Breech Presentation

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

ETIOLOGY:

  • Prematurity
  • Factors preventing spontaneous version:
  • Breech with extended legs
  • Twins
  • Oligohydramnios
  • Septate or bicornuate uterus
  • Short cord, relative or absolute
  • IUD of fetus.

Favorable adaptation:

  • Hydrocephalus
  • Placenta previa
  • Contracted pelvis
  • Cornu-fundal attachment of the placenta
  • Undue mobility of the fetus
  • Hydramnios,
  • Multiparae with lax abdominal wall.
  • Fetal abnormality: Trisomies 13, 18, 21, anencephaly and myotonic dystrophy

DIAGNOSIS:

Clinical:
 
CHARACTERISTICS COMPLETE BREECH FRANK BREECH
Per abdomen 
Fundal grip
  • Head—suggested by hard and globular mass
  • Head is ballottable
  • Irregular small parts of the feet may be felt by the side of the head
  • Head is nonballottable
Lateral grip  Fetal back is to one side & irregular limbs to other

 Irregular parts are less felt on the side

Pelvic grip
  • Breech—suggested by soft, broad and irregular mass
  • Breech is usually not engaged during pregnancy
  • Small, hard and a conical mass is felt
  • The breech is usually engaged
FHS  Usually located at a higher level round about the umbilicus  Located at a lower level in the midline
Per vaginam
During pregnancy  Soft and irregular parts are felt through fornix  Hard feel of the sacrum is felt
During labor Palpation of ischial tuberosities, sacrum and the feet by the sides of the buttocks  Palpation of ischial tuberosities, anal opening and sacrum only

  ULTRASONOGRAPHY:

  • 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.
Exam Question
 
  • Most common breech presentation is Left sacroanterior
  • Percentage of breech at term is 3 %
  • Fetal malformation , Uterine anomaly & Cornual implantation of placenta are associated with breech presentation at normal full term pregnancy
  • Prematurity  is the commonest cause for breech presentation
  •  LEAST chances of cord prolapse are seen in Frank breech
  • Causes of breech presentation are Hydramnios,Septate uterus,Hydrocephalus, Placenta praevia & Pelvic contracture
  • Recurrent breech presentation is seen In Congenital uterine anomaly
  •  Breech presentation is mostly mistaken for  Face presentation
  • In breech, engagement takes places earliest in frank 
Don’t Forget to Solve all the previous Year Question asked on Breech Presentation

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