1. Dr. Nadia Saddam AL.Assady
breech presentation By
Dr. Nadia Saddam AL.Assady
C.A.B.O.G

2. Breech presentation:
The incidence rate at term is (3-4%), but it is commoner preterm (15% at 32 weeks) & ( 20% at 28 weeks).
etiology:
A-maternal factors: null parity, older age, uterine abnormality, abnormal placental site ( placenta previa), diabetes, smocking, late or no antenatal care & white ethnicity.
B-fetal factors: the commonest association with prematurity, fetal anomali( hydrocephalus or neuromuscular dysfunction causing abnormal posture or dyskinesia), IUGR, polyhydramnios, short umblical cord, extended legs & multiple pregnancy.

5. Clinical feature:
1-the term mother complain from subcostal discomfort specially on the right side abdominal palpation: revel the hard, round ballot able head at the uterine fundus & auscultation of fetal heart sounds above the umbilicus vaginal examination: may reveal soft presenting part the landmarks being the ischial tuberosity, the anus & genitalia may also be palpable.
4-U/S examination: to confirm the presentation & exclude fetal & maternal abnormalities that affect the management.

6. Types of breech presentation:
a-extended (frank): the legs are flexed at hip & extended at the knee.It occurs at (70%) of cases &carries the lowest risk of cord prolapse & feto pelvic disproportion b-flexed (complete): both hips & knee are flexed & the buttock is the presenting part c-footlying ( incomplete): at least one leg extended at hip & knee. This carries highest risks of cord prolapse & feto pelvic disproportion.

9. Management of Preterm breech:
There are concerns that the preterm fetus may be more vulnerable to hypoxic injury than the term fetus & also since the fetal head is relatively larger than the body, in preterm (BPD is larger than bitrochanteric diameter) there is greater risk of entrapment of the after coming head. However, elective C/S is complicated by the fact that (80%) of women in threatened preterm lobar will deliver at term so there is significant risk of iatrogenic prematurity if the babies delivered by C/S before lobar is established.

10. Furthermore, elective preterm C/S does not escape the risk of head entrapment, & midline uterine incision or inverted T- incision carry increased risk of scar rupture in the future. It is generally, accepted that for the fetus prior to (34 weeks), the risk associated with prematurity & congenital anomalies far outweigh those associated with mode of delivery & there is no evidence to support a policy of elective C/S for breech presentation in preterm lobar.

11. Management of Term breech:
1-posture: knee- chest position for up to (10 minute/day) may be effective in converting breech to cephalic one, no significant benefits from this procedure so not routinely recommended.
2-external cephalic version:
It is an abdominal procedure by which the fetus is turned from breech to cephalic presentation & should be only undertaken by professional trained personal Benefits of ECV: reduce the incidence rate of vaginal breech delivery & C/S rate so reduce maternal morbidity & mortality Risk of ECV: transient bradycardia, abruption placenta, cord prolapse, feto maternal hemorrhage

12. Indication of ECV: any breech presentation after (37 completed weeks) in other wise uncomplicated pregnancy maternal request Contraindication: a-absolute C/I: multiple pregnancy. 2-antepartum hemorrhage rupture membrane fetal abnormalities hyper extended head. 6-need urgent delivery regardless the presentation e.g placenta previa need for C/S to ensure fetal wellbeing or any suspected compromise, b-relative C/I: 1-previous LSCS.2-maternal disease like (HT, DM) IUGR oligohydramnios maternal obesity nuchal cord

13. Procedure of ECV: before starting the ECV the women should be asked to drink plenty of fluid so this optimize liquor volume perform CTG to confirm normal reactive pattern.
3-U/S is useful before ECV to confirm the breech, confirm the presence of normal fetus, ensure adequate liquor volume ,confirm placenta position, observe the presence of nuchal cord & detail the fetal attitude & position of fetal legs obtained informed consent , specially the risk ensure facilities for delivery by immediate C/S are present

16. 3-vaginal breech delivery:
Criteria for allowing breech vaginal delivery: frank breech. 2-fetal weight < (3.8 Kg) no feto pelvic disproportion & clinically adequate pelvis Criteria for preclude breech vaginal delivery: footlying breech fetal weight > (3.8 Kg) star gazing or hyper extended fetal neck Risk of breech vaginal delivery: low Apgar scores at birth. 2-intracranial injuries brachial plexus injuries fracture of fetal long bones soft tissues genital tract injuries to mother.

