Breech

 presenta,on  
§  persists  at  term  in  3-­‐4  %  of  singleton  
deliveries    
§ Near  term,  the  fetus  typically  turns  
spontaneously  to  a  cephalic  presenta,on  as  the  
increasing  bulk  of  the  bu?ocks  seeks  the  more  
spacious  fundus    
 
 
 Vaginal  breech  delivery  
ACOG  recommenda.on  (2012):  
 
“the  decision  regarding  the  mode  of  delivery  
should  depend  on  the  experience  of  the  health  
care  provider”    
 
“planned  vaginal  delivery  of  a  term  singleton  
breech  fetus  may  be  reasonable  under  hospital-­‐
specific  protocol  guidelines”    
 
 
Classifica,on  of  Breech  Presenta,ons  
FRANK  
 lower  extremi,es  are  flexed  at  the  hips    and  
 extended  at  the  knees    
COMPLETE  
 one  or  both  knees  are  flexed    
INCOMPLETE  (FOOTLING)  
 one  or  both  hips  are  not  flexed,  and  one  or  
 both  feet  or  knees  lie  below  the  breech,  such  
 that  a  foot  or  knee  is  lowermost  in  the  birth  
 canal    
 
 Stargazer  fetus  
§  Also  known  as  the  flying  fetus  
§  Refers  to  a  breech  fetus  with  extreme  
hyperextension  of  the  head  
§  An  indica,on  to  do  CS  because  vaginal  
delivery  may  result  in  injury  to  the  cervical  
spinal  cord    

 
 Risk  Factors  
§  Early  AOG  
§  Abnormal  amnio,c  fluid  volume  
§  Mul,ple  gesta,on  
§  Hydrocephaly/Anencephaly  
§  Uterine  anomalies  
§  Placenta  previa  
§  Fundal  placental  implanta,on  
§  Pelvic  tumors  
§  High  parity  with  uterine  relaxa,on  
§  Prior  breech  delivery  
 
 Diagnosis  
§  PE:  
§  Leopold  manuevers  
§  LM1:  Ballo?table  head  occupies  the  fundus  
§  LM2:  fetal  back  on  one  side,  small  parts  on  the  other  
§  LM3:  Breech  
§  IE:  
§  Frank  breech  
§  Differen,ate  from  face  presenta,on  
§  The  anus  may  be  mistaken  for  the  mouth  and  the  ischial  
tuberosi,es  for  the  malar  eminences  
§  The  finger  encounters  muscular  resistance  with  the  anus,  
and  upon  removal,  may  be  stained  with  meconium  
§  The  mouth  and  the  malar  eminences  form  a  triangular  
shape,  whereas  the  ischial  tuberosi.es  and  anus  lie  in  a  
straight  line  
 Diagnosis  
§  PE:  
§  IE:  
§  Complete  breech:  the  feet  may  be  felt  alongside  the  bu?ocks  
§  Footling  breech:  one  or  both  feet  are  inferior  to  the  bu?ocks    
§  Ultrasound  
Fetal  posi,ons  in  breech  presenta,on  
§  The  fetal  sacrum  and  its  spinous  processes  are  
palpated  to  establish  posi,on    
§  designated  as  le]  sacrum  anterior  (LSA),  right  
sacrum  anterior  (RSA),  le]  sacrum  posterior  (LSP),  
right  sacrum  posterior  (RSP),  or  sacrum  transverse  
(ST)    
 
Factors  which  aid  in  determining  the  
route  of  delivery  
§  Fetal  characteris,cs  
§  Pelvic  dimensions  
§  Coexis,ng  pregnancy  complica,ons  
§  Operator  experience  
§  Pa,ent  preference  
§  Hospital  capabili,es  
 
Factors  favoring  abdominal  delivery  of  
breech  fetuses:  
§  Preterm  (breech  is  smaller  than  the  a]ercoming  
head)  
§  Fetal  weight  <2500g  or  >3800-­‐4000g  
§  Footling  breech  
§  Hyperextended  head  
§  BPD  >90-­‐100  mm  
§  Contracted  pelvis  
§  to  avoid  head  entrapment  following  delivery  of  the  
breech,  pelvic  dimensions  should  be  assessed  before  
vaginal  delivery    
 
