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Breech
Fetal pole is of similar bulk earlier in pregnancy
 Therefore, maybe be breech in early
pregnancy
May continue as Breech presentation in:
15% at 29-32 weeks
3-4% at term deliveries
Williams Obstetrics 25th Edition, Copyright © 2018 by McGraw-Hill Education
Near term, the fetus turns/rotates
within the uterus
Bulk of the buttocks seeks the more
spacious fundus
Therefore, spontaneously converted to
cephalic presentation
Williams Obstetrics 25th Edition, Copyright © 2018 by McGraw-Hill Education
Classification of breech
presentations
• Complete breech (5-10%)
• Incomplete breech (10-30%)
 Footling breech
• Frank breech (50-70%)
Williams Obstetrics 25th Edition, Copyright © 2018 by McGraw-Hill Education
1. Frank Breech
Legs are extended at
the Knees
Feet in close
proximity to face
Thighs flexed at the hip
Williams Obstetrics 25th Edition, Copyright © 2018 by McGraw-Hill Education
1. Frank Breech – IE
Ischial Tuberosity and
Anus (palpable in a
straight line)
Sacrum
Williams Obstetrics 25th Edition, Copyright © 2018 by McGraw-Hill Education
2. Complete Breech
Thighs flexed at the hip
One/Both legs are flexed
at the knee Feet lie
ALONGSIDE
the buttocks
Williams Obstetrics 25th Edition, Copyright © 2018 by McGraw-Hill Education
2. Complete Breech – IE
Feet felt
ALONGSIDE the
buttocks
Sacrum is the
presenting part
Williams Obstetrics 25th Edition, Copyright © 2018 by McGraw-Hill Education
3. Incomplete Breech
One/Both Thighs
Extended at the hip
Foot is the presenting part
Williams Obstetrics 25th Edition, Copyright © 2018 by McGraw-Hill Education
3. Incomplete Breech – IE
Feet is felt as
presenting part
Williams Obstetrics 25th Edition, Copyright © 2018 by McGraw-Hill Education
Risk Factors
associated with breech presentations
Breech – Dr Ali S Mayali https://www.slideshare.net/3lisadeq/breech-presentation-81103930
Other factors:
l Prior cesarean delivery
l Maternal diabetes
l Short umbilical cord
l Uterine anomalies
l Fundal placental implantation
l Smoking
Williams Obstetrics 25th Edition, Copyright © 2018 by McGraw-Hill Education
l Uterine anomalies
l Placenta previa
l Fundal placental implantation
l Pelvic tumors (space
occupying lesions- myoma)
l High / grand multiparity with
uterine relaxation
l Previous breech delivery
l Smoking
Williams Obstetrics 25th Edition, Copyright © 2018 by McGraw-Hill Education
Diagnosis
of breech presentations
l Inspection
l Auscultation
l Percussion
l Palpation --> Leopold maneuvers
l Vaginal Examination
l Imaging Techniques
Williams Obstetrics 25th Edition, Copyright © 2018 by McGraw-Hill Education
1. Leopold maneuvers
First maneuver
l hard, round, ballotable
fetal head
occupies the fundus
Second maneuver
l back to be on one side of
the abdomen and the small
parts on the other
Williams Obstetrics 25th Edition, Copyright © 2018 by McGraw-Hill Education
Imagetakenfrom:
http://mtresources.tripod.com/Tre
atments/maneuvers.htm
Third maneuver, if not
engaged
l breech is movable above the
pelvic inlet
Fourth maneuver
l After engaged, firm breech to
be beneath the symphysis
Williams Obstetrics 25th Edition, Copyright © 2018 by McGraw-Hill Education
Imagetakenfrom:
http://mtresources.tripod.com/Tre
atments/maneuvers.htm
2. Vaginal Examination
Frank Breech
• Ischial Tuberosity and Anus
(palpable in a straight line)
• Sacrum
• External genitalia
Complete Breech
• Foot ALONGSIDE the buttocks
