Malpresentation and Malposition- Breech

Occipito posterior position

Complete breech Introduction

A fetus is said to be in a breech presentation when the buttocks of the baby are presenting first at the bottom of the uterus, and the head is in the upper part, or fundus of the uterus.

A breech birth is the birth of a baby from a breech presentation. In the breech presentation the baby enters the birth canal with the buttocks or feet first as opposed to the normal head first presentation.

A malpresentation of the FETUS at near term or during OBSTETRIC LABOR with the fetal cephalic pole in the fundus of the UTERUS.

BREECH PRESENTATION occurs when the buttocks and/or the feet are the presenting parts.

Usually a few weeks before birth, most babies will move into delivery position, with their head moving near the birth canal. If this does not happen, the baby's buttocks and/or feet will be in place to be delivered first. This is called a breech presentation.

Incidence of breech presentation

Breech presentation occurs in 3-4% of all deliveries. The percentage of breech deliveries decreases with advancing gestational age.

1. Gestational age 21 to 24 weeks: 33% breech

2. Gestational age 25 to 28 weeks: 28% breech

3. Gestational age 29 to 32 weeks: 14% breech

4. Gestational age 33 to 36 weeks: 9% breech

5. Gestational age 37 to 40 weeks: 7% breech

Risk Factors

6. Prematurity

7. Multiple pregnancies

8. Polyhydramnios or oligohydramnios

9. Uterine abnormalities

10. Fetal abnromalities (e.g. hydrocephaly, anencephaly, Down Syndrome and other congenital abnormalities)

11. Macrosomia

12. Twin Gestation

Causes

Certain factors can encourage a breech presentation. Prematurity is likely the chief cause. Twenty five percent of fetuses are in the breech position at 32 weeks gestation; this drops to three percent at term. The increasing size of the fetus near term traps the fetus into the head down position normally. Pregnancies ending in preterm birthsimply recruit more breeches before they can turn to head down.

There is no such conform causes of breech presentation. But the following circumstances favour breech presentation.

In subsequent pregnancies(Due to lack of tone in uterus)

In multiples pregnancies

When there is history of premature delivery

In an abnormal shaped uterus or a uterus with abnormal growths, such as fibroids.

Contracted pelvis

For women with placenta previa

Polyhydramnious/ oligohydramnious

Hydrocephaly

Relative or absculate short cord

Types of breeches

There are four main categories of breech births:

Complete breech (10-15%) ( Hips flexed, knees flexed (cannonball position).)

The baby's hips and knees are flexed so that the baby is sitting crosslegged, with feet beside the bottom. The presenting part consists of two buttocks, external genitalia and two feet. It is commonly present in multiparae.

Frank breech (Breech with extended legs) The breech presents with the hips flexed and legs extended on the abdomen (with feet near the ears). 65-70% of breech babies are in the frank breech position. . The frank breech presentation is the most common and the safest position for a baby to be in if a vaginal delivery is to be attempted.

Footling breech (35-45%) ( One or both hips extended, foot presenting.)

One or both feet come first, with the bottom at a higher position. This is rare at term but relatively common with premature fetuses.

Kneeling breech - the baby is in a kneeling position, with one or both legs extended at the hips and flexed at the knees. This is extremely rare.

(Incomplete: This is due to varying degrees of extension of thighs or legs at the podalic pole eg Frank breech, Footling breech, Kneeling breech.)

Diagnosis During antenatal period

A few weeks prior to the due date, the health care provider may place his/her hands on the mother's lower abdomen to locate the baby's head, back, and buttocks. If they think the baby is in a breech position, an ultrasound may be used to confirm. Special x-rays can also determine the baby's position and measure the pelvis to determine if a vaginal delivery of a breech baby may be attempted.

On abdominal palpation

Longitudinal Fetal Lie

Firm lower pole

Limbs to one side

Hard head at uterine fundus. Head may be obscured by maternal ribs

Auscultation

Breech Fetal heart best heard above Umbilicus

Diagnosis During labour

On abdominal examination, the head is felt in the upper abdomen and the breech in the pelvic brim.

Auscultation locates the fetal heart higher than expected with a vertex presentation. Breech Fetal heart best heard above Umbilicus

On vaginal examination

Thick, dark meconium is normal.

No hard head palpated in pelvis

Fontanels and Sutures not palpable

Soft buttocks palpated with hard irregular sacrum

Feet may be presenting part in pelvis

Complete breech

Frank breech

Per abdomen

Fundal grip

Head suggested by hard and globular mass

Head is ballotable

Irregular small part of the feet may be felt by the side of the head.

Head is non ballotable due to splinting action of the legs on the trunk

Lateral grip

Fetal back is to one side and the irregular limbs to the other

Irregular parts are less felt on the side.

