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Breech Presentation: - by Drtejaswini K.R
Breech Presentation: - by Drtejaswini K.R
-By
DrTejaswini K.R
Presentation Outline
• Definition
• Incidence
• Aetiology & Risk Factors
• Types of Breech Presentations
• Consequences of Breech Presentation
• Diagnosis
• Management
• External Cephalic Version
• Vaginal Breech Delivery
Definition
Breech
A malpresentation where the foetal buttocks
lies over the maternal pelvis.
Maternal Foetal
Difficult vaginal delivery Risk of hypoxia and trauma during
Likelihood of a Caesarean delivery
delivery Irrespective of the mode of delivery,
neonatal and long-term risks are
increased
Diagnosis of a Breech Presentation
• Before 36 weeks gestation a breech presentation is not of much
concern unless the patient is in labour.
• If spontaneous version does not occur at term then the patient should
be counseled on this type of presentation- consequences, methods of
management and course of action to be taken.
• Breech presentations are commonly not diagnosed until labour.
Diagnosis of a Breech Presentation
History
Examination:
• Longitudinal lie
• Fundus: foetal head - hard, round, ballotable
• Presenting part: irregular and soft.
• Foetal heart: detected mostly above umbilicus.
USS
3. Caesarean Section
External Cephalic Version
• Undertaken around 37-39 weeks gestation
• Manoeuvres which manually convert the polarity from breech to cephalic
• The intention is to reduce the need for Caesarean Section.
• Should only be attempted where facilities are available for emergency
Caesarean section (if it becomes necessary, i.e. about 0.5% of cases)
• USS is performed before ECV to confirm presentation and lie of foetus and
after ECV to confirm version
• Foetal heart should be monitored
ECV Technique
1. USS is performed.
2. The patient’s bladder is emptied.
3. Powder is liberally applied to the mother’s
abdomen.
4. The breech is held with one hand which
gently elevates it away from the pelvic inlet
while simultaneously the other hand flexes
the foetal head.
5. The foetus is encouraged into a “Forward
Roll” (or less commonly, a ‘back flip’* in
order to change the polarity.
ECV Technique
After ECV
• The arms are then hooked down by the index finger at the foetal elbow,
bringing them down to the baby’s chest.
• If the arms are extended, Lovset’s manoeuvre allows the anterior shoulder and
then the posterior shoulder to enter the pelvis and for the arm to be delivered from
below the pubic arch.
• After delivery of the arms, the baby is allowed to hang at the vulva so that the
effect of gravity leads to further descent of the foetal head.
Lovset’s
Manoeuvre
Lovset’s
Manoeuvre
Vaginal Breech Delivery: Technique
Delivery of the aftercoming head should be gentle and controlled to avoid rapid
decompression → intracranial bleeding via
1. Mauriceau-Smellie-Veit Manoeuvre
2.Forceps
Delivery of the
Head
1) Mauriceau- Smellie- Veit
Manoeuvre
When the nape of the neck is visible,
delivery is achieved by placing 2 fingers
of the right hand over the maxilla and
two fingers of the left at the back of the
head to flex it and maternal pushing is
encouraged.
If this fails to deliver the head
2) Forceps should be applied before
the next contraction.
Delivery of the
Head
The Burns-
Marshall
Manoeuvre
• While standing on one side of
the mother, the baby’s feet are
held and outward traction is
exerted
• The baby is taken through an arc
towards the mother’s abdomen
• Note:
• there is no control of delivery of
head → possible cerebral
complications
• Incorrect method → over
-extension of neck
Complications of Vaginal Breech Delivery
• Cord prolapse and compression
• Fractures to the upper and lower limbs, ribs and pelvis
• Dislocation of the hip joint
• Visceral trauma eg liver, spleen and adrenals
• Brachial plexus injury
• Intracranial hemorrhage
• Sternocleidomastoid injury eg torticollis
• Occipital diastasis from excessive pressure on the occiput
• Stretching and spasm of the vertebral arteries
Complications of
Vaginal Breech
Delivery
Contraindications to a Vaginal Breech
Delivery
• Clinically inadequate pelvis
• Footling or kneeling breech presentation
• Large baby (> 3500g)
• Growth- restriction (<2000g)
• Other contraindications to vaginal birth e.g. placenta praevia, foetal compromise
• Previous caesarean section
• Hyperextended foetal neck in labour (USS)
• Absence of a clinician trained in vaginal breech delivery
Sources
Textbook of Obstetrics, Roopnarinesingh (3rd
Edition)
Examination
Blood pressure is 140/85 mmHg and abdominal examination suggests a breech presentation with
the sacrum not engaged.
Case
Questions
• What are the options available to the
woman?
• What management would you
recommend in this case?
• What are some of the causes of breech
presentation?
Case: Answer
At 30 weeks the incidence of breech
presentation is around 14 per cent, but is
only 2–4% by term.
• found to be less safe for singleton • involves using external manipulation of the • is safer than vaginal breech
term fetuses than planned Caesarean fetus, encouraging the baby to turn to the delivery
section cephalic presentation by way of pressure on • is suitable where
• carries a high chance of necessitating the maternal abdomen contraindications exist to external
an emergency • is often performed after giving a uterine cephalic version
• needs an experienced obstetrician relaxant such as salbutamol • can be planned for in advance,
with continuous fetal heart monitoring • carries a very small chance of abnormal fetal which women may find more
and ideally an epidural heart rate during or after the procedure which convenient
• should only be allowed if the labour could necessitate an emergency Caesarean • does not necessarily mean a
progresses spontaneously – section woman would need a Caesarean
augmentation of breech labour is • has approximately 50 % success rate overall section for any future pregnancy.
generally not recommended • some fetuses revert to breech position even
• contraindicated with placenta praevia, after successful external cephalic version
large baby, footling breech or • contraindicated with previous C- section, other
maternal condition such as pre- uterine surgery, pre-eclampsia, intrauterine
eclampsia growth retardation, oligohydramnios
• can be painful
Case: Answer
In this case the woman should be recommended external cephalic version as soon as possible, with
options for an elective Caesarean section or possible trial of breech delivery if this is unsuccessful.
Postnatal paediatric review should focus on the baby’s hips, with a neonatal ultrasound arranged
within 6 weeks to rule out congenital hip dislocation (10–15 times more common in breech
presentation).