Prepared by Helen Cooke

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Breech
Prepared by Helen Cooke February 2009
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Goals

• Discuss the incidence and causes of breech
• How to diagnose and manage antenatally
• Discuss the Term Breech Trial
• Discuss the risks and benefits of ECV
• How to diagnose and manage a breech birth

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Incidence
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Presentation

Frank
Complete
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The causes

• Prematurity
• High parity
• Uterine anomalies
• Placenta praevia
• Multiple pregnancy

• Pelvic anomalies
• Fetal anomalies
• Absolute CPD
• Previous breech
• Unknown

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Diagnosis

• Abdominal palpation (Leopolds Manouevre)
• Vaginal examination
• Ultrasound

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Antenatal Management

• Identification - palpation
• Diagnosis - ultrasound
• Management plan for birth developed

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Term Breech Trial-Conclusions

• Planned CS is safer than planned vaginal birth
  delivery for the singleton fetus in breech
  presentation at term.
• A policy of planned CS is not associated with a
  higher risk of serious maternal morbidity in the
  first 6 weeks post-partum.
• RANZCOG (2005) informed women who choose vaginal
  breech birth should be supported with decision

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However TBT does not apply to

• Preterm breech presentation.
• Breech presenting in advanced second stage
• Has changed the way we manage breech presentation
  at term.

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External Cephalic Version
Factors Associated with Success

• Parity
• Complete or Frank breech
• Normal or increased amniotic fluid
• Relaxed uterus with Tocolysis
• Gestational age lt 37 weeks
• Each unit should have a medical officer who can
  perform ECV. Alternatively women should be
  offered the opportunity to travel to a centre
  where it is offered

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Contraindications to ECV

• Multiple pregnancy
• Utero-placental insufficiency
• Non-reassuring FHR pattern
• Uterine anomalies
• Placenta praevia
• Unexplained bleeding
• Previous C/S
• No immediate access to theatres

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Complications of ECV

• Fetal bradycardia, decelerations (5 transient,
  0.4 pathological)
• Abruption (0.1)
• Fetal haemorrhage (1.5)
• Maternal haemorrhage (0.5)
• Knotted or entangled cord (0)
• Fetal mortality (0.16)
• Amniotic fluid embolus, maternal death (0)
• LSCS (0.4)

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Vaginal Breech Contraindications

• Proven CPD
• Macrosomia gt 3.8kg
• IUGR, placental insufficiency
• Footling breech
• Hyperextension of fetal head, nuchal arm
• Fetal anomalies
• non-progressive labour
• Lack of birth attendant skills

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Breech Birth

• The head of a breech presents with the same
  diameters as a cephalic presentation
• Mechanism of labour same as for cephalic
• HANDS OFF THE BREECH NO Pulling\
• Call for HELP
• Need
• efficient and effective uterine action
• maternal effort to push
• KEEP THE BACK UP and hands gently supporting the
  breech

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Breech birth

• Just let the breech birth
• May need to help the legs deliver flex the
  knees at the popliteal fossa and gently release
• Keep the back anterior
• If the back requires rotation place your hands
  gently around the babys hips with your fingers
  on bone not soft tissue and gently rotate the
  baby to keep the back uppermost

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Breech birth

• Do not pull or cut the cord
• Let the baby hang until the scapula can be seen
  or the arms are birthing.
• If the arms need some assistance, sweep them
  gently down the babys front until they are free
• Continue to let the baby hang until the nape of
  the neck is visible

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Løvset Manoeuvre (1937)

• Used when assistance is required to birth the
  arms or where there is a nuchal arm.
• rotation of the fetal body from anterior to
  oblique to encourage the arms to release under
  the pubic arch
• the arm may be gently guided out if not released
  completely
• repeat this in the opposite direction to birth
  the second arm
• rotate the baby back to the original position
  with back anterior

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Breech Birth

• Mauriceau Smellie Veit manoeuvre is used to help
  flex and birth the babys head
• place the second and fourth finger of one hand on
  the babys shoulders
• the middle finger is placed on the babys occiput
• the second and third fingers of the other hand
  are placed on the mallar prominences
• flex the babys head to assist the birth at the
  same time lifting the babys body over on to the
  mothers chest
• birth slowly to avoid tentorial tears

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Practice Points

• Detect breech presentation after 36 weeks or in
  labour
• ECV at term is an easy, safe and effective way of
  reducing the incidence of breech birth at term
• Expertise in vaginal breech birth remains
  important, and training schemes should be
  implemented as experience potentially decreases.