14th March - Breech Presentation Notes

Breech Presentation Overview

• Breech presentation occurs when the fetus presents with the buttocks or feet first instead of the head, which is the preferred position for delivery.

Types of Breech Presentation

• Complete Breech:

• Fetus is in a sitting position with legs flexed at knees and the buttocks in the pelvic inlet.

• Frank (or Extended) Breech:

• Legs are extended straight, and the buttocks are engaged in the pelvic inlet.

• Footling Breech:

• One or both feet are presenting past the buttocks, leading to an increased risk of cord prolapse.

• Kneeling Breech:

• One or both knees are presenting; this is relatively rare.

Risks Associated with Breech Presentation

• Breech births are associated with higher perinatal morbidity and mortality compared to cephalic presentations.

• Complications include:

• Prematurity: Increased likelihood due to fetal mobility during late pregnancy.

• Congenital Malformations: Such as anencephaly or other serious abnormalities affecting fetal positioning.

• Asphyxia and Trauma: Due to the nature of breech birth which can lead to difficulties during the delivery process.

Factors Predisposing to Breech Presentation

• Previous breech births, premature labor, high parity, uterine malformations (e.g., fibroids), oligohydramnios or polyhydramnios.

• Conditions such as placenta previa can also impact fetal position.

Historical Context and Changing Practices

• The Term Breech Trial (2000) highlighted higher perinatal mortality with vaginal breech deliveries, leading to increased cesarean section rates.

• The study faced criticism for its methodology yet significantly influenced practice guidelines worldwide.

Incidence of Breech Presentation

• Approximately 3-4% of pregnancies end with a breech presentation at term; this is initially higher during pregnancy but decreases as gestation progresses.

• Breech presentations are most common in the earlier trimesters, with many fetuses turning head-down by term.

Maneuvers for Breech Birth

• Mechanism of Breech Birth:

• Delivery usually begins with the buttocks followed by the legs, then the shoulders, and finally the head.

• Proper maneuvers are crucial to facilitate delivery and prevent complications.

Management in Labor

• Unexpected Breech Presentation:

• Identify presentation as early as possible; early referral to specialists if breech is diagnosed in labor is essential.

• If breech is detected and membranes intact, avoid rupture to prevent cord prolapse risk.

Moving Forward with Breech Birth

• Practitioners must be trained in specific breech delivery techniques and remain prepared for emergencies that may arise during labor.

• Continuous education and review of guidelines are necessary to provide safe and supportive care for women wishing to pursue vaginal breech births.

Summary of Breech Management Guidelines

• Follow local and national clinical guidelines.

• Offer informed choice discussions regarding the risks and benefits associated with various delivery methods.

• Encourage dialogue between expectant parents and the healthcare team to ensure feedback and shared decision-making.

Conclusion

• Breech presentation requires careful assessment and management to ensure the safety of both mother and child.

• Keeping abreast of recent studies, protocols, and local guidelines is key for healthcare practitioners involved in antenatal and intrapartum care.

Planned Cesarean Section vs. Planned Vaginal Birth for Breech Presentation at Term

• Planned Cesarean Section (CS) is often recommended for breech presentations due to the associated risks of vaginal delivery.

• Planned Vaginal Birth (VB) may be considered in selected cases where expertise is available and informed consent is obtained.

• The choice between CS and VB should be guided by clinical factors including the type of breech presentation and maternal health.

Incidence of Breech Presentations and Vaginal Births

• Approximately 3-4% of pregnancies end with a breech presentation at term.

• The incidence is higher earlier in pregnancy, and many fetuses naturally turn head-down by term.

• Vaginal breech births are less common and significantly depend on clinical settings and availability of skilled practitioners.

Understanding Unexpected Breech and Planned Breech Births

• Unexpected Breech: Detected during labor, requiring quick assessment and decision-making for delivery methods.

• Planned Breech Births: Ideally should be discussed prior to labor to prepare for possible outcomes and methods of delivery.

Mechanism of Breech Birth

• The fetal delivery sequence typically begins with the buttocks, followed by the legs, then the shoulders, and finally the head.

• Proper maneuvers are essential throughout this process to minimize risks and facilitate safe delivery.

Sequence of Physiological Standing Breech Birth

1. The mother provides gravity assistance, aiding in the descent of the fetus.

2. The buttocks emerge first, followed by the legs.

3. Body rotation is applied to aid shoulder delivery.

4. Ensure that the head is released last to avoid complications.

When It Should Be Hands-Off Breech Unless…

• It's recommended to adopt a hands-off approach unless there are signs of distress or complications arise during delivery.

• Interventions should be minimal to allow for natural progression and reduce the risk of injury.

10 Mechanisms of Upright Physiological Breech Birth

• Specific maneuvers during an upright breech birth assist in utilizing gravity and maternal positioning.

• The mechanisms include:

1. Maternal positioning to utilize gravity.

2. Gentle rotational movements to assist shoulder delivery.

3. Avoiding rapid maneuvers – allowing the body to descend gently.

4. Controlled delivery of legs to prevent cord prolapse.

5. Offering stability through maternal support.

6. Allowing for spontaneous movements of the fetus at the pelvic inlet.

7. External fetal monitoring to guide progress.

8. Recognizing the need for hands-on assistance only when absolutely necessary.

9. Maintaining fetal- maternal well-being during delivery.

10. Following local protocols regarding breech delivery to ensure safety.