Student Conference: Breech Presentation

1. Student Conference:Breech Presentation Michael Hale Chris Hong James Ross

2. The Case A 32 yo G3T2P0A0L2 woman presents for routine prenatal care at 37 weeks. Her pregnancy is complicated by the following: • Rh-negative status • Depression • History of LSIL with normal colposcopy in 1st trimester Today she reports good fetal movement and denies leaking fluid or contractions. During your examination you measure fundal height at an appropriate 37 cm, and find fetal heart tones located in the upper aspect of the uterus. A bedside ultrasound reveals frank breech presentation.

3. Breech Presentation • Most babies have head first or cephalic presentation. • A breech presentation is when the buttocks or lower extremities present first.

4. Prevalence • 3-4% of term pregnancies; 25% of pregnancies before 28 weeks. • More common in early pregnancy – the incidence decreases with an increase in gestational age. • Spontaneous version may occur at any time before delivery.

5. Types • Three main types: 1. Frank breech: hips are flexed and knees are extended (50-70%) 2. Complete breech: both hips and knees are flexed (5-10%) 3. Incomplete breech: One or both hips are not completely flexed (10-40%)

6. Types (cont.) http://birthwithoutfearblog.com/wp-content/uploads/2010/10/BreechPositions2.jpg

7. Types (cont.) • For an incomplete breech you may have one of the following: • Footling breech: feet are presenting first • Kneeling breech: knees are presenting first *It is important to note that morbidity and mortality for both mother and fetus are higher in the breech position, regardless of gestational age or mode of delivery

8. Diagnosis • Usually based on physical exam – Leopold maneuvers. • If breech presentation persists or diagnosis is uncertain a confirmatory US is recommended. • Occasionally detected by vaginal exam during labor.

9. Leopold Maneuvers

10. Risk Factors Maternal Factors • Contracted Pelvis • Uterine abnormalities including shape irregularities, intrauterine tumours, and fibroids • Extrauterine masses causing compression • Grand multiparity

11. Risk Factors (cont.) Maternal-Fetal Factors • Placenta previa • Amniotic fluid (oligo/polyhydramnios) Fetal Factors • Prematurity • Multiple gestation • Congenital malformations (6% of breeches) • Aneuploidy • Abnormal fetal tone

12. Antepartum Management • External cephalic version (ECV) • Used to convert a breech to a cephalic presentation • Increases the likelihood of cephalic vaginal birth • Overall success rate of 65%

13. ECV • Indications • <37 wk, singleton, unengaged presenting part, reactive NST • Performed around 34-35 wks of gestation • Good prognostic factors: multiparous, good fluid volume, small baby, skilled obstetrician • Contraindications • Previous T3 bleed, prior classical C/S, previous myomectomy, oligohydramnios, PROM, placenta previa, abnormal U/S, suspected IUGR, hypertension, uteroplacental insufficiency, nuchal cord

14. Intrapartum Management • Cesarean vs. vaginal delivery • Preferred option: external cephalic version with planned cesarean delivery for women with persistent breech presentation • Vaginal breech birth is associated with prolonged umbilical cord compression and delivery-related trauma • Since the risks are small, planned vaginal delivery is an acceptable alternative for women who meet selection criteria

15. Criteria for Vaginal Delivery • Frank or complete breech, GA >36 wks • EFW 2,500-3,800g based on clinical and U/S assessment • Fetal head flexed • Continuous fetal monitoring • 2 experienced obstetricians, assistant, and anesthetist present • Ability to perform emergency C/S within 30min if required

16. Method for Vaginal Breech Delivery • Encourage effective maternal pushing efforts • At delivery of after-coming head, assistant must apply suprapubic pressure to flex and engage fetal head • Delivery can be spontaneous or assisted; avoid fetal traction • Apply fetal manipulation only after spontaneous delivery to level of umbilicus

17. Cesarean Section Recommended if: • The breech has not descended to the perineum in the 2nd stage of labor after 2h of active pushing • Vaginal delivery is not imminent after 1h of active pushing

18. Management: Rh-Negative Status • 300 micrograms of Rhogam should be administered at 28 weeks as is routine • Rhogam should also be administered any time there is a heightened risk of blood mixing between mother and fetus • External cephalic version presents such a risk

19. Management – LSIL • LSIL: Low Grade Squamous Intra-epithelial Lesions

20. Management: Depression • Depression is common during pregnancy (1/10 pregnant women). • Depressed women are less likely to take care of themselves, more likely to resort to drugs, smoking or alcohol, and have a higher risk of preeclampsia • Biopsychosocial approach: psychotherapy +/- antidepressants

21. Summary • Breech presentation is when buttocks or lower extremities present first • Both maternal and fetal risk factors increase the risk of a breech presentation. • At time of delivery the patient will need to undergo a vaginal breech delivery or a Caesarian section (>37 weeks).

22. Questions? ?