Incomplete Breech (Footling)
• Foot felt BEFORE the buttocks
Williams Obstetrics 25th Edition, Copyright © 2018 by McGraw-Hill Education
3. Imaging techniques
Identify:
• Type of Breech
• Neck flexed or extended
• Maternal Pelvimetry
(to know whether safe to attempt a
vaginal delivery)
Williams Obstetrics 25th Edition, Copyright © 2018 by McGraw-Hill Education
Ultrasound
Look for …
l Gross fetal abnormalities-
hydrocephaly/anencephaly
l Neck flexion / extension
l Fetal weight and BPD
estimation
X-Ray
If fetal attitude is uncertain after the ultrasound
May attempt vaginal delivery if:
1. No gross abnormalities
2. Flexed neck
3. 2500-3800g estimated
weight
4. No growth restriction
5. BPD is <10cm
Williams Obstetrics 25th Edition, Copyright © 2018 by McGraw-Hill Education
CT Scan / MRI
They are
superior in
assessing
Pelvic
dimensions
May attempt vaginal delivery if:
1. Inlet AP diameter ≥10.5cm
2. Inlet Transverse diameter ≥12cm
3. Midpelvic interspinous diameter ≥10cm
Williams Obstetrics 25th Edition, Copyright © 2018 by McGraw-Hill Education
May attempt vaginal delivery if
(Maternal-Fetal Biometry)
1. Inlet Obstetrical conjugate – BPD ≥1.5cm
2. Inlet Transverse diameter – BPD ≥2.5cm
3. Midpelvic interspinous diameter – BPD ≥0cm
Williams Obstetrics 25th Edition, Copyright © 2018 by McGraw-Hill Education
Route of Delivery
for breech presentations
Term Breech
• May attempt vaginal delivery (in Frank)
• Planned C-section
• Emergency C-section
Preterm Breech (32-37 weeks)
• Planned C-section
• Emergency C-section
Extremely Premature Breech (<24-25 weeks)
• No emergency C-section
Williams Obstetrics 25th Edition, Copyright © 2018 by McGraw-Hill Education
• Vaginal/cervical lacerations
• Extension of episiotomy 
later causing infections
• Anesthesia causing uterine
relaxation, leading to
Uterine atony and hence
Postpartum hemorrhage
• Fetal head entrapment,
intracranial bleeds
• Fractures of fetal humerus,
femur, clavicle, skull
• Hip dysplasia
• Brachial plexus injury
• Cervical spine injuries due
to neck hyperextension
• Umbilical cord prolapse 
Asphyxiation
• Testicular injury
• Maternal/fetal death
Complications associated with vaginal delivery:
Williams Obstetrics 25th Edition, Copyright © 2018 by McGraw-Hill Education
Vaginal Delivery:
Spontaneous breech delivery
l The fetus is expelled entirely spontaneously
without any traction or manipulation other than
support of the newborn
Partial breech extraction
l The fetus is delivered spontaneously as far as the
umbilicus
l The remainder of the body is extracted or
delivered with traction and assisted maneuvers
Total breech extraction
l The entire body of the fetus is extracted by the
obstetrician
Williams Obstetrics 25th Edition, Copyright © 2018 by McGraw-Hill Education
When the bag of waters is ruptured:
There is a increased chance of cord prolapse,
especially in
SGA, Complete and Incomplete Breech
Management of RBOW:
• Vaginal examination to make sure there is no
cord prolapse
• FHT monitoring for 5-10 mins following
RBOW
Williams Obstetrics 25th Edition, Copyright © 2018 by McGraw-Hill Education
Partial Breech Extraction
Steps in Delivery (Frank Breech):
1. HANDS OFF – Wait for the baby to
deliver until the Umbilicus
Rawa Muhsin https://www.youtube.com/watch?v=gmnr_MTyKwc
Pinard Maneuver:
Press on the popliteal fossa to
flex the knee
Hence, deliver both legs
Rawa Muhsin https://www.youtube.com/watch?v=gmnr_MTyKwc
