BREECH PRESENTATION

BREECH PRESENTATION

INTRODUCTION

The majority of fetuses are in a breech presentation early in pregnancy. By week 38^th week of gestation, however, the fetus normally turns to a cephalic presentation. Although the fetal head is the widest single diameter, the fetus’s buttocks [ breech], plus the lower extremities, actually takes up more space. The fundus, being the largest part of the uterus, probably accounts for the fact that in approximately 97% of all pregnancies, the fetus turns so that the buttocks and lower extremities are in the fundus.

DEFINITION

In breech presentation, the lie is longitudinal and the podalic pole presents at the pelvic brim. The presenting diameter is bitrochanteric (10 cm) and the denominator is sacrum.

INCIDENCE

The incidence is about 1 in 5 at 28^th week and drops to 5% at 34^th week and 3% at term.

ETIOLOGY

The following are the known factors responsible for breech presentation. In a significant number of cases, the cause remains obscure.

·       Prematurity:

     It is the commonest cause of breech presentation

·       Multiple pregnancy:

           Multiple pregnancy limits the space available for each fetus to turn, which may result in one or more fetuses presenting by breech.

·       Polyhydramnios:

            Distension of uterine cavity by excessive amounts of amniotic fluid may cause the fetus to present by the breech.

·       Hydrocephaly:

               The increased size of the fetal head is more readily accommodated in the fundus.

·       Extended legs:

           Spontaneous cephalic version may be inhibited if the fetus lies with the legs extended, ‘ splinting’ the back

·       Preterm labour:

         As breech presentation is relatively common before 34 weeks gestation, it follows that breech presentation is more common in preterm labours.

·       Uterine abnormalities:

  Distortion of the uterine cavity by a septum or a fibroid may result in a breech presentation.

·       Pendulous abdomen:

         If the abdominal muscles are lax the uterus may fall so far forward that the fetal head comes to lie outside the pelvic brim causing a breech presentation.

·       Placenta praevia:

          Some  authorities believe that this may be a cause of breech presentation but there is some disagreement on this.

·       Fetal death and short umbilical cord:

TYPES OF BREECH PRESENTATION

There are two varies of  breech presentation:

I.          Complete breech [ flexed breech]

         The fetal attitude is one of complete flexion, with hips and knees both flexed and the feet tucked in beside the buttocks. The presenting part consists of two buttocks, external genitalia and two feet. It is commonly present in multiparae.

II.          Incomplete breech:

   This is due to varying degrees of extension of thighs or legs at podalic pole. Three varieties are possible;

·       Breech with extended legs [ frank breech ]

            The breech presents with the hips flexed and legs extended on the abdomen. 70% of breech presentations are of this type and it is particularly common in primigravidae whose  good uterine muscle tone inhibits flexion  of the legs and free turning of the fetus.

·       Footling breech

             This is rare. One or both feet present because neither hips nor knees are fully flexed. The feet are lower than the buttocks, which distinguishes it from the complete breech.

·       Knee presentation

             This is very rare. Thighs are extended but the knees are flexed, bringing the knees down to present at the brim.

POSITIONS

Six positions are identified. The sacrum is used as the denominator in breech presentation and depending on the position of the sacrum, a breech may present as

Left sacro – anterior [LSA]

Right sacro – anterior [RSA]

Left sacro – posterior [ LSP]

Right sacro – posterior [ RSP]

Right sacro – lateral [ RSL]

Left sacro – lateral [ LSL]

