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Breech

Presentation
Introduction
Breech presentation is when the buttocks of the fetus enter
the pelvis before the head
Breech presentation is more common remote from term.
Most often before the onset of labor the fetus turns
spontaneously to a cephalic presentation
Introduction
Etiology
Factors other than gestational age that appear to predispose
to breech presentation include:
hydramnios,
uterine relaxation assd w/ great parity,
multiple fetuses, oligohydramnios,
hydrocephaly,
anencephaly,
previous breech delivery,
uterine anomalies, and
pelvic tumors
Complications
In the persistent breech presentation, an increased
frequency of the following complications can be anticipated:
Perinatal morbidity & mortality from difficult delivery
Low birthweight from preterm delivery, growth restriction, or
both
Prolapsed cord
Placenta previa
Fetal, neonatal, and infant anomalies
Uterine anomalies and tumors
Diagnosis
frank breech presentation
The lower extremities are
flexed at the hips & extended
at the knees, & thus the feet
lie in close proximity to the
head
Diagnosis
Incomplete breech
presentation
one or both hips are not flexed
and one or both feet or knees lie
below the breech, such that a
foot or knee is lowermost in the
birth canal
Footling breech is an incomplete
breech with one or both feet
below the breech.
Diagnosis
Complete breech
presentation
It differs in that one or both
knees are flexed
Abdominal Examination
Leopold maneuvers:
1st: hard, round, readily ballotable fetal head is found to occupy
the fundus
2nd: indicates the back to be on one side of the abdomen and
the small parts on the other
3rd: if engagement has not occurred, the intertrochanteric
diameter of the fetal pelvis has not passed through the pelvic
inlet, the breech is movable above the pelvic inlet
4th: after engagement, shows the firm breech to be beneath the
symphysis

Fetal heart sounds usually are heard loudest slightly above


the umbilicus, whereas with engagement of the fetal head,
the heart sounds are loudest below the umbilicus.
Vaginal Examination
The mouth & malar eminences form a triangular shape,
whereas the ischial tuberosities and anus are in a straight
line.
Imaging Techniques
ultrasound should be used to confirm a clinically suspected
breech presentation and to identify any fetal anomalies
Prognosis
Both mother and fetus are at greater risk w/ breech
presentation compared with cephalic presentation, but to
nowhere near the same degree
Maternal Morbidity
Because of the greater frequency of operative delivery,
including cesarean delivery, there is higher maternal
morbidity and slightly higher mortality for pregnancies
complicated by persistent breech presentation
Perinatal Morbidity and Mortality
The prognosis for the fetus in a breech presentation is
considerably worse than when in a vertex presentation.
The major contributors to perinatal loss are preterm
delivery, congenital anomalies, and birth trauma.
Methods of Vaginal Delivery
There are 3 general methods of breech delivery through the
vagina:
Spontaneous breech delivery.
The infant is expelled entirely spontaneously without any

traction or manipulation other than support of the infant.


Partial breech extraction.
The infant is delivered spontaneously as far as the

umbilicus, but the remainder of the body is extracted or


delivered with operator traction and assisted maneuvers,
with or without maternal expulsive efforts.
Total breech extraction.
The entire body of the infant is extracted by the

obstetrician
Recommendations for Delivery
Cesarean delivery is commonly but not exclusively used in
the following circumstances:
A large fetus.
Any degree of contraction or unfavorable shape of the pelvis.
A hyperextended head.
When delivery is indicated in the absence of spontaneous labor
(some clinicians use oxytocin augmentation).
Uterine dysfunction (some use oxytocin augmentation).
Incomplete or footling breech presentation.
An apparently healthy and viable preterm fetus with the mother
in either active labor or in whom delivery is indicated.
Severe fetal growth restriction.
Previous perinatal death or children suffering from birth trauma.
A request for sterilization.
Lack of an experienced operator.
Technique
External cephalic version should be carried out in an area that
has ready access to a facility equipped to perform emergency
cesarean deliveries
A "forward roll" of the fetus usually is attempted first.
each hand grasps one of the fetal poles, and the buttocks are
elevated from the maternal pelvis and displaced laterally.
The buttocks are then gently guided toward the fundus, while
the head is directed toward the pelvis.
If the forward roll is unsuccessful, then a "backward flip" is
attempted.
Version attempts are discontinued for excessive discomfort,
persistently abnormal fetal heart rate, or after multiple failed
attempts.
Technique