1. BREECH PRESENTATION

2. 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.

3. 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

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

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

6. 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 ……..

7. 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.

8. Breech Presentation Mode of delivery: Vaginal: Criteria:
Frank or complete breech presentation
Gestational age > 36 weeks
Estimated foetal weight b/n 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

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

10. 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

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

12. 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???????

13. 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

14. 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

15. 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