BREECH DELIVERY and

VACUUM EXTRACTION
 BREECH EXTRACTION AND DELIVERY

BREECH
 when the buttocks of the fetus enter the pelvis before
the head
 derives from the same word as britches, which
described a cloth covering the loins and thighs
 breech presentation is more common remote from
term
 before the onset of labor the fetus turns
spontaneously to a cephalic presentation, so that
breech presentation persists in only about 3 to 4
percent of singleton deliveries
 PREVALENCE OF BREECH PRESENTATION BY
GESTATIONAL AGE

PRESENTATION
Gestational Age (wks) BREECH VERTEX TOTAL BREECH (%)
28 218 676 894 24
29 78 296 374 21
30 78 381 459 17
31 29 152 181 13
32 92 637 729 11
33 59 507 566 11
34 6 118 124 5
35 30 392 422 7
36 8 131 139 6
37-40 5 131 136 4
 ETIOLOGY

 Gestational age
 Hydramnios
 Uterine relaxation associated with great parity
 Multiple fetuses
 Oligohydramnios
 Hydrocephaly
 Anencephaly
 Previous breech delivery
 Uterine anomalies
 Pelvic tumor
 Placenta previa
 COMPLICATIONS

 Perinatal morbidity and mortality from difficult

delivery.
 Low birthweight from preterm delivery, growth
restriction, or both.
 Prolapsed cord.
 Placenta previa.
 Fetal, neonatal, and infant anomalies.
 Uterine anomalies and tumors
 3 CATEGORIES OF BREECH

 1.DOUBLE FOOTLING BREECH

 3 CATEGORIES OF BREECH

 2.COMPLETE BREECH
 3 CATEGORIES OF BREECH

 3.FRANK BREECH
ABDOMINAL EXAMINATION:
LEOPOLD’S MANEUVER
 ABDOMINAL EXAMINATION:
LEOPOLD’S MANEUVER

 1st - hard, round, readily ballotable fetal head is found to

occupy the fundus
 2nd - indicates the back to be on one side of the abdomen and
the small parts on the other
 3rd - if engagement has not occurred—the intertrochanteric
diameter of the fetal pelvis has not passed through the pelvic
inlet—the breech is movable above the pelvic inlet
 4th - shows the firm breech to be beneath the symphysis

 *Breech Presentation-Fetal heart sounds usually are heard

loudest slightly above the umbilicus
 *Cephalic Breech- the heart sounds are loudest below the
umbilicus
 VAGINAL EXAMINATION

CATEGORIES OF BREECH
 ischial tuberosities, the sacrum, and the anus usually are
palpable
 after further descent, the external genitalia may be
distinguishe
 the anus may be mistaken for the mouth and the ischial
tuberosities for the malar eminences
 the finger encounters muscular resistance with the anus
 the finger, upon removal from the anus, sometimes is
FRANK BREECH stained with meconium
 the firmer, less yielding jaws are felt through the mouth
 the mouth and malar eminences form a triangular shape,
whereas the ischial tuberosities and anus are in a straight
line
 the most accurate information: the location of the sacrum
and its spinous processes, establishes the diagnosis of
position and variety
 VAGINAL EXAMINATION

CATEGORIES OF BREECH

COMPLETE BREECH feet may be felt alongside the buttocks

one or both feet are inferior to the buttocks

foot can readily be identified as right or left
FOOTLING BREECH
on the basis of the
relation to the great toe
 IMAGING TECHNIQUES

 ULTRASOUND-
 used to confirm a clinically suspected breech presentation and to
identify, if possible, any fetal anomalies
 If cesarean delivery is planned, additional imaging is not indicated.
If, however, vaginal delivery is considered, the type of breech
presentation and the degree of flexion or deflexion of the head is
important.

 CT SCAN
 will provide pelvic measurements and configuration at lower
doses of radiation than standard radiography

 MRI
 provides reliable information about pelvic capacity and
architecture without ionizing radiation
 not always readily available
 PROGNOSIS

 Both mother and fetus are at greater risk with breech

presentation compared with cephalic presentation

 Breech presentation may not be coincidental, but

rather is a consequence of poor fetal quality

 Obstetrical intervention will not eliminate all

mortality and long-term morbidity associated with
breech presentation
 PERINATAL MORBIDITY AND
MORTALITY

 prognosis for the fetus in a breech presentation is

considerably worse than when in a vertex
presentation

 major contributors to perinatal loss: preterm

delivery, congenital anomalies, and birth trauma

With a term fetus, some degree of head molding may

be essential for it to negotiate the birth canal
successfully.
 PERINATAL MORBIDITY AND
MORTALITY
 Thus, in certain cases:
 Delivery may be delayed many minutes while the aftercoming
head accommodates to the maternal pelvis, resulting in
hypoxia and acidemia, which can become severe; or
 Delivery may be forced, causing trauma from compression,
traction, or both.
 With a preterm fetus, the disparity between the size of the
head and buttocks is even greater than with a larger fetus
 umbilical cord length is significantly shorter in breech
presentations
 multiple coils of cord entangling the fetus are more common
with breech presentations
MECHANICAL PROBLEM ENCOUNTERED
IN DELIVERY OF BREECH DELIVERY:

