Breech

International University of AfricaInternational University of AfricaFaculty of Medicine Faculty of Medicine and Health Sciencesand Health Sciences

Breech 2Breech 2Presented by:-Presented by:-

Dr. Alwaleed Dr. Alwaleed M.AlfakiM.Alfaki

Gya. & Obs.Gya. & Obs.www.doctor.sdwww.doctor.sd

BreechBreech Incidence:-Incidence:- 3-4% at term3-4% at term Type:-Type:-

1.1. Complete breechComplete breech “flexed breech“flexed breech”:-”:-- Hips and knees are both flexedHips and knees are both flexed- 25% of cases 25% of cases - Common in multiparous women Common in multiparous women - Cord prolapse is commonCord prolapse is common

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22 . .Incomplete breechIncomplete breechExtended or frank breechExtended or frank breech

- The legs are fully flexed at the hips and The legs are fully flexed at the hips and

extended at the kneesextended at the knees- 65% of cases Common in PG (-rigid 65% of cases Common in PG (-rigid

abdominal wall -good uterine tone) abdominal wall -good uterine tone)

3)Footling breech3)Footling breech- Occurs in 10% of cases Occurs in 10% of cases - High incidence of cord prolapseHigh incidence of cord prolapse

4)Knee presentation4)Knee presentation

-rare -rare


Causes of breechCauses of breech1.1. Prematurely is the commonest cause Prematurely is the commonest cause

“30-40% at 20__25 weeks” “30-40% at 20__25 weeks” “ “15%at 32 weeks “.15%at 32 weeks “.2.2. Extended legExtended leg3.3. Fetal anomalies( hydrocephalus – Fetal anomalies( hydrocephalus –

anencephaly) .anencephaly) .4.4. Multiple pregnancy.Multiple pregnancy.5.5. IUFDIUFD6.6. Short cordShort cord7.7. Placenta previa and cornual insertion of Placenta previa and cornual insertion of

the placentathe placenta


8.8. Uterine abnormalities (septate, Uterine abnormalities (septate, bicornuate ) fundal myoma bicornuate ) fundal myoma

9.9. Pelvic tumors Pelvic tumors

10.10. Poly and oligohydramnios.Poly and oligohydramnios.

11.11. Multiparty and previous breech Multiparty and previous breech delivery delivery

12.12. Idiopathic Idiopathic


Diagnosis Diagnosis

Abdominal examination reveals the Abdominal examination reveals the head (smoother rounder, harder and head (smoother rounder, harder and palatable) at the fundus.palatable) at the fundus.

Fetal heart is best heard above the Fetal heart is best heard above the umbilicus on the side of the back.umbilicus on the side of the back.

On vaginal examination the soft-On vaginal examination the soft-irregular breech can be felt. In irregular breech can be felt. In complete breech the feet can also be complete breech the feet can also be felt. felt.


Investigation Investigation Ultra sound scan:-Ultra sound scan:-- Confirm the diagnosisConfirm the diagnosis- Exclude placenta previaExclude placenta previa Lateral X-Rays abdomen:-Lateral X-Rays abdomen:-- Confirm diagnosis and type of breechConfirm diagnosis and type of breech- Reveals major skeletal malformations Reveals major skeletal malformations - Reveals degree of flexion of the head Reveals degree of flexion of the head - Pelvimetry Pelvimetry


Complication of breechComplication of breech Fetal complicationsFetal complications:-:-o Are from Asphyxia- trauma and Are from Asphyxia- trauma and

congenital malformation.congenital malformation.o Perinatal mortality at least 5 times that Perinatal mortality at least 5 times that

of cephalic presentationof cephalic presentation1.1. Fetal Asphyxia due to:-Fetal Asphyxia due to:-- Retained after coming head Retained after coming head (>10 min)(>10 min)

- Cord prolapse compression by after Cord prolapse compression by after coming head coming head

- Premature respiration Premature respiration - Premature separation of the placentaPremature separation of the placenta


2.2. traumatrauma

Fast delivery of the head before Fast delivery of the head before moulding with compression and moulding with compression and decompression of the head leads to decompression of the head leads to intracranial Hge, tentorial tear, intracranial Hge, tentorial tear, Fracture skull borne Fracture skull borne

Dislocation of cervical spine Dislocation of cervical spine Fracture and epiphyseal separation Fracture and epiphyseal separation

of femur. Humorous and clavicle of femur. Humorous and clavicle


Brachial plexus palsy and trans Brachial plexus palsy and trans section of the cord (erb’s palsy).section of the cord (erb’s palsy).

Sternomastoid muscle rupture & Sternomastoid muscle rupture & haematoma.haematoma.

