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Breech Presentation

Last updated 20.09.12

 

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Index

 

 Definition

-  Fetal buttocks or feet inferior with longitudinal lie in uterus during pregnancy &/or labour

-  a. Frank (extended): buttocks first, hips flexed, legs extended

-  b. Complete (flexed): buttocks first, hips & legs flexed (sit/squat)

-  c. Footling: one or both feet presenting

 

 

Features

-  3-4% incidence at term

-  Frank 45-50%

-  Complete 10-15%

-  Footling 35-45%

-  15% incidence at 29-32 weeks

-  Normal finding in early preterm pregnancy

-  25% spontaneously revert >35weeks

-  Frequency decreases as gestation progresses

 

Risk Factors

-  Prematurity

-  Uterine anomalies: bicornuate, septate

-  Multiple pregnancy: twins..

-  Previous breech

-  High parity

-  Fetal anomalies

-  Fetal death

-  Short umbilical cord

-  Placenta praevia or corneal placenta

-  Polyhydramnios or Oligohydramnios

 

Complications

-  Fractured clavicle or humerus

-  Entrapment of fetal head

-  PPH

-  DDH

 

Ix

-  Abdo palp

-  Ballotable head felt in fundus of uterus

-  FHR heard above umbilicus

-  Head not felt in pelvis

-  VE

-  Small parts or buttocks palpated 

-  DDx by absence of fontanelles + sutures

-  +/- meconium on finger if breech

-  US: second or third trimester

-  Confirm presentation

 

Mx

-  <37 weeks Gestation

-  Antenatal

-  Nil Mx required if uncomplicated until 37 weeks

-  If preterm delivery required: LUSCS

-  In Labour

-  LUSCS (opinion may vary) unless

-   Vaginal delivery is imminent

-   Fetal survival not effected by mode of delivery (<24 weeks gestation..)

-  >37 weeks Gestation

-  Antenatal

-  US to confirm position & exclude

-   Poly/oligohydramnios

-   Placenta praevia

-   Fetal anomaly

-  Mx options

-   External Cephalic Version (ECV)

-   Elective LUSCS at 39weeks if feasible

-  If ECV fails

-  In Labour

-  Vaginal delivery

-   Only if delivery is imminent &

-  Senior help available

-  No contraindications to vaginal birth

-  Frank or complete breech

-   US to confirm (ward based)

-   Continuous CTG

-  If vaginal delivery not imminent for LUSCS

-  Vaginal Breech Delivery

-  Continuous CTG

-  Help

-  Most senior/experienced person available

-  Paeds/other: anticipate compromised baby & neonatal resus

-  +/- Assistant for manouvres

-  Scribe

-  Active pushing only when fully dilated confirmed by VE & descent of presenting part

-  Otherwise breech/buttocks may deliver (smaller diameter) but fetal head gets entrapped (larger diameter)

-  Usually present sacroanterior

-  Hands off

-  When birthed to trunk

-  Do not touch cord unless very taut then consider pulling loop down

-  If legs not delivered

-   Place index finger in popliteal fossa & flex & abduct thigh

-  Let the breech hang down (sacroanterior)

-  Adjust fetal postion as needed to maintain scaroanterior position by holding hips

-   Avoid pressure on fetal abdomen

-  Progress until scapulas visible

-  +/- Lovesetts Manouvre

-  Used if extended arms above & behind fetal head

-   Vaginal delivery not possible unless corrected

-  Sacroanterior position

-  Grasp fetal thigh with thumbs on SIJ

-  Trunk rotated 180o

-   Anticlockwise for right arm, clockwise for left arm

-   Flex fetal elbow & draw hand across face

-   Repeat on opposite side as needed

-  Progress until nape of neck visible (hairline)

-  Mariceau-Smillie-Veit Manouvre

-  Fetal trunk draped over non-dominant hand

-   Palm supporting chest

-   2nd & 4th fingers on cheeckbones

-   3rd finger on chin to maintain flexion

-  Dominant hand on posterior back

-   2nd finger on occiput to maintain flexion

-   Other fingers over shoulders to maintain traction

-  +/- assisted by suprapubic pressure

-  Avoid hyperextension of fetal neck

-  Entrapment of fetal head

-  Duhrssen incisions of cervix 2, 6, 10 oclock

-  Post delivery

-  Cord gases

-  Neonatal resus

-  Documentation

-  Debrief

 

 

 

 

 

References

 

www.thewomens.org.au/BreechManagementofBreechPresentation (incl Pic of positions)

ALSO, AAFP, 2000

Pic (MSV): ohnmidwif.oxfordtextbookofmedicine.com/content/vol1/issue1/images/large/graphic31.jpeg

Pic (Lovesetts): www.flickr.com/photos/15327128@N05/2772738181/