Breech

DR PREETI F LEWIS
ASSOCIATE PROFESSOR/ HOU
GGMC MUMBAI
Pre assesment test
MCQ 1. Score used for trial of labor in breech ?
a) Zatuchini Anderos Score
b) Bishop score
c) Carpeg score
d) Apgar score
MCQ 2 Identify the instrument given below :

A) keillands forceps

B) pipers forceps

C) Simpson forceps

D) Elliot tucker forceps

Objectives
Definition

Classification

Mechanism of labor

Management of delivery of breech presentation

Arrest in breech presentation and assisted breech delivery

Definition
Lie: longitudinal

Fetal pelvis is the leading pole

Denominator : sacrum

A right sacrum anterior (RSA) is a breech presentation where the fetal sacrum is in the right anterior
quadrant of the mother’s pelvis.
The bi trochanteric diameter of the fetus is in the right oblique diameter of the pelvis
Incidence
20 % at 28 weeks i.e 1 in 5 pregnant women

5% at 34 weeks

3 to 4 % at term

Thus 3 out of 4 spontaneous correction into cephalic presentation occurs by 34 weeks

Most common cause of breech presentation: prematurity.

Spontaneous version till 36 weeks due to:

A) fetal kicking movements

B) AF volume

C) Fetal size
Comfortable for fetus:

Hydrocephalus – big head occupies fundus

Placenta previa

Contracted pelvis

Cornufundal attachment of placenta (decrease in space in the fundus small head sits in the fundus)

Undue fetal mobility:

Spontanoeous version is transient.

Polyhydrominos

Multipara (lax abdominal wall)

Fetal abnormality:

Trisomies

Myotonic dystrophy
Recurrent breech (habitual breech)

When breech recurs in three or more consecutive pregnancies.

Causes:

Septate uterus

Bicornuate uterus

Recurrent cornu fundal attachment of placenta.

Classification
Diagnosis
Right sacrum anterior
Mechanism of labor in breech
Cephalic and breech presentations are similar to triangles.

When the head presents, the base of the triangle leads the way:

The largest and most unyielding part of the baby comes first, and the parts that follow are
progressively smaller.
When the breech presents, on the other hand, the apex of the triangle comes first, and the succeeding
parts are progressively bigger, with the relatively large head being last.
In breech presentations, there are three mechanisms of labor:

(1) the buttocks and lower limbs

(2) the shoulders and arms

(3) the head.

Mechanism of labor : RSA
Descent: Engagement has been achieved when the bitrochanteric diameter has passed through the inlet
of the pelvis.

In RSA, the sacrum is in the right anterior quadrant of the maternal pelvis

The bi-trochanteric diameter is in the right oblique diameter of the pelvis.

Because the breech is a less efficient dilator than the head, descent is slow, and the breech may remain
high until labor has been in progress for some time.
Flexion: To facilitate passage of the breech through the pelvis, lateral flexion takes place at the waist.

The anterior hip becomes the leading part.

When the breech is frank, the baby’s legs act as a splint along the body and, by reducing lateral flexion
and maneuverability, may prevent descent into the pelvis.
Internal Rotation of Breech.

The anterior hip meets the resistance of the pelvic floor and rotates forward, downward, and toward the
midline.

The bitrochanteric diameter rotates 45° from the right oblique diameter of the pelvis to the
anteroposterior (AP).

The sacrum turns away from the midline, from the right anterior quadrant to the right transverse (RSA
to RST)
Birth of the Buttocks by Lateral Flexion:

The anterior hip impinges under the pubic symphysis, lateral flexion occurs, and the posterior hip rises
and is born over the perineum.

The buttocks then fall toward the anus, and the anterior hip slips out under the symphysis.
Mechanism of shoulder and arms
Engagement.

Engagement of the shoulders takes place in the

right oblique diameter of the pelvis as the
sacrum rotates RST to RSA
Internal Rotation of the Shoulders.

The anterior shoulder rotates under the symphysis, and the bisacromial diameter turns 45° from the
right oblique to the AP diameter of the outlet.

The sacrum goes along, RSA to RST.

Birth of Shoulders by Lateral Flexion.

