OBSTETRICS

3D MALPRESENTATION AND DELIVERY

OBII-06 Dr. Hurtado | Aug ust 13, 2019
Case: DIAGNOSIS
R.A. 30 years old, G3P1 (1011), 37 weeks AOG, Risk factors:
consulted at the ER for watery vaginal discharge - Early gestational age
1 hour prior. Her 1st baby was delivered 5 years - Extremes of amniotic fluid volume
ago via NSD in cephalic presentation with a BW - Multifetal gestation
of 3,000grams. She only had 2 PNCU at the - Hydrocephaly
local health center. LM1=fetal head at fundus; - Anencephaly
LM2=fetal back, R with FHT of 150. R; - Structural uterine abnormalities
LM3=breech; LM4=breech beneath the - Placenta previa
symphysis. EFW=2,600. - Pelvic tumors
- Prior breech delivery (10% recurrence rate, then
28%)
BREECH PRESENTATION
Incidence: Examination:
 3-5% of deliveries 1. Leopold’s maneuver
 Of term breech fetuses, 5% have hyperextended LM1 Hard, round fetal head occupies the fundus

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necks (stargazing fetus) for CS (at risk for LM2 Identifies the back to be on one side of the

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spinal cord injury if vaginal delivery) abdomen and the small parts on the other
*Flying Fetus – transverse lie, hyperextended neck LM3 If not engaged, the softer breech is movable

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above the pelvic inlet
Classification of Breech Presentation: LM4 After engagement, the breech is beneath the

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1. Complete – the thighs are flexed at the hips and symphysis
legs at knees.
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2. Frank – The knees are extended while hips are
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2. Sonographic evaluation
flexed. 3. Cervical examination
3. Incomplete – one or both hips are extended - Anus may be mistaken for the mouth and the
Footling – incomplete breech with one or both feet ischial tuberosities for malar eminences.
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below the breech

Anus Mouth
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- Finger encounters - Hard, less yielding jaws

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muscular resistance are felt

- Fingers upon removal
may be stained with
meconium
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- Ischial tuberosities and - Mouth and malar

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anus lie in straight line eminences form a

triangular line

4. Fetal sacrum is palpated in relation to maternal

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pelvis to establish position

- Left sacrum anterior (LSA)
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- Right sacrum anterior (RSA)

- Left sacrum Posterior (LSP)
- Right sacrum posterior (RSP)
- Sacrum transverse (ST)
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ROUTE OF DELIVERY
Multiple factors aid determination of the best delivery
route for a mother-fetus pair:
- Fetal characteristics
- Pelvic dimensions
- Coexistent pregnancy complications
- Operator experience
- Patient preference
- Hospital capabilities

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 OBII-06 MALPRESENTATION AND DELIVERY
ROUTE OF DELIVERY: Term breech fetus 2. Partial breech extraction
 Planned Vaginal Delivery - The fetus is delivered spontaneously as far as
- Increased neonatal morbidity and mortality the umbilicus
- Head entrapment - Remainder of the body is extracted or delivered
- Cerebral injury and intracranial hemorrhage with operator traction and assisted maneuvers,
- Cord prolapse with or without maternal expulsive efforts
- Severe asphyxia 3. Total breech extraction
 Planned CS delivery - The entire body of the infant is extracted by the
- Improved prenatal outcomes compared with obstetrician
planned vaginal delivery
ANALGESIA AND ANESTHESIA
ROUTE OF DELIVERY: Pre-term breech fetus  Anesthesia for breech decomposition and extraction
 Between 24 and 32 weeks must provide sufficient relaxation to allow
- Attempted vaginal delivery intrauterine manipulations
o Higher neonatal mortality rates  Epidural analgesia
 Between 24 and 29 weeks - May provide sufficient relaxation to allow
- No improved survival rate with CS intrauterine manipulations but increased uterine
 Between 32 and 37 weeks tone and may render the operation more difficult
- Fetal weight rather than AOG: most important  General analgesia
- Vaginal delivery reasonable if EFW >2500g - May be required to relax the uterus as well as to

