Breech presentation Breech presentation

By By

Dr.Dr. Khattab KAEO Khattab KAEO

Prof &Prof & Head of Obstetrics and Head of Obstetrics and Gynaecology Gynaecology Department Department

FacultyFaculty of Medicine, Al-Azhar of Medicine, Al-Azhar UniversityUniversity, , DamiettaDamietta

The fetal buttocks enter the pelvis first. The fetal buttocks enter the pelvis first.

Incidence: 3-4% (1:30) at term. 15% at 29-32 weeks' gestation.

Types: * Frank with flexed hips but extended knees = 50-70%. * Complete with flexed hips and knees =10%. * Incomplete with one or both feet or knees lie below the buttocks (footling & knee pre-sentation) = 10-25%.

Types of breech presentationTypes of breech presentation

Positions:Positions: Sacrum is the denominator making 8 positions: Sacrum is the denominator making 8 positions:

sacrto-anterior (Rt, Lt & direct), sacro-transverse sacrto-anterior (Rt, Lt & direct), sacro-transverse (Rt & Lt) and sacro-posterior (Rt, Lt & direct). (Rt & Lt) and sacro-posterior (Rt, Lt & direct).

Sacro-anterior is more common because concavity Sacro-anterior is more common because concavity of the front of the fetus fits into convexity of the of the front of the fetus fits into convexity of the

maternal lumbar spine. maternal lumbar spine.

Predisposing factors are conditions that decrease Predisposing factors are conditions that decrease polarity of the uterus, increase or decrease the polarity of the uterus, increase or decrease the fetal motility, or block the presenting part from fetal motility, or block the presenting part from the pelvis. These include: the pelvis. These include:

- Prematurity. The commonest cause (50%). - Prematurity. The commonest cause (50%). - Multiparity. - Multiparity. - Multiple pregnancy. - Multiple pregnancy. - Polyhydramnios. - Polyhydramnios. - Oligohydramnios. - Oligohydramnios. - Uterine anomalies- Uterine anomalies recurrent breech presentation recurrent breech presentation - Pelvic tumour. - Pelvic tumour. - Fetal anomaly as hydrocephaly. Persistent breech - Fetal anomaly as hydrocephaly. Persistent breech

may predict a neurologically abnormal fetus.may predict a neurologically abnormal fetus.- Extension of the legs. - Extension of the legs. - Idiopathic: 20%. - Idiopathic: 20%.

Contracted pelvis is not a factor in breech presentation Contracted pelvis is not a factor in breech presentation NB: Breech presentation at ≥25 w is associated with NB: Breech presentation at ≥25 w is associated with

increased risk of malpresentation at delivery. increased risk of malpresentation at delivery.

Diagnosis:Diagnosis: There may be past history of There may be past history of breech presentation or transverse lie. breech presentation or transverse lie.

* During pregnancy: There may be * During pregnancy: There may be dyspepsia & pressure symptoms in the dyspepsia & pressure symptoms in the upper abdomen. The fetal head occupies upper abdomen. The fetal head occupies the fundus, while the breech is felt by the fundus, while the breech is felt by the 1st pelvic grip. Ultrasound the 1st pelvic grip. Ultrasound examination helps to confirm the examination helps to confirm the diagnosis, exclude congenital anomalies diagnosis, exclude congenital anomalies & determine extension of the head. It & determine extension of the head. It can also roughly estimate fetal weight. can also roughly estimate fetal weight.

* During labour: 1/3 During labour: 1/3 are not diagnosed are not diagnosed until during labour. until during labour. Diagnosis depends Diagnosis depends on detecting 3bones on detecting 3bones the sacrum and 2 the sacrum and 2 ischial tuberosities.ischial tuberosities.

Differential diagnosis:Differential diagnosis: Frank breech is to be differentiated from Frank breech is to be differentiated from

vertex during abdom exam, because the vertex during abdom exam, because the extended legs may prevent ballottement extended legs may prevent ballottement of the head & the small breech may be of the head & the small breech may be mistaken for the head. mistaken for the head.

On PV exam, it should be differentiated On PV exam, it should be differentiated from face as the anus may be mistaken for from face as the anus may be mistaken for the mouth. However, the anus reflexly the mouth. However, the anus reflexly grips on the examin. finger & we can grips on the examin. finger & we can recognise the sacral spines. The mouth is recognise the sacral spines. The mouth is lax and has firm gums. lax and has firm gums.

The foot may be mistaken for a hand. Wrist The foot may be mistaken for a hand. Wrist of a dorsiflexed hand may resemble a heelof a dorsiflexed hand may resemble a heel However, if fingers are run from wrist to However, if fingers are run from wrist to palm, the 'heel' will disappear; while, if palm, the 'heel' will disappear; while, if toes are run from ankle to sole, the heel toes are run from ankle to sole, the heel will persist Toes form a straight line, while will persist Toes form a straight line, while fingers fingers unequal lengths & form a curve. unequal lengths & form a curve.

Mechanism of deliveryMechanism of delivery::

Sacro-anterior

Mechanism of deliveryMechanism of delivery::

Sacro-posterior

Complications:Complications: Fetal:Fetal: - Perinatal mortality (3-4-x - Perinatal mortality (3-4-x ) and morbidity are ) and morbidity are

mainly due to prematurity, birth trauma & mainly due to prematurity, birth trauma & associated congenital anomalies (2-3-x associated congenital anomalies (2-3-x ). The ). The commonest cause of mortality is intracranial commonest cause of mortality is intracranial haemorrhage as there is no enough time for haemorrhage as there is no enough time for moulding of the head. Rmoulding of the head. R// Maternal administr. Maternal administr. of vitamin K and slow delivery of the head. of vitamin K and slow delivery of the head.

- The incidence of cord prolapse - The incidence of cord prolapse (0.5%) (0.5%) with frank with frank breech is the same as with cephalic present. breech is the same as with cephalic present. The incidence of cord prolapse with The incidence of cord prolapse with complete breech is 5%, with footling 15%. complete breech is 5%, with footling 15%.

- Fracture dislocation of the cervical spine. The - Fracture dislocation of the cervical spine. The fetus should not be moved towards the fetus should not be moved towards the mother's abdomen until the suboccipital mother's abdomen until the suboccipital region appears below the symphysis pubis. region appears below the symphysis pubis. Also, the fetus should not be moved >90Also, the fetus should not be moved >90. .

- Retained aftercoming head for >10 min. - Retained aftercoming head for >10 min. - Rupture of abdominal organs.Rupture of abdominal organs. Maternal: Maternal: Mainly increased risk of birth trauma, Mainly increased risk of birth trauma,

particularly operative delivery. particularly operative delivery.

Thank youThank you