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BREECH PRESENTATION

 

Definition:

It is a longitudinal lie in which the buttocks is the presenting part with or without the lower limbs.

Incidence:

3.5% of term singleton deliveries and about 25% of cases before 30 weeks of gestation as most cases undergo spontaneous cephalic version up to term.

Etiology:

In general, the fetus is adapted to the pyriform shape of the uterus with the larger buttock in the fundus and smaller head in the lower uterine segment.

Any factor that interferes with this adaptation, allows free mobility or prevents spontaneous version, can be considered a cause for breech presentation as :

1- Prematurity : due to

- relatively small fetal size,

- relatively excess amniotic fluid, and

- more globular shape of the uterus.

2- Multiple pregnancy: one or both will present by the breech to adapt with the relatively small room.

3- Poly-and oligohydramnios. 4-Hydrocephalus.

5- Intrauterine fetal death. 6-Bicornuate and septate uterus.

7- Uterine and pelvic tumors. 8-Placenta praevia.

Types:

(A) Complete breech:

- The feet present beside the buttocks as both knees and hips are flexed.

- More common in multipara.

(B) Incomplete breech:

(1) Frank breech:

- It is breech with extended legs where the knees are extended while the hips are flexed.

- More common in primigravida.

(2) Footling presentation:

- The hip and knee joints are extended on one or both sides.

- More common in preterm singleton breeches.

(3) Knee presentation:

The hip is partially extended and the knee is flexed on one or both sides.

Positions : ( 8 positions)

1- Left sacro- anterior.           

2- Right sacro-anterior.

3- Right sacro - posterior.           

4- Left sacro-posterior.

In addition to

5,6- left and right sacro - transverse (lateral).

7,8 - Direct sacro- anterior and posterior.

Sacro-anterior positions are more common than sacro-posterior as in the first the concavity of the fetal front fits into the convexity of the maternal spines.

Diagnosis:

(A) During pregnancy:

(I) Inspection:

1.     A transverse groove may be seen above the umbilicus in sacro-anterior corresponds to the neck.

2.     If the patient is thin , the head may be seen as a localized bulge in one hypochondrium.

(II) Palpation:

1.     Fundal grip: the head is felt as a smooth, hard, round ballottable mass which is often tender.

2.     Umbilical grip: the back is identified and a depression corresponds to the neck may be felt.

3.     First pelvic grip: the breech is felt as a smooth, soft mass continuous with the back. Trial to do ballottement to the breech shows that the movement is transmitted to the whole trunk.

(III) Auscultation:

FHS is heard above the level of the umbilicus. However in frank breech it may be heard at or below the level of the umbilicus.

(IV) Ultrasonography:

It is used for the following:

1.     To confirm the diagnosis.

2.     To detect the type of breech.

3.     To detect gestational age and fetal weight; different measures can be taken to determine the fetal weight as the biparietal diameter with chest or abdominal circumference using a special equation.

4.     To exclude hyperextension of the head.

5.     To exclude congenital anomalies.

6.     Diagnosis of unsuspected twins.

(B) During Labor:

In addition to the previous findings, vaginal examination reveals;

1.     The 3 bony landmarks of breech namely 2 ischial tuberosities and tip of the sacrum.

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

3.     Fresh Meconium may be found on the examining fingers.

4.     Male genitalia may be felt.

Mechanism of Labor:

Delivery of the buttocks:

- The engagement diameter is the bitrochanteric diameter 10 cm which enters the pelvis in one of the oblique diameters.

- The anterior buttock meets the pelvic floor first so it rotates 1/8 circle anteriorly.

- The anterior buttock hinges below the symphysis and the posterior buttock is delivered first by lateral flexion of the spines followed by the anterior buttock.

- External rotation occurs so that the sacrum comes anteriorly.

Delivery of the shoulders:

- The shoulders enter the same oblique diameter with the biacromial diameter 12 cm (between the acromial processes of the scapulae).

- The anterior shoulder meets the pelvic floor first, rotates 1/8 circle anteriorly, hinges under the symphysis , then the posterior shoulder is delivered first followed by the anterior shoulder.

 

Delivery of the after-coming head:

- The head enters the pelvis in the opposite oblique diameter.

- The occiput rotates 1/8 circle anteriorly, in case of sacro- anterior position and 3/8 circle anteriorly in case of sacro- posterior position.

