BREECH PRESENTATION

DR.Prathibha
 DEFINITION
• BREECH PRESENTATION IS A LONGITUDINAL LIE
WITH FETAL PELVIS AS THE PRESENTING PART.
• THE DENOMINATOR IS THE SACRUM.
• THE ENGAGING DIAMETER IS THE
BITROCHANTERIC DIAMETER.
• MOST COMMON POSITION IS L.S.A.
• IT IS THE MOST COMMON FORM OF
MALPRESENTATION .
• INCIDENCE IS 3-4% AT THE ONSET OF LABOR.
TYPES OF BREECH PRESENTATIONS
• COMPLETE BREECH-
• INCIDENCE 10%
• MOSTLY IN MULTIS

1. INCOMPLETE BREECH-
1.EXTENDED OR FRANK BREECH
2.KNEELING PRESENTATION
3.FOOTLING
PRESENTATION
Frank Complete Footling
 AETIOLOGY
• MATERNAL
• MULTIPARITY
• CONTRACTED PELVIS
• MALFORMATIONS OF UTERUS
PELVIC TUMOURS
• PREVIOUS BREECH
• PLACENTAL
• PLACENTA PREVIA
• CORNUO FUNDAL PLACENTA
• HYDRAMNIOS
• OLIGOHYDROMNIOS
• FETAL
• PREMATURITY
• CONGENITAL FETAL MALFORMATIONS
• HABITUAL OR RECURRENT BREECH-
• CONGENITAL MALFORMATIONS OF THE UTERUS
• REPEATED CORNU FUNDAL ATTACHMENT OF PLACENTA
•
 Positions
• Left sacro-anterior.           
• Right sacro-anterior.
• Right sacro-posterior.           
• Left sacro-posterior.
• Left and right sacro- transverse (lateral).
• Direct sacro-anterior and posterior.
DIFFERENT POSITIONS OF BREECH
 DIAGNOSIS OF BREECH
• ABDOMINAL
EXAMINATION-
FUNDAL GRIP
LATERAL GRIP
PELVIC GRIPS
• FETAL HEART-
HEARD BEST IN THE
UPPER QUADRANT OF
THE ABDOMEN
• ON VAGINAL EXAMINATION
• DURING PREGNANCY-

• PRESENTING PART IS HIGH.

• SOFT AND IRREGULAR

• ANAL ORIFICE AND ISCHIAL TUBEROSITIES ARE IN A

STRAIGHT LINE.

• SOMETIMES A FOOT IS FELT AND MUST BE

DISTINGUISHED FROM A HAND.
• During Labor
• . In addition to the previous findings, vaginal
examination reveals;
• The 3 bony landmarks of breech namely 2 ischial
tuberosities and anal orifice are in a straight line.
• The feet are felt beside the buttocks in complete
breech.
• Fresh meconium may be found on the examining
fingers.
• Male genitalia may be felt
• ULTRASONOGRAPHY-

• FOR CONFIRMATION

• DIAGNOSIS OF HYPEREXTENSION

• ESTIMATION OF WEIGHT

• DIAGNOSIS OF MAJOR CONGENITAL

MALFORMATIONS
 MECHANISM OF LABOR IN BREECH
PRESENTATION

• In breech presentation there are three

mechanisms of labor.
Delivery of the buttocks and lower limbs
Delivery of the shoulders and arm
Delivery of the head
 MECHANISM OF LABOR buttocks and lower
limb

• Engagement and descent with compaction –

• Engagement occurs when the bitrochanteric
diameter has passed through the pelvic inlet.
• The bistrochanteric diameter is 10cm.
• Descent is slow as the breech is a less efficient
dilator.
• Compaction means that every part becomes a
little bit more flexed.
 Delivery of the buttocks and lower
limb
• Internal rotation-
• In case of RSA or LSA
bitrochanteric diameter rotates
45 degrees from the oblique
diameter to the anteroposterior
diameter.
• The sacrum turns away from the
midline from anterior quadrant
to the transverse plane.
 Delivery of the buttocks and lower
limb

