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Breech presentation

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Breech presentation

  1. 1. Breech Presentation<br />www.freelivedoctor.com<br />
  2. 2. BREECH PRESENTATION<br />Definition-It is a longitudinal lie in which the buttocks is the presenting part with or without the lower limbs.<br />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.<br />www.freelivedoctor.com<br />
  3. 3. Aetiology<br />In general, the foetus is adapted to the pyriform shape of the uterus with the larger buttock in the fundus and smaller head in the lower uterine segment.<br />Any factor that interferes with this adaptation, allows free mobility or prevents spontaneous version, can be considered a cause for breech presentation as:<br />www.freelivedoctor.com<br />
  4. 4. Aetiology<br />*Prematurity:<br />> relatively small foetal size,<br />> relatively excess amniotic fluid, and<br />>more globular shape of the uterus.<br />* Multiple pregnancy: one or both will present by the breech to adapt with the relatively small room.<br />www.freelivedoctor.com<br />
  5. 5. Aetiology<br />* Poly-and oligohydramnios.<br />* Hydrocephalus.<br />* Intrauterine foetal death.<br />* Bicornuate and septate uterus.<br />* Uterine and pelvic tumours.<br />* Placenta praevia.<br />www.freelivedoctor.com<br />
  6. 6. Types<br />Complete breech:<br /> > The feet present beside the buttocks as both knees and hips are flexed.<br />>More common in multipara.<br />www.freelivedoctor.com<br />
  7. 7. Types<br />.Incomplete breech<br />a.Frank breech:<br />>It is breech with extended legs where the knees are extended while the hips are flexed.<br />>More common in primigravida<br />b.Footling presentation:<br />>The hip and knee joints are extended on one or both sides.<br />>More common in preterm singleton breeches.<br />www.freelivedoctor.com<br />
  8. 8. Types<br />.Incomplete breech:c.Knee presentation:<br />>The hip is partially extended and the knee is flexed on one or both sides.<br />www.freelivedoctor.com<br />
  9. 9. Positions<br /> * Left sacro-anterior. <br /> * Right sacro-anterior.<br /> * Right sacro-posterior. <br /> * Left sacro-posterior.<br /> * Left and right sacro- transverse (lateral).<br /> * Direct sacro-anterior and posterior.<br />www.freelivedoctor.com<br />
  10. 10. Sacro-anterior positions are more common than sacro-posterior as in the first the concavity of the foetal front fits into the convexity of the maternal spines.<br />www.freelivedoctor.com<br />
  11. 11. Diagnosis<br />During pregnancy<br />Inspection<br />* Inspection:<br />>A transverse groove may be seen above the umbilicus in sacro-anterior corresponds to the neck.<br />> If the patient is thin, the head may be seen as a localised bulge in one hypochondrium.<br />www.freelivedoctor.com<br />
  12. 12. Diagnosis<br />* Palpation:<br />>Fundal grip: the head is felt as a smooth, hard, round ballottable mass which is often tender.<br />> Umbilical grip: the back is identified and a depression corresponds to the neck may be felt.<br />> 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.<br />www.freelivedoctor.com<br />
  13. 13. Diagnosis<br />* Auscultation:<br /> > 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.<br />www.freelivedoctor.com<br />
  14. 14. Diagnosis<br />Ultrasonography:<br /> > It is used for the following:<br />> To confirm the diagnosis.<br />> To detect the type of breech.<br />> To detect gestational age and foetal weight: Different measures can be taken to determine the foetal weight as the biparietal diameter with chest or abdominal circumference using a special equation.<br />> To exclude hyperextension of the head.<br />> To exclude congenital anomalies.<br />> Diagnosis of unsuspected twins.<br />www.freelivedoctor.com<br />
  15. 15. Diagnosis<br />During Labour<br />In addition to the previous findings, vaginal examination reveals: <br />* The 3 bony landmarks of breech namely 2 ischialtuberosities and tip of the sacrum.<br />* The feet are felt beside the buttocks in complete breech.<br />* Fresh meconium may be found on the examining fingers.<br /> * Male genitalia may be felt.<br />www.freelivedoctor.com<br />
  16. 16. Mechanism of Labour<br />Delivery of the buttocks<br />* The engagement diameter is the bitrochanteric diameter 10 cm which enters the pelvis in one of the oblique diameters.<br />* The anterior buttock meets the pelvic floor first so it rotates 1/8 circle anteriorly.<br />* 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.<br />* External rotation occurs so that the sacrum comes anteriorly.<br />www.freelivedoctor.com<br />
  17. 17. Mechanism of Labour<br />Delivery of the shoulders<br />* The shoulders enter the same oblique diameter with the biacromial diameter 12 cm (between the acromial processes of the scapulae).<br />* 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.<br />www.freelivedoctor.com<br />
