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-Deepa Mishra 
M. Sc. Nursing (OBG)
INTRODUCTION 
A breech birth is the birth of a baby from a 
breech presentation, in which the baby exits the 
pelvis with ...
DEFINITION 
It is a longitudinal lie in which the buttocks is the presenting 
part with or without the lower limbs. 
Accor...
INCIDENCE 
3-4% of fetus present by breech at 
term 
5% at 34 weeks 
20% at 28 weeks 
20% diagnosed initially in labour 
3...
TYPES 
Complete Breech 
(Flexed Breech) 
Incomplete 
Breech(30-35%)
1. Complete Breech (Flexed 
Breech) 
The normal attitude of 
full flexion is 
maintained. 
The thighs are flexed 
at the h...
2. Incomplete 
Breech(30-35%) 
Buttocks variety (70%) 
Incomplete variety with 
procidentia: One or more 
little parts (fo...
INCOMPLETE BREECH 
Frank Breech 
• It is breech with extended legs where the knees 
are extended while the hips are flexed...
TYPES OF INCOMPLETE BREECH
CLINICAL VARIETIES 
Uncomplicat 
ed 
It is defined as one 
where there is no 
other associated 
obstetric 
complications a...
POSITIONS 
Left Sacroanterior 
(LSA) 
Left Sacroposterior 
(LSP) 
Left Sacrolateral 
(LSL) 
Right Sacroanterior 
(RSA) 
Ri...
Etiology Of Breech Presentation 
Prematurity 
Factors preventing 
spontaneous version 
Favorable adaptation 
Undue mobilit...
DIAGNOSIS 
CLINICAL 
SONOGRAPHY 
RADIOLOGY
CLINICAL 
Complete Breech Frank Breech 
Per Abdomen 
Fundal Grip  Head- suggested by hard and 
globular mass 
 Head is b...
CLINICAL 
Complete Breech Frank Breech 
Pelvic Grip 
F.H.S. 
 Breech- suggested by soft, broad and 
irregular mass. 
 Br...
Ultrasonography 
1. It confirms the clinical diagnosis-specially 
in primigravidae with engaged 
frank breech or with tens...
DURING PREGNANCY 
Inspection 
• A transverse 
groove may be 
seen above the 
umbilicus in 
sacro-anterior 
corresponds to ...
DURING LABOUR 
 The 3 bony landmarks of breech namely 2 ischial tuberosities 
and tip of the scarum. 
 The feet are felt...
MECHANISM OF LABOUR 
Delivery of the 
buttocks 
Shoulders 
Head
Delivery of Buttocks 
• The engagement diameter is the bitrochantric diameter 10 cm which enters the pelvis 
in one of the...
Delivery of Shoulders 
• Bisacromial diameter (12 cm or 4 ¾”) engages in the same oblique 
diameter as that occupied by th...
Delivery of Head 
• Engagement occurs either through the opposite oblique diameter as that 
occupied by the buttocks or th...
MATERNAL 
FETAL 
PROGNOSIS
The Fetal Dangers 
• Intracranial Haemorrhage 
• Asphyxia 
• Injuries 
Prevention of the Fetal Hazards 
• The incidence of...
Identification of 
the complicating 
factors 
ANTENATAL 
MANAGEMEN 
T 
External 
cephalic 
version 
Formulation 
of the li...
External Cephalic Version 
Indications: 
Procedure 
Preliminaries 
Benefits of External Cephalic Version 
Causes of failur...
ELECTIVE CAESARIAN SECTION 
Indications for 
caesarian 
Big Baby (estimated fetal 
weight>3.5 kg) 
Hyperextension of the h...
VAGINAL BREECH DELIVERY 
Indications for vaginal 
breech delivery 
Adequate pelvis 
Average fetal weight (1.5-3.5 kg) 
Fle...
ASSISTED BREECH DELIVERY 
Preliminaries for conduction 
of normal labour 
Anaesthetist to administer 
anaesthesia as and w...
