BREECH PRESENTATION

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.

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

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

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

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 ……..

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.

Breech Presentation Mode of delivery: Vaginal: Criteria: Frank or complete breech 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, prev.c/s, pet … etc Preferably epidural analgesia

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

SOME OBSTETRIC COMPLICATIONS OF BREECH PRESENTATION 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

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

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???????

Caesarean section is safer 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

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

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