BREECH PRESENTATION

Left sacroanterior REF: Dutta 6th ed p. 376

Most common position in breech presentation is left sacroanterior > right sacroanterior.

Ans:A.)Placenta accreta 

 Breech Presentation

The following are the known factors responsible for breech presentation:

•  Prematurity: It is the most common cause of breech presentation.
•  Factors preventing spontaneous version: (a) Breech with extended legs, (b) Twins, (c) Oligohydramnios, (d) Congenital malformation of the uterus such as septate or bicornuate uterus, (e) Short cord, relative or absolute, (f ) Intrauterine death of the fetus.
•  Favorable adaptation: (a) Hydrocephalus—big head can be well accommodated in the wide fundus, (b) Placenta previa, (c) Contracted pelvis, (d) Cornu-fundal attachment of the placenta— minimizes the space of the fundus where the smaller head can be placed comfortably.
•  Undue mobility of the fetus: (a) Hydramnios, (b) Multiparae with lax abdominal wall.
•  Fetal abnormality: Trisomies 13, 18, 21, anencephaly and myotonic dystrophy due to alteration of fetal muscular tone and mobility.

Placenta accreta

• It occurs when all or part of the placenta attaches abnormally to the myometrium (the muscular layer of the uterine wall). Three grades of abnormal placental attachment are defined according to the depth of attachment and invasion into the muscular layers of the uterus:
  • Accreta – chorionic villi attach to the myometrium, rather than being restricted within the decidua basalis.
  • Increta – chorionic villi invade into the myometrium.
  • Percreta – chorionic villi invade through the perimetrium (uterine serosa).
• Complications:
  • (i) damage to local organs (e.g., bowel, bladder, ureters) and neurovascular structures in the retroperitoneum and lateral pelvic sidewalls from placental implantation and its removal; (ii) postoperative bleeding requiring repeated surgery; (iii) amniotic fluid embolism; (iv) complications (e.g., dilutional coagulopathy, consumptive coagulopathy, acute transfusion reactions, transfusion-associated lung injury, acute respiratory distress syndrome, and electrolyte abnormalities) from transfusion of large volumes of blood products, crystalloid, and other volume expanders; and (v) postoperative thromboembolism, infection, multisystem organ failure, and maternal death.

Ref: Textbook of Obstetrics By Dutta

Prematurity is the commonest cause of breech presentation.

The chance for breech presentation gradually decrease towards term.

Breech presentation is the commonest malpresentation.

In this, lie is longitudinal and podalic pole is present at the pelvic brim.

Reference: 
Textbook of Obstetrics by D.C Dutta, 6e page 374-5.

Breech is the commonest malpresentation.

• Incidence: 1 in 5 at 28th week, 5% at 34th week, 3% at term.
• Most common cause: prematurity
• Commonest position : laft sacro anterior
• Head is born by flexion
• Flexed breech is more common in multipara and extended breech is more common in primigravida
• Most common type of breech is extended. 

Umbilical cord compression and prolapse may be associated with breech delivery, particularly in complete (5%) and footling (15%) presentations. 

• This is due to the inability of the presenting part to fill the maternal pelvis, either because of prematurity or poor application of the presenting part to the cervix so that the umbilical cord is allowed to prolapse below the level of the breech. 
• Frank breech presentation offers a contoured presenting part, which is better accommodated to the maternal pelvis and is usually well applied to the cervix. 
• The incidence of cord prolapse in frank breech is only 0.5% (the same as for cephalic presentations).

Ans. is a, c and d i.e. Hydrocephalus; Pelvic contracture; and Placenta praevia

At 28 weeks of pregnancy, approximately 20% of women have breech presentation. The fetus undergoes spontaneous version usually between 30^th and 34^th week. This corrects the breech position such that, at term only 3% of pregnant women have breech presentation.

Any maternal or fetal condition, which prevents this spontaneous version will result in a persistent breech presentation.

Causes of Breech presentation Most common cause-prematurity.

Utner Causes . Factors preventing spontaneous version –

hininonic           ASD BEtween Oesophagus and Trachea

Atrial                      Anomalies of uterus (septate / bicornuate) Anomalies of fetus (trisomy 13, 18, 21)

Septa!                      Short cord

Defect               – lntra Uterine Death

BEtween                  Breech with Extended Legs

Oesophagus- Oligohydraminos

Trachea       – Twins

Favourable adaptation :            • Hydrocephalus

• Placenta praevia
• Cornufundal attachment of the placenta°
• Contracted pelvis

Undue mobility of the fetus : • Hydramnios°

• Multiparae° with lax abdominal wall

Also Know

Recurrent breech : When breech recurs in 3 or more consecutive pregnancies, it is called habitual or recurrent breech.

Causes: • Congenital malformation of uterus (septate or bicornuate).

• Repeated cornufundal attachment of the placenta.

Wait & Watch

All

Intracranial hemorrhage

Congenital uterine anomaly

Face presentation

Frank

Ans. is ‘c’ i.e., DDH

Risk factors for DDH/CDH (Remember 4Fs 1H0)

• Females
• First borns
• Familial :- DDH is found in families
• Faulty intrauterine position (Breech presentation)
• Hormone induced laxity
• Oligohydramnion