Breech Presentation

1
Breech Presentation

• Alhadi Araibi
• Alkhadra Hospital

2
What you need to know about Breech Presentation

• What is Breech Presentation?
• Types of Breech Presentation
• Importance of Breech Presentation
• Causes of Breech Presentation
• Diagnosis of Breech Presentation
• Management Options

3
What is Breech Presentation?

• Breech Presentation is a fetus in a
  longitudinal lie with the buttocks or feet
  closest to the cervix.
• Cephalic presentation is the best fit
  presentation
• Incidence
• 3-4 at term.
• 22 at 28 weeks and 7 at 32 weeks.

4
Types of Breech Presentation

• Frank Breech
• 50-70
• Flexed Hips,
• extended knees
• (pike position)

5
Types of Breech Presentation

• Complete Breech
• 5-10
• Flexed Hips
• Flexed Knees
• (cannonball position)

6
Types of Breech Presentation

• Incomplete (Footling)
• 10-30
• One or both hips extended
• Foot presenting

7
Importance of Breech Presentation

• May indicate Pathology/Abnormality
• See causes/predisposing factors.
• Affect Perinatal Mortality and Morbidity
• Perinatal mortality is increased 2- 4 folds with
  breech presentation regardless of the mode of
  delivery.
• Affect mode of delivery
• Perinatal mortality and neonatal morbidity are
  significantly lower in planned cesarean section
  than in planned vaginal delivery (5 vs 1.6).

8
Causes of Breech Presentation

• Fetal

• Maternal

• Idiopathic
• Fetal abnormality (CNS)
• Oligo- polyhydramnios
• Fetal growth restriction
• Short umbilical cord
• Extended legs
• Multiple pregnancy

• Idiopathic
• Pre-term labour
• Placenta previa/ Corneal pl
• Uterine abnormalities
• Contracted pelvis
• Maternal anticonvulsants
• Maternal substance abuse

9
Diagnosis of Breech Presentation

• Clinical Examination
• Abdominal Palpation
• Hard round ballotable structure at the fundus.
• The fetal heart commonly heard above the
  umbilicus.
• Vaginal Examination
• Soft compressible structures.
• Fetal ischial tuberosites, anus, genitalia
  foot may provide a landmarks.
• 30 of breech presentation are not diagnosed
  until labour.
• Ultrasound scan

10
Management Options

• Term Breech
• Pre-term Breech
• Second Twin Breech

11
Management Options of Term Breech

• Spontaneous Version
• External Cephalic Version
• Elective Cesarean Section vs. Vaginal Delivery

12
Management Options of Term Breech
Spontaneous Version

• It is less frequent as third trimester progress
  (lt25).
• More likely in multiparous.
• Less likely in nulliparous and breech with
  extended legs.
• Promotion of Spontaneous Version
• Full Bladder.
• Knee-Chest position 10 minutes everyday.
• Pelvis elevation, thighs abduction and relaxed
  breathing.
• All the above techniques are harmless, worth
  trying but cant be recommended in the absence of
  supporting evidence.

13
Management Options of Term Breech
External Cephalic Version (ECV)

• ECV is the transabdominal manual rotation of the
  fetus into a cephalic presentation.
• Every 100 ECV attempt prevent 34 breech births
  and 14 cesarean sections.
• Success rate 50-60.
• Higher success rate with
• Multiparous
• Flexed head and knees
• Use of tocolytics
• Use of regional anesthesia

14
External Cephalic Version (ECV)

• Prerequisites
• More than 36 weeks gestation.
• Ultrasound, to confirm breech, enough liquor
  out rule contraindication.
• CTG pre post ECV.
• Facilities to perform emergency cesarean
  section.
• Informed consent for the procedure possible
  cesarean section.
• Patient fasting more than 6 hours.
• Anti D for Rh negative women.

15
External Cephalic Version (ECV)

• Absolute Contraindications

• Relative Contraindications

• Multiple pregnancy.
• Antepartum hemorrhage.
• Placenta previa.
• Ruptured membranes.
• Fetal Anomalies.
• Deflexed head.
• Other indications for cesarean section.

• Previous cesarean section.
• IUGR.
• Severe preeclampsia.
• Rhesus Isoimmunization.
• Obesity.
• Macrosomia .

16
Management Options of Term Breech
Elective Cesarean Section

• Elective cesarean section should be offered to
  all singleton term breech and planned Vaginal
  delivery may no longer be appropriate, based on
  Hannah et al multicentre randomised clinical
  trial 2001.
• The perinatal mortalities and neonatal
  morbidities were significantly lower in planned
  cesarean section than in planned vaginal
  delivery. (5 vs 1.6)

17
Management Options of Term Breech
Elective Cesarean Section

• Prerequisites
• Informed consent
• At 39 weeks
• Ultrasound pre section to out rule
• spontaneous cephalic version.
• Intrauterine fetal death.
• Congenital anomalies uncompatible with life.

18
Management Options of Term Breech
Planned Vaginal Delivery

• Vaginal breech delivery was the norm until 1959
• Prerequisites
• Out rule contraindications.
• Informed consent.
• Facilities where emergency cesarean section can
  be done.
• Experience with vaginal breech delivery.
• Continuous monitoring.
• Augmentation of labour is controversial.
• Low threshold for cesarean section.

19
Management Options of Term Breech
Planned Vaginal Delivery

• Types of Vaginal breech delivery
• Spontaneous breech delivery No tractions or
  manipulations.
• Assisted breech delivery The infant is allowed
  to deliver spontaneously up to the umbilicus,
  then maneuvers are initiated to assist in the
  delivery of the remainder of the body, arms
  head (Pinard, Lovset Mauriceau Smellie
  maneuvers).
• Breech extraction Fetal feet are grasped, the
  entire fetus is extracted. Only for second twin.

20
Management Options of Term Breech
Planned Vaginal Delivery

• Benefits

• Risks

• Reduction in the risk of newborn Idiopathic
  Pulmonary Hypertension.
• Less maternal morbidity and mortality than
  cesarean section.

• Cord prolapse .
• Nuchal arms ? brachial plexus injuries
• Cervical spine injury.
• Rupture of internal organs.
• Bone fracture.
• Low apgar score at 1 min.
• Intracranial hemorrhage.
• Difficult birth experience.

21
Management Options of Term Breech
Planned Vaginal Delivery

• Contraindications of Vaginal breech delivery
• Other indications for cesarean section.
• Compromised fetal condition.
• Footling Complete breech.
• Estimated fetal weight 4kg.
• Hyperextended head.
• Previous cesarean section.
• Lack of experience.

22
Management Options
Pre-term Breech

• Not an indication for cesarean section. No data.
• Prematurity is the main concern regardless of the
  mode of delivery.
• Individualized approach regarding mode of
  delivery parents wishes should be considered

23
Management Options
Second-twin Breech

• Breech extraction
• Internal podalic version

24
Thank You