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 Contributors
Amita Mahendru
Specialist Registrar (Obs & Gyne) KetanGajjar
Princess Royal Hospital, Brighton, U.K Specialist Registrar (Obs & Gyne)
South-end Hospital, NHS Trust, Essex, U.K
Bharadwaj Desai
MD (Med), Consultant Hematologist LNChauhan
Unity Hospital and Bhailal Amin Hospital, Baroda Professor, Dept. of Obs & Gyne
Pramukh Swami Medical College, Karamsad
Chaitali Patel Ex-Professor & Head, Medical College, Baroda
Consultant Gynecologist
Kalpana Hospital, Baroda LataPJethwani
Consultant Obstetrician
CharuMittal Jethwani Hospital, Rajkot
MD, DNB, Assistant Professor (Obs & Gyne)
Medical College, Baroda Mala Arora
FRCOG, DA (UK), D Obst (Ire)
ChintanShah Consultant Gynecologist, Noble Hospital, Faridabad
DMRD, 3rd year Resident Radiology Chairperson FOGSI Quiz Committee
Medical College, Baroda Executive Fellow North Zone AICC RCOG

Deepika Deka MayaHazra

Professor (Obs & Gyne), AIMS Consultant Gynecologist
New Delhi Ex-Professor and Head
Dept of Obs and Gyne, Medical College, Baroda
Heena C Garg
Assistant Professor (Obst & Gyne) MeenuParhar
Medical College and New Civil Hospital, Surat MD, MRCOG, Senior SHO
Countess of Chester Hospital, Chester, UK
Hcma Divakar
Consultant Gynecologist & Director Monali Desai
Divakars Speciality Hospital, Bangalore Consultant Gynecologist and Oncologist
Senior Vice President FOGSI2005 Baroda

HetalParikh MRUpadhyay
Consultant Obstetrician and Gynecologist MD (Anesthesia), Associate Professor
Yogini Hospital, Baroda Medical College, Baroda

Jyoti Bhatt NanditaMaitra

Consultant Gynecological Endoscopist MD, MRCOG, Associate Professor
Karuna Hospital & Bhagvati Hospital Medical College
Mumbai Baroda
omes. JAMA

r al.: Placenta
United States,
if risk factor
\m J Obstet
CHAPTER
al.: Relation-
th restriction,
based study.

A: Placental
Jrtension and
Breech Presentations: Difficulties,
-thodological
Jt Gynecol Complications and Management
o/.: Placental
births in the Ketan Gajjar, Amita Mahendru
J Epidemiol

vl: Ii ance
ette smoking INTRODUCTION 28 weeks and 3-4% at term. Thus a major reason
ncy: A meta- for breech presentation in labour is preterm
-tet Gynecol The management of a fetus presenting by the
delivery, as most fetuses will turn spontaneously
breech has been an area of great controversy
I: The effect towards term.1
and changing practice. It has been widely reco-
ty: A popu- Another important cause of breech pre-
gnised that there is higher perinatal mortality and
989 through sentation is maternal and fetal abnormalities.
•.mi. morbidity with breech presentation, principally
Maternal abnormalities associated with
•ruption and due to prematurity, congenital malformations and
breech presentation are:
ates. Am J birth asphyxia or trauma. Breech presentation,
• Uterine abnormality i.e. bicornuate uterus.
whatever the mode of delivery is a signal for
. In Schwarts • Pelvic abnormality.
potential fetal handicap.
Principal of • Pelvic mass (cervical fibromyomata,
:i, 1999;101. Cesarean section for breech presentation has
ovarian cyst).
previa by been suggested as a way of reducing the asso-
• Drug and alcohol abuse.
ean section. ciated fetal problems and in many countries it
• Anticonvulsant therapy.
has become the normal mode of delivery in this
.: Expectant Fetal abnormalities associated with
re 35 weeks
situation. Although the Term Breech study has
breech presentation:
done much to clarify thinking around delivery of
• Intrauterine growth restriction.
5ailh Jest the breech infant at term, some management
1:1. • Aneuploidy/trisomy.
issues still remain an area of intense controversy.
behavior of • Abnormality, especially of central nervous
nanisms in system (CNS):
Commonw ETIOLOGY - Hydrocephalus.
The incidence of breech presentation varies with - Myelomeningocele.
gestational age, and it is approximately 20% at - Prader-Willi syndrome.