DIAGNOSIS

1. Clinical
2. Sonography
3. Radiology

 Clinical

Per abdomen	Complete breech	Frank breech
Inspection	A transverse groove may be seen above the umbilicus in sacro-anterior corresponds to the neck. If the patient is thin, the head may be seen as a localised bulge in one hypochondrium.
Fundal grip	Head suggested by hard and globular mass. Head is ballotable	Head, irregular small parts of feet may be felt by side of head, head is non – ballotable due to splinting action of legs to trunk.
Lateral grip	Fetal back is to one side and irregular limbs to the other	Irregular parts are less felt on the side
Pelvic grip	Breech suggested by soft, broad and irregular mass. Usually not engaged	Small hard and a conical mass is felt. Breech – usually engaged
FHS	Usually located at a higher level round about the umbilicus.	Located at a lower level in the midline due to early engagement of the breech.
Per vaginum
During pregnancy	Soft and irregular parts are felt through the fornix	Hard feel of the sacrum is felt which is mistaken for caput succedaneum
During labor	Palpation of ischial tuberosities, sacrum and feet by sides of buttocks. The foot felt is identified by the prominence of the heel and lesser mobility of the great toe	Palpation of ischial tuberosities, anal opening and sacrum only. Fresh meconium on examining finger is diagnostic.

Ultrasonography

It is more informative

It confirms the clinical diagnosis, especially in primigravidae with engaged frank breech or with tense abdominal wall and irritable uterus

It can detect fetal congenital abnormality and also congenital anomalies of  the uterus.

It measures biparietal diameter, gestational age and approximate weight of the fetus

It also localizes the placenta

Assessment of liquor volume

Attitude of the head flexion or hyperextension

Radiology

A straight X – ray is rarely done:

To confirm the clinical diagnosis

To exclude bony congenital malformation [ hydrocephalus]

To note the size of the baby

To note the position of the limbs and the head

MECHANISM OF LEFT SACROANTERIOR POSITION

Lie: longitudinal

Attitude: complete flexion

Presentation : breech

Position : left sacroanterior

Denominator : sacrum

Presenting part : anterior [ left] buttocks

The bitrochanteric diameter, 10 cm, enters the pelvis in the left oblique diameter of the brim

The sacrum points to the left iliopectineal eminence.

Compaction:

Descent takes place with increasing compaction, owing to increased flexion of the limbs

Internal rotation of the buttocks:

 The anterior buttocks 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 anteroposterior diameter of the outlet.

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.

Restitution of the buttocks:

The anterior buttock turns slightly to the mother’s right side.

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.

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 suboccipital region [ the nape of the neck] impinges on the undersurface of the symphysis pubis.

External rotation of the body:

At the same time the body turns so that the back is uppermost.

Birth of the head:

The chin, face and sinciput sweep the perineum and the head is born in a flexed attitude.

Sacro posterior  position

 In sacro posterior position, the mechanism is not substantially modified. The head has to rotate through 3\8^th of a circle to bring the occiput behind the symphysis pubis.

PROGNOSIS

Maternal:

 Labour is usually not prolonged. But because of increased frequency of operative delivery including caesarean section, the morbidity is increased. The risk include;

• Traums to the genital tract
• Operative vaginal delivery [ episiotomy, forceps]
• Caesarean section
• Sepsis
• Anesthetic complications

As a consequence, maternal morbidity is slightly raised.

Fetal:

The fetal risk in terms of perinatal mortality is considerable in vaginal breech delivery. The overall perinatal mortality still remains 3 – 10%.

 The factors which significantly influence the fetal risks are:

• Skill of the obstetrician
• Weight of the baby
• Position of the legs
• Type of  pelvis

Fetal Dangers

 The fetal dangers in vaginal breech delivery are as follows:

1.     Intracranial haemorrhage:

          Compression followed by decompression during delivery of the unmoulded after coming head results in tear of the tentorium cerebella and haemorrhage in the subarachnoid space. The risk is more in premature when the head is small and fragile. Baby can withstand anoxia following cord compression with the delivery of the trunk for about 5 -7 minutes.

2.     Asphyxia :

         It is due to

• Cord compression soon after the buttocks are delivered and most after the head enters into the pelvis
• Retraction of the placental site
• Premature attempt at respiration while the head is still inside.
• Delayed delivery of the head cord prolapsed.

3.     Injuries

           The injuries are inflicted during manipulative deliveries.

• Haematoma : over the sternomastoid or over the thighs.
• Fractures : the common sites are femur, humerus, clavicle, odontoid process and ribs. There may be dislocation of the hip joint, mandible or 5^th and 6^th cervical vertebrae.
• Viscera : visceral injuries include rupture of the liver, kidneys, suprarenal glands, lungs and haemorrhage in the testicles
• Nerve : medullary coning, spinal cord injury, stretching of the brachial plexus causes either Erb’s or Klumpke’s palsy.

