BREECH PRESENTATION DEFINITION TYPES INCIDENCE ETIOLOGY/PREDISPOSING FACTORS

MANAGEMENT:- DIAGNOSIS: -CLINICAL PRESENTATION - INVESTIGATIONS MODE OF DELIVERY - CAESEREAN SECTION - ASSISSTED VAGINAL DELIVERY - EXTERNAL CEPHALIC VERSION

DEFINITION Breech presentation is the entrance of the fetal buttocks or

lower extremities into the maternal pelvic inlet. It is the commonest form of malpresentation.

TYPES 1. Frank or extended: hips flexed,knees extended. 2. Complete or flexed: hips flexed,knees flexed. 3. Footling or incomplete: one or both hips extended with a foot

presenting.INCIDENCE The incidence of breech presentation is about 25% at 28-

30weeks gestation, 15% at 32weeks gestation but by 34weeks most have undergone spontaneous version to cephalic presentation such that at term the incidence is about 2-4%. Frank breech is the commonest type of breech presentation, accounting for 50-70% of cases, Footling for 10-30% of cases and complete for 5-10%.

Etiology Idiopathic

PREDISPOSING FACTORS Maternal:- abn. of maternal pelvis, uterine abn (bicornate uterus), low lying

pelvic tumors (fibroids, ovarian cysts) maternal diabetes . Fetal:- Prematurity (commonest), fetal abns (hydrocephalus, cns mal. Neck

masses), multiple pregnancy, placenta praevia,short cord, abn of liquor vol (oligo, polyhydramnios), intra-uterine fetal death.

Drugs – anticonvulsant - phenytoin

DIAGNOSIS: Based on clinical presentation, usually an incidental finding on abdominal

examination. Palpation:- soft, globular, non ballotable fetal part at the lower uterine pole

and a hard, rounded and ballotable part felt above the umbilicus (uterine fundus). Difficulties in making a diagnosis by palpation arise when the anterior abdominal wall is obese, extended legs obscure ballotment of the fetal head with the fetus in dorso-anterior position and polyhydramnios present.

Auscultation:- the area of greatest intensity of the fetal heart sounds is above the level of the maternal umbilicus although if the legs are extended, the sounds tend to be heard at a lower level.

Vaginal examination:- fetal buttock is felt, if cervix is dilated and membrane ruptured, natal cleft is felt, feet felt alone or close to buttocks, cord may also be felt.

INVESTIGATIONS:• Pelvic u/scan: confirm breech presentation - R/o PDF (fetal cong. Abn, p.praevia, multiple preg) - Estimate fetal weight• Pelvimetric assessment: clinical pelvimetary, x-ray pelvimetary (plain abdo

x-ray, CTScan, MRI) - Role in the management of breech is controversial:- has not changed the incidence of c/s nor the success of V.B.D

MODE OF DELIVERY: The management of breech presentation remains controversial due to the

associated high perinatal morbidity and mortality following breech deliveries. Options employed to reduce the perinatal mortality and improve the maternal and fetal outcome include: Caesarean section, vaginal breech delivery and external cephalic version.

E.C.V is a manipulative transabdominal conversion of an abnormal presentation to

cephalic presentation. Arguments: Those in favour of E.C.V say it has reduced the incidence and therefore the

risk factors associated with vaginal breech delivery or caesarean section while those against E.C.V say its complications outweigh its benefits (eg prelabour rupture of fetal membranes, cord prolapse, premature labour, prematurity, fetal heart rate abnormalities, abruptio placenta, cord entanglements, uterine rupture)

when E.C.V is considered it is carried out only at term and after exclusion of contraindications such as; placenta praevia, multiple pregnancy, PROM, APH, PIH, Previous c/s, prematurity and contraindications to vaginal delivery.

STEPS: E.C.V to be done in labour ward unit or theatre.

1. Obtain consent after explaining procedure to the woman

2. u/scan to R/O contraindications.

3. Maternal B.P measurement.

4. Fetal heart rate measurement (b/4 and after procedure):- non stress test (CTG)

5. Tocolytics (eg salbutamol, ritodrine) for uterine relaxation.

6. Mother placed in a steep lateral position with her back supported with a cushion or in a supine position and comfortable.

7. Breech disengaged from pelvic inlet using both hands, E.C.V carried out when breech is above the inlet.

8. One hand on lower pole, other on upper pole, manipulate in the direction which increases flexion of the fetus and makes it do a forward somersault,

bringing the head to the lower uterine pole.

9. On completion of version the fetus is steadied by lateral pressure while the mother is transferred to the supine or semi-recumbent position.

10. Check fetal heart rate after procedure. N/B: If procedure fails or becomes difficult, it is

abandoned. it is easier to perform ECV in multiparous women due to

laxity of uterus and abdominal wall. No place for E.C.V in preterm – high failure rate. E.C.V at term is what is recommended - to allow for

spontaneous version (reversion less likely, if successful), delivery of term baby in case of spontaneous labour or

complications that require C/S, other unidentified P.D.F would have become obvious, associated with higher success rate,

ECV success rate is between 25-97% of breech presentation.

