Breech delivery Lecture, Medical Students 2D, NTNU 2009, Pepe Salvesen

Breech presentation Prevalence: 2-3% at term More frequent in preterm deliveries 30% at 30 weeks - 15% at 34 weeks Breech presentation is associated with increased morbidity/mortality ( i.e. Cerebral Palsy) - independent of mode of delivery

Breech presentation - terminology Extended breech “Frank” breech Flexed breech Complete breech Footling

Risk factors Preterm delivery Multiparity Uterus- and fetal anomalies Myoma, pelvic tumors Poly- and oligohydramnios Previous breech

Breech Exercises Not scientifically proven! Knee Chest Position Deep Trendelenburg Not scientifically proven!

External cephalic version (ECV) Success factors Multiparity Frank breech Normal amount of amniotic fluid Relaxed uterus Gestational length < 37 weeks Tocolysis

Lift the breech out of the pelvic inlet

Fetal forward somersault (or backwards) No use of force Attempted version

Fetus in transverse lie Check with ultrasound

Succesful version - in about 50%

Contraindications for ECV Multiple pregnancy Placenta previa Previous CS or myomectomy History of antepartum bleeding Pathologic CTG Uterus anomalies

Complications are rare Placental abruption Cord accident PROM, bleeding Transplacental haemorrhage Fetal bradycardia (CTG) IUFD Amniotic fluid embolism?

The most favourable head diameter is similar Head and breech delivery The most favourable head diameter is similar Symphysis Symphysis Sacrum Sacrum Breech delivery Cephalic delivery

Practical routines breech delivery Avoid amniotomy, but examine when the water breaks (umbilical cord) CTG monitoring Avoid pushing too early (epidural) Do not pull ! Never! Spontaneous delivery of lower part of the body down to apex of the anterior scapula Active delivery of shoulders (Løvset’s method) Head delivery by Mauriceau – Veits – Smellie method or forceps

Vaginal breech delivery Remember to get the back anterior

Leg delivery

Be active when the cord insertion is delivered

Shoulder delivery Løvset’s method

MSV maneuver + suprapubic pressure

Cervical cut if the head is stuck

Contraindications - breech delivery Cephalopelvic disproportion (X ray pelvimetry) Macrosomia (> 4000 g) Preterm delivery (< 34 weeks) IUGR – placental failure Footling breech Extended neck or nuchal arm Inexperienced birth attendants

Pelvimetry - vaginal breech delivery Pelvic inlet - Conjugata vera > 11,5 cm Sum pelvic outlet > 32,5 cm Interspina diameter + intertubar diameter + sagital outlet The clinical value of X ray (or CT) pelvimetry is debatable

Information to pregnant women with breech presentaion Don’t wait home, but come to the labour ward immediately when the contractions start Epidural – pro and cons Baby is delivered by an obstetrician

Breech delivery outside hospitals Should be avoided! Advice: Get help (midwife) No active pushing (panting breath with open mouth – no Valsalva) Do not pull !! Let the baby hang from the head Mother lies across the bed

Hannah-study: Term breech trial Lancet 2000; 356: 1375-83 RCT - 26 countries and 121 OB dept. N = 2088 women with breech presentation randomised to CS or vaginal delivery Mortality 0,3 % / 1,3 % Morbidity 1,4 % / 3,8 % Study heavily critized Results probably not applicable in Norway