Rupture of abdominal viscera.Rupture of abdominal viscera. ↑ ↑ incidence of malformation incidence of malformation

Maternal complicationMaternal complication:-:- genital track laceration genital track laceration Postpartum haemorrhagePostpartum haemorrhage Danger of emergency anaesthesia Danger of emergency anaesthesia

and C/S and C/S


ManagementManagement (mode of delivery) (mode of delivery)

1.1. Elective caesareanElective caesarean section.section.• Breech presentation associated Breech presentation associated

with any other obstetric adverse with any other obstetric adverse factors is generally factors is generally delivereddelivered by by C/S :-C/S :-

• fetal weight >3.5kg fetal weight >3.5kg • footling breech footling breech • Hyperextension of the head Hyperextension of the head


- Any degree of pelvic contraction & - Any degree of pelvic contraction & abnormal shape abnormal shape

- Associated pregnancy complications like Associated pregnancy complications like APH, PIH diabetes . BOHAPH, PIH diabetes . BOH

2.2. External cephalic version:-External cephalic version:-- Changing the breech to cephalic by trans Changing the breech to cephalic by trans

abdominal manipulation.abdominal manipulation.- Usually done after 36 week.Usually done after 36 week.- Risks are 1% mortality –rupture Risks are 1% mortality –rupture

memebranes with preterm labour-memebranes with preterm labour-abruptio placenta- cord accident- feto abruptio placenta- cord accident- feto maternal transfusion- rupture uterus ) maternal transfusion- rupture uterus )


Contraindication:- (indication of c/s –Contraindication:- (indication of c/s –APH- PIH-scar uterus- multiple APH- PIH-scar uterus- multiple pregnancy- congenital malformation of pregnancy- congenital malformation of the uterus –B.O.H- elderly PG –rupture the uterus –B.O.H- elderly PG –rupture membrane - IUFD-IUGR.membrane - IUFD-IUGR.

Cause of failure of ECV. Are (extension Cause of failure of ECV. Are (extension of the les –large fetus. Undiagnosed of the les –large fetus. Undiagnosed twins- short cord-scanty liquor-irritable twins- short cord-scanty liquor-irritable uterus- uterine anormalies –rigid uterus- uterine anormalies –rigid abdominal wall- obesity –engaged abdominal wall- obesity –engaged breech).breech).

3.3. Vaginal breech delivery Vaginal breech delivery 1. spontaneous ,1. spontaneous , 2. assisted breech delivery 2. assisted breech delivery 3. breech extraction) 3. breech extraction)


1/ 1/ assisted breech deliveryassisted breech delivery

Delivery particularly of the head is Delivery particularly of the head is usually assisted to a varying degree usually assisted to a varying degree this involves gentle manipulation to this involves gentle manipulation to control and guide the fetus during control and guide the fetus during the mother’s expulsive effort so that the mother’s expulsive effort so that the delivery is affected with the delivery is affected with minimum of trauma and maximum of minimum of trauma and maximum of safetysafety. .


Acceptable if:-Acceptable if:-- Pelvis normal in size and in shape Pelvis normal in size and in shape - Fetal weight about 3.5kg or less Fetal weight about 3.5kg or less - Flexed headFlexed head- No other obstetric complicationNo other obstetric complication Should be under taken in fully Should be under taken in fully

equipped hospital equipped hospital Fist stageFist stage :-managed as high risk :-managed as high risk

labour (NPO- I.V fluid –pain relief- labour (NPO- I.V fluid –pain relief- maternal & fetal monitoring)maternal & fetal monitoring)

Second stageSecond stage:-:- lithotomy or modified lithotomy or modified lithotomy position –episiotomy. lithotomy position –episiotomy.


Delivery of after coming headDelivery of after coming head..

1- 1- forceps:-forceps:- more safe –because of more safe –because of controlled delivery of headcontrolled delivery of head

2- Buns- marshall’s technique :-2- Buns- marshall’s technique :-

The baby is grasped by the ankles with The baby is grasped by the ankles with maintained traction and is swung through maintained traction and is swung through a wide arc towards the mother abdomen.a wide arc towards the mother abdomen.

3- jaw flexion- shoulder traction3- jaw flexion- shoulder traction (mauriceau –smellie veit technques(mauriceau –smellie veit technques--not recommended –traction may cause not recommended –traction may cause brachial –plexus injury) brachial –plexus injury)


2/ 2/ spont breech delivery:-spont breech delivery:-

- Should not be allowed - Should not be allowed - Occur rarely except in multiparous Occur rarely except in multiparous

patient, in preterm labour patient, in preterm labour - Carry high perinatal mortality & Carry high perinatal mortality &

morbidity. morbidity. -


3/ breech extraction:-3/ breech extraction:-- Delivery of the fetus with no assistance Delivery of the fetus with no assistance

from the motherfrom the mother- Indication :- in second stage of labourIndication :- in second stage of labour- -fetal distress -fetal distress - Cord prolapseCord prolapse- Delay of delivery of second twin Delay of delivery of second twin - Maternal distress Maternal distress - Should be done in the theatre & only if:Should be done in the theatre & only if:- No Cephalo pelvic disproportion No Cephalo pelvic disproportion - Cervix fully dilated Cervix fully dilated - Patient adequately anaesthetized Patient adequately anaesthetized - Enough liquor. To allow manipulation Enough liquor. To allow manipulation


Date post:	18-Dec-2014
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Breech

Health & Medicine