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Breech presentation
Noor H. Sadiq
Wasit university/college of medicine
Iraq
10-10-2016
objectives
Insidence Types Diagnosis ECV Managem
ent and
labor
prognosis
INCIDENCE
3-4% of fetus present by breech at term
5% at 34 weeks
20% at 28 weeks
25% of cases before 30 weeks of gestation
undergo spontaneous cephalic version up to
term.
Types
Frank breech where the hips are flexed and legs extended
Complete breech where the hips and knees are flexed and the feet are not
below the level of the fetal buttocks
Footling breech where one or both feet are presenting as the lowest part of
the fetus
Risk factors
maternal
• Polyhydraminos
• oligohydraminos
• Uterine anomalies
• Space occupying
lesions
• Placental
abnormalities
• Multiparity
fetal
• Prematurity
• Fetal anomalies (
hydrocephalus,
anenecephaly)
• Multiple
pregnancy
• Fetal death
• Short umbilical
cord
Clinical
Sonography
radiography
Diagnosos
•A transverse groove
may be seen above
the umbilicus in
sacro-anterior
corresponds to the
neck.
•If the patient is thin,
the head may be
seen as a localized
bulge in one
hypochondrium
Inspection
•Fundal Grip: The head
is felt as a smooth,
hard, round
ballottable mass
which is often tender.
•First pelvic Grip: The
breech is felt as a
smooth, soft mass
continues with the
back. Trial to do
ballottement to the
breech shows that the
movement is
transmitted to the
whole trunk.
Palpation
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.
Auscultation
• To confirm the
diagnosis.
• To detect the type of
breech.
• 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.
• To exclude
hyperextension of the
head.
• To exclude congenital
anomalies.
• Diagnosis of
unsuspected twins.
Ultrasonography
Management
If diagnosed before 34 weeks in multiparous
and 32 weeks in nulliparous, no need to do
anything because there is a good chance for
spontaneous version to cephalic .
If diagnosed after 34 weeks or 32 weeks in
nulliparous then external cephalic version .
External cephalic version
ECV should be performed with a tocolytic
(e.g. nifedipine) as this has been shown to
improve the success rate, With ultrasound
guidance , A fetal heart rate must be
performed before and after the procedure
and it is important to administer anti-D if
the woman is Rhesus-negative.
If ECV is successful then
follow up weekly till delivery
occur as normal cephalic .
If the procedure fails or returns
again then … persistant breech
presesntation.
ECV is a safe technique and has been shown
to reduce the number of Caesarean sections
due to breech presentations.
Success rates may reach 50% and are
higher in multiparous women.
The procedure is performed at or after
37 completed weeks by an experienced
obstetrician at or near delivery facilities.
Breech presentation
Contraindications to ECV
• Fetal abnormality (e.g. hydrocephalus)
• Placenta praevia
• Oligohydramnios or polyhydramnios
• History of antepartum haemorrhage
• Previous Caesarean or myomectomy scar on the uterus
• Multiple gestation
• Pre-eclampsia or hypertension
• Plan to deliver by Caesarean section anyway
Risks of ECV
• Placental abruption
• Premature rupture of the membranes
• Cord accident
• Transplacental haemorrhage
• Fetal bradycardia
Management of persistent breech
• reassess the patient for any medical or obstetrical problems like; PET,
bad obstetrical history, diabetes or Rh isoimmunisation .. etc. ; if any
abnormality present then CS is indicated .also if footling breech then CS
is indicated.
• study for fetopelvic disproportion; Clinical pelvimetry + fetal weight
estimation by: US
• X- ray pelvimetry ; With only single exposure – lateral erect position ..
Any pelvic abnormality or if the head is extended then CS.
• CT scan can give better result , but more x-ray exposure.
• if after reassessment everything is normal and CS is not necessary then
vaginal delivery of breech may be allowed.
Prerequisites for vaginal breech delivery
 Feto-maternal:
 • The presentation should be either extended (hips flexed,
knees extended) or flexed (hips flexed, knees flexed but feet
not below the fetal buttocks).
 • There should be no evidence of feto-pelvic disproportion with
a pelvis clinically thought to be adequate and an estimated
fetal weight of 3500 g (ultrasound or clinical measurement).
 • There should be no evidence of hyperextension of the fetal
head, and fetal abnormalities that would preclude safe vaginal
delivery (e.g. severe hydrocephalus) should be excluded.
Delivery of the buttocks
Shoulders
Head
MECHANISM OF LABOUR
Deliveryofthebuttocks
full dilatation and descent of the breech will have occurred
naturally.
