BREECH PRESENTATION

A breech presentation is an unusual presentation but it should not be considered abnormal as the fetus lies longitudinally with the buttocks in the lower pole of the uterus. The presenting diameter is bithrochanteric (10 cm) and the denominator the sacrum. Breech presentation occurs in 3-4% of all deliveries. The occurrence of breech presentation decreases with advancing gestational age. Breech presentation occurs in 25% of births that occur before 28 weeks gestation, in 7% of births that occur at 32 weeks, and 1-3% of births that occur at term. Perinatal mortality is increased 2- to 4 fold with breech presentation, regardless of the mode of delivery. Deaths most often are associated with malformations, prematurity, and intrauterine fetal demise.

MEANING In breech presentation, the lie is longitudinal and the podalic pole presents at the pelvic brim. It is the commonest mal presentation. DEFINITIONS MALPRESENTATION- Malpresentation is the situation where a fetus within the uterus is in any position that is not cephalic. BREECH PRESENTATION- Breech presentation is defined as a fetus in a longitudinal lie with the buttocks or feet closest to the cervix.

INCIDENCE This occurs in 3-4% of all deliveries. The percentage of breech deliveries decreases with advancing gestational age from 22% of births prior to 28 weeks' gestation to 7% of births at 32 weeks' gestation to 1-3% of births at term. The incidence is about 1 in 5 at 28th week and drops to 5% at 34th week and to 3% at term. Thus in 3 out of 4, spontaneous correction into vertex presentation occurs by 34th week.

Gestational age and frequency of breech birth

GESTATIONAL AGE IN WEEKS 21-24 25-28 29-32 33-36 37-40 33 28 14 9 7 % BREECH

FREQUENCY OF VARIOUS PRESENTATIONS & POSITIONS AT TERM Vertex 96% Breech 3.5% Face 0.3% Shoulder 0.4%

CLASSIFICATION There are two varieties of breech presentation Complete Incomplete

COMPLETE (flexed breech)

The normal attitude of full flexion is maintained. The thighs are flexed at the hips and the legs at the knees. The presenting part consists of two buttocks, external genitalia and two feet. It is commonly present in multipara.

INCOMPLETE
This is due to varying degrees of extension of thighs or legs at the podalic pole. Three varieties are possible. Breech with extended legs (frank breech) In this condition, the thighs are flexed on the trunk and the legs are extended at the knee joints. The presenting part consists of the two buttocks and external genitalia only. It is commonly present in primigravida, about 70%. The increased prevalence in primigravida is due to a tight abdominal wall, good uterine tone and early engagement of breech.

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

Knee presentation- Thighs are extended but the knees are flexed, bringing the knees down to present at the brim

CLINICAL VARIETIES In an attempt to find out the dangers inherent to breech, breech presentation is clinically classified as Uncomplicated- It is defined as one where there is no other associated obstetric complication apart from the breech, prematurity being excluded. Complicated When the presentation is associated with conditions which adversely influence the prognosis such as prematurity, twins, contracted pelvis, placenta praevia etc. it is called complicated breech. Extended legs, extended arms, cord prolapse or difficulty encountered during breech delivery should not be called complicated breech but are called complicated or abnormal breech delivery.

Prematurity it is the commonest cause of breech presentation Factors preventing spontaneous version Breech with extended legs Twins Oligohydramnios Congenital malformation of the uterus such as septate or bicornuate uterus Short cord, relative of absolute Intrauterine death of the fetus Favorable adaptation Hydrocephalus big head can be well accommodated in the wide fundus Placenta praevia Contracted pelvis Cornufundal attachment of the placenta- minimizes the space of the fundus where the smaller head can be placed comfortably. Undue mobility of the fetus Hydramnios Multipara with lax abdominal wall

ETIOLOGY

RECURRENT OR HABITUAL BREECH On occasion the breech presentation recurs in successive pregnancies. When it recurs in three or more consecutive pregnancies, it is called habitual or recurrent breech. The probable causes are Congenital malformation of the uterus Septate or bicornuate Repeated Cornufundal attachment of the placenta

