Alexandria Obstetrics Textbook

; d is midway between flexion

Definition: in which the
hea ang
It's a cephalic presentati on tal bone O’ f
the fetal head.
i
nat or i
i the fro n|
extension. The denomi

N/ |
Figure (13-9): Brow presentation
Types an d ocauses:
Brow like face presentation has the same types and causes. The secondary
.
type is much more common.
o Brow presentation might be transient early in labor or persistent when
diagnosed in late first and second stages of labor.
Diagnosis:
1. Abdominally:
¢ Non-engagement of the head because the antero-posterior diameter of the
head is the largest; mento-vertical (13.5 cm).
IL Vaginally:
Early rupture of membranes with great risk of cord
prolapse.
¢ High Presenting part.
¢ Landmarks of brow:
1.Orbital ridges.
2.Nasal bridge.
3.Anterior fontanell
e.
Mechanism of labor:
* R eism
No mechan for s Pontaneou: s delii very whicich h isi due
to the largest mento-vert
Management; ical
:

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ilest niria Obstetrics Textbook for ¢ ndergradiare,

reech Presentaion
pefinition:
» It's an abnormal Presentation
in which the
denominator is the back of the Presenting Part is the
fe tal sacrum, fetal buttocks, The
iciodence:
The incidence isi high duyrin,
o Itis > 40% of Pr 8 Pregnancy, then, it decreases markedly
egnant cases at
20 wee near term.
majority of cases by the 36t ks
then it become
week of gestation will undergs 3-4% at ful term. So, the
st o spontaneous correction.
1e. Frank breech or br
eech With extended
e It's the most comm legs:
on ty Pe. It accounts
extended at knee for >70% of cases. Here, the legs are
, flexed at hip joints
2. Complete breech or , |
breech with flexed leg
s:
* It's less common than
the first type. The legs are flexed at bot
joints. h knee and hip
3. Footling or incomplete breech )
:
* The legs are extended at bot |
h knee and hip joints. It's
with premature. rare and usually occurs
1
4. Knee presentation:
e The legs are flexed at knee, 1
extended at hip joints. It's ext
remely rare,

Frank | h Complete breech Footling

Figure (13-10): Types of incomplete breech presentation.

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 Textbook J¢ or
Undergras ot
Alexandria Obstetr ics

isposing factors:
Etiology or pred presentatm
n,
Fetal causes: r ne st ca us e of breech
1. o
Its the comm
1. Prematurit y: ction.
ow th restri
Intra-uterine gr
ncy
Multiple pregna phalufi .
s as hydm(u
Fetal anomalie
Intrauterine fetal death.
a.
6.Placenta praevi mmos,
am ni os OF oligohydra
7. Hy dr pif
II. Maternal causes: pt att e or bicorn
uate uterus.
se
1k Uterine anomal
ie s as
arian tumors).
fi br om yo ma or huge ov
(uterine
2. Pelvic tumors
3. Multiparity. tion.
Pr ev io us his tor y of bree ch presenta
4.

Positions: are 4 positions:

are more common. There
The anterior positions
LSA.
. 1+ position left sacroanterior
RSA.
I 20 position right sacroanterior
RSP.
[ 3¢ position right sacroposterior
IV. 4% position left sacroposterior. LSP.

Diagnosis: S|
1. Symptoms:
; i;me patients may feel upper abdominal discomfort or a hard tender lump.
s 5 so, they may) feel excessi
xcessive lower abdominal
i fetal movements. .

a. Abdominally:
1.The fundal level vel isis higher
hi than vertex presentation.
2.The fundal grij p may reveal t| 2
breech). y he head with its characteristics (complete

3.The pelvic gripgri reveals the butt ocks, conti 5 i

4.The ‘-“UOusiwlth eac
ab
heard above
s
b Vaginally:he fetal heart sounds are the umbilicus.
:
The followin g landmark: -
a. Soft. SR
b. P resence of 3 bony prominenc
es:
1.P
2Ischial tuberosities s and
tipi of sacrum
& Free passage ge of of mec
; onit
d. External genitalia,
i
@, Feet (C(’mplete bl‘eech)

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 Ultrasonography:
1t's very beneficial for the following:
a. Confirm the diagnosis and specify the type
of breech.
Confirm the gestational age.
Estimate the fetal weight.
EENE
Estimate the amniotic fluid volume,
Confirm the placental localization.
Exclude fetal anomalies as hydrocephalus.
Exclude any associated pathology like fibroid tumor.

erential diagnosis:
o Although U/S differentiates accurately frank breech from complete one, the
following are, also, clinical points to differentiate:
o The fundal grip reveals the feet beside the fetal head.
o The fetal head becomes non-ballottable due to splinting effect of the extended
legs.
On pressing the uterine fundus, there will be no convexity of fetal back.
The presenting part of frank breech is relatively smaller, more rounded,
harder and deeply engaged in pelvis than in complete breech.

