MALPRESENTATIONBreech Presentation Prof. D r. Bushra J. AL-Rubayae University of Babylon College of Medicine
Objectives:●What is breech presentation.●It’s importance to diagnose antenatal & intrapartum .●Types of breech .●Types of breech delivery.●Options of management antenatal & intrapartum.●Complications .
MALPRESENTATION●Malpresentation is the situation where a fetus within the uterus is in any position that is not cephalic
Etiologic factors in mal-presentation●Maternal Grandmultiparity Pelvic tumors Pelvic contracture Uterine malformation●Fetal Prematurity Multiple gestation Hydramnios Macrosomia Hydrocephaly Trisomies AnencephalyPlacenta previa
Breech PresentationIntroduction : Breech presentation occurs in 3-4% of all deliveries. The occurrence of breech presentation decreases with advancing gestational age. - It occurs in 20% of births that occur at 30 weeks’ gestation. - 1-3% of births that occur at term. .
●Perinatal mortality is increased 2- to 4-fold with breech presentation, regardless of the mode of delivery.●Congenital malformation 6%.●Deaths most often are associated with Malformations.● Prematurity.● Intrauterine fetal demise.
Predisposing factors●prematurity, uterine abnormalities (e.g, malformations, fibroids),● fetal abnormalities (e.g, CNS malformations, neck masses, aneuploidy), and multiple gestations. ● AF abnormality. Abnormal placentat ion. Contracted pelvis .MG . Pelvic tumor .
Types of breeches●Frank breech (50-70%) - Hips flexed, knees extended.●Complete breech (5-10%) - Hips flexed, knees flexed.●Footling or incomplete (10-30%) - One or both hips extended, foot presenting
positionSA,SP,LST,RSTLSP,RSP.LSA,RSADIAGNOSIS●History.●Physical exam.●Palpations and ballottement●Pelvic exam●X-ray studies●Ultrasound
MANAGEMENT●Antenatal●Ante-partum●During labor●DeliveryAntenatal Management:●If found during obstetric exam in the third trimester we re-assure her and explain that spontaneous version could occur at any time.●We wait until 36 weeks of gestation .●Then decision been one of three options: 1-to perform external cephalic version or, 2-operative delivery or, 3-trial of assisted vaginal delivery.
VERSION●External●Internalexternal cephalic version●It has important personal benefits by helping avoid major abdominal surgery, and lowering the overall Cesarean rate. ●If everyone with a breech at term attempted a version then 50% been successful, Of them75% give birth vaginally .● So more than a third with term breech pregnancies could avoid a Cesarean if everyone attempted a version.
complicationThe rate of serious complications (placenta abruption or stillbirth) was 0.24%. ●stillbirths to the external version or unexplained. The unexplained stillbirths within 10 to 31 days after the version. ●Placenta abruption abruptions resulted in an emergency Cesarean.●Other complications included cord prolapse, temporary abnormal fetal heart rate patterns, vaginal bleeding , and PROM.
Contraindications:●Should NOT have a version ●If they have a history of placenta abruption or if placenta abruption is suspected,● If complicated pregnancy as severe pre-eclampsia, DM.● If there are signs of fetal distress. If vaginal birth is contraindicated then a version also be contraindicated.If multiple pregnancy.
Internal podalic version ●It’s only indicated for delivery of second twin if external cephalic version failed, during second stage of labour.
Internal podalic versionCriteria for VD orCS●VD FrankGA>34wFW=2000-3500grAdequate pelvisFlexed headNonviable fetusNo indication Good progress labor●CSFW<1500or> 3500grFootlingSmall pelvisDeflexed headArrest of laborGA24-34wElderly PGInf or poor historyFetal distress
VAGINAL BREECH DELIVERY●Three types of vaginal breech deliveries: 1.Spontaneous breech delivery 2.Assisted breech delivery3.Total breech extraction
Assisted vaginal breech delivery●Thick meconium passage is common as the breech is squeezed through the birth canal. This is not associated with meconium aspiration because the meconium passes out of the vagina and does not mix with the amniotic fluid.
The Ritgen maneuver is applied to take pressure off the perineum during vaginal delivery. Episiotomies often are cut for assisted vaginal breech deliveries, even in multiparous women, to prevent soft-tissue dystocia.
● No downward or outward traction is applied to the fetus until the umbilicus has been reached.
With a towel wrapped around the fetal hips, gentle downward and outward traction is applied in conjunction with maternal expulsive efforts until the scapula is reached. An assistant should be applying gentle fundal pressure to keep the fetal head flexed.
After the scapula is reached, the fetus should be rotated 90° to deliver the anterior arm.
The anterior arm is followed to the elbow, and the arm is swept out of the vagina.The fetus is rotated 180°, and the contralateral arm is delivered , The infant is then rotated 90° to the back-up position in preparation for delivery of the head.
The fetal head is maintained in a flexed position by using the Mauriceau-Smellie-Veit maneuver, by placing the index and middle fingers over the maxillary prominence on either side of the nose. The fetal body is supported in a neutral position with care to not overextend the neck.
Piper forceps application used only for the aftercoming head of a breech presentation to keep the head flexed during extraction of the fetal head. An assistant is needed to hold the infant while apply the forceps from below.
P ediatrician should be present for the delivery as neonatal resuscitation is needed.Picture 12. Assisted vaginal breech delivery - The neonate after birth
Risks: ●Lower Apgar scors●An entrapped head●Nuchal arms●Cervical spine injury●Cord prolapse,