| Breech birth | |
|---|---|
| Classification and external resources | |
Frank breech, William Smellie, 1792 |
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| ICD-10 | O32.1, O64.1, O80.1, O83.0, P03.0 |
| ICD-9 | 652.1 |
| DiseasesDB | 1631 |
| MedlinePlus | 002060 |
| eMedicine | med/3272 emerg/868 |
| MeSH | D001946 |
A breech presentation is defined as the condition in which the baby is in Longitudinal lie and the podalic pole presenting at the pelvic brim with the head occupying upper pole of uterus. A breech birth is the birth of a baby from a breech presentation. In the breech presentation the baby enters the birth canal with the buttocks or feet first as opposed to the normal head first presentation.In breech presentation Fetal Heart Sounds are heard just above the umblicus.
The bottom-down position, called breech presentation, presents some hazards to the baby during the process of birth, and the mode of delivery (vaginal versus Caesarean) is controversial in the fields of obstetrics and midwifery.
Though labour and vaginal birth are possible for the breech baby, certain fetal and maternal factors influence the safety of vaginal breech birth (see below). The majority of breech babies born in the United States are delivered by Caesarean section.
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Certain factors can encourage a breech presentation. Prematurity is likely the chief cause. Twenty five percent of fetuses are in the breech position at 32 weeks gestation; this drops to three percent at term. The increasing size of the fetus near term traps the fetus into the head down position normally. Pregnancies ending in preterm birth simply recruit more breeches before they can turn to head down. Factors predisposing to term breech presentation include:
It is postulated that the baby normally assumes a head down presentation because of the weight of the baby's head. As the mass of the fetal head is the same as that of the pelvis, it is more likely that the enlarging fetus is more and more restricted in its movements, and simply becomes entrapped. The shape of the uterus is a more likely determinant of the final fetal presentation as uterine shape anomalies are strong predictors of breech presentation and other malpresentations.
Researchers generally cite a breech presentation frequency at term of 3-4%[2][3] at the onset of labour though some claim a frequency as high as 7%.[4] When labour is premature, the incidence of breech presentation is higher. At 28 weeks' gestation 25% of babies are breech, and the percentage decreases approaching term (40 weeks' gestation).--
There are either three or four main categories of breech births, depending upon the source:
In addition to the above, breech births in which the sacrum is the fetal denominator can be classified by the position of a fetus. Thus sacro-anterior, sacro-transverse and sacro-posterior positions all exist, but Left Sacro-anterior is the commonest presentation. Sacro-anterior indicates an easier delivery compared to other forms.
As in labour with a baby in a normal head-down position, uterine contractions typically occur at regular intervals and gradually cause the cervix to become thinner and to open. In the more common breech presentations, the baby’s bottom (rather than feet or knees) is what is first to descend through the maternal pelvis and emerge from the vagina.
At the beginning of labour, the baby is generally in an oblique position, facing either the right or left side of the mother's back. As the baby's bottom is the same size in the term baby as the baby's head. Descent is thus as for the presenting fetal head and delay in descent is a cardinal sign of possible problems with the delivery of the head.
In order to begin the birth, Descent of podalic pole along with Compaction and internal rotation needs to occur. This happens when the mother's pelvic floor muscles cause the baby to turn so that it can be born with one hip directly in front of the other. At this point the baby is facing one of the mother's inner thighs. Then, the shoulders follow the same path as the hips did. At this time the baby usually turns to face the mother's back. Next occurs external rotation, which is when the shoulders emerge as the baby’s head enters the maternal pelvis. The combination of maternal muscle tone and uterine contractions cause the baby’s head to flex, chin to chest. Then the back of the baby's head emerges and finally the face.
Due to the increased pressure during labour and birth, it is normal for the baby's leading hip to be bruised and genitalia to be swollen. Babies who assumed the frank breech position in utero may continue to hold their legs in this position for some days after birth.
Umbilical cord prolapse may occur, particularly in the complete, footling, or kneeling breech. This is caused by the lowermost parts of the baby not completely filling the space of the dilated cervix. When the waters break the amniotic sac, it is possible for the umbilical cord to drop down and become compressed. This complication severely diminishes oxygen flow to the baby and the baby must be delivered immediately (usually by Caesarean section) so that he or she can breathe. If there is a delay in delivery, the brain can be damaged. Among full-term, head down babies, cord prolapse is quite rare, occurring in 0.4 percent. Among frank breech babies the incidence is 0.5 percent, among complete breeches 4-6 percent, and among footling breeches 15-18 percent.
