Breech Presentation

By, Ashrith K.C. Shimoga Institute Of Medical Sciences, Shimoga, K’taka, India

Definition

The presentation that the fetus is in longitudinal lie and the podalic pole presents at pelvic brim.

Incidence

Thus in 3 out of 4, spontaneous correction into vertex presentation occurs at 34th week.

The incidence is low in hospitals where high parity births are minimal and routine cephalic version is done in antenatal period.

Types of breech

Complete ( Flexed breech )

flexed at hips and flexed at knees. the presenting part consists of two buttocks,external genitalia and two feet. it’s commonly present in multiparae(10%).

Incomplete Breech

due to varying degree of extension of thighs or legs at podiac pole.

3 varieties possible:

» Frank breech ( breech with extended legs )

» Footling presentation (25%)

» Knee presentation

» Frank breech ( breech with extended legs ) the thighs are flexed on the trunk and the legs are extended at the knee joints.

the presenting part consists of two buttocks and external genitalia only.

commonly present in primigravidae (70%); due to tight abdominal wall, good uterine tone and early engagement of breech.

» Footling presentation (25%)

both the thighs and legs are partially extended bringing legs to present at brim.

» Knee presentation

thighs are extended but knees are flexed, bringing the knees down to present at the brim.

Clinical VarietiesUncomplicated Breech defined as one where there is no other associated obstetric complications apart from breech, prematurity being excluded.

Complicated Breech when presentation is associated with conditions which adversely influence prognosis such as prematurity, twins, contracted pelvis, placental praevia etc.

Extended legs, extended arms, cord prolapse or difficulty during breech delivery should not be called complicated breech but are called abnormal or complicated breech delivery.

Etiology Smaller size of foetus and comparatively larger

volume of amniotic fluid allow the foetus to undergo spontaneous version by kicking movements until by 36th week when the position becomes stabilized.

Known factors responsible for breech presentation:

»Prematurity

»Factors preventing spontaneous version

»Favourable adaptation

»Undue mobility of foetus

»Foetal abnormality

» Prematurity: commonest cause of breech presentation.

» Factors preventing spontaneous version: a) breech with extended legs

b) Twins

c) Oligohydramnios

d) Congenital malformation of uterus like septate or bicornuate uterus

e) Short cord; relative or absolute

f) Intrauterine death of foetus

» Favourable adaptation:

a) Hydrocephalous; big head can be well accommodated in wide fundus

b) Placenta praevia

c) Contracted pelvis

d) Cornufundal attachment of placenta; minimizes the space of fundus where smaller head can be placed

comfortably.

» Undue mobility of foetus:

a) Hydramnios

b) Multiparae with lax abdominal wall

» Foetal abnormality:

a) trisomies 13, 18, 21

b) anencephaly

c) myotonic dystrophy due to alteration of foetal muscular tone and

mobility.

Recurrent Breech: On occasion the breech presentation recurs in successive pregnancies. When it recurs in 3 or more consecutive pregnancies, it’s called Recurrent Breech.

Cause:

» Congenital malformation of uterus; Septate or bicornuate

» Repeated cornufundal attachment of placenta

Diagnosis

» Clinical:

a) Per abdomen

b) Per vaginam

» Sonography:

» Clinical diagnosis:

» Sonography:

1) It confirms the clinical diagnosis

2) It can detect foetal congenital abnormality

3) Type of breech

4) It measures biparietal diameter, gestational age

and approximate weight of foetus

5) Localises the placenta

6) Assessment of liquor volume (Important for ECV)

7) Attitude of the head

Positions: The sacrum is the denominator of the breech and there are 4 positions.

In anterior positions, the sacrum is directed towards iliopubic eminence.

In posterior positions the sacrum is directed to sacro-iliac joint.

The positions are:

(1.) 1st position – Left sacro-anterior (LSA) – being comonest

(2.) 2nd position – Right sacro-anterior (RSA)

(3.) 3rd position – Right sacro-posterior (RSP)

(4.) 4th position – Left sacro-posterior (LSP)

Thank you