Pregnancy management in breech presentation

Pregnancy management tactics

Management of patients with breech presentation depends directly on the gestational age.

• Before 28–30 weeks, an exclusively expectant management is applied. During this period, the fetus is still sufficiently mobile, and spontaneous cephalic version occurs in 70% of multiparous and 30% of nulliparous women.
• After 30 weeks, patients are prescribed special corrective exercises that promote spontaneous turning of the fetus into the correct position. The pregnant woman lies on a couch and alternately turns to her right and left side, staying in each position for 10 minutes. 3–4 such turns are performed per session, and the complex should be repeated three times a day.
• At 38 weeks, external prophylactic cephalic version (versio cephalica externa) is indicated. The procedure is performed strictly in a hospital setting. A mandatory condition is preliminary medical preparation—administration of $\beta$-mimetics to relax the myometrium and reduce uterine tone. To monitor the condition of the fetus, cardiotocography (CTG) is performed before the manipulation begins and for one hour after its completion.

Vaginal delivery complications

Breech delivery is a priori considered pathological due to the features of the biomechanism and the high risk of complications at all stages.

Complications of the first stage:

1. Premature rupture of membranes. Occurs due to increased pressure on the fetal membranes. A prolonged anhydrous interval significantly increases the risk of infection of the uterus, placenta, and the fetus itself.
2. Prolapse of the umbilical cord loops and small parts. Occurs at the time of membrane rupture. Due to the absence of a tight contact zone between the pelvic pole and maternal tissues, this is initially a less formidable situation than in cephalic presentation. However, when the pelvic pole engages in the pelvic inlet, the prolapsed umbilical cord is compressed, leading to acute hypoxia.
3. Labor anomalies. Primary and secondary uterine inertia develop 2–3 times more often. This is due to the functional inferiority of the uterus and the lack of adequate pressure from the dense head on the lower uterine segment. Clinically, this manifests as slow cervical dilation, while the pelvic pole remains above the pelvic inlet for a long time.

Complications of the second stage: The main problem is disproportion of volumes. The pelvic pole is born first, which is not capable of sufficiently dilating the birth canal for the passage of the larger shoulder girdle and head.

• Umbilical cord compression. An inevitable complication starting from the moment of fetal delivery up to the level of the navel. If the torso and head are not delivered within 3–5 minutes, acute hypoxia develops, and if this time is exceeded, fetal death.
• Arm entrapment. An iatrogenic complication resulting from improper obstetric manual aid or premature extraction attempts. The arms may be located in front of the face (degree I), along the sides of the head (degree II), or behind the occiput (degree III). Spontaneous delivery is impossible in this case.
• Head extension. Occurs during the formation of a sacroposterior position (when the fetus turns its back posteriorly). The chin catches on the pubic symphysis. Delivery is impossible without immediate obstetric aid.
• Impacted buttocks in the pelvis. It is a consequence of fetopelvic disproportion.

Choice of delivery method and indications for CS

The method of delivery must be determined by the physician before labor begins. For this, planned hospitalization in an obstetric hospital at 39 weeks is indicated.

The choice between the vaginal route and cesarean section (CS) depends on many factors: the woman's age and parity, obstetric history, pelvic dimensions, type of presentation, position of the head, and estimated fetal weight. Due to the high risks of trauma and hypoxia, the modern trend is that obstetricians expand the indications for surgical intervention.

Absolute indications for planned CS in nulliparous women:

• Estimated fetal weight less than 2000 g or more than 3600 g.
• Grade III head extension (confirmed by ultrasound).
• Patient age over 30 years.
• Pregnancy resulting from IVF (especially after repeated attempts).
• Anatomic pelvic contraction or malformations of the internal genital organs.
• Presence of a uterine scar.
• Grade III fetal growth restriction (FGR) or signs of hypoxia according to CTG data.
• Post-term pregnancy.
• Extragenital pathologies requiring the exclusion of pushing efforts, as well as pronounced fat metabolism disorders.

Briefly: answers to topical questions

Class and exam questions

What else to study on this topic

• Biomechanism of labor in occipito-posterior position formation
• Technique of manual obstetric assistance for arm entrapment
• Medical preparation and contraindications for external cephalic version
• Assessment of cardiotocography (CTG) in fetal hypoxia
• Ultrasound diagnostics of degrees of head extension

Other topics in the "Obstetrics" section

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