THE WHITE ARMY

OBSTETRICS AND GYNECOLOGY

BREECH PRESENTATION
 INDEX
• INCIDENCE
• TYPES
• RISK FACTORS
• DIAGNOSIS
• ANTENATAL MANAGEMENT
• EXTERNALCEPHALIC VERSION
• SELECTION OF PROCEDURE AND DECISION MAKING
• LABOUR MANAGEMENT
• COMPLICATION
• Breech presentation :COMMONEST
MALPRESENTATION.
Lie: Longitudinal
Podalic pole occupies the pelvic brim.
Incidence:
20%-28th week
5%-34th week
3-4%-At term
 TYPES:

1.FRANK BREECH
2.COMPLETE(FLEXED BREECH)
3.INCOMPLETE BREECH:
1.FRANK BREECH:
Flexed at hip, extended at the knee.
Feet lie close to the head.
Presenting part consists of buttocks and external genitalia only.
Commonly seen in primigravidae.
2.COMPLETE(FLEXED BREECH):
Both hips flexed, one or both knees flexed
commonly present in multiparae.
Presenting part: Buttocks, external genitalia, feets.
3.INCOMPLETE BREECH:
One or both hips extended. One or both knees or feet lie lowermost in
birth canal.
Footling/kneeling can be seen.
Chances of cord prolapse :High
 CLINICAL CLASSIFICATION

• Uncomplicated
• Complicated
Note: The difference between complicated breech and
complicated breech delivery.
 ETIOLOGY AND FACTORS RESPONSIBLE
FOR BREECH PRESENTATION
• Prematurity: Commonest cause of breech presentation.
• Factors preventing spontaneous version.
• Favorable adaptation.
• Undue mobility of the fetus.
• Fetal abnormality.
Note: Recurrent breech or habitual breech.
 FIVE POSITIONS
Sacrum is the denominator of breech:
In anterior position: Sacrum is directed toward iliopubic eminences.
In posterior positions:Sacrum is directed to sacroiliac joints.
1. First position: Left sacroanterior(LSA):Being the most common.
2. Second position :Right sacroanterior (RSA)
3. Third position :Right sacroposterior (RSP)
4. Fourth position :Left sacroposterior (LSP).
5. Sacrum transversus.
 ANTENATAL MANAGEMENT
1. Identification of the complicating factors related with
breech presentation.
2. External cephalic version, if not contraindicated.
3. Formulation of the line of management, if the version
fails or is contraindicated.
DIAGNOSIS
DIAGNOSIS OF BREECH PRESENTATION
CLINICAL
SONOLOGICAL
 EXTERNAL CEPHALIC VERSION
Prerequisites:
• Facility for emergency cesarean delivery.
• Sonographic assessment
• Intravenous access
• Nil per oral- 6hours
• Cardiotocography (CTG) should ideally be done before and after the
procedure.
• Anti-D immunoglobulin if needed
• Tocolysis and regional analgesia
• The woman is placed in left lateral tilt to aid uteroplacental perfusion
• Trendelenburg positioning helps during elevation of the breech
Time of version: 36 weeks on wards.
 TECHNIQUE

• A forward roll of the fetus usually is attempted first.

• One or two providers may participate, and one hand grasps
the head.
• The fetal buttocks are then elevated from the maternal
pelvis and displaced laterally .
• The buttocks are then gently guided toward the fundus,
while the head is simultaneously directed toward the pelvis.
• If the forward roll is unsuccessful, a backward flip is
attempted.
• ECV attempts are discontinued for excessive discomfort,
persistently abnormal fetal heart rate, or after multiple
failed attempts. Failure is not always absolute.
• If ECV is successful, a nonstress test is repeated until a
normal test result is obtained.
• If version is completed before 39 weeks gestation, then
awaiting spontaneous labor and fetal maturity is preferred.
• In some studies, immediate labor induction is linked to
higher cesarean delivery rates.
• CAUSES OF FAILURE OF VERSION:
(1) Breech with extended legs—early engagement of
presenting part and difficult to flex the trunk because of
splinting action of the limbs.
(2) Scanty liquor or big size baby.
(3) Mechanical—obesity, increased tone of the abdominal
muscles and irritable uterus.
(4) Short cord—either relative (common) or absolute.
(5) Uterine malformations—septate or bicornuate
• BENIEFITS OF VERSION
(i) Reduction in the incidence of
breech presentation at term.
(ii) Reduction in the incidence of
breech delivery
(iii) Reduction in the incidence of
cesarean delivery by 5%.
• DANGERS OF VERSION
(1) Premature onset of labor,
(2) Premature rupture of the
membranes.
(3) Placental abruption and
bleeding,
(4) entanglement of the cord round
the fetal part or formation of a true
knot leading to impairment of fetal
circulation and fetal death
(5) Increased chance of
fetomaternal bleed.
(6) Amniotic fluid embolism.
• SUCCESSFUL VERSION IS LIKELY IN CASES OF:
(i) Complete breech
(ii) Nonengaged breech
(iii) Sacroanterior position (fetal back anteriorly)
(iv) Adequate liquor
(v) Non obese patient.
FORMULATION OF THE LINE OF MANAGEMENT,
IF THE VERSION FAILS OR IS CONTRAINDICATED

