Epidemiological Profile of Breech Presentation

 

Bansal A., Bansal Manish, Bansal A.K. and Shrivastava P.K.

Govt. Medical College, Jagdalpur ( Bastar ) – 494001 INDIA.

ABSTRACT:

Background: Breech is the commonest malpresentation.There is higher incidence of breech in earlier weeks of pregnancy .Smaller size of the fetus and comparatively larger volume of amniotic fluid allow the fetus to undergo spontaneous version by kicking movements until by 36th.week when the position becomes stabilized .Objective: To know the Epidemiological profile of Breech presentation. Results: On analysis of the collected data ,it was noted that 84 % were registered cases while remaining 16 %unregistered (referred from periphery or come directly for delivery purposes because of complicated cases).47 % primaegravidae,and 6% were grand multipara.50 % of the cases were of the gestational age of 37 weeks and more .61 % breech belongs to 20 -25 years of age mothers .Conclusion: To make aware the community about various aspect of breech by judicious use of media mix ( Traditional and modern media).

 

KEYWORDS: Gestational age, Mother’s age, Parity

 

INTRODUCTION:

Hippocrate, the father of the modern medicine had recognized the existence of breech and the inherent danger to the mother and child. In Ayurveda breech delivery was known as “Prasav Vikar”. Pliay, in his “Natural history” recorded that it is contrary to the nature for a baby to be delivered with feet first. Such babies are called “AGRIPPA”, because of it’s fanciful associations with a word “Agripartus” meaning born with difficulty. Breech is a malpresentation where the podalic pole of the fetus lies at the pelvic brim with the fetus in the longitudinal lie. There is hardly any Obstetrician who has not missed breech presentation occasionally during his or her professional carrier. By taking in to consideration the above facts and in 1957 a study group of World Health Organization (W.H.O.) has expressed the view that in order to get a comprehensive picture of disease (health problem) more and more studies have to be carried out, Garg Narendra K. (1), the authors have under taken this study to analysis the Epidemiological profile of Breech presentation.

 

MATERIAL AND METHODS:

This is a analytic study of 100 cases of breech presentation, delivered in a tertiary care hospital from July, 1998 to June, 1999. Study variables included, breech as per parity, gestational age, mother’s age .

A detailed history (2) including Obstetric history, menstrual history, past and family history was noted..In majority of instances of breech presentation definite diagnosis can be made by abdominal palpation .However when following conditions are associated with breech presentation, it is difficult to reach any conclusion.

-Hydramnios

-Oligohydramnios

-Obesity

-Rigid abdominal wall

-Breech with extended legs when breech is deeply engaged in the pelvis or legs are in front of head

-Well flexed head with the spine anterior.

Clinical Diagnosis :In the later weeks of pregnancy suspicion of breech presentation may occasionally be aroused by the patients sensation .In many instances ,the patient, if required ,indicates she is aware of hard swelling to one or other side of fundus and has slight tenderness over corneal area specially on pressure.

Per Abdominal Examination:

A, Inspection; Outline of the uterus seldom presents any characteristic features.

 

B.   Palpation    ; Fundal Grip –reveals head as a hard smooth and globular mass and is ballot able in complete breech while in frank breech irregular small parts of the feet may be felt by the side of the head and head is not ballot able .Very frequently head is in one or other uterine cornu rather than in middle of fundus and often it is partially hidden under costal margin making the diagnosis difficult.

 

Lateral Grip; In complete breech, foetal back is found on one side of abdomen according to the position of sacrum and irregular parts of the foetal limbs on to the other side ; while in frank breech irregular parts are less felt on the sides. JC Russel has stated the “Rule of side of head”. It may indicate whether the legs are extended or flexed .If the foetal head lies in the same side of the back of the fetus, probably it is a case of breech with extended legs and when the head lies opposite to the back of the foetus, probably it is complete breech. This rule was confirmed by X-Ray examination and is accurate in 60-70%of cases.

 

Pelvic Grip: Reveals breech as a soft, broad irregular mass in complete breech and in frank breech, it is suggested by smooth small conical mass which is always engaged, which may be mistaken for vertex.

 

c.         Auscultation: In complete breech usually the area of greatest intensity of FHS is located at a higher level round about the umbilicus and in frank breech at the lower level in the midline due to early engagement of breech.

 

Per-Vaginal Examination:

During Pregnancy –In complete breech soft and irregular parts are felt through the fornices .In frank breech hard feel of the sacrum is felt which may be mistaken for head.

a.         During labour – In the early stage of labour when the membranes are intact, the bag of membranes is sausage shaped and tense. In frank breech characteristically the ischial tuberculosis, sacrum and anus are felt and after further descent external genitalia may be distinguished. When labour is prolonged buttocks may be swollen, rendering differentiation of face and breech very difficult. This can be differentiated by hard alveolar ridges in the mouth in face presentation, muscular resistance in anal orifice and meconuium stains the finger in breech location. Sacrum establishes the diagnosis and the type.

 

In complete breech feet may be felt along the side of the buttocks and in footling presentation one or both feet may hang down into vagina. The foot felt is identified by the prominence of the heel and lesser mobility of greater toe.