The anterior shoulder impinges under the symphysis, and the posterior shoulder and arm are born over
the perineum as the baby’s body is lifted upward.

The baby is then lowered, and the anterior shoulder and arms pass out under the symphysis
Management of delivery of breech
Classification of breech deliveries:
Elective Cesarean Section The following factors are unfavorable for safe vaginal delivery, and cesarean section may be best.

1. Poor obstetrical histories, such as a difficult delivery or a damaged baby

2. Contracted, borderline, or abnormal pelvis

3. Placental insufficiency, including IUGR, diabetes mellitus, and hypertensive disorders 4. Preterm rupture of the membranes or
preterm labor

5. Placenta previa of any degree

6. Prolapse of the umbilical cord, especially in footling breeches

7. Small baby (4000 g)

9. Hyperextension of the fetal head

10. Footling breech. The limbs and pelvis of the footling breech deliver easily but do not dilate the maternal soft parts sufficiently to
make room for the after-coming head. This may make delivery of the head difficult, especially in premature infants
Trial of labor: Zatuchini Anderos
Score
Prognostic score for vaginal delivery in breech presenation at term.

Based on 6 clinical variables

If score less than 4 accurately predict poor outcomes -> poor

Delivery of breech
1. The patient is encouraged to bear down with the contractions but must rest between them

2. As long as there is no fetal or maternal distress, spontaneous delivery to the umbilicus is awaited. Up to this point,
there is no urgency, and the operator should not interfere

3. Once the umbilicus has been delivered, time becomes an important factor, and the remainder of the birth is expedited
gently and skillfully. A free airway to the mouth should be available within 3 to 5 minutes to obviate anoxic brain
damage

4. The legs usually deliver spontaneously; if not they are easily extracted. Do not extract the legs until the popliteal
fossae are visible (Pinard’s maneuver)

5. The baby is covered with a warm towel, and the body is supported

6. A loop of umbilical cord is pulled down to minimize traction on it in case it is caught between the head and the pelvic
wall. At the same time, it is palpated for pulsations.
Delivery of the Shoulders and Arms

1. The assistant exerts suprapubic pressure on the head to maintain its flexion

2. The operator depresses the buttocks and delivers the body to the anterior scapula so that the anterior
shoulder comes under the symphysis

3. To deliver the anterior arm, the accoucheur passes his or her hand up the baby’s back, over the shoulder, and
down the chest, thus sweeping the arm and hand out under the pubis with his or her finger (Loveset maneuver)

4. The baby is raised so that the posterior scapula and then the posterior arm are born over the perineum by the
same maneuver.

5. Some obstetricians deliver the posterior arm first

Delivery of the Head

1. In almost every case, the back turns anteriorly spontaneously. This must be encouraged so that the
head rotates the occiput to the pubis and the face toward the sacrum. Rarely, there is a tendency for the
back to turn posteriorly.

The obstetrician must counteract this and rotate the back anteriorly to prevent the head’s rotating face
to pubis, a serious and always avoidable complication

2. Once the back has rotated anteriorly and the fetal head is in the AP diameter of the pelvis, the body
is lowered so that the occiput appears under the symphysis and the nape of the neck pivots there.
3. At the same time, the assistant maintains suprapubic pressure to guide the head through the pelvis
and to keep it flexed

4. The body is then raised gently so that there is slight extension at the neck

5. Then by further suprapubic pressure (Kristellar maneuver, also known as Bracht maneuver) the
head is delivered in flexion—the chin, mouth, nose, forehead, bregma, and vertex being born, in that
order, over the perineum.

6. The speed of delivery of the after-coming head must be considered. The rapid passage of the head
through the pelvis causes sudden compression and decompression of the cranial contents. In the
extreme, the ligaments of the brain tear, leading to hemorrhage, cerebral damage, and death. On the
other hand, too slow delivery of the head results in asphyxia, which may also be fatal.
Arrest in breech presentation
Arrest of head:

Maneuver's :

Wigand-Martin Maneuver

The body of the baby is placed on the arm of the operator with the middle finger of the hand of that arm placed in the
baby’s mouth and the index and ring fingers on the malar bones.

