BREECH PRESENTATION AND

MANAGEMENT
BY SOLOMON HURUY(R-3)
june,2013
 Outline of discussion
 Definition
 Discuss the incidence and causes of breech
presentation
 How to diagnose and manage antenatally
 discuss types of VBD
 Discuss the Term Breech Trial and other studies
 Discuss the risks and benefits of ECV
 ACOG recommendations

2
BREECH
Definition
The fetal pelvis or lower extremities engage
the maternal pelvic inlet.
Pathogenesis
 In some pregnancies, breech presentation may be
a chance occurrence.
In others, it may be a marker for underlying
maternal, fetal, or placental conditions.
It is hypothesized that adopting the cephalic
presentation is due to an active process whereby a
mobile, normally proportioned fetus in an average
volume of amniotic fluid finds the position of best
fit in the available intrauterine space.
Clinical conditions
Decreased vertical polarity of uterus
Increased or decreased fetal mobility
Obstructed pelvic inlet
Fetal malformation
 Incidence

Gestation (weeks) % Breech

21 - 24 33%
25 - 28 28%

29 - 32 14%

33 – 36 9%

37 – 40 3%

7
 Etiologies
 Prematurity Pelvic masses
 High parity Fetal anomalies
 Uterine anomalies Absolute CPD
 Placenta praevia Previous breech
 Multiple pregnancy Unknown

8
Types

Frank breech (50-70%) - Hips flexed, knees

extended, common at term
Complete breech (5-10%) - Hips flexed,
knees flexed
Footling or incomplete (20-30%) - One or
both hips extended, foot presenting,
common in premature
 Diagnosis
o History(,parity,previouse breech,kicking..)
o Abdominal
Leopold’s first-head in the fundus
Leopold’s third-no tapering b/n the buttocks
and the body
Auscultation-FHR in the upper quadrants
o Vaginal –frank:anal orifice,ischial tuberosities and no feet.
Diagnosis….

o Complete: anal orifice,ischial tuberosities & feet above the

buttock
o Incomplete:one or more feet/knees felt
o Ultrasound: in difficult cases and to see associated
anomalies, weight estimation and fetal attitude.
position
MANAGEMENT
oAntepartum
oDuring labor
oDelivery
Antepartum
 Fetuses remote from termNo intervention
 External cephalic version near term
 Asses for congenital anomaly
 Estimate fetal weight near term
 Pelvimetry
ECV
 ECV is recommended in women with breech fetuses
who have completed 36 weeks of gestation .
 The advantages of ECV at or near term are:
1- it is usually successful,
2- the fetus is likely to remain cephalic after
successful ECV (>95percent)
3- the fetus is mature in the event of complications
necessitating cesarean delivery
 EXTERNAL CEPHALIC
VERSION.
Objective: To have vertex presentation in labor
Indication
Non cephalic presentation at or after 36 weeks of gestation
Time of version:
At 35 – 37 weeks
Benefits:
Decrease incidence of breech presentation at term,
Decrease the incidence of breech delivery and associated
complications,
Decrease the incidence of C/S delivery by about 5%.
 TECHNIQUES AND STEPS IN ECV

 Ultra sound examination(confirm Dx,AFV,anomally)