Pelvic grip

Breech suggested by soft, broad and irregular mass.

Breech is usually not engaged during pregnancy.

Small hard and conical mass is felt

The breech is usually engaged.

F.H.S.

Usually located at a higher level round about the umbilicus.

Located at a lower level in the middle due to early engagement of the breech.

Per vaginam

Palpation of ischial tuberosities, sacrum and feet by the sides of the buttocks.

Palpation of ischial tuberosities, anal opening and sacrum only.

Management

During antenatal Period:

Evaluate for cause in all breech presentation

Consider postural Exercises for patient

Technique 1: Knee chest

Knee-chest position for 15 minutes

Repeat 3 times daily for 5 days

Consider pelvic rocking while performing

Technique 2: Deep trendelenburg position

Patient supine with hips elevated 9-12 inches

Perform 10 minute, once to twice daily

Consider pelvic rocking while performing

Identification of the complicating factors related with breech presentation

External cephalic version, if not contraindicated

Formulation of the line of management, if the version fails or is contraindicated. The pregnancy is to be continued with usual check up.Two methods of delivery can be planned.

To perform an elective CS.

To allow spontaneous labour to start and vaginal delivery to occur.

Management during labour

Footling or Incomplete Breech

-Cesarean Section

Frank or Complete Breech

-Attempt External Cephalic Version if:

breech presentation is present at or after 37 weeks (before 37 weeks, a successful version is more likely to spontaneously revert back to breech presentation);

vaginal delivery is possible;

membranes are intact and amniotic fluid is adequate;

There are no complications (e.g. fetal growth restriction, uterine bleeding, previous caesarean delivery, fetal abnormalities, twin pregnancy, hypertension, fetal death).

-If external version is successful, proceed with normal childbirth

-If external version fails proceed with vaginal breech delivery (see below) or caesarean section.

Complete Breech with foot protruding through cervix

Dangerous! (Very high risk)

Emergent Cesarean section

VAGINAL BREECH DELIVERY

Three types of vaginal breech deliveries are described, as follows:

Spontaneous breech delivery: No traction or manipulation of the infant is used. This occurs predominantly in very preterm deliveries.

Assisted breech delivery: This is the most common type of vaginal breech delivery. The infant is allowed to spontaneously deliver up to the umbilicus, and then maneuvers are initiated to assist in the delivery of the remainder of the body, arms, and head.

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 singleton fetuses because the cervix may not be adequately dilated to allow passage of the fetal head. If the feet prolapse through the vagina, treat expectantly as long as the fetal heart rate is stable to allow the cervix to completely dilate around the breech. Total breech extraction for the singleton breech is associated with a birth injury rate of 25% and a mortality rate of approximately 10%.

Ideally, every breech delivery should take place in a hospital with surgical capability.

A vaginal breech delivery by a skilled health care provider is safe and A vaginal delivery may be attempted for a baby in the breech position if:

The baby is in a frank breech position its hips are bent and its legs extend up.

Fetus is not too large or the baby is small enough (usually under 8 pounds) to pass easily through the vagina.

Adequate clinical pelvimetry

The pregnant woman has no previous caesarean section for cephalopelvic disproportion and no obstetrical problems, such as placenta previa, that might complicate the delivery.

The pregnant woman's pelvis is a normal or above average size.

The baby has already descended well into the pelvis as labor begins.

The baby's head is tucked down toward its chest - not extended.

Examine the woman regularly and record progress on a partograp.

If the membranes rupture, examine the woman immediately to exclude cord prolapse.

Note: Do not rupture the membranes.

If the cord prolapses and delivery is not imminent, deliver by caesarean section.

If there are fetal heart rate abnormalities (less than 100 or more than 180 beats per minute) or prolonged labour, deliver by caesarean section.

Note: Meconium is common with breech labour and is not a sign of fetal distress if the fetal heart rate is normal.

The woman should not push until the cervix is fully dilated. Full dilatation should be confirmed by vaginal examination.

CAESAREAN SECTION FOR BREECH PRESENTATION

A caesarean section is safer than vaginal breech delivery and recommended in cases of:

Double footling breech;

Small or malformed pelvis;

Very large fetus;

Previous caesarean section for cephalopelvic disproportion;

Abnormal uterine contraction

Maternal and fetal distress

Hyper extended or deflexed head.

Note: Elective caesarean section does not improve the outcome in preterm breech delivery.

COMPLICATIONS

Mother

Rupture of uterus may occur during version.

Prolonged labour

Premature Rupture of Membranes

Obstructed labour due to impacted breech.

Cord prolapse may occur, particularly in the complete, footling, or kneeling breech. This is caused by the lowermost parts of the baby not completely filling the space of the dilated cervix.

