Seminar presentation

1. BREECH PRESENTATION
MUHAMMAD AFFAN SYAFIQI | NUR AMANINA NASIR | NIK NOR LIYANA SUHAIMI
FETAL MALPRESENTATION
AT TERM

2. WHAT IS
BREECH? Malpresentation is a
presentation that is not cephalic
 The most commonly
encountered malpresentation in
pregnancy is breech
presentation
Breech means that your baby is lying bottom first or feet first
in the womb (uterus) instead of in the usual head first
position. As pregnancy continues, a baby usually turns
naturally into the head first position.

3. INCIDENCE
This presentation occurs in:
1. 3-4% of term pregnancies.
2. 7% of pregnancies at 32 weeks
3. 25% of pregnancies of less than 28 weeks’

4. TYPES OF BREECH
FRANK BREECH FOOTLING BREECHCOMPLETE BREECH
 Extended or frank breech – the baby is
bottom first, with the thighs against the
chest and feet up by the ears. Most
breech babies are in this position (most
common)
 Flexed breech – the baby is bottom first,
with the thighs against the chest and the
knees bent
 Footing breech – the baby’s foot or feet
are below the bottom
A BREECH BABY MAY BE LYING IN ONE OF THE
FOLLOWING POSITIONS

5. WHY ARE SOME BABIES BREECH?
Sometimes it’s just a matter of chance that a baby does not
turn and remains the breech position. At other times, certain
factors make it difficult for a baby to turn during pregnancy.
These might include the amount of fluid in the womb (either
too much or too little), the position of placenta or if there’s
any more than one baby in the womb.
The vast majority of breech babies are born healthy. For a few
babies, breech may be a sign of a problem with the baby

6. PREDISPOSING FACTORS
MATERNAL
FETAL / PLACENTAL
 Fibroids
 Congenital uterine abnormalities
 Uterine surgery
 Multiple Gestation
 Prematurity
 Placenta praevia
 Abnormality, e.g. anencephaly or hydrocephalus
 Fetal neuromuscular condition
 Oligohydramnios
 Polyhydramnios

7. DIAGNOSIS
• The diagnosis of breech presentation may be
made by:
1. Abdominal palpation
2. Vaginal examination
3. Confirmed by ultrasound
If breech presentation is clinically suspected at or after 36
weeks, this should be confirmed by ultrasound scan. The
scan should document fetal biometry, amniotic fluid
volume, placental site and position of fetal legs. The scan
should also look for any anomalies previously undetected.

8. CLINICAL
DIAGNOSIS• Palpation
– Fundal grips; the head is felt with its characters.
– Pelvic grip; the breech is felt, with its characters.
• Auscultation
– The fetal heart sounds are head just at, or above the level of the umbilicus
• Slow dilatation of cervix
• After rupture of the membranes, the presenting part is felt that is , the two buttocks
with the anus in between , the genitalia on one side and the sacral spines on the
opposite side.
• In case of complete breech, the feet are felt on the same level as the buttocks.
• In case of breech with extended legs, the buttocks only are felt.
• In case of footling presentation, the feet are at a lower level than the buttocks.
• In case of knee presentation, the knees are a lower level than the buttocks.
ABDOMINAL EXAMINATION
VAGINAL EXAMINATION

9. WHAT CAN
BE
DONE?AFFA
N

10. MANAGEM
ENT
1.EXTERNAL CEPHALIC
VERSION
2.Vaginal delivery
3.Lower segment caesarean
section

11. MANAGEMENT
 ECV is a relatively straightforward and safe technique and has
been shown to reduce the number of Caesarean sections due to
breech presentations.
 Should be offered at 36-37 weeks of pregnancy.
 Success rate is around 50 per cent and are higher in multiparous
women who tend to have more lax abdominal musculature.
However it depends on the experience of the obstetrician.
 A fetal heart rate trace must be performed before and after the
procedure.
 It is important to administer anti-D if the woman is Rhesus-
negative.
1. EXTERNAL CEPHALIC VERSION

12. MANAGEMENT
1. EXTERNAL CEPHALIC VERSION
 The procedure is performed at or after 37 completed weeks by an
experienced obstetrician.
 ECV should be performed with tocolytics (e.g. nifedipine) as this
has been shown to improve the success rate.
 The woman is laid flat with a left lateral tilt having ensured that
she has emptied her bladder and is comfortable.
HOW IS IT DONE?
With ultrasound guidance the breech is elevated from the pelvis and one hand is
used to manipulate this upward in the direction of a forward role, while the other
hand applies gentle pressure to flex the fetal head and bring it down to the
maternal pelvis.

