27.Breech presentation

Question 1

what is Breech presentation?

Answer 1

Occurs when the fetal buttocks or lower extremities present into the maternal pelvis.

Incidence is approx. 4% of all deliveries.

Question 2

what is the most important factor predisposing to breech presentation?

Answer 2

prematurity
20-30% of all breeches are of low birth weight (< 2500 g)

Question 3

risk factors for breech presentation

Answer 3

1. fetal structure anomalies (hydrocephalus)- restrict the ability of the fetus to present at vertex
2. uterine anomalies
3. multiple gestations
4. placenta previa
5. hydramnios
6. contracted maternal pelvis
7. pelvic tumors

Question 4

types of breech presentation

Answer 4

Frank breech (65%)- Hip flexed, knee extended
complete breech (25%)- Hip flexed, knees flexed
incomplete (footling) breech (10%)- Hip extended (one or both),One or both knees or feet lying below the buttocks

Question 5

how is the diagnosis of breech presentation made?

Answer 5

by the Leopold examination
US may be required for definitive diagnosis

Question 6

what is external cephalic version (ECV)?

Answer 6

a procedure in which the obstetrician manually converts the breech fetus to a vertex presentation via external uterine manipulation under US guidance

Question 7

when is External cephalic version (ECV) performed?

Answer 7

considered in a breech presentation at term before the onset of labor.

*not carried out before 36-37 weeks gestation because of the tendency for the premature fetus to revert spontaneously to a breech presentation.

Question 8

why should a ECV be performed in a hospital equipped to perform an emergency cesarean delivery?

Answer 8

because of the small risk of placental abruption or cord compression.

Question 9

what is the current standard of care in case of breech presentation?

Answer 9

deliver all breech pregnancies by cesarean to avoid the potential morbidities of umbilical cord prolapse, head entrapment, birth asphyxia, and birth trauma

Question 10

what are Piper forceps?

Answer 10

forceps used in breech vaginal delivery
shown to result in delivery of the head with the least amount of trauma to the fetus.

Question 11

Criteria for performing vaginal breech delivery

Answer 11

• Frank or complete breech
• Favorable pelvis (clinical evaluation, radiograph, MRI, CT pelvimetry)
• Flexed head
• Estimated fetal weight 2000-3800 g
• Gestational age > 36 w’
• No other maternal/fetal indications for cesarean delivery

Question 12

why is it so important for premature breech fetuses to be delivered by cesarean delivery

Answer 12

head-abdominal size disparity
can result in fetal asphyxia and birth trauma