The purpose of the finger in the mouth is not for traction but to encourage and maintain flexion.

With the other hand, the obstetrician exerts suprapubic pressure on the head through the mother’s abdomen

The baby is raised so that the posterior scapula and then the posterior arm are born over the perineum by the same
maneuver.

Some obstetricians deliver the posterior arm first

Mauriceau-Smellie-Veit Maneuver

The position is the same as the Wigand-Martin maneuver, with one finger in the baby’s mouth and two
on the malar bones.

The difference is that the accoucheur places his or her other hand astride the baby’s shoulders and
produces traction in this way.

The efficiency of this procedure is increased by an assistant’s applying suprapubic pressure on the fetal
head while the operator is performing the Mauriceau maneuver
Piper forceps
Piper Forceps on the After-Coming Head With the exception of simple suprapubic pressure, the best
method of delivering the after-coming head is by the use of the Piper forceps.

In contrast to maneuvers in which traction on the head is applied through the neck, the forceps exert
traction directly on the head, thereby avoiding damage to structures in the baby’s neck.

Although any type of forceps can be used for this procedure, the Piper forceps, which was designed
especially for this operation, is best.

The handles are depressed below the arch of the shanks, the pelvic curve is reduced, and the shanks are
long and curved.

These features make this instrument easier to apply to the after-coming head.
Application of Forceps
1. The baby’s feet are grasped by an assistant, and the body is raised. Care must be taken not to elevate the body too much for
fear of damage to the sternomastoid muscles. The lower and upper limbs and the umbilical cord are kept out of the way. A
good way to keep the arms out of the way is to use a folded towel as described by Savage

2. The handle of the left blade is grasped in the left hand

3. The right hand is introduced between the head and the left postero-lateral wall of the vagina

4. The left blade is then inserted between the head and the fingers into a mentooccipital application

5. The fingers are removed from the vagina, and the handle is steadied by an assistant

6. The handle of the right blade is grasped with the right hand

7. The left hand is introduced between the head and the right postero-lateral wall of the vagina

8. The right blade is introduced between the head and the fingers into a mentooccipital application

9. The fingers are removed from the vagina

10. The forceps are locked and vaginal examination is made to be certain that the application is correct
Extraction of the Head
1. Traction is outward and posterior until the nape of the neck is in the subpubic angle

2. The direction is then changed to outward and anterior, and the face and forehead are born over the
perineum in flexion

3. An episiotomy should be used

When there is delay in delivery of the head and one is waiting for help or instruments, an ordinary
vaginal retractor can be used temporarily to clear an airway in the vagina to the baby’s mouth . The
retractor is placed in the vagina and pressure exerted posteriorly. The vaginal contents are sponged out
so that air can get to the baby if he or she breathes.
Chin to pubis rotation
Anterior rotation of the chin is rare and occurs usually as part of posterior rotation of the back. The
preferred management is as follows:

(1) Institute deep anesthesia.

(2) Cease all traction.

(3) Dislodge the chin from behind the pubis.

(4) Rotate the face posteriorly and the back anteriorly.

(5) Flex the chin.

(6) Effect engagement by suprapubic pressure.

(7) Deliver the head with Piper forceps.

When this technique fails, the Prague maneuver may be used.

Here the fingers are placed over the shoulders, and outward and upward traction is made. The legs are
grasped with the other hand, and the body is swung over the mother’s abdomen. With this procedure,
the occiput is born over the perineum.

Because this method carries with it the danger of overstretching or breaking the infant’s neck, it is used
rarely.
Prague manuvere
Duhrssen incision
Duhrssen`s incision

If the fetus is preterm and the cervix is effaced, but incompletely dilated, the cervical os can be
surgically enlarged– At 2,10,6 o’clock– Rarely don
Post assessment
MCQ 1. Score used for trial of labor in breech ?
a) Zatuchini Anderos Score
b) Bishop score
c) Carpeg score
d) Apgar score
MCQ 2 Identify the instrument given below :

A) keillands forceps

B) pipers forceps

C) Simpson forceps

D) Elliot tucker forceps