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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
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
According to Wikipedia
3-4% of fetus present by breech at
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.
1. Complete Breech (Flexed
The normal attitude of
full flexion is
The thighs are flexed
at the hips and the
legs at knees.
The presenting part
consists of two
genitalia and two feet.
It is commonly present
Buttocks variety (70%)
Incomplete variety with
procidentia: One or more
little parts (footling,
knees) precede the
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
• It is breech with extended legs where the knees
are extended while the hips are flexed.
• More common in primigravida.
• The hip and knee joints are extended on one or
• More common in preterm singleton breeches.
• The hip is partially extended and the knee is
flexed on one or both sides
It is defined as one
where there is no
from the breech,
the prognosis such
as prematurity, twins,
placenta praevia etc.
Etiology Of Breech Presentation
Undue mobility of the fetus
Complete Breech Frank Breech
Fundal Grip Head- suggested by hard and
Head is ballottable
Irregular small parts of the feet
may be felt by the side of the
Head is non-ballottable due to
splinting action of the legs on
Lateral Grip Fetal back is to one side and the
irregular limbs to the other
Irregular parts are less felt on the
Complete Breech Frank Breech
Breech- suggested by soft, broad and
Breech is usually not engaged during
Usually located at a higher level round about
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
Soft and irregular parts are felt through the
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
Hard feel of the sacrum is felt, often mistaken
for the head
• Palpation of ischial tuberosities, anal
opening and sacrum only
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
4. It measures biparietal diameter,
gestational age and approximate weight of
5. It also localizes the placenta.
6. Assessment of liquor volume (important
• A transverse
groove may be
seen above the
• If the patient is
thin, the head may
be seen as a
localized bulge in
• Fundal Grip: The
head is felt as a
mass which is often
• Umbilical Grip: The
back is identified
and a depression
• First pelvic Grip:
The breech is felt
as a smooth, soft
with the back. Trial
to do ballottement
to the breech
shows that the
transmitted to the
FHS is heard above
the level of the
in frank breech it
may be heard at or
below the level of
• To confirm the
• To detect the type of
• To detect gestational
age and foetal
measures can be
taken to determine
the foetal weight as
diameter with chest
a special equation.
• To exclude
• To exclude
• Diagnosis of
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.
MECHANISM OF LABOUR
Delivery of the
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.
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 :
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.
The Fetal Dangers
• Intracranial Haemorrhage
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.
of the line of
External Cephalic Version
Benefits of External Cephalic Version
Causes of failure of version
Dangers of Version
Management, if version fails or is contraindicated
ELECTIVE CAESARIAN SECTION
Big Baby (estimated fetal
Hyperextension of the head
Footling presentation (risk of cord
Suspected pelvic contraction
Any obstetrical or medical
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
VAGINAL BREECH DELIVERY
Indications for vaginal
Average fetal weight (1.5-3.5 kg)
Flexed head and without any
Management of Vaginal
ASSISTED BREECH DELIVERY
Preliminaries for conduction
of normal labour
Anaesthetist to administer
anaesthesia as and when
An assistant to push down the fundus
Instruments and suture materials
A pair of obstetric forceps for the
after coming head, if required.
Appliances for revival of the baby, if
Principles in conduction
Never to rush
Never pull from below but push from
Always keep the fetus with the back
Patient is to be placed in
lithotomy position when the
posterior buttock distends the
To avoid aortocaval compression
Patient is encouraged to bear
Soon after the trunk upto the
umbilicus is born
Delivery of the arms
Delivery of the after
Malar Flexion and
Smellie- Veit technique)
Resuscitation of the baby
ASSISTED BREECH DELIVERY
Arrest of the
Delayed in Descent of the Breech
Arrested at the Outlet
In the absence of outlet
contraction and feto-pelvic
Arrest of the breech at or above
the level of ischial spines
Frank Breech Extraction
Extended arms is due to faulty technique in delivery using
unnecessary traction, forgetting the principle of ‘never pull but push
Diagnosis is made by noting the winging of the scapula and absence
of the flexed limbs in front of the chest.
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:
Arrest of After Coming Head
At the Brim
In the Cavity
At the Outlet
Delivery of the head through an incompletely dilated
Occipito- posterior position of the head through an
incompletely dilated cervix
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