|
Breech birth
OVERVIEW: At the time of delivery the fetal buttocks are the presenting part in the maternal pelvis
• Frank breech presentation - the fetal hips are flexed and the knees extended with the feet near the shoulders, accounting for 60-65% of breech presentations at term
• Incomplete breech presentation - one or both of the fetal hips are incompletely flexed, resulting in some part of the fetal lower extremity as the presenting part. Thus the terms single footling, double footling, knee presentation. Accounts for 25-35% of breech presentations.
• Complete breech - similar to frank breech except one or both knees are flexed rather than extended. Accounts for 5% of breech presentations.
System(s) affected: Reproductive
Genetics: Fetal anomalies including anencephaly, hydrocephalus, trisomy 21
Incidence/Prevalence in USA: 3-4% of singleton term deliveries and up to 15-30% of low birth weight infants (< 2500 grams)
Predominant age: N/A
Predominant sex: Female only
SIGNS AND SYMPTOMS: • Anus palpable on digital vaginal exam
• Leopold's maneuver reveals ballottable head in fundal region
CAUSES: Probably a combination of one or more of the risk factors listed below
RISK FACTORS: • Fetal anomalies including anencephaly, hydrocephalus, trisomy 21
• Uterine anomalies
• Uterine relaxation associated with great parity
• Uterine overdistension as in polyhydramnios or multiple gestation
• Placenta previa
• Placental implantation in cornual-fundal region
• Low birth weight or premature infant
• Macrosomia
DIAGNOSIS DIFFERENTIAL DIAGNOSIS: Diagnosis is made by vaginal exam and confirmed by ultrasound. Can be confused with face presentation on digital vaginal exam.
LABORATORY: None
Drugs that may alter lab results: N/A
Disorders that may alter lab results: N/A
PATHOLOGICAL FINDINGS: Congenital malformation among term breech infants: Overall incidence 9.0%
SPECIAL TESTS: N/A
IMAGING: • Ultrasound - confirms presenting part
• X-ray - flat plate of abdomen and pelvimetry to determine extent of head flexion and pelvic measurements
DIAGNOSTIC PROCEDURES: N/A
TREATMENT APPROPRIATE HEALTH CARE: Inpatient for labor and delivery
GENERAL MEASURES: N/A
SURGICAL MEASURES:
• Breech delivery is accomplished either vaginally or by cesarean section
• When a patient presents in labor with the fetus in breech position, a decision about a trial of labor or immediate cesarean section must be made
• Obtain a scout film of abdomen with pelvimetry and/or ultrasound to document fetal presentation, to check for fetal abnormalities, and to estimate fetal weight in deciding candidacy for vaginal delivery
• The selection criteria for vaginal delivery are fairly strict to reduce morbidity and mortality for both mother and infant
• Cesarean section is recommended in the following circumstances unless the fetus is too immature to survive:
• Large (> 3500 grams) or small (< 1500 grams) fetus, estimated by ultrasound or skilled observer
• Pelvic contraction or unfavorable pelvic shape (platypelloid and android)
• Hyperextended head
• Significant fetal heart rate abnormality
• Footling breech
• Severe fetal growth retardation
• Premature fetus greater than 26 weeks with mother in active labor
• Previous cesarean section (sometimes)
• Abnormal labor including failure to dilate, prolonged second stage, and failure of descent
• Cesarean section procedure:
• Prepare for cesarean section by starting IV fluids and obtaining blood type and screen, in all patients, in case needed for emergency
• A low transverse cesarean section may need to be extended vertically if there is difficulty with head entrapment (this extension produces a weak scar)
• General anesthesia with isoflurane can rapidly relax the uterus and allow delivery of an entrapped after-coming head
• Cord blood gases should be obtained following delivery
• Vaginal delivery procedures:
• The candidate for vaginal delivery needs to be attended by a birth attendant skilled in breech delivery, a scrubbed assistant, an anesthesiologist capable of rapid induction of general anesthesia, and an individual skilled in neonatal resuscitation
• Leave membranes intact as long as possible to prevent possible cord prolapse
• The patient should not push until fully dilated
• Cut large episiotomy to allow sufficient room for delivery
• The infant should not be touched before the umbilicus crosses the maternal perineum
• Traction prior to this point constitutes a complete breech extraction and is associated with higher risk of perinatal morbidity and mortality
• With the fetal back anterior, maintain downward traction while grasping the fetal hips until the scapula becomes visible
• Check for nuchal arm
• As one axilla becomes visible rotate the infant until the shoulders are oriented anteriorly and posteriorly allowing their delivery
• The fetal head is delivered in a face down position with either piper forceps or manual flexion of the head
• Cord blood gases should be obtained following delivery
ACTIVITY: Bedrest during labor
DIET: Nothing by mouth until delivery accomplished
PATIENT EDUCATION: Come to the hospital at the first sign of labor
MEDICATIONS DRUG(S) OF CHOICE: None
Contraindications: N/A
Precautions: N/A
Significant possible interactions: N/A
ALTERNATIVE DRUGS: N/A
FOLLOW UP PATIENT MONITORING: • Continuous fetal heart rate monitoring should be done during labor and delivery
• Six weeks postpartum care is done as with other deliveries
PREVENTION/AVOIDANCE: • External version
• Conversion to vertex presentation can be attempted from 30-36 weeks gestation
• External version can cause abruption, premature rupture of membranes, and fetal-maternal hemorrhage
• Should only be attempted with continuous fetal heart monitoring in the delivery suite where immediate cesarean section can be done
• Contraindications to external version include pelvic engagement of presenting part, placenta previa, previous uterine surgery, premature rupture of the membranes, or marked oligohydramnios
POSSIBLE COMPLICATIONS: • Trauma to head, soft tissue, brachial plexus and spinal cord - not always prevented by cesarean
• Asphyxia secondary to cord compression or prolapse
EXPECTED COURSE AND PROGNOSIS: • Perinatal morbidity and mortality are much higher in breech births. A large proportion of the deaths are related to congenital abnormalities.
• In patients properly selected for vaginal delivery, potentially perinatal morbidity and mortality, and maternal morbidity are reduced
• For infants 750 -1500 grams, there is a much higher rate of cerebral hemorrhage and perinatal death associated with vaginal compared to cesarean delivery
MISCELLANEOUS ASSOCIATED CONDITIONS: See Risk Factors
AGE-RELATED FACTORS:
Pediatric: N/A
Geriatric: N/A
Others: N/A
PREGNANCY: A problem of pregnancy
SYNONYMS: N/A
ICD-9-CM: 652.2 Breech presentation without mention of version
763.0 Breech delivery and extraction
763.4 Cesarean delivery
(see
images)
Want to discuss this term? Visit
our forum or our chat
room.
SEE ALSO (Enter the keywords below
into our search box or click on the link):
Placenta previa
Premature labor
|
IE 5.0