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provide analgesia

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MANAGEMENT OF LABOR
BREECH PRESENTATION AND DELIVERY

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Rapid - Membranes, labor and fetal condition

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assessment - Close surveillance: FHT, UC Mechanism of Labor: Delivery of buttocks
- An OB skilled in the art of breech

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extraction Delivery of shoulders

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- Anesthesia/skilled OB assist/ pedia
Delivery of head
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Plan for the - Assess the cervix, station and type of
route of presentation
delivery - Satisfactory progress in labor is the *DO NOT PULL!!! Traction deflexes the fetal head and
best indicator of pelvic adequacy may cause nuchal arm (arm is impacted at pelvic inlet).
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- Sonographic assessment of fetal

 Delivery of Legs (PINARD’S MANEUVER)
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biometry, head flexion and fetal

anatomy - Insert two fingers along one leg to the knee,
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Choice for - Based on the factors favoring CS then push away from the midline (abducted)
abdominal or while flexing leg at hip
vaginal
delivery
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Factors favoring cesarean delivery of the breech fetus:

- Lack of operator experience
- Patient request for CS delivery: prior CS
- Large fetus (>3800 to 4000g)
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- Apparently healthy and viable pre-term fetus

- Severe fetal growth restriction

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- Fetal anomaly incompatible with vaginal delivery (e.g. Delivery of arms

hydrocephalus) - Good maternal pushing
- Prior perinatal death or neonatal birth trauma - Deliver when scapula
- Incomplete or footling breech presentation (can visible
cause cord prolapse and head entrapment when - Rotate to shoulder
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cervix is not fully dilated) anterior

- Hyperextended head - Sweep humerus across
- Pelvic contraction the chest and deliver
(LOVESET
METHODS OF BREECH DELIVERY MANEUVER)
1. Spontaneous breech delivery - Rotate to other
- Fetus is expelled entirely spontaneously without shoulder anterior and
any traction of manipulation other than support sweep second arm to
of the newborn deliver

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 OBII-06 MALPRESENTATION AND DELIVERY
 Delivery of the head (MAURICEAU-SMELLIE-VEIT SUMMARY OF LABOR AND DELIVERY
MANEUVER) MANAGEMENT
- Flexion maintained with suprapubic pressure CONSENT/HELP
- Pressure on maxilla ANESTHESIA
- Hyperextension of the neck is avoided EPISIOTOMY
SPONTANEOUS EXPULSION TO UMBILICUS. WAIT,
DON’T PULL!
MANEUVER DESCRIPTION
PINARD’S Deliver Lateral rotation of thighs
legs and flexion of knees-keep
sacrum anterior
Deliver Deliver when winging of
arms scapulae is seen, rotate
arm to anterior
LOVESET Sweep humerus across
the chest and deliver
Rotate other arm anterior
and repeat to deliver
 Delivery of the head with forceps Nape Suprapubic pressure
- Assistant supporting the baby of neck Avoid over extension

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MAURICEAU- Delivery of aftercoming

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- Direct pelvic application
- Uses Piper forceps or Laufe-Piper forceps SMELLIE-VEIT head

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PIPER FORCEPS

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Inspect for injuries/Laceration
Documentation

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rs e COMPLICATIONS IN VAGINAL BREECH DELIVERY
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Perinatal Morbidity and Mortality
Common injuries:
- Fractures of humerus, clavicle and femur
(traction can separate scapular, humeral or
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femoral epiphysis)
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- Upper extremity paralysis, Erb or Duchenne

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- Spoon-shaped depression or actual fractures of

the skull
- Spinal cord injury or vertebral fracture
- Testicular injury
- Umbilical cord prolapse; hip dysplasia
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EXTERNAL CEPHALIC VERSION

 With version, fetal presentation is altered by
physically substituting one pole of the longitudinal
presentation for the other or converting an oblique or
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transverse lie into a longitudinal presentation.

