DR. RAZAQ O. MASHA, FRCOGDR. RAZAQ O. MASHA, FRCOGConsultant, Ob/Gyn Dept.Consultant, Ob/Gyn Dept.

Breech presentation occurs in 3-4% of Breech presentation occurs in 3-4% of all deliveries. The percentage of all deliveries. The percentage of breech deliveries decreases with breech deliveries decreases with advancing gestational age from 25% of advancing gestational age from 25% of births prior to 28 weeks gestation to 7% births prior to 28 weeks gestation to 7% of births at 32 weeks gestation to 1-3% of births at 32 weeks gestation to 1-3% of births at termof births at term

PREDISPOSING FACTORSPREDISPOSING FACTORS PrematurityPrematurity Uterine malformations or fibroidsUterine malformations or fibroids

Placenta praeviaPlacenta praevia Fetal abnormalities, (e.g. CNS Fetal abnormalities, (e.g. CNS

malformations, neck masses)malformations, neck masses) Multiple gestationsMultiple gestations

Fetal abnormalities are observed in 17% of preterm Fetal abnormalities are observed in 17% of preterm breech deliveries and 9% of term breech deliveries. breech deliveries and 9% of term breech deliveries. Perinatal Mortality is increased 2-4 fold with breech Perinatal Mortality is increased 2-4 fold with breech presentation, regardless of the mode of delivery.presentation, regardless of the mode of delivery.

Deaths are most often associated with malformations, Deaths are most often associated with malformations, prematurity and intrauterine fetal demise.prematurity and intrauterine fetal demise.

TYPES OF BREECHES:TYPES OF BREECHES: Frank breech (50-70%) – Hips Frank breech (50-70%) – Hips flexed, flexed, knees extendedknees extended Complete breech (5-10%) – Hips Complete breech (5-10%) – Hips flexed, knees flexedflexed, knees flexed Footling or incomplete (10-30%) Footling or incomplete (10-30%) One or One or both hips extended, foot both hips extended, foot presentingpresenting

EXTERNAL CEPHALIC VERSION (ECV)EXTERNAL CEPHALIC VERSION (ECV)

This is the trans-abdominal manual rotation of This is the trans-abdominal manual rotation of the fetus into a cephalic presentation.the fetus into a cephalic presentation. Improved outcome may be related to Improved outcome may be related to the the use of non stress tests both before and use of non stress tests both before and

after ECVafter ECV Improved selection of low-risk fetusesImproved selection of low-risk fetuses Rh immune globulin to prevent Rh immune globulin to prevent isoimmunizationisoimmunization

PROCEDURE:PROCEDURE: Prepare for the possibility of Prepare for the possibility of caesarean caesarean delivery.delivery. Perform a non-stress test – to Perform a non-stress test – to confirm fetal well being.confirm fetal well being. Perform the ECV, in or near a Perform the ECV, in or near a delivery suitedelivery suite After ECV, repeat the non-stress After ECV, repeat the non-stress test.test. Administer Rh immune globulin Administer Rh immune globulin to to women who are Rh- negativewomen who are Rh- negative

RISKS:RISKS: Precipitation of labour or Precipitation of labour or premature premature rupture of membranesrupture of membranes Abruptio placentaeAbruptio placentae Feto-maternal haemorrhageFeto-maternal haemorrhage Cord entanglementCord entanglement Fractured fetal bonesFractured fetal bones

CONTRAINDICATIONS:CONTRAINDICATIONS: Multiple gestationsMultiple gestations Contra indications to vaginal Contra indications to vaginal delivery delivery (e.g. herpes simplex virus (e.g. herpes simplex virus infection, placenta praevia)infection, placenta praevia) Non reassuring fetal heart rate Non reassuring fetal heart rate tracingtracing

VAGINAL BREECH DELIVERYVAGINAL BREECH DELIVERYThe three types of vaginal breech deliveries The three types of vaginal breech deliveries are described:are described: Spontaneous breech delivery. No Spontaneous breech delivery. No traction or manipulation of the infant is traction or manipulation of the infant is used. This occurs predominantly in used. This occurs predominantly in very very preterm deliveries.preterm deliveries. Assisted breech delivery: The most Assisted breech delivery: The most common type of vaginal breech delivery.common type of vaginal breech delivery. Total breech extraction. Use for a non Total breech extraction. Use for a non

cephalic second twin and caesarean cephalic second twin and caesarean deliveriesdeliveries

RISKS:RISKS:♣♣ Lower apgar scoresLower apgar scores

♣♣ Fetal head entrapmentFetal head entrapment

♣♣ Cervical spine injuryCervical spine injury

♣♣ Cord prolapse Cord prolapse