Breech presentation

by Dr. R. OMOZUAPO

1. MANAGEMENT OF BREECH PRESENTATION AT TERM By: Dr. Omozuapo (MB.BS. Uniben ) 1

2. outline Introduction Epidemiology Variety/types Aetiology /risk factors Diagnosis Management Antenatal/ECV Options on mode of delivery Methods of vaginal breech delivery Complicated breech delivery Complication Conclusion References 2

3. INTRODUCTION Commonest malpresentation Occurs when the fetal pelvis or lower extremities engage in the maternal pelvic inlet , Or A presentation where the fetal buttocks or feet are closest to the cervix. It occurs in 3-4% of all deliveries at term. Larger % before term 3

4. Epidemiology Incidence Gestational age 35% <28wks 25% 28-32wks 20% 32-34wks 8% 34-36 wks 4-5% 36wks 3-4% Term Frank breech presentations occur in 65% of all breech deliveries. Footling and complete breech presentations occur in 25% and 10% respectively. Lower in hospitals where ECV is done 4

5. EPIDEMIOLOGY ctd Breech (presentation) deliveries increases with decreased gestational ages. 3-4% occur at term. Majority of breech revert or turn spontaneously on or before 36weeks. 5

6. VARIETIES In frank breech, the hips are flexed with extended knees bilaterally. In complete breech, both hips and knees are flexed. In footling breech, 1 ( single footling breech) or both ( double footling breech) legs are extended below the level of the buttocks. 6

7. VARIETIES 7

8. Studies have shown that In singleton breech presentations in which the infant weighs less than 2500 g, 50% footling breech, 40% are frank breech, 10% complete breech. With birth weights of more than 2500 g, 65% are Frank breech, 25% footling breech, and 10% complete breech. 8

9. AETIOLOGY/ RISK FACTORS Prematurity: (commonest) relatively large fetal head to body ratio. Polyhydramnious / oligohydramnious Pelvic tumours Placenta Previa Congenital anomalies of the uterus Congenital anomaly of the fetus Multiple pregnancy and high parity. Fetal macrosomia Contracted pelvis 9

10. DIAGNOSIS (during pregnancy and labour ) ABDOMINAL EXAMINATION Palpation and ballottement helps to confirm breech presentation. On palpation, the presenting part feels firm but not bony hard and less rounded than the head. On auscultation with the Pinnard stethoscope, the area of greatest intensity of the fetal heart sounds will be above the level of the maternal umbilicus although, if the legs are extended, the sounds tend to be heard at a lower level. 10

11. VAGINAL EXAMINATION On vaginal examination The fetal feet may be felt close to the buttocks or may be the sole presenting part as in a footling breech. However, if no presenting part is discernable , further studies are necessary. 11

12. ULTRASOUND Confirmation of a diagnosis of breech presentation is easily accomplished by ultrasound. Ultrasonographic scanning by an experienced examiner will document fetal presentation, attitude, Est. FW, multiple gestation, location of the placenta, and amniotic fluid volume. Exclude congenital anomaly, type of breech. 12

13. D. During Labour V. E. may reveal 2 Ischial tuberosities and tip of the sacrum The feet are felt besides the buttocks in complete breech Fresh meconium may be found on the examining fingers Genitalia may be felt. 13

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15. Possible Positions Fetal sacrum as the point of reference to the maternal pelvis. Eight possible: (SA), (SP), (LST), (RST), (LSA), (LSP), (RSA), and (RSP). 15

16. MANAGEMENT OF BREECH PRESENTATION ANTENATAL CARE /MANAGEMENT Early booking gives the obstetrician the opportunity to evaluate the previous obstetric performance of the patient. Interventions are unnecessary up to 36 completed weeks of gestation as spontaneous version to cephalic presentation will occur in many cases if uterine/gross fetal abnormalities are absent. 16

17. Radiographic pelvimetry using X-Ray, Computed tomography, or magnetic resonance imaging should be done to rule out women with a borderline or contracted pelvis. If breech presentation persists beyond 36weeks of gestation, external cephalic version should be considered . 17

18. Management ctd During antenatal Identify complicating factors related with breech External cephalic version, if not contraindicated. Formulation of line of management, if ECV failed or is contraindicated. 18