132 Emergencies in Obstetrics and Gyneeology
Feto-maternal abnormalities associated
with breech presentation:
• Preterm.
• Placenta praevia.
• Previous pregnancy complicated by a
breech presentation at term.
• Multiple pregnancy.
• Oligohydramniosorpolyhydramnios.
DIAGNOSIS OF BREECH
PRESENTATION
Three clinical breech presentations are
recognized:
• Extended (frank breech): 60-70%. It carries
the lowest risk of cord prolapse and feto-pelvic
disproportion.
• Flexed (complete breech): 10-15%.
• Footling (incomplete breech): 30-40%. It
carries the highest risks of cord prolapse and
feto-pelvic disproportion.
Clinical diagnosis of breech presentation may
be difficult by palpation alone and about 30% of
breech presentations are not diagnosed until the
onset of labour.
Following features may suggest breech
presentation:
• History of subcostal discomfort, with the
palpation of a solid fetal pole at the uterine
fundus.
• Auscultation of the fetal heart sounds
above the umbilicus.
• Palpation of the fetal ischial tuberosities,
sacrum and anus during vaginal exami-
nation. It may be difficult to differentiate
it from a face presentation. The bony land-
marks of face presentation palpated are
like malar eminences, mentum and mouth
with its obvious bony margin.
As abdominal palpation has been shown to
have a sensitivity of 28% and specificity of 94%,
confirmation by ultrasound scan must therefore
be regarded as the gold standard.'
I
i
MANAGEMENT OF BREECH practice
PRESENTATION breech
should i
The management of the breech delivery is a
Success
balance of risks and benefits to the mother and
mately 4
the fetus. The risks to the mother are easy to
cephalic
quantify.
The
• Breech presentation confers an increased
of succt
likelihood of cesarean section.2 Hence the
risks associated with future deliveries are also
considerable due to the scar on the uterus.
• E
• Vaginal breech delivery may be associated
• F
with perineal discomfort and morbidity.3
• C
• The perinatal mortality with breech delivery 1
(corrected for the fetal abnormality) is four
times that of cephalic presentation.4 TRIAL
• The morbidity and mortality is more with DELIV
vaginal breech delivery than with cesarean
Pt^idp
section. The breech is smaller than the head
relies o:
and it is the delivery of the unmoulded fetal
is a con
head which creates the potential for problems. expulsi
The incompletely dilated cervix is a major attenda
problem especially with the preterm and to enat
footling breeches, as the presenting part may and ma
pass through the partially dilated cervix and fetal at
give the mother an uncontrollable urge to push. Pre
However, the unmoulded head will not des-
cend past the cervix and result in delay in
delivery of the head, cord compression,
asphyxia and probably fetal trauma from
uncontrolled efforts to deliver the baby.5
ANTENATAL MANAGEMENT
•
Role of External Cephalic Version and Com-
plications:
External cephalic version is associated with a
significant reduction in the risk of cesarean section
[odds ratio OR of 0.4; 95% confidence interval
(CI) 0.3-0.6] without an increased risk to the
baby. It does not improve the outcomes if offered
before term. It can be offered in early labour
provided membranes are intact. It is current best
 Breech Presentations: Difficulties, Complications and Management 133
practice that all women with an uncomplicated fetal neck is an important finding asso-
breech pregnancy at term (37-42 weeks) ciated with spinal cord and brain injuries
:ry is a should be offered ECV. [Evidence level la]. during birth due to nuchal cord i.e. cord
her and Success rates of ECV at term reach approxi- around the fetal neck, fundal placenta,
easy to mately 40%, with 97.5% of fetuses remaining in spasm of fetal neck musculature, and ute-
cephalic presentation till delivery. rine abnormalities. Extension more than
creased The following are considered as predictors 90 degrees is associated with a particularly
nee the of success of ECV: 6-7 poor prognosis and delivery by cesarean
• Multiparity. section is recommended.9
are also
• Adequate liquor volume.
items,
• Breech above the pelvic brim. Management of First Stage of Labour
ociated
• Fetal head easy to feel.
:y.3 • Place of delivery where anaesthetist, pedia-
• Operators' experience and skill (Box
lelivery trician and facilities for immediate cesarean
12.1).
is four section available.
TRIAL OF VAGINAL BREECH • Discuss epidural analgesia (if facilities
re with DELIVERY available) as it prevents premature maternal
;sai expulsive efforts especially pushing of pre-
ic head Principle: Spontaneous vaginal breech delivery
mature fetus through incompletely dilated
id fetal relies on pushing forces from the mother which
cervix and facilitates delivery, but it may inhibit
