References:

Obstetric illustrated

TB of obstetric DC Dutta
e-medicine:

http://emedicine.medscape.com/article/262 159-overview#aw2aab6b3 Rcog: http://www.rcog.org.uk/files/rcogcorp/GtG%20no%2020b%20Breech%20pres entation.pdf

 occurs in 3-4% of all deliveries Incidence decreases with advancing gestational age: 20% at 20wks to 3-4% at term Definition
The lie is longitudinal Podalic pole presents at the pelvic brim

This is the most common mode of

malpresentation.

Types
A) Complete (flexed

breech) -The limbs and body wil be in flexed attitude -Presenting part consists of: -buttocks -external genitalia -2 feet

B) Frank breech -thighs flexed, legs are extended at the knee joints. -presenting part consists of the buttocks and external genitalia only.

c) Footling or Incomplete breech -both the thighs and the legs are partially extended. -legs are present at the brim.

Aetiology:
1)Prematurity 2)Factors preventing spontaneous version:

i. Twins (multiple fetus) ii. oligohydramnios iii. breeeech with extended legs iv. short cord v. congenital malformation of the uterus vi. intrauterine death of the fetus

 3)Undue mobility of the fetus:

i. polyhydramnios ii. multiparae with the lax abdomen wall

4)Favourable adaptation: i. Hydrocephalus ii. Placenta praevia iii. Contracted pelvis iv. Cornufundal attachment of the placenta

5)Fetal abnormality: eg: trisomies 13,18,21 and myotonic dystrophy

6)Recurrence or habitual breech

Diagnosis
Clinically per abdomen,

-head: smooth,hard, round, ballotable mass is felt during fundal grip -back to one side & irregular limbs to the other - soft,broad, round mass of buttock -the fetal heart is best heard at the level of the umbilicus or above

Diagnosis of breech presentation

Per vagina
Palpation of ischial tuberosities &

tip of sacrum feet beside the buttocks in complete breech Fresh meconium on examining fingers Male genitalia may be felt

Ultrasound 1.confirms the clinical diagnosis 2.detect fetal abnormalities & congenital anomalies of the uterus 3.measures biparietal diameter, gestational age, and approximate weight of the fetus 4.localises the placenta 5.assessment of the liquor volume 6.attitude of the head, eg flexed or hyperextension

Management of breech
1. External cephalic version
2. Vaginal delivery 3. Caesarean section

External cephalic version

After 35 to 37 week (but can be attempted

any time thereafter upto early labour) Success rate : ~69% Causes of failure - large fetus, oligo/polyhydramnios, short umbilical cord, uterine anomalies, irritable uterus, obesity, rigid abdominal wall, frank breech extended legs

External cephalic version

Contraindication

- antepartum hemorrhage -fetal causes:cong.anomalies, dead fetus, hyperextensio. Of head - multiple pregnancy -ruptured membranes - previous caesarean: risk of scar rupture -uterine abnormalities

Technique of ECV
In a delivery unit set-up where facilities are

available for emergency CS Supine with legs & abdomen relaxed Patient should empty bladder prior to version Anesthesia contraindicated pain is a safeguard against rough manipulation 1 hand on lower pole of fetus (breech) 1 hand on upper pole (head)

Technique of ECV
When uterus is relaxed

Breech displaced out

of pelvis laterally toward iliac fossa Head pushed toward pelvis in opposite direction

Technique of ECV
Procedure complete when fetal head

overlies the pelvic brim Patient is observed for one hour & CTG performed Note fetal heart rate, fetal movements, abdominal pain, vaginal bleeding Seen again 3-7 days Seen immediately if symptoms develop

External cephalic version

Complications

- placental separation - rupture of membranes - preterm labour - fetal distress - cord presentation/prolapse - entanglement of cord around fetal parts - fetomaternal hemorrhage

Vaginal breech delivery

Favourable in :

- frank breech - estimated fetal weight 2.0 - 3.8 kg - flexed head - adequate pelvis - normal progress of labour - uncomplicated pregnancy - multiparas - intrauterine fetal death - an experienced obstetrician

Unfavourable if:
Footling breech

Large baby
Small baby Hyperextended neck

Previous CS
Inadequate pelvis

Placenta previa
Pre-eclampsia

Vaginal breech delivery

1. Spontaneous breech delivery

- minimal support - multigravida/precipitate labor/ antenatal fetal death 2. Assisted breech delivery - assistance indicated for delivery of shoulders & after-coming head - delivery up to umbilicus spontaneously 3. Breech extraction

Assisted breech delivery

Delivery of buttocks :

- patient asked to bear down during uterine contractions & relax in between until perineum is distended by buttocks - an episiotomy done - the legs are hooked out but without traction

- when umbilicus appears, a loop of cord is hooked(min. compression) & detect its pulsation - fetus is covered with warm towel

Assisted breech delivery

Delivery of shoulders :

- gentle steady downward traction applied over the fundus during uterine contraction - gradual rotation of fetus to bring shoulders in AP diameter of pelvis - anterior scapula appear below symphysis - both arms delivered by hooking the index finger at elbow & sweep forearm across fetal chest - the back is rotated anteriorly

Assisted breech delivery

Delivery of after-coming head :

1) Burns-Marshalls method 2) Jaw flexion shoulder traction (Mauriceau- Smellie-Veit technique) 3) Forceps delivery

 Total breech extraction:

The fetal feet are grasped, and the entire

fetus is extracted. Total breech extraction

should be used only for a noncephalic

second twin; it should not be used for a

singleton fetus because the cervix may not

be adequately dilated to allow passage of the

fetal head

Breech extraction
Indications - maternal/fetal distress

- prolonged 2nd stage - to shorten 2nd stage in maternal respiratory & heart diseases - prolapsed pulsating cord with fully dilated cervix Contraindication - grand multipara - post-caesarean pregnancy - incompletely dilated cervix

Technique breech extraction

Same as assisted breech delivery (except) Done under GA Both legs are bringing down Traction on legs is done helped by fundal

pressure to deliver breech & trunk After-coming head delivered by jaw flexion shoulder traction / forceps

Complicated breech delivery

Arrest of buttock at pelvic brim

- inefficient uterine contractions - contracted pelvis - large-sized baby Arrest of buttock at pelvic outlet - inefficient uterine contractions - contracted outlet - rigid perineum - extended legs (frank breech)

Complicated breech delivery

Arrest of shoulders

- extension of arms due to traction on breech before full dilatation of cervix - nuchal position of arm (forearm displaced behind the neck due to rotation of trunk in wrong direction)

Complicated breech delivery

Arrest of after-coming head

(a) Faults in head - large head - hydrocephalus - extended head - posterior rotation of occiput (b) Faults in passages - contracted pelvis - rigid perineum - incomplete dilated cvx

Mx of complicated breech delivery

Pinards manoeurve: to convert frank to footling breech

 Lovesets manoeurve:

Caesarean section
Indications (contraindication of vaginal del.)

- large fetus - preterm fetus weight > 1.25kg - footling/complete breech-risk of cord prolapse - hyperextended head - contracted pelvis - uterine dysfunction - breech in primigravida

Caesarean section
-complicated pregnancy with : hypertension DM placenta previa PROM > 12 hours post-term IUGR placental insufficiency

Complications breech delivery

Maternal - prolonged labor with maternal

distress - obstructed labor - perineal laceration - postpartum hemorrhage - puerperal sepsis

Thank you!!