DIAGNOSTIC EVALUATION Clinical Radiological Sonography

CLINICAL
Complete breech Frank breech

Per abdomen fundal grip

Head suggested by hard and Head globular mass Head is ballotable Irregular small parts of the feet may be felt by the side of the head Head is non-ballottable due to splinting action of the legs on the trunk

Lateral grip

Fetal back is to one side and Irregular parts are less felt on

the irregular limbs to the the side

other Pelvic grip Breech suggested by soft, Small, hard and a conical broad and irregular mass mass is felt

Breech is usually not engaged The breech is usually engaged

during pregnancy

FHS

Usually

located

at

a Located at a lower level

higher level round about in the midline due to

the umbilicus early engagement of the breech Per vaginam During pregnancy Soft and irregular parts Hard feel of the sacrum is are felt through the fornix felt, often mistaken for the head

During labor

Palpation

of

ischial Palpation

of

ischial

tuberosities, anal opening, tuberosities, anal opening sacrum and the feet by and sacrum only. the sides of the buttocks The foot felt is identified by the prominence of the heel and lesser mobility

of the great toe

RADIOLOGICAL A straight X-ray may be done in cases of persistent breech at term for To confirm the clinical diagnosis- specially in primigravida with deeply engaged frank breech or with tense abdominal wall and irritable uterus To exclude bony congenital malformation (hydrocephalus) To note the size of the baby To note the position of the limbs and the head SONOGRAPHY Sonography is most informative. It measures biparietal diameter Estimates the weight of the fetus Precisely localizes the placenta Detects congenital anomalies of the uterus apart from those inferred by radiography.

BREECH SCORING
Zatuchni-Andros Breech Scoring If the score is 0-4, cesarean delivery is recommended

ADD 0 POINTS PARITY GESTATIONAL AGE (WEEK) EFW (1b) PREVIOUS BREECH DILATATION STATION 2 -3 8 0 0 39+

ADD 1 POINT 1 38

ADD 2 POINTS 2 <37

7-8 1

<7 2

3 -2

4 -1

MECHANSIM OF LABOUR IN BREECH PRESENTATION Mechanism of delivery DEFINITION- As the fetus descends, soft tissue and bony structures exert pressures that lead to descent through the birth canal by a series of movements. Collectively, these movements are called the mechanism of labour. PRINCIPLES Descent takes place Whichever part leads and first meets the resistance of the pelvic floor will rotate forwards until it comes under the symphysis pubis Whatever emerges from the pelvis will pivot around the pubic bone

PARAMETERS Lie- longitudinal Attitude is one of complete flexion Presentation breech Position- left sacro anterior Denominator- sacrum Presenting part- anterior (left) buttock The bitrochanteric diameter 10 cm enters the pelvis in the left oblique diameter of the brim. The sacrum points to the left iliopectinal eminence.

STEPS Compaction Internal rotation of the buttocks Lateral flexion of the body Restitution of the buttocks Internal rotation of the shoulders Internal rotation of the head External rotation of the body Birth of the head.

1. COMPACTION Descent takes place with increasing compaction, owing to increased flexion of the limbs. 2. INTERNAL ROTATION OF THE BUTTOCKS The anterior buttock reaches the pelvic floor first and rotates forwards 1/8 of a circle along the right side of the pelvis to lie underneath the symphysis pubis. The bitrochanteric diameter is now in the anterio- posterior diameter of the outlet. 3. LATERAL FLEXION OF THE BODY The anterior buttock escapes under the symphysis pubis, the posterior buttock sweeps the perineum and the buttocks are born by a movement of lateral flexion. 4. RESTITUTION OF THE BUTTOCKS The anterior buttock turns slightly to the mothers right side.

5. INTERNAL ROTATION OF THE SHOULDERS The shoulders enter the pelvis in the same oblique diameter as the buttocks, the left oblique. The anterior shoulder rotates forwards 1/8 of a circle along the right side of the pelvis and escapes under the symphysis pubis; the posterior shoulder sweeps the perineum and the shoulders are born. 6. INTERNAL ROTATION OF THE HEAD The head enters the pelvis with the sagittal suture in the transverse diameter of the brim. The Occiput rotates forwards along the left side and the sub occipital region (the nape of the neck) impinges on the undersurface of the symphysis pubis. 7. EXTERNAL ROTATION OF THE BODY At the same time the body turns so that the back is uppermost. 8. BIRTH OF THE HEAD The chin, face and sinciput sweep the perineum and the head is born in a flexed attitude.

