Breech Presentation

Diagnosis Categories

• Frank breech presentataion • Complete breech presentation • Incomplete breech presentation

Diagnosis Categories

Joan Pitkin, Alison B. Peattie, Brian A. Magowan. Obstetrics and Gynaecology An Illustrated Coloured Text.2003, Elsevier Science Limited.2003. Philadelphia, USA:Elsivier Limited

History • • • • • • • • • •

Risk Factor

Uterine anomalies, Fibroids, Placenta previa, Grandmultiparity, Contracted maternal pelvis, Pelvic tumors, Prematurity Multiple gestation, Polyhydramnios, Short umbilical cord, fetal anomalies (e.G. Anencephaly, hydrocephalus), • Abnormal fetal motor ability, • Prior breech delivery. Vincenzo Berghella MD. Obstetric Evidence Based Guidelines. 2007. Informa, UK: London. http://emedicine.medscape.com/article/797690.overview

Physical Examination Abdominal Examination

• Leopold maneuvers • 1 the hard, round, readily ballotable fetal head  fundus. • 2 the back to be on one side of the abdomen and the small parts on the other • 3 if engagement has not occurred ”the intertrochanteric diameter of the fetal pelvis has not passed through the pelvic inlet ”the breech is movable above the pelvic inlet. • 4 shows the firm breech to be beneath the symphysis, after engagement • (Fetal heart sounds usually are heard loudest slightly above the umbilicus, whereas with engagement of the fetal head, the heart sounds are loudest below the umbilicus.

Physical Examination Vaginal Examination

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Rendering differentiation of face and breech very difficult ”the anus may be mistaken for the mouth and the ischial tuberosities for the malar eminences. Careful examination, however, should prevent this error, because the finger encounters muscular resistance with the anus, whereas the firmer, less yielding jaws are felt through the mouth. Furthermore, the finger, upon removal from the anus, sometimes is stained with meconium. The mouth and malar eminences form a triangular shape, whereas the ischial tuberosities and anus are in a straight line. The most accurate information, however, is based on the location of the sacrum and its spinous processes, which establishes the diagnosis of position and variety. In complete breech presentations, the feet may be felt alongside the buttocks, and in footling presentations, one or both feet are inferior to the buttocks. In footling presentations, the foot can readily be identified as right or left on the basis of the relation to the great toe. When the breech has descended farther into the pelvic cavity, the genitalia may be felt.

Physical Examination Vaginal Examination Frank Breech Presentation

Anus VS Face

Supporting Examination Imaging Techniques •

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Ideally, ultrasound should be used to confirm a clinically suspected breech presentation and to identify, if possible, any fetal anomalies. If cesarean delivery is planned, additional imaging is not indicated. If, however, vaginal delivery is considered, the type of breech presentation and the degree of flexion or deflexion of the head is important. Ultrasound also may supply this additional information (Fontenot and associates, 1997; Rojansky and colleagues, 1994). Computed tomographic (CT) scanning also can be used and will provide pelvic measurements and configuration at lower doses of radiation than standard radiography (see Chap. 20, Computed Tomographic (CT) Scanning). Magnetic resonance imaging (MRI) provides reliable information about pelvic capacity and architecture without ionizing radiation, but it is not always readily available (van Loon and colleagues, 1997). The role of x-ray pelvimetry in deciding the mode of delivery for breech presentation is controversial (Morrison and co-authors, 1995). Cheng and Hannah (1993) reviewed 15 studies of breech delivery at term in which either xray or CT pelvimetry was used as one of the criteria for allowing vaginal delivery. They concluded that although the utility of x-ray pelvimetry was difficult to assess because "permissible" pelvic dimensions varied among studies, in most there was no correlation between pelvic measurements and labor outcome. One study demonstrated that the incidence of complicated labor rose with decreasing pelvic capacity (OhlsA©n, 1975). Van Loon and colleagues (1997) reported that although MRI pelvimetry did not significantly lower the overall cesarean rate or improve neonatal outcomes, its use was associated with a lower rate of emergency cesarean delivery.