• Birth of buttocks by lateral

flexion-
• The anterior hip impinges
under the pubic symphysis,
lateral flexion occurs and
the posterior hip raises and
is born over the perineum.
• Then the anterior hip slips
out under the pubic
symphysis.
 Delivery of
shoulders and arms
• Engagement –
• Occurs in the oblique diameter of
the pelvis.
• Internal rotation of the shoulders-
• The bisacromial diameter turns 45
degrees from the oblique to the
anteroposterior diameter of the
outlet.
• The bisacromial diameter is 12cm.
• Birth of the shoulders by lateral
flexion-
• Anterior shoulder impinges under
pubic syphysis and the posterior
shoulder and arm are born followed
by anterior shoulder.
 Delivery of after coming head
• Descent and engagement-
• Head enters the pelvis in the
opposite oblique diameter .
• Flexion
• Internal rotation
• The occiput comes under the
pubic symphysis.
• Birth of the head by flexion-
• The nape of the neck pivots
under the symphysis pubis and
the chin, mouth, nose, forehead,
bregma, and occiput are born by
movement of flexion.
 Prognosis of breech delivery
• Depends on age and parity and past obstetric
performance.
• Weight and maturity.
• Type of breech.
• Pelvic configuration.
• Uterine dysfunction.
• Other complications.
• Skill of obstetrician
Complications with Vaginal Delivery for Breech

• Maternal injuries
1. Uterine rupture
2. Lacerations of the birth canal
3. Extension of the episiotomy
4. Deep perineal tears
• Infection
• Atonic PPH
Complications with Vaginal Delivery for Breech

FETAL INJURIES
Cord prolapse
Fetal acidosis
Skeletal injuries
Brachial plexus injury – paralysis of the arm
Testicular injury
Spoon-shaped depression or fracture of the skull(?)
Perinatal loss
Complications with Vaginal Delivery for Breech

• The main causes of the death of term fetus are

head entrapment, cerebral injury and
hemorrhage, cord prolapse, and severe
asphyxia.
• The causes of the death of preterm fetus are
hypoxia and physical trauma.
 MANAGEMENT OF BREECH
PRESENTATION AT TERM
Management options

(1) external cephalic version(antenatally)

(2) elective caesarean section

(3) trial of vaginal delivery

 EXTERNAL CEPHALIC VERSION

• An series of movements done by which the

fetus is turned in utero through the abdominal
wall for the purpose of changing to cephalic
presentation.

• Indications-
Breech presentation at 36 completed weeks.
Transverse lie
 EXTERNAL CEPHALIC VERSION
• Methods

• 1-forward roll

• 2-backward flip
 EXTERNAL CEPHALIC VERSION
• Method –
• Place –in a unit where facilities for LSCS
• Position-supine with relaxed abdomen.
• Patient –with empty bladder.
• Obstetrician should stand on right side of the
patient with hands on fundus and lower pole.
• Movements –displace breech out of pelvis,
push the head towards pelvis.
 Prerequisites

• Informed Consent
• Skilled Obstetrician
• Ready access to C/S facilities
• Tocolysis (controversial)
• Ongoing Ultrasound surveillance of FHR
• FHR monitoring 15 mins with reactive NST before &
30 mins after procedure
• RH immune globulin as required following
 Elevate
breech
with
suprapubic
hand
 Push
breech
into iliac
fossa

Assistant
flexes
head
Now fetus in
transverse
lie

Ultrasound
is used to
monitor
progress and
heart rate
Fetus is past
transverse

Little effort
required to
guide head
into a vertex
presentation
 Ultrasound
confirmation
of fetal
presentation
 Absolute Contraindications
• Multiple gestation
• IUGR, major anomaly
• Hyperextension of fetal head
• PROM
• Oligohydramnios
• Ante partum bleeding
• Placenta previa
• PIH, preeclampsia
• Maternal cardiac disease
• Uterine scar
• Uterine malformation
• CPD
 Relative Contraindications
• Macrosomia (>4000g)
• Excess maternal obesity
• Active labor
 Complications of ECV
• Fetal bradycardia, decelerations
• Abruption
• Fetal hemorrhage
• Maternal hemorrhage
• Knotted or entangled cord
• Fetal mortality
• Amniotic fluid embolus, maternal death
34
 ACOG guidelines (Feb, 2006)