When the buttocks become visible and begin to distend the perineum,
preparations for the delivery are made.
The buttocks will lie in the anterior–posterior diameter.
Once the anterior buttock is delivered and the anus is seen over the
fourchette (and no sooner than this), an episiotomy can be cut.
Deliveryofthelegsand
lowerbody
If the legs are flexed, they will deliver spontaneously.
If extended, they may need to be delivered using Pinard’s
manoeuvre.
This entails using a finger to flex the leg at the knee and
then extend at the hip,first anteriorly then posteriorly.
With contractions and maternal effort, the lower body will
be delivered.
Deliveryoftheshoulders
The baby will be lying with the shoulders in the transverse
diameter of the pelvic mid-cavity.
As the anterior shoulder rotates into the anterior–posterior diameter,
the spine or the scapula will become visible.
At this point, a finger gently placed above the shoulder will help to
deliver the arm.
As the posterior arm/shoulder reaches the pelvic floor, it too will
rotate anteriorly (in the opposite direction).
Loveset’s manoeuvre essentially copies these natural movements .
Deliveryofthehead
The head is delivered using the Mauriceau–Smellie– Veit maneuver:
the baby hang down with downward traction with the direction of birth
canal for one minute or till the hair line become visible at the vulva
(Burns Marshal Method) and then delivered the head via a finger in the
mouth and one on each maxilla .
Delivery occurs with first downward and then upward
movement toward the maternal abdomen (praque seizure
method ) (as with instrumental deliveries).
If this maneuver proves difficult, forceps need to be applied.
Breech presentation
Breech presentation
Risks of vaginal breech birth
● other contraindications to vaginal birth (e.g. placenta praevia,
compromised fetal condition)
● clinically inadequate pelvis
● footling or kneeling breech presentation
● large baby (usually defined as larger than 3800 g)
● growth-restricted baby (usually defined as smaller than 2000 g)
● Hyperextended fetal neck in labour (diagnosed with ultrasound or X-ray
where ultrasound is not available)
● lack of presence of a clinician trained in vaginal breech delivery
● previous caesarean section.
prognosis
The Fetal Dangers
• Intracranial Haemorrhage
• hypoxia
• Injuries
The maternal danger
• Increase operative delivery
• Increase genital tract injuries
• Increase caesarean section
• Increase anesthetic complications
THANK
YOU
‘source; The Ten Teachers obstetric

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Breech presentation

  • 1. Breech presentation Noor H. Sadiq Wasit university/college of medicine Iraq 10-10-2016
  • 2. objectives Insidence Types Diagnosis ECV Managem ent and labor prognosis
  • 3. INCIDENCE 3-4% of fetus present by breech at term 5% at 34 weeks 20% at 28 weeks 25% of cases before 30 weeks of gestation undergo spontaneous cephalic version up to term.
  • 4. Types Frank breech where the hips are flexed and legs extended Complete breech where the hips and knees are flexed and the feet are not below the level of the fetal buttocks Footling breech where one or both feet are presenting as the lowest part of the fetus
  • 5. Risk factors maternal • Polyhydraminos • oligohydraminos • Uterine anomalies • Space occupying lesions • Placental abnormalities • Multiparity fetal • Prematurity • Fetal anomalies ( hydrocephalus, anenecephaly) • Multiple pregnancy • Fetal death • Short umbilical cord
  • 7. •A transverse groove may be seen above the umbilicus in sacro-anterior corresponds to the neck. •If the patient is thin, the head may be seen as a localized bulge in one hypochondrium Inspection •Fundal Grip: The head is felt as a smooth, hard, round ballottable mass which is often tender. •First pelvic Grip: The breech is felt as a smooth, soft mass continues with the back. Trial to do ballottement to the breech shows that the movement is transmitted to the whole trunk. Palpation 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. Auscultation • To confirm the diagnosis. • To detect the type of breech. • 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. • To exclude hyperextension of the head. • To exclude congenital anomalies. • Diagnosis of unsuspected twins. Ultrasonography
  • 8. Management If diagnosed before 34 weeks in multiparous and 32 weeks in nulliparous, no need to do anything because there is a good chance for spontaneous version to cephalic . If diagnosed after 34 weeks or 32 weeks in nulliparous then external cephalic version .