Head entrapment is caused by the failure of the fetal head to negotiate the maternal midpelvis. At full term, the fetal bitrochanteric diameter (the distance between the outer points of the hips) is about the same as the biparietal diameter (the transverse diameter of the skull) - simply put the size of the hips are the same as the size of the head. The relatively larger buttocks dilate the cervix as effectively as the head does in the typical head-down presentation. In contrast, the relative head size of a preterm baby is greater than the fetal buttocks. If the baby is preterm, it may be possible for the baby’s body to emerge while the cervix has not dilated enough for the head to emerge.
Because the umbilical cord—the baby’s oxygen supply—is significantly compressed while the head is in the pelvis during a breech birth, it is important that the delivery of the aftercoming fetal head not be delayed. The head only just fits through the pelvis, and if the arm is extended alongside the head, delivery will not occur. If this occurs, the Løvset manoeuvre may be employed, or the arm may be manually brought to a position in front of the chest. The Løvset manoeuvre involves rotating the fetal body by holding the fetal pelvis. Twisting the body such that an arm trails behind the shoulder, it will tend to cross down over the face to a position where it can be reached by the obstetrician's finger, and brought to a position below the head. A similar rotation in the opposite direction is made to deliver the other arm. In order to present the smallest diameter (9.5 cm) to the pelvis, the baby’s head must be flexed (chin to chest). If the head is in a deflexed position, the risk of entrapment is increased. Uterine contractions and maternal muscle tone encourage the head to flex. If the birth attendant pulls on the baby’s body, this action may deflex the head.
Oxygen deprivation may occur from either cord prolapse or prolonged compression of the cord during birth, as in head entrapment. If oxygen deprivation is prolonged, it may cause permanent neurological damage or death.
Injury to the brain and skull may occur due to the rapid passage of the baby's head through the mother's pelvis. This causes rapid decompression of the baby's head. In contrast, a baby going through labor in the head-down position usually experiences gradual molding (temporary reshaping of the skull) over the course of a few hours. This sudden compression and decompression in breech birth may cause no problems at all, but it can injure the brain. This injury is more likely in preterm babies. The fetal head may be controlled by a special two handed grip call the Mariceau-Smellie-Veit manoeuvre or the elective application of forceps. This will be of value in controlling the rate of delivery of the head and reduce decompression. Related to potential head trauma, researchers have identified a relationship between breech birth and autism.[5]
Squeezing the baby’s abdomen can damage internal organs. Positioning the baby incorrectly while using forceps to deliver the aftercoming head can damage the spine or spinal cord. It is important for the birth attendant to be knowledgeable, skilled, and experienced with all variations of breech birth. In the United States, because Cesarean section is increasingly being used for breech babies, fewer and fewer birth attendants are developing these skills.
Injury may occur even if a birth attendant uses appropriate interventions during labour. A majority of full-term term frank breech babies would be born without problems even without assistance. However, in a minority of cases, expert assistance is needed for the baby to be born safely. This must be placed in perspective. It is this minority that determines the safety of the choice of vaginal delivery of the breech. A fetal death rate as low as 1% might be acceptable to some societies if a greater benefit could accrue. Take a country like the United States with a population of 300 million, and a 14.14/1000 birth rate, assume a 3% breech rate, and the aforementioned 1% mortality. This would result in an annual attributable death rate from breech delivery of 1,273 babies per year. Attributable death rate implies that the deaths occurred because of the selection of vaginal delivery and not from concurrent problems, such as congenital abnormalities or prematurity.
There are many methods which have been attempted with the aim of turning breech babies, with varying degrees of success:
Using hypothetical scenarios, a small study in the Netherlands found that few obstetric practitioners would attempt ECV in the presence of oligohydramnios.[9] A case report of treating oligohydramnios with amnioinfusion, followed by ECV, was successful in turning the fetus.[10]
Various manoeuvres are suggested to assist spontaneous version of a breech presenting pregnancy. These include maternal positioning or other exercises. A study has shown that there is insufficient evidence as to the benefit of maternal positioning in reducing the incidence of breech presentation.[8]
Caesarean section is the most common way to deliver a breech baby in the USA, Australia, and Great Britain. Like any major surgery, it involves risks. Maternal mortality is increased by a Caesarean section, but still remains a rare complication in developed countries. Third World statistics are dramatically different, and mortality is increased significantly. There is remote risk of injury to the mother's internal organs, injury to the baby, and severe hemorrhage requiring hysterectomy with resultant infertility.
One large study has confirmed that elective cesarean section has lower risk to the fetus and a slightly increased risk to the mother than planned vaginal delivery of the breech.[11] However, elements of the methodology used have undergone some criticism.[12][13]
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