Breech Presentation and Other Abnormal Presentations

Inna V. Landres MD
Basics
Description
Fetal presentation is the portion of the fetal body foremost within the birth
canal or closest in proximity to the birth canal.
In lonit!dinal lies" the presentin part is either cephalic or breech#
o $ephalic# Vertex" sincip!t %forehead&" brow" face
o Breech# Fran'" complete" footlin
In trans(erse lies" the sho!lder is the presentin part
Abnormal lie
Ae)*elated Factors
+A related#
Breech has decreasin pre(alence with +A#
o ,erm %-./01&# -/02 pre(alence
o -0 wee's# 32
o -4 wee's# 552
o -1 wee's# 5.2
o 46 wee's# 402
o $hance of spontaneo!s (ersion after -7 wee's is 432
8pidemioloy
Fetal presentation %from 76"19. sinleton prenancies at Par'land :ospital&#
o $ephalic %97.62&
o Breech %4..2&
o ,rans(erse %1.-2&
o $ompo!nd %1.52&
o Face %1.32&
o Brow %1.152&
Breech presentation#
o Fran' breech %31/.12 of all breech&# Both hips flexed and both 'nees
extended
o $omplete breech %3/512 of all breech&# Both hips and both 'nees
flexed
o Footlin or incomplete breech %51/012 of all breech&# 5 or both hips
not flexed" 5 or both feet or 'nees present before the b!ttoc's
*is' Factors
Abnormal placental implantation#
o Pre(ia" low)lyin placenta
;terine anomalies#
o <eptate !ter!s
o Bicorn!ate !ter!s
o Lare leiomyomata
Fetal anomalies
Preterm deli(ery
Abnormal amniotic fl!id (ol!me#
o Oliohydramnios" polyhydramnios
M!ltiple estation
Prior breech presentation
Pathophysioloy
Persistent breech presentation is associated with increased ris' of#
Perinatal morbidity from diffic!lt deli(ery
Prolapsed cord
;terine anomalies %sept!m" fibroids&
Placenta pre(ia
Fetal" neonatal anomalies
Associated $onditions
Face
Ment!m %chin& anterior or posterior#
Manaement#
o ;s!ally s!ccessf!l (ainal deli(ery
o A(oid fetal scalp electrodes
o A(oid man!al or forceps rotation
Brow
*arest=
;s!ally con(erts to face or occip!t#
o Manaement#
If small fet!s and lare pel(is" try (ainal deli(ery.
If larer fet!s" cesarean is !s!ally re>!ired.
,rans(erse
Dorsos!perior %bac' !p&" or dorsoinferior %or bac' down&
Manaement#
o Attempt (ersion after -9 wee's
o If labor" deli(ery by cesarean only
Deli(ery for trans(erse bac')down presentation re>!ires a (ertical !terine
incision or intra)abdominal (ersion
Proloned labor ris's incl!de !terine r!pt!re
$ompo!nd
An extremity presentin sim!ltaneo!sly with the presentin part#
In (ainal deli(ery" the arm will typically retract with descent
Dianosis
<ins and <ymptoms
:istory
$onsider ris' factors predisposin to abnormal presentation %see abo(e&
Physical 8xam
Leopold mane!(ers
Vainal exam#
o Face presentation is often conf!sed for breech=
Imain
;< to confirm s!spected breech
If considerin (ainal deli(ery" e(al!ate for type of breech and deree of head
flexion
?)ray pel(imetry is not ro!tinely !sed#
o $linical pel(imetry may be helpf!l if (ainal deli(ery is considered
Differential Dianosis
@ith fran' breech" palpation of an!s may s!est little cer(ical dilation
Breech and face presentations may be conf!sed
Fetal anomalies may ma'e determination diffic!lt#
o Breech with sacrococcyeal teratoma
o Anencephaly
,reatment
+eneral Meas!res
A$O+ $ommittee Opinion A!ly 4117 states that# Bthe decision reardin mode of
deli(ery sho!ld depend on the experience of the health care pro(ider.C
8$V#
<ho!ld be offered to all women near term with breech presentation %Le(el A
e(idence&.
<!ccessf!l (ersion translates into lower cesarean rates.
Patient candidates for 8$V#
o <ho!ld ha(e completed -7 wee's
o *eass!rin fetal heart tones by D<,
o 8$V sho!ld not be attempted in labor or in patients with P*OM
o Ass!re a(ailability of O* and anesthesia in case of emerency
cesarean
o Variable reported s!ccess rates# -3/632
o ,rans(erse lie# 61/912 s!ccess for 8$V
o <!ccess is more li'ely for parity" normal amniotic fl!id" and an
!nenaed fet!s.
o $onsider tocolysis for n!lliparas.
o 8arlier estation increases s!ccess rate b!t also increases rate of
spontaneo!s re(ersion.
o $omplications#
Placental abr!ption
;terine r!pt!re
Preterm labor
Fetal distress
o Isoimm!niEation# Always chec' *h stat!s and i(e *hoam if
indicated.