 At times, the buttocks and lower extremities of the

preterm fetus will pass through the cervix and be
delivered, and yet the cervix will not be dilated
adequately for the head to escape

 Mechanical problem with breech delivery is

entrapment of the fetal arm behind the neck (nuchal
arm), which complicates up to 6 percent of vaginal
breech deliveries and is associated with increased
neonatal mortality
MECHANICAL PROBLEM ENCOUNTERED
IN DELIVERY OF BREECH DELIVERY:

 DUHRSSEN’S INCISION
 at 10 o'clock (already cut) and 2 o'clock (being
cut with bandage scissors) to relieve entrapped
aftercoming head. Infrequently, an additional
incision is required at 6 o'clock
 The incisions are so placed as to minimize
bleeding from the laterally located cervical
branches of the uterine artery.
 UNFAVORABLE PELVIS

 Because there is no time for molding of the

aftercoming head, a moderately contracted pelvis
that had not previously caused problems in delivery
of an average-size cephalic fetus might prove
dangerous with a breech
 Gynecoid (round) and anthropoid (elliptical)
pelves are favorable configurations
 platypelloid (anteroposteriorly flat) and android
(heart-shaped) pelves are not favorable
 HYPEREXTENSION OF THE
FETAL HEAD

 STARGAZER/FLYING FETUS- hyperextension

of the fetal head
 may result in injury to the cervical spinal cord
LABOR INDUCTION AND AUGMENTATION

 Induction of labor in women with a breech

presentation is defended by some clinicians and
condemned by others
 TERM BREECH FETUS

 PLANNED VAGINAL DELIVERY:

 Increased neonatal mortality and morbidity
 causes of death were head entrapment, cerebral injury and
intracranial hemorrhage, cord prolapse, and severe asphyxia

 PLANNED CS DELIVERY:
 PRETERM FETUS
 The aftercoming head of a preterm fetus may be trapped by a
cervix that is sufficiently effaced and dilated to allow passage
of the thorax but not of the less-compressible head.
 The consequences of vaginal delivery :hypoxia and physical
trauma
 preterm infants undergoing cesarean delivery had a better
prognosis
 RECOMMENDATIONS FOR DELIVERY

 Cesarean delivery is commonly but not exclusively used in

the following circumstances:
 A large fetus.
 Any degree of contraction or unfavorable shape of the
pelvis.
 A hyperextended head.
 When delivery is indicated in the absence of spontaneous
labor (some clinicians use oxytocin augmentation).
 Uterine dysfunction (some use oxytocin augmentation).
 RECOMMENDATIONS FOR DELIVERY

 Incomplete or footling breech presentation.

 An apparently healthy and viable preterm fetus with the
mother in either active labor or in whom delivery is
indicated.
 Severe fetal growth restriction.
 Previous perinatal death or children suffering from birth
trauma.
 A request for sterilization.
 Lack of an experienced operator
TECHNIQUES FOR BREECH DELIVERY
LABOR AND SPONTANEOUS DELIVERY
 Vaginal delivery requires skilled participation by the
obstetrician for a favorable outcome

 Engagement and descent

 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
 when the resistance of the pelvic floor is met, internal
rotation of 45 degrees usually follows, bringing the
anterior hip toward the pubic arch and allowing the
bitrochanteric diameter to occupy the anteroposterior
diameter of the pelvic outlet.
 If the posterior extremity is prolapsed, however, it rotates
to the symphysis pubis rather than the anterior hip.
TECHNIQUES FOR BREECH DELIVERY
LABOR AND SPONTANEOUS DELIVERY

 After rotation
 descent continues until the perineum is distended by the
advancing breech, and the anterior hip appears at the
vulva.
 By lateral flexion of the fetal body, the posterior hip then
is forced over the perineum, which retracts over the
buttocks, thus allowing the infant to straighten out when
the anterior hip is born.
 The legs and feet follow the breech and may be born
spontaneously or with aid.
 TECHNIQUES FOR BREECH DELIVERY
LABOR AND SPONTANEOUS DELIVERY

