Breech Presentation

PRESENTED BY,

Dr. (Mrs). S. Anuchithra,

Vice Principal Cum HOD OBG Nursing, P.D.Bharatesh College of Nursing, Halaga, Belgaum.

Meaning
An unusual presentation Not to be considered abnormal - fetus lies

longitudinally with the buttocks in the lower

pole of the uterus.

Presenting

diameter is the bitrochanteric

(10cm)
Denominator the sacrum.

Breech presentation

Breech presentation

Breech presentation

 It is the commonest malpresentation Reassure mother for normal labour and birth. Ensuring informed consent - that not all

breech babies can or should be born vaginally.

Incidence Breech Presentation

1 in 5 at 28th week

5% at 34th week - 3 out of 4, spontaneous

correction in to vertex
In mid-trimester frequency is much higher -

greater proportion of amniotic fluid facilitates free movement of the fetus.

 The incidence in all pregnancies is about 3-4%. Advancing gestational age - % of breech

deliveries decreases
25% of births prior to 28 weeks' gestation 7% of births at 32 weeks' gestation 1-3% of births at term.

 Fetal abnormalities are observed in

17% of pre-term breech deliveries and In 9% of term breech deliveries.

Cord prolapse occurs in 7.5% of all breeches.

This incidence varies with the type of breech:
0-2% with frank breech,
5-10% with complete breech, and

 10-25% with footling breech.

Cord prolapse occurs twice as often in women

who

have

had

previous

pregnancy

(or

multiparas) (6%) than in the first time pregnancy (or primigravidas) (3%).

 Nuchal arms(one or both

arms are wrapped around the back of the neck) present in 0-5% of

vaginal breech deliveries and in 9% of breech extractions.

 Fetal head entrapment - result from an

incompletely dilated cervix and head that lacks time to mould to the maternal pelvis - occurs in 0-8.5% of vaginal breech deliveries.

Types or Varieties
Complete
Incomplete

Complete Breech
Normal attitude of full flexion

is maintained.
The thighs are flexed at the

hips and the legs at the knees.

The presenting part consists of

two

buttocks,

external

genitalia and two feet.

Commonly

present

in

multipara.

Incomplete Breech
Due to varying degrees of

extension of thighs or legs at the podalic pole.

Three varieties are possible

Incomplete Breech

Breech with Extended Legs

Footling Presentation

Knee Presentation

Breech with Extended Legs

Thighs are flexed on the trunk and

the legs are extended at the knee joints.

The presenting part - the two

buttocks and external genitalia only.

Common in primigravida 70% -

tight abdominal wall, good uterine

tone and early engagement of

breech.

Footling Breech
Both the thighs and the

legs

are

partially
the

extended

bringing

legs to present at the

brim.

Knee presentation
Thighs are extended but

the knees are flexed,

bringing the knees down

to present at the brim.

Clinical varieties
Uncomplicated Complicated
Defined as one where When the presentation is

there

is

no

other

associated conditions

with which

associated complications from the

obstetric apart breech,

adversely influence the prognosis - prematurity,

prematurity
excluded.

being

twins, contracted pelvis,

placenta praevia etc.

Six positions - Breech Presentation

RSP

LSP

RSL

LSL

RSA

LSA

Etiology
Cause remains obscure. Prematurity Factors preventing spontaneous version

Favourable adaptation
Undue mobility of the fetus

Fetal abnormality
Recurrent or habitual breech

Diagnosis
I. Antenatal diagnosis

a. Abdominal examination,
b. Ultrasound examination,

c. X-ray examination
II. Diagnosis during labour

a. Abdominal examination,
b. Vaginal examination

I. Antenatal diagnosis a. Abdominal examination

1. Listen to the mother,
2. Palpation and

3. Auscultation

I. Antenatal diagnosis 2. Palpation

Primigravida difficult to diagnose - firm

abdominal muscles.
Lie is longitudinal with a soft presentation-

easily felt using pawliks grip

Head felt in the fundus - round hard mass.