PREVENTION OF FETAL HAZARDS

• The incidence of breech can be minimized by external  cephalic version; if not contraindicated.
• If version fails or contra indicated, delivery is done by caesarean section
• Vaginal breech delivery should be conducted by a skilled obstetrician along with an organized team consisting of a skilled anesthetist and an assistant.
• Vaginal manipulative delivery should be done by a skilled person with utmost gentleness, especially during delivery of head

ANTENATAL MANAGEMENT

Antenatal management in breech presentation consists of:

 Identification of the complicating factors related to breech presentation

  It can be detected by clinical examination, supplemented by 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

 Management , if version fails or is contraindicated:

      The pregnancy is to be continued with usual check up and unexpectedly, one may find that spontaneous version has occurred. But if breech persists, the assessment of the case is to be done with respect to:

Ø  Age of the mother especially in primigravidae

Ø  Associated complicating factors

Ø  Size of the baby

Ø  Pelvic capacity

 Elective caesarean section

Indications:

• Large foetus i.e. > 3.5 kg estimated by ultrasound.
• Preterm foetus but estimated weight is still more than 1.25 kg.
• Footling or complete breech: as the presenting irregular part is not well fitting with the lower uterine segment leading to;
• Less reflex stimulation of uterine contractions.
• Susceptibility to cord prolapse.
• Early bearing down as the foot passes through partially dilated cervix and reaches the perineum.
• Hyperextended head: diagnosed by ultrasound or X-ray.
• Contracted pelvis: of any degree.
• Uterine dysfunction.
• Complicated pregnancy with:
• Hypertension.
• Diabetes mellitus.       
• Placenta praevia.
• Pre - labour rupture of membranes for ≥ 12 hours.
• Post-term.
• Intrauterine growth retardation.
• Placental insufficiency.
• Primigravidas: breech in primigravida equals caesarean section in opinion of most obstetricians as the maternal passages were not tested for delivery before.

Vaginal breech delivery

Prerequisites:

• Frank breech.
• Estimated foetal weight not more than 3.5 kg.
• Gestational age: 36-42 weeks.
• Flexed head.
• Adequate pelvis.
• Normal progress of labour by using the partogram.
• Uncomplicated pregnancy.
• Multiparas.
• An experienced obstetrician.
• In case of intrauterine foetal death.

EXTERNAL CEPHALIC VERSION

External cephalic version is done to bring the favourable cephalic pole in the lower pole of the uterus.

Procedure

The maneuver is carried out as an outdoor procedure in earlier weeks. But if performed in later weeks or under tocolytic drugs, it should be performed in the vicinity of labour – delivery complex.  Any one of the toccolytics , [ terbutaline 0.25mg or Isoxsuprine 50 - 100µg\min]  can be administered by intravenous infusion which is set up with Ringer lactate solution for about 15 – 30 minutes prior hand.  The maternal heart rate and blood pressure are measured every 5 minutes. A reactive NST should precede the maneuver.

Preliminaries

The patient is asked to empty her bladder. She is to lie on her back with the shoulders slightly raised and the thighs slightly flexed. Abdomen is fully exposed. The obstetrician is to stand on the right side. The presentation, position of the back and limbs are checked and FHR is auscultated. The manipulation should be temporarily stopped during Braxton hicks contraction, and to be withheld,  if the patient is in pain.

Steps

1.     The breech is mobilized using both hands to one iliac fossa towards which the back of the fetus lies. The podalic pole is grasped by the right hand in a manner like that Pawlik’s grip while the head is grasped by the left hand. If the breech is engaged, it should be lifted up using both the hands. Rarely, the gloved fingers of an assistant may have to be introduced inside the vagina to push up the breech.

2.     The pressure is now exerted to the head and the breech in the opposite directions to keep the trunk well flexed which facilitates version. The pressure should be intermittent to push the head down towards the pelvis and the breech towards the fundus until the lie becomes transeverse. The FHR is once more to be checked.

