Breech Presentation

Question 1

Definition and Epidemiology:

1. Definition
2. Epidemiology
3. Types

Answer 1

1. buttock presentation
2. 3% term pregnancies, 25% premature labour.
3. Extended/frank(70%), Flexed/complete(15%), Footling(15%)

Question 2

AETIOLOGY:

Answer 2

Previous breech(8%), prematurity.

1. Fetal abn.
2. Placenta praevia
3. Twins(2nd twin often breech)
4. Fibroids
5. Pelvic tumours
6. Pelvic deformities
7. Lax uterus due to multiparity
8. Poly/oligohydraminos

Question 3

DIAGNOSIS:

Answer 3

1. Abdominal palpation.

2. US

Question 4

COMPLICATIONS;

Answer 4

1. Increase long term perinatal morbidity and mortality
2. Labour hazardous, might require Caesarean section
3. increased rate of cord prolapse.
4. higher rate of fetal abn ie neurological handicap.
5. Birth asphyxia

Question 5

EXTERNAL CEPHALIC VERSION(ECV)

Answer 5

• from 36w in nulliparous, 37w in multiparous
• where ECV fails, only 3% turn spontaneously before delivery.
• success rate 30-80%
• about 3% successful ECV turn back.
• May administer uterine relaxant, no anaesthetic.
• US-guidance
• CTG at admisison and after ECV.
• Anti-D if Rh negative.
• Complications: Low risk of fetal dmg, placental abruption, uterine rupture. Immediate Emergency C-section in 0.5%.
• Absolute Contraindications: C-section req, APH within last 7d, abn. CTG, major uterine anomaly, ruptured membranes, multiple pregnancy(exclude 2nd twin)

-Relative contraindications: SGA w abn Doppler, pre-eclampsia, oligohydraminos, major fetal anomalies, scarred uterus, unstable lie.

• factors affecting lower success rate: nulliparity, Caucasian, breech engaged and head not easily palpable, high uterine tone, high BMI, reduced liquor volume
• max 3 attempts.
• if unsuccessful, elective C-section/vaginal breech delivery.
• report if reduced fetal movements, bleeding, SRM

Question 6

CAESAREAN SECTION:

Answer 6

1. Indications: ECV failed/contraindicated/presentatiion missed.
2. Benefits: reduces neonatal mortality by about 1% and short-term morbidity. no effect on long-term outcomes.
3. > 1/3 attempts at vaginal breech delivery end in Emergency C-section, higher maternal risks > elective procedure.
4. Increased risk of serious immediate complications compared to planned vaginal birth, uncertain of long-term effects on future pregnancy outcomes.

Question 7

VAGINAL BREECH DELIVERY:

• frank/flexed breech
• fetal W <3800g
• No hyperextension of fetal head

CI: placenta praevia, big baby, IUGR(<2000g), compromised fetal condition, footling/kneeling breech, clinically inadequate pelvis, hyperextended fetal neck in labour, lack of presence of trained clinician, prev. C-section.

Answer 7

1. Risky w fetus >4kg, evidence of fetal compromise, extended head/footling
2. Usually epidural analgesia, CTG, pushing only when buttocks visible, slow cerrvical dilatation in 1st stage/poor descen tin 2nd. Usually indicates C-section
3. 10% req skill. Episiotomy, arms hooked and swept down over chest, Lovset’s procedure if X reach arms, Mauriceau-Smellie-veit/Burns-Marshall manoeuvre, forceps if this fails to deliver head.
4. Upright positions most effective.
5. Labour augmentation not recommended.