MANAGEMENT ANTENATAL MANAGEMENT Antenatal management in breech presentation consists of Identification of complicating factors related with breech presentation External cephalic version Formulation of line of management, if the version fails or is contraindicated IDENTIFICATION OF COMPLICATING FACTORS The presence of complicating factors can be detected by clinical examination, supplemented by radiography or Sonography. Sonography is particularly useful to detect congenital malformations of the fetus, the precise location of the placental site and congenital anomalies of the uterus.

EXTERNAL CEPHALIC VERSION External cephalic version (ECV) is the transabdominal manual rotation of the fetus into a cephalic presentation. The success rate of version is about 70-80%. Contraindications Absolute contraindications for External Cephalic Version include Multiple gestations with a breech presenting fetus Contraindications to vaginal delivery (eg, herpes simplex virus infection, placenta previa) Non-reassuring fetal heart rate tracing.

Relative contraindications include Polyhydramnios or Oligohydramnios, Fetal growth restriction, Uterine malformation, Major fetal anomaly. Time of version The ideal time for version has been considered to be 35-37 weeks but can be attempted at any time thereafter before the onset of labor Conditions Unfavorable For Breech Delivery Fetus weight more than 3500 g Unfavorable pelvis Breech delivery does not allow sufficient time for molding of the fetal head; thus, a platypelloid or android pelvis decreases ability fetal head to navigate maternal pelvis Hyperextension of the head increases risk of cervical spine injury Footlings- incidence of umbilical cord prolapse increases with coiling of the umbilical cord around the legs of the fetus

Complications of ECV Fractured fetal bones Precipitation of labor Premature rupture of membranes, Abruptio placentae, Feto-maternal hemorrhage (0-5%) Cord entanglement (< 1.5%). A more common risk of ECV is transient slowing of the fetal heart rate (in as many as 40% of cases). This risk is believed to be a vagal response to head compression with ECV. It usually resolves within a few minutes after cessation of the ECV attempt and is not usually associated with adverse sequele for the fetus.

Mortality and Morbidity Increased birth trauma: As duration of umbilical cord compression increases deliver the infant more rapidly increasing birth trauma Decreased birth weight may result from preterm delivery/growth restriction Incidence of prolapsed umbilical cord depends on type of breech presentation : Footling 17%, Complete 5%, Frank 0,5%

MANAGEMENT DURING LABOUR Type of Delivery Vaginal delivery:

Spontaneous Partial breech extraction Total breech extraction

Cesarean of delivery

VAGINAL BREECH DELIVERY SPONTANEOUS BREECH (RARE): no manipulation of the infant is necessary other than supporting the infant. This occurs predominantly in very preterm, often previable, deliveries. PARTIAL BREECH EXTRACTION: This is the most common type of vaginal breech delivery. Fetus descent spontaneously to where umbilicus is at the vaginal introitus, and then maneuvers are initiated to assist in the delivery of the remainder of the body, arms, and head. TOTAL BREECH EXTRACTION: the entire body is extracted. This is indicated only if there is evidence of fetal distress unresponsive to routine maneuvers and a cesarean delivery is possible.

TECHNIQUES FOR ASSISTED VAGINAL BREECH DELIVERY The delivery is explained in order to help the woman to appreciate the importance of not pushing until full dilatation of the cervix has been confirmed. When the buttocks are distending the perineum, the woman is placed in the lithotomy position and the vulva is swabbed and draped with sterile towels. The bladder must be empty and it is usually catheterized at this stage. If epidural analgesia is not being used, the perineum is infiltered with up to 10ml of 0.5% plain lidocaine (lignocaine) prior to an episiotomy being performed. The woman is encouraged to push with the contractions and the buttocks are delivered spontaneously. If the legs are flexed, the feet disengage at the vulva and the baby is born as far as the umbilicus. A loop of cord is gently pulled down to avoid traction on the umbilicus. Spasm of the cord vessels can be caused by manipulating the cord or by stretching it. If the cord is being nipped behind the pubic bone it should be moved to one side. The midwife should feel for the elbows, which are usually on the chest. If so, the arms will escape with the next contraction. If the arms are not felt, they are extended.