3.     The hand is now changed one after the other to hold the fetal poles to prevent crossing of the hand. The intermittent pressure is exerted till the head is brought to the lower pole of the uterus. As far as possible, the fetus should be allowed to turn by its own limb movements.

4.     An attempt is made to push the head down to the brim. This may be difficult when the version is attempted in earlier period of gestation.

 A reactive NST should be obtained after completing the procedure. There may be undue bradycardia due to head compression which is expected to settle down by 10 minutes. If however fetal bradycardia persists, the possibility of cord entanglement should be kept in mind and in such cases reversion may have to be considered.

The patient is to be observed for about 30 minutes:

·       To allow the FHR to settle down to normal

·       To note for any vaginal bleeding or evidence of premature rupture of the membranes.

Instructions

o   The patient is advised to come on the next day to check the corrected position

o   To report to the physician even earlier if there is vaginal bleeding or escape of liquor amnii or labour starts.

o   Rh – negative non – immunized women must be protected by intramuscular administration of 100µg anti – D gamma globulin.

 Risks of ECV

Uncommon risks of ECV include

§  Fractured fetal bones

§  Precipitation of labor or premature rupture of membranes

§  Abruptio placentae

§  Fetomaternal 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).

Contraindications

a. Absolute contraindications for ECV include

   Multiple gestations with a breech-presenting fetus
 Contraindications to vaginal delivery (eg, herpes simplex virus infection, placenta previa)
 Non reassuring fetal heart tracing is fetal heart tracing suggestive of hypoxia, which may be Fetal         Tachycardia (>160), Fetal bradycardia(<120),Variable decelerations, and early decelerations.

b.Relative contraindications include

 Polyhydramnios or oligohydramnios
 Fetal growth restriction
 Uterine malformation
 Fetal anomaly.

Scheme of management of breech presentation

                                        Breech presentation

    

     Uncomplicated                                                                                    Complicated

                       Sonography or   X ray                                                                Sonography or X- ray

             ECV                                                                                                CS

   At 37 wks or beyond

          Labour suite

         With tocolytes, if needed

                Fails

                      Formulation of delivery protocol

                                                          

Elective CS                             Vaginal delivery

• Big babies                                 Average size baby
• Hyperextended head                  pelvis adequate

• Pelvis inadequate 

      MANAGEMENT OF VAGINAL BREECH DELIVERY

First stage

    The management protocol is similar to that mentioned in normal labour. The following are the important considerations. Spontaneous onset  labour increases the chance of successful vaginal delivery.

Ø  Vaginal examination is indicated

a)     At the onset of labour for pelvic assessment

b)     Soon after rupture of the  membranes to exclude cord prolapsed

Ø  An intravenous line is sited with Ringer’s solution, oral intake is avoided, blood is sent for group and cross matching

Ø  Adequate analgesia is given, epidural is preferred

Ø  Fetal status and progress of labour are monitored

Ø  Oxytocin infusion may be used for augmentation of labour.

Indication of caesarean section

·       Cases seen for the first time in labour with presence of complications.

·       Arrest in the progress of labour

·       Fetal distress

·       Cord presentation or prolapsed

Second stage

 There are three methods of vaginal breech delivery:

Ø  Spontaneous [ 10%]:  Expulsion of the fetus occurs with very little assistance.

Ø  Assisted  breech : The delivery of the fetus is by assistance from the beginning to the end. This method should be employed in all cases.

Ø  Breech extraction: When the entire body of  the fetus is extracted by the obstetrician. It is rarely done these days as it produces trauma to the fetus and the mother.

ASSISTED BREECH DELIVERY

Breech delivery should be conducted by a skilled obstetrician. The following are to be kept ready before hand, in addition to those required for conduction of normal labour;

v Anaesthetist

v An assistant to push down the fundus during contraction

v Instruments and suture materials for episiotomy

v A pair of obstetric forceps for aftercoming head, if required

v Appliances for revival of the baby, if asphyxiated.

Principles in conduction

• Never to rush
• Never pull from below, but push from above
• Always keep the fetus with back anteriorly.

