Dr. Yasir Katib mbbs, frcsc, perinatologest

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Dr. Yasir Katibmbbs, frcsc, perinatologest
BREECH PRESENTATION
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Definitions

• Presentation is delineated by the portion of the
  fetus that leads into the birth canal
• Cephalic Vertex, face, brow, occiput 96
• Breech frank, footling, double footling,
  complete 3-4
• Shoulder
• Compound When both the head or breech and an
  extremity lead into the birth canal

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Case Study
A 26 years old primigravida was referred to the
antenatal clinic at 36 weeks gestation with a
history of persistent breech presentation since
the 28th week. Your abdominal examination
confirms the finding with fundal height of 38
weeks size. How would you manage the patient and
what advice would you give the patient regarding
the mode of delivery.
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Breech Presentation

• Incidence
• gt 28 weeks25 Term 2-3 1/3 are
  undiagnosed in labour

• Classification
• 1. Frank (65) The foetal hips are flexed and
  the knees are extended.
• 2. Complete (25) The foetal hips and knees are
  flexed.
• 3. Incomplete (10) The foetal feet or knees
  are the lowermost presenting part

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Breech Presentation

• Etiology
• Prematurity
• Congenital anomalies, 6 2-3gtgtgt
  anencephaly,hydrocephalus
• Uterine anomalies, septate.
• Multiple gestation
• Placenta praevia
• Ployhydramnios
• Pelvic tumors, fibroids ovarian..

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Breech Presentation

• Diagnosis
• Clinical examination
• abdominal
• vaginal

• Radiological examination
• x-ray
• ultrasound scan

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Breech Presentation

• Management During Pregnancy
• If persisted till 34 weeks. Then ultrasound
  scan to exclude abnormality, Ployhydramnios,
  placenta praevia.
• By completed 37 weeks External Cephalic Version

• 45-80 success rate
• 5 revert back to breech
• Protocol to avoid complications

• Contra-indications ..

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External Cephalic Version

• In delivery room
• NPO and ready for c/s
• CTG USS
• Tocolytic
• Head down position
• Dislodge breech then
• gently turn around
• Uss and CTG after procedure.

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Breech Presentation

• Mode of delivery

1. Vaginal

• Criteria
• Frank or complete breech presentation
• Gestational age gt 36 weeks
• Estimated foetal weight b/n 2.5-3.5 kg
• Foetal head must be flexed
• Adequate maternal pelvis, x-ray or ct pelvimetry
  ???
• No other obstetric complications, privacy/s, pet
  etc
• Preferably epidural analgesia

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Breech Presentation

• Types of vaginal breech delivery
• Spontaneous breech delivery
• Assisted breech delivery
• Breech extraction

• Mechanism of delivery

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SOME OBSTETRIC COMPLICATIONS OF BREECH
PRESENTATION

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Mode of delivery
2. Caesarean Section

• Indications
• Any abnormality of the bony pelvis 10.
  Footling breech
• Foetal weight gt 3.5 kg
  11.Preterm labour
• Hyperextension of foetal head
  12. Previous c/s
• Previous difficult labour
  13. PRIMIGRAVIDA
• IUGR
• Bad obstetric history
• Diabetes
• Severe pre-eclampsia
• Failure to progress in first stage or descent in
  second stage

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Caesarean section

• is caesarean section safer for the foetus than
  vaginal delivery?
• Breech mortality rate do not differ
  significantly b/n vaginal delivery and c/s!!!!!
  WHY?
• Increased PM due to lethal congenital anomalies,
  Prematurity, birth trauma and birth anoxia

• So should delivery be vaginal or abdominal???????

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The Answer is
The Canadian trial
Multi-centric International trial to determine
the safer way to deliver babies in the breech
presentation trial had to be stopped because
analysis of preliminary results showed
Caesarean section is safer
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Preterm Breech Presentation

• 25 of lt 28 weeks in breech presentation in
  Preterm labour of which 18 are congenitally
  abnormal
• Has a higher antepartum stillbirth and neonatal
  death rate than babies presenting by the head
  irrespective of the mode of delivery

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Face presentation
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Brow presentation
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REMEMBER

• High perinatal mortality in the breech baby
  irrespective of the mode of delivery
• Reducing morbidity for vaginal breech delivery
  is by careful selection, clear intrapartum guide
  lines and expertise
• Despite recent evidence, difficulty in favoring
  a mode of delivery due to social consideration
• External Cephalic Version should be tried unless
  contra-indication
• Preterm breech is safer to be delivered by c/s
  if normal