Breech Presentation

 Commonest malpresentation.
 The incidence is highly dependent on the gestational age.
 At 28 weeks about 20 % preganacies, at 34 weeks, 5 %.
 By full term, the incidence is about 3%.
 Etiology
Factors that appear to predispose to breech presentation -
 Prematurity – commonest cause
 Polyhydramnios / oligohydramnios
 Lax abdominal wall associated with great parity
 Multiple fetuses
 Hydrocephalus , Anencephaly
 Pelvic tumor
 Placenta implantation at cornual-fundal region
 Uterine abnormalities - Malformation, fibroids
 Fetal abnormalities - CNS Malformations; Neck Masses ,
IUD
 Previous breech delivery
Types Of Breech
• Complete (10%) : The hips
and knees are flexed
• Incomplete (25%) : due to
varying degrres of
extension of thighs or
legs.
- Frank (65%) : Hips are
flexed, knees are
extended.
- Footling : one of the
lower extremities is
lowermost.
- Knee : one /both knee
are lowermost
 Clinical Varieties
 Complicated breech
 Complicated breech delivery
 Positions
 Sacrum – denominator.
 Anterior positions - sacrum towards iliopubic eminence.
L.S.A.
R.S.A.
 Posterior positions - sacrum towards sacro-iliac joint.
R.S.P.
L.S.P.
 Diagnosis
 Abdominal examination –

– Hard round and ballotable fetal head is found to occupy the

fundus
– FHS heard loudest above the umbilicus
Leopold Maneuvers
 Diagnosis
Vaginal examination
 Frank breech -
• Both ischial tuberosities, sacrum and anus are palpable
• The mouth and malar eminences form triangular shape in
face whereas the ischial tuberosities and anus are in
straight line.
 Complete breech -
• Feet & external genitalia may be felt alongside the buttock
 Incomplete breech
• One or both feet are inferior to the buttock. Foot can be
differentiated from hand by position of thumb &
prominence of heel.
 Diagnosis
Imaging technique – Ultrasound
• Confirms a clinically suspected breech presentation and
fetal anomalies, liquor, placental localization
• If vaginal delivery is considered
– Type of breech presentation
– Degree of flexion or deflexion of head
 Mechanism of labor
Mechanism of labor -
 Delivery of buttocks
 Delivery of shoulders
 Delivery of aftercoming head
 Mechanism of labor in L.S.A.
Delivery of buttocks –
 Engagement and descent of breech
– Bitrochanteric diameter (10 cm) in lt. oblique diameter of
inlet
 Internal rotation of breech towards sacrum through 45°
– Bitrochanteric diameter in anteroposterior pelvic diameter
 Descent on perineum
 Lateral flexion of body – Forced by perineal floor – delivery
 Restitution of breech to relive torsion on trunk
 Mechanism of labor in L.S.A.
Delivery of shoulders -
 Engagement - Bisacromial diameter in lt. oblique diameter

