Breech presentation

Dr Musonda
 Def: presentation of buttocks
 Incidence :3% of term pregnancies and 2-3% of all
labours.30% are missed
 Frank breech(65%)-both legs extended at the knees
 Complete breech(10%)-both legs flexed at hip and
knee
 Footling breech(25%)-one or both feet tucked
underneath the buttocks
Aetiology

 Extended legs preventing spontaneous

version
 Conditions preventing the pp entering pelvis
eg p praevia, tumours, deformities
 Uterine anomaly
 Chance
Associations

 Fetal anomalies
 Preterm delivery
 Multiple pregnancy
Diagnosis

 Is common
 Only important after 37 weeks or in labour
 Hard head palpable and ballotable at fundus
 Upper abdominal discomfort
 U/S confirms diagnosis ,helps detect tumour,
anomaly, p praevia
Complications

 Increased perinatal and longterm morbidity

 Fetal anomalies common
 Cord prolapse risk
 Trapped after-coming head
Antenatal management

 Spontaneous version is likely up to 34 weeks

 External cephalic version is safe for mother
and baby in carefully selected patients and
reduces the need for elective c/s
 ECV not advised before 36 weeks
Hazards of ECV

 Preterm labour
 Placental abruption and cord accidents
 Uterine rupture ( if previous section)
 Isoimmunisation
 Sudden fetal death
Contraindications to ECV
Absolute

 Multiple pregancy
 APH
 Ruptured membranes
 Oligohydramnios
 Significant fetal anomaly
 Caesarean section indicated for other
reasons
Relative

 Previous caesarean section

 IUGR
 Hypertension
 Rhesus iso-immunisation
 High parity
 Anterior placenta
 obesity
Prerequisites for ECV

 GA at least 36 weeks
 Recent ultrasound to confirm presentation, normal
fetus and adequate liquor volume
 Reactive FHR
 Informed consent of the mother
 Facilities for rapid progression to caesarean
section,if necessary
 Rh-D-negative women must be given anti-D-
immunoglobulin
Mode of delivery

 If ECV has failed the choice is between elective C/S

and an attempt at vaginal delivery
 Evidence suggests better outcome with elective C/S
– Reduced perinatal and neonatal mortality and morbidity
– 50% trials end up as C/S
– No overall increase in maternal morbidity+mortality
– C/S is relatively safe nowadays
Disadvantages of elective C/S

 One C/S increase risk of c/s in next

pregnancy
 Skill for breech delivery will be lost
Prerequisites for breech vaginal
delivery

 Skilled attendant
 Patient selection
– Not footling breech
– Weight <4.0kg
– No maternal /fetal complication
– Willing mother
– Frank breech
– Normal fetal assessment
– Known placental site
– Altitude known to be flexed
Breech delivery
spontaneous vs assisted delivery

 Assisted breech delivery is favoured

 Do episiotomy when buttocks distend
perineum
 Fetus delivered up to umbilicus without
traction
 Legs flexed out of vagina
 When scapula visible,deliver anterior then
posterior arm by hooking
Delivery of after head

 Mauriceau-Smellie-Veit manouvre –the operator

supports the entire weight of the fetus on one palm
and forearm,with his finger in its mouth to guide the
head over the perineum and maintain flexion
 With same intent ,his other hand presses against the
occiput and an assistant applies suprapubic pressure
 This method is reserved for the extended head
 For the flexed head the Burns-Marshal
method is used
 Once the back of the neck is visible ,forceps
are applied ,and with the next contraction
the head is lifted slowly out of the vagina
 Note that augmentation of labour with
oxytocin is contraindicated
Role of internal podalic version

 Def-convert to breech and extract with no

maternal effort
 Indicated in second twin
 Membranes intact or just ruptured
 No scar on the uterus