Steps 
Patient is to be placed in 
lithotomy position when the 
posterior buttock distends the 
perineum. 
To avoid aortoc...
Delayed in 
Descent of 
the Breech 
MANAGEMENT OF 
COMPLICATED 
BREECH DELIVERY 
Extended 
Arms 
Arrest of the 
After-comi...
Delayed in Descent of the Breech 
Arrested at the Outlet 
In the absence of outlet 
contraction and feto-pelvic 
dispropor...
Extended arms is due to faulty technique in delivery using 
unnecessary traction, forgetting the principle of ‘never pull ...
Arrest of After Coming Head 
At the Brim 
In the Cavity 
At the Outlet 
Delivery of the head through an incompletely dilat...
CONCLUSION: 
The incidence of Breech presentation 
expected to be low in hospitals where high parity 
births are minimal a...
Breech presentation
Breech presentation
Breech presentation
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Breech presentation

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Breech presentation

  1. 1. -Deepa Mishra M. Sc. Nursing (OBG)
  2. 2. INTRODUCTION A breech birth is the birth of a baby from a breech presentation, in which the baby exits the pelvis with the buttocks or feet first as opposed to the normal head-first presentation. In breech presentation, fetal heart sounds are heard just above the umbilicus. In a breech presentation, the lie is longitudinal and the podalic pole presents at the pelvic brim. It is the commonest malpresentation.
  3. 3. DEFINITION It is a longitudinal lie in which the buttocks is the presenting part with or without the lower limbs. According to Nima Bhaskar A breech birth is the birth of a baby from a breech presentation, in which the baby exits the pelvis with the buttocks or feet first as opposed to the normal head-first presentation. According to Wikipedia
  4. 4. INCIDENCE 3-4% of fetus present by breech at term 5% at 34 weeks 20% at 28 weeks 20% diagnosed initially in labour 3.5% term singleton deliveries and about 25% of cases before 30 weeks of gestation undergo spontaneous cephalic version up to term.
  5. 5. TYPES Complete Breech (Flexed Breech) Incomplete Breech(30-35%)
  6. 6. 1. Complete Breech (Flexed Breech) The normal attitude of full flexion is maintained. The thighs are flexed at the hips and the legs at knees. The presenting part consists of two buttocks, external genitalia and two feet. It is commonly present in multiparae.
  7. 7. 2. Incomplete Breech(30-35%) Buttocks variety (70%) Incomplete variety with procidentia: One or more little parts (footling, knees) precede the buttocks. Sacro-anterior positions are more common than sacroposterior as in the first the concavity of the fetal front fits into the convexity of the maternal spines
  8. 8. INCOMPLETE BREECH Frank Breech • It is breech with extended legs where the knees are extended while the hips are flexed. • More common in primigravida. Footling Presentation • The hip and knee joints are extended on one or both sides. • More common in preterm singleton breeches. Knee Presentation • The hip is partially extended and the knee is flexed on one or both sides
  9. 9. TYPES OF INCOMPLETE BREECH
  10. 10. CLINICAL VARIETIES Uncomplicat ed It is defined as one where there is no other associated obstetric complications apart from the breech, prematurity being excluded. Complicate d When the presentation is associated with conditions which adversely influence the prognosis such as prematurity, twins, contracted pelvis, placenta praevia etc.