- Rarely, the occiput rotates posteriorly and this should be prevented by the obstetrician.

N.B.

The head is delivered by movement of flexion in:

1.     Direct occipito-posterior (face to pubis).

2.     Face mento-anterior.

3.     The aftercoming head in breech presentation.

The head is delivered by extension in normal labor only i.e. occipito - anterior positions.

Management of Breech Presentation

(I) External Cephalic Version:

It regains its importance after increased rate of caesarean sections nowadays.

Timing:

After the 32nd weeks up to the 37th week and some authors extend it to the early labor as long as the membranes are intact and there is no contraindications.

Version is not done earlier because:

1.     Spontaneous version is liable to occur.

2.     Return to breech presentation is liable to occur.

3.     If labor occurs the fetus will have a lesser chance for survival.

Version is difficult after 37th. Weeks due to :

1.     Larger fetal size.

2.     Relatively less liquor.

3.     More irritability of the uterus.

The aim :

1.     To detect cephalo-pelvic disproportion.

2.     Cephalic delivery is safer for the mother and fetus.

Success rate:

50-70%.

Causes of failure:

1- Large sized fetus.

2- Oligo - or polyhydramnios. 

3- Short umbilical cord.

4- Uterine anomalies as bicornuate or septate uterus.

5- Irritable uterus. Tocolytic drugs may be started 15 minutes before the procedure to overcome this.

6- Obesity.

7- Rigid abdominal wall.  

8- Frank breech because the legs act as a splint.

Contraindications:

1- Contracted pelvis.

2- Multiple pregnancy.    

3- Hydrocephalus.

4- Antepartum hemorrhage.   

5- Uterine scar.

6- Hypertension as the placenta is more susceptible to separation.

7- Elderly primigravida.

8- Ruptured membranes.

9-Anaesthesia during version is contraindicated as pain is a safeguard against rough manipulations.

Complications:

1- Accidental hemorrhage due to separation of the placenta.

2- Rupture of membranes .       

3- Preterm labor.  

4- Fetal distress.

5- Cord presentation or prolapse.    

6- Entangling of the cord around the fetus.

7- Isoimmunization in Rh-negative mothers due to feto - maternal transfusion.

(II) Caesarean Section:

Indications:

1.     Large fetus i.e. > 3.75 kg estimated by ultrasound.

2.     Preterm fetus but estimated weight is still more than 1.25 kg.

3.     Footling or complete breech :as the presenting irregular part is not well fitting with the lower uterine segment leading to;

- Less reflex stimulation of uterine contractions.

- Susceptibility to cord prolapse.

- Early bearing down as the foot passes through partially dilated cervix and reaches the perineum.

  4. Hyper extended head: diagnosed by ultrasound or X-ray.

  5. Contracted pelvis: of any degree.

  6. Uterine dysfunction.

  7. Complicated pregnancy with:

- Hypertension.

- Diabetes mellitus.       

- Placenta praevia.

- Pre - labor rupture of membranes for 12 hours.

- Post-term.

- Intrauterine growth retardation.

- Placental insufficiency.

8. Primigravida: breech in primigravida equals caesarean section in opinion of most obstetricians as the maternal passages were not tested for delivery before.

(III) Vaginal Delivery:

Prerequisites:

1.     Frank breech.

2.     Estimated fetal weight not more than 3.75 kg.

3.     Gestational age : 36-42 weeks.

4.     Flexed head.

5.     Adequate pelvis.

6.     Normal progress of labor by using the partogram.

7.     Uncomplicated pregnancy.

8.     Multipara.

9.     An experienced obstetrician.

10. . In case of intrauterine fetal death.

N.B.

During vaginal delivery, premature are more susceptible to:

- hypoxia,

- trauma, and

- retained after-coming head as the partially dilated cervix allows the passage of the body but the less compressible relatively larger head will be retained.

However, caesarean section should only be done if the premature fetus has a reasonable chance of post - natal survival.

Management of Vaginal Breech Delivery:

First stage: as other malpresentations.

Second stage: The fetus may be delivered by one of the following methods:

(I) Spontaneous breech delivery:

This is rarely occurs in multipara with adequate pelvis, strong uterine contractions and small sized baby. The baby is delivered spontaneously without any assistance but perineal lacerations may occur.

(II) Assisted breech delivery:

- This is the method of delivery in far majority of cases.

