obstetrical condition

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

5. Associations and
Causes

6. Maternal factors
• Polyhydraminos
• Uterine anomalies (bicornuate, septate)
• Space occupying lesions (e.g fibroids)
• Placental abnormalities (praevia, cornual)
• Multiparity (in particular grand multips)

7. Fetal factors
• Prematurity
• Fetal anomalies (e.g neurological,
hydrocephalus, anenecephaly)
• Multiple pregnancy
• Fetal death
• Short umbilical cord

8. • 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

9. What information should be given
to women with breech
presentation regarding mode of
delivery?

10. 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

11. • 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)

12. • 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).

13. adverse perinatal outcome was lowest with
prelabour caesarean section and increased
with caesarean section in labour

14. • 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

15. • death or neurodevelopmental delayat age 2
years, was similar between the two groups.

16. 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

17. What factors affect the safety of
vaginal breech delivery
should be assessed
carefully before
selection for vaginal
breech birth

18. 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.

19. 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

20. • Epidural analgesia should not be routinely
advised; women should have a choice of
analgesia during breech labour and birth.

21. • 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.

22. • 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.

23. • Three types of vaginal breech deliveries
Spontaneous breech delivery
Assisted breech delivery
Total breech extraction

24. 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.

25. 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%

27. 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

28. Risk of ECV
• umbilical cord entanglement
• abruptio placenta
• premature rupture of the membranes (PROM)
• severe maternal discomfort

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