CASE PRESENTATION ON

BREECH PRESENTATION
ANATOMY AND PHYSIOLOGY
 ANATOMY AND PHYSIOLOGY
•The uterus is a hollow, pear shaped muscular organ located in the true pelvis between the bladder and

the rectum.

SHAPE AND SIZE:

•It’s pear shaped, being flattened anterio-posteriorly.

MEASUREMENTS:

Length- 3 inches (7.5cm)



Breadth- 2 inches (5cm)



Thickness- 1 inches (2.5cm)



Weight- 30-40 grams


 FUNCTIONS OF UTERUS

 Organ of reproduction(main) serves for reception, implantation ,

retention and nutrition of the fetus.

 Organ of menstruation.

 Uterine contractions for the expulsion of the fetus during delivery and

to seal torn blood vessels after placental delivery.

 DEFINITION

Breech Presentation,

When a fetus with a longitudinal lie presents by its lower pole, i.e.
buttocks with or without the lower limbs, it is know as breech
presentation.
 INCIDENCE

 The incidence is about 20% at the 20th week and drops to 5% at the 34th

week and 3-4% at term.

 The incidence increases in preterm fetuses and multiple gestations and

in women with a history of breech birth.

 The incidence is expected to be low in hospitals were high parity birth

are less and routine external cephalic versions is done in antenatal

period.
 TYPES

 There are two types of breech presentations:

1) Complete 2)Incomplete
 TYPES

oComplete (Flexed Breech):

• When all parts are completely

flexed (squatting) it is complete

breech .

• Presenting parts consists of two

buttocks, external genitalia and two

feet.

• Commonly present in multipara

(10%)
 TYPES
o Incomplete

• Here the flexion altitude is

incomplete.

• This is due to varying degrees of

extension of thighs or legs at the
podalic pole.

• Three varieties are possible.

1) Breech with extended legs (Frank

breech)

2) Footling Presentation

3) Knee Presentation
 BREECH WITH EXTENDED LEGS
(Frank Breech)

 The breech presents with the hip flexed and legs extended on abdomen.

 About 70% of breech presentations are of this type.

 Presenting part consists of two buttocks and external genitalia only.

 Commonly present in primigravida whose good uterine muscle tone

inhibits flexion of the legs and the free turning of fetus.

 FOOTLING PRESENTATION

 One or both feet present because neither hips nor knees are fully flexed.

 The feet are lower than the buttocks, which distinguish this

presentation from the complete breech.

 KNEE PRESENTATION

 One or both hips are extended with the knees flexed.

 This is very rare.

 ETIOLOGY

1. Prematurity

2. Multiple Pregnancy

3. Polyhydramnios / Oligohydramnios

4. Factors preventing the head from entering the pelvic cavity:

contracted pelvis, cervical fibroids, placenta previa, hydrocephalus

5. Undue mobility of fetus.

6. Fetal abnormality

7. Recurrent breech

8. Maternal smoking
 CLINICAL MANIFESTATIONS

1. Babies change the position often.

2. Prolonged labor pain.

3. Women feel kicking low in the abdomen when a baby is in breech

position.

4. Early rupture of the membrane.

5. Mother can feel the fetal head in the upper portion of the abdomen.
 INVESTIGATIONS

1. Abdominal Examination
2. X-ray abdomen and pelvis
3. Ultrasonography
4. C.T Scan
 MANAGEMENT

 ANTENATAL MANAGEMENT:

1. Identification of complicating factors related with breech

presentation.

2. External Cephalic Version (ECV)

3. Exercise : Tilt position, Lie on back with knees bent.

4. Elective Cesarean Section
 MANAGEMENT

MANAGEMENT OF VAGINAL BREECH DELIVERY:

 First Stage

1. Avoid early rupture of membrane by avoiding enema, unnecessary

per vaginal examinations.