Deliver the cord to prevent cord
compression
Rawa Muhsin https://www.youtube.com/watch?v=gmnr_MTyKwc
Sweep across baby’s face to
deliver one arm
Rawa Muhsin https://www.youtube.com/watch?v=gmnr_MTyKwc
In case of a nuchal arm …
Lovset Maneuver:
Rotate baby to aid the delivery
of the other arm
Rawa Muhsin https://www.youtube.com/watch?v=gmnr_MTyKwc
Sweep across baby’s face to
deliver the other arm
Rawa Muhsin https://www.youtube.com/watch?v=gmnr_MTyKwc
Delivery of
aftercoming head
1st Hand:
Baby’s maxilla lifted by index
finger + middle finger
Rest the baby’s body on the
hand + forearm
2nd hand:
Use index finger + middle
finger to grasp the baby’s
shoulder
Assistant: (Crede Maneuver)
Apply suprapubic pressure
1. Mauriceau-Smellie-Veit
maneuver
Rawa Muhsin https://www.youtube.com/watch?v=gmnr_MTyKwc
Delivery of
aftercoming head
2. Burns-Marshall
maneuver
Feet are grasped and with
gentle traction swept in a slow
arc over the maternal
abdomenRawa Muhsin https://www.youtube.com/watch?v=gmnr_MTyKwc
Delivery of
aftercoming head
2. Burns-Marshall
maneuver
Feet are grasped and with
gentle traction swept in a slow
arc over the maternal
abdomen
Rawa Muhsin https://www.youtube.com/watch?v=gmnr_MTyKwc
Delivery of
aftercoming head
3. Piper Forceps
A. The fetal body is held
elevated using a warm towel
and the left blade of 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
Williams Obstetrics 25th Edition, Copyright © 2018 by McGraw-Hill Education
In case of Head Entrapment …
1. Duhrssen incision
The incompletely dilated cervix is cut at 2 o’clock,
which is followed by a second incision at 10 o’clock
(and another at 6 o’clock if needed)
Theincisionsaresoplaced as to minimize bleeding
from the laterally located cervical branches of the
uterine artery
Williams Obstetrics 25th Edition, Copyright © 2018 by McGraw-Hill Education
In case of Head Entrapment …
2. Symphysiotomy
• Surgically divides the intervening symphyseal
cartilage and much of its ligamentous support to
widen the symphysis pubis up to 2.5 cm
• Indication:
Cesarean section is not available or unsafe for
the mother
• Complication:
Serious maternal pelvic or urinary tract injury
Williams Obstetrics 25th Edition, Copyright © 2018 by McGraw-Hill Education
In case of Head Entrapment …
3. Zavanelli maneuver
• replacement of the fetus higher into the vagina
and uterus, followed by cesarean delivery, can
be used to rescue an entrapped breech fetus
that cannot be delivered vaginally
Williams Obstetrics 25th Edition, Copyright © 2018 by McGraw-Hill Education
BREECH
In Twin Pregnancy
Both twins are in breech
presentation
Twin A is vertex, but Twin B is breech
• Vaginal of Twin A
then.
• External cephalic version
• Breech extraction
• C-section for the Twin B (vaginal-plus-C-section
If both twins were breech
• C-section
https://www.ijrcog.org/index.php/ijrcog/article/view/572/528
If Twin A is breech, Twin B is cephalic
• C-section
• Vaginal delivery can be considered as an
option for first twin breech specially in
multigravida – but is associated with an
increased chances of Locking/Locked
Twin
Leading twin in breech presentation, is routine caesarean section
necessary?
Lopamudra B. John, Reddi Rani P., Seetesh Ghose (Vol5 No2, 2016)
https://www.ijrcog.org/index.php/ijrcog/article/view/572/528
MULTIPLE PREGNANCY Supervisor : Prof. Salah Roshdy https://slideplayer.com/slide/6979329/
Thank you! 

