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 34th 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.
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
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.
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
· 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
ii. fetal abnormalities – anencephaly and hydrocephaly
iii. multiple pregnancy –twins
iv. intrauterine death.
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
The abdomen looks normal except in Frank breech when the abdomen looks long and narrow
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.
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
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 1st 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.
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.
Immediately a woman is admitted in labor with breech, the doctor should be informed; all cases of breech should be delivered in the hospital.
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.
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.
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
· prolonged labour,severe lacerations,infections
· post partum hemorrhage due to atony of the uterus ,anemia
· retention of urine – due to laxed sphincter muscle
· 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