Breech presentation

1. BREECH PRESENTATION
Dr Amit Kumar Shrestha
MDGP Second Year Resident
( NAMS)
Bharatpur Hospital
Department of Obstetrics and Gynaecology
2073-12-31

2. -In breech presentation, the lie is longitudinal and the podalic pole
presents at the pelvic brim.
-It is the most common malpresentation.
Incidence:
-20% at 28th week
-5% at 34th week
-3–4% at term.

3. VARIETIES
• Complete (Flexed breech)
• Incomplete:
-Breech with extended legs (Frank breech)
-Footling presentation
-Knee presentation
Clinical varieties
(1) Uncomplicated
(2) Complicated - prematurity, twins, contracted pelvis, placenta previa, etc.

4. ETIOLOGY
• Prematurity: most common
• Factors preventing spontaneous version: (a) Breech with extended legs, (b) Twins,
(c) Oligohydramnios, (d) Congenital malformation of the uterus such as septate or
bicornuate uterus, (e) Short cord, relative or absolute, (f ) Intrauterine death of
the fetus.
• Favorable adaptation: (a) Hydrocephalus (b) Placenta previa, (c) Contracted
pelvis, (d) Cornu-fundal attachment of the placenta
• Undue mobility of the fetus: (a) Hydramnios, (b) Multiparae
• Fetal abnormality: Trisomies 13, 18, 21, anencephaly and myotonic dystrophy due
to alteration of fetal muscular tone and mobility.

5. DIAGNOSIS
CLINICAL-
• Clinical:

6. ULTRASONOGRAPHY
• confirms the clinical diagnosis
• detect fetal congenital abnormality and also congenital anomalies of the uterus.
• Type of breech
• It measures biparietal diameter, gestational age and estimated weight of the
fetus.
• localizes the placenta.
• Assessment of liquor volume
• Attitude of the head

7. POSITIONS:
Sacrum is the denominator
• First position—left sacroanterior -most common
• Second position— right sacroanterior (RSA)
• Third position—right sacroposterior (RSP) and
• Fourth position—left sacroposterior (LSP).

8. MECHANISM OF LABOR
• SACROANTERIOR POSITION
Buttocks
• engaging diameter is bitrochanteric
• Descent of the buttocks
• Internal rotation of the anterior buttock
• Further descent with lateral fl exion of the trunk
• Delivery of the trunk and the lower limbs follow.
• Restitution occurs so that the buttocks occupy the original position as during engagement in
oblique diameter.

9. Shoulders :
-Bisacromial diameter engages
- Descent occurs with internal rotation of the shoulders
- Delivery of the posterior shoulder followed by the anterior one is completed by anterior fl exion of the
delivered trunk.
- Restitution and external rotation
Head :
- engaging diameter of the head is suboccipitofrontal
-Descent with increasing fl exion occurs.
- Internal rotation of the occiput occurs anteriorly, through 1/8th or 2/8th of a circle placing the occiput
behind the symphysis pubis.
- Further descent occurs until the subocciput hinges under the symphysis pubis.
-Head is born by fl exion—chin, mouth, nose, forehead, vertex and occiput appearing successively.

10. PROGNOSIS OF VAGINAL BREECH DELIVERY
MATERNAL:
risks include
-trauma to the genital tract,
-operative vaginal delivery (episiotomy, forceps),
-cesarean section,
-sepsis
-anesthetic complications.

11. FETAL:
• perinatal mortality ranges from 5 to 35 per 1,000 births.
• The overall perinatal mortality in breech still remains 9–25% compared with 1–2%
for nonbreech deliveries.
• The factors which significantly influence the fetal risk are—
(a) skill of the obstetrician,
(b) weight of the baby,
(c) position of the legs and
(d) type of pelvis.