 May be made to move independently - with one

or both hands.
Extended legs & feet prevents nodding.

When the breech is anterior and the fetus well

flexed - may be difficult to locate the head - but

use of the combined grip (upper and lower

poles) may aid diagnosis.

I. Antenatal diagnosis 3. Auscultation

FHS clear above umbilicus - If breech has not

passed through the pelvic brim.

FHS heard at a lower level -

when legs are

extended & breech descends into the pelvis.

I. Antenatal diagnosis b. Ultrasound examination

Used to demonstrate a breech presentation.

(1) Confirms the clinical diagnosis

(2) Can detect fetal congenital abnormality (3)Measures biparietal diameter, GA and approximate weight of the fetus. (4) Locates the placenta. (5) Assessment of liquor volume (important for ecv). (6) attitude of the head

I. Antenatal diagnosis c. X-ray examination

Added advantage - allowing pelvimetry to be

performed
A straight x-ray is rarely done:

(1) To confirm the clinical diagnosis. (2)To exclude bony congenital malformation (hydrocephalus). (3) To note the size of the baby. (4) To note the position of the limbs and the head.

II. Diagnosis during labour a. Abdominal examination

Examination Complete breech Frank breech

Per abdomen

Head suggested Head irregular small parts by hard and of the feet may be felt by the side of the head.

Fundal grip globular mass.

Head is ballotable. Head is non-ballotable due

to splinting action of the legs

on the trunk

Examination

Complete breech

Frank breech

Lateral grip Fetal back is to one side Irregular parts are less and the irregular limbs to felt on the side the other. Pelvic grip Breech suggested by Small hard and conical soft, broad and irregular mass is felt mass. Breech engaged pregnancy. usually The breech is usually not engaged during

Examination

Complete breech

Frank breech

FHS

Usually

above Located in lower level in the

the umbilicus

midline

due

to

early

engagement of the breech Per vaginal Soft, During pregnancy parts through fornix irregular Hard feel of sacrum is felt, are felt often mistaken for the head. the Palpation of ischial

tuberosities, anal opening and sacrum only.

II. Diagnosis during labour b. Vaginal Examination

The breech feels soft and irregular with no

sutures palpable,
Occasionally the sacrum may be mistaken for a

hard head and the buttocks mistaken for caput succedaneum.

 The anus may be felt and fresh meconium on

the examining finger is usually diagnostic.

If the legs are extended - external genitalia are

very evident (become edematous).

An edematous vulva may be mistaken for a

scrotum.

 If a foot is felt - differentiate it from the hand. Toes are all the same length, shorter than fingers and the big toe cannot be

opposed to other toes.

The foot is at right angles to the leg, and

the heel has no equivalent in the hand.

No feet felt; the legs are extended.

Feet felt; complete breech presentation

Antenatal Management
Identification of the complicating factors External cephalic version Formulation of the line of management

Identification of the complicating factors

Clinical examination,
Sonography - useful to detect
Congenital malformations of the fetus,
The precise location of the placental site and Congenital anomalies of the uterus.

External cephalic version

Definition: External cephalic version (ECV) is

the use of external manipulation on the

mothers abdomen to convert a breech to a

cephalic presentation.

 The success rate of version is about 60% Successful

version

reduces

the

risk

of

caesarean section significantly.

Prior Sonography should be a routine.
Cardiotocography should ideally be done

before and after the procedure.

Time of version:
At 35-37 weeks but can be attempted at any

time thereafter up to early labour.

Version in the early weeks is easy but chance of

reversion is more.
Late version may be difficult - increasing size of

the fetus and diminishing volume of liquor amnii tocolysis makes less difficult.

 Time of version:
Routine version at 35 to 37 weeks may have

advantages.
It minimises chance of reversion and

Developed

fetal

complications

can

be

effectively tackled by caesarean section.

