Revista Colombiana de Obstetricia y Ginecología Vol. 70 No. 4 • Septiembre-Diciembre 2019 • (253-264) MEDICAL EDUCATION DOI: https://doi.org/10.18597/rcog.3345 BREECH PRESENTATION DELIVERY CARE: A REVIEW OF CHILDBIRTH SEMIOLOGY, MECHANISM AND CARE Atención del parto con feto en presentación pelviana: revisión de la semiología, el mecanismo y la atención del parto Carlos Fernando Grillo-Ardila1, MD, MSc; Alejandro Antonio Bautista-Charry2, MD, MS(c); Mariana Diosa-Restrepo3, MD Received: March 25, 2019 / Accepted: December 27, 2019 ABSTRACT semiology and physiology of this condition as well Objective: To review the concepts underlying as the obstetric maneuvers to facilitate an uncom- breech presentation delivery as well as the semiol- plicated delivery. ogy and the obstetric maneuvers contributing to Conclusions: The mechanism of childbirth in successful perinatal and maternal outcomes. breech presentation is complex and requires knowl- Materials and methods: Based on a hypothetical edge of its physiology and multiple obstetric ma- scenario to set the stage for a practical approach to neuvers by the obstetrician as well as the general the topic, an explanatory paper built on a narrative practitioner, in order to ensure adequate care when review is created in order to examine the prin- there is no other option. ciples related to diagnosis, mechanism of delivery Key words: Breech presentation; obstetric compli- and maternal care, emphasizing maneuvers to ease cations of childbirth; continuing medical education; fetal extraction. dystocia. Results: Breech presentation delivery must be managed through the vaginal canal when already RESUMEN in the expulsion phase with fetal engagement. For Objetivo: revisar los conceptos que subyacen al tra- diagnosis and care, it is essential to know the unique bajo de parto con feto en presentación pelviana, su semiología y las maniobras obstétricas que facilitan un resultado materno perinatal exitoso. * Corresponding author: Carlos Fernando Grillo-Ardila, Departamento Materiales y métodos: a partir de un caso hipo- de Obstetricia y Ginecología, Universidad Nacional de Colombia, tético que ambienta de manera práctica el tema, se Carrera 30 No. 45-03, Edificio 471, Oficina 205, Bogotá, Colombia. Tel.: +57 1 316 5000 extensión 15122. [email protected] crea un documento explicativo construido a partir 1 Assistant professor, Department of Obstetrics and Gynecology, de una revisión narrativa, en donde se examinan National University of Colombia, Bogotá, Colombia. 2 Associate Professor; Director, Department of Obstetrics and Gynecology, los preceptos relacionados con el diagnóstico, el National University of Colombia, Bogotá, Colombia. 3 Third-year resident of Obstetrics and Gynecology, School of Medicine, mecanismo del parto en presentación pelviana y el National University of Colombia, Bogotá, Colombia. manejo intraparto de la gestante, con énfasis en la Rev Colomb Obstet Ginecol ISSN 2463-0225 (On line) 2019;70:253-264 254 Revista Colombiana de Obstetricia y Ginecología Vol. 70 No. 4 • 2019 adecuada ejecución de las maniobras que facilitan considered the worst in terms of prognosis for the la extracción fetal. spontaneous course of childbirth, given that it is Resultados: el parto en presentación pelviana debe frequently associated with arm deflexion at the fetal ser atendido por vía vaginal cuando se encuentra shoulders (nuchal arm extension) and deflexion of en periodo expulsivo con encajamiento cumplido. the cephalic pole (3). Para su diagnóstico y atención es esencial hacer According to the literature, it is estimated that una adecuada identificación de la presentación, así 20% of fetuses less than 28 weeks of gestational age como conocer su fisiología, la indicación y adecuada are in breech presentation (5) and, of these, 4% will ejecución de las maniobras obstétricas que facilitan remain in that position beyond week 36 (6); con- un parto sin complicaciones. sequently, this presentation can only be considered Conclusiones: el mecanismo del parto en pre- abnormal at term (1). As the pregnancy advances, sentación pelviana es complejo y requiere, cuando the fetus must accomplish “fetal version” as a result no hay otra alternativa para la atención, que tanto of an active phenomenon in which the healthy fetus el obstetra como el médico general conozcan su adopts the “best fit” position, following the classi- fisiología y las múltiples maniobras obstétricas que cal principles of Pajot’s laws (5). Therefore, breech facilitan obtener buen resultado materno perinatal. presentation at the end of gestation is a finding Palabras clave: presentación pelviana; compli- that prompts the search for a triggering factor (5, caciones obstétricas del parto; educación médica 7), which may arise from the presence of maternal continuada; distocia. (1, 2) or fetal pathologic conditions, mainly fetal anomalies or aneuploidy, altered amniotic fluid INTRODUCTION dynamics, disruptions of the birth canal, abnormal Breech presentation occurs when the pelvic or