Steps

1. The patient is brought to the table when the anterior buttock and fetal anus are visible. She is placed in lithotomy position when the posterior buttock distends the perineum.
2. Antiseptic cleaning is done, bladder is emptied with an ‘in and out’ catheter.
3. Episiotomy: It should be done in all cases of primigravidae and selected multiparae. Its advantages are;

·       To straighten the birth canal which specially facilitates the delivery of breech with extended legs where lateral flexion is inadequate.

·       To facilitate intravaginal manipulation and for forceps delivery.

·       To minimize compression of the after coming head.

4. The patient is encouraged to bear down as the expulsive forces from above ensure flexion of the fetal head and safe descent. The ‘no touch of the fetus’policy is adopted until the buttocks are delivered along with the legs in flexed breech and the trunk slips upto the umbilicus.
5. Soon after the trunk upto the umbilicus is born the baby is wrapped with a sterile towel to prevent slipping when held by the hands and to facilitate manipulation, if required.
6. Delivery of the arms:

            The assistant is to place a hand over the fundus and keep a steady pressure during uterine contractions to prevent extension of the arms. Soon, the  anterior scapula is visible, the position of the arm should be noted. The arms are delivered one after the other only when one axilla is visible, by simply hooking down each elbow with a finger.  The baby should be held by the feet over the sterile towel while the arms are delivered.

7. Delivery of the after – coming head:

    This is the most crucial stage of the delivery.  The time between the delivery of umbilicus and delivery of mouth should preferably be 5 to 10 minutes. There are various methods of delivery for after – coming head. The following are the common methods employed;

1. Burns – Marshall method

·       The baby is allowed to hang by its own weight.

·       The assistant is asked to give suprapubic pressure with flat of hand in a downward and backward direction, the pressure is to be exerted more towards the sinciput. The aim is to promote flexion of the head so that favourable diameter is presented to the pelvic cavity.

·       When the nape of the neck is visible under the pubic arch, the baby is grasped by the ankle with a finger in between the two.

·       Maintaining a steady traction and forming a wide circle, the trunk is swung in upward and forward direction

·       With the left hand to guard the perineum, slipping the perineum off successively the face and brow.

·       When the mouth is cleared off the vulva, there should be no hurry.

·       Mucous of the mouth and pharynx is cleared by mucus sucker. The trunk is depressed to deliver rest of the head.

·       Forceps delivery can be used as a routine.

2. Malar flexion and shoulder traction { modified Mauriceau – Smellie – Veit technique}

o   The baby is placed on the supinated left forearm with the limbs hanging on either sides.

o   The middle and the index fingers of the left hand are placed over the malar bones on either sides . this maintains the flexion of the head.

o   The ring and little fingers of the pronated right arm are placed on the child’s right shoulder,  the index finger is placed on the left shoulder and the middle finger is placed on the suboccipital region.

o   Traction is now given in downward and backward direction till the nape of the neck is visible under  the pubic arch.

o   The assistant gives suprapubic pressure during the period to maintain flexion.

o   Thereafter, the fetus is carried in upward and forward direction towards the mother’sabdomen releasing the face, brow, and lastly, the trunk is depressed to release the occiput and vertex.

Third stage

The third stage is usually uneventful. The placenta is usually expelled out soon after the delivery of the head.

The prophylactic ergometrine is to be given, it should be administered intravenously with the crowing of the head.

MANAGEMENT OF COMPLICATED BREECH DELIVERY

When a woman presents in advanced labour it may be difficult to decide what would be ideal mode of delivery. However, if breech is not visible at the perineum it may be possible to deliver the baby caesarean section unless the attending staff has necessary expertise for vaginal breech delivery.

Frank – breech extraction [ Pinard’s maneuver]

 It is done by intrauterine manipulation to convert a frank breech to a footling breech. This is possible when the membranes have ruptured recently.