Hypertonus

or irritable uterus can be

overcome with the use of tocolytic drugs.

 Benefits of ECV are Reduction

in

the

incidence

of

breech

presentation at term,
Reduction in the incidence of breech delivery

and the associated complications,

Reduction in the incidence of caesarean

delivery by 5%.

 Successful version is likely in cases of:

Complete breech, Non-engaged breech sacroanterior position, Adequate liquor Non obese patient.

Causes of failure of version:

Breech

with

extended

legs-

difficult

to

disimpact because of early engagement and difficult to flex the trunk because of splinting action of the limbs,
Scanty liquor Big size baby.

Causes of failure of version:

Mechanical
Obesity, Increased tone of the abdominal muscles and Irritable uterus.

Short cord - either relative or absolute, Uterine malformations- septate or bicornuate.

Method
An ultrasound scan
To localize the placenta
To confirm the position and Presentation of the fetus.

If tocolysis site a cannula to allow venous

access.

Method
A 30min CTG
To confirm no fetal compromise Maternal blood pressure and Pulse.

Ask woman to empty her bladder.

Provide a comfortable supine position.

Method
Elevate the foot of the bed - help free the

breech from the pelvic brim.

Dust the abdomen with talcum powder - to

prevent pinching of the mothers skin during the procedure.

Method
ECV - uncomfortable but it should not be

painful.
The breech is displaced from the pelvic brim

towards an iliac fossa.

Simultaneous force is then used as with one

hand on each pole the operator makes the fetus

perform a forward somersault (Fig).

The right hand lifts the breech out of the pelvis. The left hand makes the head follow the nose. Flexion of head and back is maintained throughout.

Flexion is continued. The left hand brings the head downwards. The right hand pushes the breech upwards.

Pressure is exerted on head and breech simultaneously until the head is lying at the pelvic brim.

Method
If this is not successful then a backward

somersault can be attempted.

If fetus does not turn easily, then the procedure

is abandoned but may be tried again a few days later.

 Repeat CTG following the procedure. Rhesus negative woman an injection of anti-D

immunoglobulin

prophylaxis

against

isoimmunization caused by any placental

separation.

 If the version is performed immediately

prior to the onset of labour, this can be delay Injection - until after birth when the blood group of the baby is known.
In this case if anti-D is needed, it must be

given within 72hrs of the version.

 Dangers of version Premature onset of labour, Premature rupture of the membranes,

Placental separation and bleeding,

Entanglement of the cord - round the fetal part

or formation of a true knot - impairment of

fetal circulation and fetal death and,

 Dangers of version Increased chance of feto-maternal bleed and Amniotic fluid embolism.

Immunoprophylaxis

with

anti-D

gamma

globulin for non-immunized Rh- negative

mother.

Management-if version fails or is contraindicated

Continue pregnancy - usual check up and possible

unexpected spontaneous version

But if the breech persists case assessment to be

done
Age of the mother especially in primigravida

Size of the baby and,

Pelvic capacity.

 Clinical

assessment

of

the

pelvis

all

primigravida
CT or MRI is a better alternative. Ultrasonographic examination - gold standard for

decision making.
Two methods of delivery can be planned.
Elective caesarean section. To allow spontaneous labour to start and vaginal

breech delivery to occur.

Elective Caesarean section

Tendency to liberalize the caesarean section -

risk involved in vaginal breech delivery

The indications of C.S. In breech are
Big baby fetal weight >3.5kg
Hyperextension of the head

Footling presentation.
Any associated complication

 The overall incidence of CS in breech range

from 15-50%, out of which about 80% is elective.

Delivery of preterm breech by caesarean

section is commonly done but in selected

centers, equipped with intensive neonatal

care unit.

Vaginal breech delivery

Considered in cases with

Adequate pelvis,
Average fetal weight flexed head and

Without any other complications.