is a combination of uterine activity and maternal
)blems. pushing in the second stage and may be asso-
expulsive efforts rather than traction from birth
i major ciated with more prolonged labours and an
attendants. Assisted breech delivery is supposed
•m and increase in cesarean section.
to enable control of the baby to prevent delay
irt may • Intravenous access, full blood count and group
and malposition but risks trauma and alteration in
/ix and fetal attitude.5 and keep cross-matched blood ready.
:o push, Pre-requisites are: • Continuous electronic fetal monitoring—the
ot des- • Careful counselling about risks of vaginal monitoring electrode may be applied to buttock
elay in breech delivery to fetus and mother and if abdominal transducer is not giving a good
;ssion, confirm her informed choice. trace. Fetal blood sampling can be performed
a from • Absence of any medical or obstetric from the buttock.
•y-5 complications which are associated with • Artificial rupture of membranes performed
difficulties in delivery. only if presenting part is applied well to the
• No evidence of feto-pelvic disproportion cervix.
Com- and clinically adequate pelvis although • Perform vaginal examination immediately
clinical judgement is subjective and no after spontaneous rupture of membranes to
with a other form of pelvimetry has been proven exclude cord prolapse and observe CTG
section to be of increased benefit and not needed closely for 10 minutes due to the risk of occult
nterval to be used routinely.8 cord prolapse.
to the • Ultrasound assessment as fetuses with • Poor progress despite good contractions
iffered severe abnormalities, hyperextension of suggests that the pelvis is inadequate.
labour the fetal neck or presenting with a footling • Augmentation is not contraindicated, however
nt best breech may be excluded. Hyper-extended to be used with caution.
 T
134 Emergencies in Obstetrics and Gynecology
Box 12.1: External cephalic version (ECV) • Progre
Contraindications. Absolute: gram ;
Multiple pregnancies with first or both twins, preser
Antepartum hemorrhage (after 20 weeks).
Conditions requiring cesarean section regardless of the presentation, i.e. placenta praevia. Managei
Ruptured membranes. Labour
Fetal abnormality.
Suspected fetal compromise-need for urgent delivery for fetal well-being. • Princi
Cord completely encircling the fetal neck on ultrasound. • Ensun
Declined consent. for th
Relative:
Previous cesarean section (apparent safety).10
perine
Maternal disease, e.g. hypertension, diabetes. • In gen
Fetal growth restriction or Oligohydramnios. flexioi
Maternal obesity: BMI > 20% of the ideal to increase the success rates. tractio
Complications: • The o
Transient bradycardia (8%).
the ba
Decelerations.
Abruption or direct cord effects occur less frequently.
Feto-matemal hemorrhage -between 5 and 28%. .^ exi
Procedure: diffici
Ultrasound is useful before ECV to: the sir
• Confirm the breech. there i
• Confirm the presence of a normal fetus.
• Ensure adequate liquor volume. Delivery
• Confirm placental position.
• Observe for the presence of nuchal cord. • Theh
• Detail the fetal attitude and position of the fetal legs. the pe
CTG is necessary before and after the procedure.
thispc
Informed consent is necessary detailing the risks i.e. failure, cesarean delivery.
Tocolysis may be given (250 meg of terbutaline I.V./S.C.) and short time allowed for the drug to exert its effect;
positit
Anti-D if mother is rhesus negative. perfor
It should be performed with facilities for rapid access for operative delivery if required. infiltr;
Operator should perform ECV in one manoeuvre and uterine manipulation should be limited to a total of 10 minutes meets
duration [vast majority turn with 5 minutes]. buttO
• The breech is manipulated out of the pelvis by steady and continuous abdominal pressure.
medic
• A forward or backward roll/somersault of the fetus can then be performed with the pressure aimed maximally at
moving the breech upward and one hand used to maintain the head in flexion. this p<
• If this sequence is unsuccessful then rotation in the opposite direction may be tried and fetus will often rotate
easily. .epe
If successful the attitude of the fetus should be maintained manually for a couple of minutes and CTG is performed Spont
till a normal and reassuring pattern is seen and then the woman is allowed to go home with a follow up appointment to mater
confirm it is still breech.
If unsuccessful or reversion to breech occurs then a repeat ECV or delivery by cesarean section may be offered.
delive
extern
thefo
thigh
very c
 Breech Presentations: Difficulties, Complications and Management 135
• Progress should be documented in the parto-
gram and should be as expected for cephalic