Take into consideration:

• Age of the mother especially in primigravidae
• Associated complicating factors
• Size of the baby
• Pelvic capacity
• Clinical and radiological assessment
• Plan to perform an elective cesarean section OR
• To allow spontaneous labor to start and vaginal breech
delivery to occur.
Vaginal breech delivery: Criteria to be fulfilled
1. Average fetal weight (between 1.5 kg and 3.5 kg)
2. Flexed fetal head
3. Adequate pelvis
4. Without any other (medical or obstetric) complications,
5. Availability of facilities for emergency cesarean section
(anesthetists, neonatologist)
6. Facilities for continuous labor monitoring (preferably electronic)
7. Presence of obstetrician experienced with vaginal breech
delivery
8. Informed consent.
Frank breech is preferred.
 FIRST STAGE:
• Vaginal examination :(a) At the onset of labor for pelvic assessment
(b) Soon after rupture of the membranes to exclude cord prolapse.
• An intravenous line is sited with Ringer’s solution, oral intake is
avoided, blood is sent for group and cross matching (considering the
chance of CS).
• Adequate analgesia is given, epidural is preferred.
• Fetal status and progress of labor are monitored.
• Oxytocin infusion may be used for augmentation of labor.
• Indications of Cesarean Section (CS):
1. Cases seen for the first time in labor with presence of complications
2. Arrest in the progress of labor
3. Non-reassuring FHR pattern (Fetal distress)
4. Cord presentation or prolapse.
 SECOND STAGE:
• Spontaneous breech delivery
• Assisted breech delivery
• Partial /Complete breech extraction
 SPONTANEOUS BREECH DELIVERY

• Engaging diameters :
o Buttock:Bitrochanteric diameter(10cm).
o Shoulder:Bisacromial diameter (12cm)
o Head:Suboccipitofrontal diameter (10 cm).
• Engagement and descent occurs through bitrochanteric diameter in one of the
oblique diameter of the pelvis.
• The anterior hip descends more rapidly than the posterior hip.
• Internal rotation of 45 degrees .
• Anterior hip toward the pubic arch and the bitrochanteric diameter to occupy
the anteroposterior diameter of the pelvic outlet.
• Descent continues: Anterior hip appears at the vulva.
• Lateral flexion of the fetal body-breech is born.
• Followed by legs and feet.
• External rotation, with the back turning anteriorly as the shoulders are brought
into relation with one of the oblique diameters of the pelvis.
• The shoulders then descend rapidly and undergo internal rotation, with the
bisacromial diameter occupying the anteroposterior plane.
• The head enters the pelvis in one of the oblique diameters and then rotates to
bring the posterior portion of the neck under the symphysis pubis.
• The head is then born in flexion.
ASSITED BREECH DELIVERY
 PREREQUISITES:

1. Skilled provider
2. Anesthetist
3. An assistant
4. Instruments and suture materials for episiotomy.
5. A pair of obstetric forceps for the aftercoming head.
6. Appliances for resuscitation of the baby, if asphyxiated.
7. Neonatologist
PRINCIPLES IN CONDUCTION:
(1) Never to rush
(2) Never pull from below but push from above
(3) Always keep the fetus with the back anteriorly.
STEPS:
Delivery of breech
Delivery of arms
Delivery of after coming head
Resuscitation of the baby.
 STEPS:
• The patient is brought to the table when the anterior
buttock and fetal anus are visible.
• She is placed in lithotomy position.
• To avoid aortocaval compression, the woman is tilted
laterally (15°) using a wedge under the back.
• Antiseptic cleaning is done, bladder is emptied with an “in
and out” catheter.
• The patient is encouraged to bear down as the expulsive
forces from above ensure flexion of the fetal head and safe
descent.
• The “no touch to the fetus” policy is adopted until the
buttocks are delivered along with the legs in flexed breech
and the trunk slips up to the umbilicus.
• Soon after ,the trunk up to the umbilicus is born following
are to be done.
• The extended legs (in frank breech) are to be decomposed
by pressure on the knees (popliteal fossa) in a manner of
abduction and flexion of the thighs.
• The umbilical cord is to be pulled down and to be mobilized to
one side of the sacral bay to minimize compression.
• There may be transient abnormality in cord pulsation at this
stage which has got no prognostic significance.
• An attempt of hasty delivery for this reason alone should be
avoided.
• If the back remains posteriorly, rotate the trunk to bring the
back anteriorly (sacroanterior).
• The baby is wrapped with a sterile towel to prevent slipping
when held by the hands and to facilitate manipulation, if
required.
DELIVERY OF THE ARMS
 DELIVERY OF THE AFTERCOMING HEAD:

• This is the most crucial stage of the delivery.

• The time between the delivery of umbilicus to delivery of
mouth should preferably be 5–10 minutes.
MANAGEMENT OF COMPLICATED
BREECH DELIVERY
 1.DELAY IN DESCENT OF THE BREECH.

1.At the outlet:

Management: If the outlet is contracted and/or the baby is
big, cesarean section even at this stage, is the method of
choice. In the absence of outlet contraction and feto-pelvic
disproportion: Liberal episiotomy and fundal pressure
2.Arrest of the breech at or above the level of ischial spines:
Management: Cesarean section
 2.FRANK BREECH EXTRACTION

Pinard’s maneuver is done by intrauterine manipulation (for

breech decomposition) to convert a frank breech to a footling
breech. This is possible when the membranes have ruptured
recently.
In Pinard’s maneuver, the middle and the index fingers are
carried up to the popliteal fossa. It is then pressed and
abducted so that the fetal leg
is flexed. The fetal foot is then grasped at the ankle and
breech extraction is accomplished.
 3.EXTENDED ARMS

1. CLASSICAL:
2. LOVSET’S MANEUVER:
 4.ARREST OF THE AFTER COMING HEAD
HOW TO MANAGE THE SAME.

• AT THE BRIM:
• AT THE CAVITY
• AT THE OUTLET
1.At the brim:
(1) Deflexed head
(2) Contracted pelvis
(3) Hydrocephalus.
Mx:
(1) If the arrest is due to a deflexed head, the delivery is to be
completed by malar flexion and shoulder traction along with
suprapubic pressure by the assistant. The head is to be negotiated
through the brim in the transverse diameter and rotated in the cavity.
Forceps should not be applied in high head.
(2) If the arrest of the head is due to contracted pelvis
or hydrocephalus, perforation of head is to be done .
2. In the cavity:
(1) Deflexed head
(2) Contracted pelvis.
• Mx: Delivery of the head by forceps which is effective in both the
circumstances. Malar flexion and shoulder traction may be
effective only in deflexed head.
3. At the outlet:
(1) Rigid perineum
(2) Deflexed head.
• Mx: Episiotomy followed by forceps application or malar flexion
and shoulder traction is quite effective.
 5.DELIVERY OF THE HEAD THROUGH AN
INCOMPLETELY DILATED CERVIX
1.Premature baby
2.Macerated baby
3.Footling presentation
4.Hasty delivery of breech before the cervix is fully dilated.
Management:
• If the baby is living, the cervix is to be pushed up while traction of
the fetal trunk is made by malar flexion and shoulder traction
(shoe-horn method).
• If necessary, Duhrssen’s incision can be made at 2 and10 O’ clock
position on the cervix.
• If the baby is dead, perforation of the head is better than watchful
expectancy, hoping for full dilatation of the cervix.
 THIRD STAGE OF LABOUR
• Watch for any complications:
COMPLICATIONS Mother Baby
OF BREECH • Trauma to the • Intrapartum fetal
DELIVERY genital tract. death specially
with preterm
• Operative vaginal babies.
delivery • Injury to brain
(episiotomy, and skull.
forceps).
• Birth asphyxia.
• Cesarean section • Birth Injuries.
• Sepsis • High incidence of
• Anesthetic congenital
complications. malformations.
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