 Should be done in labor and delivery unit where OR
setup is available
 Non-stress test/BPP done to assess fetal well being.
 Tocolytic drugs to relax the uterus--terbutalin 250mg
sc 20 minutes prior.
 Take informed consent
 Empty her bladder
 Put her in supine position with her hip and knee flexed
 powder
STEPS IN ECV
o STEP 1-mobilize the breech to one illiac fossa. Podalic
pole by the right hand and head by the left hand.
o STEP 2-pressure exerted to opposite directions to keep
the trunk well flexed.(forward roll)
o STEP 3-The hand changed one after the other to hold
the fetal poles to prevent crossing of the hand
o If the above procedure failed twice then-backward
flip is tried
o Check FHR(every 2minute) after each attempt or NST.
o Anti-D immunoglobulin to Rh negative non-sensitized
mother.
Failed ECV
Maternal discomfort
Continuous FHB abnormality
After maximum of three attempts
Contin..
 The mother to be observed for about 30 minutes.
 Instructions given to the mother and follow up.
 Some causes of failure in ECV
 Breech with extended legs
 Engaged breech,difficulity to palpate the head, tense uterus
 nulliparity
 Scanty liquor or big baby.
 Short cord.
 obesity
 Uterine malformations.
 Anterior and posterior positions of fetal spine
Favorable factors for successful ECV
High parity
Unengaged breech
Complete breech
Posterior placenta
Contin..
One of the scores developed uses-
Parity
GA ,EFW
Station
Cervical dilation
Placental location
Contin..
Interventions which was believed to increased success
Vibrouaccoustic stimulation
Aminioinfussion
Anesthesia
tocolitics
Complications of ECV
Fetal bradycardia, decelerations (5% transient, 0.4% pathological)
Abruption (0.1%)
Fetal hemorrhage (1.5%)
Maternal hemorrhage (0.5%)
Knotted or entangled cord (0%)
Fetal mortality (0.16%)
Amniotic fluid embolus, maternal death (0%)
LSCS (0.4%)
PROM & PTL
Uterine scare dehiscence
CONTRA INDICATIONS FOR
ECV.
 Multiple pregnancy.
 Evidence of utero-placental insufficiency.
 APH(with in 7 days)
 Suspected IUGR,IUFD.
 Amniotic fluid abnormalities.
 Uterine malformations.
 Maternal cardiac disease,hypertension.
 Scared uterus,major fetal anomalies,ruptured
membrane,bad obstetric history,contracted pelvis.
 None- reassuring fetal heart rate pattern.
Safety of ECV
 The safety of ECV is well documented. In review of
44 studies by Collaris, published between 1990 and
2002, with a total of 7,377 patients, the most
frequently reported complications were transient
abnormal fetal heart rate patterns (5.70%),
fetomaternal transfusion (3.70%), vaginal bleeding
(0.47%), emergency cesarean (0.43%), persisting
pathologic fetal heart rate patterns (0.37%), and
placental abruption (0.12%). The incidence of
perinatal mortality was 0.16%.
conti..
 ACOG recommends, in Committee Opinion No. 340,
July 2006, that obstetricians should offer and perform
external cephalic version whenever possible
 Mode of delivery in breech presentation.
1-Cesarean delivery
o -The over all incidence of C/S in breech ranges from
15%-50% of which majority(80%) are elective.
A-absolute indications for C/S are:-
o -Estimated fetal weight >3500 grams.
o -Any degree of pelvic contracture.
o -Footling presentations.
o -Breech presentation with hyper extended head.
o -Breech with other poor obstetric performance.
o -Old premigravid
VAGINAL BREECH DELIVERY.
Cases with no absolute maternal or fetal indications for
direct C/S.
EFW<3500 grms.
Frank or complete breech.
Flexed head and adequate pelvis.
Gross fetal malformations judged to be incompatible
with extra uterine life
Zutuchani androse score>4
 Zatuchni-Andros Breech Scoring

Add 0 Add 1 Add 2

Points Point Points

Parity 0 1 2

Gestationa
l age (wk)
39+ 38 <37

7-8 lb(3.2- <7

EFW (lb) 8lb (3.6kg)
3.6kg) lb(<3.2kg)
Previous
breech
0 1 2

Dilatation 2 3 4
Station -3 -2 -1

If the score is 0-4, cesarean delivery is

recommended
decision regarding mode of delivery should depend
on the experience of the health care provider
Labor management in breech delivery.
Admission evaluation .Hx,PE,US exam
1-first stage of labor-
securing iv line.
progress of labor is not remarkably different,
Avoid ARM
Augmentation is contra-indicated in breech.
Experienced obstetrician
Anesthesiologist
pediatrician
 Labor follow up &
management
Electronic Fetal Monitoring is essential
One-to-one(every 15min)
fetal electrocardiographic electrode - avoid injury to
the fetal anus, perineum, and genitalia
Intrauterine pressure catheter - to assess the frequency,
strength, and duration of uterine contractions
PV immediate rupture of membrane
 Second stage of labor in breech.
Delivery may occur in one of the three ways.
1-spontaneous vaginal breech delivery.
2-assisted breech delivery
3-breech extraction.alternative to emergency C/S in desperate
conditions.some of the indications are:fetal distress in
second stage, delivery of the second twin after internal
podalic version, cord prolapse or entanglement around the
leg,extended legs arrested at the cavity or at the outlet.
The preconditions are;fully dilated cervix,no mechanical
obstruction,no uterine scare,mother should not be grand
multi-parous-
Types of vaginal breech delivery
1. Spontaneous breech delivery
 operator simply supports the body as it delivers
 Thick meconium passage is common as the breech is
squeezed through the birth canal. This usually is not
associated with meconium aspiration because the
meconium passes out of the vagina and does not mix
with the amniotic fluid
Mechanism of labor

