labour
Cesarean section
Vaginal delivery
Spontaneous breech delivery
Assisted breech delivery
Total...
Indications of vaginal delivery
a) Frank or complete breech presentation
b) Gestational age > 36 weeks
c) Estimated foetal...
Management during labour
During labour:
1. If there is contracted pelvic, and fetus is
living and good; do caesarean secti...
Partial breech extraction or
Assisted breech delivery
Second stage :
Delivery of the aftercoming head
 Burns Marshall met...
Burns Marshall Method
Mauriceau-Smellie-Veit Maneuver
Prague maneuver
The back of the fetus fail to rotate to the anterior
Piper Forceps
Total breech extraction
Indication
1. Prolonged second stage of labor
2. Twins
3. Maternal disease
4. Prolapsed cord
5. Fe...
Total Breech Extraction
Cesarean section
Indications:
 Large fetus
 Contraction or unfavorable shape of pelvis
 Hyperextended head(Star gazing)...
Indications of Cs in Breech
 Healthy preterm
 Severe fetal growth restriction
 Previous perinatal death or newborn
 co...
Complications of Breech
Delivery
Maternal complications
 Risk of Operative intervention
 Risk of infection due to Manipu...
Complications cont.
Fetal complications
 Preterm delivery & low birth weight & IUGR
 Prolapse cord
 Birth aphyxia
 Fet...
THAN
K
YOU
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Breech presentation

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Breech presentation

  1. 1. Breech presentation Dr Ayman Shehata
  2. 2. Definition Breech presentation is the presentation in which the fetus is in longitudinal lie and its buttock is the lower most part .
  3. 3. Incidence  28 weeks…25%  Term 2-3%  1/3 are undiagnosed in labour
  4. 4. classifications  Frank breech (65%): where the hips are flexed and legs extended  Complete breech (25%): 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  Kneeling: kneesare the lowermost presenting part
  5. 5. Kneeling presentation
  6. 6. Positions the denominate is the sacrum:  First position; left sacro-anterior (back anterior and to left).  Second position; right sacro-anterior (back anterior and to right).  Third position; right sacro-posterior (back posterior and to right).  Fourth position; left sacro-posterior (back posterior and to left).
  7. 7. Etiology
  8. 8. Maternal factors  Polyhydraminos  Oligohydramnios  Uterine anomalies (bicornuate, septate)  Space occupying lesions (e.g fibroids)  Placental abnormalities (praevia, cornual)  Multiparity (in particular grand multiparas)  Contracted pelvis
  9. 9. Fetal factors  Prematurity  Fetal anomalies (e.g neurological, hydrocephalus, anenecephaly)  Multiple pregnancy  Fetal death  Short umbilical cord  Extended legs; because they splint the trunk, and so interfere with spontaneous cephalic version.
  10. 10. Mechanism of delivery  Engagement  Descent  Internal rotation  Lateral flexion  External rotation  Birth : breech then body then head
  11. 11. Diagnosis of Breech  Clinical examination:  abdominal  vaginal  Radiological examination:  x-ray  ultrasound scan  CT  MRI
  12. 12. Clinical Diagnosis Abdominal examination  Palpation 1. Fundal grips; the head is felt with its characters. 2. Pelvic grip; the breech is felt, with its characters.  Auscultation The fetal heart sounds are head just at, or above the level of the umbilicus.
  13. 13. Vaginal examination 1. Slow dilatation of cervix, sausage-chapel bag of fore- waters, and liability to premature rupture of the membrane and prolapse of the cord. 2. After rupture of the membranes, the presenting part is felt, that is , the two buttocks with the anus in between , the genitalia on one side and the sacral spines on the opposite side. 3. In case of complete breech, the feet are felt on the same level as the buttocks. 4. In case of breech with extended legs, the buttocks only are felt. In case of footling presentation, the feet are at a lower level than the buttocks. In case of knee presentation, the knees are a lower level than the buttocks.
  14. 14. Imaging Techniques  Ultrasound  CT  MRI
  15. 15. US breech
  16. 16. Management of Breech
  17. 17. BREECH PRESENTATION Management during pregnancy After 36 weeks Spontaneous version External cephalic version
  18. 18. Management of breech  Management During Pregnancy:  If persisted till 34 weeks…. Then ultrasound scan to exclude; abnormality, Ployhydramnios, placenta praevia.  By completed 37 weeks External Cephalic Version:
  19. 19. Version  External cephalic version  Internal podalic version
  20. 20. External Cephalic Version
  21. 21. In delivery room NPO and ready for c/s CTG & USS Tocolytic Head down position Dislodge breech then gently turn around US and CTG after procedure.
  22. 22. Internal podalic version
  23. 23. Risks of External Cephalic Version  Placental abruption  Premature rupture of the membranes  Cord accident  Transplacental haemorrhage(remember anti-D aministration in Rhesus-negative women)  Fetal bradycardia
  24. 24. Contraindications of External Cephalic Version  Absolute contraindication:  Previous scar on the uterus  Placenta praevia  Unexplained APH  Pre-eclampsia  Multiple pregnancy  Relative contraindications:  Rhesus isoimmunisation  Elderly primigravida  IUGR  Oligohydramnios  Polyhydramnios
  25. 25. Management during labour Cesarean section Vaginal delivery Spontaneous breech delivery Assisted breech delivery Total breech extraction
  26. 26. Indications of vaginal delivery a) Frank or complete breech presentation b) Gestational age > 36 weeks c) Estimated foetal weight b/n 2.5-3.5 kg d) Foetal head must be flexed e) Adequate maternal pelvis, x-ray or ct pelvimetry f) No other obstetric complications.
  27. 27. Management during labour During labour: 1. If there is contracted pelvic, and fetus is living and good; do caesarean section. 2. First stage Rest in bed and avoid repeated vaginal examination to prevent premature rupture of the membranes. But vaginal examination is done after rupture of membranes to exclude cord prolapse.
  28. 28. Partial breech extraction or Assisted breech delivery Second stage : Delivery of the aftercoming head  Burns Marshall method  Mauriceau-Smellie-veit maneuver  Prague maneuver  Piper forceps
  29. 29. Burns Marshall Method
  30. 30. Mauriceau-Smellie-Veit Maneuver
  31. 31. Prague maneuver The back of the fetus fail to rotate to the anterior
  32. 32. Piper Forceps
  33. 33. Total breech extraction Indication 1. Prolonged second stage of labor 2. Twins 3. Maternal disease 4. Prolapsed cord 5. Fetal distress
  34. 34. Total Breech Extraction
  35. 35. Cesarean section Indications:  Large fetus  Contraction or unfavorable shape of pelvis  Hyperextended head(Star gazing)  Uterine dysfunction  Incomplete or footling presentation  Primigravida
  36. 36. Indications of Cs in Breech  Healthy preterm  Severe fetal growth restriction  Previous perinatal death or newborn  complication of birth trauma  Lack of an experienced operator
  37. 37. Complications of Breech Delivery Maternal complications  Risk of Operative intervention  Risk of infection due to Manipulations  Intrauterine maneuvers : Rupture of the uterus +/- lacerations of Cx  Extensions of the episiotomy  Uterine atony , Postpartum hemorrhage
  38. 38. Complications cont. Fetal complications  Preterm delivery & low birth weight & IUGR  Prolapse cord  Birth aphyxia  Fetal Injuries  Fx of humerous and clavicle  Fx of femur  Hematomas of sternocleidomastoid  Separation of epiphyses of scapular,humerus or femur  Brachial plexus  Avulsion of upper C-spine  Skull Fx , intracerebral injury
  39. 39. THAN K YOU

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