• All women near term (>36-6/7 wks) with

breech presentations should be offered a
version attempt
• Fetal assessment before and after procedure
• Attempt ECV only in settings in which C/S
services are readily available
ACOG Practice Bulletin #13 (2006)
ECV Algorithm
 Zatuchni-Andros Breech Scoring

Add 0 Points Add 1 Point Add 2 Points

Parity 0 1 2

Gestational age
(wk) 39+ 38 <37

EFW (lb) 8 7-8 <7

Previous breech 0 1 2

Dilatation 2 3 4

Station -3 -2 -1

If the score is 0-4, cesarean delivery is recommended

 Indications for caesarean section
Elective LSCS Emergency LSCS
 Elderly primi • IN 1ST STAGE-
 History of infertility • cord prolapse
 Bad obstetric history
• fetal distress
 Contracted pelvis
 IUGR • In 2nd stage –
 PROM • non progress of labor
 Placenta previa • fetal distress
 Footling breech
 Hyperextension of the fetal head
 Breech score of <3
 Large baby-EFW >3800 gms
 Premature infant
 Vaginal breech delivery

• 1.spontaneous
• 2.assisted breech delivery
• 3.breech extraction
 Complicated breech
• PROM
• Cord prolapse
• Uterine inertia
• Impacted breech
• Impacted shoulder –extended arms
• nuchal arms
• After coming head-
 Trial of labor
• Criteria-
• Frank breech
• Gestational age of 36 to 42 weeks
• EFW between 2500 and 3800 gms
• Fetal biparietal diameter <9.5cms
• Flexed fetal head
• Adequate maternal pelvis
• Breech score of 4 or more
 Trial of labor
• Conditions –
• Fetal heart rate should be monitored
continuously.
• Progress of labor should be observed.
• When the progress is slow caesarean section
should be performed.
• Patient must be prepared and ready for
caesarean section.
 Management of labour in the progressing
case
• First stage of labor-
• Observant expectancy and supportive therapy and
absence of interference are best.
• The patient is best in bed.
• Best to maintain intact membranes until cervical
dilatation has far advanced.
• When membranes rupture rule out cord prolapse.
• Meconium is no cause for alarm as long as fetal
heart rate is normal.
 Management of delivery in the progressing
case
• Second stage-
• Position for delivery- lithotomy
• Fetal heart should be checked frequently.
• Premature traction on the baby should be avoided.
• patient must be encouraged to bear down.
• No interference until the body is born to the umbilicus.
• Maintain supra pubic pressure to keep head in flexion.
• Keep the back anterior.
Management of delivery in the progressing
case
• Necessary equipment –
• Warm dry towel to wrap the baby to prevent
stimulation of respiration.
• Pipers forceps for the after coming head.
• Equipment for resuscitation of the infant.
• Episiotomy –
• Performed just before the buttocks crown
• Delivery of the
breech-
• Bracht technique
no interference till
umbilicus is delivered.
• Delivery of legs – flex the
knees at the popliteal fossa
and gently release
• A loop of umbilical cord is
pulled down .
• Baby is covered with warm
towel. And the body is
supported horizontally on
forearm
• Delivery of shoulders and
arms-

• Supra pubic pressure on the head

to maintain its flexion.

• Operator depress the buttocks

and deliver the body to the
anterior scapula.

• If the arms need some

assistance, sweep them gently
down the baby’s front until they
are free.
• Delivery of the after coming
head-

• Back must be anterior which

encourages rotation of occiput towards
the pubis.

• The body is lowered so that the nape of

the neck pivots under the pubic
symphysis

• At the same time maintain flexion of

the head by supra pubic pressure.

