Breech Presentation

BREECH PRESENTATION

DR.Prathibha

DEFINITION

• BREECH PRESENTATION IS A LONGITUDINAL LIE WITH FETAL PELVIS AS THE PRESENTING PART.

• THE DENOMINATOR IS THE SACRUM.• THE ENGAGING DIAMETER IS THE

BITROCHANTERIC DIAMETER.• MOST COMMON POSITION IS L.S.A.• IT IS THE MOST COMMON FORM OF

MALPRESENTATION .• INCIDENCE IS 3-4% AT THE ONSET OF LABOR.

TYPES OF BREECH PRESENTATIONS

• COMPLETE BREECH-• INCIDENCE 10%• MOSTLY IN MULTIS

1. INCOMPLETE BREECH- 1.EXTENDED OR FRANK BREECH 2.KNEELING PRESENTATION 3.FOOTLING PRESENTATION

Frank Complete Footling

AETIOLOGY• MATERNAL• MULTIPARITY• CONTRACTED PELVIS• MALFORMATIONS OF UTERUS PELVIC TUMOURS• PREVIOUS BREECH

• PLACENTAL• PLACENTA PREVIA• CORNUO FUNDAL PLACENTA • HYDRAMNIOS• OLIGOHYDROMNIOS

• FETAL• PREMATURITY• CONGENITAL FETAL MALFORMATIONS • HABITUAL OR RECURRENT BREECH-• CONGENITAL MALFORMATIONS OF THE UTERUS • REPEATED CORNU FUNDAL ATTACHMENT OF PLACENTA •

Positions• Left sacro-anterior.           • Right sacro-anterior.• Right sacro-posterior.           • Left sacro-posterior.• Left and right sacro- transverse (lateral).• Direct sacro-anterior and posterior.

DIFFERENT POSITIONS OF BREECH

DIAGNOSIS OF BREECH

• ABDOMINAL EXAMINATION-

FUNDAL GRIPLATERAL GRIPPELVIC GRIPS• FETAL HEART- HEARD BEST IN THE

UPPER QUADRANT OF THE ABDOMEN

• ON VAGINAL EXAMINATION• DURING PREGNANCY-

• PRESENTING PART IS HIGH.

• SOFT AND IRREGULAR

• ANAL ORIFICE AND ISCHIAL TUBEROSITIES ARE IN A STRAIGHT LINE.

• SOMETIMES A FOOT IS FELT AND MUST BE DISTINGUISHED FROM A HAND.

• During Labor• . In addition to the previous findings,

vaginal examination reveals;• The 3 bony landmarks of breech namely

2 ischial tuberosities and anal orifice are in a straight line.

• The feet are felt beside the buttocks in complete breech.

• Fresh meconium may be found on the examining fingers.

• Male genitalia may be felt

• ULTRASONOGRAPHY- • FOR CONFIRMATION

• DIAGNOSIS OF HYPEREXTENSION

• ESTIMATION OF WEIGHT

• DIAGNOSIS OF MAJOR CONGENITAL MALFORMATIONS

MECHANISM OF LABOR IN BREECH PRESENTATION

• In breech presentation there are three mechanisms of labor.Delivery of the buttocks and lower

limbsDelivery of the shoulders and arm

Delivery of the head

MECHANISM OF LABOR buttocks and lower limb

• Engagement and descent with compaction –

• Engagement occurs when the bitrochanteric diameter has passed through the pelvic inlet.

• The bistrochanteric diameter is 10cm.• Descent is slow as the breech is a less

efficient dilator. • Compaction means that every part

becomes a little bit more flexed.

Delivery of the buttocks and lower limb

• Internal rotation-• In case of RSA or LSA

bitrochanteric diameter rotates 45 degrees from the oblique diameter to the anteroposterior diameter.

• The sacrum turns away from the midline from anterior quadrant to the transverse plane.