Delivery Of The Shoulders The uterine contractions and the weight of the body will bring the shoulders down on to the pelvic floor where they will rotate into the anterio-posterior diameter of the outlet. It is helpful to wrap a small towel around the babys hips, which preserves warmth and improves the grip on the slippery skin. The midwife now grasps the baby by the iliac crests with her thumbs held parallel over his sacrum and tilts the baby towards the maternal sacrum in order to free the anterior shoulder. When the anterior shoulder has escaped, the buttocks are lifted towards the mothers abdomen to enable the posterior shoulder and arm to pass over the perineum. As the shoulders are born the head enters the pelvic brim and descends through the pelvis with the sagittal suture in the transverse diameter. The back must remain lateral until this has happened but will afterwards be turned uppermost. If the back is turned upwards too soon, the anterio-posterior diameter of the brim and may become extended. The shoulders may then become impacted at the outlet and the extended head may cause difficulty.

Delivery Of The Head When the back has been turned the infant is allowed to hang from the vulva without support. The babys weight brings the head on to the pelvic floor on which the Occiput rotates forwards. The sagittal suture is now in the anterio-posterior diameter of the outlet. If rotation of the head fails to take place, two fingers should be placed on the molar bones and the head rotated. The baby can be allowed to hang for 1 or 2 minutes. Gradually delivery of the head is vital to avoid any sudden change in intracranial pressure and subsequent cerebral hemorrhage.

There are three methods used. Forceps delivery- Most breech deliveries are performed by an obstetrician, who will apply forceps to the after coming head to achieve a controlled delivery.

BURNS MARSHALL METHOD- The midwife or doctor stands facing away from the mother and with the left hand grasps the babys ankles from behind with forefinger between the two. The baby is kept on the stretch with sufficient traction to prevent the neck from bending backwards and being fractured. The sub-occipital region and not the neck should pivot under the apex of the pubic arch or the spinal cord may be crushed. The feet are taken up through an arc of 180 degree until the mouth and nose are free at the vulva. The right hand may guard the perineum in order to prevent sudden escape of the head. An assistant may now clear the airway and the baby will breathe. The mother should be asked to take deliberate, regular breaths which allow the vault of the skull to escape gradually, taking 2 or 3 minutes.

MAURICEAU- SMELLIE-VEIT MANOEURE (jaw flexion and shoulder traction). This is mainly used when there is delay in descent of the head because of extension. Excessive shoulder traction may cause Erbs palsy. The baby is laid astride the right arm with the palm supporting the chest. Two fingers are inserted well back into the mouth to pull the jaw downwards and flex the head. Two fingers of the left hand are hooked over the shoulders with the middle finger pushing up the Occiput to aid flexion. Traction is applied to draw the head out of the vagina and when the suboccipital region appears, the body is lifted to assist the head to pivot around the symphysis pubis. The speed of delivery of the head must be controlled so that it does not emerge suddenly like a cork popping out of a bottle. Once the face is free, the airways may be cleared and the vault is delivered slowly.

Alternative positions- When the woman has chosen to deliver in an alternative position, it is upright or supported squat that is the most suitable. The delivery techniques described above will be adapted accordingly and the midwife will observe and encourage the spontaneous mechanism of delivery

Delivery of extended legs- The frank breech descends more rapidly during the first stage of labour. The cervix dilates more quickly and there is a risk of the cord becoming compressed between the legs and the body. Cord prolapse is less likely than in other breech presentations because the frank breech is a better- fitting presenting part. Delay may occur at the outlet because the legs splint the body and impede lateral flexion of the spine. The baby can be born with legs extended but assistance is usually required. When the popliteal fossa appear at the vulva, two fingers are placed along the length of one thigh with the fingertips in the fossa. The leg swept to the side of the abdomen (abductng the hip) and the knee is flexed by the pressure on its under surface.

