Breech presentation and delivery

Obstetrics

1. Breech Delivery Natangwe Shimhanda 201208214

2. Definition The presentation that the fetus is in a longitudinal lie and the podalic pole presents at pelvic brim.

3. Incidence Thus in 3 out of 4, spontaneous correction into vertex presentation occurs at 34th week. The incidence is low in hospitals where high parity births are minimal and routine cephalic version is done in antenatal period.

4. Types of breech

5. Complete ( Flexed breech ) flexed at hips and flexed at knees. the presenting part consists of two buttocks, external genitalia and two feet. it’s commonly present in multiparae (10%).

6. Frank breech ( breech with extended legs ) the thighs are flexed on the trunk and the legs are extended at the knee joints. the presenting part consists of two buttocks and external genitalia only. commonly present in primigravidae (70%); due to tight abdominal wall, good uterine tone and early engagement of breech.

7. Etiology Smaller size of fetus and comparatively larger volume of amniotic fluid allow the fetus to undergo spontaneous version by kicking movements until by 36th week when the position becomes stabilized. Known factors responsible for breech presentation: » Prematurity »Factors preventing spontaneous version »Favorable adaptation »Undue mobility of fetus »Fetal abnormality

8. Prematurity : commonest cause of breech presentation. Factors preventing spontaneous version : a) breech with extended legs b) Twins c) Oligohydramnios d) Congenital malformation of uterus like septate or bicornuate uterus e) Short cord; relative or absolute f) Intrauterine death of fetus

9. Favourable adaptation : a) Hydrocephalus; big head can be well accommodated in wide fundus b) Placenta praevia c) Constricted pelvis d) Cornufundal attachment of placenta; minimizes the space of fundus where smaller head can be placed comfortably. Undue mobility of foetus : a) Hydramnios b) Multiparae with lax abdominal wall

10. Diagnosis ABDOMINAL EXAMINATION No head is felt at the lower end and a hard, rounded knob is ballottable at the upper end of the uterus. VAGINAL EXAMINATION Confirms there is no head in the pelvis. INVESTIGATIONS Ultrasound scan confirms the situation.

11. Clinical Varieties Uncomplicated Breech defined as one where there is no other associated obstetric complications apart from breech, prematurity being excluded Complicated Breech when presentation is associated with conditions which adversely influence prognosis such as prematurity, twins, contracted pelvis, placental praevia etc. Extended legs, extended arms, cord prolapse or difficulty during breech delivery should not be called complicated breech but are called abnormal or complicated breech delivery.

12. Management of a breech presentation in pregnancy 1. From about 37 weeks onwards external cephalic version (ECV) is worth trying. External cephalic version is a process by which a breech baby can sometimes be turned from buttocks or foot first to head first. It is usually performed after about 37 weeks. It is often reserved for late pregnancy because breech presentation greatly decreases with every week

13. ECV If it works, the woman should be seen weekly to ensure the fetus stays as a cephalic presentation. If it fails, the woman should be counseled about the route of delivery. Version is performed using external manual pressure to lift the presenting part out of the pelvis and then turning the fetus around to a cephalic presentation. Success rate 40-80%. Depends on cases and obstetrician skills

14. ECV Procedure Place woman in semi-lateral position Use a powder to allow free movement of hands and get a firm grip Administer salbutamol 200 micrograms IV to relax the uterus

15. ECV Confirm fetal wellbeing whether ECV was successful or not By doing a non-stress cardiotocographic test If the mother’s blood group is RH neg : 100 micrograms anti-D IG serum must be given after attempting ECV

16. Risks ECV complications: Rupture of membranes Abruptio placentae Tightening of loop of umbilical cord Feto -maternal hemorrhage Ruptured uterus (rare) Contraindications to doing ECV Pregnancy < 37 weeks Rupture of Membranes Antepartum hemorrhage Multiple pregnancy Other Indication for C/S HIV seropositivity Relative Contraindications Previous C/S Suspicion of placenta insufficiency HT disorder in pregnancy

17. 2. Vaginal breech delivery VS Caesarean section

18. Vaginal Breech Delivery In a breech delivery, the head (the largest part of the fetus) is coming last and it is too late to wait and see if this fits the pelvis. Therefore an estimate of the chances of delivery has to be made on the ultrasound measurements. It is wise to deliver most breech presentations by 41 weeks. If the woman has not gone into spontaneous labour before this time then induce or do an elective Caesarean section. If there is any other variation from normal, many obstetricians will deliver a breech presenting baby by elective Caesarean section at 38–39 weeks.

19. Conducting a Breech Delivery: Precautions Labour to be conducted in a hospital with C/S facilities IV infusions must be set up with large bore cannulas Continuous electronic fetal monitoring Epidural anaesthesia may be beneficial Latent phase not to exceed 8 hours Partogram -monitored labour progress not to be less than 1cm/hour of cervical dilatation in the active phase Oxytocin Augmentation is not allowed An experienced midwife or Obstetrician must be available

20. C/S preferred mode of delivery Some women may present in 2 nd stage, when it may be too late to do a C/S Lithotomy position is preferred Others

21. Management of a breech presentation in labour FIRST STAGE Increased risk of early rupture of the membranes. When they do a vaginal examination should exclude a prolapse of the cord. An epidural anaesthetic is a good method of pain relief as the normal delivery can rapidly be changed to an operative one if necessary (but is not mandatory).

22. Second Stage Delivery is by the most senior obstetrician or midwife available with an anaesthetist and a paediatrician close to the labour ward. A propped up dorsal position of the mother is the easiest to manage. The labour bed should be capable of breaking in the middle for delivery of the baby’s body, so that the mother can assume a lithotomy position. The buttocks progress down the birth canal and, when on the point of crowning, an episiotomy may be required. The baby is rotated to sacroanterior . Chin to Pubis delivery should be avoided at all costs. The baby will often progress as far as the umbilicus with the mother’s own expulsive efforts. The legs are assisted down, especially if extended. Commonly, the arms are flexed across the chest and so delivery occurs readily with the next contraction.

23. If the arms are extended they have to be manipulated down. After delivery of the body, it is allowed to hang and traction may be gently applied to the legs until the suboccipital region appears under the maternal pubis. The head is delivered slowly by placing one finger in the baby’s mouth or gently flexing the head with forceps, the blades applied to either side of the fetal head from the front of the body which is held up by an assistant. The rest of the head is slowly delivered, not allowing any sudden decompression which could result in pressure alterations inside the skull and so cause intracerebral venous bleeding. The head should not be allowed to pop out as sudden decompression of the skull may cause intracranial injuries.

24. Maneuvers to assist delivery of the fetal head Several methods have been described to primarily prevent the head from popping out of the vaginal canal. Mauriceau-Smellie Veit method Burns-Marshall method Forceps delivery Loveset maneuver

25. Maneuvers

26. Third stage Syntometrine is given with the delivery of the head for there is an increased risk of PPH. The placenta is delivered as described in normal labour .

27. Risks to the fetus of breech delivery Intracranial damage Hypoxia at the time of delivery (too slow delivery of the head). Cord Prolapse (poorly fitting presenting part) Physical injury (obstetric maneuvers)

28. References Diana Hamilton, 2004. Obstetrics and Gynaecology Lecture Notes. Second edition. Blackwell Publishing Inc Cronje H.S, Cilliers J, Pretorius M, 2011. Clinical Obstetrics, a South African perspective. Van Schaik Publishers Inc