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Dr. Yasir Katib mbbs , frcsc , perinatologest

BREECH PRESENTATION. Dr. Yasir Katib mbbs , frcsc , perinatologest. Presentation is delineated by the portion of the fetus that leads into the birth canal: Cephalic : Vertex, face, brow, occiput 96% Breech : frank, footling, double footling, complete 3-4% Shoulder

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Dr. Yasir Katib mbbs , frcsc , perinatologest

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  1. BREECH PRESENTATION Dr. YasirKatibmbbs, frcsc, perinatologest

  2. Presentation is delineated by the portion of the fetus that leads into the birth canal: • Cephalic: Vertex, face, brow, occiput 96% • Breech: frank, footling, double footling, complete 3-4% • Shoulder • Compound: When both the head or breech and an extremity lead into the birth canal Definitions

  3. Case Study A 26 years old primigravida was referred to the antenatal clinic at 36 weeks gestation with a history of persistent breech presentation since the 28th week. Your abdominal examination confirms the finding with fundal height of 38 weeks size. How would you manage the patient and what advice would you give the patient regarding the mode of delivery.

  4. Breech Presentation • Incidence: > 28 weeks…25% Term 2-3% 1/3 are undiagnosed in labour • Classification: 1. Frank (65%): The foetal hips are flexed and the knees areextended. 2. Complete (25%): The foetal hips and knees are flexed. 3. Incomplete (10%): The foetal feet or knees are the lowermost presenting part

  5. Breech Presentation • Etiology: • Prematurity • Congenital anomalies, 6% {2-3%}>>> anencephaly,hydrocephalus • Uterine anomalies, septate…. • Multiple gestation • Placenta praevia • Ployhydramnios • Pelvic tumors, fibroids… ovarian..

  6. Breech Presentation • Diagnosis : • Clinical examination: • abdominal • vaginal • Radiological examination: x-ray ultrasound scan

  7. Breech Presentation • Management During Pregnancy: • If persisted till 34 weeks…. Then ultrasound scan to exclude; abnormality, Ployhydramnios, placenta praevia. • By completed 37 weeks External Cephalic Version: • 45-80% success rate • 5% revert back to breech • Protocol to avoid complications • Contra-indications ……..

  8. External Cephalic Version • In delivery room • NPO and ready for c/s • CTG & USS • Tocolytic • Head down position • Dislodge breech then • gently turn around • Uss and CTG after procedure.

  9. Breech Presentation • Mode of delivery: Vaginal: • Criteria: • Frank or completebreech presentation • Gestational age > 36 weeks • Estimated foetal weight b/n 2.5-3.5 kg • Foetal head must be flexed • Adequate maternal pelvis, x-ray or ct pelvimetry ??? • No other obstetric complications, privacy/s, pet … etc • Preferably epidural analgesia

  10. Breech Presentation • Types of vaginal breech delivery: • Spontaneous breech delivery • Assisted breech delivery • Breech extraction • Mechanism of delivery:

  11. COMPLICATION INCIDENCE FETAL/NEONATAL Intrapartum foetal death 16 times (x) non-breech Intrapartum foetal asphyxia 3 to 8 x non-breech Intrapartum foetal distress ~60% (of all breech presentations Umbilical cord prolapse 2.5 % overall (18 x non-breech) Birth trauma = < 13 x non-breech Entrapment of aftercoming head ~9% (of babies > 2500 g) Perinatal/neonatal mortality(mainly intracranial hemorrhage) 3 to 5 x non-breech[25/1000 vs 1-2/1000] MATERNAL (Largely due to cesarean section) Variable SOME OBSTETRIC COMPLICATIONS OF BREECH PRESENTATION

  12. Mode of delivery: 2. Caesarean Section: • # Indications • Any abnormality of the bony pelvis 10. Footling breech • Foetal weight > 3.5 kg 11.Preterm labour • Hyperextension of foetal head 12. Previous c/s • Previous difficult labour 13. PRIMIGRAVIDA • IUGR • Bad obstetric history • Diabetes • Severe pre-eclampsia • Failure to progress in first stage or descent in second stage

  13. Caesarean section • is caesarean section safer for the foetus than vaginal delivery? • Breech mortality rate do not differ significantly b/n vaginal delivery and c/s!!!!! WHY? • Increased PM due to lethal congenital anomalies, Prematurity, birth trauma and birth anoxia • So should delivery be vaginal or abdominal???????

  14. The Answer is : The Canadian trial Multi-centric International trial to determine the safer way to deliver babies in the breech presentation……… trial had to be stopped because analysis of preliminary results showed::::::::: Caesarean section is safer

  15. Preterm Breech Presentation • 25% of < 28 weeks in breech presentation in Preterm labour of which 18% are congenitally abnormal • Has a higher antepartum stillbirth and neonatal death rate than babies presenting by the head irrespective of the mode of delivery

  16. Face presentation

  17. Brow presentation

  18. REMEMBER • High perinatal mortality in the breech baby irrespective of the mode of delivery • Reducing morbidity for vaginal breech delivery is by careful selection, clear intrapartum guide lines and expertise • Despite recent evidence, difficulty in favoring a mode of delivery due to social consideration • External Cephalic Version should be tried unless contra-indication • Preterm breech is safer to be delivered by c/s if normal

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