Steps

1. The patient is put under general anaesthesia and usual surgical asepsis is undertaken. The hand, the palmar surface of which corresponds with the  ventral aspect of the fetus is to be introduced to disimpact the buttocks so that the anterior buttock can be pushed up atleast to the level of the symphysis pubis.
2. The middle and the index fingers are to follow the thigh, preferably the anterior until the popliteal fossa is reached. With the fingers, the popliteal fossa is pressed and abducted so that the leg becomes partially flexed. Simultaneously, with the external hand the head is pressed down so that the footling drops down when it can be caught at the ankles by the internal fingers. The leg is pulled down by a movement of abduction.
3. The other leg is similarly brought down and the delivery is completed by breech extraction.

Extended arms

One or both arms may be fully stretched along the side of the head or lie behind the neck. The cause is usually the faulty technique in delivery,  using unnecessary traction, forgetting the principle of ‘ never pull but push from above’. Arrest occur with the delivery of the trunk upto the costal margins. The diagnosis is made by noting the winging of the scapula and absence of the flexed limbs in front  of the chest.

Management

The management calls for the urgent delivery of the arms, first the posterior and then the anterior one. The delivery of the arm may be accomplished by adopting the following method;

 Lovet’s maneuver

 It is widely  practiced. The advantages are:

• Wider applicability: it can be applied even when the classical method becomes difficult.
• Intrauterine manipulation is nill
• A single manipulation is effective to all types of displacement of the arms
• General anaesthesia is usually not needed

Principles

Because of the curved birth canal, when the anterior shoulder remains above the symphysis pubis, the posterior shoulder will be below the sacral promontory. If the fetal trunk is rotated keeping the back anterior and maintaining a downward traction, the posterior shoulder will appear below the symphysis pubis.

Procedure

The baby [ wrapped in a warm dry towel] is grasped, using both hands by femoropelvic grip keeping the thumbs parallel to the vertebral column. The maneuver should start only when the inferior angle of the anterior scapula is visible underneath the pubic arch.

Steps

1. The baby is lifted slightly to cause lateral flexion. The trunk is rotated through 180˚ keeping the back anterior and maintaining a downward traction. This will bring the posterior arm to emerge under the pubic arch which is then hooked out.
2. The trunk is then rotated in the reverse direction keeping the back anterior to deliver the rest while anterior  shoulder under the symphysis pubis.

ARREST OF THE AFTER – COMING HEAD

 At Brim

 The cause of arrest are:

ü  Deflexed head

ü  Contracted  pelvis

ü  Hydrocephalus

Management

 If arrest is due to a deflexed head, the delivery is to be completed by malar flexion and shoulder traction along with suprapubic pressure by the assistant. The head is to be negotiated through the brim in the transverse diameter and rotated in the cavity.

In the cavity

The causes of arrest of the head in the cavity are:

ü  Deflexed head

ü  Contracted pelvis

Management

The delivery of the head by forceps which is effective in both circumstances. Malar flexion and shoulder traction may be effective only in deflexed head.

At the outlet

The causes of arrest are:

ü  Rigid perineum

ü  Deflexed head

Management

          Episiotomy followed by forceps application or malar flexion and shoulder traction is quite effective.

COMPLICATIONS

v Impacted breech:  Labour  becomes obstructed when the fetus is disproportionately large for the size of the maternal pelvis

v Cord prolapsed: this is more common in a flexed or footling breech, as these have ill – fitting presenting parts

v Birth injury

o   Superficial tissue damage.

o   Fractures of humerus, clavicle of femur or dislocation of shoulder or hip

o   Erb’s palsy: this is due to the damage of brachial plexus.

o   Trauma to internal organs: rupturing of liver and spleen, which is produced by grasping the abdomen

o   Damage to the adrenals: this can be caused by grasping the baby’s abdomen, leading to shock caused by adrenaline release.

o   Spinal cord damage or fracture of the spine: this is caused by bending the body backwards over the symphysis pubis while delivering the head.

o   Intracranial haemorrhage: caused by rapid delivery of the head, which has had no opportunity to mould

v Fetal hypoxia: this may due to cord prolapsed or cord compression or to premature separation of the placenta

v Premature separation of the placenta:

                                NURSING DIAGNOSIS

Ø  Risk for alteration in labour progress related to abnormal fetal presentation

Ø  Risk for fetal distress  related to increased risk of prolapsed cord

Ø  Anxiety related to concern about possible cesarean section