Breech Presentation

Breech Presentation

Presentation is said to be breech when the buttocks occupy the lower pole of the uterus.

It is the commonest type of all mal-presentations. During the first trimester the fetus usually presents mainly by breech. As pregnancy advances spontaneous version occurs:

At 20weeks                                40% are breech

At 28weeks                                15% are breech

At 34weeks                                6% are breech

At 40weeks                                3% are breech

Mostly by 34^th week over ¾ of the baby who previously presented by the breech have undergone spontaneous cephalic version in singleton.

Breech is most common in premature births and multiple pregnancies. Common causes of dystocia and a major cause for caesarean section.

Positions of Breech

i.                  Left Sacro-Anterior ; LSA

ii.                  Right Sacro-Anterior;  RSA

iii.                  Left Sacro-Posterior  ;LSP

iv.                  Right Sacro-Posterior ; RSP

v.                  Left Sacro-Lateral ; LSL

vi.                  Right Sacro-Lateral ; RSL

Various types

1. Complete or full Breech

In this type the fetus lies in attitude of complete flexion, the thighs and legs are both flexed and the head is well flexed on the chest.

The presenting part is therefore bulky consisting of buttocks external genitalia and both feet.

Incomplete Breech

2. Franck Breech/extended Breech

In this type the breech presents with the thighs flexed and the legs extended on the fetal abdomen - common type (70%)

3. Footling Breech Rare; 25% of breech

In this type both legs or one leg is fully extended at the knee but partially extended at hip

4. Knee presentation

The knee is flexed while the thigh is extended at the hip. In frank Breech the buttocks fit the cervix accurately and cord prolapse is uncommon, but may not in other types. The hands may be extended above the head during labour

Causes

·              mostly unknown

·              conditions that favour Breech presentation include

i.                  contracted (brim) pelvis

ii.                  placenta praevia

iii.                  pelvic tumors – fibroids

iv.                  grand multiparity , polyhydramnios

v.                  abnormal  uterus – bicornate uterus

Fetal causes

i.                  prematurity

ii.                  fetal abnormalities – anencephaly and hydrocephaly

iii.                  multiple pregnancy –twins

iv.                  intrauterine death.

Diagnosis

It is very important to diagnose Breech pregnancy before 34 weeks so that version may be attempted between 32 and 36 weeks. But 25% are not detected until during vaginal examination in labour

In pregnancy:

On inspection:

The abdomen looks normal except in Frank breech when the abdomen looks long and narrow

On Palpitation

The breech is felt as soft irregular mass in the lower pole of the uterus – better detected by policks’ grip, while th e head is felt as hard ballotable mass in the fundus. But when the legs are extended the head is less mobile.

On Auscultation

The fetal heart sound is usually heard above the umbilicus or at the level if the buttocks are engaged

In cases of doubt X-ray of abdomen or ultrasound scan may be done

In Labor

On vaginal examination

Soft irregular mass is felt. The external genitalia, the ischial tuberosities , the sacrum and the coccyx may also be felt.

The anterior buttocks are felt 1^st and separated from that of posterior by genital organs.

The absence of legs and feet will confirm the diagnosis of extension of legs. The Breech is sometimes confused with face particularly if the part (face) is oedematous. If the examining finger is inserted into the anus it will be gripped by the anal sphincter and the finger will be meconeum stained. Diagnosis may be difficult in primigravidae with firm muscle of the abdominal wall or uterine irritability.

Management

In pregnancy

Because of high fetal loss associated with breech delivery external version should be done at 32 -36 weeks. Before 32 weeks the fetus can revert back to breech. After 36 weeks the manipulation is difficult to accomplish due to less room and reduced liquor amni. If the correction fails the breech should be left alone.

All cases of breech should be referred to doctor to perform version. Regardless of parity all cases of breech should be delivered in the hospital to reduce the fetal mortality. Caesarean section is the method of choice in the delivery of breech in recent years to avoid damages to the baby e.g. fracture, intracranial injuries.

Management of Breech Presentation in Labor

Immediately a woman is admitted in labor with breech, the doctor should be informed; all cases of breech should be delivered in the hospital.

First Stage

The usual normal management for cephalic presentation is done. But her cooperation is greatly needed in his case because she has to push the baby out. So the midwife needs to be patient, never to rush to deliver the baby until the cervix is fully dilated. She must be ready to receive an asphyxiated baby and resuscitate the baby. Vaginal examination should be made early in labour to confirm the presentation, position and that the pelvis is adequate in size.

A second vaginal examination is mandatory when the membranes rupture to: exclude prolapse of the cord, and to know if the breech is complete or incomplete.

Sedation could be given as the labor is likely to be prolonged. The woman should be prevented from pushing prematurely, until the buttocks appear at the vulva. If she pushes through undilated cervix the labour may be delayed after the delivery of the shoulders. She should be encouraged to breathe through her mouth if she has the urge to push.

Second Stage

A vaginal examination must always be made to confirm full dilation of the cervix before the patient is allowed to push. With the appearance of the anterior buttock at the vulva the patient is placed in a lithotomy position at the edge of the bed. Knees flexed and abducted to allow the body to hang. The bladder is catheterized to make sure the bladder is empty. The vulva is swabbed and sterile drapes are put on. Having done that, the woman is encouraged to bear down with each contraction. With this the buttocks will advance well and be expelled from the vulva followed by the legs the rest of the body is delivered using Burn’s Marshall Maneuver (the midwife may perform a medio-lateral episiotomy to give more room.

Complications that may arise :

Extended legs. This can be delivered using the Pinead’s method. Extended hands. This can be delivered using the Lovset’s Maneuver.

Extended head. This can be delivered using the Mauriceau-Smellie Veit’s Method

Dangers of Breech Presentation

Mother:

·              prolonged labour,severe lacerations,infections

·              post partum hemorrhage due to atony of the uterus ,anemia

·              retention of urine – due to laxed sphincter muscle

Baby:

·              asphyxia due to

o     Compression of the cord

o     Early separation of placenta as a result of fundal pressure

o     Cord prolapse

·              Intral Cranial Injury

o     Hemorrhage. This is the most common cause of death

·              Other injuries

o     Erb’s Palsy – due to damage to the brachial plexus

o     Fracture of Humerus – extended arm

o     Fracture of Femur – extended legs

o     Rupture of the liver and internal organs due to increase rough handling of the body