3. Definitions
• Breech Presentation-It is a longitudinal lie in which the buttocks is
the presenting part with or without the lower limbs.
• The cephalic pole in the uterine fundus
• 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
4. Epidemiology
• The commonest abnormal presentation 3 to 4% of all pregnancies
• Increases with decreasing gestational age
• 7 to 10% at 32 weeks
• 25 to 35% at < 28 weeks
• Normal in preterm when he fetus is more mobile, should not be taken
as abnormal until late pregnancy
5. Types/Classification
1. Complete breech: Both knees and hips are flexed, feet not below
level of buttocks. (5-10%) Cannon ball position More common in
multipara and Cord prolapse common
2. Frank breech: knees are extended while the hips are flexed. Most
common (50-70%) in pike position. More common in primgravida
3. Footling breech: The hip and knee joints are extended on one or
both sides. (10 – 30 %) high risk of cord and foot prolapse
• More common in preterm singleton breeches
8. Diagnosis (Clinically and Investigation)
Inspection
• Abdomen appear asymmetrical, SFL may be less than expected,
Distended abd? Polyhydramnios, difficult to felt fetal part, +ve fluid
thrill
Palpation
• Longitudinal lie, Broad lower pole, Hard at the fundus
Auscultation
• Fetal heart heard above the umbilicus
Vaginal Exam
• Soft buttock felt/ Feet in pelvis as leading part
Ultrasound
• Confirm the breech presentation
10. Cont.
Antenatal Care <37 weeks
• Wait for spontaneous version by 32-34w
• if not at 36w
1. Do an U/S to:
– Exclude fetal abnormality
– Confirm the presentation
– Localized the placenta
– Attitude of the fetal head
11. 2. Pelvimetry to
– Assess sacral curve
– Measure outlet and inlet
3. History taking
– To exclude contraindication criteria for ECV
• If not contraindicated: Perform an ECV
Intrapartum care
• Perform EMCS for any woman presenting in preterm labour with
breech presentation except where;
• vaginal birth is imminent
• The medical circumstances are such that survival of the fetus is
assessed to be unchanged by mode of delivery
12. External Cephalic Version
Contraindications to ECV
• Multiple pregnancy
• Vaginal Bleeding
• Low lying placenta
• Suspected IUGR
• Amniotic fluid abnormalities
• Uterine malformation
• Maternal cardiac disease
• Pregnancy-induced hypertension
• Major fetal anomaly
• PROM
Complications of ECV
• Premature Labour
• PROM
• Haemorrhage
• Fetal Distress
• The baby may turn back to
breech after ECV has been done
13. Types of Vaginal breech delivery
1. Spontaneous Breech Delivery
• No traction or manipulation of the infant is used. This occurs
predominantly in very preterm deliveries.
2. Total Breech Extraction
The fetal feet are grasped, and the entire fetus is extracted. Used only
for a non-cephalic second twin
3. Assisted Breech Delivery Most common
The infant is allowed to spontaneously deliver up to the umbilicus, and
then maneuvers are initiated to assist in the delivery of the remainder
of the body, arms, and head.
14. Prerequisites for a Safe Vaginal Breech Delivery
• In hospital with facilities for CS
• Adequate clinical pelvimetry
• The fetus is not too large
• No previous caesarean section for CPD
• Flexed head
• Frank or complete breech
• Birth is imminent/ normal labor progress
• Experienced Obstetrician
• IUFD
• Multiparas
15. Contraindications to vaginal breech delivery
• Large baby
• Small pelvis on pelvimetry or very flat sacrum
• Primigravid
• Previous casearean section
• Poor obstetric history
• Advanced maternal age
• Extended neck
• Footling
17. First stage
1. Set IV line
2. Obtain blood for FBC, Group and Save
3. Continuous CTG monitoring
4. Empty the bladder and rectum
5. Consider epidural analgesia
6. Patient in lithotomy
7. VE to look for cord presentation or prolapse and confirm cervical
dilatation
8. ARM if - cervix fully effaced, active phase of labour establish, no cord
presentation
18. Second stage
• 1.Delivery of buttocks, leg and lower body
• Once the buttocks have entered the vagina tell the woman she
can bear down with the contractions.
• Maternal expulsion delivers the frank breech from the lower
birth canal, while the contractile forces of the uterus maintain
flexion of the fetal head
19. • Let the buttocks deliver until the lower back and then the
shoulder blades are seen.