  • 9. External cephalic version ECV should be performed with a tocolytic (e.g. nifedipine) as this has been shown to improve the success rate, With ultrasound guidance , A fetal heart rate must be performed before and after the procedure and it is important to administer anti-D if the woman is Rhesus-negative. If ECV is successful then follow up weekly till delivery occur as normal cephalic . If the procedure fails or returns again then … persistant breech presesntation. ECV is a safe technique and has been shown to reduce the number of Caesarean sections due to breech presentations. Success rates may reach 50% and are higher in multiparous women. The procedure is performed at or after 37 completed weeks by an experienced obstetrician at or near delivery facilities.
  • 11. Contraindications to ECV • Fetal abnormality (e.g. hydrocephalus) • Placenta praevia • Oligohydramnios or polyhydramnios • History of antepartum haemorrhage • Previous Caesarean or myomectomy scar on the uterus • Multiple gestation • Pre-eclampsia or hypertension • Plan to deliver by Caesarean section anyway
  • 12. Risks of ECV • Placental abruption • Premature rupture of the membranes • Cord accident • Transplacental haemorrhage • Fetal bradycardia
  • 13. Management of persistent breech • reassess the patient for any medical or obstetrical problems like; PET, bad obstetrical history, diabetes or Rh isoimmunisation .. etc. ; if any abnormality present then CS is indicated .also if footling breech then CS is indicated. • study for fetopelvic disproportion; Clinical pelvimetry + fetal weight estimation by: US • X- ray pelvimetry ; With only single exposure – lateral erect position .. Any pelvic abnormality or if the head is extended then CS. • CT scan can give better result , but more x-ray exposure. • if after reassessment everything is normal and CS is not necessary then vaginal delivery of breech may be allowed.
  • 14. Prerequisites for vaginal breech delivery  Feto-maternal:  • The presentation should be either extended (hips flexed, knees extended) or flexed (hips flexed, knees flexed but feet not below the fetal buttocks).  • There should be no evidence of feto-pelvic disproportion with a pelvis clinically thought to be adequate and an estimated fetal weight of 3500 g (ultrasound or clinical measurement).  • There should be no evidence of hyperextension of the fetal head, and fetal abnormalities that would preclude safe vaginal delivery (e.g. severe hydrocephalus) should be excluded.
  • 15. Delivery of the buttocks Shoulders Head MECHANISM OF LABOUR
  • 16. Deliveryofthebuttocks full dilatation and descent of the breech will have occurred naturally. When the buttocks become visible and begin to distend the perineum, preparations for the delivery are made. The buttocks will lie in the anterior–posterior diameter. Once the anterior buttock is delivered and the anus is seen over the fourchette (and no sooner than this), an episiotomy can be cut.
  • 17. Deliveryofthelegsand lowerbody If the legs are flexed, they will deliver spontaneously. If extended, they may need to be delivered using Pinard’s manoeuvre. This entails using a finger to flex the leg at the knee and then extend at the hip,first anteriorly then posteriorly. With contractions and maternal effort, the lower body will be delivered.
  • 18. Deliveryoftheshoulders The baby will be lying with the shoulders in the transverse diameter of the pelvic mid-cavity. As the anterior shoulder rotates into the anterior–posterior diameter, the spine or the scapula will become visible. At this point, a finger gently placed above the shoulder will help to deliver the arm. As the posterior arm/shoulder reaches the pelvic floor, it too will rotate anteriorly (in the opposite direction). Loveset’s manoeuvre essentially copies these natural movements .
  • 19. Deliveryofthehead The head is delivered using the Mauriceau–Smellie– Veit maneuver: the baby hang down with downward traction with the direction of birth canal for one minute or till the hair line become visible at the vulva (Burns Marshal Method) and then delivered the head via a finger in the mouth and one on each maxilla . Delivery occurs with first downward and then upward movement toward the maternal abdomen (praque seizure method ) (as with instrumental deliveries). If this maneuver proves difficult, forceps need to be applied.
  • 22. Risks of vaginal breech birth ● other contraindications to vaginal birth (e.g. placenta praevia, compromised fetal condition) ● clinically inadequate pelvis ● footling or kneeling breech presentation ● large baby (usually defined as larger than 3800 g) ● growth-restricted baby (usually defined as smaller than 2000 g) ● Hyperextended fetal neck in labour (diagnosed with ultrasound or X-ray where ultrasound is not available) ● lack of presence of a clinician trained in vaginal breech delivery ● previous caesarean section.
  • 23. prognosis The Fetal Dangers • Intracranial Haemorrhage • hypoxia • Injuries The maternal danger • Increase operative delivery • Increase genital tract injuries • Increase caesarean section • Increase anesthetic complications
  • 24. THANK YOU ‘source; The Ten Teachers obstetric