13. MANAGEMENT

14. RISK OF ECV
 Placental abruption
 Premature rupture of membrane (PROM)
 Cord accident
 Transplacental hemorrhage
 Fetal bradycardia

15. CONTRAINDICATIONS
 Fetal abnormality (e.g. hydrocephalus)
 Placenta praevia
 Oligohydramnios or polyhydramnios
 History of antepartum haemorrhage
 Previous Caesarean or myomectomy scar on the uterus
 Multiple gestation
 Pre-eclampsia or hypertension
 Plan to deliver by Caesarean section anyway

16. Pros and cons
ADVANTAGES
DISADVANTAGES
 Reduction in breech presentation in term pregnancies
 Reduction in Caesarian or Vaginal Breech Delivery (lower the risk of going
to LSCS).
 If fails, about 3% will turn to spontaneous delivery
 Placental Abruption
 Umbilical Cord Entanglement
 Premature Rupture of Membrane
 Severe maternal discomfort
 Fetal bradycardia and non-reactive CTG
 Alteration in umbilical artery and mid cerebral artery waveform
 Increase in Amniotic Fluid Volume

17. WHAT
CHOICES
FOR
BIRTH?
ARE MY

18. MODE OF DELIVERY
VAGINAL
BREECH
DELIVERY
2
..

19. INDICATIONS
 Presentation should be either extended or
flexed
 No evidence of feto pelvic disproportion
 Estimated fetal weight < 3.5 kg
 No evidence of hyperextension of fetal head
and fetal abnormalities (hydrocephalus)
 No other obstetric complications.

20. MANAGEMENT
DURING LABOUR Fetal well being and progress of labour should
be monitored
 Epidural administration can prevent pushing
before full dilatation
 Fetal blood sampling to monitor acid base
status
 Operator experienced in delivering breech
babies should be available.

21. TECHNIQUE
 Descent of the buttocks occurs until
the anterior buttock touches the
pelvic floor. ( naturally )
 Internal rotation of the anterior
buttock occurs through 1/8th of a
circle placing it behind the symphysis
pubis.
 Further descent with lateral flexion of
the trunk occurs until the anterior hip
hinges under the symphysis pubis
which is released first followed by the
posterior hip.
 Legs are flexed (deliver
spontaneously)
 Legs are extended, (deliver
using pinard’s manoeuvre)
 Using a fingers to flex the leg at
the knee and then extend the
hip
 With contractions and maternal
effort, lower body will delivered
1. Delivery of the buttocks 2. Delivery of the legs and
lower body

22. TECHNIQUE

23. TECHNIQUE
3. Delivery of SHOULDERS
 Baby will be lying the shoulders in the
transverse diameter of the pelvic mid
cavity
 Descent occurs with internal rotation
of the shoulders bringing the shoulders
to lie in the antero-posterior diameter
of the pelvic outlet.
 Finger will gently above the shoulder
 Posterior arm/ shoulder reaches the
pelvic floor, it will rotate anteriorly
 Once the spine become visible,
delivery of the second arm will follow
 Loveset’s manoeuvre .

24. TECHNIQUE

25. TECHNIQUE
4. Delivery of THE HEAD
 Delivered using the Mauriceau-
smellie-veit Manoeuvre
 Lies between obstetrician arm
with downward traction being
levelled on the head via finger in
the mouth and one on each
maxilla
 If difficult, forceps need to be
applied

26. TECHNIQUE

27. COMPLICATIO
NS
 The greatest fear with a vaginal breech is that the baby will
get ‘stuck’.
 Interference in the natural process by the inappropriate use
of oxytoxic agents or by trying to pull the baby out (breech
extraction) will (paradoxically) increase the obstruction
occuring.
 When delay occurs, particularly with delivery of the
shoulders or head, the presence of an experienced
obstetrician will reduce the risk of death or serious injury.

28. MODE OF DELIVERY
CESAREAN
SECTION
3
..

29. Hannah ME, Hofmeyr
GJ Trial Studies had proven that a patient with Breech
presentation should go for C-Sect
 “Planned C-sect is safe for singleton term
breech babies than planned vaginal birth,
managed accordingly to a clinical protocol, but
more complications for mothers.”
 The review of the this study showed that
Planned C-sect was safer for the singleton
breech baby at term than planned VBD.

30. INDICATIONS
 Clinically inadequate pelvis
 Footling or kneeling breech presentation
 Large baby (usually defined as larger than 3800 g)
 Growth-restricted baby (usually defined as smaller than
2000 g)
 Hyperextended fetal neck in labour
 Previous caesarean section.
 Delay in the descent of the breech at any stage in the
second stage of labour.
 Other contraindications to vaginal birth
– placenta praevia, compromised fetal condition

31. PROCEDURE
 Informed consent
 Surgical basis
– The pfannenstiel
incision
– The infra-umbilical
incision
– Uterine incision

32. COMPLICATIO
NS Bowel damage
 Caesarean hysterectomy
 Haemorrhage
 Placenta previa
 Urinary tract damage
 Infection
 Pulmonary emboli /DVT
INTRAOPERATIVE
POST-OPERATIVE

33. REFERENCES
 Obstetrics Ten Teachers 19th Edition by Philip
N Baker and Louise C Kenny
 http://www.rcog.org.uk/globalassets/docume
nts/patients/patient-information-
leaflets/pregnancy/a-breech-baby-at-the-end-
of-pregnancy.pdf