 Internal rotation of shoulder – Bisacromial in AP diameter

 External rotation of the trunk

 Delivery of posterior followed by anterior shoulders

 Restitution to relive the torsion on neck

 Mechanism of labor in L.S.A.
Delivery of aftercoming head –
 Flexion of head upon the thorax
 Engagement of head – suboccipitofrontal (10 cm) in Rt.
oblique diameter of inlet ( rarely transverse )
 Internal rotation of occiput through 45o or 90o as to bring
the occiput behind pubic symphysis
 Further descent so that subocciput hinges under pubic
symphysis
 Delivery of head by flexion – chin – mouth - face - brow –
vertex – occiput succesively
 Antenatal Management
 Identification of complicating factors
 ECV
 Selection of patient for vaginal delivery
 ECV
External cephalic version : The object of this procedure is to
substitute a vertex for a less favourable presentation
Indication : The common indication for external cephalic
version is a breech or shoulder presentation diagnosed in
the last weeks of pregnancy.
Timing :
 A majority of the malpresentations correct themselves by
the 34th week of pregnancy. Therefore, it is advisable to
correct, by external version, breech and shoulder
presentations found persisting after 34 weeks.
 Correction could also be done prior to 34 weeks but more
often the abnormal presentation recurs.
 ECV
Prerequisites: - Before resorting to this procedure it is
necessary to make sure that
1) the abdominal wall is sufficiently thin to permit accurate
palpation,
2) the uterus is lax and contains sufficient liquor to help easy
mobility of the fetus,
3) the membranes have not ruptured, and
4) the presenting part is not deeply engaged.
5) Anti D Immunoglobulin in non immunized Rh-negative
mother
 ECV
Contraindications -
 A large baby, major congenital anomalies, IUD
 Significant contraction of the pelvis,
 Antepartum hemorrhage,
 Obstetric complications - Pre-eclampsia, multiple
pregnancy
 Previous caesarean section scar
 Uterine malformation
 PROM
 ECV
Technique:
 It is best to avoid anesthesia.
 The patient’s abdomen is bared and the presentation and
position of the fetus are carefully ascertained.
 Each hand then seizes each of the fetal poles. The cephalic
pole is then gently manipulated toward the pelvic inlet
while the other is moved in the opposite direction. By a
series of gentle stroking and pushing movements the head
is brought over the pelvic brim.
 To keep it in position, an abdominal pad and binder may be
applied.
 ECV
During the manipulations - which should always be gentle,
 The fetal heart should be auscultated frequently. Any
significant alterations in the fetal heart rate should be
taken as a warning, and it would be wise not to proceed
with the version.
 As far as possible the attitude of flexion in the fetus must
be maintained.
Follow up –
These patients should be re-examined a few days later (1
week)when if needed, version may be tried again. External
version can be attempted early in labour also, and chances
of recurrence of the malpresentation are very much
reduced.
 ECV
Causes of failure of version :
Frank breech, Oligohydramnios
Large baby, Obesity
Short cord
Complications :
 Abruption
 PPROM
 Preterm labor
 Entanglement of cord around fetal parts & formation of
true knot
 Fetomaternal haemorrhage
 Amniotic fluid embolism
 Management During Labor
 Types of Delivery -
Vaginal delivery:
- Spontaneous
- Partial breech extraction
- Total breech extraction
Cesarean of delivery
 Types Of Vaginal Breech Delivery
• Spontaneous breech (rare) : No manipulation of the infant
is necessary, other than supporting the infant.
• Assisted breech delivery (Partial breech extraction) : lower
half of Fetus (upto umbilicus) descends spontaneously at
the vaginal introitus; then the fetus is extracted
completely.
• Total breech extraction : The entire body is extracted. This
is indicated only if there is evidence of fetal distress
unresponsive to routine maneuvers and a cesarean delivery
is not possible.
 Conditions Unfavorable For Vaginal
Delivery
 Fetus weight more than 3500 g
 Unfavorable pelvis – Breech delivery does not allow
sufficient time for molding of the fetal head; thus a
platypelloid or android pelvis decreases ability of fetal
head to navigate maternal pelvis
 Hyperextension of the head – increases risk of cervical
spine injury
 Footling - incidence of umbilical cord prolapse increases
with coiling of the umbilical cord around the legs of the
fetus
 Indications For Cesarean Delivery
 Primi with breech
 Footling breech
 Any degree of contraction or unfavorable shape of pelvis
 Hyperextended head
 When delivery is indicated in the absence spontaneous
labor
 A large fetus
 Healthy ,viable preterm fetus with mother in active labor
 Severe IUGR
 Lack of an experienced operator
 Vaginal Delivery
Prerequisites –
 Multipara patient with previous normal delivery
 Uncomplicated breech presentation
 Estimated fetal weight – 1.5 – 3.5 kg
 Pelvic adequacy
 Flexed head
 Experienced operator
 Management Of Labor
 No place for induction of labor
 Rapid assessment of the patient
– Satisfactory progress in labor is the best indicator of pelvic
adequacy
– Close surveillance FHR and Uterine Contraction
 Assessment of fetal condition
– USG to detect anomalies and extended head if vaginal
delivery is planned
– Monitoring FHS every 15 min,
– When membranes rupture, per vaginum examination to
check for cord prolapse,
 Breech Vaginal Delivery
 The anterior buttock appears at the introitus
 A mediolateral episiotomy
 Further descent of the anterior buttock
 Both buttocks come into view.
 The buttocks are expelled by
voluntary maternal effort.
 The fetal sacrum rotates
anteriorly.
Breech Vaginal Delivery
 Breech Vaginal Delivery
 The legs are delivered by flexion of the thighs and knees.
 Assisted Delivery Of Frank Breech
 Moderate traction exerted by finger in each groin and
facilitated by generous episiotomy

 Pinard maneuver - Two fingers are inserted along one

extremity to the knee , then pushed away from midline
after spontaneous flexion to deliver a foot into vagina
 Assisted Delivery Of Frank Breech
Both groin method Pinard maneuver
 Breech Vaginal Delivery
 No downward or outward traction is applied until the
umbilicus has been reached
 A towel wrapped around the fetal hips, gentle downward
and outward traction in conjunction with maternal
expulsive efforts until the scapula is reached
 Don’t elevate body and keep the body low.
 Assisted Vaginal Breech Delivery
 After the scapula is reached,
the fetus should be rotated 90°
in order to deliver the anterior
arm.
 The anterior arm is
followed to the elbow,
and the arm is swept out
of the vagina.
 Assisted Vaginal Breech Delivery
 The fetus is rotated 180°,
and the contralateral arm
is delivered.
 The infant is then
rotated 90° to the
backup position in
preparation for delivery of
the head.
 Breech Vaginal Delivery
• Delivery of the anterior
shoulder - delivery of the
posterior shoulder.