presentation.11
Management of Second Stage of
Labour
• Principle is "hands off the breech".
• Ensure full dilatation of the cervix by waiting
for the descent of the breech on to the
perineum before pushing commences.
• In general, manoeuvres involving rotation and
flexion of limb are helpful and those involving
traction are not.
• The consequences of premature traction on
the baby with a breech presentation are the
conversion of the baby's attitude from flexion
to extension of the arms and neck and
difficulties in delivery.5 (This is in response to
the simple law of physics that to every action
there is an equal and opposite reaction). -
Delivery of Breech and Legs
• The breech should be allowed to descend to
the perineum with maternal effort alone. At
this point the patient can be placed in lithotomy
jffect.t position and if appropriate, a pudendal block
performed, together with local anaesthetic
infiltration of the perineum. As the breech
10 minutes meets the opposition of perineum the anterior
buttock 'climbs up' the fourchette. A
aximally at mediolateral episiotomy can be considered at
this point. In a footling breech, episiotomy
>ften rotate should be performed when buttock reaches
the perineum.
perfo. .ied
• Spontaneous progression is allowed with
>intment to
maternal efforts for buttocks and legs to
iffered. deliver. Only if it is a frank breech with
extended legs will assistance be necessary in
the form of two fingers placed behind the fetal
thigh to flex the hip and knee and allow deli-
very of leg. This is done for each leg in turn.
1
The reminder of fetal abdomen and lower
trunk will then follow by maternal efforts
alone. If the fetal back show any tendency to
rotate posteriorly, it should be gently guided
to anterior position. It is very important not to
put traction on the fetus at this point, as this
will serve only to extend the fetal arms and
head. This requires discipline, as one instinc-
tively wants to aid the process of delivery.12
(Box 12.2).
Delivery of Shoulders and Arms
• With maternal effort alone, the reminder of
the trunk should be expelled and the lower
border of one scapula will become visible
under the pubic arch.
• The fetal head is now entering the pelvic brim
and the umbilical cord will be partially
occluded. This is when fine judgement is
required to decide between excessive haste
and a potentially traumatic delivery and
waiting too long so that hypoxia supervenes.
• Once the scapula is visible, the arms will
probably be flexed in front of the fetus. Their
delivery, if not spontaneous, can easily be
achieved by passing the index and middle
fingers over the shoulder and then splinting
and sweeping the humerus down across the
chest. The fetal back is rotated gently at 90
degrees to bring the other scapula into the
view and the procedure repeated on the arm.
• For rotation of the fetal back or other mano-
euvres required to deliver extended arms,
appropriate placement of operators' arm is
important. The instinct is to grasp the infant
around the hips and abdomen. This is
potentially traumatic to the intra-abdominal
contents. The hands must be placed lower
than this—around the thighs and hips of the
fetus, so that thumbs are on sacrum and the
upper fingers are around the iliac crest. A
 Breech Presentations: Difficulties, Complications and Management 137
small sterile towel will help to maintain the
grip during the manoeuvr" (Fig. 12.1).
id obstetric
Extended Arms
When extended arms occur, it is usually because
inappropriate traction has been placed on the fetus
before this point. Lovset's manoeuvre is an
and saved.
effective way of dealing with this application. It
is based on the principle that the posterior fetal
3500 g by shoulder enters the maternal pelvic cavity before
increasing the anterior shoulder. In the manner mentioned
above, the fetal thighs and hips are grasped and
ibilicus the
the body lifted anteriorly to cause lateral flexion
deliveries. and promote descent of the posterior shoulder
below the sacral promontory. The fetal back is
kept uppermost, as the body is rotated 180
she- be
degrees so that the posterior shoulder (below the
pelvic brim) is now rotated to become the anterior
shoulder. As such, it is now below the symphysis
and the humerus can be hooked down with ease.
The body is then rotated back through 180
degrees, which brings the other shoulder below
the symphysis and allows delivery of that arm
(Fig. 12.2).
Nuchal Arm
In this situation, the shoulder is extended and the
elbow flexed so that the forearm is trapped behind
the occiput. It usually occurs because of inappro-
priate traction and rotational manoeuvres at an
earlier stage in the delivery. To overcome this
problem, the fetal trunk is rotated in the direction

