ObjectivesIncidence and SignificanceSelectionManagementIntrapartumDelivery

Definitionlongitudinal liebreech or lower extremity presentingcephalic pole in the uterine fundus

Typesfrank- flexed hips, extended kneescomplete- flexed hips, flexed kneesfootling- extended hip(s)

Types of BreechCompleteFootlingFrank

Incidence3 to 4% of all pregnanciesincreases with decreasing gestational age 7 to 10% at 32 weeks 25 to 35% at < 28 weeks

Etiology of Breech Presentation

idiopathicprematurity (head to trunk size)uterine or pelvic structural abnormalityuterine fibroidfetal anomaly or abnormalitypolyhydramniosmultiple gestation

Diagnosis maternal perception of movementLeopolds maneuversFH auscultated above umbilicusvaginal examultrasoundX-ray

Recommendations for Breech Deliveryrecommend trial of labour at 36 weeks or when estimated weight is 2500 to 4000 gramsoffer trial of labour at 31 to 35 weeks gestation or when estimated weight is 1500 to 2500 gramsoffer caesasean section at 30 weeks gestation or when estimated weight is < 1500 grams*no recommendation for when estimated weight is > 4000 grams* * acknowledged lack of evidence for recommendation

Selection Criteria for Trial of Labourfrank or complete breechfetal head not hyperextendedestimated fetal weight 2500 to 4000g

Ultrasound Assessmentconfirm lie and type of breechassess head positionobtain estimate of fetal weightassess for IUGR and congenital anomaliesassess amniotic fluid volumeconfirm placental localization

Contraindications to Trial of Labourfetal or maternal contraindication to labourfootling breechhyperextension of the fetal headabsence of informed consentabsence of experienced maternity health care giver

Management in Labourplanned delivery in hospitaladmission in early labour or with ROMappropriate fetal surveillanceepidural and ARM for usual indicationsimmediate vaginal exam at ROM to rule out cord prolapsegood progress in labour ( 0.5 cm/h after 3 cm)induction and augmentation permissible

Management at Deliveryexperienced newborn resuscitator presentempty maternal bladdermaternity attendant with experience in breech delivery forceps if available, may be helpful

Entering the PelvisObstetrics - Normal and Problem Pregnancies, 2nd EditionEdited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

Descent of the BreechObstetrics - Normal and Problem Pregnancies, 2nd EditionEdited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

Spontaneous ExpulsionObstetrics - Normal and Problem Pregnancies, 2nd EditionEdited by SG Gabbe, JR Niebyl, JL Simpson. (1991)spontaneous expulsion to the umbilicusthe sacrum should be gently guided anteriorlysingleton breech extraction is contraindicatedC/S is indicated for failure of descent or expulsion

Hurry up & Wait!

DONT PULL!traction deflexes the fetal headmay cause nuchal armObstetrics - Normal and Problem Pregnancies, 2nd EditionEdited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

Deliver Legs by lateral rotation of thighs and flexion of knees - keep sacrum anteriorObstetrics - Normal and Problem Pregnancies, 2nd EditionEdited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

Delivery of Armsgood maternal pushingdeliver when winging of scapulae seenrotate arm to anteriorsweep humerus across the chest and deliverrotate other arm anterior and repeat to deliverObstetrics - Normal and Problem Pregnancies, 2nd EditionEdited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

Avoid Over-extensionObstetrics - Normal and Problem Pregnancies,2nd EditionEdited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

Delivery of the head Mauriceau - Smellie - Veit manoeuvre to deliver the head in flexion The body should be supported in a horizontal position

Delivery of the headObstetrics - Normal and Problem Pregnancies, 2nd EditionEdited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

Delivery of the headForcepsassistant elevating babedirect applicationObstetrics - Normal and Problem Pregnancies, 2nd EditionEdited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

Prevention of Breech

consider external cephalic version at 36 weeks gestation for eligible candidatessuccess rate 30 - 70% depending on experienceresults in lower cesarean section rate

Conclusions

proper selection of patientsthorough explanation and informed consentgood progress in labour ( 0.5 cm/h after 3 cm)induction and augmentation permissibleexperienced attendantsstandard fetal monitoringassisted delivery - DONT PULL - stay cool!