BREECH PRESENTATION AND

DELIVERY
Dr.Moly Sam K
 Introduction

Definition:-
It is a longitudinal lie where the

podalic pole presents and the

denominator is sacrum.

Commonest among all

mal presentations
 It occurs in 3 – 4 % of all deliveries.

 The occurrence of breech presentation

decreases with advancing gestational age.

 This presentation occurs in 25 % of births

that occurs before 28 weeks, in 7 % of
birth that occurs at 32 weeks and 1-3 %
of birth which occurs at term.
 Incidence of Breech presentation

Gestation (weeks) % Breech

21 - 24 33%

25 - 28 28%

29 - 32 14%

33 – 36 9%

37 – 40 3%
Types of Breeches
 Types of breeches
 Complete breech or Flexed breech ( 5-10 % ) Hips
Flexed, Knees Flexed
 Incomplete breech:-
 a) Frank breech or Extended breech (50-70%)
- Hips flexed, knees extended
 b) Knee presentation extension at hip and
flexion at knees
 c) Footling (10-30%) – Extension at hip and
knees, feet are presenting
 Complicated breech – breech presentation
associated with any fetal or maternal
complications
 Uncomplicated breech – breech presentation
without any other complications
 Etiology
 Fetal
a) Prematurity –
Commonest cause
Maternal b) Multiple gestation
a) Multi parity c) Hydramnios
( producing uterine d) Macrosomia
relaxations )
e)Hydrocephalus
b) Pelvic tumors
c) Contracted pelvis f) Anencephaly
d) Uterine g) Trisomie
malformation – h)Myotonic dystrophy
Recurrent breech
presentation seen in i) Placenta previa and
uterine anomalies. cornuofundal
attachment of placenta
j) Oligoamnios
 Etiology contin……
 IUD

 Extended legs – When legs are extended

the kicking movements of fetus against

uterine wall are hampered and this results

in persistence of breech presentation

 DIAGNOSIS

 Abdominal Exmination – Head felt in

fundus
 1st Pelvic grip – breech felt
 FH heard above the umbilicus.
 P/V :-
- Conical bag of membrane
- Presenting part high up
- Flexed breech-ischial tuberosities,
anus, sacrum,buttocks and feet are
palpable
 diagnosis contn…..
Extended breech : - feet not felt. Can
palpate both ischial tuberosities sacrum
and anus are usually palpable and with
further descent external genitalia may
be distinguished
- Footling :- feet are presenting part
with buttocks high up
- Sacrum is usually in the anterior
quadrant.
- D/d – Face presentation
 diagnosis contn……

Imaging Techniques :-
a)
- U S S - Ideal to confirm the presentation
and
type of breech
- To rule out anomalies placenta
previa, hyper extension of head
- Assessment of fetal weight. liq.
vol.
- USG is helpful in ECV
b) CT - Pelvimetry for pelvic
measurements
c) X-ray - Pelvimetry in deciding mode of
delivery in breech is
 Position

LSA,RSA,RSP,LSP
RSL, LSL
 MANAGEMENT
Antepartum

Delivery

During labor
 Version of the breech
 Spontaneous version

 ECV

 Internal podalic version

 Version of the breech - ECV
 Procedure whereby the presentation other
than cephalic is converted by external
manipulation into a cephalic presentation
 Indications:- Breech or Shoulder presentation
diagnosed in the last week of pregnancy
 Success rate 65 %
 Timing of ECV at 36 weeks
 Advantage – incidence of CS rate decrease
 Contraindications of ECV:- ( Absolute )
Placenta previa, Multiple pregnancy, PROM,
APH, PIH, Prematurity and contraindication to
vaginal delivery, Significant fetal abnormality.
 Contraindication Contn…
 Relative Contraindication :-

 Previous CS
 IUGR
 Obesity
 Rhesus iso-immunization
 Anterior placenta
 Grand multipara
 Precious baby
 Newman’s Score for ECV
Score 0 1 2
Parity 0 1 >2
Estimated fetal weight (kg) < 2.5 2.5-
3.5> 3.5
Placental position anterior posterior
Lateral or fundal
Cervical dilatation > 3 1-2 0
Station of presenting part > -1 -2 -3

Because of significant overlap in scores

between successful and unsuccessful
ECV, this scoring system is clinically less
useful.
 ECV contn…….
ECV should be carried out in an area that has
ready access to a facility equipped to perform
emergency CS

