لخّصلي

The presenting part of the foetus is the buttocks, i.e. the ‘breeches’ end. Approximately 3% of foetuses present buttocks first at term. In the middle trimester it is much more common, owing apparently to there being more room to move at this stage, but the majority eventually turn to become cephalic presentations. A breech presentation is potentially dangerous because of the severe intermittent pressure on the after-coming head from the dominant part of the uterus. In addition the foetal head, which is the largest part, will not have been moulded to the bony birth canal so there could be the risk of cephalopelvic disproportion. There is also some anxiety that the cervix might close on the foetal neck and obstruct the passage of the head; forceps may therefore be used to protect and guide the after-coming head. It is now believed that the major cause of intracranial haemorrhage in a breech delivery is anoxia (Sweet 1997). Other dangers of breech delivery include fractures, dislocations, brachial 74 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY MATERNAL DISTRESS MALPRESENTATION BREECH PRESENTATION plexus lesions, rupture of abdominal organs and genital oedema and bruising (Sweet 1997). The American College of Obstetricians and Gynecologists (ACOG 2002) reported and recommended, as a result of the large and well-controlled Term Breech Trial, that: • obstetricians continue to reduce breech deliveries in singleton pregnancies by applying ECV whenever possible • planned vaginal delivery of a singleton breech may no longer be appropriate • if breech vaginal deliveries are pursued then it must be with great caution • those with persistent breech presentation at term singleton gestation should undergo a planned caesarean section • a planned caesarean delivery does not apply to: • those in advanced labour with a breech presentation in whom delivery is imminent • those in whom a second twin is in a non-vertex position. For many the choice will lie between external cephalic version and elective caesarean section (Young & Johanson 2001). Meanwhile the best mode for preterm breech is unclear (Mukhopadhyay & Arulkumaran 2002). Vaginal delivery will be unavoidable in certain circumstances but as a consequence of the Term Breech Trial, progressively fewer midwives and junior doctors will gain the experience and confidence to conduct a vaginal breech delivery. It may be that regular teaching using video clips or mannequins will be necessary to preserve skills (Mukhopadhyay & Arulkumaran 2002). There are three types of breech: 1. fully flexed – both legs are flexed and drawn up on the abdomen, most common in multigravidae 2. extended – legs are flexed at the hips but extended at the knees, and the feet are in contact with the baby’s shoulders, most common in primigravidae 3. footling – one or both feet present first (below the buttocks) with the hips and knees extended.