Diagnosis can be confirmed by the following investigations:-

a.         Ultasonography- helps to confirm-

i.          Breech presentation

ii.        Type of breech

iii.       Maturity of fetus

iv.       Foetal weight

v.        Position of foetus and placenta

vi.       Rule out any congenital anomaly of fetus

vii.      To rule out any malformation in maternal genital organ.

 

Ultrasonography is an alternate supplement to radiography and it is without any hazards of radiation.

b.        Radiograph;-

A straight X-Ray abdomen with pelvis will help to know –

i.    Confirmation of breech presentation

ii    Type of breech presentation

iii    Maturity of foetus

iv     Bony congenital malformation of foetus

v.        Assessment of pelvis

vi.       Size and position of head.

Full pelvimetry should be obtained at term or in early labour in all primipara with breech presentation.

 

The AP view should be taken not to have a fallacious diagnosis of hydrocephalous and to reduce the magnification of head .Ill effects by exposure of fetal gonads still remains as a matter of difference of opinion.

 

OBSERVATIONS AND DISCUSSIONS:

On analysis of the collected data ,it has been found that out of total 5874 deliveries took place from July ,1998 to June,1999,in the hospital  247 (4.21 %) were breech presentation(Table-I).Breech is the commonest malpresentation (9).

 

TABLE – I: INCIDENCE OF BREECH DELIVERIES

Total Number of deliveries

5874

Number of Breech deliveries

247

Percentage of Breech deliveries

4.21%

 

According to other authors ,the percentage was 3-4 percent which was more or less in accordance of the findings of the present study.

 

Out of 247 cases an analytic review of 100 cases were carried out and it was noted that out of one hundred cases 84%were registered cases i.e. attended ante natal clinic and the rest 16%were admitted in emergency with no antenatal care .Most of these 16% were either referred from periphery or from rural areas(Table-II).

 

TABLE – II: INCIDENCE OF REGISTERED AND EMERGENCY CASES

Type of breech

No. of Cases

Percentage

Emergency cases

16

16

Registered cases

84

84

Total

100

100

 

Incidence of breech according to parity: Out of the total 100 cases of breech , 47% were Primaegravida and all three-2ND.3RD.and 4TH gravidae( 47 %) and the remaining 6 % Grand multigravida i.e.5th.and above (Table –III) Incidence of various type of breech presentation: (Table-IV) reveals that there were 65%frank breech cases ,26 %of complete breech and the remaining  9 % of footling presentation.

 

TABLE – III: INCIDENCE OF BREECHACCORDING TO PARITY

Parity

No. of Cases

Percentage

Primigravida

47

47%

IInd, IIIrd, IVth,

Gravida

47

47%

Vth and above

(Grand Multipara)

6

6%

Total

100

100%

 

 

TABLE – IV: INCIDENCE OF VARIOUS TYPES OF BREECH PRESENTATION

Type of breech

No. of Cases

Percentage

Frank

65

65%

Complete

26

26%

Footing

9

9%

 

Gestational age and incidence of breech; Half of the total breech presentations cases were of 37 and above weeks of gestational age group while 33 and 17 % of breech cases belongs to 32 -36 and below 32 weeks of gestational age group respectively .

 

Regarding mother’s age and breech presentation ,on analysis it was noted that 61 percent cases were of 20 to 25 years of age group,24 percent belongs to 26 to 30 years of age group ,and 10 percent of cases were above 30 years of age .Only 5 % were found below 20 years of age mothers.

.Mode of delivery -46 percent were assisted breech deliveries ,5 percent were spontaneous breech deliveries and breech extraction was done in only 2 percent cases Both breech extraction were done for breech with footling with cord prolapsed(Table-V).

 

TABLE – V: MODE OF DELIVERY

Mode of delivery

No. of Cases

Percentage

Assisted breech delivery

46

46

Spontaneous breech delivery

5

5

Breech extraction

2

2

Caesarean section

47

47

 

 

 

 

Birth weight of new borne of breech presentation:- Weight of 56 % of new borne babies were 2500 g. or above i.e. desired as per W.H.O. definition .25 % new borne carries weight of 2000 to 2499 g.,15 percent 1000 to 1999 g. and the remaining 4 % new borne were of even less than 1000g.of weight.(Table VI).

 

TABLE – VI: BIRTH WEIGHT OF BABIES (BREECH PRESENTATION)

Birth weight (g)

No. of Cases

Percentage

Less tan 1000g

4

4

1000 to 1499

5

5

1500 to 1999

10

10

2000 to 2499

25

25

2500 to 2999

33

33

3000 to 3499

21

21

More than 3500

2

2

 

From above observations and discussions the authors reached to the conclusion that 47 % were primae and equal percentage were belongs to all three 2nd.,3rd.and 4th.multigravidaemothers.Regarding mother’s age was concerned maximum were of 20 to 25 years of age .Similarly 50 % of cases were of 37 and above age of gestation.

 

To bring awareness among the community members, an awareness drive is to be carried out with the help of mass media (Traditional and Modern) which suited to the community culture and customs. A flow chart is being formulated for this purpose.

 

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Received on 21.04.2011

Modified on 20.05.2011

Accepted on 10.06.2011                                               

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Research J. Pharmacology and Pharmacodynamics. 4(1):Jan. - Feb., 2012, 37-40