Breech presentation and ECV

Breech presentation
• 22% of births prior to 28 weeks' gestation
• 7% of births at 32 weeks' gestation
• 1-3% of births at term
Lie stable at 36 weeks

Types of breeches
• Frank breech (50-70%) - Hips flexed, knees extended
• Complete breech (5-10%) - Hips flexed, knees flexed
• Footling or incomplete (10-30%) - One or both hips extended, foot presenting

Aetiology /Associations
Uterine/placenta
• Uterine Anomalies ( bicornuate, Septate)
• lax uterus (multi parity)
• uterine Fibroids
• Placenta previa
• Polyhydroamnios
• Oligohydroamnios
Fetus
• Multiple praganancy
• Fetal congenital anomalies (hydrocephalus, anancaphaly)
• Intrauterine Death
• Prematurity

Management
• ECV
• If fail decide on mode of delivery ie. Vaginal Delivery Vs LSCS

Vaginal breech delivery Vs planned LSCS

Planned LSCS carries a reduced perinatal mortality compared with planned vaginal birth.


Favorable for Vaginal Delivery Unfavorable for vaginal breech birth
Good pelvimetry ( previous delivery of normal sized infant) Nulliparous / Clinically inadequate pelvis
EFW 2 – 3.8 kg 2kg >EFW >3.8 kg
Extended Breech/flexed Footling
Flexed Neck Hyper extended Neck
Normal liquor volume Oligohydroamnios/ polyhydroamnios
Previous Caserian section
Other contraindications to vaginal birth (e.g., placenta praevia, compromised fetal condition)


Intrapartum Management of vaginal breech Delivary
 Maternal position : dorsal or lithotomy position
 Stage 1 :
• VE ; exclude cord presentation, cord prolapsed (common in flexed breech)
• Adequate analgesia
 Stage2:
• episiotomy to facilitate delivery of aftercoming head
• delivery of the leg : pinnard’s maneuver
• delivery of the shoulders : the Lovset maneuver
• delivery of head may be delivered with forceps, the Mauriceau-Smellie-Veit maneuver.

 If conservative methods fail, symphysiotomy or caesarean section should be performed.

Complications of vaginal breech delivery
• Fetal hypoxia ;
 cord prolapsed,
 placental separation before delivery of head,
 compression of umbilical cord,
 premature inspiration of mucus obstructing the airways

• intracranial hemorrhage: rapid decent of the after coming head causing sudden compression followed by decompression leading to tentorial tear and ICB
• Entrapment of after coming head
• Trauma to the baby: Femur #, hip dislocation, damage to viscera, shoulder dystocia with humerus #



External cephalic version (ECV)
External cephalic version (ECV) is the manipulation of the fetus through the maternal abdomen to a cephalic presentation.
An overall success rate
40% for nulliparous,
60% for multiparous
Spontaneous reversion to breech presentation after successful ECV occurs in less than 5%


When should ECV be offered?

36 weeks in nulliparous women
from 37 weeks in multiparous women.


Contraindications for ECV

• antepartum haemorrhage within the last 7 days
• proteinuric pre-eclampsia
• major uterine anomaly
• scarred uterus
• placenta previa
• ruptured membranes
• oligohydramnios
• multiple pregnancy (except delivery of second twin
• IUGR
• major fetal anomalies
• abnormal cardiotocography
• unstable lie.







Complications

• placental abruption
• fetomaternal transfusion (rhesus sensitization of mother)
• uterine rupture /scar dehiscence
• cord prolapse,
• rupture of membranes
• Amniotic fluid embolism
• stillbirth
• transient abnormal fetal heart rate changes
• emergency cesarean delivery
Prerequisites for ECV/ procedure :

1. informed consent include

2. an ultrasound examination : to confirm fetal and placental position /liquor volume

3. CTG – Reactive CTG

4. Check rhesus status (anti-D immunoglobulin is normally offered to rhesus-negative women)

5. Facilities for rapid progression to LSCS, if necessary

 Fasting 4-6 hours

 beta-adrenergic receptor agonist (eg, salbutamol or terbutaline) to relax the uterus

 apply powder (eg, cornstarch) over the patient's abdomen

 breech is disengaged from the pelvis

 version performed in a way that it favors flexion

Maximum 3 attempts


Post ECV
• CTG for at least 30 mins
• Check for PV bleeding or loss of liquor
• If rhesus negative, give anti D
• If unsuccessful repeat after one week or elective LSCS