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Breech Presentation

Alhadi Araibi Alkhadra Hospital. Breech Presentation. What you need to know about Breech Presentation. What is Breech Presentation? Types of Breech Presentation Importance of Breech Presentation Causes of Breech Presentation Diagnosis of Breech Presentation Management Options.

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Breech Presentation

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  1. Alhadi Araibi Alkhadra Hospital Breech Presentation

  2. What you need to know about Breech Presentation • What is Breech Presentation? • Typesof Breech Presentation • Importance of Breech Presentation • Causes of Breech Presentation • Diagnosisof Breech Presentation • Management Options

  3. What is Breech Presentation? Breech Presentation is a fetus in a longitudinal lie with the buttocks or feet closest to the cervix. Cephalic presentation is the best fit presentation Incidence : • 3-4% at term. • 22% at 28 weeks and 7% at 32 weeks.

  4. Typesof Breech Presentation • Frank Breech 50-70% Flexed Hips, extended knees (pike position)

  5. Typesof Breech Presentation • Complete Breech 5-10% Flexed Hips Flexed Knees (cannonball position)

  6. Typesof Breech Presentation • Incomplete (Footling) 10-30% One or both hips extended Foot presenting

  7. Importanceof Breech Presentation • May indicate Pathology/Abnormality • See causes/predisposing factors. • Affect Perinatal Mortality and Morbidity • Perinatal mortality is increased 2- 4 folds with breech presentation regardless of the mode of delivery. • Affect mode of delivery • Perinatal mortality and neonatal morbidity are significantly lower in planned cesarean section than in planned vaginal delivery (5% vs 1.6%).

  8. Causes of Breech Presentation Fetal Maternal • Idiopathic • Fetal abnormality (CNS) • Oligo- polyhydramnios • Fetal growth restriction • Short umbilical cord • Extended legs • Multiple pregnancy • Idiopathic • Pre-term labour • Placenta previa/ Corneal pl • Uterine abnormalities • Contracted pelvis • Maternal anticonvulsants • Maternal substance abuse

  9. Diagnosis of Breech Presentation • Clinical Examination • Abdominal Palpation; • Hard round ballotable structure at the fundus. • The fetal heart commonly heard above the umbilicus. • Vaginal Examination; • Soft compressible structures. • Fetal ischial tuberosites, anus, genitalia & foot may provide a landmarks. • ~ 30% of breech presentation are not diagnosed until labour. • Ultrasound scan

  10. Management Options • Term Breech • Pre-term Breech • Second Twin Breech

  11. Management Options of Term Breech • Spontaneous Version • External Cephalic Version • Elective Cesarean Section vs. Vaginal Delivery

  12. Management Options of Term Breech Spontaneous Version • It is less frequent as third trimester progress (<25%). • More likely in multiparous. • Less likely in nulliparous and breech with extended legs. • Promotion of Spontaneous Version • Full Bladder. • Knee-Chest position 10 minutes everyday. • Pelvis elevation, thighs abduction and relaxed breathing. • All the above techniques are harmless, worth trying but can’t be recommended in the absence of supporting evidence.

  13. Management Options of Term Breech External Cephalic Version (ECV) • ECV is the transabdominal manual rotation of the fetus into a cephalic presentation. • Every 100 ECV attempt prevent 34 breech births and 14 cesarean sections. • Success rate 50-60%. • Higher success rate with: • Multiparous • Flexed head and knees • Use of tocolytics • Use of regional anesthesia

  14. External Cephalic Version (ECV) • Prerequisites • More than 36 weeks gestation. • Ultrasound, to confirm breech, enough liquor & out rule contraindication. • CTG pre & post ECV. • Facilities to perform emergency cesarean section. • Informed consent for the procedure & possible cesarean section. • Patient fasting more than 6 hours. • Anti D for Rh negative women.

  15. External Cephalic Version (ECV) Absolute Contraindications Relative Contraindications • Multiple pregnancy. • Antepartum hemorrhage. • Placenta previa. • Ruptured membranes. • Fetal Anomalies. • Deflexed head. • Other indications for cesarean section. • Previous cesarean section. • IUGR. • Severe preeclampsia. • Rhesus Isoimmunization. • Obesity. • Macrosomia .

  16. Management Options of Term Breech Elective Cesarean Section • Elective cesarean section should be offered to all singleton term breech and planned Vaginal delivery may no longer be appropriate, based on Hannah et al multicentre randomised clinical trial 2001. • The perinatal mortalities and neonatal morbidities were significantly lower in planned cesarean section than in planned vaginal delivery. (5% vs 1.6%)

  17. Management Options of Term Breech Elective Cesarean Section • Prerequisites • Informed consent • At 39 weeks • Ultrasound pre section to out rule: • spontaneous cephalic version. • Intrauterine fetal death. • Congenital anomalies uncompatible with life.

  18. Management Options of Term Breech Planned Vaginal Delivery • Vaginal breech delivery was the norm until 1959 • Prerequisites • Out rule contraindications. • Informed consent. • Facilities where emergency cesarean section can be done. • Experience with vaginal breech delivery. • Continuous monitoring. • Augmentation of labour is controversial. • Low threshold for cesarean section.

  19. Management Options of Term Breech Planned Vaginal Delivery Types of Vaginal breech delivery: • Spontaneousbreechdelivery: No tractions or manipulations. • Assisted breechdelivery: The infant is allowed to deliver spontaneously up to the umbilicus, then maneuvers are initiated to assist in the delivery of the remainder of the body, arms & head (Pinard, Lovset & Mauriceau Smellie maneuvers). • Breech extraction: Fetal feet are grasped, the entire fetus is extracted. Only for second twin.

  20. Management Options of Term Breech Planned Vaginal Delivery Benefits Risks • Reduction in the risk of newborn Idiopathic Pulmonary Hypertension. • Less maternal morbidity and mortality than cesarean section. • Cord prolapse . • Nuchal arms →brachial plexus injuries • Cervical spine injury. • Rupture of internal organs. • Bone fracture. • Low apgar score at 1 min. • Intracranial hemorrhage. • Difficult birth experience.

  21. Management Options of Term Breech Planned Vaginal Delivery Contraindications of Vaginal breech delivery: • Other indications for cesarean section. • Compromised fetal condition. • Footling & Complete breech. • Estimated fetal weight ≥ 4kg. • Hyperextended head. • Previous cesarean section. • Lack of experience.

  22. Management Options Pre-term Breech • Not an indication for cesarean section. No data. • Prematurity is the main concern regardless of the mode of delivery. • Individualized approach regarding mode of delivery & parent’s wishes should be considered

  23. Management Options Second-twin Breech • Breech extraction • Internal podalic version

  24. Thank You

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