Better to do it under USG guidance

1. Obtain consent after explaining procedure to
the woman
2. u/scan to R/O contraindications.
3. Maternal B.P measurement.
4. Fetal heart rate measurement (b/4 and after
procedure):-non stress test (CTG)
5. Tocolytics (eg salbutamol, ritodrine) for
uterine relaxation.
 ECV Contn…..
6. Mother placed in a steep lateral position with
her back supported with a cushion or
in a supine position and comfortable.
7. Breech disengaged from pelvic inlet using both
hands, E.C.V carried out when breech is above
the inlet.
8. One hand on lower pole, other on upper pole,
manipulate in the direction which increases
flexion of the fetus and makes it do a forward
roll, bringing the head lower uterinepole.
9. The “back flip” technique is then tried if
unsuccessful
 ECV contn….
10. On completion of version the fetus is steadied
by lateral pressure while the mother is
transferred to the supine or semi-recumbent
position.
11. Check fetal heart rate after procedure.
N/B: If procedure fails or becomes difficult, it
is abandoned.
it is easier to perform ECV in multiparous
women due to laxity of uterus and abdominal
wall.
No place for E.C.V in preterm – high failure
rate.
Factors influencing the success of ECV

Maternal: parity - higher in multipara. Normal

amount of liquor
Race : higher in black women - due to late
engagement
Fetal : Type of breech - flexed>frank
descent of presenting part not
occurred into the pelvis
Failure : Diminished liquor, Excessive maternal
wt., anterior placental location,
cervical dilatation, descent of the
breech into the pelvis and anterior or
posterior positioning of the fetal spine.
 Complications of ECV

 Placental abruption
 Uterine rupture
 Amniotic fluid embolism
 Fetomaternal hemorrhage – 4 %
 Iso-immunization
 Preterm labour
 Fetal distress
 Fetal demise
 Fetal heart deceleration - 40 %
 Internal podalic version

 This maneuver consist of turning the fetus

by
inserting a hand into the uterine cavity,
seizing
one or both feet and drawing them
through the
cervix.

 Operation is followed by breech extraction

 Indications:- Transverseli of 2nd of twin

 DURING LABOUR
 Management of term breech :-
 CS
 Vaginal breech delivery
 Indication of CS:-
a) All complicated breech
b) Contracted or borderline pelvis
c) Weight of the baby more than 3.5 kg
d) Severe IUGR
e) Hyper extension of fetal head
f) Footling or knee presentation
g) Flexed breech
h) Preterm with wt. less than 1.5 kg
 Nowadays individualization of cases to

decide on elective CS or Vaginal delivery is

reasonable standard of care in modern

obstetric practice. At CS the baby should

be delivered in exactly the same as it is

during a Vaginal delivery.

 VAGINAL BREECH DELIVERY
Three types of
vaginal breech
deliveries:-

1. Spontaneous breech delivery

2. Assisted breech delivery

3.Total breech extraction

 Criteria for VD or CS

 VD
 CS
Frank
FW<1500or>
GA>34w 3500gr
FW=2000-3500gr Footling
Adequate pelvis Small pelvis
Flexed head Deflexed head
Nonviable fetus Arrest of labor
No indication GA24-34w
Good progress laborElderly PG
Inf or poor history
Fetal distress
 Mechanism of Labour
Denominator – Sacrum
Commonest position - LSA
 Mechanism of Labour
 Engagement

 Descent

 Internal rotation

 Lateral flexion

 External rotation

 Birth : breech - body

head
 Engagement
Descent with increasing compaction

Engaging diameter is
bitrochanteric – 10
cm. Engagement
occurs in left Oblique
diameter of pelvis.
 Internal rotation
Lateral flexion

Anterior buttocks
touches the pelvic floor,
it rotates through 1/8 of
circle so it is behind
pubic symphysis.
Anterior hip appears
first & impinges under
the Sym. Pubis and by
lateral flexion, the post.
hip is born
External rotation
Birth - Breech
 Birth - Body- Head

Head – eng. dia. Suboccipito

bregmatic dia. 9.4 cm in the opposite
oblique dia. to that in which the
buttocks engaged.

