BREECH PRESENTATION

INTRODUCTION:

• In breech presentation, the lie is longitudinal and the podalic pole presents at the pelvic brim.
• Most common breech presentation is Left sacroanterior
• Breech presentation is mostly mistaken for  Face presentation
• Percentage of breech at term is 3 %

VARIETIES:

Complete (Flexed breech):

• Commonly present in multiparae(10%).
• Presenting part :2 buttocks, external genitalia and two feet

 

Incomplete:

Breech with extended legs (Frank breech):

• Presenting part:2 buttocks and external genitalia
• Present in primigravidae(70%).
• Least chances of cord prolapse  
• In breech, engagement takes places earliest in frank 

Footling presentation (25%): 

• Both thighs and legs are partially extended bringing the legs to present at brim.

• Knee presentation: 
  • Thighs are extended but the knees are flexed, bringing the knees down to present at the brim. 

Clinical varieties:

• Uncomplicated:no other associated obstetric complications
• Complicated:associated with conditions which adversely influence prognosis such as prematurity, twins, contracted pelvis, placenta previa

• Prematurity

Factors preventing spontaneous version:

• Breech with extended legs
• Twins
• Oligohydramnios
• Septate or bicornuate uterus
• Short cord, relative or absolute
• IUD of fetus.

• Detect fetal congenital abnormality
• Detect primigravidae with engaged frank breech or with tense abdominal wall and irritable uterus
• Type of breech
• It measures biparietal diameter, gestational age and estimated weight of the fetus
• Localizes the placenta
• Assessment of liquor volume
• Attitude of the head

POSITIONS:

• First position: Left sacroanterior (LSA)—being the most common
• Second position: Right sacroanterior (RSA)
• Third position: Right sacroposterior (RSP)
• Fourth position: Left sacroposterior (LSP).

MECHANISM OF LABOR IN BREECH PRESENTATION:

SACROANTERIOR POSITION:

Principal movements occur at three places

Buttocks:

• Engaging diameter is bitrochanteric (10 cm or 4″)
• Breech is engaged when diameter passes through the pelvic brim
• Descent of the buttocks: Till anterior buttock touches the pelvic floor
• Internal rotation of the anterior buttock(1/8th of a circle)
• Further descent with lateral ! exion of the trunk
• Delivery of the trunk and the lower limbs
• Restitution 

Shoulders:

• Bisacromial diameter (12 cm or 4 3/4″) engages
• Descent occurs with internal rotation of the shoulders bringing the shoulders to lie in the anteroposterior diameter of the pelvic outlet
• Ttrunk simultaneously rotates externally through 1/8th of a circle
• Delivery of the posterior shoulder followed by the anterior 
• Restitution and external rotation

Head:

• Engagement:Engaging diameter of the head is suboccipitofrontal (10 cm).
• Descent with increasing # exion occurs
• Internal rotation of the occiput(anteriorly, through 1/8th or 2/8th of a circle)
• Further descent occurs until the subocciput hinges under the symphysis pubis
• Head is born by ! exion—chin, mouth, nose, forehead, vertex and occiput appearing successively.

Sacroposterior position:

• In sacroposterior position, the mechanism is not substantially modified.
• The head has to rotate through 3/8th of a circle to bring the occiput behind the symphysis pubis.

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