 Delivery of the head when back of the fetus fails to - External version: manipulation performed
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rotate to the anterior through abdominal wall that yield a cephalic

- PRAGUE presentation
MANEUVER: two - Internal version: manipulation accomplished
fingers of one hand inside the uterine cavity that yield a breech
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grasp the presentation

shoulders of the  Indications:
back-down fetus - ECV reduces the rate of non-cephalic
from below while presentation at birth
the other hand - ECV is attempted before labor in a woman who
draws the feet up has reached 37 weeks AOG
and over the - Absolute contraindications:
maternal  Vaginal delivery is not an option (e.g. in
abdomen. placenta previa)
 Multifetal gestation

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 OBII-06 MALPRESENTATION AND DELIVERY
- Relative contraindications: SHOULDER PRESENTATION
 Early labor  In transverse lie
 Oligohydramnios or rupture of  The side of the mother on which the acromion rests
membranes determines the designation of the lie as right or left
 Known nuchal cord acromial
 Structural uterine abnormalities, fetal  Dorsoanterior/dorsoposterior
growth restriction  Etiology
 Prior abruption or its risks - Abdominal wall relaxation from high parity
 Complications: - Preterm fetus
- Placental abruption - Abnormal uterine anatomy
- Preterm labor - Hydramnios
- Fetal compromise - Contracted pelvis
- Uterine rupture DIAGNOSIS
- Fetomaternl hemorrhage  Inspection
- Alloimmunization - Abdomen is unusually wide
- Amniotic fluid embolism - Uterine fundus extends to only slightly above the
- Death umbilicus
- No fetal pole is detected in the fundus
- Ballotable head is found in one iliac fossa and
FACE PRESENTATION the breech in the other

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- Head is hyperextended  Vaginal examination

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- The occiput is in contact with the fetal back and - Position of the axilla: indicates the side of the
the chin (mentum) is presenting

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mother toward which th shoulder is directed
- Rarely deliver vaginally

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 Position of the back in transverse lie
Causes: - Anterior: a hard resistance plane extends across

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- Preterm infants the front of the abdomen
- Fetal malformations and hydramnios rs e
- Marked enlargement of the neck or coils of cord - Posterior: irregular nodulations representing
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fetal small parts are felt through the abdominal
- Anencephalic fetuses wall
- Contracted pelvis MANAGEMENT
- Very large fetus  Cesarean delivery
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- High parity
MECHANISM OF LABOR
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- Descent COMPOUND PRESENTATION

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- Internal rotation Incidence and etiology:

- Flexion - Extremity prolapses alongside the presenting
- Extension part and both present simultaneously in the
- External rotation pelvis
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MANAGEMENT MANAGEMENT AND PROGNOSIS

 Fetal heart rate monitoring  Most case are left alone
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- Better done with external devices to avoid - Will not interfere with labor
damage to the face and eyes
 If the arm is prolapsed alongside the head
 Cesarean delivery (contracted pelvis) - Observed closely to ascertain whether the arm
 Attempts to converts a face presentation manually
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retracts out of the way with descent of the

into a vertex presentation presenting part
- Dangerous and should not be attempted
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 Failure to retract and if it appears to prevent

descent of the head
 The prolapsed arm should be pushed gently
BROW PRESENTATION
upward and the head simultaneously downward by
Etiology and Diagnosis
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fundal pressure.
 Same as those for face presentation
 Unstable
- converts to face or an occiput presentation
VAGINAL EXAMINATION STUDY GUIDE QUESTIONS 24th EDITION
28–1. What percentage of term singleton pregnancies
 The frontal sutures, large anterior fontanel, orbital
present breech?
ridges, eyes and root of the nose are felt
a. 1–2%
 Mouth nor the chin is palpable
b. 3–4%
c. 5–6%
d. 7–8%
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 OBII-06 MALPRESENTATION AND DELIVERY
28–2. Regarding the prevalence of breech presentation,
which of the following statements is true?
a. It is stable throughout pregnancy.
b. It approximates 80% at 24 weeks’ gestation.
c. Across pregnancy, it increases with gestational age.
d. Across pregnancy, it decreases with gestational
age.
28–3. The Term Breech Collaborative Group studied
vaginal delivery of the breech fetus. Which of the
following is a criticism of this study?
a. Serious morbidity was defined too strictly.
b. Only nulliparas were included in the trial.
c. Most of the providers were unskilled at breech
delivery.
d. More than 10% of participants had radiological
pelvimetry.
28–4. All EXCEPT which of the following are true
regarding the “stargazer” breech fetus?
a. The fetal head is hyperextended.
b. Forceps are indicated for delivery.
28–9. All EXCEPT which of the following statements are
true regarding maternal morbidity and mortality in
breech delivery?
a. Hysterotomy extensions can occur with forceps use.
b. Maternal genital tract lacerations can lead to
infection.
c. Maternal death is less likely if the breech is
delivered by cesarean.
d. Anesthesia needed for relaxation to deliver the
breech can lead to postpartum hemorrhage.
28–10. Which of the following is the least common bone
fractured in neonates who are delivered vaginally
from a breech presentation?
a. Femur
b. Radius
c. Humerus
d. Clavicle
28–11. Which of the following outcomes that may be
seen with breech presentation is not related to delivery
mode?