Delivery of the buttocks and lower limb

• Birth of buttocks by lateral flexion-

• The anterior hip impinges under the pubic symphysis, lateral flexion occurs and the posterior hip raises and is born over the perineum.

• Then the anterior hip slips out under the pubic symphysis.

Delivery of shoulders and arms

• Engagement –• Occurs in the oblique diameter

of the pelvis.• Internal rotation of the

shoulders-• The bisacromial diameter turns

45 degrees from the oblique to the anteroposterior diameter of the outlet.

• The bisacromial diameter is 12cm.

• Birth of the shoulders by lateral flexion-

• Anterior shoulder impinges under pubic syphysis and the posterior shoulder and arm are born followed by anterior shoulder.

Delivery of after coming head • Descent and engagement-• Head enters the pelvis in the

opposite oblique diameter .• Flexion• Internal rotation• The occiput comes under

the pubic symphysis.• Birth of the head by flexion-• The nape of the neck pivots

under the symphysis pubis and the chin, mouth, nose, forehead, bregma, and occiput are born by movement of flexion.

Prognosis of breech delivery

• Depends on age and parity and past obstetric performance.

• Weight and maturity.• Type of breech.• Pelvic configuration.• Uterine dysfunction.• Other complications.• Skill of obstetrician

Complications with Vaginal Delivery for Breech

• Maternal injuries 1. Uterine rupture 2. Lacerations of the birth canal

3. Extension of the episiotomy4. Deep perineal tears

• Infection • Atonic PPH

Complications with Vaginal Delivery for Breech

FETAL INJURIES Cord prolapse Fetal acidosis Skeletal injuries

Brachial plexus injury – paralysis of the arm Testicular injury Spoon-shaped depression or fracture of the skull(?) Perinatal loss

Complications with Vaginal Delivery for Breech

• The main causes of the death of term fetus are head entrapment, cerebral injury and hemorrhage, cord prolapse, and severe asphyxia.

• The causes of the death of preterm fetus are hypoxia and physical trauma.

MANAGEMENT OF BREECH PRESENTATION AT TERM

Management options

(1) external cephalic version(antenatally)

(2) elective caesarean section

(3) trial of vaginal delivery

EXTERNAL CEPHALIC VERSION

• An series of movements done by which the fetus is turned in utero through the

abdominal wall for the purpose of changing to cephalic presentation.

• Indications- Breech presentation at 36 completed

weeks. Transverse lie

EXTERNAL CEPHALIC VERSION

• Methods

• 1-forward roll

• 2-backward flip

EXTERNAL CEPHALIC VERSION

• Method –• Place –in a unit where facilities for LSCS• Position-supine with relaxed abdomen.• Patient –with empty bladder.• Obstetrician should stand on right side of the

patient with hands on fundus and lower pole.• Movements –displace breech out of pelvis,

push the head towards pelvis.

Prerequisites

• Informed Consent • Skilled Obstetrician• Ready access to C/S facilities• Tocolysis (controversial)• Ongoing Ultrasound surveillance of FHR • FHR monitoring 15 mins with reactive NST

before & 30 mins after procedure• RH immune globulin as required following

Elevate breech

with suprapub

ic hand

Push breech

into iliac fossa

Assistant flexes

head

Now fetus in transverse lie

Ultrasound is used to monitor progress and heart rate

Fetus is past transverse

Little effort required to guide head

into a vertex

presentation

Ultrasound confirmation of fetal presentati

on

Absolute Contraindications

• Multiple gestation• IUGR, major anomaly• Hyperextension of fetal head• PROM• Oligohydramnios• Ante partum bleeding• Placenta previa• PIH, preeclampsia• Maternal cardiac disease• Uterine scar• Uterine malformation• CPD

Relative Contraindications

• Macrosomia (>4000g)• Excess maternal obesity• Active labor

Complications of ECV

• Fetal bradycardia, decelerations • Abruption • Fetal hemorrhage • Maternal hemorrhage• Knotted or entangled cord • Fetal mortality • Amniotic fluid embolus, maternal death

