BREECH PRESENTATION

DEFINITION: It is a longitudinal lie in which the PP is the breech (=lower pole = podalic pole) with the sacrum as the denominator.

INCIDENCE:........

TYPES:

  A- Complete breech--> Hip & Knee are flexed.

  B-Incomplete breech-->

        1.Frank breech = Hip flexed,Knee extended.

        2.Knee presentation = Hip extended,Knee flexed.

        3.Footling presentation = Hip&Knee extended

POSITIONS: L.S.A=>R.S.A=>R.S.P=>L.S.P.

AETIOLOGY: *commonest cause is prematurity.

                   *Frank breech is considered a cause of breech malpr.

DIAGNOSIS:............

MECHANISM OF LABOR

1.Delivery of the buttocks:

 *Descent-->

 *Engagement: engaging diameter is the bitrochanteric(10.5cm)which enters into one of the oblique dtrs(12.5cm) e.g LSA-->Left oblique.

 *Internal rotation:The anterior buttock hits the PF first,rotates ant.1/8 of a circle=>now bitrochanteric dtr occupies the AP dtr of the outlet

 *Anterior buttock hinges below S.P&the posterior buttock delivers by lateral flexion of the spine which then straightens=>ant.buttock delivers.

2.Delivery of the shoulders:

 *Descent-->

 *Engagement of the biacromial dtr(12cm) into the same oblique dtr.

 *Internal rotation-->anterior shoulder hinges below S.P-->delivery

of the post.shoulder by lateral flexion of the spine--->delivery of the

anterior shoulder by straightening of the spine.

 

3.Delivery of the aftercoming head:

 *Descent-->

 *Engagment of the occipitofrontal dtr(11.5cm)into the opposite

oblique dtr.

 *Internal rotation: as the occiput meets the PF it rotates 1/8 if SA

or 3/8 of a circle if SP.The occiput is now anterior.

 *The occiput hinges below the S.P & the head delivers by Flexion.

MANAGMENT OF BREECH PRESENTATION

I.MANAGEMENT DURING PREGNANCY

   1.Exclude CFMF.

   2.Exclude indications for C.S

   3.ECV may be tried between 34 - 36 wks,recently done after 37 wks.

II.MANAGEMENT DURING LABOR

1st Exclude indications of C.S then proceed to VD which may be:

Uncomplicated breech delivery managed by:

  1. Spontaneous breech delivery
  2. Assisted breech delivery
  3. Breech extraction

Then during proceeding with the management a complication occurs, which is now called Complicated breech delivery, 

Breech delivery may be complicated by:

  1. Arrest of the buttocks
  2. Arreast of the shoulders
  3. Arrest of the After-coming head

 Indications of C.S :

 1.Any degree of contracted pelvis.

 2.Expected fetal weight > 3.5 Kg

 3.Premature fetus(why?)

 4.Knee & footling presentations(why?)

 5.Extended head of breech diagnosed by U/S.

 6.Other obstetric indication:elderly PG,MG with bad obst.history,cord presentation or prolapse,presence of uterine scar, ,cx dystocia,fetal distress.

N.B Before performing a C.S, CFMF must be ruled out.

Management of vaginal delivery:

  1. 1.Management of the first stage:......................
  2. 2.Management of the second stage:

I.MANAGEMENT OF UNCOMPLICATED BREECH DELIVERY

A.Spontaneous breech delivery:

- The fetus is delivered with no assisstance or interference except :

          -Episiotomy when the breech distends the vulva.

          -Covering the trunk by warm towels.

          -Pulling down a loop of cord when the umbilicus appears.

          -Kristeller maneuver may be used to keep the head flexed

         after delivery of the shoulders & arms.

- Expected to occur in cases of roomy pelvis &small or dead fetus.

B.Assissted breech delivery:

Assisstance is to delivery of the shoulders and aftercoming head.

-Indication:When spontaneous delivery will not occur

                   When rapid delivery is indicated.

1-Delivery of the breech & trunk:

     *Same as spontaneous delivery.

     *Resist the temptation to pull on the limbs

     *The obstetrician assissts delivery of the shoulders,arms&head.

2-Delivery of the shoulders & arms:

     -When the both scapulae appear the body is rotated till the right shoulder lies below S.P then bring down the right arm.

     -The body is rotated again to bring the left arm in the same way.

     -After both arms are delivered the spine rests directly under the S.P

3-Delivery of the aftercoming head :

   One of the following techniques may be used:

a)Burns-Marshall :

    -The fetus is left hanging from the mother,this helps engagement & increases flexion-->when the suboccipital region hinges below the S.P

the head is delivered by lifting the body towards the mothers abdomen

[between contractions,no bearing down,not more than 90 degrees]-->

head delivers by flexion.

b)Mauriceau-Smellie-Veit (Jaw flexion-shoulder traction):

    -Fetal abdomen rests on the left forearm with 2 fingers on the maxilla

or one finger in mouth (to increase flexion) + 2 fingers of the right arm

fork over the fetal's shoulder.

    -Both hands pull the fetal head downward & posteriorly(direction of pelvic axis)till the occiput hinges below the S.P ,then lift the fetal trunk towards the mothers abdomen.Head delivers in flexion.

    -Complications: -Dislocation or fracture mandible

                             -Injury of the spine or brachial plexus

                             -Sternomastoid hematoma

c)Forceps to the aftercoming head:

    -Using Piper's forceps which has a ccc perineal curve.

   -Lift the trunk & forceps applied from the ventral aspect of the fetus.

   -Advantages:     -Promotes head flexion.