Traumatic post partum haemorrhage

Baby

Lower Apgar scores, especially at 1 minute, are more common with vaginal breech deliveries.

Oxygen deprivation may occur from either cord prolapse or prolonged compression of the cord during birth, as in head entrapment

Injury to the brain and skull may occur due to the rapid passage of the baby's head through the mother's pelvis.

Birth trauma as a result of extended arm or head, incomplete dilatation of the cervix or cephalopelvic disproportion.

Broken neck.

Edematous external genitalia in male.

.

Technique and tips for assisted vaginal breech delivery

Leave the fetal membranes intact as long as possible to act as a dilating wedge and to prevent overt cord prolapse.

Oxytocin induction and augmentation are controversial. In many previous studies, oxytocin was used for induction and augmentation, especially for hypotonic uterine dysfunction. However, others are concerned that nonphysiologic forceful contractions could result in an incompletely dilated cervix and an entrapped head.

An anesthesiologist and pediatrician should be present for all vaginal breech deliveries. A pediatrician is needed because of the higher prevalence of neonatal depression and the increased risk for unrecognized fetal anomalies. An anesthesiologist may be needed if intrapartum complications develop and the patient requires general anesthesia.

Perform an episiotomy when the breech delivery is imminent. This is advocated by many authors for all breech deliveries, even in multiparas, to prevent soft tissue dystocia (see Images 2-3).

The Pinard maneuver may be needed with a frank breech to facilitate delivery of the legs, only after the fetal umbilicus has been reached. Pressure is exerted against the inner aspect of the knee. Flexion of the knee follows, and the lower leg is swept medially and out of the vagina. No traction should be exerted on the infant until the fetal umbilicus is past the perineum, after which time maternal expulsive efforts should be used along with gentle downward and outward traction of the infant until the scapula and axilla are visible (see Image 4).

Use a dry towel to wrap around the hips (not the abdomen) to help with gentle traction of the infant (see Image 5). An assistant should exert transfundal pressure from above to keep the fetal head flexed.

Once the scapula is visible, rotate the infant 90 and gently sweep the anterior arm out of the vagina by pressing on the inner aspect of the elbow (see Images 6-7). Rotate the infant 180 in the reverse direction, and sweep the other arm out of the vagina. Once the arms are delivered, rotate the infant back 90 so that the back is anterior (see Image 8).

The fetal head should be maintained in a flexed position during delivery to allow passage of the smallest diameter of the head. The flexed position can be accomplished by using the Mauriceau Smellie Veit maneuver, in which the operator's index and middle fingers lift up on the fetal maxillary prominences, while the assistant applies suprapubic pressure (see Image 9).

Alternatively, Piper forceps can be used to maintain the head in a flexed position (see Image 10). In many early studies, routine use of Piper forceps was recommended to protect the head and to minimize traction on the fetal neck. Piper forceps are specialized forceps that are placed from below the infant and, unlike conventional forceps, are not tailored to the position of the fetal head (ie, pelvic, not cephalic, application). The forceps are applied while the assistant supports the fetal body in a horizontal plane.

During delivery of the head, avoid extreme elevation of the body, which may result in hyperextension of the cervical spine and potential neurologic injury (see Images 12-13).

(Enlarge Image)

Media file 1: Footling breech presentation. Once the feet have delivered, one may be tempted to pull on the feet. However, a singleton gestation should not be pulled by the feet because this action may precipitate head entrapment in an incompletely dilated cervix or may precipitate nuchal arms. As long as the fetal heart rate is stable and no physical evidence of a prolapsed cord is evident, management may be expectant while awaiting full cervical dilation.

[ CLOSE WINDOW ]

Footling breech presentation. Once the feet have delivered, one may be tempted to pull on the feet. However, a singleton gestation should not be pulled by the feet because this action may precipitate head entrapment in an incompletely dilated cervix or may precipitate nuchal arms. As long as the fetal heart rate is stable and no physical evidence of a prolapsed cord is evident, management may be expectant while awaiting full cervical dilation.

(Enlarge Image)

Media file 2: Assisted vaginal breech delivery. Thick meconium passage is common as the breech is squeezed through the birth canal. This is usually not associated with meconium aspiration because the meconium passes out of the vagina and does not mix with the amniotic fluid.

[ CLOSE WINDOW ]

Assisted vaginal breech delivery. Thick meconium passage is common as the breech is squeezed through the birth canal. This is usually not associated with meconium aspiration because the meconium passes out of the vagina and does not mix with the amniotic fluid.

(Enlarge Image)

Media file 3: Assisted vaginal breech delivery. The Ritgen maneuver is applied to take pressure off the perineum during vaginal delivery. Episiotomies are often performed for assisted vaginal breech deliveries, even in multiparous women, to prevent soft tissue dystocia.