Frank breech is preferred - ensure close

monitoring of labour and facilities for immediate caesarean delivery.

Complications
Knotting of the umbilical cord
Separation of the placenta

Rupture of the membranes

Relative contraindications
The presence of a uterine scar

Contraindications
Pre-eclampsia or hypertension

Multiple pregnancy
Oligohydramnios Ruptured membranes Any condition that would require delivery by

caesarean section.

Persistent breech presentation

Mechanism of left sacroanterior position

Description of fetus
The lie is longitudinal The attitude is one of complete flexion The presentation is breech The position is left sacroanterior The denominator is the sacrum The presenting part is the anterior (left) buttock

The bitrochanteric diameter, 10cm, enters the pelvis in the left oblique
diameter of the brim The sacrum points to the left iliopectineal eminence.

Main Movements of LSA

Compaction Internal rotation of the buttocks Lateral flexion of the body

Restitution of the buttocks

Internal rotation of the shoulders Internal rotation of the head External rotation of the body Birth of the head

Management of vaginal breech delivery

First stage
The management protocol is similar in normal

labour.
Spontaneous

onset labour increases the

chance of successful vaginal delivery.

First stage
Vaginal examination is indicated
Onset of labour - pelvic assessment. Soon after ROM to exclude cord prolapse.

An intravenous line is sited

Ringers solution,

NPO
Blood is sent for group and cross matching

First stage
Adequate analgesia - preferred epidural. Monitor Fetal status and progress of labour Oxytocin infusion - augmentation of labour.

Indication of Caesarean Section (C.S.)

Cases seen for the first time in labour with

presence of complications.
Arrest in the progress of labour.
Non-reassuring fhr pattern (fetal distress).

Cord presentation or prolapse.

In labor
1st stage of labor :

Proper history Review of the A.N c. Records Investigation IV fluids Keep fasting Give anti acid Partogram Continuous fetal monitoring Analgesia Inform neonatologist Keep theater staff and the anesthetist Informed

Early Care In First Stage of Labour

i)

Cleanliness and Comfort

Bowel Preparation

ii) Perineal Shave

iii) Bath or Shower

iv) Clothing

Early Care In First Stage of Labour

Analgesia Records Drug Records

SECOND STAGE
There are three methods of vaginal breech

delivery
Spontaneous (10%) very little assistance

Assisted breech Assistance from beginning to

end
Breech extraction - entire body of the fetus is

extracted by the obstetrician

SECOND STAGE
Breech extraction
Indications are:

Delivery of the second twin Cord prolapsed

Extended legs arrested at the cavity or at

the outlet.

ASSISTED BREECH DELIVERY

Conducted by a skilled obstetrician.

The

following

are to be kept ready

beforehand in addition
Anaesthetist
An assistant

ASSISTED BREECH DELIVERY

Instrument

and

suture

materials

for

episiotomy
A pair of obstetric forceps - after coming

head
Appliances

for

revival

of

the

Baby-

Asphyxiated

Principles in conduction
Never to rush, Never to pull from below but push from

above,
Always keep the fetus with the back

anteriorly.

Steps
Woman brought to the table - anterior buttock

and fetal anus are visible - place in lithotomy

position when the posterior buttock distends

the perineum.
Woman is tilted laterally using wedge under

the back - to avoid aortocaval compression.

Steps
Antiseptic cleaning,

Bladder is emptied with catheterization.

Pudendal block with perineal infiltration or

epidural
Episiotomy - best time - the perineum is

distended and thinned by the breech.

 The patient is encouraged to bear - ensure

flexion of the fetal head and safe descent.

Policy adopted - no touch - until the buttocks

are delivered along with the legs in flexed breech and the trunk slips up to the umbilicus.

 Soon after the trunk up to the umbilicus is

born. The Following are to be done:

The extended legs The umbilical cord If the back remains posteriorly The baby is wrapped

 Delivery of the arms Assistants gives steady fundal pressure during

uterine contractions to prevent Extension of the arms.