12. THE DANGERS TO THE BABY
(1) Intrapartum fetal deaths
(2) Injury to brain and skull —
-Intracranial hemorrhage
-Fracture of the skull
(3) Birth asphyxia: It is due to—
-Cord compression
-Retraction of the placental site
-Premature attempt at respiration
-Delayed delivery of the head
-Cord prolapse
- Prolonged labor.
(4) Birth Injuries
-Hematoma
-Fractures
-Visceral injuries
-Nerve injuries
(5) Congenital Malformations

13. PREVENTION OF THE FETAL HAZARDS
-The incidence of breech can be minimized by external cephalic version where
possible.
-If the version fails or is contraindicated, delivery is done by elective cesarean
section.
-Vaginal breech delivery should be conducted by a skilled obstetrician along with an
organized team consisting of a skilled anesthetist and neonatologist .
-Vaginal manipulative delivery should be done by a skilled person with utmost
gentleness, especially during delivery of the head.

14. ANTENATAL MANAGEMENT
-Identifi cation of the complicating factors
-External cephalic version, if not contraindicated.
- Formulation of the line of management, if the version fails or is
contraindicated

15. External Cephalic Version (ECV):
• The success rate of version is about 65%
• Time of version: ECV has been considered
from 36 weeks onward

16. Benefits of ECV are—
(i) Reduction in the incidence of breech presentation at term,
(ii) Reduction in the incidence of breech delivery (Vaginal or cesarean) and the associated complications
(iii) Reduction in the incidence of cesarean delivery by 5%.
Successful version is likely in cases of:
(i) Complete breech,
(ii) Nonengaged breech,
(iii) Sacroanterior position (fetal back anteriorly),
(iv) Adequate liquor,
(v) Nonobese patient.
Causes of failure of version:
(1) Breech with extended legs
(2) Scanty liquor or big size baby.
(3) Mechanical—obesity
(4) Short cord— either relative (common) or absolute.
(5) Uterine malformations—septate or bicornuate.

17. Dangers of version:
(1) premature onset of labor,
(2) premature rupture of the membranes,
(3) placental abruption and bleeding,
(4) entanglement of the cord
(5) increased chance of fetomaternal bleed.
(6) Amniotic fluid embolism.
Management, if version fails or is contraindicated:
the assessment of the case is to be done —
(1) age of the mother especially in primigravidae,
(2) associated complicating factors,
(3) size of the baby and
(4) pelvic capacity
Ultrasonographic examination is the gold standard for decision making
Two methods of delivery can be planned.
- To perform an elective cesarean section.
-To allow spontaneous labor to start and vaginal breech delivery to occur.

18. Elective Cesarean Section:
The indications of CS in breech are:
• Big baby (estimated fetal weight >3.5 kg), small baby (<1.5 kg),
• hyperextension of the head (stargazing fetus),
• footling presentation (risk of cord prolapse),
• suspected pelvic contraction or severe IUGR.
• Any associated complications (obstetric or medical)
The overall incidence of cesarean section in breech ranges from 15% to 50%,

19. Vaginal breech delivery:
Criteria to be fulfilled are—
(i) average fetal weight (between 1.5 kg and 3.5 kg),
(ii) flexed fetal head,
(iii) adequate pelvis,
(iv) without any other (medical or obstetric) complications,
(v) availability of facilities for emergency cesarean section (anesthetists, neonatologist),
(vi) facilities for continuous labor monitoring (preferably electronic) and
(vii) presence of obstetrician experienced with vaginal breech delivery,

20. MANAGEMENT OF VAGINAL BREECH DELIVERY
FIRST STAGE:
• Vaginal examination is indicated—
• (a) at the onset of labor for pelvic assessment,
• (b) soon after rupture of the membranes to exclude cord prolapse.
• An intravenous line is sited with Ringer’s solution, oral intake is avoided, blood is sent for group
and cross matching (considering the chance of CS).
• Adequate analgesia is given, epidural is preferred.
• Fetal status and progress of labor are monitored.
• Oxytocin infusion may be used for augmentation of labor.
Indications of Cesarean Section (CS):
(a) Cases seen for the first time in labor with presence of complications;
(b) Arrest in the progress of labor;
(c) Nonreassuring FHR pattern (Fetal distress);
(d) Cord presentation or prolapse.