  11. 11. POSITIONS Left Sacroanterior (LSA) Left Sacroposterior (LSP) Left Sacrolateral (LSL) Right Sacroanterior (RSA) Right Sacroposterior (RSP) Right Sacrolateral (RSL)
  12. 12. Etiology Of Breech Presentation Prematurity Factors preventing spontaneous version Favorable adaptation Undue mobility of the fetus Fetal abnormality
  13. 13. DIAGNOSIS CLINICAL SONOGRAPHY RADIOLOGY
  14. 14. CLINICAL Complete Breech Frank Breech Per Abdomen Fundal Grip  Head- suggested by hard and globular mass  Head is ballottable  Head  Irregular small parts of the feet may be felt by the side of the head.  Head is non-ballottable due to splinting action of the legs on the trunk. Lateral Grip  Fetal back is to one side and the irregular limbs to the other  Irregular parts are less felt on the side
  15. 15. CLINICAL Complete Breech Frank Breech Pelvic Grip F.H.S.  Breech- suggested by soft, broad and irregular mass.  Breech is usually not engaged during pregnancy  Usually located at a higher level round about the umbilicus  Small, hard and a conical mass is felt  The breech is usually engaged • Located at a lower level in the midline due to early engagement of the breech Per Vaginum During Pregnancy During labour  Soft and irregular parts are felt through the fornix  Palpation of ischial tuberosities, sacrum and the feet by the sides of the buttocks  The foot felt is identified by the prominence of the heel and lesser mobility of the great toe.  Hard feel of the sacrum is felt, often mistaken for the head • Palpation of ischial tuberosities, anal opening and sacrum only
  16. 16. Ultrasonography 1. It confirms the clinical diagnosis-specially in primigravidae with engaged frank breech or with tense abdominal wall and irritable uterus. 2. It can detect fetal congenital abnormality and also congenital anomalies of the uterus. 3. Type of breech (complete or incomplete). 4. It measures biparietal diameter, gestational age and approximate weight of the fetus. 5. It also localizes the placenta. 6. Assessment of liquor volume (important for ECV).
  17. 17. DURING PREGNANCY Inspection • A transverse groove may be seen above the umbilicus in sacro-anterior corresponds to the neck. • If the patient is thin, the head may be seen as a localized bulge in one hypochondrium Palpation • Fundal Grip: The head is felt as a smooth, hard, round ballottable mass which is often tender. • Umbilical Grip: The back is identified and a depression • First pelvic Grip: The breech is felt as a smooth, soft mass continues with the back. Trial to do ballottement to the breech shows that the movement is transmitted to the whole trunk. Auscultatio n FHS is heard above the level of the umbilicus. However in frank breech it may be heard at or below the level of the umbilicus. Ultrasonograp hy • To confirm the diagnosis. • To detect the type of breech. • To detect gestational age and foetal weight: Different measures can be taken to determine the foetal weight as the biparietal diameter with chest or abdominal circumference using a special equation. • To exclude hyperextension of the head. • To exclude congenital anomalies. • Diagnosis of
  18. 18. DURING LABOUR  The 3 bony landmarks of breech namely 2 ischial tuberosities and tip of the scarum.  The feet are felt beside the buttocks in complete breech.  Fresh meconium may be found on the examining fingers.  Male genitalia may be felt.
  19. 19. MECHANISM OF LABOUR Delivery of the buttocks Shoulders Head
  20. 20. Delivery of Buttocks • The engagement diameter is the bitrochantric diameter 10 cm which enters the pelvis in one of the oblique diameters. • Descent of the buttocks occurs until the anterior buttock touches the pelvic floor. • Internal rotation of the anterior buttock occurs through 1/8th of a circle placing it behind the symphysis pubis. • Further descent with lateral flexion of the trunk occurs until the anterior hip hinges under the symphysis pubis which is released first followed by the posterior hip. • 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.
  21. 21. Delivery of Shoulders • Bisacromial diameter (12 cm or 4 ¾”) engages in the same oblique diameter as that occupied by the buttocks at the brim soon after the delivery of breech. • Descent occurs with internal rotation of the shoulders bringing the shoulders to lie in the antero-posterior diameter of the pelvic outlet. The trunk simultaneously rotates externally through 1/8th of a circle. • Delivery of the posterior shoulder followed by the anterior one is completed by anterior flexion of the delivered trunk. • Restitution and external rotation :
  22. 22. Delivery of Head • Engagement occurs either through the opposite oblique diameter as that occupied by the buttocks or through the transverse diameter. The engaging diameter of the head is suboccipito-frontal (10 cm). • Descent with increasing flexion 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 sub-occiput hinges under the symphysis pubis. • The head is born by flexion- The chain, mouth, nose, forehead, vertex and occiput appearing successively. The expulsion of the head from the pelvic cavity depends entirely upon the bearing efforts and not at all on uterine contractions. • Sacro-posterior position: The mechanism is not substantially modified. The head has to rotate through 3/8th of a circle to bring the occiput behind the symphysis pubis.
