breech pregnancy

1. Nur Amalina Aminuddin Baki
0820121000 67

2. Introduction
 Commonest malpresentation
 Longitudinal lie
 Podalic pole at pelvic brim

3. Incidence
Incidence Gestational age
20% 28th
5% 34th
3-4% At term
 Lower in hospital where:
 External cephalic version is done
 Minimal high parity births

4. Varieties
Complete
(Flexed)
Incomplete
Frank Footling Knee

5. Complete breech
• Flexed at hips and knees
• Two buttocks, external genitalia and two feet
• Common in multiparae (10%)
Frank breech
• Flexed at hips and extended at knees
• Two buttocks, external genitalia
• Common in primigravidae (70%)
Footling presentation (25%)
• Thighs and legs are partially extended
• Legs
Knee presentation
• Etended thighs and flexed knees
• Knees

6. Clinical varieties
 Uncomplicated
 No other associated obstetric complications
 Complicated
 When associated with conditions that adversely
influence prognosis
 Prematurity, twins, contracted pelvis, placenta
previa

7. Etiology
 Prematurity
 Factors preventing spontaneous version
 Breech with extended legs, twins, oligohydramnios, septate/ bicornuate
uterus, short cord, IUFD
 Favourable adaptation
 Hydrocephalus, placenta previa, contracted pelvis, cornufundal
placental attachment
 Undue mobility of fetus
 Hydramnios, multiparae with lax abdomen
 Fetal abnormalities
 Trisomies 13, 18, 21, anencephaly, myotonic dystrophy
Recurrent/ habitual breech
 >3 recurrent breech presentation
 septate/ bicornuate uterus,cornufundal placental attachment

8. Diagnosis

9. Clinical
Complete Breech Frank Breech
Per abdomen
Fundal grip • Ballotable head • Non-ballotable head
(splinting action of legs)
• Irregular parts of feet by
side of head
Lateral grip • Fetal back on one side
• Irregular limbs on one side
• Irregular parts are less felt
Pelvic grip • Soft, broad,irregular mass
• Not engaged during pregnancy
• Small ,hard, conical mass
• Usually engaged
Fundal Height
Shrinking
• Located at higher level near
umbilicus
• Located at lower level in
midline
Per vaginam
During pregnancy • Soft,irregular parts felt at fornix • Hard feel of sacrum felt
During labor • Palpation of ischial
tuberosities,sacrum and feet
(prominence of heel and lesser
mobility of great toe)
• Palpation of ischial
tuberosities, anal opening
and sacrum only

10. Sonography
 Confirm clinical diagnosis
 Detect anomalies of fetus or uterus
 Type of breech
 Measures BPD, gestational age and approximate fetal
weight
 Locate placenta
 Liquor volume assessment
 Attitude of head
CT and MRI
 Assess pelvic capacity

11. Positions
Denominator: sacrum
Anterior: sacrum towards iliopubic eminence
Posterior : sacrum towards sacroiliac joints
 Left sacro-anterior (LSA)
 Right sacro-anterior (RSA)
 Left sacro-posterior (LSP)
 Right sacro-posterior (RSP)

12. Mechanism of Labor
 Principal movements at
 Buttocks
 Shoulders
 Head
Buttocks and shoulders are bigger but more
compressible
Head is non-moulding ( rapid descent)

13. Buttocks Shoulders Head
Diameter of engagement: oblique diameter
Engaging diameter: bi-
trochanteric (10cm)
Bi- sacromial (12cm) Sub occipitofrontal (10cm)
Descent of buttocks till anterior
buttocks touches the pelvic
floor
Descent of shoulders Descent with increasing flexion
Internal rotation of 1/8th of a
circle
Further descent till anterior hip
hinges under the pubic
symphysis
Internal rotation of 1/8th of a
circle
External rotation 1/8th of a
circle of buttocks
Internal rotation of occiput 1/8th
or 2/8th of a circle
Further descent till subocciput
hinges under the pubic
symphysis
Delivery of anterior and
posterior hips and lower limbs
Delivery of posterior and
anterior shoulder
Head is born by flexion: chin,
mouth, nose, forehead,vertex
and occiput
Restitution Restitution causing anterior
shoulder towards right thigh
(LSA) / left thigh (RSA)
External rotation of shoulder
Due to internal rotation of

15. Sacro- posterior
 Similar mechanism with
sacro-anterior
 Internal rotation of head is
3/8th of a circle occiput
behind pubic symphysis

16. Prognosis
Maternal
 Increased operative
delivery
increased genital
tract trauma,sepsis,
anesthetic
complications
Increased morbidity
Fetal
 Perinatal mortality 9-25%
 Perinatal death 3-5 times
higher
 Fetal mortality least in
frank breech and
maximum in footling
presentation
 Factor influencing fetal
risk:
 Skill of obstetrician
 Weight of baby
 Leg’s position
 Type of pelvis