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ACOG guidelines (Feb, 2006)

• All women near term (>36-6/7 wks) with breech presentations should be offered a version attempt

• Fetal assessment before and after procedure

• Attempt ECV only in settings in which C/S services are readily available

ACOG Practice Bulletin #13 (2006)

ECV Algorithm

Zatuchni-Andros Breech Scoring

Add 0 Points Add 1 Point Add 2 Points

Parity 0 1 2

Gestational age (wk) 39+ 38 <37

EFW (lb) 8 7-8 <7

Previous breech 0 1 2

Dilatation 2 3 4

Station -3 -2 -1

If the score is 0-4, cesarean delivery is recommended

Indications for caesarean section

Elective LSCS Elderly primi History of infertility Bad obstetric history Contracted pelvis IUGR PROM Placenta previa Footling breech Hyperextension of the fetal

head Breech score of <3 Large baby-EFW >3800 gms Premature infant

Emergency LSCS• IN 1ST STAGE-• cord prolapse• fetal distress• In 2nd stage –• non progress of labor• fetal distress

Vaginal breech delivery

• 1.spontaneous • 2.assisted breech delivery• 3.breech extraction

Complicated breech

• PROM• Cord prolapse• Uterine inertia• Impacted breech• Impacted shoulder –extended arms• nuchal arms• After coming head-

Trial of labor

• Criteria-• Frank breech• Gestational age of 36 to 42 weeks• EFW between 2500 and 3800 gms• Fetal biparietal diameter <9.5cms• Flexed fetal head• Adequate maternal pelvis• Breech score of 4 or more

Trial of labor

• Conditions –• Fetal heart rate should be monitored

continuously.• Progress of labor should be observed.• When the progress is slow caesarean

section should be performed.• Patient must be prepared and ready

for caesarean section.

Management of labour in the progressing case

• First stage of labor-• Observant expectancy and supportive

therapy and absence of interference are best.• The patient is best in bed.• Best to maintain intact membranes until

cervical dilatation has far advanced.• When membranes rupture rule out cord

prolapse.• Meconium is no cause for alarm as long as

fetal heart rate is normal.

Management of delivery in the progressing case

• Second stage-• Position for delivery- lithotomy• Fetal heart should be checked frequently.• Premature traction on the baby should be

avoided. • patient must be encouraged to bear down.• No interference until the body is born to the

umbilicus.• Maintain supra pubic pressure to keep head in

flexion.• Keep the back anterior.

Management of delivery in the progressing case

• Necessary equipment –• Warm dry towel to wrap the baby to

prevent stimulation of respiration.• Pipers forceps for the after coming head.• Equipment for resuscitation of the infant.• Episiotomy –• Performed just before the buttocks

crown

• Delivery of the breech-

• Bracht technique no interference till

umbilicus is delivered.• Delivery of legs – flex

the knees at the popliteal fossa and gently release

• A loop of umbilical cord is pulled down .

• Baby is covered with warm towel. And the body is supported horizontally on forearm

• Delivery of shoulders and arms-

• Supra pubic pressure on the head to maintain its flexion.

• Operator depress the buttocks and deliver the body to the anterior scapula.

• If the arms need some assistance, sweep them gently down the baby’s front until they are free.

• Delivery of the after coming head-

• Back must be anterior which encourages rotation of occiput towards the pubis.

• The body is lowered so that the nape of the neck pivots under the pubic symphysis

• At the same time maintain flexion of the head by supra pubic pressure.

• The body is then raised slowly ( marshall burns technique) and then by further supra pubic pressure (kristellar maneuver) the head is delivered in flexion.

Arrest in breech presentation

• Arrest may occur at the- Buttocks Shoulders and

arms

Head

Management of arrest at buttocksPinards maneuver

• Introduce one hand in to the uterus.