• The body is then raised slowly

( marshall burns technique) and then
by further supra pubic pressure
(kristellar maneuver) the head is
delivered in flexion.
 Arrest in breech presentation
• Arrest may occur at the-
Buttocks

Shoulders and arms

Head
 Management of arrest at buttocks
Pinards maneuver
• Introduce one hand in to
the uterus.
• Reach the popliteal fossa
along the thigh.
• Now pressure is applied
along backward and
outward direction which
causes flexion of the knee
and foot falls down.
• Both feet can be brought
down in this way.
 Arrest of the shoulders and arms
• Extended arms-

• Ordinarily the arms are well flexed and easily

delivered.

• At times one or both arms may be extended.

• This is dealt with by Lovsets maneuver.

 Lovset’s maneuver
• Steady and gentle traction downwards on the feet,
with the back of the baby facing right or left .

• It brings the axillary fold in to view.

• Now a finger is passed along the arm down to the

elbow, which is then flexed.

• Now the baby is rotated so that the posterior shoulder

comes under the pubic symphysis and the same
maneuver is repeated.
Lovset’s maneuver
Arrest of the shoulders and arms
• NUCHAL ARMS

• Here the hand is behind the

occiput.

• Diagnosis is made when the

medial border of the scapula
is not parallel to the spine.

• Managed by rotating the

baby in the direction in
which fingers are pointing.
 Arrest at the neck
• Occasionally the cervix
clamps down around the
baby’s neck after the trunk
and shoulders have born.

• In this case incisions at 2’0

and 10 ‘o clock positions
on the cervix with the
scissors.

Duhrssen’s incision
 Management of arrest of head
• One of the measures should be under taken.

1. Mauriceau smellie veit maneuver

2. Pipers forceps for the after coming head

3. Modified prague maneuver

 Mauriceau Smellie Veit manoeuvre
• is used to help flex and deliver the baby’s head
– place the second and fourth finger of one hand on the
baby’s shoulders
– the middle finger is placed on the baby’s occiput
– the second and third fingers of the other hand are
placed on the mallar prominences
– flex the baby’s head to assist the birth at the same time
lifting the baby’s body over on to the mother’s
abdomen
– birth slowly to avoid tentorial tears
Mauriceau Smellie Veit manoeuvre
 Application of pipers forceps
• Assistant lifts the baby’s body
up.

• Introducing the right hand

between head and left posterior
wall of vagina ,left blade is
inserted into a mento occipital
position.

• Like wise the left blade is

introduced.

• The forceps are locked and

traction is applied.
 Modified prague maneuver

• used when fetal back is

posterior.

• With one hand operator

catches the shoulders of
the baby and with other
hand lifts the baby up.
 Hyperextension of the fetal head
• Etiology-
• spasm or congenital
shortening of the extensor
muscles of the neck.
• Cord round the neck.
• Uterine anomalies.
• Fetal malformations.
• Tumors in the placeental site
 Hyperextension of the fetal head
• Diagnosis is by X-ray, ultra sound.
• Star gazing breech.
• Dangers
• Excessive stretching of the spinal cord.
• Epidural hemorrhage.
• Dislocation or fracture of the vertebrae.
 Failure of descent of the breech
• In spite of good uterine contractions if there is no
proper descent disproportion should be suspected.

• In this case
• cesarean section should be performed.
• Decomposition can be done.(Decomposition is
reducing the bulk of the breech.)
• In case of frank breech Pinard’s maneuver should
be carried out.
 Impacted breech
• Occurs when the breech is extended.
• May occur at the brim, cavity, or the outlet.
• The most common cause is disproportion
between the size of the breech and the pelvis.
• If the impaction is at the cavity or at higher
level delivery is by cesarean section.
• Impaction at the outlet is dealt by episiotomy
and traction with a finger in the groin.
 Breech extraction
• Immediate vaginal extraction of the baby
when signs of fetal distress demand delivery
with out delay.
• Prerequisites
• Adequate pelvis
• Cervix must be fully dilated.
• Bladder and rectum should be empty.
• Expert and deep anesthesia
 Breech extraction
• Procedure –
• Lithotomy position
• Under anesthesia
• The feet are pulled down if the
breech is complete.
• The Pinard’s maneuver is used
if the breech is frank.
• The baby is extracted rapidly.
• It should be carried out only in
situations where cesarean
section can not be performed
quickly.
summary of management
Thank you
for your
attention !