                             -Prevents traction on the neck.

                             -Protects the head from compression-decompression.

   -Disadvantage:  -May cause facial palsy. 

d)Wigand maneuver: Jaw fleion and suprapubic pressure.

C. Breech extraction

Indications (= indications of forceps in cephalic presentation):

  1.Maternal or fetal distress, Maternal dz indicating to shorten the second stage, or prolonged 2nd stage (not due to contracted pelvis)

  2.Prolapsed pulsating cord.,

However fetal complications are very likely so it is replaced by C.S

in all these conditions & the only indication for breech extraction

in modern obstetrics is to deliver a retained second twin.

Technique:

   1.General anesthesia.

   2.Groin traction or bringing down a leg to deliver the buttocks.

   3.Lovset maneuver or bringing down an arm to deliver the shoulders

   4.Head delivered as in assissted breech delivery
 

II.MANAGEMENT OF COMPLICATED BREECH DELIVERY                       

A.Arrest of the buttocks:

  I.At the pelvic brim:

              Cause                                      Management

   1.C.P or soft tissue obstruction----------->C.S

   2.Macrosomia-------------------------------->C.S

   3.Inertia---------------------------------->Augmentation

   4.Contraction ring--------------------->Treatment of CR

II.At the pelvic outlet:

            Cause                                       Management

   1.Contracted outlet--------------------------->C.S

   2.Macrosomia--------------------------------->C.S

   3.Inertia---------------------------------->Augmentation

   4.Frank breech----deeply engaged-->Groin traction    } under

                         ----not deeply eng.-->Pinard maneuver } G.A

*Groin traction:

   -Index finger of both hands hook over the groin[or groin traction hook if dead fetus]-->traction applied downwards & forwards (direction of pelvic axis) till the anterior buttock hinges below S.P,the posterior buttock is delivered first followed by the anterior.

*Bringing down a leg:

  -Hand is passed along the ventral aspect of the fetus following the thigh to the popliteal fossa of the anterior leg-->gentle pressure---> flexion of the knee.

  - Foot is grasped & brought down followed by breech extraction.

B.Arrest of the shoulders:

 -Cause may be extension of the arm or nuchal displacement.

#Management of the extended arm:

  1.Bringing down an arm:

    -The hand is passed along the back-->shoulder-->posterior arm

-->apply gentle pressure on the cubital fossa to flex the elbow.

    -The hand of the fetus is grasped & brought down.
  2.Lovset maneuver:

    -May be done without general anesthesia.

    -Its idea depends on obliquity of the pelvis[short anterior wall &

 long posterior wall]so when the posterior shoulder is rotated anteriorly it becomes at a lower level.

Technique: -Apply downward, backward traction on the fetal trunk till the inferior angle of the scapula appears below the S.P , rotate the trunk 180 bringing the posterior shoulder anteriorly[keep the back anterior]which is now at a lower level , this is repeated till the arm is delivered.    

#Management of nuchal displacement:

   -Rotate the trunk in the direction of the fingertips--->nuchal displacement is changed to extended arm.  

C.Arrest of the aftercoming head:

          Cause                             Management

1.Contracted pelvis------->Symphisiotomy if living or Perforation if demised

2.Cx not fully dilated----->Cx incisions------Wait for cx dilatation

3.Rigid perineum---------------------->Episiotomy

4.Hydrocephalus---------------------->Perforation

5.Extended head---------------------->Assissted delivery

6.Posterior rotation of the occiput----------------->

                   -Irving maneuver (Rotate the head 180 to bing the occiput anterior), if failed try :

                   -JFST to deliver the head as face to pubis 

                   -Prague maneuver: Shoulder traction-->lift the fetus towards the mothers abd.{flexion of the

                             head in the birth canal}

COMPLICATIONS of BREECH PRESENTATION AND BIRTH:

  Maternal:..........................................

I-Fetal mortality 5-10% due to:

      1.Intra cranial Hge:

       -Rapid compression-decompression------> tearing between the

 falx cerebri&tentorium cerebelli---->rupture vein of Galen  

    -This is avoided by:

        1.Forceps to the aftecoming head.

        2.Slow delivery of the head with generous episiotomy.

        3.C.S for the premature breech presentation.

        4.Gentle Kristeller maneuver.

        5.Vit. K to mother before delivery&fetus after delivery

2.Intrapartum asphyxia:

  Due to:

   1.Prolapse & compression of the cord(manifest or occult)

   2.Premature respiration-->Meconium or liquor aspiration.

   3.Premature placental separation.

   4.Prolonged retention of the aftercoming head.

3.Fracture dislocation of the cervical spines.

4.Rupture of an abdominal organ --->grasp the fetus from the hips.

5.Fracture of base of the skull.

II-Fetal morbidity:

   1.Depressed skull fractures&cephalhematoma(from forceps)

   2.Facial nerve palsy.

   3.Sternomastoid hematoma

   4.Injury of the brachial plexus:

           C5,C6----->Erb's palsy

        C7,C8,T1------>Klumpk's palsy

   5.Injury to shoulder girdle:

          Fracture clavicle,humerous,ribs

          Dislocation shoulder

   6.Injury to pelvic girdle:

          Fracture femur,pelvis

          Dislocation hip

    7.Injury to external genitalia.

    8.Dislocation of Knee or ankle.

    9.Injury to sciatic nerve.

   10.Complications of prematurity :

       a)Immediate: RDS, NNJ , Infections , anemia &malnutrition, anoxic ICH,Hypothermia,Hypoglycemia        

       b)Remote: Retrolental fibroplasia, MR