[ CLOSE WINDOW ]

Assisted vaginal breech delivery. The Ritgen maneuver is applied to take pressure off the perineum during vaginal delivery. Episiotomies are often performed for assisted vaginal breech deliveries, even in multiparous women, to prevent soft tissue dystocia.

(Enlarge Image)

Media file 4: Assisted vaginal breech delivery. No downward or outward traction is applied to the fetus until the umbilicus has been reached.

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Assisted vaginal breech delivery. No downward or outward traction is applied to the fetus until the umbilicus has been reached.

(Enlarge Image)

Media file 5: Assisted vaginal breech delivery. With a towel wrapped around the fetal hips, gentle downward and outward traction is applied in conjunction with maternal expulsive efforts until the scapula is reached. An assistant should be applying gentle fundal pressure to keep the fetal head flexed.

[ CLOSE WINDOW ]

Assisted vaginal breech delivery. With a towel wrapped around the fetal hips, gentle downward and outward traction is applied in conjunction with maternal expulsive efforts until the scapula is reached. An assistant should be applying gentle fundal pressure to keep the fetal head flexed.

(Enlarge Image)

Media file 6: Assisted vaginal breech delivery. After the scapula is reached, the fetus should be rotated 90 in order to deliver the anterior arm.

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Assisted vaginal breech delivery. After the scapula is reached, the fetus should be rotated 90 in order to deliver the anterior arm.

(Enlarge Image)

Media file 7: Assisted vaginal breech delivery. The anterior arm is followed to the elbow, and the arm is swept out of the vagina.

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Assisted vaginal breech delivery. The anterior arm is followed to the elbow, and the arm is swept out of the vagina.

(Enlarge Image)

Media file 8: Assisted vaginal breech delivery. The fetus is rotated 180, and the contralateral arm is delivered in a similar manner as the first. The infant is then rotated 90 to the backup position in preparation for delivery of the head.

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Assisted vaginal breech delivery. The fetus is rotated 180, and the contralateral arm is delivered in a similar manner as the first. The infant is then rotated 90 to the backup position in preparation for delivery of the head.

(Enlarge Image)

Media file 9: Assisted vaginal breech delivery. The fetal head is maintained in a flexed position by using the Mauriceau maneuver, which is performed by placing the index and middle fingers over the maxillary prominence on either side of the nose. The fetal body is supported in a neutral position, with care to not overextend the neck.

[ CLOSE WINDOW ]

Assisted vaginal breech delivery. The fetal head is maintained in a flexed position by using the Mauriceau maneuver, which is performed by placing the index and middle fingers over the maxillary prominence on either side of the nose. The fetal body is supported in a neutral position, with care to not overextend the neck.

(Enlarge Image)

Media file 10: Piper forceps application. Piper forceps are specialized forceps used only for the after-coming head of a breech presentation. They are used to keep the fetal head flexed during extraction of the head. An assistant is needed to hold the infant while the operator gets on one knee to apply the forceps from below.

[ CLOSE WINDOW ]

Piper forceps application. Piper forceps are specialized forceps used only for the after-coming head of a breech presentation. They are used to keep the fetal head flexed during extraction of the head. An assistant is needed to hold the infant while the operator gets on one knee to apply the forceps from below.

(Enlarge Image)

Media file 11: Assisted vaginal breech delivery. Low 1-minute Apgar scores are not uncommon after a vaginal breech delivery. A pediatrician should be present for the delivery in the event that neonatal resuscitation is needed.

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Assisted vaginal breech delivery. Low 1-minute Apgar scores are not uncommon after a vaginal breech delivery. A pediatrician should be present for the delivery in the event that neonatal resuscitation is needed.

Media file 12: Assisted vaginal breech delivery. The

2. Management

Conclusions

Vaginal breech delivery requires an experienced obstetrician and careful counseling for the parent(s). Although studies on the delivery of the preterm breech are limited, the recent multicenter term breech trial found an increased rate of perinatal mortality and serious immediate perinatal morbidity.

Parents must be informed about potential risks and benefits to the mother and neonate for both vaginal breech delivery and cesarean delivery. The likelihood is high that the trend will continue toward 100% cesarean delivery for term breeches and that vaginal breech deliveries will no longer be performed.

ECV is a safe alternative to vaginal breech delivery or cesarean delivery, reducing the cesarean delivery rate for breech by 50%. The ACOG, in its 2000 Practice Bulletin, recommends offering ECV to all women with a breech fetus near term. Consider adjuncts such as tocolysis, regional anesthesia, and acoustic stimulation to improve ECV success rates. Before performing a delivery or ECV on a mother whose fetus is in a breech presentation, assess for any underlying fetal abnormalities or uterine conditions that may result in a malpresentation.