2. Give bed rest and sedations.

3. Repeat per vaginal examination every 3-4 hrs and at rupture of
membranes to rule out cord prolapse (in footling position).
 MANAGEMENT

MANAGEMENT OF VAGINAL BREECH DELIVERY:

 Second stage:

1. Spontaneous breech birth

2. Partial (Assisted) Breech extraction

3. Total breech extraction

 MANAGEMENT OF COMPLICATED BREECH

CAUSES MANAGEMENT
Inefficient uterine contractions Oxytocin drip + breech presentation

Contracted outlet Caesarean section

Rigid perineum Episiotomy

Extended legs •Breech deeply impacted:

(frank breech) Groin traction

•Breech not deeply impacted:
Bring down a leg + breech extraction
•If the outlet is contracted or the baby is
large do C.S
FRANK BREECH EXTRACTION (PINARD’S
MANEUVER)

•It’s a procedure in which the

infant’s feet are grasped by the
operator and the fetus is extracted
from the uterine cavity through the
vagina.
•Two fingers are carried up along
one extremity to the knee to push it
away from the midline.
•Spontaneous flexion follows.
(Delivery of extended leg)
LOVSET’S MANEUVER

•To release extended arms.

• Baby pelvis is held firmly, traction
is provided, back is rotated upwards
in 180◦ (Baby facing maternal
pelvis.)
•Arm is released, arms are flexed
and sweep down over face and
chest.
•It is repeated in opposite direction.
BURNS MARSHAL METHOD

•For the delivery of the after coming head.

•It is commonly practiced when baby is
allowed to hang for a minute or so.
•Once the nape of the neck is visible,
identified by the hairline, the baby’s trunk
is gently lifted and swung towards
mother’s abdomen holding the baby just
above the ankle through the arc of 180◦
MAURICEAU SMELLIE VELT MANEUVER

•Delivery of the after coming head.

•Index and middle finger applied over
the maxillae to flex the head.
•Other hand is placed on the back with
fingers over the shoulder.
•A firm downward traction is then
applied till the chin is seen when the
body is seen when the body is elevated
to the mother’s abdomen and head
delivered.
PRAGUE MANEUVER

•Delivery of after coming head when

back is posterior.
•Modified Prague Maneuver, consists
of two fingers of one hand grasping
the shoulders of back down fetus
from below while the other hand
draws the feet up and over the
maternal abdomen.
FORCEPS FOR AFTERCOMING HEAD OF BREECH

•It is the method of choice for the

delivery of the after coming head.
•Piper’s forceps is used.
1. Direct traction on cranium and not
on spine.
2. Promotes flexion of head.
3. Rate of delivery of head can be
controlled thus preventing sudden
compression and decompression of the
head.
 CESAREAN DELIVERY IN BREECH

INDICATIONS OF CESAREAN DELIVERY IN BREECH:

Elective
1. Feto-pelvic disproportion (FPD)
2. Fetal weight 800-2500 g and > 3500 g

3. H/o Cesarean delivery for previous breech.

4. Past history of dystocia.

5. Footling breech in primigravida.

6. Primigravida: Breech in primigravida is an indication for cesarean

section in opinion of most obstetricians.

 CESAREAN DELIVERY IN BREECH

 Emergency:

1. Fetal distress

2. Cord Prolapse
3. Absence of adequate progress in labor
 MEDICATIONS

Tab. Ceftum 500 mg BD

Inj. Metronidazole 100 cc TD

Inj. Pantoprazole 40 mg OD

Inj. Emset 4 mg OD
 COMPLICATIONS

 MATERNAL:

1. Prolonged labor with maternal distress.

2. Obstructed labor with its sequelae (a condition which is the

consequence of previous disease or injury). may occur as in impacted
breech with extended legs.

3. Postpartum hemorrhage due to prolonged labor and lacerations.

 COMPLICATIONS

 FETAL:

1. Forceps delivery of the after coming head.

2. Episiotomy

3. Slow delivery of the head

4. Asphyxia due to Cord Prolapse or premature aspiration.

5. Fractures and dislocations

6. Rupture of abdominal organ

7. Non fatal injuries

8. Premature separation

9. Congenital malformation
 PREVENTION

Practice External Cephalic Version where possible.



Delivery in well equipped hospitals.



Careful pelvic assessment.



Rule out other complicating factors.



Vaginal breech delivery should be conducted by a skilled obstetrician along



with an organized team consisting of skilled anesthetist and neonatologist.

Ensure that the cervix is fully dilated before attempting vaginal delivery.

 HEALTH EDUCATION

 Nutrition

 Medications

 Breast Care and Breast feeding

 Rest

 Care of baby

 Personal Hygiene

 Follow up