BREECH PRESENTATION

CONTENTS

• Definition• Classification• Etiology• Diagnosis• Complications• Mechanism of Labour• Management

Fetus in longitudinal lie and the podalic pole or the buttocks present with the legs extended or flexed

INCIDENCE

Gesatational Age (in weeks) Percentage

28 25%

32 7%

Term 3-4%

CLASSIFICATION

ETIOLOGY• MATERNAL FACTORS

• Multiparity• Uterine Anomalies• Fibroid Uterus

• FETAL FACTORS• Multiple pregnancy• Fetal anomalies

• Hydrocephalus• Fetal neuromuscular d.o

• PLACENTAL AND AMNIOTIC FLUID FACTORS• Placenta previa• Cornuofundal placenta• Relative/ Absolute Increase in

AF• Prematurity• Polyhydramnios

COMPLICATIONS OF BREECH PRESENTATION

• Fetal Complications• Inherent problems in the fetus• Complications in delivery

• Cord Accidents• Birth Asphyxia• Entrapment of after coming

head• Birth trauma

• Maternal Complications• Increased Cesarean delivery• Genital tract injuries

DIAGNOSIS

• Abdominal Examination

• Ultrasound

• Pelvic Examination

ABDOMINAL EXAMINATION

VAGINAL EXAMINATION

ULTRASOUND

MECHANISM OF LABOUR

• Denominator - sacrum

• Engaging Diameter - Bitrochanteric diameter (9.5 cm)

• Positions - 6

MECHANISM OF LABOUR

MANAGEMENT• Antenatal Period

• External Cephalic Version• Performed at 36-37 weeks• Pre-requisites• Higher Success Rates

• Multiparous lady• Good liquor volume• Average fetal weight• Complete Breech

ECV- PROCEDURE

ECV - COMPLICATIONS

• Fetal bradycardia

• Placental Abruption

• Fetomaternal Haemorrhage

• Uterine rupture

MANAGEMENT OF BREECH AT TERM

• Mode of Delivery• Elective Cesarean Section

• Estimated fetal wt <3.5 kg• Footling Breech• Hyperextended head (Stargazing fetus)• Complicated Breech• Placenta previa• Contracted pelvis

VAGINAL BREECH DELIVERY

• Spontaneous breech (rare): No manipulation of the infant is necessary, other than supporting the infant

• Assisted breech delivery: Fetus descend spontaneously upto the umbilicus then, the rest of the fetus is extracted using additional manouvres

• Total breech extraction: The entire body is extracted. This is indicated only if there is evidence of fetal distress unresponsive to routine maneuvers and a cesarean delivery is not possible

VAGINAL BREECH DELIVERY

• Criteria for patient selection• Complete/ Frank Breech• EFW- 2-3.5 kg• Flexed head• Uncomplicated Breech

ASSISTED BREECH DELIVERY

• Obstetrician skilled in breech delivery

• Facilities for EFM

• Neonatologist on call

• Facilities for 24 hour C section

• Forceps for after coming head

GENERAL GUIDELINES

• Patient and attenders to be counselled• Informed written consent• IOL - not recommended• Late ARM• Oxytocin Augmentation - usually avoided• Maintain Partogram

PROCEDURE

DELIVERY OF AFTER COMING HEAD

MAURICEAU- SMELLIE- VEIT TECHNIQUE

PIPERS FORCEPS

DIFFICULTIES DURING ASSISTED BREECH DELIVERY

Extended Legs – Pinard’s Manouvre

EXTENDED ARMS- LOVSET MANOUVRE

BRINGING DOWN POSTERIOR ARM

NUCHAL ARM

ENTRAPMENT OF AFTER COMING HEAD

DUHRSSEN’S INCISION

POSTERIOR ROTATION OF HEAD- PRAGUE MANOUVRE

BIRTH INJURIES DURING BREECH DELIVERY

• Tentorial tears• Intracranial Haemorrhage• Brachial plexus injury• Spinal cord injuries• Fracture of clavicle, humerus, femur• Depressed fracture skull• Injury to external genitalia• Injury to abdominal viscera