 After the birth of the breech, there is slight external

rotation, with the back turning anteriorly as the
shoulders are brought into relation with one of the
oblique diameters of the pelvis.
 The shoulders then descend rapidly and undergo
internal rotation, with the bisacromial diameter
occupying the anteroposterior plane.
 Immediately following the shoulders, the head, which is
normally sharply flexed upon the thorax, enters the
pelvis in one of the oblique diameters and then rotates in
such a manner as to bring the posterior portion of the
neck under the symphysis pubis.
 The head is then born in flexion.
 TECHNIQUES FOR BREECH DELIVERY
LABOR AND SPONTANEOUS DELIVERY

 The breech may engage in the transverse diameter of the

pelvis, with the sacrum directed anteriorly or posteriorly.
The mechanism of labor in the transverse position differs
only in that internal rotation occurs through an arc of 90
rather than 45 degrees. Infrequently, rotation occurs in
such a manner that the back of the infant is directed
posteriorly instead of anteriorly. Such rotation should be
prevented if possible. Although the head may be
delivered by allowing the chin and face to pass beneath
the symphysis, the slightest traction on the body may
cause extension of the head, which increases the
diameter of the head that must pass through the pelvis.
 METHODS OF VAGINAL DELIVERY

 3 GENERAL METHODS OF BREECH DELIVERY

 Spontaneous breech delivery. The infant is expelled
entirely spontaneously without any traction or
manipulation other than support of the infant.
 Partial breech extraction. The infant is delivered
spontaneously as far as the umbilicus, but the remainder
of the body is extracted or delivered with operator
traction and assisted maneuvers, with or without
maternal expulsive efforts.
 Total breech extraction. The entire body of the infant
is extracted by the obstetrician.
 MANAGEMENT OF LABOR

 Assessment to establish the status of the membranes,

labor, and fetal condition.
 Close surveillance of fetal heart rate and uterine
contractions.
 Recruitment of nursing, obstetrical, and anesthesia team
to accomplish a vaginal or abdominal delivery, nursery is
notified.
 A venous catheter is inserted and an infusion begun as
soon as the woman arrives in the labor suite.
 Emergency induction of anesthesia, or hemorrhage from
lacerations or from uterine atony, are but two of many
reasons that may require immediate intravenous access
for the administration of medications, fluids, or blood.
 STAGE OF LABOR

 Assessment of cervical dilatation and effacement

and the station of the presenting part are essential
for planning the route of delivery
 FETAL CONDITION

 Cesarean delivery is not performed under

emergency conditions for an anomalous infant
with no chance of survival.
 FETAL MONITORING

 Fetal heart rate is recorded at least every 15

minutes.
 Most clinicians prefer continuous electronic
monitoring of fetal heart rate and uterine
contractions.
 Vaginal examination should be performed
following rupture to check for cord prolapse.
 ROUTE OF DELIVERY

 choice of abdominal or vaginal delivery is based on

the type of breech, flexion of the head, fetal size,
quality of uterine contractions, and size of the
maternal pelvis
 TIMING OF DELIVERY

 Delivery is easier, and in turn, morbidity and mortality

are probably lower, when the breech is allowed to deliver
spontaneously to the umbilicus

 Delivery team include:

 1.An obstetrician skilled in the art of breech extraction.
 2.An associate to assist with the delivery.
 3.Anesthesia personnel who can assure adequate
analgesia or anesthesia when needed.
 4.An individual trained to resuscitate the infant
ASSISTED FRANK BREECH DELIVERY
ASSISTED FRANK BREECH DELIVERY
ASSISTED FRANK BREECH DELIVERY
ASSISTED FRANK BREECH DELIVERY
ASSISTED FRANK BREECH DELIVERY
FRANK BREECH EXTRACTION
FRANK BREECH EXTRACTION
COMPLETE/INCOMPLETE BREECH
EXTRACTION
COMPLETE/INCOMPLETE BREECH
EXTRACTION
COMPLETE/INCOMPLETE BREECH
EXTRACTION
COMPLETE/INCOMPLETE BREECH
EXTRACTION
COMPLETE/INCOMPLETE BREECH
EXTRACTION
COMPLETE/INCOMPLETE BREECH
EXTRACTION
 DELIVERY OF THE AFTERCOMING
HEAD
 MAURICEAU

 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 forearm is straddled by the fetal legs.

 Two fingers of the other hand then are hooked over the fetal
neck, and grasping the shoulders, downward traction is applied
until the suboccipital region appears under the symphysis.

 Gentle suprapubic pressure simultaneously applied by an

assistant helps keep the head flexed. The body then is elevated
toward the maternal abdomen, and the mouth, nose, brow, and
eventually the occiput emerge successively over the perineum.
 It is emphasized that with this maneuver, the
operator uses both hands simultaneously and
in tandem to exert continuous downward
gentle traction simultaneously on the fetal
neck and on the maxilla.