Delivery of shoulder – engaging

diameter is bisacromial diameter
12 cm. Engagement occurs in the
same oblique diameter as the
breech
 VBD
Spontaneous breech delivery – The fetus is expelled
entirely spontaneously without any traction or
manipulation.
In modern obstetric practise there is no place for
S.V.B.D
A.V.B.D is the choice of delivery but in well selected
cases ( women properly assessed:- R/O F P D, &
other C/I to V.D )
Scoring index for A.V.B.D:- Andros-Zatuchni Scoring
index
Parameters of index:- Parity, gestational Age, Previous
V.B.D, estimated fetal weight, cervical dilatation
and station
Zatuchi-Andros scoring index is used in labour
 Zatuchni Andros Scoring Index (1965)

parameter Score 0 Score 1 Score 2

parity 0 1 >2
Gestational age (weeks) 39+ 38 < 37
Previous vag breech delivery 0 1 2
Estimated fetal weight (kg) > 4.0 3.5-
4.0< 3.5
Cervical os dilatation (cm) 2 3 >4
Station of presenting part -3 -2 -1

Score - 0 to 4 = CS
Score - 5 or more allow Vaginal breech
delivery
 STEPS IN A.V.B.D

1. Transfer to 2nd stage room when

fully
dilated
2. Place in lithotomy position and
cleanse
lower abdomen, vulva, vagina and
thighs
with swabs soaked in betadine soln.

3. Apply sterile drapes

 Steps in A V B D
4. Empty bladder with a plastic catheter and repeat V.E to
confirm full cervical dilatation.
5. With each contraction she is encouraged to bear down while
the descent of the breech is observed without interference
6. The perineum is infiltrated with 10mls of 1% xylocaine
7. A right mediolateral episiotomy is given as the breech
distends the perineum, the descent of the baby allowed to
continue until the umbilicus and popliteal fossa become
visible
8. Each extended lower limb is delivered by the pinard’s
manoeuvre (pressure applied with two fingers to the popliteal
fossa to flex the knee and gently abduct and flex the thigh)
9. Mother encouraged to bear down until the trunk, up to the
scapula becomes visible, cord pulsation checked and a loop of
cord pulled down to prevent cord compression
10. Baby gently held by the groin and trunk rotated 90o in one
direction witha downward traction applied and the back facing
upwards to deliver the anterior shoulder (lovset maneouvre for
extended arms)

11. Procedure repeated in the opposite direction, with a rotation of 1800 to

deliver the posterior shoulder.

12. Mother further encouraged to bear down until the hair lines is visible
(thenape of the neck become visible) under the pubic symphysis

13. The aftercoming head is delivered by one of the following methods:

- Burns Marshall Technique

- Mauriceau-Smellie-Veit manoeuvre (jaw flexion and shoulder traction)

- Obstetric forceps (piper’s)

The most important aspect of V B D is delivery of after coming head.

Classical Method
Lovset’s Method
 Mauriceau-Smellie-Veit
Maneuver
 The index and middle finger of one hand are
applied over the maxilla, to flex the head,
while fetal body rests upon the palm
of the hand and forearm.

The two fingers of other hand then hooked

over the fetal neck and grasping shoulders,
downward traction is applied until sub
occipital region appears under the symphysis.

Give gentle supra pubic pressure to flex the

head. The body of the fetus is then elevated
towards the maternal abdomen and the head
is deliverd
Mauriceau-Smellie-Veit
Maneuver
Piper Forceps
 Prague Maneuver
back of the fetus fail to rotate
to the anterior
 Prague maneuver
 It is used for delivery of the after coming

head in case of failure of fetal trunk to rotate

anteriorly. Two fingers of one hand grasping

the shoulders of the back-down fetus, from

below, while the other hand draws the feet

up over maternal abdomen

 Bracht Maneuver (Bracht
1936 )
 The breech is allowed to deliver spontaneously up
to the umbilicus.
 The fetal body is then held, but not pressed,
against the maternal symphysis. This force
is meant to be the equivalent of gravity.
The suspension of the fetus in this position
coupled with the effects of uterine contractions
and moderate suprapubic pressure by an
assistant, results in spontaneous delivery.
 Complications of breech
delivery
 Morbidity & Mortality
 Maternal Injuries
 Risk : Operative intervention
 Manipulations : Risk infection
 Intrauterine maneuvers : Rupture of the
 uterus +/- lacerations of Cx
 Extensions of the episiotomy
 Uterine atony , Postpartum hemorrhage
 Perinatal Morbidity & Mortality
 Preterm delivery & low birth weight & IUGR
 Birth aphyxia
 Fetal Injuries
 Fx of humerous and clavicle
 Fx of femur
 Hematomas of sternocleidomastoid
 Separation of epiphyses of scapular,humerus or
femur
 Brachial plexus
 Avulsion of upper C-spine
 Skull Fx , intracerebral injury
 PROM & Cord Prolapse- Incidence of Cord Prolapse in
flexed breech is 6 % & footling is 12 %. Extended
breech only 0.5% ( Vertex 0.4 % )
In flexed & footling – limbs may slipout before full
dilatation and can cause entrapment of head.
 Perinatalmortality is
increased 2- to 4-fold with
breech presentation,
regardless of the mode of
delivery.