• Back is kept anterior.

• The trunk is allowed to
hang to encourage
descent of the head.
 Delivery Of The Aftercoming Head
 Modified Mauriceau – Smellie - Veit maneuver
 Burns-Marshall method
 Forceps
 Prague maneuver
 Modified Mauriceau – Smellie – Veit
Maneuver
 Modified Mauriceau – Smellie – Veit maneuver – (Jaw
flexion shoulder traction )
– Baby placed on supinated left forearm with limbs on either
side
– Index and middle finger of one hand are applied over maxilla
to flex the head (originally index finger was introduced in
the mouth, not done to avoid dislocation of jaw).
– Use the other hand to grasp the baby’s shoulders.
– Downward traction until subocciput appears beneath the PS
– Elevate body toward maternal abdomen.
– Head flexion maintained by suprapubic pressure given by
assistant.
 Burns-Marshall Method
 Burns-Marshall method:
Fetus is left hanging.
Its weight will exert traction -- when occiput appears under
symphysis, fetus is grasped by feet and elevated upwards
towards mother’s abdomen.
 Forceps
 Forceps – Application of Piper forceps, employing towel
sling support.
 The forceps are introduced from below, left blade first
aiming directly for intended positions on sides of the head.
 Suspension of body in a towel effectively holds the fetus
and help keep the arm out of the way
 Type: Piper’s forceps which have long shank, perineal
curve
 Long Shank

Perineal Curve
 Piper Forceps
 Advantages:
1- Promotion of flexion
2- Traction is directly applied on head preventing
overstretch of neck so protecting roots of brachial plexus
3- Prevention of sudden compression and
decompression of head thus preventing ICH
4- Protection of head from injury by projecting ischial
spines in cases of mild degrees of contracted pelvis
 Difficulties
 Extended arm (nuchal arm)

 Entrapment Of Aftercoming Head

 Lovset's Maneuver
Extended Arm (nuchal arm) -
 Prerequisites- inferior angle of scaula is visible
underneath the pubic arch
 Anaesthesia – not required as intrauterine manipulation
is nil.
 Principle: The maneuver is based on the fact that the
posterior shoulder enters the pelvic cavity before the
anterior because of the curved birth canal. If the fetal
body is rotated with slight traction keeping back anterior
through 180° posterior shoulder will appear below the
pubic symphysis.
 Lovset's Maneuver
 Technique - The fetal body is lifted slightly and supported
by the obstetrician's hands, and is rotated with slight
traction through 180° (keeping back anterior), so that the
posterior shoulder comes to lie in front.
 Since it is on a lower level than the anterior shoulder, it will
deliver spontaneously or may be hooked out.
 The other shoulder may deliver spontaneously.
 If it is not delivered, the body of the child is now rotated
through 180° in the opposite direction, so that the other
arm is brought into the anterior position again, and the
arm and shoulder are born spontaneously. The back then
to be rotated to lie anteriorly.
 Entrapment Of Aftercoming Head
 Prague maneuver – in occipitoposterior

 Dührssen incision - Incision at 10 o’clock , 2 o’clock and

may required at 6 o’clock

 Symphysiotomy - rarely use, serious maternal injury

 Prague Maneuver
 Prague maneuver – Rarely, the back of the fetus is
posterior.
 Prague maneuver Consists of two fingers of one
hand grasping the shoulders of the back-down fetus from
below while the other hand draws the feet up over maternal
abdomen.
 Maternal Complications
 Increase risk of infection - caused by manual
manipulation within birth canal
 Maternal injuries -
- Rupture of uterus and cervical laceration - intrauterine
maneuver, delivery of after coming head through an
incompletely dilate cervix
- Deep perineal tear
- Extension of episiotomy
 Perinatal Complications
 Fetal injuries from difficult delivery-
Intracranial haemorrhage – tentorium cerebelli tear
Fracture humerus, clavicle & femur
Hematoma of sternocleidomastoid muscle
Dislocations – hip joint, cervical vertebrae, mandible
Brachial plexus injuries (paralysed arm)
Visceral injuries
 LBW from preterm delivery, IUGR or both
 Cord prolapse
 Anomalies
 Operative intervention, especially cesarean delivery