Breech

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Breech

• Prof. Abdulhafid Abudher
• MBBch,DGO,MD,FABOG,FRCOG

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Definetion

• This is a malpresentation where the podalic pole
  presents at the pelvic inlet.
• The lie is longitudinal
• The denominator is sacrum

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Various positions

• Anterior
• RSA-right sacroanterior (common)
• SA-sacroanterior
• LSA-left sacroanterior
• Posterior
• RSP-right sacroposterior
• SP- Sacroposterior
• LSP-left sacroposterior

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Incidence

• At term 2.2 to3.7
• 29-32 weeks up to 25
• Accounts for 4.8 of all births in USA (Haugley
  1985)

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Types of Breech (Seed and Cafalo 1982)

• Complete 5-12
• Frank 48-73
• Incomplet 10-30
• Footling
• Kneeling

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Etiology

• Predisposing Factors
• Abnormal uterine shape
• Excessive fetal mobility
• Interference in fetopelvic relationship
• 1-Maternal factors
• 2-Placental,Liquor and cord factors
• 3-Fetal Factors

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Maternal Factors

• Cephalopelvic disproportion at the pelvic inlet
• Soft tissue dystocia
• Congenital uterine anomalies
• Grand multipara
• Anticonvulsants and maternal alcohol intake
  (Robertson 1984)

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Placental,Liqure,Cord Factors

• Placenta previa
• Cornufundal implantation of placenta(fainu and
  vaclavinkova 1978)
• Polyhydramnios
• Oligohydramios
• Very long or very short cord

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Fetal Factors

• Multiple gestation
• Congenital anomalies
• Prematurity
• Large baby
• Postdate
• Intra uterine fetal death
• Fetal aneuploidy (Zhang and Schingle 1993)

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Diagnoses of Breech

• Abdominal examination
• Fetal heart sounds
• Vaginal examination
• Ultrasound examination

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Mechanism of labour

• Delivery of lower limbs and buttocks
• Delivery of shoulders and arms
• Delivery of aftercoming head

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Delivery of lower limbs and buttocks

• Engagement
• Descent
• Flexion
• Internal rotation
• Birth of Buttocks

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Delivery of shoulders and arms

• Engagement
• Descent continuous
• Internal rotation
• Birth of shoulders
• Restitution

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Birth of after coming head

• Engagement
• Descent
• Flexion
• Internal rotation
• Birth of the head

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Mechanism of labour in other positions

• Sacroanterior position
• Sacroposterior position
• Moulding

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Investigations

• Routine antenatal investigations
• US
• Anomalies
• Head extension
• Maturity
• Site and grade of placenta
• Adequacy of liquor
• Multiple gestation
• Confirming fetal presentation

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Investigations

• X-ray abdomen (history)
• Skeletal anomalies
• Maturity
• Pelvimetry
• Multiple gestation

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Management during pregnancy

• External cephalic version
• Trial of labour
• Caesarean delivery

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Vaginal breech delivery

• Spontaneous
• Assisted
• Total breech extraction

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Indications for trial of labour

• Frank breech
• Gestational age 36 to 42 weeks
• Estimated fetal weight 1500 to 3900 grm
• Flexed fetal BPD less than 9.5
• Adequate maternal pelvis

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Breech Vaginal Delivery

• First Stage
• Second stage
• Episiotomy
• Assisted
• Lovsets maneuver
• Aftercoming head
• Kristellars maneuver
• Brachts maneuver
• Wigand-Martin maneuver
• Mauriceau-Smellie-Veit maneuver
• Forceps delivery (Savages maneuver)
• Occipto-posterior position
• Rotating face posterior
• Prague maneuver

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Total breech extraction

• Rapid delivery -FD
• Pre-requisites
• No fetopelvic disproportion
• Fully dilated cervix
• Empty balder and rectum
• Anesthesia
• Good assistance

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Hyper extension of the head

• Etiology
• Spasm or congenital shortening of the extensors
  muscles of neck
• Umbilical cord looped around the neck
• Congenital tumors of the neck ,teratoma or cystic
  hygroma
• Uterine anomalies
• Placental tumors

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Hyper extension of the head

• Diagnosis
• X-ray (star gazing foetus)
• Ultrasound (measurement of the craniospinal
  angle)
• Risk of spinal cord damage
• Excessive longitudinal stretching
• Extreme flexion of neck during delivery
• Marked tortion

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Indications for elective C/S

• Contracted, border line or abnormal pelvis
• Placenta previa
• Large baby
• Hyperextension of head
• Footling breech
• Premature baby
• Previous caesarean section
• Elderly primgavida , BOH ,primary infertility
• IUGR
• BPD more than 9.5 cm

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Prognosis for breech presentation

• Maternal
• Genital laceration
• Bleeding
• Fetal
• Injury to the brain and skull
• Intracranial hemorrhage
• Fracture of skull bones
• Brain dysfunction
• Prematurity
• Congenital anomalies
• Congenital dislocation of hip
• Hydrocephaly
• Anencaphaly
• meningomyelocele

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Prognosis for breech presentation

• Birth asphyxia may occur due to
• Prolonged compression of cord
• Cord prolapse
• Aspiration of liquor and vaginal secretions
• Prolonged labor
• Fetal injuries
• Fracture of neck,humerus,clavical,femur
• Cervical and brachial plexus palsies
• Hepatic rupture
• Splenic laceration
• Adrenal gland rupture
• Pharyngeal injury

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Thank you