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.

Incidence:

> 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

Breech Presentation

Breech Presentation Etiology:

1. Prematurity

2. Congenital anomalies, 6% {2-3%}>>> anencephaly,hydrocephalus

3. Uterine anomalies, septate….

4. Multiple gestation

5. Placenta praevia

6. Ployhydramnios

7. Pelvic tumours, fibroids… ovarian..

Breech Presentation

Diagnosis :

i. Clinical examination:

abdominal

vaginal

ii. Radiological examination:

x-ray

ultrasound scan

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:

Contra-indications ……..

• 45-80% success rate

• 5% revert back to breech

• Protocol to avoid complications

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.

Breech Presentation Mode of delivery:

1. Vaginal:Vaginal:

Criteria:

a) Frank or complete breech presentation

b) Gestational age > 36 weeks

c) Estimated foetal weight b/n 2.5-3.5 kg

d) Foetal head must be flexed

e) Adequate maternal pelvis, x-ray or ct pelvimetry ???

f) No other obstetric complications, prev.c/s, pet … etc

g) Preferably epidural analgesia

Breech Presentation Types of vaginal breech delivery:

1. Spontaneous breech delivery

2. Assisted breech delivery

3. Breech extraction

Mechanism of delivery:

SOME OBSTETRIC COMPLICATIONS OF BREECH PRESENTATION

COMPLICATION 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

Mode of delivery:2. Caesarean Section:# Indications

1. Any abnormality of the bony pelvis 10. Footling breech

2. Foetal weight > 3.5 kg 11.Preterm labour

3. Hyperextension of foetal head 12. Previous c/s

4. Previous difficult labour 13. PRIMIGRAVIDA

5. IUGR

6. Bad obstetric history

7. Diabetes

8. Severe pre-eclampsia

9. Failure to progress in first stage or descent in second stage

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???????

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:::::::::

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

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