Factors  favoring  abdominal  delivery  of  
breech  fetuses:  
§  Lack  of  operator  experience  
§  Pa,ent  preference  
§  Severe  IUGR  
§  Fetal  anomaly  incompa,ble  with  vaginal  delivery  
§  Prior  CS  
§  Prior  perinatal  death  or  neonatal  birth  trauma  
 
Perinatal  morbidity  associated  with  
breech  presenta,on:  
§  Entrapment  of  a]ercoming  head  (most  common)  
§  Umbilical  cord  prolapse  
§  Preterm  delivery  
§  Birth  trauma  
§  Fractures  of  the  humerus,  clavicle,  femur  
§  Trac,on  may  separate  scapular,  humeral,  or  femoral  
epiphyses  
§  Hematomas  of  the  sternocleidomastoid  muscles  
§  Tes,cular  injury  
§  Perineal  tears  
§  Upper  extremity  paralysis  (Erb  or  Duchenne)  
§  Secondary  to  brachial  plexus  stretching  
 Pelvimetry  
§  Imaging  modali,es  used:  
§ One-­‐view  CT  
§ MRI  
§ Plain  film  radiographs  
 

 
Fundamental  difference  between  labor  and  
delivery  in  cephalic  and  breech  presenta.ons:    
•  With  a  cephalic  presenta,on,  once  the  head  is  
delivered,  the  rest  of  the  body  typically  
follows  without  difficulty.    
•  With  a  breech,  successively  larger  and  less  
compressible  parts  are  born  (problem  of  
delivering  the  a]ercoming  head).    
 Methods  of  Vaginal  Breech  Delivery  
1.  Spontaneous  breech  delivery  
§  fetus  is  expelled  en,rely  spontaneously  without  any  
trac,on  or  manipula,on  other  than  support  of  the  
newborn    
2.  Par.al  breech  extrac.on  
§  fetus  is  delivered  spontaneously  as  far  as  the  umbilicus,  
but  the  remainder  of  the  body  is  extracted  or  delivered  
with  operator  trac,on  and  assisted  maneuvers,  with  or  
without  maternal  expulsive  efforts  
3.  Total  breech  extrac.on  
§  the  en,re  body  of  the  fetus  is  extracted  by  the  
obstetrician  (as  in  the  2nd  of  a  twin,  following  internal  
podalic  version);  also  used  during  cesarean  delivery  
 DR  Staff  required  for  vaginal  breech  
delivery:  
(1) an  obstetrician  skilled  in  the  art  of  breech  
extrac,on  
(2)  an  associate  to  assist  with  the  delivery  
(3)  anesthesia  personnel  who  can  ensure    
           adequate  analgesia  or  anesthesia  when    
           needed  
(4)  an  individual  trained  in  newborn    
           resuscita,on    
 Management  of  Labor:  
•  On  arrival,  rapid  assessment  should  be  made  to  
establish  the  status  of  the  membranes,  labor,  and  fetal  
condi,on    
•  If  labor  is  too  far  advanced,  there  may  not  be  sufficient  
,me  to  obtain  pelvimetry,  otherwise,  sonographic  fetal  
biometry  and  assessment  of  head  flexion  are  
completed  
•  a  vaginal  examina,on  should  be  performed  following  
membrane  rupture  to  exclude  cord  prolapse    
•  With  all  breech  deliveries,  unless  there  is  considerable  
relaxa,on  of  the  perineum,  an  episiotomy  should  be  
made  and  is  an  important  adjunct  to  delivery.    
 Cardinal  Movements  with  Breech  
Delivery  
•  Engagement  and  descent  of  the  breech  
usually  take  place  with  the  bitrochanteric  
diameter  in  one  of  the  oblique  pelvic  
diameters.    
•  The  anterior  hip  usually  descends  more  
rapidly  than  the  posterior  hip    
