Prof. Abdulhafid Abudher

MBBch,DGO,MD,FABOG,FRCOG

Definetion  This is a malpresentation where the podalic pole presents at the pelvic inlet.

 The lie is longitudinal  The denominator is sacrum

Various positions  Anterior  RSA-right sacroanterior (common)  SA-sacroanterior  LSA-left sacroanterior  Posterior  RSP-right sacroposterior  SP- Sacroposterior  LSP-left sacroposterior

Incidence  At term  29-32 weeks  Accounts for 2.2% to3.7% up to 25% 4.8% of all births in USA (Haugley 1985)

Types of Breech

(Seed and Cafalo 1982)

 Complete 5-12%  Frank 48-73%  Incomplet 10-30%  Footling  Kneeling

Etiology  Predisposing Factors  Abnormal uterine shape  Excessive fetal mobility  Interference in fetopelvic relationship 1-Maternal factors 2-Placental,Liquor and cord factors 3-Fetal Factors

Maternal Factors  Cephalopelvic disproportion at the pelvic inlet  Soft tissue dystocia  Congenital uterine anomalies  Grand multipara  Anticonvulsants and maternal alcohol intake

(Robertson 1984)

Placental,Liqure,Cord Factors  Placenta previa  Cornufundal implantation of placenta

(fainu and vaclavinkova 1978)

 Polyhydramnios  Oligohydramios  Very long or very short cord

Fetal Factors  Multiple gestation  Congenital anomalies  Prematurity  Large baby  Postdate  Intra uterine fetal death  Fetal aneuploidy

(Zhang and Schingle 1993)

Diagnoses of Breech  Abdominal examination  Fetal heart sounds  Vaginal examination  Ultrasound examination

Mechanism of labour  Delivery of lower limbs and buttocks  Delivery of shoulders and arms  Delivery of aftercoming head

Delivery of lower limbs and buttocks  Engagement  Descent  Flexion  Internal rotation  Birth of Buttocks

Delivery of shoulders and arms  Engagement  Descent continuous  Internal rotation  Birth of shoulders  Restitution

Birth of after coming head  Engagement  Descent  Flexion  Internal rotation  Birth of the head

Mechanism of labour in other positions  Sacroanterior position  Sacroposterior position  Moulding

Investigations  Routine antenatal investigations  US  Anomalies  Head extension  Maturity  Site and grade of placenta  Adequacy of liquor  Multiple gestation  Confirming fetal presentation

Investigations  X-ray abdomen (history)  Skeletal anomalies  Maturity  Pelvimetry  Multiple gestation

Management during pregnancy  External cephalic version  Trial of labour  Caesarean delivery

Vaginal breech delivery  Spontaneous  Assisted  Total breech extraction

Indications for trial of labour  Frank breech  Gestational age 36 to 42 weeks  Estimated fetal weight 1500 to 3900 grm  Flexed fetal BPD less than 9.5

 Adequate maternal pelvis

  Breech Vaginal Delivery First Stage Second stage    Episiotomy Assisted  Lovset’s maneuver Aftercoming head  Kristellar’s maneuver      Bracht’s maneuver Wigand-Martin maneuver Mauriceau-Smellie-Veit maneuver Forceps delivery (Savage’s maneuver) Occipto-posterior position   Rotating face posterior Prague maneuver

Total breech extraction  Rapid delivery -FD  Pre-requisites:  No fetopelvic disproportion  Fully dilated cervix  Empty balder and rectum  Anesthesia  Good assistance

Hyper extension of the head  Etiology      Spasm or congenital shortening of the extensors muscles of neck Umbilical cord looped around the neck Congenital tumors of the neck ,teratoma or cystic hygroma Uterine anomalies Placental tumors

Hyper extension of the head  Diagnosis  X-ray (star gazing foetus)  Ultrasound (measurement of the craniospinal angle) • Risk of spinal cord damage  Excessive longitudinal stretching  Extreme flexion of neck during delivery  Marked tortion

Indications for elective C/S           Contracted, border line or abnormal pelvis Placenta previa Large baby Hyperextension of head Footling breech Premature baby Previous caesarean section Elderly primgavida , BOH ,primary infertility IUGR BPD more than 9.5 cm

Prognosis for breech presentation   Maternal   Genital laceration Bleeding Fetal    Injury to the brain and skull   Intracranial hemorrhage Fracture of skull bones  Brain dysfunction Prematurity Congenital anomalies  Congenital dislocation of hip    Hydrocephaly Anencaphaly meningomyelocele

Prognosis for breech presentation   Birth asphyxia may occur due to:     Prolonged compression of cord Cord prolapse Aspiration of liquor and vaginal secretions Prolonged labor Fetal injuries  Fracture of neck,humerus,clavical,femur      Cervical and brachial plexus palsies Hepatic rupture Splenic laceration Adrenal gland rupture Pharyngeal injury