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c. Cesarean delivery is the safest delivery route. a. Erb palsy b. Hip dysplasia

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d. The cervical spinal cord can be injured during c. Spinal cord injury d. SCM muscle hematoma
vaginal delivery. 28–12. Based on imaging studies, which of the following

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28–5. What is the risk that breech presentation will biometric thresholds should be used to assess fetal

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reoccur at term in a second pregnancy? suitability for vaginal breech delivery?

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a. 0.5% a. BPD > 80 mm b. EFW < 2500 g
b. 2%
c. 10% rs e c. EFW > 3500 g d. None of the above
28–13. What is the best indicator of pelvic adequacy for
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d. 12% vaginal breech delivery?
28–6. Which of the following is a known risk factor for a. Fetal lie
breech presentation? b. Pelvic radiograph
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a. Oligohydramnios c. Clinical pelvimetry

b. Maternal diabetes d. Normal progression of labor
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c. Prior forceps delivery 28–14. Which of the following statements is false

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d. Anterior placental implantation regarding the cardinal movements of breech delivery?

28–7. After reviewing all available studies, which of the a. The fetal head is born by flexion.
following general statements can be made regarding b. The back of the fetus is directed posteriorly.
vaginal delivery of the term breech fetus compared c. The anterior hip usually descends more rapidly than
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with cesarean delivery? the posterior hip.

a. Neonatal mortality rates are lower with cesarean d. Engagement and descent usually occur with the
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delivery. bitrochanteric diameter in an oblique plane.

b. Neonatal morbidity rates are lower with cesarean 28–15. Which of the following best describes a breech
delivery. fetus that delivers spontaneously up to the umbilicus, but
c. After vaginal breech birth, children at age 2 years whose remaining body is delivered with operator
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have lower intelligence scores. traction?

d. None of the above a. Breech decomposition
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28–8. Which of the following statements is true regarding b. Total breech extraction
the preterm breech fetus? c. Partial breech extraction
a. It is always best to deliver a preterm breech by d. Spontaneous breech delivery
cesarean. 28–16. A 24-year-old G4P2 presents at term for a
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b. Neonatal survival rates are equal with vaginal or routine prenatal visit. She has had two prior vaginal
cesarean delivery. deliveries of 6-pound neonates and one prior
c. There are no randomized studies regarding miscarriage. On examination, you suspect a breech
optimal delivery route for the preterm breech presenting fetus. Which of the following does not favor
fetus. vaginal breech delivery?
d. None of the above a. The fetal head is hyperflexed.
b. Fetal weight approximates 7lbs.
c. The patient requests cesarean delivery.
d. The patient has had a prior pregnancy loss.