  23. 23. MATERNAL FETAL PROGNOSIS
  24. 24. The Fetal Dangers • Intracranial Haemorrhage • Asphyxia • Injuries 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 caesarean section. • A skilled obstetrician along with an organized team consisting of a skilled anesthetist and an assistant should conduct vaginal breech delivery. • Vaginal manipulative delivery should be done by a skilled person with utmost gentleness, specially during delivery of the head.
  25. 25. Identification of the complicating factors ANTENATAL MANAGEMEN T External cephalic version Formulation of the line of management
  26. 26. External Cephalic Version Indications: Procedure Preliminaries Benefits of External Cephalic Version Causes of failure of version Dangers of Version Management, if version fails or is contraindicated
  27. 27. ELECTIVE CAESARIAN SECTION Indications for caesarian Big Baby (estimated fetal weight>3.5 kg) Hyperextension of the head Footling presentation (risk of cord prolapse) Suspected pelvic contraction Any obstetrical or medical complications During First Stage Cases seen first time in labour with presence of complications Arrest in the progress of labour Non-reassuring FHR pattern Cord presentation or prolapse
  28. 28. VAGINAL BREECH DELIVERY Indications for vaginal breech delivery Adequate pelvis Average fetal weight (1.5-3.5 kg) Flexed head and without any other complications Management of Vaginal Breech Delivery First Stage Second Stage
  29. 29. ASSISTED BREECH DELIVERY Preliminaries for conduction of normal labour Anaesthetist to administer anaesthesia as and when required An assistant to push down the fundus during contractions. Instruments and suture materials for episiotomy A pair of obstetric forceps for the after coming head, if required. Appliances for revival of the baby, if asphyxiated Principles in conduction Never to rush Never pull from below but push from above Always keep the fetus with the back anteriorly.
  30. 30. Steps Patient is to be placed in lithotomy position when the posterior buttock distends the perineum. To avoid aortocaval compression Antiseptic cleaning Pudendal block Episiotomy Patient is encouraged to bear down Soon after the trunk upto the umbilicus is born Delivery of the arms Delivery of the after coming head Burn-Marshall method Forceps delivery Malar Flexion and Shoulder traction (modified Mauriceau- Smellie- Veit technique) Resuscitation of the baby Third Stage ASSISTED BREECH DELIVERY
  31. 31. Delayed in Descent of the Breech MANAGEMENT OF COMPLICATED BREECH DELIVERY Extended Arms Arrest of the After-coming Head
  32. 32. Delayed in Descent of the Breech Arrested at the Outlet In the absence of outlet contraction and feto-pelvic disproportion Arrest of the breech at or above the level of ischial spines Frank Breech Extraction (Pinard’s Maneuver)
  33. 33. Extended arms is due to faulty technique in delivery using unnecessary traction, forgetting the principle of ‘never pull but push from above’ Diagnosis is made by noting the winging of the scapula and absence of the flexed limbs in front of the chest. Management : The management calls for the urgent delivery of the arms, first the posterior and then the anterior one. The delivery of the arm may be accomplished by adopting any one of the following methods: Classical Lovset Extended Arms
  34. 34. Arrest of After Coming Head At the Brim In the Cavity At the Outlet Delivery of the head through an incompletely dilated cervix Occipito- posterior position of the head through an incompletely dilated cervix
  35. 35. CONCLUSION: The incidence of Breech presentation expected to be low in hospitals where high parity births are minimal and routine external cephalic version done in antenatal period. Breech presentation can be managed by early diagnosis and effective management strategies. By using different maneuvers and skillful observation of the obstetrician.

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