Soon, the anterior scapula is visible - position of

the arm should be noted.

 When the arms are flexed-vertebral border of

the scapula - parallel to the vertebral column and when extended - winging of the scapula.
The arms are delivered one after the other only

when one axilla is visible-hooking down each elbow with a finger.

Breech delivery. Delivering the buttocks (A); feeling for the arms for delivery one at a time (B); the hairline over the nape of the neck is visible (C); lifting the legs slowly over the mothers abdomen (D).

Delivery of the after-coming head

Most crucial stage of the delivery.

The time between the delivery of umbilicus to

delivery of mouth should preferably be 5 to 10

minutes.
There are various methods of delivery for the

after- coming head.

Delivery of the after-coming head

Each one is quite safe

Effective

in

the hands of

an

expert,

conversant with that particular technique.

Employed common methods are:

Burns Marshall Method

Forceps delivery
Malar flexion and shoulder traction

Burns Marshall Method

The baby is allowed to hang by its own weight. Assistant - gives suprapubic pressure with the

flat of hand in a downward and backward direction-more towards the sinciput - aim is to promote flexion of the head so favourable diameter is presented to the pelvic cavity. Not > 1-2 minutes are required to achieve the objective.

 When the nape of the neck is visible under

the pubic arch, the baby is grasped by the ankles with a finger in between the two.
Maintaining a steady traction and forming a

wide arc of a circle, the trunk is swung in

upward and forward direction.

 Meanwhile, with the left hand to guard the

perineum,

slipping

the

perineum

off

successively the face and brow. When the mouth is cleared off the vulva, there should be no hurry. Mucus of the mouth and pharynx is cleared by mucus sucker.
The trunk is depressed to deliver rest of the

head.

Burns Marshall Method

(A)The baby is grasped by the feet and held on the stretch. (B) The mouth and nose are free. The vault of the head is delivered slowly.

Forceps delivery

Malar flexion and shoulder traction

MauriceauSmellieVeit manoeuvre (jaw flexion and shoulder traction)

MauriceauSmellieVeit manoeuvre for delivering the aftercoming head of breech presentation (A) The hands are in position before the body is lifted. (B) Extraction of the head.

 Resuscitation of the baby: The baby may be

asphyxiated and need to be resuscitated.

THIRD STAGE
Usually uneventful.
The placenta is usually expelled out soon after

delivery of the head.

Prophylactic ergometrine - administered

intravenously with the crowing of the head.

Preterm breech
ECV with preterm breech presentation is

not recommended.
Cs - fetal weight is <1500gm

MANAGEMENT OF COMPLICATED BREECH DELIVERY

Delay in Descent of the breech

Frank Breech Extraction

Extended Arms - Lovsets Maneuver

Nuchal displacement of arm

Arrest of the After coming head

Delivery of the head through an incompletely

dilated cervix

Delay in Descent of the breech

The breech may be arrested:
At the outlet In the cavity At the brim

Arrest At the outlet

Causes are
Big

size

baby

with

extended

legs

(commonest)
Weak uterine contractions
Rigid perineum and Outlet contraction.

Management
Caesarean section: outlet is contracted, baby

is big.
In the absence of outlet contraction and

fetopelvic disproportion
Liberal episiotomy and fundal pressure

Arrest of the breech at or above the level of ischial spines

The causes of arrest are-contracted pelvis,

weak uterine contractions, big baby.

Management:
Best

treatment - delivery by ceasarean

section.

Frank Breech Extraction

Intrauterine manipulation to convert a frank

breech to a footling breech.

Possible - membranes have ruptured recently.

Frank Breech Extraction

In pinards maneuver - the middle and the

index fingers are carried up to the popliteal

fossa. It is then presses and abducted so that the

fetal leg is flexed. The fetal foot is then grasped

at the ankle and breech extraction is

accomplished.