• Gently hold the buttocks in one hand but do not pull.
• If the legs do not deliver spontaneously, deliver one leg at a
time:
Pinard’s manoeuvre
• Do this by splinting the thigh whilst flexing and abducting the
hip.
•
20. • At this point the breech should hang downwards, while maternal
efforts expel the infant until the lower border of the scapula is
visible below the pubic arch.
• Wrap the baby in a towel and hold by the hips.
• Do not hold the baby by the flanks or abdomen as this may
cause kidney or liver damage.
• Gentle support by the clinician ensures the back does not rotate
posteriorly
21. 2.Delivery of shoulder
• For delivery of the shoulders and arms, the clinicians thumbs
overlie the sacrum with the fingers around the iliac crests, so that
the hands cradle the fetal pelvis
22. • Allow the arms to disengage spontaneously one by one.Only
assist if necessary.
• If the fetal arms have not become extended, the clinician
passes the index and middle fingers over the shoulder, and
sweeps the left arm medially across the chest, thus delivering it.
Repeat for the right arm
23. • If the fetal arms have extended, the clinician applies Lovset's
manoeuvre.
24. • The clinician rotates the body with the back uppermost, 180
degrees. The posterior
shoulder has been rotated anteriorly, and lies beneath the
symphysis.
• The clinician hooks the arm downwards, then rotates the body
back 180 degrees, to deliver the other arm in the same manner.
• If the baby’s body cannot be turned to deliver the arm that is
anterior first, deliver the shoulder that is posterior.
• Hold and lift the baby up by the ankles.
25. • Move the baby’s chest towards the woman’s inner leg.
The shoulder that is posterior should deliver.
26. • Lay the baby back down by the ankles. The shoulder that is
anterior should now deliver.
• Gentle elevation of the fetal trunk allows the clinician to access
to the fetal airway. You must avoid over-extension, because of
the risk of fetal cervical injury, and hyperextension of the fetal
head.
27. 3.Delivery of head
• Deliver the head by the Mauriceau Smellie Veit manoeuvre
• Lay the baby face down with the length of its body over your
hand and arm
• Place the first and third fingers of this hand on the baby’s
cheekbones and place the second finger beneath the chin,
ease the cheeks down and flex the head
• Use the other hand to grasp the baby’s shoulders
28. • With two fingers of this hand, gently flex the baby’s head
towards the chest while applying downward pressure on the
chicks to bring the baby’s head down until the hairline is visible.
• Pull gently to deliver the head
29. • However, even with optimum management of breech labour, the
fetal head may become trapped.
•
• Catheterize the bladder.
• Have an assistant hold the baby up towards the mothers
abdomen and apply forceps.
• Use the forceps to flex the baby’s head and deliver the head.
30. • If unable to use forceps, apply firm pressure above the mother’s
pubic bone to flex the baby’s head and push it through the pelvis.
• Clamp the cord early and continue with active management of
third stage of labor.
31. Complications of Vaginal breech delivery
Maternal:
• Prolonged labour with maternal
distress
• Obstructed labour.
• Laceration especially perineal.
• PPH due to prolonged labour
and lacerations.
• Puerperal sepsis.
Fetal
• Cord prolapse
• Birth trauma as a result of
extended arm or head,
incomplete dilatation of the
cervix or CPD
• Asphyxia from cord prolapse,
cord compression, placental
detachment or arrested head
• Damage to abdominal organs
• Broken neck
It confirms the clinical diagnosis- specially in primigravidae with engaged frank breech or with tense abdominal wall and irritable uterus.
It can detect fetal congenital abnormality and also congenital anomalies of the uterus.
Type of breech (complete or incomplete).
It measures biparietal diameter, gestational age and approximate weight of the fetus.
It also localizes the placenta.
Assessment of liquor volume (important for ECV).
Attitude of the head- flexion or hyperextension (Important for decision making at the time of delivery).
CT and MRI can be used to assess the pelvic capacity in addition to all the above mentioned information.
Should not be used for the single fetus
because the cervix may not be adequately
dilated to allow passage of the fetal head
Total breech extraction for the singleton
breech is associated with a birth injury rate of 25% and a mortality rate of approximately 10%.
If the perineum is very tight, consider an episiotomy to prevent soft tissue dystocia
Meconium is common with breech labour and is not a sign of fetal distress if the fetal heart rate is normal.
The woman should not push until the cervix is fully dilated.