Par,al  Breech  Extrac,on  
Following  delivery  of  the  legs,  the  
fetal  bony  pelvis  is  grasped  with  
both  hands,  using  a  cloth  towel  
moistened  with  warm  water.  The  
fingers  should  rest  on  the  anterior  
superior  iliac  crests  and  the  
thumbs  on  the  sacrum,  minimizing  
the  chance  of  fetal  abdominal  so]  
,ssue  injury.  Maternal  expulsive  
efforts  are  used  in  conjunc,on  
with  downward  trac,on  to  effect  
delivery.  
 Par,al  Breech  Extrac,on  
•  A  cardinal  rule  in  successful  breech  extrac,on  is  
to  employ  steady,  gentle,  downward  trac,on  
un,l  the  lower  halves  of  the  scapulas  are  
delivered,  making  no  aUempt  at  delivery  of  the  
shoulders  and  arms  un.l  one  axilla  becomes  
visible.    
•  As  the  scapulas  become  visible,  the  fetal  back  
tends  to  turn  spontaneously  toward  the  side  of  
the  mother  to  which  it  was  originally  directed.  
The  appearance  of  one  axilla  indicates  that  the  
.me  has  arrived  for  shoulder  delivery.    
 Par,al  Breech  Extrac,on  
Methods  of  delivering  the  shoulders:  
•  In  the  first  method,  with  the  scapulas  visible,  
the  trunk  is  rotated  in  such  a  way  that  the  
anterior  shoulder  and  arm  appear  at  the  vulva  
and  can  easily  be  released  and  delivered  first  
 Par,al  Breech  Extrac,on  
Methods  of  delivering  
the  shoulders:  
•  The  body  of  the  
fetus  is  then  rotated  
180  degrees  in  the  
reverse  direc,on  to  
deliver  the  other  
shoulder  and  arm  
 Par,al  Breech  Extrac,on  
Methods  of  delivering  the  shoulders:  
•  The  second  method  is  employed  if  trunk  rota,on  is  
unsuccessful.  With  this  maneuver,  the  posterior  
shoulder  is  delivered  first.  For  this,  the  feet  are  
grasped  in  one  hand  and  drawn  upward  over  the  inner  
thigh  of  the  mother,  toward  which  the  ventral  surface  
of  the  fetus  is  directed.  In  this  manner,  leverage  is  
exerted  on  the  posterior  shoulder,  which  slides  out  
over  the  perineal  margin,  usually  followed  by  the  arm  
and  hand.  Then,  by  depressing  the  body  of  the  fetus,  
the  anterior  shoulder  emerges  beneath  the  pubic  arch,  
and  the  arm  and  hand  usually  follow  spontaneously.    
 Par,al  Breech  Extrac,on  
•  A]er  both  shoulders  are  delivered,  the  back  of  
the  fetus  tends  to  rotate  spontaneously  in  the  
direc,on  of  the  symphysis.    
•  If  upward  rota,on  fails  to  occur,  it  is  
completed  by  manual  rota,on  of  the  body.    
•  Delivery  of  the  head  may  then  be  
accomplished.    
 Par,al  Breech  Extrac,on  
•  Delivery  of  the  a]ercoming  head:  
MAURICEAU  MANUEVER  
•  the  index  and  middle  finger  of  one  hand  are  applied  
over  the  maxilla,  to  flex  the  head,  while  the  fetal  body  
rests  on  the  palm  of  the  hand  and  forearm    
•  the  operator  uses  both  hands  simultaneously  and  in  
tandem  to  exert  con,nuous  downward  gentle  trac,on  
simultaneously  on  the  fetal  neck  and  on  the  maxilla  
•  At  the  same  ,me,  appropriate  suprapubic  pressure  is  
applied  by  an  assistant    
 Par,al  Breech  Extrac,on  
•  Delivery  of  the  
a]ercoming  
head:  
 