 At the same time, appropriate suprapubic pressure

applied by an assistant is helpful in delivery of the
head
 DELIVERY OF THE AFTERCOMING
HEAD

 2.PRAGUE MANEUVER
 the back of the fetus fails to rotate to the anterior.
 When this occurs, rotation of the back to the anterior
may be achieved by using stronger traction on the fetal
legs or bony pelvis.
 If the back still remains oriented posteriorly, extraction
may be accomplished using the Mauriceau maneuver and
delivering the fetus back down.
 If this is impossible, the fetus still may be delivered using
the modified Prague maneuver, which, as practiced
today, 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 the maternal abdomen
 FORCEPS TO AFTERCOMING HEAD

 PIPER FORCEPS –specialized forceps used to deliver the

aftercoming head.
 The blades of the forceps should not be applied to the
aftercoming head until it has been brought into the pelvis by
gentle traction, combined with suprapubic pressure, and is
engaged. Suspension of the body of the fetus in a towel
effectively holds the fetus and helps keep the arms out of the
way.

 A.The fetal body is elevated using a warm towel and the left
blade of the forceps is applied to the aftercoming head.
 B. The right blade is applied with the body still elevated.
 C. Forceps delivery of the aftercoming head.
 ENTRAPMENT OF THE AFTERCOMING
HEAD

 small preterm fetuses, the incompletely dilated

cervix will not allow delivery of the aftercoming
head. With gentle traction on the fetal body, the
cervix, at times, may be manually slipped over the
occiput.
DUHRSSEN INCISION
 ANALGESIA AND ANESTHESIA

 Anesthesia for breech decomposition and extraction

must provide sufficient relaxation to allow
intrauterine manipulations

 EPIDURAL ANALGESIA-provide sufficient

relaxation to allow intrauterine manipulations
 GENERAL ANESTHESIA-may be required to
relax the uterus as well as to provide analgesia
 MATERNAL INJURIES

 increase the risk of infection.

 rupture of the uterus, lacerations of the cervix
 extensions of the episiotomy and deep perineal tears
 Anesthesia sufficient to induce appreciable uterine
relaxation may cause uterine atony and, in turn,
postpartum hemorrhage.
 FETAL INJURIES

 Fracture of the humerus, clavicle and femur

 Hematomas of the sternocleidomastoid muscles
 brachial plexus injury
 VERSION

 procedure in which the fetal presentation is altered

by physical manipulation, either substituting one
pole of a longitudinal presentation for the other or
converting an oblique or transverse lie into a
longitudinal presentation
 PODALIC VERSION-the head or breech is made
the presenting part
 EXTERNAL CEPHALIC VERSION-
manipulations are performed exclusively through the
abdominal wall
INDICATIONS OF EXTERNAL CEPHALIC
VERSION

 breech presentation is recognized prior to labor in a

woman who has reached 36 weeks' gestation,
external cephalic version should be considered.
 should nIncreasing parityot be attempted if there is a
contraindication to vaginal delivery
 prior uterine incision is a relative contraindication
 FACTORS ASSOCIATED WITH
SUCCESSFUL VERSION

 Increasing parity
 fetal presentation, and then the amount of amnionic
fluid
 Gestational age
 maternal obesity, anterior placenta, cervical
dilatation, descent of the breech into the pelvis, and
anterior or posterior positioning of the fetal spine
TECHNIQUE
 UTZ is performed to confirm nonvertex presentation
and adequacy of amnionic fluid volume, to rule out
obvious fetal anomalies if not done previously, and
to identify placental location
 External monitoring is performed to assess fetal
heart rate reactivity.
 The nonstress test is repeated after version until a
normal test result is obtained
 FORWARD ROLL
 Each hand grasps one of the fetal poles, and the
buttocks are elevated from the maternal pelvis and
displaced laterally.
 The buttocks are then gently guided toward the
fundus, while the head is directed toward the pelvis

 BACKWARD FLIP
 CONDUCTION ANALGESIA- increased success
with version when epidural analgesia is used

 TOCOLYSIS- uterine relaxation with a tocolytic

agent
 COMPLICATIONS

 Placental abruption
 Uterine rupture
 Amnionic fluid embolism
 Fetomaternal hemorrhage
 Isoimmunization
 Preterm labor
 Fetal distress
 Fetal demise
 INTERNAL VERSION

 accomplished inside the uterine cavity

 used only for delivery of a second twin
 INTERNAL VERSION

 Insertion of a hand 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 to transabdominally push the
upper portion of the fetal body in the opposite
direction.
 The operation is followed by breech extraction
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