19. External Cephalic Version (ECV) ECV is a transabdominal manipulative procedure of converting breech to cephalic presentation Popular in 1960s & 1970s Disappeared thereafter due to report of fetal death Re-introduced in 1980 in America and now became increasingly popular 19

20. External cephalic version Done to bring favorable cephalic pole into the lower pole of the uterus Mean Success rate is 60% ≥36wks Less chance of spontaneous reversion If complications arise, delivery of a term infant can be accomplished. 20

21. Contraindications Engaged presenting part hyperextended head Abnormal CTG Premature rupture of membrane Antepartum hemorrhage Placenta previa Uterine anomalies Multiple gestation, Previous CS delivery Obstetric complications: severe pre- eclampsia , obesity, elderly primigravida , IUGR 21

22. Successful version likely in Complete breech Non-engaged breech Sacro -anterior position Adequate liquor Non-obese patient Failed version likely in: Frank breech Scanty liquor/big baby Mechanical –obesity, irritable uterus Short cord Uterine malformations 22

23. ADVANTAGES Reduces breech incidence at term Reduces breech delivery incidence Reduces CS 23

24. Newman’s scoring system for ECV 1 2 Parity 1 ≥2 Placenta Ant Post Lateral, fundal Cervical Dilatation >3cm 1 – 2cm EFW <2.5Kg 2.5 – 3.5Kg >3.5Kg station -1 - 2 - 3 24

25. Procedure Informed consent USS guidance – confirms diagnosis and adequate liquor A reactive NST, FHR auscultation, Empty bladder, If desired admin tocolytic Position of patient: supine, thighs slightly flexed, and abdomen fully exposed. Lubricant should be applied per abdomen. Fetal presentation, position of back and limbs are checked 25

26. Forward roll movt . Step 1 Mobilize breech using both hands towards which back of fetus lie. Right hand: grasp podalic pole Left hand: grasp head. 26

27. Step 2 L: Pressure exerted to head to push breech R: Pressure in opposite direction to guide vertex Intermittent pressure given till lie becomes transverse FHR is checked. 27

28. Step 3 Changing of hands Intermittent pressure exerted till head is brought to lower pole of uterus. 28

29. Patient is observed for 30minutes to 1 hr Allow FHR to settle down Note any bleeding PV/PROM Patient is advised for follow up, to report any vaginal bleeding /leakage and Rh-neg woman is given 300ug anti D Ig immunoglobulin. 29

30. COMPLICATIONS OF ECV Complications are rare, occurs in 1-2% of all ECVs Preterm labour Fetal distress Fetal demise Placental abruption Uterine rupture Rupture of membranes and cord prolapse Fetomaternal heamorrhage 30

31. It is advised that the procedure (ECV) be performed in a facility where immediate caesarean section or delivery can be performed . Following the procedure, external fetal heart rate monitoring should be continued for 1 hour to ensure stability of the fetus. 31

32. If ECV failed/contraindicated Continue with usual check up Assess again based on maternal age Associated complicating factors Size of baby Pelvic capacity Then clinical assessment of the pelvis is done to plan the method of delivery. 32

33. OPTIONS ON MODE OF DELIVERY OF BREECH Vaginal breech delivery Spontaneous Assisted VBD Breech extraction Ceasarean section 33

34. DECISION ON MODE OF DELIVERY The decision regarding mode of delivery must be individualized. Delivery is either by vaginal route or Caesarean section. In the past (before 1980’s), virtually all viable singleton breech presentations were delivered vaginally. C/S was reserved for specific fetal indications- Fetal distress, cord prolapse or maternal indications such as placenta praevia , abruption placentae or failure of progress of labour . 34

35. However, breech newborn/ infants delivered vaginally had a higher fold morbidity and mortality rate compared to the cephalic presentations. Caesarean delivery for breech presentation has now become much more common in breech presentation , with lower rates of perinatal morbidity and mortality. 35

