OBSTETRIC EMERGENCY

WORKSHOP

BREECH PRESENTATION AND

DELIVERY

DR PRAVIN PERABA
MD (UKM) MASTERS O&G (UKM)
 OVERVIEW

 WHAT IS A BREECH?
 WHAT’S CHANGED IN THE
MANAGEMENT?
 HOW TO CONDUCT A BREECH
VAGINALLY.
 SUMMARY
 DEFINITION

 Derived from the Old English word Brec (plural

of Broc - a German word initially for garment
covering the loins and thighs)
 Breeches refers to pants worn in olden day
England
 Medical terminology – refers to the
buttocks/hind parts
 Breech delivery – Delivery of the baby from the
pelvis either buttock or feet first as opposed to
head first
 INCIDENCE

 Theincidence varies with

gestation
 20% of pregnancies at 28 weeks
 10% at 34 weeks
 3-4% at 37 weeks

- Cheng et al 1993 J Obs Gyn

 CAUSES OF BREECH

 Endogenous and exogenous factors

 Endogenous refers to the inability of the fetus
to adequately move
 Exogenous refers to insufficient intrauterine
space for fetal movements
 This can broadly be divided into factors
concerning amniotic fluid, placental location
and uterine abnormalities.
 Fetal anomalies must also be considered.
 TYPES OF BREECH

 Frank or Extended breech is where the bottom

comes first, the legs are flexed at the hip and
extended at the knees (account for 60-70%)

 Complete or Flexed breech where the legs and

knees are both flexed so the baby is in a sitting
position (crosslegged)

 Incomplete or Footling breech where one or

both feet are below the buttocks (rare at term
but common in premature fetuses)
TYPES OF BREECH
 MANAGEMENT OPTIONS

 External Cephalic Version (ECV)

 Assisted Vaginal Breech delivery
 Elective Lower Segment Caesarean
Section
 HOW TO DECIDE?

 Suitability of the fetus for ECV or assisted

vaginal breech delivery – exclude absolute
contraindications like Placenta Praevia and
congenital anomalies.
 Relative contraindications include a previous
scar, amniotic fluid abnormalities and extremes
of fetal weight.
 Risks and possible complications highlighted.
 Couples wishes taken into account.
 WHAT HAS CHANGED?

 TERM BREECH TRIAL

 Carried out in 121 centers in 26 countries in
2000
 Mary Hannah and the collaborative
postulated that planned LSCS was better
than vaginal breech delivery at term
 Published to much acclaim in The Lancet in
2000.
 CRITERIA

 Inclusion
 Singleton
 Frank (Extended) or Complete (Flexed) breech
 More than 37 completed weeks
 Exclusion
 EFW more than 4kg
 Fetal anomaly or lethal congenital malformation
 Hyperextension of fetal head
 Contraindication to vaginal delivery like Placenta
Praevia
 FINDINGS

 Fetuses in planned LSCS groups were three

times less likely to die or experience poor
neonatal outcomes (Birth trauma, Apgar <4 at 5
mins, Intubation and need for NICU admission)
 For every extra 14 LSCS done one baby will
avoid death or serious morbidity.
 No significant difference to maternal outcomes
in terms of death or serious morbidity (EBL >
1.5L, VTE/DVT or Hysterectomy)
 WEAKNESSES

 Some of the neonatal morbidity was not

related to delivery but rather post delivery
care.
 Patients were recruited while in labour.
 Differing levels of clinicians with varying
experience attended vaginal breech
deliveries.
 Parity not taken into account when
analysing data.
Assisted Vaginal Breech Delivery

 Still has a role in developing countries.