associated

i
of delivery

i increases

>r cesarean
ch is equal

; mandible

X X
Figure 12.1: Unacceptable methods of handling a baby during an assisted breech delivery
138 Emergencies in Obstetrics and Gynecology
• Mau
• Bun
• Fore

MauriceaL
(Fig.12.4)
With the fe
\ the accouct
are placed
promote fie
Figure 12.2: Lovset's maneuver is placed (
pushing do
of fetal hand. The occiput thus rotates past the by its own weight as this may paradoxically, flexion of
arm and with further rotation, flexion of the promote extension of the head. Once the hairline resting on
shoulder should occur and allow delivery of arm on the fetal neck is visible beneath the pubic arch, a downwa
(Fig. 12.3). the head is ready for assisted delivery. Assistance nece- -rryi
at this stage is necessary to avoid sudden decom- by u^/arc
Delivery of the Head pression of the perineum on the fetal head at the over the pe
After delivery of the arms, the baby is suspended point of delivery. This may lead to tentorial tears avoided as
vertically with partial support from the operator's and intracranial hemorrhage. For this reason, the and cervic
hand. Mild suprapubic pressure from assistant head must be controlled at delivery in all cases tion is nee
may help descent and flexion of the fetal head. and there are three main techniques to achieve forceps.
The baby should not be allowed to hang entirely this:
Burns-Mi
The baby
Suprapubi
and backv
soon as na;

