ABNORMAL LABOUR:

BREECH AND SHOULDER

DYSTOCIA
ANGELO NYAMTEMA
Learning Objectives
At the end of this session you should be able
to:
1.List types of breech
2.Outline the prevalence of breech presentation
3.Describe the complications associated with breech
and dystocia
4.Manage breech and shoulder dystocia
I. PREVALENCE

Prevalence of breech presentation

varies with gestational age.
 21-24 weeks = 33%
 29-32 weeks = 14%
 At Term = 3-4%
Why breech?
• Perinatal mortality and morbidity
• Increase 2- to 4-fold with breech presentation,
regardless of the mode of delivery.
• Congenital malformation - 6%
• Umbilical cord prolapse
• More prevalent (except with frank breech
presentation)
RISK FACTORS
1. High parity
2. Prematurity
3. Multiple gestation
Due to the limited space in
the uterus
4. Polyhydramnios
5. Oligohydramnios
6. Short umbilical cord
7. Uterine Malformations.
 Septate or bicornuate
uterus.
 Fibroids in the lower part
of the uterus.
8. Fetal abnormalities:
 Malformations of brain, neck
masses etc
 TYPES OF BREECHES

• Frank breech (50-70%)

• Hips flexed, knees extended
• Complete breech (5-10%)
• Hips flexed, knees flexed
• Footling or incomplete (10-30%)
• One or both hips extended, foot
presenting
POSITIONS

SA, SP, LST, RST

LSP, RSP, LSA,
RSA
 DIAGNOSIS OF BREECH

•Palpations and ballottement

•Pelvic exam
•Ultrasound
MANAGEMENT
1. Antepartum: External cephalic version
2. Breech delivery
– Spontaneous breech delivery
– Assisted breech delivery
– Total breech extration
EXTERNAL CEPHALIC VERSION

Success rate approx. 50-80%

VERSION OF BREECH PRESENTATION
• Predictors for success
– Presenting part not engaged
– Normal amount of amniotic fluid
– Fetal back not positioned posteriorly
– Mother not obese
– Facilities for emergency CS are available
– Vaginal delivery is possible

• Contraindications
– Obvious CPD or anomaly
– Surgically scarred uterus
Criteria for VD or CS
1. Vaginal Delivery 2. CS delivery
• Frank • FW<1500 or > 3500gr
• GA >34/40 • Footling
• FW = 2000-3500g • Small pelvis
• Adequate pelvis
• Deflexed head
• Flexed head
• GA = < 34wks
• Nonviable fetus
• Primigravidae
• No indication for CS
• Good progress of labor • Fetal distress
VAGINAL BREECH DELIVERIES

Three types:
1. Spontaneous breech delivery
2. Assisted breech delivery
3. Total breech extration
ASSISTED VAGINAL BREECH DELIVERY
Cardinal rule
Employ steady gentle, downward
traction until the lower halves of the
scapulae are delivered, making no
attempt at delivery of the shoulders
and arms until one axilla is seen.
DELIVERY OF ARMS
Løvset's Manoeuvre (1937)
Involves rotation of the trunk of the foetus during a breech birth to
facilitate delivery of the extended foetal arms and the shoulders.

Deliver the anterior arm

DELIVERY OF THE HEAD

1. Modified Prague Maneuver

•Rotate the back to the anterior
•Two fingers of one hand grasp the
shoulders of the back-down fetus
while the other hand draws the feet
up and over the maternal abdomen
Mauriceau-Smellie-Velt Maneuver
TOTAL BREECH EXTRACTION
Indication: second twin who is in breech presentation
COMPLICATIONS OF BREECH DELIVERY

Maternal complications
1.Entrapment of the aftercoming head
Due to an incompletely dilated cervix (esp preterm breech).
2.Cord Prolapse
3.Inco-ordinate Labor
4.Traumatic Injuries
–deep perineal tears,
–vaginal & cervical lacerations
SHOULDER DYSTOCIA
Definition
The inability to deliver the
fetal shoulders after
delivery of the head,
without the aid of specific
maneuvers (i.e., other than
gentle downward traction
on the head).
Shoulder dystocia results from a size
discrepancy between the fetal shoulders
and the pelvic inlet when:
1. The bisacromial diameter is large
relative to the biparietal diameter
2. Pelvic prim is flat rather than gynecoid
• Prevalence: 0.2 - 2%,
• Risk factors:
• Macrosomia, DM,
multiparity, postterm.
• 50% of SD have no
risk factor

.
 COMPLICATIONS

Maternal (25%) Fetal

1.Postpartum hemorrhage 11% 1.Brachial plexus injuries
2.Vaginal laceration 19% <10%
3.Perineal tears 2nd&3rd 4% 2.Fractures of the humerus
and
4.Cervical laceration 2%
3.Brain hypoxia
MANAGEMENT (Within 5- 7 minutes)

1. Suprapubic pressure
2. McRobert manoeuver
3. Rubin’s manoeuver
5. Deliver the posterior shoulder
6. Woods cockscrew
7. Zavanelli
8. Cleidotomy
9. Symphysiotomy .
McRoberts manoeuvre: X ray pelvimetry study

No increase in pelvic dimensions.

Decrease in the angle of pelvic inclination P=0.001
Straightening of the sacrum P= 0.04%
Tends to free the impacted anterior shoulder

Gherman et al Obstet Gynecol 95:43, 2000

3. Rubin’s Maneuver
4. Delivery of the posterior arm
By inserting a hand into the
posterior vagina and ventrally
rotating the arm at the shoulder

delivery over the

perineum
Management: If Mc Roberts failed
5. Woods manoeuvre
•The hand is placed behind the
posterior shoulder of the fetus.
•The shoulder is rotated progre-
ssively 180° in a corkscrew
manner so that the impacted
anterior shoulder is released.
.
GASKIN MANEUVER: ALL FOURS
POSITION
• The woman is placed on her hands and
knees
• Gravity pushes the posterior shoulder
anteriorly
• The flexibility of the sacro-iliac joints
increases the sagital diameter of the pelvic
inlet and 1-2cm of the pelvic outlet
• It disimpacts the shoulders, allowing it to
slide over the sacral promontory
• The posterior shoulder is delivered first
Zavanelli maneuver
Involves pushing back the
delivered fetal head into the
birth canal in anticipation of
performing a cesarean section.
Indication
Bilateral shoulder dystocia
Mechanism
Involves rotating the fetal head
into a direct occiput anterior
position, then flexing and
pushing the vertex back into the
birth canal, while holding
continuous upward pressure until
cesarean delivery is
accomplished.