21. SECOND STAGE:
There are three methods of vaginal breech delivery:
-Spontaneous (10%):
Expulsion of the fetus occurs with very little assistance. Th is is not preferred
-Assisted breech: The delivery of the fetus is by assistance from the beginning to the end.
This method should be employed in all cases (see below).
- Breech extraction (partial or total):
When part or the entire body of the fetus is extracted by the obstetrician.
It is rarely done these days as it produces trauma to the fetus and the mother.
Indications are:
(a) Delivery of the second twin after IPV
(b) Cord prolapse
(c) Extended legs arrested at the cavity or at the outlet..

23. ASSISTED BREECH DELIVERY
• lithotomy position
• avoid aortocaval compression
• Antiseptic cleaning
• Pudendal block
• Episiotomy
• patient is encouraged to bear down
• Soon after the trunk up to the umbilicus is born.
Th e following are to be done:
(a) Th e extended legs (in frank breech) are to be decomposed by pressure on the knees (popliteal
fossa) in a manner of abduction and flexion of the thighs
(b) Th e umbilical cord is to be pulled down
(c) If the back remains posteriorly, rotate the trunk to bring the back anteriorly (sacroanterior).

24. Delivery of the arms:

25. Delivery of the aftercoming head:
(a) Burns-Marshall method

26. (b) Forceps delivery

27. (c) Malar flexion and shoulder traction (modified Mauriceau-
Smellie-Veit technique):

28. MANAGEMENT OF COMPLICATED BREECH DELIVERY
DELAY IN DESCENT OF THE BREECH
• Arrested at the outlet are—(a) big size baby with extended legs (the most common), (b) weak
uterine contractions, (c) rigid perineum and (d) outlet contraction.
• Management:
- If the outlet is contracted and/or the baby is big, cesarean section .
- In the absence of outlet contraction and feto-pelvic disproportion: Liberal episiotomy and
fundal pressure with or without groin traction
• Arrest of the breech at or above the level of ischial spines: The causes may be: (i) Pelvic
contraction, (ii) Big baby, (iii) Weak uterine contraction.
The best treatment in such cases is delivery by cesarean section.

30. Frank breech extraction (Pinard’s maneuver)

31. EXTENDED ARMS
• One or both the arms may be fully stretched along the side of the head or lie
behind the neck (nuchal displacement).
• LOVSET’S MANEUVER

33. ARREST OF THE AFTERCOMING HEAD
At the brim:
• The causes of arrest are—(1) deflexed head (2) contracted pelvis and (3 hydrocephalus.
• Management:
(1) If the arrest is due to a deflexed head, the delivery is to be completed by malar flexion and
shoulder traction along with suprapubic pressure by the assistant.
In the cavity:
The causes of arrest of the head in the cavity are—(1) deflexed head and (2) contracted pelvis.
• The best management is delivery of the head by forceps which is effective in both the
circumstances.
• Malar flexion and shoulder traction may be effective only in deflexed head.

34. At the outlet:
The causes of arrest are—(1) rigid perineum and (2) deflexed head.
Episiotomy followed by forceps application or malar flexion and shoulder
traction is quite effective.
Delivery of the head through an incompletely dilated cervix:
The common causes are—(1) premature baby, (2) macerated baby, (3) footling
presentation and (4) hasty delivery of breech before the cervix is fully dilated.
Management:
If the baby is living, the cervix is to be pushed up while traction of the fetal
trunk is made by malar flexion and shoulder traction (shoe-horn method). If
necessary, Duhrssen’s incision can be made at 2 and 10 O’ clock position on the
cervix.

35. References-
1. Williams Obstetrics , 24 th edition
2. Textbook of Obstetrics, D C Dutta , 8 th edition

36. THANK YOU