Engages with bitrochanteric diameter (9.5cm)

transverse → descent → internal rotation &
bitrochanteric diameter lies anteroposteriorly
(sacrum transverse) → born by lateral flexion of
the trunk →External rotation (sacrum ant).
Crowning occurs when bitrochanteric diameter
passes under the pubic symphysis.
Breech typically enters the inlet with the bitrochanteric diameter aligned with one of
the diagonal diameters, with the sacrum as the point of designation in the other
diagonal diameter. This is a case of left sacrum posterior (LSP).
With labor and descent, the bitrochanteric diameter generally rotates toward the
anteroposterior axis and the sacrum toward the transverse
Contin..
Shoulders: enter pelvis with bisacromial diameter
transverse, rotate through 90° emerging in the
oblique/AP diameter.
Head: enters pelvis with sagittal suture transverse
and rotates 90°.
anesthesia
spontaneous breech delivery in multipara - only
intravenous analgesia for pain relief during labor
and pudendal anesthetic during delivery.
partial breech extraction, including application of
Piper forceps to aftercoming head – Epidural
emergency circumstances - inhalation anesthesia
or intravenous nitroglycerin
Assisted breech delivery.
Should be employed in all cases.
Patient kept in lithotomy position and bladder
emptied.
Vaginal examination to ascertain full cervical
dilatation,presence of cord prolapse.
Do episiotomy when the fetal anus is visible and
perineum distended.
Wait with out intervention till body is born to the
level of the umbilicus.
 Assisted breech delivery .
1-delivery of the legs -sweep the legs away from the
midline or pressure on the popliteal fossae in manner
of abduction and flexion of the thighs.
Grasp the fetal anterior superior iliac spine and the
sacrum using cloth towel moistened with warm water.
Gentle, steady down ward traction till the lower
halves of the scapula delivered.
Rotate the trunk to bring the back anteriorly.
2-Delivery of the arms when the axilla is visible by
hooking down each elbow with a finger.
Pinard maneuver

used in case of a frank breech presentation to

deliver a foot into the vagina
Delivery of the shoulder.
Attended by one of the two methods.
1-When the scapula is visible the trunk is rotated in
a way that allows the anterior shoulder, the arm to
appear at the vulva and can easily be released and
delivered first; then rotate in the reverse direction
to deliver the other shoulder and arm.
2-If the trunk rotation unsuccessful the posterior
shoulder must be delivered first by elevating the
trunk and anterior shoulder by depressing the body.
making the baby chest to wards mothers thigh
As breech extraction continues, the scapulas becomes
visible and the body rotates, usually to the side of the
mother to which it was originally directed
As breech extraction continues, upward traction is
employed, effecting delivery of the posterior shoulder. This
is followed by delivery of the posterior arm (inset).
Delivery of the head .
Most crucial stage of delivery.
The time interval between delivery of the umbilicus to
delivery of the mouth should preferably be 5-10
minutes.
There are several methods ;each one is safe and
effective at the hands of an expert.
contin..
1-MaurieauSmellieViet[MSV].
-Fetal body lies on the palm of the hand.
-The index and middle finger applied over the maxilla to
keep the head flexed.
-The two fingers of the other hand are hooked over the fetal
neck.
-Grasping the shoulder,gentle down ward traction until the
sub occipital region become visible under symphysis pubis.
-Gentle supra-pubic pressure to keep the head flexed.
-The body of the fetus is then elevated to mothers abdomen.
Delivery of the aftercoming head using the MSV maneuver. Note that
as the fetal head is being delivered, flexion of the head is maintained
by suprapubic pressure provided by an assistant, & simultaneously by
pressure on the maxilla (inset) by the operator as traction is applied
Contin..
2-modified Prague maneuver;
-Used when the back of the fetus fails to rotate
anteriorly.
-Grasp the shoulder of back down fetus from below
with two fingers of one hand while the other hand
draws the feet up over the mothers’ abdomen.
two fingers of one hand grasping the shoulders of the back-
down fetus from below while the other hand draws the
feet up over the maternal abdomen
 contin..
3-Burn’s marshal maneuver:-
-Baby allowed to hang by its own weight.
-supra-pubic pressure in downward and back ward
direction.
-No more than 1-2 minutes.
-When the nape of the neck is visible under the pubic
arc the baby is grasped by the ankles with fingers in
between.
-Steady traction and forming wide arc of the circle and
the trunk is swung in upward and forward direction.
Contin..
4-Bracht maneuver-only support after delivery of the
body.
5-Forceps delivery for after coming head.
-Piper forceps is usually used
-Could be applied electively or after MSV maneuver.
A. The fetal body is elevated using a warm towel and the left blade of
the forceps is applied to the aftercoming head. B. The right blade is
applied with the body still elevated. C. Forceps delivery of the
aftercoming head.
 Piper forceps

Reverse pelvic curve

 MANAGEMENT OF DIFFICULTIES DURING VBD.