  18. 18. Mechanism of Labour<br />* The head enters the pelvis in the opposite oblique diameter.<br />* The occiput rotates 1/8 circle anteriorly, in case of sacro- anterior position and 3/8 circle anteriorly in case of sacro- posterior position.<br />* Rarely, the occiput rotates posteriorly and this should be prevented by the obstetrician.<br />www.freelivedoctor.com<br />
  19. 19. The head is delivered by movement of flexion in:<br />* Direct occipito-posterior (face to pubis).<br />* Face mento-anterior.<br />* The after coming head in breech presentation.<br />www.freelivedoctor.com<br />
  20. 20. Management of Breech Presentation<br />External Cephalic Version<br />It regains its importance after increased rate of caesarean sections nowadays.<br />Timing: After the 32nd weeks up to the 37th week and some authors extend it to the early labour as long as the membranes are intact and there is no contraindications.<br />www.freelivedoctor.com<br />
  21. 21. Management of Breech Presentation<br />Version is not done earlier because:<br />* Spontaneous version is liable to occur.<br />* Return to breech presentation is liable to occur.<br />* If labour occurs the foetus will have a lesser chance for survival.<br />www.freelivedoctor.com<br />
  22. 22. Management of Breech Presentation<br />Version is difficult after 37th weeks due to:<br />* Larger foetal size.<br />* Relatively less liquor.<br />* More irritability of the uterus.<br />www.freelivedoctor.com<br />
  23. 23. Management of Breech Presentation<br />Causes of failure<br />* Large sized foetus.<br /> * Oligo- or polyhydramnios. <br />* Short umbilical cord.<br /> * Uterine anomalies as bicornuate or septate uterus.<br />* Irritable uterus. Tocolytic drugs may be started 15 minutes before the procedure to overcome this.<br />*Obesity<br />* Rigid abdominal wall. <br />* Frank breech because the legs act as a splint.<br />www.freelivedoctor.com<br />
  24. 24. Caesarean Section<br />Indications:<br />a. Large foetus i.e. > 3.75 kg estimated by ultrasound.<br />b.Pretermfoetus but estimated weight is still more than 1.25 kg.<br />c.Footling or complete breech: as the presenting irregular part is not well fitting with the lower uterine segment leading to;<br />> Less reflex stimulation of uterine contractions.<br />> Susceptibility to cord prolapse.<br />> Early bearing down as the foot passes through partially dilated cervix and reaches the perineum.<br />www.freelivedoctor.com<br />
  25. 25. Caesarean Section<br />Indications<br />d. Hyperextended head: diagnosed by ultrasound or X-ray.<br />e. Contracted pelvis: of any degree.<br /> f. Uterine dysfunction.<br />www.freelivedoctor.com<br />
  26. 26. Caesarean Section<br />Indications:<br />g.Complicated pregnancy with:<br /> > Hypertension.<br /> > Diabetes mellitus. <br /> > Placenta praevia.<br /> > Pre - labour rupture of membranes for = 12 hours.<br />> Post-term.<br />> Intrauterine growth retardation.<br /> > Placental insufficiency.<br />www.freelivedoctor.com<br />
  27. 27. Caesarean Section<br />Indications<br /> h. Primigravidas: breech in primigravida equals caesarean section in opinion of most obstetricians as the maternal passages were not tested for delivery before.<br />www.freelivedoctor.com<br />
  28. 28. Vaginal Delivery<br />Prerequisites:<br />* Frank breech.<br />* Estimated foetal weight not more than 3.75 kg.<br />* Gestational age: 36-42 weeks.<br />* Flexed head.<br /> * Adequate pelvis.<br />* Normal progress of labour by using the partogram.<br />* Uncomplicated pregnancy.<br />* Multiparas.<br />* An experienced obstetrician.<br />* In case of intrauterine foetal death.<br />www.freelivedoctor.com<br />
  29. 29. Vaginal Delivery<br />During vaginal delivery, prematures are more susceptible to:<br />* hypoxia,<br />* trauma, and<br /><ul><li>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.</li></ul> However, caesarean section should only be done if the premature foetus has a reasonable chance of post - natal survival.<br />www.freelivedoctor.com<br />
  30. 30. Management of Vaginal Breech Delivery<br />First stage: as other malpresentations.<br />Second stage: The foetus may be delivered by one of the following methods:<br />a.Spontaneous breech delivery<br />b.Assisted breech delivery<br />c.Breech extraction<br />www.freelivedoctor.com<br />
  31. 31. Complicated Breech Delivery<br />www.freelivedoctor.com<br />
  32. 32. Arrest of the buttocks at the pelvic brim<br />www.freelivedoctor.com<br />
  33. 33. Arrest of the buttocks at the pelvic outlet<br />www.freelivedoctor.com<br />
  34. 34. Complications of Breech Delivery<br />Maternal:<br />>Prolonged labour with maternal distress<br />> Obstructed labour with its sequelae may occur as in impacted breech with extended legs.<br />> Laceration especially perineal.<br />>Postpartum haemorrhage due to prolonged labour and lacerations.<br />> Puerperal sepsis.<br />www.freelivedoctor.com<br />
  35. 35. Complications of Breech Delivery<br />FoetalComplications:<br />Foetal mortality due to<br />a.Intracranialhaemorrhage<br />b. Fracture dislocation of the cervical spines<br />c. Asphyxia <br />www.freelivedoctor.com<br />