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Breech Delivery

  • 2. Fetal pole is of similar bulk earlier in pregnancy  Therefore, maybe be breech in early pregnancy May continue as Breech presentation in: 15% at 29-32 weeks 3-4% at term deliveries Williams Obstetrics 25th Edition, Copyright © 2018 by McGraw-Hill Education
  • 3. Near term, the fetus turns/rotates within the uterus Bulk of the buttocks seeks the more spacious fundus Therefore, spontaneously converted to cephalic presentation Williams Obstetrics 25th Edition, Copyright © 2018 by McGraw-Hill Education
  • 5. • Complete breech (5-10%) • Incomplete breech (10-30%)  Footling breech • Frank breech (50-70%) Williams Obstetrics 25th Edition, Copyright © 2018 by McGraw-Hill Education
  • 6. 1. Frank Breech Legs are extended at the Knees Feet in close proximity to face Thighs flexed at the hip Williams Obstetrics 25th Edition, Copyright © 2018 by McGraw-Hill Education
  • 7. 1. Frank Breech – IE Ischial Tuberosity and Anus (palpable in a straight line) Sacrum Williams Obstetrics 25th Edition, Copyright © 2018 by McGraw-Hill Education
  • 8. 2. Complete Breech Thighs flexed at the hip One/Both legs are flexed at the knee Feet lie ALONGSIDE the buttocks Williams Obstetrics 25th Edition, Copyright © 2018 by McGraw-Hill Education
  • 9. 2. Complete Breech – IE Feet felt ALONGSIDE the buttocks Sacrum is the presenting part Williams Obstetrics 25th Edition, Copyright © 2018 by McGraw-Hill Education
  • 10. 3. Incomplete Breech One/Both Thighs Extended at the hip Foot is the presenting part Williams Obstetrics 25th Edition, Copyright © 2018 by McGraw-Hill Education
  • 11. 3. Incomplete Breech – IE Feet is felt as presenting part Williams Obstetrics 25th Edition, Copyright © 2018 by McGraw-Hill Education
  • 12. Risk Factors associated with breech presentations
  • 13. Breech – Dr Ali S Mayali https://www.slideshare.net/3lisadeq/breech-presentation-81103930
  • 14. Other factors: l Prior cesarean delivery l Maternal diabetes l Short umbilical cord l Uterine anomalies l Fundal placental implantation l Smoking Williams Obstetrics 25th Edition, Copyright © 2018 by McGraw-Hill Education
  • 15. l Uterine anomalies l Placenta previa l Fundal placental implantation l Pelvic tumors (space occupying lesions- myoma) l High / grand multiparity with uterine relaxation l Previous breech delivery l Smoking Williams Obstetrics 25th Edition, Copyright © 2018 by McGraw-Hill Education
  • 17. l Inspection l Auscultation l Percussion l Palpation --> Leopold maneuvers l Vaginal Examination l Imaging Techniques Williams Obstetrics 25th Edition, Copyright © 2018 by McGraw-Hill Education
  • 18. 1. Leopold maneuvers First maneuver l hard, round, ballotable fetal head occupies the fundus Second maneuver l back to be on one side of the abdomen and the small parts on the other Williams Obstetrics 25th Edition, Copyright © 2018 by McGraw-Hill Education Imagetakenfrom: http://mtresources.tripod.com/Tre atments/maneuvers.htm
  • 19. Third maneuver, if not engaged l breech is movable above the pelvic inlet Fourth maneuver l After engaged, firm breech to be beneath the symphysis Williams Obstetrics 25th Edition, Copyright © 2018 by McGraw-Hill Education Imagetakenfrom: http://mtresources.tripod.com/Tre atments/maneuvers.htm
  • 20. 2. Vaginal Examination Frank Breech • Ischial Tuberosity and Anus (palpable in a straight line) • Sacrum • External genitalia Complete Breech • Foot ALONGSIDE the buttocks Incomplete Breech (Footling) • Foot felt BEFORE the buttocks Williams Obstetrics 25th Edition, Copyright © 2018 by McGraw-Hill Education