36. CRITERIA FOR VAGINAL OR CAESAREAN DELIVERY IN BREECH PRESENTATION FACTORS SUPPORTING VAGINAL DELIVERY Frank breech presentation Estimated gestational age of 36weeks or more EFW of 2.5 to 3.5kg Flexed fetal head Adequate maternal pelvis (as determined by CT pelvimetry) No maternal or fetal indication for C/S Previable fetus Documented lethal fetal congenital anomalies Presentation of patient (mother) in advanced labour with no fetal or maternal distress 36

37. FACTORS SUPPORTING CAESAREAN SECTION Estimated fetal weight ≥3.5kg or < 1.5kg Contracted or borderline maternal pelvis Deflexed or hyperextended fetal head Prolonged rupture of membranes Unengaged presenting part Mother with infertility problems Elderly Primigravida Poor or bad obstetric history Premature fetus (gestational age of 26 to 36weeks) Footling breech Fetus with variable heart rate deceleration on electronic fetal monitoring. 37

38. VAGINAL BREECH DELIVERY METHODS Obstetricians who contemplate performing a vaginal breech delivery should be experienced in the manoeuver and should be assisted by 3 physicians: An experienced Obstetrician who will assist with the delivery. A Neonatologist to resuscitate the newborn. An Anaesthesiologist to ensure that the patient is comfortable and cooperative during labour and delivery and for possible reversion to CS. 38

39. METHODS OF VAGINAL BREECH DELIVERY: SPONTANEOUS - Usually occurs in a multigravida with a small baby. ASSISTED VAGINAL BREECH DELIVERY The fetus is delivered with the assistance of the obstetrician. It should be encouraged in all cases. 39

40. BREECH EXTRACTION When the entire body of the fetus is extracted by the obstetrician with minimal or no aid from the mother. It is carried out under anaesthesia in case of fully dilated cervix with maternal/ fetal distress, cord prolapse and conversion to CS. It is done very infrequently these days in a live baby. 40

41. Mechanism of labour in breech Principal movts at Buttocks Shoulders Head 41

42. SPONTANEOUS VAGINAL DELIVERY: the buttocks 42 • The diameter of engagement: oblique diameters of the inlet. The engaging diameter is bi- trochanteric with the sacrum directed towards the ilio -pubic eminence. When the diameter passes through the pelvic brim, the breech is engaged . • Descent of the buttocks occurs until the anterior buttock touches the pelvic floor. • Internal rotation of the anterior buttock occurs placing it behind the symphysis pubis. Descent with lateral flexion of the trunk occurs until the anterior hip hinges under the pubis sym. which is released first followed by the posterior hip.• Delivery of the trunk and the lower limbs follow.

43. The shoulders Bisacromial diameter engages in the transverse diameter at the brim soon after the delivery of the breech. • Descent occurs with internal rotation of the shoulders bringing the shoulders to lie in the anteroposterior diameter of the pelvic outlet. The trunk rotates externally • Delivery of the posterior shoulder followed by the anterior one is completed by anterior flexion of the delivered trunk. • Restitution and external rotation : the fetal trunk is now positioned as dorso -anterior. 43

44. The head Engagement occurs through the same oblique diameter as that occupied by the buttocks. The engaging diameter of the head is suboccipitofrontal . • Descent with increasing flexion occurs. • Internal rotation of the occiput occurs anteriorly , placing the occiput behind the symphysis pubis. • Further descent occurs until the subocciput hinges under the symphysis pubis. • The head is born by flexion. 44

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46. ASSISTED VAGINAL BREECH DELIVERY Breech delivery should be conducted by a skilled obstetrician. The following are to be ready before hand when planning an assisted breech delivery in addition to the requirements for the conduction of normal labour : Anaesthetist , An assistant, Nurses / midwives, Paediatrician (Neonatologist) GXM blood 46

47. Pudendal block and infiltration of the perineum or epidural anaesthesia Instruments and suture materials for episiotomy. A breech towel, A pair of Piper’s forceps for the after coming head Appliances for neonatal resuscitation. 47

48. Principles In Conduction Of Assisted Vaginal Breech Delivery Never rush delivery Never pull from below but push from above. Always keep the fetus with the back anteriorly . Aggressive and hasty pull affects breech delivery adversely by causing: Entrapment of the after coming fetal head through the incompletely dilated cervix. Nuchal arm Deflexed head 48

