BREECH PREGNANCY கருவளர்ச்சி பற்றிய தகவல்களும் மருந்துகளும்

BREECH PREGNANCY
(BREECH PRESENTATION AT THE END OF PREGNANCY)

Most babies are delivered head first. But in a small minority of cases the parts of the body that come first during labour are either the buttocks,the feet or a combination of both.

These variations make up what is known as BREECH presentation.
The foetus is housed in the womb in a pool of fluid (amniotic fluid) contained in a sealed amniotic sac.

For most of the pregnancy the foetus is a relatively smallish structure suspended in a large pool. It swims and somersaults at will hardly able to maintain any position for long. This state of affairs persists until towards the end of pregnancy.

At about 36 weeks gestation the foetus has attained a good size and the fit inside the womb becomes tighter with the foetus assuming a more stable position, not quite able to move around as freely as it did earlier in pregnancy.

So breech or other abnormal presentations occur in more than 50% of pregnancies in the early and middle part of the pregnancy. But after 36 weeks most babies will turn around to assume a final head-first position heading towards delivery and only 3-5% of presentations remain breech by the end of pregnancy.

That is why pregnant women are strongly advised to ignore the foetal presentation written on scan reports in the early or middle stages of pregnancy as the position is bound to change several times within a 24-hour period. Obstetricians start taking heed of foetal presentation after 36 of gestation.

TYPES OF BREECH PRESENTATION.

1 . FRANK BREECH PRESENTATION:
The two buttocks present with the legs outstretched across the abdomen to the face.

2. COMPLETE(FLEXED)BREECH: The buttocks present together with both feet.

3. INCOMPLETE BREECH: The buttocks present with only one foot.

4. FOOTLING BREECH: Both feet are presenting.

RISK FACTORS FOR BREECH PRESENTATION.

There is no single cause for breech presentation. What is indisputable is that certain factors make breech presentation more likely.

They are:

1. Women having their first pregnancy are more likely to have breech presentation compared to those who have had previous deliveries.

2. POLYHYDRAMNIOS (too much liquor)/ OLIGOHYDRAMNIOS (too little liquor)When the fluid round the foetus is too much maintaining a fixed position becomes almost impossible. On the other hand when the liquor volume is diminished the foetus is liable to be “trapped “ in an abnormal position inside the womb.

3.UTERINE ABNORMALITIES: certain congenital structural abnormalities of the uterus can grossly distort the womb cavity forcing a foetus to assume a breech or transverse position.

4. FIBROIDS: Fibroids are lumps that can grow in any part of the womb. The ones that grow on the inside can become quite large, obtruding into the uterine cavity taking up part of the space needed by the developing foetus.

The foetus could end up being confined to a small section of the womb. This can lead to miscarriage or premature labour, poor foetal growth and abnormal or breech presentation at the end of pregnancy.

5. PLACENTA PRAEVIA (low-lying placenta): The placenta usually lies high above or to the side of the foetus inside the womb. But sometimes it lies below the baby. If the lie is very close to the outlet it takes up valuable space thereby preventing the foetus from assuming a head-first position.

DIAGNOSIS OF BREECH PRESENTATION.

Breech presentation can only be suspected when the abdomen is palpated. One of the values of attending the antenatal check-ups regularly is that it offers the Obstetricians or midwife the opportunity to detect anything that may be going wrong with the pregnancy even though the woman may have no complaints whatsoever. Breech presentation is one of those things.

But an ultrasound scan is required to confirm that the presentation is actually breech.

MANAGEMENT OF BREECH PRESENTATION.

Women and their relatives get unduly alarmed when the diagnosis of breech presentation is made. But frankly, it is not that bad. It is the duty of the healthcare provider to provide correct information about breech and the options about delivery to the patient instead of frightening her.

The main difference between head-first and breech delivery and the major source of the possible difficulties ,complications and fear revolves around the behaviour of the head of the baby during labour.

Under normal circumstances the head of a full term foetus will be too big to fit into and pass through the woman’s pelvis. But nature , at its wondrous creative best,came up with an easy way out by subdividing the skull of the baby into several small bones ( instead of one single structure) with spaces (sutures) between them.

This allows the baby’s head to “ squeeze “ ,with the bones overriding one another thereby reducing the overall diameter of the head by up to 2 centimetres. This adaptation allows the head to assume the shape of the pelvic canal as it travels through the passage during the many hours of labour.

This is why the head of the baby at delivery has a funny conical shape . The normal shape is restored within 3-4 days and the sutures close up by the time the child is a year old restoring the “single” bone look to the skull.

During breech delivery the head arrives the pelvis suddenly in its full diameter(, denied the long process of adaptation and squeezing enjoyed by a head-first baby) and must be delivered immediately.

Herein lies the problem and the danger. If the head is pulled out with force the baby is bound to suffer bleeding inside the brain and possible brain damage which could leave the child with a permanent disability and vegetative existence.

Forceful head extraction could result in stillbirth or death soon after delivery. To prevent this outcome certain manoeuvres have been devised for easy and safe delivery of the head. .

NOT ALL OBSTETRICIANS/MIDWIVES HAVE BEEN TRAINED ON THE USE OF THESE MANOEUVRES.

So there will be serious consequences if an untrained or improperly - trained provider attempts to deliver the head.
So, it is the duty and responsibility of the attending Obstetrician to discuss management options with the woman.

They include:

1. EXTERNAL CEPHALIC VERSION (ECV): involves the application of gentle but firm pressure on the woman’s tummy to help the baby turn in the uterus to a head-first position. ECV is usually performed after 37-37 weeks of pregnancy but can be carried out up until the end of pregnancy.

It succeeds in about 50% of cases. Some of the cases could revert to the breech position. Some obstetricians do not subscribe to ECV as they believe that you only succeed in turning those babies that would have turned on their own.

The rate of breech presentation remains about the same,3-4% both in centres that practice ECV and in those that do not
ELECTIVE (PLANNED)CAESAREAN SECTION: In the UK and a majority of western countries women are discouraged from vaginal breech deliveries for the reasons stated above.

They are offered planned delivery by Caesarean section at or after 39 weeks. But in recent years ,because of the rising rate of CS deliveries (30% or over in some hospitals)and in an effort to lower it the policy on breech has become more flexible.

Maternity units are being urged to offer vaginal delivery to some women,especially those who have had successful vaginal deliveries in the past and to ensure that staff are adequately trained in breech delivery.

Wholesale CS for all breech cases in a country like nigeria apart from the cost is unwise and dangerous. Unlike in Europe where a woman might just want a child or two ,most of our women want many children.

Most of them do not know or choose not to believe the dangers in a scarred uterus and the need to deliver subsequent children in a specialist facility.. They might end up in a pastor’s all-night chapel in an attempt to avoid a repeat CS sustain uterine rupture and die.

VAGINAL BREECH DELIVERY:

Breech can be successfully delivered vaginally. But the most important requirement is that the delivery must be undertaken/supervised by a well-trained Obstetrician.He would be able to select the suitable patients for and provide the suitable obstetric environment for a successful breech delivery.

BOTTOMLINE.

Breech presentation is not as dangerous as it is made out to be. Any woman diagnosed with breech presentation in late pregnancy should ask around in her locality for a specialist facility that conducts vaginal deliveries.

A woman’s choice of facility should be based on merit and competence ,not on sentiments

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