  • 21. 3. Imaging techniques Identify: • Type of Breech • Neck flexed or extended • Maternal Pelvimetry (to know whether safe to attempt a vaginal delivery) Williams Obstetrics 25th Edition, Copyright © 2018 by McGraw-Hill Education
  • 22. Ultrasound Look for … l Gross fetal abnormalities- hydrocephaly/anencephaly l Neck flexion / extension l Fetal weight and BPD estimation X-Ray If fetal attitude is uncertain after the ultrasound May attempt vaginal delivery if: 1. No gross abnormalities 2. Flexed neck 3. 2500-3800g estimated weight 4. No growth restriction 5. BPD is <10cm Williams Obstetrics 25th Edition, Copyright © 2018 by McGraw-Hill Education
  • 23. CT Scan / MRI They are superior in assessing Pelvic dimensions May attempt vaginal delivery if: 1. Inlet AP diameter ≥10.5cm 2. Inlet Transverse diameter ≥12cm 3. Midpelvic interspinous diameter ≥10cm Williams Obstetrics 25th Edition, Copyright © 2018 by McGraw-Hill Education
  • 24. May attempt vaginal delivery if (Maternal-Fetal Biometry) 1. Inlet Obstetrical conjugate – BPD ≥1.5cm 2. Inlet Transverse diameter – BPD ≥2.5cm 3. Midpelvic interspinous diameter – BPD ≥0cm Williams Obstetrics 25th Edition, Copyright © 2018 by McGraw-Hill Education
  • 25. Route of Delivery for breech presentations
  • 26. Term Breech • May attempt vaginal delivery (in Frank) • Planned C-section • Emergency C-section Preterm Breech (32-37 weeks) • Planned C-section • Emergency C-section Extremely Premature Breech (<24-25 weeks) • No emergency C-section Williams Obstetrics 25th Edition, Copyright © 2018 by McGraw-Hill Education
  • 27. • Vaginal/cervical lacerations • Extension of episiotomy  later causing infections • Anesthesia causing uterine relaxation, leading to Uterine atony and hence Postpartum hemorrhage • Fetal head entrapment, intracranial bleeds • Fractures of fetal humerus, femur, clavicle, skull • Hip dysplasia • Brachial plexus injury • Cervical spine injuries due to neck hyperextension • Umbilical cord prolapse  Asphyxiation • Testicular injury • Maternal/fetal death Complications associated with vaginal delivery: Williams Obstetrics 25th Edition, Copyright © 2018 by McGraw-Hill Education
  • 28. Vaginal Delivery: Spontaneous breech delivery l The fetus is expelled entirely spontaneously without any traction or manipulation other than support of the newborn Partial breech extraction l The fetus is delivered spontaneously as far as the umbilicus l The remainder of the body is extracted or delivered with traction and assisted maneuvers Total breech extraction l The entire body of the fetus is extracted by the obstetrician Williams Obstetrics 25th Edition, Copyright © 2018 by McGraw-Hill Education
  • 29. When the bag of waters is ruptured: There is a increased chance of cord prolapse, especially in SGA, Complete and Incomplete Breech Management of RBOW: • Vaginal examination to make sure there is no cord prolapse • FHT monitoring for 5-10 mins following RBOW Williams Obstetrics 25th Edition, Copyright © 2018 by McGraw-Hill Education
  • 30. Partial Breech Extraction Steps in Delivery (Frank Breech): 1. HANDS OFF – Wait for the baby to deliver until the Umbilicus Rawa Muhsin https://www.youtube.com/watch?v=gmnr_MTyKwc
  • 31. Pinard Maneuver: Press on the popliteal fossa to flex the knee Hence, deliver both legs Rawa Muhsin https://www.youtube.com/watch?v=gmnr_MTyKwc
  • 32. Deliver the cord to prevent cord compression Rawa Muhsin https://www.youtube.com/watch?v=gmnr_MTyKwc