Mechanism of labor:
though the majority of cases will undergo planned CS, cases who will deliver
spontaneously will pass through the following steps:
L. Delivery of buttocks:
a. The bi-trochanteric diameter (10 cm) engages in one of oblique diameters of
pelvic brim.
b. The breech will undergo descent, internal rotation and born by lateral flexion
of the trunk.
Delivery of shoulders:
a. The shoulders engage by the bi-acromial diameter (12 cm) in the same oblique
diameter of pelvic brim which is occupied by breech.
b. Descent of the shoulder followed by internal rotation, then the anterior
shoulder emerges first under the pubic arch and quickly followed by posterior
shoulder.
Delivery of the after-coming head:
a. The flexed head engages by suboccipito-bregmatic diameter (9.5 cm) in the
opposite oblique diameter of pelvic brim.
b. It will undergo internal rotation bringing the occiput to lie behind the
symphysis pubis.

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Managemep, of non-¢ omp
licated breech
Vanagemen t dy, Ting preg
.
IL Mode of deli3very; vaginal nanc y thro3ugh the external
> versus cephalic vers;,
delivery CS. g
0.
External Cephalic Version /
(ECv):
* ECVisa relatively safe procedure, [
S0 the rate of CS and incidence ofredufetal
ces the rate of breech Presentatio,
morbidity and mortality iy e {
reduced.
® Theaverage success rate of ECV is 40-5 ey \i
0% of cases.
* ECV involves the lifting of the fetal buttock
with one hand whilst the fety)
pushed down with the other, moving the fetus in an an ti-clockwise
should be done before and after the proce direction Qh
dure. -G
The proper timing for ECV for breech correction
is at 3 6 completeq Weeks o
nulliparous and 37 for multiparous cases.
¢ Itisn't done before that for the following:
1. Spontaneous cephalic version may occur.
fi
2. Version is liable to recur.
3. Risk of preterm labor.
* ECVis contraindicated in: ’
1. Twin pregnancy.
2. Hydrocephalus.
3. Placenta praevia.
4 Preeclampsia and hypertension.
5. Presence of a uterine scar; CS or myomectomy.
¢

Contracted pelvis.
R

Risks and complications of ECV:

1. Placental abruption.
2. Premature rupture of membranes,
3. Cord accidents; compression, prolapse.
4. Fetal bradycardia.
5, Transplacental hemorrhage and Rh sensitizat
ion.

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 #

Fetus in breech presentation External cephalic version Fetus in cephalic presentation

Figure (13-11): External cephalic versi
on.

Mode of delivery in breech presentation:

1. Caesarean section:
e Has been considered, now, the main mode of delivery for term breech
presentations in Europe and USA, as it reduces the risk of birth-related
complications.
o The incidence of CS becomes over 85% of all breech births in comparison to,
only, 15% in 1970.
II. Vaginal delivery:
e There are certain prerequisites for vaginal breech delivery.
e U/Sisamust to fulfill the following criteria:
1.Frank breech and some carefully selected complete breech.
2.Gestational age of 34 weeks or more.
3.Estimated fetal weight is < 3.5 kg.
4.Adequate maternal pelvis i.e. no feto-pelvic disproportion.
5.Flexed fetal head.
6.Any fetal anomalies like hydrocephalus should be excluded.
7.No other associated obstetric complications e.g. placenta praevia,
preeclampsia.
8.No history of previous CS.
9.An expert obstetrician should be available.

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 Management of vaginal breech delivery:
I First stage of labor:
1. Vaginal examination early in labor to confirm diagnosis anq
€nsure the
adequacy of the pelvis. Minimize vaginal examination to decrea.
'se the rig) ;
PROM.
2. Second vaginal examination is essential when membranes Tupture to
cord prolapse. exclude

3. Observation of progress of labour, fetal and maternal conditions

first stage. throughey,
4. Never pull on breech before full cervical dilatation.