- The assistance is indicated for delivery of the shoulders and after-coming head and the infant is allowed to be delivered up to the umbilicus spontaneously.

(1) Delivery of the buttocks:

- The golden rule is to "Keep your hands off".

- The patient is asked to bear down during uterine contractions and relax in between until the perineum is distended by the buttocks.

- An episiotomy is done especially in primigravida to avoid much lateral flexion of the spines, perineal lacerations and intracranial hemorrhage due to sudden compression and decompression of the after - coming head.

- The legs are hooked out but without traction.

- When the umbilicus appears, a loop of the cord is hooked to prevent traction or compression of the cord and detect its pulsation.

- The fetus is covered with warm towel to prevent premature stimulation of respiration.

(2) Delivery of the shoulders:

- Gentle steady downward traction is applied to the fetal pelvic girdle during uterine contractions with gradual rotation of the fetus to bring the shoulders in the antero-posterior diameter of the pelvis.

- When the anterior scapula appears below the symphysis, both arms are delivered by hooking the index finger at the elbow and sweep the forearm across the chest of the fetus

- The back is rotated anteriorly.

- Kristeller maneuvers: gentle Fundal pressure is done during uterine contractions to guide the head into the pelvis and maintain its flexion.

(3) Delivery of the after -coming head:

It is delivered by one of the following methods:

(a) Jaw flexion- shoulder traction (Mauriceau- Smellie -viet) method:

- Two fingers of the left hand, (as originally described) or better on the malar eminencies (the maxillae) to avoid dislocation of the jaw.

- The index and ring finger of the right hand are placed on each shoulder while the middle finger is pressing against the occiput to promote flexion and act as a splint for the neck , preventing hyperextension and hence cervical spine injury.

- Traction is commenced downwards and backwards till the nape of the fetus appears, the body is lifted towards the motherís abdomen.

(b) Burns - Marshallís method:

The fetus is left hanging so that its weight exerts gentle downwards and backwards traction. When the nape appears, grasp the feet and left the body towards the motherís abdomen.

(C) Forceps:

- Piperís forceps is more suitable than the ordinary forceps as it has a perineal but not pelvic curve and has longer shanks. It is applied from the ventral aspect of the fetus.

- Traction is applied downwards and backwards till the nape appears, then downwards and forwards to deliver the head by flexion.

- Forceps delivery has the following advantages:

1.     It promotes flexion of the head.

2.     Traction is applied on the head and not on the neck.

3.     It prevents sudden compression and decompression of the head.

4.     It protects the head from compression by pelvic bones or rigid perineum.

(III) Breech extraction:

Indications:

1.     Maternal or fetal distress.

2.     Prolonged second stage.

3.     To shorten the second stage in maternal respiratory and heart diseases.

4.     Prolapsed pulsating cord with fully dilated cervix.

Technique:

Like assisted breech delivery except that:-

i) It is done under general anesthesia.

ii) Both legs are bringing down.

iii) Traction on the legs is done helped by Fundal pressure to deliver the breech and the trunk.

iv) The after - coming head is delivered by jaw flexion - shoulder traction or forceps.

Complicated Breech Delivery

(I) Arrest of the buttocks at the pelvic brim:

 

Causes

Management

1-Inefficient uterine contractions.

Oxytocin drip, if contraindicated do caesarean section.

Breech extraction - if cervix is fully dilated.

2- Contracted pelvis.

Caesarean section.

3- Large - sized baby.

Caesarean section.

(II) Arrest of the buttocks at the pelvic outlet

Causes

Management

1- Inefficient uterine contractions.

Breech extraction.

2- Contracted outlet.

Caesarean section.

3- Rigid perineum.

Episiotomy.

4- Extended legs ( frank breech).

Breech deeply impacted : Groin traction.

Breech not deeply impacted : Bring down a leg+ breech extraction. If the outlet is contracted or the baby is large do C.S.

Groin traction:

a- Living fetus:

- Traction is done by the index or the index and middle fingers put in the anterior groin in a downward and backward direction.

- The traction is done towards the trunk to avoid dislocation of the femur.

- Traction is done during uterine contractions and aided by Fundal pressure.

- When the posterior buttock appears traction is done by the 2 index fingers in both groins in a downward and forward direction.

b- Dead fetus:

Groin traction is done by breech hook.

Bringing down a leg (Pinardís method):

- Under general anesthesia.