  • 33. Sweep across baby’s face to deliver one arm Rawa Muhsin https://www.youtube.com/watch?v=gmnr_MTyKwc
  • 34. In case of a nuchal arm … Lovset Maneuver: Rotate baby to aid the delivery of the other arm Rawa Muhsin https://www.youtube.com/watch?v=gmnr_MTyKwc
  • 35. Sweep across baby’s face to deliver the other arm Rawa Muhsin https://www.youtube.com/watch?v=gmnr_MTyKwc
  • 36. Delivery of aftercoming head 1st Hand: Baby’s maxilla lifted by index finger + middle finger Rest the baby’s body on the hand + forearm 2nd hand: Use index finger + middle finger to grasp the baby’s shoulder Assistant: (Crede Maneuver) Apply suprapubic pressure 1. Mauriceau-Smellie-Veit maneuver Rawa Muhsin https://www.youtube.com/watch?v=gmnr_MTyKwc
  • 37. Delivery of aftercoming head 2. Burns-Marshall maneuver Feet are grasped and with gentle traction swept in a slow arc over the maternal abdomenRawa Muhsin https://www.youtube.com/watch?v=gmnr_MTyKwc
  • 38. Delivery of aftercoming head 2. Burns-Marshall maneuver Feet are grasped and with gentle traction swept in a slow arc over the maternal abdomen Rawa Muhsin https://www.youtube.com/watch?v=gmnr_MTyKwc
  • 39. Delivery of aftercoming head 3. Piper Forceps A. The fetal body is held elevated using a warm towel and the left blade of 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 Williams Obstetrics 25th Edition, Copyright © 2018 by McGraw-Hill Education
  • 40. In case of Head Entrapment … 1. Duhrssen incision The incompletely dilated cervix is cut at 2 o’clock, which is followed by a second incision at 10 o’clock (and another at 6 o’clock if needed) Theincisionsaresoplaced as to minimize bleeding from the laterally located cervical branches of the uterine artery Williams Obstetrics 25th Edition, Copyright © 2018 by McGraw-Hill Education
  • 41. In case of Head Entrapment … 2. Symphysiotomy • Surgically divides the intervening symphyseal cartilage and much of its ligamentous support to widen the symphysis pubis up to 2.5 cm • Indication: Cesarean section is not available or unsafe for the mother • Complication: Serious maternal pelvic or urinary tract injury Williams Obstetrics 25th Edition, Copyright © 2018 by McGraw-Hill Education
  • 42. In case of Head Entrapment … 3. Zavanelli maneuver • replacement of the fetus higher into the vagina and uterus, followed by cesarean delivery, can be used to rescue an entrapped breech fetus that cannot be delivered vaginally Williams Obstetrics 25th Edition, Copyright © 2018 by McGraw-Hill Education
  • 44. Both twins are in breech presentation Twin A is vertex, but Twin B is breech • Vaginal of Twin A then. • External cephalic version • Breech extraction • C-section for the Twin B (vaginal-plus-C-section If both twins were breech • C-section https://www.ijrcog.org/index.php/ijrcog/article/view/572/528
  • 45. If Twin A is breech, Twin B is cephalic • C-section • Vaginal delivery can be considered as an option for first twin breech specially in multigravida – but is associated with an increased chances of Locking/Locked Twin Leading twin in breech presentation, is routine caesarean section necessary? Lopamudra B. John, Reddi Rani P., Seetesh Ghose (Vol5 No2, 2016) https://www.ijrcog.org/index.php/ijrcog/article/view/572/528
  • 46. MULTIPLE PREGNANCY Supervisor : Prof. Salah Roshdy https://slideplayer.com/slide/6979329/

Notas do Editor

  1. Because of the lower chances of fetal survival, it is not worth the risk of putting the mother through the risks of an emergency C-section