 Congenital malformation
6%
 Risks

Lower Apgar scors

An entrapped head
Nuchal arms ,

Cervical spine injury

Cord prolapse
 Entrapment of the after coming head
 Occurs in case of delivery of the
small pre term fetuses. The body of
the fetus is delivered through an
incompletely dilated cervix and it will
not allow delivery of the after coming
head.
 Bracht Maneuver may be tried.
 Duhrssen incisions can be made in
the cervix.
 Under GA
 Replacement of the fetus higher in to
the vagina and uterus followed by CS (
Abdominal rescue by CS )
Birth Asphyxia
Total breech extraction

Entire body of the infant is

extracted by the
Obstetrician
 Indication of Total breech Extraction

1. Prolong second stage of labor

2. 2nd of the Twin

3. Cord Prolapse complicates the late

2nd
stage

4. Fetal distress
 Contraindication of Total
breech extraction

 Cervix not fully dilated

2. FPD
 Picture 3. Assisted
vaginal breech
delivery: The Ritgen
maneuver is applied
to take pressure off
the perineum during
vaginal delivery.
Episiotomies often are
cut for assisted
vaginal breech
deliveries, even in
multiparous women,
to prevent soft-tissue
dystocia.
 Assisted vaginal breech
delivery
 Thick meconium
passage is common as
the breech is squeezed
through the birth canal.
This usually is not
associated with
meconium aspiration
because the meconium
passes out of the vagina
and does not mix with
the amniotic fluid.
 Picture4. Assisted vaginal breech
delivery: No downward or outward
traction is applied to the fetus until
the umbilicus has been reached.
 Footling breech presentation
: Once the feet have delivered,
there may be temptation to
pull on the feet. However, this
should never be done with a
singleton gestation because it
may precipitate an entrapped
head in an incompletely
dilated cervix or it may
precipitate nuchal arms. As
long as the fetal heart rate is
stable and no physical
evidence of a prolapsed cord
exists, expectant management
may be followed, awaiting full
cervical dilatation.
Picture 5. Assisted vaginal breech delivery: With
a towel wrapped around the fetal hips, gentle
downward and outward traction is applied in
conjunction with maternal expulsive efforts until
the scapula is reached. An assistant should be
applying gentle fundal pressure to keep the
fetal head flexed.

                               
Picture 9. Assisted vaginal breech delivery: The fetal head
is maintained in a flexed position by using the Mauriceau-
Smellie-Veit maneuver, which is performed by placing the
index and middle fingers over the maxillary prominence
on either side of the nose. The fetal body is supported in a
neutral position with care to not overextend the neck.

                               
Picture 6. Assisted vaginal breech delivery:
After the scapula is reached, the fetus should
be rotated 90° in order to delivery the
anterior arm.

                               
Picture 7. Assisted vaginal breech delivery: The
anterior arm is followed to the elbow, and the arm
is swept out of the vagina.

                               
Picture 8. Assisted vaginal breech delivery: The
fetus is rotated 180°, and the contralateral arm is
delivered in a similar manner as the first. The
infant is then rotated 90° to the back-up position in
preparation for delivery of the head.

                               
Picture 12. Assisted vaginal
breech delivery - The
neonate after birth

                               
Picture 11. Assisted vaginal breech delivery: Low 1-minute Apgar scores are not
uncommon after a vaginal breech delivery. A pediatrician should be present for
he delivery in the event that neonatal resuscitation is needed.

                               
Picture 10. Piper forceps application: Pipers are
specialized forceps used only for the aftercoming
head of a breech presentation. They are used to
keep the head flexed during extraction of the fetal
head. An assistant is needed to hold the infant
while the operator gets on one knee to apply the
forceps from below.