Breech

Question 1

What is breech presentation?

Answer 1

• the lie is longitudinal and the buttocks are in the lower pole of the uterus and is the presenting part
• the presenting diameter is bi trochanteric 10cm
• the denominator is the sacrum
• occurs in 3-4% of pregnancies at term

Question 2

What are the 3 variations of breech presentation?

Answer 2

• extended breech (frank) —> presents with flexion at the hips and extension at the knees so that the feet are lying near the fetal head which results in a well-fitting pp
• flexed breech (complete) —> the flexed breech presents with flexion at the hips and knees with the feet beside the buttocks which results in a poor fitting presenting part and increases the risks of early SROM and cord prolapse
• footling breech (incomplete) —> presents with extension at both the hips and the knees leading to one or both feet or knees presenting, high risk of cord prolapse

Question 3

What are the pre-disposing factors?

Answer 3

• premature labour
• multiple pregnancy
• contracted pelvic inlet
• IUGR
• grand multiparity
• polyhydramnios
• oligohydramnios
• uterine anomalies (bicornate uterus)
• pelvic tumour or fibroids
• placenta praevia
• congenital abnormality e.g. hydrocephaly

Question 4

What is the definition of breech birth?

Answer 4

• the baby descends in the birth canal and is born by the expulsive efforts and movements of the mother and baby without traction from the attending practitioner

Question 5

What is the definition of a breech delivery?

Answer 5

• where manoeuvres are used to facilitate the birth of the baby, skill is needed, risks increase, lithotomy in itself is an intervention, more of a medical approach

Question 6

What is the mechanism of labour with breech presentation?

Answer 6

• The sacrum is anterior and enters the pelvis in a slightly lateral or direct anterior position , internally the genital cleft would be felt in the oblique or anterior posterior diameter of the pelvis
• the baby descends to the pelvic floor and rotates to the sacro lateral position, the midwife should observe for distension of the perineum, dilatation of the maternal anus and gaping of the vulva, the genital cleft will be visible at the perineum in the transverse diameter
• as the buttocks are born, rotation occurs and the shoulders enter the pelvic brim in the oblique or transverse position, at this point the midwife should observe the colour of the baby and the fetal HR, the anterior buttock is usually born first then the posterior buttock sweeps the perineum and is born with the help of the baby making lateral movements of its hips, the baby rotates to sacro anterior
• further descent of the head into the midcavity of the pelvis and rotates to bring the saggital suture into the AP diameter of the pelvis, the anterior arm and shoulder are usually released first, then slight rotation may occur either way to free the second arm in the oblique
• the head flexes and the chin is brought onto the chest, the midwife should continue to note colour of baby and cord, the arms, shoulder and neck are born (have hands poised)
• maternal movement moves her pelvis round the flexed head, the baby often lifts both its knees/legs which aids flexion, the chin, mouth and nose will sweep the perineum
• the occiput will pivot on the internal aspect of the symphysis pubic, most women at this point will drop their hands and knees or position themselves to their spine is horizontal (guide her to move if she does not), now gentle hands on to support babies weight, ease out the vault of the head by supporting the weight of the baby

Question 7

What are the assisted manoeuvres that may be used in vaginal breech birth?

Answer 7

• spontaneous birth of the limbs and trunk is preferable but the legs may need to be released by applying pressure to the popliteal fossae (extended legs manoeuvre)
• when handling the baby it is important to ensure that support is provided over the bony prominences of the iliac crests to the reduce the risk of soft tissue internal injury
• continue to allow hands off as much as possible, if arms require assistance perform Lovsett’s manoeuvre
• allow hands off birth of shoulders and neck, when the nape of the neck I visible, flex baby’s head by placing fingers of one hand on the baby’s shoulders ad back of the head and the 1st, 3rd fingers of the other hand on the baby’s cheek bones to aid flexion of the head (Mauriceau-Smelliie Veit)

Question 8

What are some of the fetal risks associated with vaginal breech birth?

Answer 8

• intrapartum death
• intracranial haemorrhage
• HIE
• brachial plexus injury
• rupture of the liver, kidney or spleen
• dislocation of the neck, shoulder or hip
• fractured clavicle, humerus or femur
• cord prolapse