MODIFIED  
PRAGUE  
MANUEVER  
Forceps    
(Piper  forceps)  
delivery  
of  the    
a]ercoming  
head  
 Entrapment  of  the  A]ercoming  Head  
•  Most  common  perinatal  complica,on  
associated  with  vaginal  breech  delivery  
•  Occurs  especially  with  a  small  preterm  fetus—
the  incompletely  dilated  cervix  will  constrict  
around  the  neck  and  impede  delivery  of  the  
a]ercoming  head  
•  At  this  point,  it  must  be  assumed  that  there  is  
significant  and  even  total  cord  compression,  
and  thus  ,me  management  is  essen,al.    
 Entrapment  of  the  A]ercoming  Head  
•  With  gentle  trac,on  on  the  fetal  body,  the  
cervix,  at  ,mes,  may  be  manually  slipped  over  
the  occiput.  
•   If  this  is  not  successful,  then  Dührssen  
incisions  may  be  necessary.    
 Entrapment  of  the  A]ercoming  Head  
•  As  a  last  resort,  replacement  of  the  fetus  higher  
into  the  vagina  and  uterus,  followed  by  cesarean  
delivery,  can  be  done.    This  maneuver  was  
described  for  the  protruding  head  with  
intractable  shoulder  dystocia  and  is  termed  the  
Zavanelli  maneuver.  
•  Symphysiotomy  is  also  used  to  aid  delivery  of  an  
entrapped  a]ercoming  head.  Using  local  
analgesic,  this  opera,on  surgically  divides  the  
intervening  symphyseal  car,lage  and  much  of  its  
ligamentous  support  to  widen  the  symphysis  
pubis  up  to  2.5  cm    
 Breech  Decomposi,on  (Pinard)  
•  Maneuver  to  convert  frank  breech  into  a  
footling  breech  
•  Usually  followed  by  total  breech  extrac.on  
•  Pharmacological  relaxa,on  by  general  
anesthesia,  intravenous  magnesium  sulfate,  or  
a  beta-­‐mime,c  agent  such  as  terbutaline,  250  
μg  subcutaneously,  may  be  required.    
 Version  
•  With  this  procedure,  fetal  presenta,on  is  
altered  by  physical  manipula,on,  either  
subs,tu,ng  one  pole  of  a  longitudinal  
presenta,on  for  the  other,  or  conver,ng  an  
oblique  or  transverse  lie  into  a  longitudinal  
presenta,on.    
•  INTERNAL  or  EXTERNAL  
•  PODALIC  or  CEPHALIC  
 External  Cephalic  Version  
•  a?empted  before  labor  in  a  woman  who  has  
reached  36  weeks’  gesta,on  with  a  breech  
fetus    
•  Version  is  contraindicated  if  vaginal  delivery  is  
not  an  op,on    
§  Other  contraindica,ons  include  rupture  of  
membranes,  known  uterine  malforma,on,  
mul,fetal  gesta,on,  and  recent  uterine  bleeding.  
§  Prior  uterine  incision  is  a  rela,ve  contraindica,on.    
 External  Cephalic  Version  
Factors  influencing  success:  
§  mul,parity  
§  abundant  amnionic  fluid  
§  unengaged  presen,ng  part  
§  fetal  size  2500  to  3000  g  
§  posterior  placenta  
§  nonobese  pa,ent    
 External  Cephalic  Version  
Risks:  
•  placental  abrup,on  
•  uterine  rupture  
•  fetomaternal  hemorrhage  
•  alloimmuniza,on,  
•  preterm  labor  
•  fetal  compromise/death  
 External  Cephalic  Version  
Technique:  
•  Uterine  relaxant  must  be  used  
•  Sonographic  examina,on  is  performed  to  
confirm  nonvertex  presenta,on,  document  
amnionic  fluid  volume  adequacy,  exclude  obvious  
fetal  anomalies    
•  should  be  carried  out  in  an  area  that  has  ready  
access  to  a  facility  equipped  to  perform  an  
emergency  cesarean  delivery  
•  External  monitoring  is  performed  to  assess  fetal  
heart  rate  reac,vity.    
 External  Cephalic  Version  
•  A  forward  roll  of  the  fetus  usually  is  
a?empted  first.  Each  hand  grasps  one  fetal  
pole,  and  the  fetal  bu?ocks  are  elevated  from  
the  maternal  pelvis  and  displaced  laterally.  
The  bu?ocks  are  then  gently  guided  toward  
the  fundus,  while  the  head  is  directed  toward  
the  pelvis.    
•  If  the  forward  roll  is  unsuccessful,  then  a  
backward  flip  is  a?empted.    
 External  Cephalic  Version  
Version  a?empts  are  discon,nued  for:  
•   excessive  discomfort  
•  persistently  abnormal  fetal  heart  rate  
•  a]er  mul,ple  failed  a?empts  
 Internal  Podalic  Version  
•  used  only  for  delivery  of  a  second  twin    
•  with  the  membranes  preferably  s,ll  intact,  a  
hand  is  inserted  into  the  uterine  cavity  to  turn  
the  fetus  manually.  The  operator  seizes  one  or  
both  feet  and  draws  them  through  the  fully  
dilated  cervix,  while  using  the  other  hand  
transabdominally  to  push  the  upper  por,on  of  
the  fetal  body  in  the  opposite  direc,on    
•  This  is  then  followed  by  total  breech  extrac.on.