Breech presentation for 4th year med.students

BREECH PRESENTATION
FOR 4TH YEAR MED. STUDENTS
Associate Clinical Prof. Aisha M. Elbareg. MD, PhD
Senior Consultant (Ob-Gyn) with Subspeciality in Reproductive Medicine
Faculty of Medicine, Misurata, Libya

Definition:
28 August 2017 May All Be Happy & Healthy
2
 When the buttocks, foot
or feet of the fetus enter
the pelvis instead of the
head, the presentation
is breech.
 Incidence: 3 to 4 % of
full term deliveries.
Incidence
Cephalic
Breech
others

1. Complete Breech (Flexed)
The normal attitude of
full flexion is
maintained.
The thighs are flexed at
the hips and the legs at
knees.
The presenting part consists
of two buttocks, external
genitalia and two feet.
It is commonly
present in multiparae.
10%

Frank Breech 60%
It is breech with extended legs
where the knees are extended
while the hips are flexed.
More common in primigravida.
Footling Presentation 30%
The hip and knee joints are
extended on one or both sides.
More common in preterm
singleton breeches.
2. incomplete Breech

28 August 2017May All Be Happy & Healthy9

Predisposing factors:
 Prematurity:
Incidence of Breech
is as follows:
 28 weeks: 25 %
 32 weeks: 12 %
 36 weeks: 6 %
 40 weeks: 4 %
10

 Low birth Wt (20-30%)
 Placenta Previa:
 Uterine anomaly:
 Septate
 fibroid
11

 Polyhydroamnios
 Oligohydramnios
 Multiple pregnancy:
12

 Fetal anomaly:
 Hydrocephalus
 Anencephaly
 Aneuploidy (chromosomal)
 Previous breech delivery
& grand-multipara
13

Complications:
1. Increased Perinatal
morbidity and mortality
from difficult delivery.
16
Sym.

Complications:
2. Prolapsed cord:
 Frank: 0.5 %,
 Complete: 5 %
 Footling: 15 %
3. Long term health problems
due to birth hypoxia & injury.
4. Increased LSCS rate
increases maternal morbidity.
17

Associated problems:
1. Low birth weight from
preterm delivery, growth
restriction, or both.
2. Placenta previa.
3. Fetal, neonatal, and
infant anomalies.
4. Uterine anomalies and
tumors.
19
< 2.5 kg.

Breech VS Cephalic presentation
1. Increased neonatal morbidity
2. Increased perinatal or neonatal mortality
3. Increased short-term maternal morbidity
But why ??
• High prevalence of fetal anomalies
• Higher risk of prematurity
• Higher chance of umbilical cord prolapse
• Higher birth traumas

Diagnosis:
 P/A Examination:
 Fundal Grip.
 Pelvic Grips.
 Location of FHS.
 P/ V Examination:
22

Diagnosis:
 USS:
 Confirms the diagnosis.
 Detect fetal anomaly &
IUGR.
 Location of placenta.
23

Antenatal Management:
 Antenatal care as ‘High
risk’ pregnancy.
 Rule out:
1. Placenta Previa
2. Fetal anomaly
3. Uterine anomaly
4. Contracted pelvis
25

 Explain the complications
of vaginal breech delivery
& let the woman decide
about mode of delivery.
 Discuss about External
Cephalic Version (ECV)
26

should be assessed
carefully before
selection for vaginal
breech birth
unfavourable factors for vaginal
breech birth

unfavourable for vaginal breech birth
● Other contraindications to vaginal birth (e.g.
placenta previa, compromised fetal condition)
● Clinically inadequate pelvis
● Footling breech presentation
● Large baby
● Growth-restricted baby
● Hyperextended fetal neck in labour
● Lack of presence of a clinician trained in
vaginal breech delivery
● Previous caesarean section.