P.-73
$esarean Deli(ery
A planned $esarean deli(ery is the preferred mode for most patients d!e to
lower neonatal morbidity and mortality as well as decreasin expertise of
health care pro(iders.
,he ,erm Breech ,rial" a lare" randomiEed" international m!lticenter trial
demonstrated impro(ed neonatal o!tcomes with a planned cesarean compared
with a planned (ainal deli(ery %5.72 (s. 32 perinatal mortality" neonatal
mortality" and serio!s morbidity&
Vainal Deli(ery
May be an option for select patients with an experienced pro(ider
$riteria for patient selection#
o +A F-. wee's
o Fran' or complete breech presentation
o Ade>!ate maternal pel(is %prior term (ainal deli(ery preferred&
o Detailed patient informed consent
<pecial ,herapy
$omplementary and Alternati(e ,herapies
D!rse midwi(es and complementary medicine recommendations for
con(ertin near)term breech to cephalic presentation incl!de#
o Gnee)chest position twice a day. Data for efficacy not a(ailable.
o Lyin head down on an ironin board positioned on a chair %creatin
anled s!rface&. Data for efficacy not a(ailable
o Moxib!stion ac!p!nct!re %b!rnin of moxa herbal preparation&H
benefit shown in 5 small *$,.
o :ypnosisH benefit shown in 5 small *$,
o Aco!stic stim!lation while performin 8$V
<!rery
<ee abo(e for planned cesarean deli(ery.
Follow!p
Disposition
Iss!es for *eferral
*eferral to specialist with expertise in 8$V co!ld be considered.
Pronosis
Maternal#
o +reater maternal morbidity d!e to hih fre>!ency of cesarean"
emerency s!rery" and failed 8$V
o <imilar labor lenth with cephalic presentation for s!ccessf!l (ainal
deli(ery
Fetal#
o +reater neonatal morbidity and mortality at e(ery stae of estation
compared with cephalic presentation
$omplications
Vainal Deli(ery of Breech
:ead entrapment leadin to hypoxia and acidemia
,ra!ma from compression and traction
$ord prolapse# More common with footlin breech %532&
8ntrapment of fetal arm behind nec'
Fract!res of fetal h!mer!s" cla(icle
:yperextension of fetal head
Preterm fet!s# Incomplete cer(ical dilation
Manaement of head entrapment#
o Ma!ricea! mane!(er# Flex head by s!prap!bic press!re and press!re
on the maxilla
o Piper forceps
o DIhrssen cer(ical incisions for incomplete cer(ical dilation
$esarean Deli(ery
Maternal morbidity d!e to s!rery
Loner hospital stay
Increased blood loss
Patient Monitorin
;< to confirm s!spected breech or abnormal presentation
A(oid fetal scalp electrode for face presentation
$ontin!o!s external fetal monitorin for footlin breech d!e to hih ris' of
cord prolapse
D<, before and after 8$V
Biblioraphy
A$O+ Practice B!lletin Do. 5-. 8xternal $ephalic Version. @ashinton D$# A$O+H
Febr!ary 4111.
A$O+ Practice B!lletin Do. -01. Mode of ,erm <inleton Breech Deli(ery.
@ashinton D$# A$O+H A!ly 4117.
$!nniham F+. @illiams Obstetrics" 44nd ed. Dew Jor'# Mc+raw):illH 4113
:annah M8" et al. Planned cesarean section (ers!s planned (ainal birth for breech
presentation at term# A randomiEed m!lticentre trial. Lancet. 4111H-37#5-.3.
Miscellaneo!s
$linical Pearls
K BA breech is not L!st a (ertex !pside down.C %@8 Brenner and $: :endric's&
K Increased ris' of str!ct!ral and chromosomal anomalies
Abbre(iations
K 8$VM8xternal cephalic (ersion
K +AM+estational ae
K D<,MDonstress testin
K P*OMMPremat!re r!pt!re of membranes
K *$,M*andomiEed control trial
$odes
I$D9)$M
K 734.5 Breech or other malpresentation s!ccessf!lly con(erted to cephalic
presentation
K 734.4 Breech presentation witho!t mention of (ersion
K 734.- ,rans(erse or obli>!e presentation
K 734.0 Face or brow presentation
K 779.7 Breech extraction" witho!t mention of indication
K .75.. Malpresentation before labor
K .7-.1 Breech deli(ery and extraction
K .7-.5 Other malpresentation" malposition" and disproportion d!rin labor and
deli(ery
Patient ,eachin
A$O+ Patient 8d!cation Pamphlet# If Jo!r Baby Is Breech