• Reach the popliteal fossa along the thigh.

• Now pressure is applied along backward and outward direction which causes flexion of the knee and foot falls down.

• Both feet can be brought down in this way.

Arrest of the shoulders and arms• Extended arms-

• Ordinarily the arms are well flexed and easily delivered.

• At times one or both arms may be extended.

• This is dealt with by Lovsets maneuver.

Lovset’s maneuver• Steady and gentle traction downwards on the

feet, with the back of the baby facing right or left .

• It brings the axillary fold in to view.

• Now a finger is passed along the arm down to the elbow, which is then flexed.

• Now the baby is rotated so that the posterior shoulder comes under the pubic symphysis and the same maneuver is repeated.

Lovset’s maneuver

Arrest of the shoulders and arms• NUCHAL ARMS

• Here the hand is behind the occiput.

• Diagnosis is made when the medial border of the scapula is not parallel to the spine.

• Managed by rotating the baby in the direction in which fingers are pointing.

Arrest at the neck• Occasionally the cervix

clamps down around the baby’s neck after the trunk and shoulders have born.

• In this case incisions at 2’0 and 10 ‘o clock positions on the cervix with the scissors.

Duhrssen’s incision

Management of arrest of head

• One of the measures should be under taken.

1. Mauriceau smellie veit maneuver

2. Pipers forceps for the after coming head

3. Modified prague maneuver

Mauriceau Smellie Veit manoeuvre

• is used to help flex and deliver the baby’s head– place the second and fourth finger of one hand

on the baby’s shoulders– the middle finger is placed on the baby’s occiput– the second and third fingers of the other hand

are placed on the mallar prominences– flex the baby’s head to assist the birth at the

same time lifting the baby’s body over on to the mother’s abdomen

– birth slowly to avoid tentorial tears

Mauriceau Smellie Veit manoeuvre

Application of pipers forceps• Assistant lifts the baby’s body

up.

• Introducing the right hand between head and left posterior wall of vagina ,left blade is inserted into a mento occipital position.

• Like wise the left blade is introduced.

• The forceps are locked and traction is applied.

Modified prague maneuver

• used when fetal back is posterior.

• With one hand operator catches the shoulders of the baby and with other hand lifts the baby up.

Hyperextension of the fetal head

• Etiology-• spasm or congenital

shortening of the extensor muscles of the neck.

• Cord round the neck.• Uterine anomalies.• Fetal malformations.• Tumors in the

placeental site

Hyperextension of the fetal head

• Diagnosis is by X-ray, ultra sound.• Star gazing breech. • Dangers • Excessive stretching of the spinal

cord.• Epidural hemorrhage.• Dislocation or fracture of the

vertebrae.

Failure of descent of the breech

• In spite of good uterine contractions if there is no proper descent disproportion should be suspected.

• In this case• cesarean section should be performed.• Decomposition can be done.(Decomposition is

reducing the bulk of the breech.)• In case of frank breech Pinard’s maneuver should

be carried out.

Impacted breech

• Occurs when the breech is extended.• May occur at the brim, cavity, or the outlet.• The most common cause is disproportion

between the size of the breech and the pelvis.

• If the impaction is at the cavity or at higher level delivery is by cesarean section.

• Impaction at the outlet is dealt by episiotomy and traction with a finger in the groin.

Breech extraction

• Immediate vaginal extraction of the baby when signs of fetal distress demand delivery with out delay.

• Prerequisites• Adequate pelvis• Cervix must be fully dilated.• Bladder and rectum should be empty.• Expert and deep anesthesia

Breech extraction• Procedure –• Lithotomy position• Under anesthesia• The feet are pulled down if

the breech is complete.• The Pinard’s maneuver is

used if the breech is frank.• The baby is extracted

rapidly.• It should be carried out

only in situations where cesarean section can not be performed quickly.

summary of management

Thank you for

your attention

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