1. Arrest of delivery of the legs

-Frank breech extraction by intra uterine manipulation to
convert frank breech to footling breech-PINNARD
maneuver.
Pinard maneuver

used in case of a frank breech presentation to

deliver a foot into the vagina
 MANAGEMENT OF
DIFFICULTIES DURING VBD
2. Extended arms and difficult to deliver the shoulder;
-Loveset’s –The baby is lifted slightly to cause lateral
flexion ,the trunk is rotated through 1800 keeping the back
anterior and maintaining a down ward traction, this will
bring the posterior arm to emerge under the pubic arch
which is then hooked out.
The trunk is then rotated in the reverse direction keeping
the back anterior to deliver the anterior shoulder under the
symphysis pubis.
Clockwise rotation of fetal pelvis 1800 brings the sacrum from anterior
to LST. Simultaneously, the application of gentle downward traction
effects delivery of the scapula
Counterclockwise rotation from SA to RST along with gentle
downward traction effects delivery of the right scapula
Difficulties during VBD.
3-Nuchal arms
-Attempt rotation in a direction to bring the arms anterior.
-Manual delivery like in pinnard maneuver for the
leg.
4-Arrest of the after coming head by incompletely
dilated cervix;
Try to slip it manually
Try Bracht maneuver
Duherssen’s incision.
Reduction of nuchal arm being accomplished by rotating the
fetus through 1800 counterclockwise so that the friction
exerted by the birth canal will draw the elbow toward the face
Dührssen incisions at 10 (already cut) & 2 o'clock (being cut with
bandage scissors) to relieve entrapped aftercoming head. Infrequently,
an additional incision is required at 6 o'clock. The incisions are so placed
as to minimize bleeding from the laterally located Cx branches of the
uterine artery. After delivery, the incisions are repaired
Contn…
5-Arrest of after coming head at pelvic inlet
causes includes ,deflexed head,hydrocephalus,CPD
o Management -MSV
-CEPHALOCENTASIS
-ZAVALLENI MANUAVER
-SYMPHYSIOTOMY
 Total breech extraction
 For complete/ footling
presentation grasp both feet and
apply gentle downward pressure
(direct AP diameter) until buttocks
are delivered.
 Then gently grasp fetal pelvis,
with both thumbs placed directly
on either side of sacrum. The spine
rotated until it rests under pubic
symphysis. Gentle, firm downward
pressure applied to body until both
scapulas are visible.
 Cont.
 If fetus is in frank breech
presentation, index finger of
right hand placed into anterior
groin of fetus and gentle
downward pressure applied.
then left index finger inserted
into posterior groin, and gentle
downward traction applied,
until buttocks are delivered
through vaginal introitus. fetus
gently rotated until spine rests
directly under pubic symphysis.
 Cont.
 Breech decomposition
accomplished by Pinard
maneuver - To deliver
extended legs, place
index finger in popliteal
fossa of 1 leg and apply
pressure upward and
outward, causing knee
to flex -foot is seen or
easily palpated.
Delivery of the trunk
A cardinal rule in the successful breech extraction
is to employ steady ,gentle ,down ward traction
until the lower half of the scapulas are delivered
outside the vulva, making no attempt at delivery of
the shoulders and arms until one axilla becomes
visible.
Premature aggressive traction causes deflexion of
the fetal vertex and increases risk of entrapment
of the head and entrapment of the nuchal arms.
Delivery of breech with 1 finger in the groin. The wrist is supported
with the other hand. When the posterior groin is accessible, the index
finger of the other hand is placed in the groin to complete delivery of
the breech
Flexion and abduction of the thigh to deliver extended leg
Complications of breech delivery.
 Increased perinatal and maternal mortality and
morbidity.
 LBW and IUGR.
 Cord prolaps 15% in footling and 5% in complete
breech presentation.
 Increased operative interventions especially C/S
delivery.
 Fetal congenital anomalies.
 CONTI..