- Press by 2 fingers in the popliteal fossa of the anterior leg to flex it then grasp the ankle and bring it down. This will prevent the anterior buttock from over-riding the symphysis pubis.

- If the posterior leg was brought down first it must be rotated anteriorly with the trunk then bring the other leg which is now becomes posterior.

N.B. The foot has the following features differentiating it from the hand:

1-Presence of the heel.

2- Absence of the mobile thumb.

3- The toes are shorter than the fingers.

(III) Arrest of the shoulders:

Causes

Management

Extension of the arms: due to traction on the breech before full dilatation of the cervix.

The shoulders are delivered by:

-Classical method or

-Lövsetís method.

Nuchal position of the arm: The forearm is displaced behind the neck due to rotation of the trunk in a wrong direction.

Rotation of the foetal trunk in the direction of the finger tips of the displaced arm.

Classical method:

- Under epidural or general anesthesia.

- As there is more space posteriorly, bring down the posterior arm first by using 2 fingers pressing against the cubital fossa and sweep the arm in front of the fetal body to avoid fracture humerus.

- The anterior arm is then brought down by the same maneuver. If this is difficult rotate the body180o to make the anterior arm posterior and bring it down.

Lövset method:

- Under epidural or general anesthesia.

- Gentle downward and backward traction is applied to the fetus by grasping its pelvis till the inferior angle of the anterior scapula appears; the fetal trunk is rotated 180o to bring the posterior shoulder anteriorly emerging beneath the symphysis pubis. So the arm can be brought down.

- The trunk is again rotated 180o in the opposite direction to bring the other shoulder anteriorly emerging beneath the symphysis so the second arm can be brought down.

- The back should be kept always anterior during rotation.

(IV) Arrest of the after - coming head:

Causes

Management

(A) Faults in the head:

1- Large head.

Living fetus : Symphysiotomy.

Dead fetus : Craniotomy.

2- Hydrocephalus.

Craniotomy.

3- Extended head.

Jaw flexion - shoulder traction.

4- Posterior rotation of the occiput.

Jaw flexion - shoulder traction till the sinciput hinges below the symphysis then deliver the head by flexion. If the head is extended do Prague maneuver.

(B) Faults in passages:

1- Contracted pelvis.

Living fetus : Symphysiotomy.

Dead fetus : Craniotomy.

2- Rigid perineum.

Episiotomy + forceps delivery.

3- Incompletely dilated cervix.

DŁhrssen cervical incisions especially if the fetus is living : 2 incisions of 1-2 cm are made with scissors at 2 and 10 oíclock then sutured after delivery. A third incision at 6 oíclock may be needed.

Prague maneuver:

- When the occiput rotates posteriorly and the head extends, the chin hangs above the symphysis pubis.

- Fetus is grasped from its feet and flexed towards the motherís abdomen, while the other hand is doing simultaneous traction on the shoulders to deliver the head by flexion.

Complications of Breech Delivery:

(A) Maternal:

1.     Prolonged labor with maternal distress.

2.     Obstructed labor with its squeal may occur as in impacted breech with extended legs.

3.     Laceration especially perineal.

4.     Postpartum hemorrhage due to prolonged labor and lacerations.

5.     Puerperal sepsis.

(B) Fetal:

(I) Fetal mortality :

Is about 4% in multipara and 8% in primigravida which may be due to:

1. Intracranial hemorrhage : is the commonest cause of death due to sudden compression and decompression of the head as there is no gradual moulding of the head.

This can be avoided by:

a) Forceps delivery of the after -coming head.

b) Episiotomy.

c) Slow delivery of the head.

d) Vitamin K to the mother early in labor.

2. Fracture dislocation of the cervical spines prevented by avoiding lifting the body towards the motherís abdomen until the nape appears below the symphysis.

3. Asphyxia due to:

i- Cord prolapse or compression by the head.

ii- Premature stimulation of respiration leading to inhalation of mucus, liquor or blood. This can be avoided by covering the body of the fetus with warm towels during delivery.

4. Rupture of an abdominal organ : from rough manipulations avoided by grasping the fetus from its hips only.

(II) Non-fatal injuries:

1.     Fracture femur, humerus or clavicle.

2.     Dislocation of joints or lower jaw.

3.     Injury to the external genitalia.

4.     Brachial plexus injury.

5.      Lacerations to the sternomastoid muscles.

 

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 dec.2005

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