As this movement is continued the lower part of the leg will emerge from the vagina. This process should be repeated in orser to deliver the second leg. The knee is a hinge joint, which bends in one direction only. If the knee is pulled forwards from the abdomen, severe injury to the joint can result.

Delivery Of Extended Arms Extended arms are diagnosed when the elbows are not felt on the chest after the umbilicus is born. Prompt action must be taken to avoid delay and consequent hypoxia. This may be dealt with by using the lovset manoeuvre. This is a combination of rotation and downward traction that may be employed to deliver the arms whatever position they are in. the direction of rotation must always bring the back uppermost and the arms are delivered from under the pubic arch. When the umbilicus is born and the shoulders are in the anteroposterior diameter, the baby is grasped by the iliac crests with the thumbs over the sacrum. Downward traction is applied until the axilla is visible.

Maintaining downward traction throughout, the body is rotated through half a circle, 180 degree, starting by turning the back uppermost. The friction of the posterior arm against the pubic bone as the shoulder becomes anterior sweeps the arm in front of the face. The movement allows the shoulders to enter the pelvis in the transverse diameter. The arm which is now anterior is delivered. The first two fingers of the hand that is on the same side as the babys back are used to splint the humerus and draw it down over the chest as the elbow is flexed. The body is now rotated back in the opposite direction and the second arm delivered in a similar fashion.

COMPLICATIONS Lower Apgar scores, especially at 1 minute, are more common with vaginal breech deliveries. Cervical spine injury is predominantly observed when the fetus has a hyperextended head prior to delivery. Cord prolapse may occur in 7.4% of all breech labors. Intracranial Hemorrhage Intracranial hemorrhage Birth asphyxia

NURSING MANAGEMENT Observe closely for abnormal labor patterns. Monitor fetal heart beat and contractions continuously. Anticipate forceps-assisted birth. Anticipate cesarean birth for incomplete breech or shoulder presentation. Be prepared for childbirth emergencies such as cesarean section, forceps-assisted delivery, and neonatal-resuscitation. Position pt. in Trendelenburg or knee-chest position. Manually raise the presenting part aseptically Encourage the mother to lie on her side from the fetal back, which may help with rotation. Continue support and encouragement Keep client and family informed progress Praise clients efforts to maintain control.

NURSING DIAGNOSES Impaired gas exchange Encourage the mother to lie on her side from the fetal back, which may help with rotation. Knee chest position may facilitate rotation. Pelvic rocking may help with rotation. Monitor FHB appropriately Be prepared for childbirth emergencies such as cesarean section, forceps-assisted delivery, and neonatal-resuscitation. Pain Encourage relaxation with contractions. Apply sacral counter pressure with heel of hand to relieve back pain. Provide comfortable environment. Teach breathing exercises for use during early labor until client receives pharmacologic relief. Monitor physical response for example, palpitations/rapid pulse.

Fatigue Assess psychological and physical factors that may affect reports of fatigue level Monitor physical response for example, palpitations/rapid pulse Monitor fetal heart beat and contractions continuously. Refraining from intervening with client during contraction. Anxiety Keep client and family informed progress. Provide support during labor through personal touch and contact. These methods convey concern. Continue support and encouragement. Make the client feel she is somewhat in control of her situation. Provide client and family teaching. Identify clients perception of the threat presented by the situation

CESAEREAN SECTION A large fetus ( > 3.500 gr ) A Hyperextended fetus Uterine dysfunction Footling presentation Any degree of contraction or unfavorable shape restriction Previous perinatal death or children suffering from birth trauma

CRITERIA FOR VAGINAL DELIVERY AND CESAEREAN SECTION VAGINAL DELIVERY Frank Gestational Age->34wks Fetal Weight=2000-3500grms Adequate pelvis Flexed head Nonviable fetus No indication Good progress labor

CESAEREAN SECTION Fetal Weight <1500or> 3500gr Footling Small pelvis Deflexed head Arrest of labor Gestational age 24-34weeks Elderly Primi gravida Fetal distress