I Delivery of buttocks:
1. Episiotomy is performed under anaesthesia.
2. After the buttocks being expelled by uterine contractions it should be Totateq
to bring fetal back anterior and baby slips out to the level of umbilicus,
3. Delay of delivery of buttocks may be helped by some groin traction anq
fundal pressure (Kristeller's maneuver) during uterine contractions
4. Iflegs are extended are dislodged by pressure behind the knees to abdyct and
flex the thigh.
The baby is wrapped by warm sterile towel to prevent premature
Tespiration,
o

Figure (13-12): Delivery of but

tocks.
Il Delivery of shoulders:
The baby is rotated to bring the shoulder
s in antero-posterior diameter of
pelvic outlet and traction is made downwards and
backwards till lower angle
of the scapula appears,
¢ When the el Ao
e ringe: bows appear at the introitus, the arms are disentangled from the

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 or Undergraduates

Figure (13-13): Delivery of shoulders.

« Lgvsets' maneuver:
o It helps descent of the arms and might be done prophylactically to
prevent their extension. When the lower angle of the scapula appears,
* the back of the fetus is rotated to the other side and then returned
again. This might be repeated two or three times till the elbow appear.

Figure (13-14): Lovsets' maneuver

~ IV. Delivery of after-coming head:

head. All aim to
) Several techniques are available to assist delivery of the
head can pass
maintain flexion of the head so that small diameters of the
through the pelvis:
o Kristeller's technique:
backwards
« Fundal pressure by external hand in a downwards and
.
direction to flex and push the head in the pelvis

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 Figure (13-15):Kristeller's technique

Burns - Marshall Technique: .

o The baby is allowed to hang unsupported with slight supra-pubic
pressure. ' ‘
When nape of neck appears under pubic arch, the baby is grasped and
moved upwards towards mother’s abdomen till delivery of the head.

free his mouthand

suck him out
Figure (13-16):Burns - Marshall tec
hnique

Mauriceau-Smellie-Veit technique (jaw

flexion shoulder traction):
® The fetus is supported on one forearm
and the index finger of the same
hand is introduced in his mouth
to do jaw flexion.
¢ The index and middle fingers of the other hand are
placed over d\e
shoulders to enable traction in a downward
and forewords direction
till the nape
of the neck appears as mentioned
above.

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 Textbooh for Undergraduates

sistant /
\,
'| middle finger presses on |

SN\
{‘ ,, -

finger in
his mouth

Figure (13-17): Mauriceau-Smellie-Veit technique

V. Obstetric forceps:
o Forceps protects and controls slow delivery of head through birth canal so
avoiding sudden compression and decompression of fetal head.
VI. Symphysiotomy:
» It's rarely needed to deliver the after-coming head.

Complications of vaginal breech delivery:

1. Premature rupture of membranes.

2. Cord prolapse particularly with complete breech and footling.
3. Arrest of the after-coming head (will be mentioned).
4. Rapid delivery of the after-coming head might be complicated by intracranial
hemorrhage as a result of sudden compression/decompression.
5. Delay in delivery, leading to asphyxia due to cord compression and placental
separation.
6. Traumatic birth injuries including cervical injuries from hyperextension, fractures of
the humerus, femur or clavicle and brachial plexus injuries.

. Elderly primigravida (235 years).

History of infertility or still birth.
. Gestational age < 34 weeks to avoid intracranial hemorrhage during vaginal delivery.
4. Pelvic contraction (even mild).
Estimated fetal weight of > 3500 gram or <2500 gram.
eflexed or extended fetal head.
on—engagemem of the breech.
ciated placenta praevia.
ged rupture of amniotic membranes.

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 e |
Arrest of the after-coming head:
In this condition, vaginal breech delivery has been decided, howeyer
unfortunately, the after-coming head becomes arrested. Proper evalya
tion of the
condition will guard against this hazardous complication. The arrest
may oceyy at
different levels of the pelvis; pelvic brim, cavity or outlet.
Etiology:
b, Extension of head.
wp Posterior rotation of occiput.
Incomplete cervical dilatation.
Pelvic contraction.
NSOk

Hydrocephalus.
Extension of arms or becomes behind the neck.
Rigid perineum.
8. Locked twins.
Management:
The management depends on the cause of arrest. The following are examples;
1. Extension of the head:
¢ Do jaw flexion - shoulder traction.
Posterior rotation of the occiput:
¢ Try rotation to anterior position
¢ Jaw flexion - shoulder traction but in a reverse direction
to that in case of well
flexed head.
¢ Prague's maneuver:
1. Fingers of left hand are hooked over the shoulders
and gentle traction
is made.
ii. The other hand holds the feet and lifts the baby
upwards and towards
the mother's abdomen
iii. Suprapubic pressure downwards and back
wards may help.

Figure (13-18): Prague techni

Forceps extraction: que.
oo w

Symphysiotomy.
l({Iix-a.niotomy of the head
in a dead baby.
gid perineum: Do generous
or even bilateral episioto
my.

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