Figure 12.3: Nuchal arm Figure 12

 Breech Presentations: Difficulties, Complications and Management 13!
• Mauriceau-Smellie-Veit manoeuvre.
• Burns-Marshall method.
• Forceps to the aftercoming head.
Mauriceau-Smellie- Veil Manoeuvre
(Fig.12.4)
With the fetus supported on the right forearm of
the accoucheur, the fore finger and middle fingers
are placed on the maxilla beside the nose and
promote flexion of the fetal head. The other hand
is placed on the fetal back, the middle finger
pushing downwards on occiput also to enhance
•xically, flexion of the head, while the other fingers are
hairline resting on the fetal shoulders. Gentle traction in
?ic arch, a downward and backward direction may be
sistance necessary until delivery of the fetal chin followed
decr-Ti- by upward guidance of the face and forehead
td a, .e over the perineum. Excessive traction should be
ial tears avoided as it risks trauma to the brachial plexus
son, the and cervical spine. If more than very mild trac-
ill cases tion is needed then this should be applied with
achieve forceps.
Burns-Marshall Method
The baby is allowed to hang by its own weight.
Suprapubic pressure is to be applied in downward
and backward direction to maintain flexion. As
soon as nape of the neck is visible under the pubic
Figure 12.4: Mauriceau-Smellie-Veit maneuver
arch, the baby is grasped by the ankle with a
finger in between the two ankles. Maintaining a
constant traction and forming a wide arc, the trunk
is swung in upward and forward direction. Baby
delivers face first, then brow. The trunk is
depressed to deliver the rest of the head.
Forceps to the Aftercoming Head
This method provides protection and controlled
delivery of fetal head. They also encourage flexion
of the head and are a safer way to apply the mild
traction that may be necessary to complete the
delivery.
While the assistant holds the fetal body just
above the horizontal plane the forceps are applied
below the body at the four and eight O'clock
positions along the sides of the fetal head. Most
of the long-handled forceps can be used but
Piper's forceps were especially developed for
this purpose as they have a long shank. Do not
raise the fetal body to much above the horizontal,
as this risks hyper-extension of and trauma to
the fetal cervical spine. As the fetal head is
delivering, once the fetal chin and mouth are
visible, the forceps and the body of the fetus ar~
raised together to complete the delivery (Fig.
12.5).
Should the head fail to descend into the
pelvis following delivery of the shoulders?
• The body of the fetus should be turned
sideways and suprapubic pressure applied
to increase flexion and encourage entry
through the pelvic inlet in the occipito-
lateral position; a McRobert's manoeuvre
may help.
• Consideration must be given to incising the
cervix (preferably at 4 and 8 O'clock)
should descent of the head have begun
before full cervical dilatation is achieved.
• Consideration must be given to the possi-
bility of fetal abnormalities such as
140 Emergencies in Obstetrics and Bynecology
Figure 12.5: Piper's forceps for aftercoming head of
breech
hydrocephalus—ultrasound confirmation
may be helpful; vaginal delivery may only
be possible in cases of hydrocephalus by
drainage of cerebrospinal fluid aspiration
through foramen magnum.'
Variable Decelerations
Variable decelerations of the fetal heart rate are
common due to umbilical cord compression. If
decelerations manifest with asphyxial features
then cesarean section may be required.
Umbilical Cord Presentation or
Prolapse (5%)
This is commoner in breech presentation than in
vertex presentation, especially when the fetal
attitude is of flexed legs or footling breech. Vaginal
examinations should be performed immediately
after membrane rupture. If cord presentation or
prolapse is found then, almost universally, crash
cesarean section should be performed. The only
exception is in the multiparous woman with a fully
dilated cervix with a favourable feto-pelvic
relationship, where breech extraction is safe in
skilled hands.
Breech Extraction
Breech extraction is rarely performed nowadays
because of the risks of fetal and maternal trauma
and because of the effects of excessive traction . The heg
on the fetal body. Its main current indication is lower sf
for the delivery of a second twin after internal to be en
podalic version, or if cord prolapse complicates the acc<
the late second stage. It may also be appropriate
MANAGE
if the fetus is dead. In breech extraction, traction BREECH
is exerted on body of the fetus to expedite deli very.
Groin traction is performed to draw the breech Approxinu
over the perineum, Lovset's manoeuvre is emp- at these ges
loyed routinely and downward traction is exerted
to bring the head into the pelvis. In effect, all the
stages of assisted vaginal delivery are achieved Medico
obstet
actively by the obstetrician.3
contrail
to labc
CESAREAN SECTION vqgins
The Term Breech Trial: The multicentre term ,ver
breech trial has provided randomised controlled
data to indicate that planned cesarean section
can reduce the overall risk of perinatal death for
term complete or frank breeches by 75%
(Relative risk = 0.23; CI 0.07-0.8).8
• Ultrasound confirmation of breech presen-
tation is necessary before cesarean section.
• During LSCS care should be taken while
opening the uterus-scalpel injuries to the baby
are more likely to happen in breech than
cephalic presentation.
• It should be remembered that the perfor-
mance of a cesarean section does not prevent
the possibility of birth injury and many of the
above considerations about careful delivery
of the aftercoming head and the dangers of
traction on the fetal spine still apply.
• Delivery at full dilatation in the absence of
liquor may be difficult as an arm may prolapse
through the uterine incision; it should
immediately be pushed back. Instead, a leg
should be grasped and brought through the
incision. Traction will then effect the resi < >
the delivery.
 ins: Difficulties, Complications and Management 141
traction The head can be trapped in a well-contracted cephalic version is not useful in preterm breech
nation is lower segment and the incision will then need presentation. 7
internal to be enlarged in a j-shaped fashion to increase
iplicates the access-3 (Algorithm 12.1). Labour and Delivery
Topriate When compared with vertex-presenting counter-
traction MANAGEMENT OF PRETERM
parts, the premature breech often:
BREECH: 26-36 COMPLETED WEEKS
lelivery. • Is small for gestational age.
: breech Approximately 25 percent of all babies delivered • Has a high head-to-body circumference ratio.
is emp- at these gestations will be by the breech. External
exerted
c, all the ~* \h p
resentation at term
chieved Medical or
obstetric f ^
contraindication / r-^ Gee in
to labor and / V offered > clinic to