49. Traction from below may result in deflection of the fetal head causing longer occipito -frontal diameter at the pelvic inlet. 49

50. STEPS The patient is placed in lithotomy position (and tiltled laterally using a wedge under the back to avoid aortocarval compression) when the breech starts distending the perineum and the fetal anus is visible. Antiseptic cleaning is done as well as draping. The urinary bladder is emptied with an in and out catheter. Local anaesthesia is administered 50

51. Episiotomy is performed and delivery is allowed by maternal efforts alone up to the umbilicus. Px is encouraged to bear down as it ensures flexion of head and safe descent. The ‘no touch of the fetus’ policy is adopted until the buttocks are delivered along with the legs in flexed breech and the trunk slips up to the umbilicus. 51

52. Delivery of trunk For the extended breech, the buttock is palpated to reach the popliteal fossa and a gentle depression is made (PINARD MANOUVRE) followed by delivery of the flexed leg. Same is repeated for the second limb Umbilical cord is gently pulled down and mobilized to one side to minimize compression. Ensure a dorsoanterior position of the fetal back 52

53. The fetus in dorsoanterior position is allowed to hang on its weight. Delivery is allowed to continue until the inferior border of the scapula is seen Position of the arm is noted. Arm is delivered when one axilla is visible by hooking down elbow with a finger 53

54. Delivery of the arms If flexed, vertebral border of the scapula is parallel to the vertebral column. Reach out for the shoulder and then the arm which will be delivered. Same is done for the contralateral limb. If extended, there is winging of the scapula. Reach out for the shoulder, and then the cubittal fossa . With a gentle depression(LOVSET MANOUVRE) on it, there is flexion followed by sweeping of the arm over the chest and then subsequent delivery. Same is done for the contralateral limb. 54

55. Delivery of the head This is done when the nape of the neck is seen. Methods of delivery of the aftercoming head include; Mauriceau-Smellie-Veit technique Burns M arshall method Forceps delivery 55

56. MAURICEAU- SMELLIE -VEIT TECHNIQUE (JAW FLEXION AND SHOULDER TRACTION) This technique is named after 3 great obstetricians who described the use of the grip independently. The baby is placed on the supinated left forearm with the limbs hanging on either side. The middle and index fingers of the left hand are placed over the malar bones on either side. This maintains the flexion of the head. The ring and little fingers of the pronated right hand are placed on the child's right shoulder, the index finger is placed on the left shoulder while the middle finger is placed on the sub-occipital region. 56

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58. Burns Marshall method Baby allowed to hang by its weight Assistant: downward, backward, suprapubic pressure to promote head flexion. Right hand: grasp ankles with a finger in between (when nape of neck is visible under the pubic arch) Trunk is swung upward and forward till mouth is cleared off the vulva Depress the trunk to deliver the rest of the head Left hand: guides the perineum. 58

59. Forceps delivery Baby allowed to hang by its weight Assistant Give suprapubic pressure Raises legs of child when occiput is against pubic symphysis . Piper forceps is used by the most skilled personnel. 59

60. Complicated bree c h delivery 60

61. Arrest of buttocks 1. At the outlet Causes Big baby and extended legs Weak uterine contraction Rigid perineum Contracted pelvis/ Big baby ---CS In absence of contracted pelvis and big baby do an episiotomy , fundal pressure with groin traction Groin traction Index finger is placed in groin fold and traction is given towards trunk till delivery of the knee. 61

62. Arrest of the buttocks 2. In the cavity ( Ischial spine) Pinnards maneuver CS Pinnards manouver Middle and index fingers are carried up to popliteal fossa , then exert pressure and leg is abducted. Fetal foot is grasped at ankle and pulled down. 62

63. Arrest at the shoulder: classical manouvre Baby is grasped using both hands by femoro -pelvic grip Start only when inferior angle of ant. Scapular is visible under the pubic arch. then lift baby slightly and rotate 180 with downward traction and deliver post arm. Trunk is rotated in reverse and ant. arm is delivered. 63

64. Nuchal arms Excessive downward traction on the body results in a single or double nuchal arm because of the rapid descent of the body, leading to extension of 1 or both arms, which become lodged behind the neck. Rotate the body 180 to bring the elbow toward the face. Identify the humerus and deliver by gentle downward traction ( Lovset ). 64