Pinards maneuver

Extended Arms
One or both the arms are fully stretched along

the side of the head or lie behind the neck.

The cause - faulty technique in delivery- using

unnecessary traction, forgetting the principle of never pull but push from above.

Extended Arms
Arrest - delivery of the trunk up to the costal

margins.
Diagnosis - by noting the winging of the

scapula and absence of the flexed limbs in front

of the chest.

Management
Urgent delivery of the arms - first the

posterior and then the anterior one.

Any one of the following methods: classical,

lovset.

Management - Classical
Same principle - lovsets maneuver.

Addition - intra uterine manipulation with

patient is in GA.
First - posterior arm is delivered followed by

the anterior arm.

 Left hand is introduced along the curve of the

sacrum while the baby is pulled slightly

upwards.
With firm pressure over the humerus, the

posterior arm is pushed over the babys face.

The extended anterior arm is in the same

manner, while the babys trunk is depressed

towards the perineum.

Management - Lovsets Maneuver

Widely practiced

Advantages
Wider applicability

Intrauterine manipulation is nil,

A single manipulation is effective

General anesthesia is usually not needed.

Management - Lovsets Maneuver

Principles: Because of curved birth canal, when the anterior

shoulder remains above the symphysis pubis, the posterior shoulder will be below the sacral

promontory.
If the fetal trunk is rotated keeping the back

anterior and maintaining a downward traction,

the posterior shoulder will appear below the symphysis pubis.

Procedure
The baby is grasped, using both hands by

femoropelvis grip keeping the thumbs parallel

to the vertebral column.
Start only when the inferior angle of the

anterior scapula is visible underneath the

pubic arch.

Procedure
Step-1:

Lift baby slightly to cause lateral flexion.

The trunk is rotated through 180 keeping the

back anterior and maintaining a downward

traction.
Posterior arm to emerge under the pubic arch -

hooked out.

Procedure
Step-2:

Rotate the trunk in the reverse direction

keeping the back anterior to deliver the

erstwhile

anterior

shoulder

under

the

symphysis pubis.

Nuchal Displacement of Arm

Arm is flexed at the elbow and extracted at the

elbow and extended at the shoulder and lies

behind the fetal head.
Lovsetts maneuver.
If this fails, the arm is forcibly extracted by

hooking - fracture almost always follows

Arrest of the After coming head

At
Brim

Cavity
Outlet

Arrest of the After coming head at Brim

The causes deflexed head, contracted pelvis

and, hydrocephalus.
Management:
If the arrest by a deflexed head - completed by

malar flexion and shoulder traction along with suprapubic pressure by the assistant.

Arrest of the After coming head at Brim

The head is to be negotiated though the brim in

the transverse diameter and rotated in the cavity.

Forceps should not be applied in high head.
If the arrest of the head - contracted pelvis or

hydrocephalus, perforation of head is to be done.

Arrest of the After coming head In the cavity

Causes - deflexed head and, contracted pelvis.
The best management is delivery of the

head by forceps which is effective in both the

circumstances.
Malar flexion and shoulder traction - only in

deflexed head.

Arrest of the After coming head At the outlet

The causes - rigid perineum and, 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

Causes premature baby, macerated baby, and

footling presentation and, hasty delivery of

breech before the cervix is fully dilated.

Delivery of the head through an incompletely dilated cervix

Management:
If the baby is living- push up the cervix, malar

flexion and shoulder traction (Shoe- Horn Method).

If necessary, Duhrssens incision can be made

at 2 and 10 Oclock position on the cervix.

Occipito- posterior position of the head

Usually occurs in spontaneous breech delivery.

The fetal trunk and the head are rotated to

bring them anteriorly.
For rotation, the fetal trunk and the head are

to be grasped; the hand and the fingers are

poisoned

like that in malar flexion and

shoulder traction.