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 OBII-06 MALPRESENTATION AND DELIVERY
28–17. The patient in Question 28-16 is now in
advanced labor and presents to Labor and Delivery. She
wishes to attempt vaginal breech delivery. Sonographic
evaluation shows that her fetus has both hips flexed
and both knees extended. Which best describes fetal
position?
a. Frank breech b. Total breech
c. Complete breech d. Incomplete breech
28–18. Following emergence of the fetal legs during
vaginal or cesarean delivery of a breech fetus, this
photograph demonstrates which next step?
a. Traction on the fetal waist
b. Continued traction on the fetal legs
c. Placement of thumbs on the fetal sacrum
d. Placement of thumbs on the anterior superior iliac
crests
28–19. To resolve the complication shown in this image,
which of the following should be attempted?
a. The fetus should be rotated through a half circle.
b. The fetus should be pulled downward to release the
28–25. What is the eponym given to the maneuver
described in Question 28–24?
a. Piper maneuver b. Pinard maneuver
c. Mauriceau maneuver d. Zavanelli maneuver
28–26. What is likely to be the most adequate method of
anesthesia for a vaginal breech delivery?
a. General anesthesia b. Pudendal anesthesia
c. Epidural anesthesia d. Intravenous sedation
28–27. A 26-year-old G2P1 presents for a routine visit at
32 weeks’ gestation. She is worried because her fetus
was breech during her most recent sonographic
examination. Which of the following are correct
statements during your counseling regarding external
cephalic version?
a. The success rate is 80%.
b. It can be performed when she presents in labor.
c. It should be performed after 36 weeks’ gestation.
d. Amnionic fluid volume is unrelated to the success
rate.
28–28. The patient in Question 28–27 chooses an
external cephalic version attempt at 37 weeks’ gestation.

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arm.

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c. The fetus should be rotated to bring its back directly Sonographically, the fetus has a transverse lie, the
posterior. amnionic fluid index is 18 cm, and the estimated fetal

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d. The humerus or clavicle should be fractured to weight is 2800 g. The placenta is anterior. Which of the

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reduce the bisacromial diameter. following does not aid successful version completion?

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28–20. What is the utility of the Prague maneuver shown a. Multiparity
in this image?
a. Breech decomposition rs e b. Anterior placenta
c. Abundant amnionic fluid
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b. Safest delivery method for the head of a preterm d. Fetal size of 2500–3000 g
breech 28–29. Before proceeding with the requested version
c. Fetal head delivery when the back is oriented attempt, you counsel the patient in Question 28–27
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posteriorly regarding potential risks. Which of the following are

d. Release of the aftercoming head in an incompletely complications of external cephalic version?
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dilated cervix a. Uterine rupture

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8–21. Which of the following is true regarding the b. Placental abruption

forceps used in this image? c. Emergency cesarean delivery
a. They have a prominent pelvic curve. d. All of the above
b. They have a downward arc in the shank. 28–30. All EXCEPT which of the following are absolute
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c. They must be rotated through a 45-degree angle. contraindications for external cephalic version?
d. They must be disarticulated prior to fetal head a. Placenta previa
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delivery. b. Prior myomectomy

28–22. A patient presents in preterm labor at 30 weeks’ c. Multifetal gestation
gestation. Her cervix is completely dilated, and the fetus d. Nonreassuring fetal status
is breech. You are unable to deliver the fetal head. What 28–31. Which of the following interventions has been
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procedure, used to resolve this complication, is shown most consistently to increase the success rate
demonstrated in this image? of external cephalic version attempts?
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a. Symphysiotomy a. Nifedipine b. Terbutaline

b. Zavanelli maneuver c. Nitroglycerin d. Epidural analgesia
c. Dührssen incisions 28–32. Internal podalic version is usually reserved for
d. Mauriceau maneuver which of the following clinical situations?
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28–23. If the procedure performed in Question 28–22 is a. Frank breech deliveries

not successful, which of the following may aid fetal b. Complete breech deliveries
delivery? c. Delivery of an aftercoming twin
a. Piper forceps b. Fundal pressure d. Preterm breech deliveries, regardless of
c. Zavanelli maneuver d. Intravenous nitroglycerin presentation
28–24. What is the process called in which a frank
breech presentation is converted to a footling breech
presentation within the upper birth canal? Don’t let your future self tell you,
a. Retraction b. Relaxation “I should have done better.”
c. Displacement d. Decomposition _K
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