65. Nuchal Arm ctd For double nuchal arm, rotate the fetus counterclockwise to dislodge and deliver the right arm and rotate clockwise to deliver the left arm. If unsuccessful, insert a finger and identify the humerus , and extract the arm, resulting in fracture of the humerus or clavicle. 65

66. Delivery of the head through incompletely dilated cervix Causes: footling presentation , hasty breech delivery Management : Dührssën’s incision at 2,6,and 10 O’ clock position on the cervix 66

67. Arrest of the head At the outlet: causes: rigid perineum Episiotomy or forceps or MSV, Burns Marshall, or symphysiotomy or CS 67

68. Occipito -posterior head Usually in spontaneous breech delivery Grasp fetal trunk and head with hands positioned like that in malar flexion and shoulder traction, (MSV) then rotate to bring them anteriorly . ( prague manuevre ) head is delivered face to pubis by reverse malar flexion and shoulder traction. Forceps 68

69. Management of unbooked breech in labour Presents as emergency, no prior clinical assessment Prior unskilled interference can compound the clinical problem. Careful clinical assessment by the most experienced member of the team is necessary before decision on management can be taken. 69

70. Maximum score is 11 Score >7 predict good prognosis for vaginal delivery 1 2 PARITY 1 GA 39+wks 38wks 37wks DILATATION 2cm 3cm 4cm PREVIOUS BREECH 1 2 STATION -3 -2 -1 EFW 3.6kg 3.2-3.6kg <3.2kg ZATUCHNI ANDROS PROGNOSTIC SCORING INDEX 70

71. Deflexion of the head Hyperextension of the head is defined as deflexion or extension of the head posteriorly beyond the longitudinal axis of the fetus. Deflexion causes impaction of the occipital portion of the head behind the pubic symphysis , which may lead to fractures of the cervical vertebrae, lacerations of the spinal cord, epidural and medullary hemorrhages, and perinatal death. If head deflexion is diagnosed prior to delivery, caesarean section should be performed to avert injury. 71

72. COMPLICATIONS Maternal Increased operative delivery Increase genital tract trauma, sepsis, anaesthetic complications Fetal Perinatal trauma Perinatal death Birth ashyxia Intra cranial hemorrhage Birth injuries Heamatoma–sternomastoid /thighs Fracture–femur, humerus , clavicle, odontoid process Visceral injuries Nerve– erbs , klumpke 72

73. COMPLICATIONS Fetal cntd Factor influencing fetal risk: skill of obstetrician, Wt of the baby, legs position, Type of pelvis Prevention of fetal hazards Minimise breech incidence by ECV Delivery by CS Vaginal breech delivery by skilled obsterician , anaesthetist , neonatologist. 73

74. Conclusion ECV Assisted breech delivery Buttocks: knee abduction Shoulders: hooking down elbow Head: burns- marshall method, forceps delivery, malar flexion and shoulder traction. Complicated breech delivery Buttocks/LL: groin traction, Pinnard’s manouvre Shoulders/UL: Classical, lovset’s manouvre Head: MSV , Burns Marshall, Forceps, Dührss ë n’s method, Prague method. C/S 74

75. VIDEO 75

76. References Alarab M, Regon C, et al: Singleton Vaginal Breech Delivery at Term: still a safe option. ObstGynacol 103: 43-44 Alan H. D et al (2013). Malpresentation and Cord Prolapse . Current Diagnosis & Treatment Obstetrics and Gynecology 11 th Ed. 19, 583-599. Albrechsten S, Rasmussen S, Reigstad H et al: Evaluation Protocol for Selecting Fetuses in Breech Presentation for Vaginal Delivery or CS. Amj . Obstetric Gynecol 177:586-588 American College of Obstetricians and Gynecologists. External Cephalic Version. ACOG Practice Bulletin No. 13. Washington, DC: ACOG; 2000. Dr. Amerijoye . Senior Registrar, Obstetrics and Gynaecology Dept, FETHI, EKITI. Gary Cunningham F., et al (2014).Breech Presentation Williams Obstetrics 24,574-583.