 Proper antenatal follow-up and strict criteria
must be met.
 Counseling of the patient and her partner.
 Hospital with a trained clinician and with
Neonatal Intensive Care support as well as OT
facilities.
 Experienced clinician to conduct the delivery.
 RCOG RECOMMENDATIONS

 Exclude
 Lack of trained clinician
 Baby either < 2000g or > 3800g
 Hyperextended fetal neck (diagnosed with
ultrasound or x-ray)
 Footling breech
 Previous LSCS
 Contraindications to vaginal delivery such as
Placenta Praevia
 1ST STAGE OF LABOUR

 Induction of labour for breech presentation may

be considered in individual cases
 Augmentation of labour is not recommended
 Fetal heart monitoring should be done by CTG
 Fetal blood sampling of the buttocks is not
recommended
 Delay in progress should be delivered via LSCS

- RCOG GREENTOP GUIDELINE 20a

 2ND STAGE OF LABOUR

 Position of the patient

 Lithotomy
 Standing

 Allow the buttock to climb the perineum

 Role of Episiotomy
PERINEAL PHASE
CLIMBING
 The buttock climbs the perineum on the
mothers own expulsive efforts.
 Do not drag it or pull it unless there is
need for urgent delivery ie fetal distress.
 The legs are either delivered
spontaenously or swept out.
 If they are swept out, flex the back of the
knee at the popliteal fossa and gently
sweep the foot out.
HOLDING THE HIPS
 LOVSET’S MANOUVRE

 The fetal pelvis is held carefully with a dressing

towel or pack (always at the hip bones not the
abdomen!)
 The fetal pelvis is then rotated from side to side
and traction applied in a downward direction
 The umbilical cord is lengthened
 Once the scapula can be seen Lovset’s
manouvre is stopped.
LOVSET’S MANOUVRE
LOVSET’S MANOUVRE
 DELIVERY OF THE ARMS

 Once the scapula is seen, the fetal arms can be

delivered.
 Once again the arm is flexed at the elbow joint
by depressing the antecubital fossa.
 The arm is then swept out gently across the
fetus.
 The same procedure is repeated on the other
arm.
 The body is then allowed to hang on your arm
till the hairline/neck is visible
REACHING THE HEAD
 DELIVERY OF THE
AFTERCOMING HEAD

 Mariceau-Smellie-Veit (MSV Manouvre)

 Forceps

 Burns Marshall technique

 MSV MANOUVRE
 Named after François Mauriceau, William
Smellie and Gustav Veit.
 This procedure involves letting the fetus lie
on your left hand with the index and ring
fingers placed on the malar prominences
and the middle finger on the chin.
Alternatively 2 fingers can be placed on the
maxillae
 The ring and index fingers on the right
hand are placed on the parietal eminences
on the back of the skull and the middle
finger on the occiput.
 The head is the flexed downwards
before being pulled outwards which
mimics extension
 The combined neck flexion, traction
on the fetus toward the hip/pelvis,
and the suprapubic pressure on the
mother/uterus allows for delivery of
the head of a breech infant.
 FORCEPS

 A useful method to deliver the head.

 Neville Barnes forceps most commonly used
but Pipers curved forceps widely used in the
United States.
 Similar principals of application to forceps for
cephalic presentation. Slide in the left blade
while the contralateral hand is protecting the
vaginal wall followed by the right blade.
 Traction downwards then upwards to mimic
flexion then extension.
FORCEPS
 BURNS MARSHALL
TECHNIQUE
 Least used method. More common during
LSCS with wider incision/opening.
 Both ankles grasped by the clinician and
traction applied upwards until the baby’s body
is almost vertical and subsequently once head is
delivered swept onto the mothers abdomen.
 Higher risk of trauma both to baby and
maternal perineum with inadequate support.
BURNS MARSHALL
Assisted Vaginal Breech Delivery.mp4
 SUMMARY

 The causes of breech presentation are

multifactorial.
 Despite the TBT there is still a role for assisted
vaginal breech delivery in modern obstetrics.
 Careful patient selection with adherence to
inclusion/exclusion criterias and adequate
counseling is required before attempting
assisted vaginal breech delivery
 Neonatal and OT facilities as well as a trained
clinician are a must.
 Do not attempt to deliver alone – always call
for help.
 Allow the labour to progress spontaenously and
assist the delivery gently.
 Lovset’s manouvre to deliver the fetal arms.
 Use any of the three techniques to deliver the
aftercoming head but MSV and Forceps are
recommended.
THANK YOU