Adam Fogel, Christopher Elliot, Miso Gostimir Breech Presentation Adam Fogel, Christopher Elliot, Miso Gostimir

Case A 32 yo G3T2P0A0L2 woman presents for routine prenatal care at 37 weeks. Her pregnancy is complicated by Rh-negative status, depression and a history of LSIL with normal colposcopy in first 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.

Outline & Objective Objective: List strategies for management of abnormal fetal presentations, as well as the relative timing of each intervention. Specific Goals: Review Types of Breech presentation Review Risk Factors for Breech presentation Discuss Management of Breech, antepartum and intrapartum

What is Breech Presentation?

What is Breech Presentation? Breech Presentation:  the presenting fetal part is the buttocks 60% 10% 30% Legs folded with feet at the level of the buttocks (Knees flexed) Legs Point up with feet by baby’s head (knees extended) One or both feet point down so the legs would emerge first

Epidemiology Occurs in 3-4% of term pregnancies Higher incidence in early pregnancy (14%) Many of these cases will spontaneously convert to vertex by term Risk Factors: Previous breech delivery Preterm gestation (25% < 28 weeks, only 3-4% at term) Uterine anomalies (septate Uterus, Fibroids) Placental Anomalies (Placenta previa, Polyhydramnios, Oligohydramnios) Congenital anomalies (Hydrocephaly, Anencephaly ) Multiparity Advanced Maternal Age Aneuploidy Low birth weight (20-30% of breech babies)

Breech vs Cephalic Presentation Increased neonatal morbidity Increased perinatal or neonatal mortality Increased short-term maternal morbidity But Why? High prevalence of fetal anomalies Higher risk of prematurity Higher chance of umbilical cord prolapse Higher birth traumas

Diagnosis & Management - Antepartum Leopold Maneuver – find head in upper abdomen Ultrasound Assessment – confirm breech position If NO U/S available C-section recommended Management: External Cephalic Version Vaginal Delivery Considered Consider booking a C-section date

Management – Antepartum - ECV External Cephalic Version (ECV) Push on mothers abdomen to turn fetus to achieve a vertex presentation ~50% ECV procedures are successful (5-10% flip back to breech) Criteria: < 37 weeks Singleton pregnancy Unengaged presenting part Reactive Non-stress test Anti-D recommended in RH negative women ECV = Reduced non-cephalic vaginal birth, RR 0.46 (95% CI 0.33 to 0.62)

External Cephalic Version (ECV) https://www.youtube.com/watch?v=qT2jBxVoOQc

Management – Antepartum - ECV Contraindications: Risks of the procedure: Previous T3 bleed Prior C-section Previous myomectomy (removal of fibroids) Oligohydramnios PROM Placenta Previa Abnormal U/S or suspected IUGR Nuchal cord Hypertension Uteroplacental insufficiency Rupture of membranes Placental abruption Preterm birth Cord accidents

How to get from:

Management – Intrapartum –Vaginal Delivery GA > 37 weeks & fetal weight between 2500-3800g Induction of labour NOT recommended. Contraindications: Cord presentation Fetal growth restriction or macrosomia Any presentation other than frank or complete with flexed or neutral head attitude Inadequate maternal pelvic (can be clinically measured) Fetal anomaly not compatible with vaginal delivery Continuous Fetal heart rate monitoring suggested in 1st stage, and required in second stage of labour If absence or inadequate process of labour  C-section Near OR & must be able to perform C-section in 30 minutes

Management – Intrapartum –C-section Indications: Footling presentation Dystocia Any contraindication for vaginal delivery Patient preference (informed consent) Planned C-sections vs Breech Delivery have: Reduced neonatal morbidity, RR 0.33 (95% CI 0.19 to 0.56) Reduced perinatal or neonatal death, RR 0.29 (95% CI 0.10 to 0.86) increased short-term maternal morbidity RR 1.29 (95% CI 1.03 to 1.61)

Management? Music Breech tilt – raise hips 30 cm off floor for 10-15 min 3x a day & concentrate on baby without tensing your body Chiropractic care Moxibustion – burn “mugowrt” near acupressure point of pinky toes Hypnosis

Moxibustion

Case A 32 yo G3T2P0A0L2 woman presents for routine prenatal care at 37 weeks. Her pregnancy is complicated by Rh-negative status, depression and a history of LSIL with normal colposcopy in first 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.

Case Review At 37 weeks – can consider External Cephalic Version RH negative = would need to give WinRHO Frank Breech = can consider vaginal delivery (assume no contraindications met) Discussion with the patient about options What would you recommend?

References SOGC Guidelines – Vaginal Delivery of Breech Presentation http://sogc.org/guidelines/vaginal-delivery-of-breech-presentation/ Obstetrics and Gynecology 6th edition by Beckmann UpToDate – Breech Presentation Americanpregnacy.org http://americanpregnancy.org/labor-and-birth/breech-presentation/ Toronto Notes 2014