vaginal Repe< it confirm

re te"n delivery proce dure \ cephalic
ntro. a rnay o e \
section off ere d Unwanted/ N^
^ Unsuccessful
eath for Successful
y 75% J/
- 1 / r-,'
Counselling of p atient— Risk v/s
presen- Benefits of vagin
•ection. if wished
i while >f
ne baby • Footling breech Wish expressed for trial of vaginal delivery
-h than • Macrosomic fetus
• Abnormal fetus \f Ultrasoun
• Hyperextension o
perfor- d scan
fetal head
orevent
v of the > f
elivery • Extended or flexed breech
gers of • Flexed fetal head, no macrosomia

> f
^ . r
Clinical p<jlvimetry Trial of vaginal
rolapse breech delivery
;hould
!, a leg
f >r
Advise C.S.
; f

gh the Obvious pelvic abnormality

rest of
Algorithm 12.1: Management of breech presentation at term
142 Emergencies in Obstetrics and Gynecology
• Has a higher association with antepartum still Management of Preterm Deliv.
birth and neonatal demise. Breech in Labour rienced c
The problems with preterm breech delivery present a
Although majority of obstetricians use delivery available
include:
by LSCS for the uncomplicated preterm breech, been she
• Intraventricular and periventricular
only a minority believe that there is sufficient fetus.3
damage due to hypoxia or hemorrhage.
evidence to justify this policy. The poor outcome An ej
Although these injuries may be related to
for very low birthweight infants is mainly related pushing 1
the mechanics of delivery, avoiding such
to complications of prematurity and not to the This will
circumstances may not prevent them
mode of delivery. Evidence from the Term the painl
occurring.
Breech trial cannot be directly extrapolated to coming
• Damage to the internal organs, transec-
preterm breech delivery, which remains an area delivery,
tion of the spinal cord, nerve palsies and
of clinical controversy. There is insufficient followin;
fracture of long bones—these frequently
evidence to support routine cesarean section for insertion
results from injudicious use of traction on
preterm breech delivery.1'13 may be ;
presenting parts.
When a woman is not in labour and an indi- incision
• Entrapment of the aftercoming head.
cation exists to expediting delivery i.e. severe pre- dt <be<
The risk of such a problem increases when
eclampsia, IUGR; the preferred route should be Cesa:
the active second stage has begun before
by cesarean section. When time permits, such transvers
the full dilatation of cervix is achieved
an intervention should always be preceded by of the rr
(more common with footling than with
the mother being given a course of antenatal certain, .
other presentations). This may require j-shaped
incising the cervix at 4 and 8 O'clock with steroids.
In labour the management depends on: has man
scissors. A complete examination must be inverted
performed following delivery, the hemor- • An accurate diagnosis of labour (50
percent of cases of presumed preterm mortality
rhage must be arrested and the defect below 2:
must be repaired. labour settle spontaneously).
• Tocolysis to delay labour whilst steroids best inte
• The occipital bone of the fetus is parti- bearing 1
cularly exposed to damage due to its are administered.
impact upon the maternal pubis during • Confirmation of presentation and gestation Managt
descent of the head in the second stage as the very preterm infant is unlikely to
benefit from cesarean section and mater- In the n
of labour. Such forces may act to separate problem
the central portion of the occipital bone nal risks will be higher.
• Exclusion of fetal abnormalities (a detailed relate to
from the lateral part (occipital diastasis), H sve
with potential damage to the cerebellum ultrasound scan should be performed if
time and labour permits). pregnan
and herniation of brain tissue through problem
the foramen magnum. If this does not • The progress of labour: This is often very
quick and cesarean section may not be delivery
result in stillbirth or early neonatal death, discussi>
the diagnosis may be delayed until the child realistic.
• Fetal status: At gestations with expected onset of
is older, when signs of ataxic cerebral
palsy may be displayed. Fortunately, this good outcomes, non-reassuring fetal status
is a rare occurrence. indicates cesarean section.