 External Cephalic Version:
 Turning of the fetus from
breech to cephalic presentation
to allow vaginal delivery
 Done at 37 weeks.
 Success rate is about 60 %.
 One must be ready to do
emergency LSCS.
29

Favorable factors for ECV:
1. Multiparous woman with
lax abdominal muscles
2. Good amount of liquor
3. Breech not engaged
4. Co-operative & average
built woman
30

Complications of ECV:
1. Placental abruption
2. Uterine rupture
3. Amniotic fluid embolism
4. Fetomaternal hemorrhage
5. Isoimmunization
6. Preterm labor
7. Fetal distress, and fetal death.
31

Contraindication to ECV
• Preterm
• Multiple pregnancy
• significant third trimester bleeding
• IUGR, oligohydramnion
• PROM
• PIH
• Previous uterine scar
• non-reassuring foetal monitoring patterns
• all contraindications to vaginal birth are
concerned to execute ECV

Vaginal breech Delivery:
 LSCS is done in about 85
to 90 % cases.
 Practically all primigravida
undergo LSCS.
 Multiparous woman with
roomy pelvis & average
term baby is considered for
vaginal delivery.
33

Types of breech deliveries:
 Spontaneous breech
delivery: Spontaneous
delivery without any
traction or manipulation
other than support of the
infant.
34

 Partial breech extraction:
The infant is delivered
spontaneously as far as the
umbilicus.
 But the remainder of the
body is extracted or
delivered with operator
traction and assisted
maneuvers.
35

Total breech extraction:
 The entire body of the
infant is extracted by the
obstetrician.
 2nd non-vertex twins.
36

Delivery of the buttocks
Shoulders
Head
MECHANISM OF LABOUR

• The engagement diameter is the bitrochantric diameter
10 cm which enters the pelvis in one of the oblique
diameters.
• Descent of the buttocks occurs until the anterior buttock
touches the pelvic floor.
• Internal rotation of the anterior buttock occurs through
1/8th of a circle placing it behind the symphysis pubis.
• Further descent with lateral flexion of the trunk occurs
until the anterior hip hinges under the symphysis pubis
which is released first followed by the posterior hip.
• Delivery of the trunk and the lower limbs follow.
• Restitution occurs so that the buttocks occupy the
original position as during engagement in oblique
diameter.
Delivery of Buttocks

• Bisacromial diameter (12 cm or 4 ¾”) engages in the same
oblique diameter as that occupied by the buttocks at the
brim soon after the delivery of breech.
• Descent occurs with internal rotation of the shoulders
bringing the shoulders to lie in the antero-posterior
diameter of the pelvic outlet. The trunk simultaneously
rotates externally through 1/8th of a circle.
• Delivery of the posterior shoulder followed by the
anterior one is completed by anterior flexion of
the delivered trunk.
• Restitution and external rotation :
Delivery of Shoulders

•Engagement occurs either through the
opposite oblique diameter as that occupied
by the buttocks or through the transverse
diameter. The engaging diameter of the
head is suboccipito-frontal (10 cm).
•Descent with increasing flexion occurs.
•Internal rotation of the occiput occurs anteriorly,
through 1/8th or 2/8th of a circle placing the
occiput behind the symphysis pubis.
Delivery of Head

•Further descent occurs until the sub-occiput hinges
under the symphysis pubis.
•The head is born by flexion- The chain, mouth, nose,
forehead, vertex and occiput appearing successively. The
expulsion of the head from the pelvic cavity depends
entirely upon the bearing efforts and not at all on uterine
contractions.
•Sacro-posterior position: The mechanism is
not substantially modified. The head has to
rotate through 3/8th of a circle to bring the
occiput behind the symphysis pubis.
Delivery of Head

Summary:
 Incidence: 3 to 4 % at term
 Fetal anomaly or uterine anomaly may be
associated with it.
 Causes ↑ perinatal mortality
 Multiparous woman with roomy pelvis & term
average size fetus is considered for vaginal
delivery. 85 to 90 % woman undergo LSCS.
 ECV is a safe procedure to reduce incidence
of breech presentation. It is done at 37 weeks.
42

Breech presentation for 4th year med.students

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