17. The procedure of breech vaginal delivery:
the principle of vaginal breech delivery is to allow the spontaneous delivery of the fetus through the combination of uterine activity & maternal expulsive efforts, operator intervention should be limited to a few well trained maneuvers with injudicious traction on the fetal body or limbs avoided at all costs, not only can traction lead to direct injury such interventions may also increase displacement of the fetal limbs from their normal attitude increasing the relative disproportion between fetus & pelvis that may already exist.

18. Management during the 1st stage of lobar:
1-lobar should be conducted within setting that allows rapid intervention by C/S if needed the diagnosis of lobar & presentation of the fetus by breech should be confirmed IV access established & fetal monitoring started epidural anesthesia may be recommended in order to prevent involuntary expulsive efforts prior to full cervical dilatation & to permit emergency delivery by C/S however epidural is not essential the use of oxytocin should be discouraged because any failure of progression is indication for C/S specially for breech.

19. Management during the 2nd stage:
It is begins with full cervical dilatation & visualization of the fetal anus at the perineum & must be managed by operator trained in the delivery of breech. There are 3 option for breech delivery , spontaneous breech delivery assissted breech delivery breech extraction.
1-the patient is adopted lithotomy position pudendal block can be provided if there is no epidural in situ episiotomy may be performed to facilitate manipulation of the after coming head.

20. 4-the breech should be allow to deliver spontaneously to the level of umbilicus, a loop of cord is then brought down to minimize the risk of traumatic delivery once the legs & abdomen have emerged the fetus allowed to hang from the perineum until the scapula seen & the arms are usually folded across the fetal chest & require nothing to deliver them.
6-if the arms are extended over the fetal head so used Lovset,s maneuver to free them . In this case, the fetus is grasped over the bony pelvis with your thumb along the sacrum & turned so as to bring the posterior arm anterior. So elbow appear below the symphysis pubis & than the arm delivered by sweeping it across the fetal body & this maneuver repeated for other hand.

21. 7-nuchal arm these are lying above & behind the fetal head( flexed at elbow & extend at shoulder) so it is a consequence of inappropriate traction on the breech, so we can used modified Lovset,s maneuver ( rotating the fetal back in the direction of trapped arm, thus forcing the elbow towards the fetal face over the fetal head once free so traditional Lovset,s maneuver may then be performed the fetus then allowed to hang from the vulva for a few seconds until the nape of neck is visible at vulva, this allow the head to descend in the pelvis & avoid the complication of hyperextension that can occur with traction at this stage. the duration of the time from appearance of umbilicus to fetal mouth clearing the perineum is( min).

23. Delivery of fetal head:
a-Burns-Marshall technique: the operator ,s assistant should grasp the ankle of the fetus & raise the body above the mother abdomen, this promotes flexion of fetal head & encourages it into the A-P diameter of pelvic outlet so allow spontaneous delivery of fetal head without further intervention.
b-Mauriceau-Smelli-Veit maneuver: with the fetus supported on the right arm of the operator, the middle finger is placed in the fetal throat & the forefinger & ring finger are placed either on the malar eminences, pressure is applied to the fetal tongue to encourage the flexion of the head.

29. Thus present the sub occipito- bregmatic diameter to the pelvis.
c-forceps application used straight forceps like Kielland forceps.
Head entrapment:
1-Mc Robert,s manoevure: the body of the fetus should be turned sideways & suprapubic pressure applied to increase flexion & encourage entry through the pelvic inlet in the occipito-lateral position.
2-Dehursson,s incision: incising the cervix at 4, 8, o'clock if descent occur before full cervical dilatation is achieved.
3-craniotomy & delivery of the head by C/S.

30. Notes: pediatrician should always be present at delivery & documentation of all events.
Breech extraction:
The only indication is to deliver the 2nd twin by foot extraction in fully dilated cervix.
C/S:
Performing C/S does not prevent the possibility of birth injuries like abdominal organs, spine & brain injury.

32. Thank you