Factors influencing success of E.C.V Maternal: parity - higher in multip Race - higher in black women - due to late engagement

Fetal: type of breech - flexed>frank descent of presenting part

CAESAREAN SECTION:

Due to the high perinatal mortality and morbidity associated with breech presentation, the global trend now for breech delivery is C/S Recent randomised controlled trial (mary hannah in canada) has shown that planned c/s is better than V.B.D, however in our society where there is an aversion for c/s, and where women with previous c/s attempt vaginal delivery to avoid repeat c/s outside the hospital with the possible risk of uterine rupture, liberal c/s for breech delivery is not justified.

INDICATIONS FOR C/S IN BREECH PRESENTATION:

1. Previous c/s

2. P.I.H

3. B.O.HX

4. Previous infertility

5. Contracted pelvis

6. Primigravida breech with inadequate pelvis

7. Elderly primigravida

8. Preterm breech,

9. Footling breech

V.B.D

In modern obstetric practise there is no place for S.V.B.D

A.V.B.D is the choice of delivery but in well selected cases (women properly assessed:- R/O P.D.F, C/I to V.D)

Scoring index for A.V.B.D:- Andros-Zatuchni Scoring index

Parameters of index:- Parity, gestational Age, Previous V.B.D, estimated fetal weight, cervical dilatation and station

Zatuchi-Andros scoring index is used in labour.

STEPS IN A.V.B.D:-

1. Transfer to 2nd stage room when fully dilated

2. Place in lithotomy position and cleanse lower abdomen, vulva, vagina and thighs with swabs soaked in hibitane soln.

3. Apply sterile drapes to isolate the vulva

4. Empty bladder with a plastic catheter and repeat V.E to confirm full cervical dilatation.

5. With each contraction she is encouraged to bear down while the descent of the breech is observed without interference

6. The perineum is infiltrated with 10mls of 1% xylocaine

7. A left mediolateral episiotomy is given as the breech distends the perineum, the descent of the baby allowed to continue until the umbilicus and popliteal fossa become visible

8. Each extended lower limb is delivered by the pinard’s manoeuvre (pressure applied with two fingers to the popliteal fossa to flex the knee and gently abduct and flex the thigh)

9. Mother encouraged to bear down until the trunk, up to the scapula becomes visible, cord pulsation checked and a loop of cord pulled down to prevent cord compression

10. Baby gently held by the groin and trunk rotated 90o in one direction with a downward traction applied and the back facing upwards to deliver the anterior shoulder (lovset maneouvre for extended arms)

11. Procedure repeated in the opposite direction, with a rotation of 1800 to deliver the posterior shoulder.

12. Mother further encouraged to bear down until the hair lines is visible (the nape of the neck become visible) under the pubic symphysis

13. The aftercoming head is delivered by one of the following methods:

- Mauriceau-Smellie-Veit manoeuvre (jaw flexion and shoulder traction)

- Burns Marshall

- Obstetric forceps (piper’s)

The most important aspect of V.B.D is delivery of the aftercoming head

Zatuchni Andros scoring index(1965)

• Score 0-4 - Caesarean delivery recommended

• Score > 5 – allow vaginal breech delivery

parameter Score 0 Score 1 Score 2

parity 0 1 > 2

Gestational age (weeks)

39+ 38 < 37

Previous vag breech delivery

0 1 2

Estimated fetal weight (kg)

> 4.0 3.5-4.0 < 3.5

Cervical os dilatation (cm)

2 3 > 4

Station of presenting part

- 3 - 2 - 1

Newman’s score for ECV

Because of significant overlap in scores between successful and unsuccessful ECV, this scoring system is clinically less useful

Score 0 1 2

Parity 0 1 > 2

Estimated fetal weight (kg)

< 2.5 2.5-3.5 > 3.5

Placental position

anterior posterior Lateral or fundal

Cervical dilatation

> 3 1-2 0

Station of presenting part

> -1 -2 -3

BREECH EXTRACTION:

No maternal effort in V.B.D (breech extraction)

Mother under general anaesthesia

INDICATIONS:

- Retained 2nd twin with breech presentation

- Transverse lie (do prior internal podalic version, then breech extraction)

- I.U.F.D with breech presentation

COMPLICATIONS OF A.V.B.D

- Trauma to fetal head (I.C.H)

- Fractured limbs (clavicular #, humerus #, shoulder dislocation)

- Dislocation of the neck

Other methods of achieving spontaneous version

• Mousi Burston manouvre used by the chinese – where they burn a herb on the patient feet to achieve version.

• Elkin’s manouvre – patient is advised to be in repeated knee-chest position to encourage spontaneous