Breech presentation By Dr. Khattab KAEO Prof & Head of Obstetrics and Gynaecology Department Faculty of Medicine, Al-Azhar University, Damietta

The fetal buttocks enter the pelvis first.

Incidence: 3-4% (1:30) at term. 15% at weeks' gestation. Types: * Frank with flexed hips but extended knees = 50-70%. * Complete with flexed hips and knees =10%. * Incomplete with one or both feet or knees lie below the buttocks (footling & knee pre- sentation) = 10-25%.

Types of breech presentation

Positions: Sacrum is the denominator making 8 positions: sacrto- anterior (Rt, Lt & direct), sacro-transverse (Rt & Lt) and sacro-posterior (Rt, Lt & direct). Sacro-anterior is more common because concavity of the front of the fetus fits into convexity of the maternal lumbar spine.

Predisposing factors are conditions that decrease polarity of the uterus, increase or decrease the fetal motility, or block the presenting part from the pelvis. These include: - Prematurity. The commonest cause (50%). - Multiparity. - Multiple pregnancy. - Polyhydramnios. - Oligohydramnios. - Uterine anomalies recurrent breech presentation - Pelvic tumour. - Fetal anomaly as hydrocephaly. Persistent breech may predict a neurologically abnormal fetus. - Extension of the legs. - Idiopathic: 20%. Contracted pelvis is not a factor in breech presentation NB: Breech presentation at ≥25 w is associated with increased risk of malpresentation at delivery.

Diagnosis: There may be past history of breech presentation or transverse lie. * During pregnancy: There may be dyspepsia & pressure symptoms in the upper abdomen. The fetal head occupies the fundus, while the breech is felt by the 1st pelvic grip. Ultrasound examination helps to confirm the diagnosis, exclude congenital anomalies & determine extension of the head. It can also roughly estimate fetal weight.

During labour: 1/3 are not diagnosed until during labour. Diagnosis depends on detecting 3bones the sacrum and 2 ischial tuberosities. * During labour: 1/3 are not diagnosed until during labour. Diagnosis depends on detecting 3bones the sacrum and 2 ischial tuberosities.

Differential diagnosis: Frank breech is to be differentiated from vertex during abdom exam, because the extended legs may prevent ballottement of the head & the small breech may be mistaken for the head. On PV exam, it should be differentiated from face as the anus may be mistaken for the mouth. However, the anus reflexly grips on the examin. finger & we can recognise the sacral spines. The mouth is lax and has firm gums. The foot may be mistaken for a hand. Wrist of a dorsiflexed hand may resemble a heel However, if fingers are run from wrist to palm, the 'heel' will disappear; while, if toes are run from ankle to sole, the heel will persist Toes form a straight line, while fingers  unequal lengths & form a curve.

Mechanism of delivery: Sacro-anterior

Mechanism of delivery: Sacro-posterior

Complications: Fetal: - Perinatal mortality (3-4-x ) and morbidity are mainly due to prematurity, birth trauma & associated congenital anomalies (2-3-x ). The commonest cause of mortality is intracranial haemorrhage as there is no enough time for moulding of the head. R / Maternal administr. of vitamin K and slow delivery of the head. - The incidence of cord prolapse (0.5%) with frank breech is the same as with cephalic present. The incidence of cord prolapse with complete breech is 5%, with footling 15%. - Fracture dislocation of the cervical spine. The fetus should not be moved towards the mother's abdomen until the suboccipital region appears below the symphysis pubis. Also, the fetus should not be moved >90. - Retained aftercoming head for >10 min. -Rupture of abdominal organs. Maternal: Mainly increased risk of birth trauma, particularly operative delivery.

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