cau- placentation (8) or fetal demise (1, 2, 5). It is impor- dal end of the fetus is in direct relationship to the tant to highlight that the frequency of major fetal upper strait of the maternal pelvis, filling it com- anomalies is 17% in premature breech deliveries, pletely, and follows a known childbirth mechanism 9% in term breech deliveries, and 50% in neonates (1). Three modalities of breech presentation are born in that presentation who then die (9). considered: complete, frank and incomplete (2). Breech presentation fetuses have higher morbid- Complete breech occurs when the fetal thighs are ity and mortality when compared to those born in flexion over the abdomen and the legs are on in cephalic presentation, even if they are born by top of the thighs. In this modality, the flexed fetal cesarean section (5). Multiple studies have found position is maintained in all the poles of the fetus an association between breech presentation and an (3). Frank breech (simple breech) occurs when the increased risk of neonatal death (relative risk [RR] fetal thighs are in flexion over the abdomen but the = 2.3; 95% confidence interval [CI]: 2.1- 2.6) (10) legs are straight; it is the most frequent of the three or fetal demise (RR = 12.52; 95% CI: 7.86-9.95) modalities, occurring in 64% of cases (4). Finally, (11), prolonged labor (RR = 8.05; 95% CI: 3.00- incomplete breech (partial presentation) occurs when 11.47), asphyxia (RR = 10.24; 95% CI: 4.92-21.31) one or both feet are closest to the birth canal (1); (12), trauma (RR = 9.9; 95% CI: 1.8-55.6) (13) or the fetus is literally standing in the birth canal in low APGAR score (RR=2.4; 95% CI: 1.1-4.6) (14). a true feet-first presentation. The Spanish school These results confirm that this presentation is in does not accept this modality, considering it just a itself a marker of poor prognosis (7, 15). transient phase as the fetus moves into one of the The scenario in clinical practice is not very en- two positions described above (3). This modality is couraging either. A recent study shows that not even BREECH PRESENTATION DELIVERY CARE: A REVIEW OF CHILDBIRTH SEMIOLOGY, MECHANISM AND CARE 255 15% of obstetricians feel confident when it comes REVIEW OF THE LITERATURE to vaginal delivery of a fetus in breech presentation, Elements of obstetric semiology and only 32% are trained to solve this clinical con- in brech presentation dition (16, 17). In view of this scenario, with a low Labor with the fetus in breech presentation is di- level of confidence, the anxiety that surrounds this agnosed by means of maternal abdominal palpa- process, the fear of malpractice lawsuits, and the tion (Leopold maneuvers) in order to determine challenges imposed by this situation, many people fetal presentation, position and attitude, and try to resort to universal cesarean section (18, 19). ascertain the presence of cephalic extension which There are occasional instances in clinical prac- could create the risk of retained after-coming head tice in which patients arrive when the fetus has (6, 20, 21). The clinician must not forget that aus- descended into the birth canal and is engaged in the cultation of the fetal heart at the upper part of the pelvis. Therefore, the objective of this document is maternal abdomen must lead to suspicion of this to review the concepts underlying labor with a fetus presentation (1, 2). in breech presentation, as well as the semiology and In the context of established labor, the prac- obstetric maneuvers that contribute to successful titioner must perform a vaginal exam in order to maternal and perinatal outcomes. identify the presentation landmarks (6, 20-22). If the cervix is sufficiently dilated, palpation reveals MATERIALS AND METHODS an irregular, soft surface, with bumps and dips; a Explanatory document created using a hypotheti- mass divided into two because of the presence of a cal case in order to offer a narrative review of the rather pronounced sulcus (intergluteal cleft), with concepts related to diagnosis, the mechanism of a small pit in the middle corresponding to the anus childbirth and care of the pregnant woman, finish- (22, 23). ing with the maneuvers that help with the process In one of the ends of the cleft it is possible to of fetal extraction. identify a small, slightly flexible bony triangular ridge, which corresponds to the coccyx and, above CLINICAL SCENARIO it, three or four bony protuberances that correspond A 39-year-old woman with no relevant medical his- to the sacral crest, landmark of this presentation. tory, in the 37th week of the third gestation, who The sacrococcygeal prominence is essential for the attends the local referral hospital complaining of diagnosis of the presentation and it is almost always regular painful uterine contractions and the urge to easy to recognize (22, 23). push. She had not attended prenatal visits. She re- To make the distinction between a foot and a ports spontaneous rupture of membranes one hour hand during the exam, the practitioner needs to before.