Maternal Morbidity
↑ed operative delivery, genital tract lacerations, rupture of
the uterus, lacerations of the cervix and vaginal walls,
extensions of episiotomy and deep perineal tears, uterine
atony(anesthesia) and postpartum hemorrhage, infection.
maternal mortality
 Schutte and colleagues (2007) reported deaths of four

women as a result of elective cesarean delivery - a case

fatality rate of 0.47 maternal deaths per 1000 births.
contin..
Perinatal Morbidity and Mortality
Due to preterm delivery, congenital anomalies,
and birth trauma.
at every stage of gestation, neonatal deaths
were significantly greater among breeches.
Fractures
Brachial plexus injury
Genital injury….
 Contin..
o In 2000, international multicenter randomized clinical trial
(Term Breech Trial)
 perinatal/ neonatal mortality and serious morbidity were
significantly lower in planned cesarean delivery (17/1,039
[1.6%] versus 52/1,039 [5%]), no difference in maternal
morbidity or mortality observed.
 the American College of Obstetricians and Gynecologists’
Committee on Obstetric Practice in 2001 recommended that
planned vaginal delivery of a term singleton breech was no
longer appropriate.
Cont..
 follow-up studies - At 3 months postpartum, risk of
urinary incontinence was lower for women in planned
cesarean delivery group but no difference at 2 years.
 At 2 years postpartum, maternal morbidity, was not
different for most maternal parameters, including
breast feeding, pain, depression, menstrual problems,
fatigue, and distressing memories of the birth
experience .
Cont..
 Follow up study to address the outcome of children at
age of 2 years was done at 85 of the original centers
 risk of death or neurodevelopmental delay was no
different among the planned c/s and vaginal delivery
(14 children [3.1%] versus 13 children [2.8%]
 retrospective reports - 298 & 481women in a vaginal
breech trial with no perinatal morbidity and mortality .
 Although they are not randomized trials those reports
detailed the outcome of specific management
protocols and potential safety of VBD in properly
selected patients
Impact of TBT
o Reitberg and associates recently published a
compelling paper reporting on the effects that the
publication of the Term Breech Trial had on medical
practice and neonatal outcome in the Netherlands.
Within 25 months of publication, the overall cesarean
rate for breech presentation increased from 50% to
80%.
o USA-87% in2004
Cont..
 In 2004, the Term Breech Trial authors reported the risk
of death and neurodevelopmental delay of the children 2
years after delivery. Those authors concluded that
planned cesarean delivery is not associated with a
reduction in the risk of death or neurodevelopmental
delay in children at 2 years of age. Their follow-up data
showed that the benefits of planned cesarean delivery are
limited to reducing perinatal and neonatal mortality and
serious neonatal morbidity during the first 6 weeks of
life.
 Many European studies also confirms on safety of VBD
in properly selected patients!
Cont..
 The ACOG issued Committee Opinion No. 340 in July
2006, which recommends that the decision regarding
mode of delivery should depend on the experience of
the health care provider. Before a vaginal breech
delivery is planned, women should be informed that
the risk of perinatal or neonatal mortality or short-term
serious neonatal morbidity may be higher than if a
cesarean delivery is planned and the patient's informed
consent should be documented.
ACOG recommendations
1-The decision regarding the mode of delivery should
depend on the experience of the health provider
2-Obstetrician should offer and perform ECV whenever
possible
3-Planned VBD may reasonable under hospital specific
protocol guidelines for both eligibility and labor
management
4-In those situations in which VBD is pursued great care
should be exercised and detailed informed consent
should be documented
Conti..
5-Before embarking planned VBD the women should be
informed about perinatal and neonatal mortality and
serious early neonatal morbidity may be higher than
c/s delivery
6-There is no recent data to support the recommendation
of c/s delivery to those patients whose second twin is
non vertex
Premature breech presentation
 There is no adequate data regarding mode of delivery
 However cesarean delivery is preferable for the
premature breech.
FINALLY
 in developing countries where there are poor facilities
for anesthesia, blood transfusion and aseptic
conditions etc, a policy of caesarean section for all
breech presentations would increase the risk to women
as well as put them at greater risk in their future
pregnancies due to the presence of the scar in the
uterus. Thus, in some settings the risk of caesarean
section may outweigh the risk of vaginal birth.
 for every infant saved by c/s, there was one uterine
rupture in subsequent pregnancy(VBAC)
Contin.
 The number of additional caesarean sections necessary
to avoid having one dead or compromised infant was
around seven in countries with a low perinatal
mortality rate and 39 in countries with a high perinatal
mortality rate. Thus, the resource implications of
performing more caesarean sections in these countries
are greatest
references
 Williams obstetrics 23th edition
Gabe obstetrics
Current diagnosis and treatment 10th edition
Danforth obstetrics and gynecology
ACOG practical bulletin, number 340,july 2006
Up-to-date 19.1
madscape
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