17. Fetal dangers
 Intrapartum fetal death
 Intracranial
hemorrhage
 Birth asphyxia
 Birth injuries
 Hematoma -
sternomastoid/ thighs
 Fracture – femur,
humerus, clavicle,
odontoid process
 Visceral injuries- liver/
kidney / lungs rupture
 Nerve – Erb’s /
Klumpke’s palsy
 Long-term neurological
damage
Prevention of
fetal hazards
 Minimize breech
incidence by ECV
 Delivery by cesarean
section
 Vaginal breech
delivery by skilled
obstetrician,
anesthesist,
neonatologist

18. Management

19. Antenatal management
 Identify complicating factors related with
breech
 External cephalic version, if not
contraindicated
 Formulation of line of management,if ECV
failed

21. External Cephalic Version
 Done to bring favourable cephalic pole in the
lower pole of uterus
 Success rate 60%
 > 36 weeks
 Late version is difficult but
 Less chance of reversion
 Effective management of any fetal
complications
 Use of tocolytic reduces difficulties

22. Contraindications
 Antepartum hemorrhage
 Fetal : hyperextended head, > 3.5 kg, dead fetus,
IUGR
 Multiple pregnancy
 Malformations of uterus
 Abnormal CTG
 Previous cesarean delivery
 Obstetric complications: severe pre-eclampsia,
obesity, elderly primigravida, BOH
 Rhesus isoimmunization

23. Successful version likely in :
 Complete breech
 Non-engaged breech
 Sacro-anterior
position
 Adequate liquor
 Non-obese patient
Failed version likely in:
 Frank breech
 Scanty liquor/ big
baby
 Mechanical- obesity,
irritable uterus
 Short cord
 Uterine
malformations

24. Advantages
 Reduce breech
incidence at term
 Reduce breech
delivery incidence
 Reduce cesarean
delivery
Dangers
 Premature labor
 PROM
 Placental separation
 Cord entanglement
 Feto-maternal
bleeding
 Amniotic fluid
embolism

25. Procedures
 Administration of tocolytic ( terbutaline 0.25mcg
SC/ Isoxsuprine 50-100 µg IV)
 USG – confirm diagnosis and adequate liquor
 A reactive NST
 Empty bladder
 Position of patient: supine with shoulders slightly
raised, thighs slightly flexed and abdomen fully
exposed
 Fetal presentation, position of back and limbs are
checked
 FHR auscultated

26. ‘Forward Roll’ Movement
Step 1
 Mobilize breech using
both hands towards
which back of fetus lie
 Right hand : grasp
podalic pole
 Left hand: grasp head

27. Step 2
 L:Pressure exerted to
head to push breech
 R:Pressure in opposite
direction to guide
vertex
 Intermittent pressure
given till lie become
transverse
 FHR is checked

28. Step 3
 Changing of hands
 Intermittent pressure
exerted till head is
brought to lower pole
of uterus

29.  Reactive NST should be obtained
 Undue bradycardia ( head compression) is
settled down by 10 minutes
 If persist, cord entanglement may occur and
reversion is done.
 Patient is observed for 30 minutes to :
 Allow FHR to settle down
 Note any vaginal bleeding/ sign of PROM
 Patient is advised for follow-up, to report any
vaginal bleeding/leakage and Rh-negative
woman is given 100µg anti-D IG IM.

30. If ECV / contraindicated
 Continue with usual check-up
 Assessment is done based on
 Maternal age
 Associated complicating factors
 Size of baby
 Pelvic capacity
 Clinical assessment of pelvis is done
 Eg.CT/MRI/ USG
 To plan the method of delivery

31. Elective Cesarean Section
 15-50%
 >3.5 kg baby
 Stargazing fetus
 Footling presentation
 Contracted pelvis
 Severe IUGR
Vaginal Breech Delivery
 Average fetal weight
 Flexed fetal head
 Adequate pelvis
 No other
complications
 Availability of:
 Emergency LSCS
facilities
 Continuous labor
monitoring facilities
 Experienced
obstetrician

32. Management of Vaginal
Breech Delivery

33. First Stage:
 Vaginal examination
 At onset of labor for pelvic adequacy
 Soon after membrane rupture for cord prolapse
 IV line with Ringer’s solution, avoid oral intake and
send blood for group and cross-matching
 Adequate analgesia is given
 Fetal status and progression of labor are
monitored
 Oxytocin infusion for augmentation of labor
 Indication for CS:
 Arrest of labor
 Non-reassuring FHR pattern
 Cord presentation/prolapse

34. Second stage
 Spontaneous (10%):
 not preferred
 Assisted breech :
 by assistance from beginning to the end
 Breech extraction :
 part/entire body of fetus is extracted by obstetrician
 Indications:
 delivery of 2nd twin after IPV
 Cord prolapse
 Extended legs

35. Assisted
Breech
Delivery

36.  The following are to
be kept ready
beforehand:
 Anesthetist
 Assistant
 Instrument and
suture for
episiotomy
 A pair of obstetric
forceps
 Appliances to
resuscitate baby
 Neonatologist
 Principles in
conduction :
 Never to rush
 Never to pull from
below but push from
above
 Always keep fetal
back anteriorly

37. Steps
 Woman in lithotomy position is tilted laterally(15%)
using a wedge uder the back to avoid aortocaval
compression
 Bladder is emptied and antiseptic cleaning is done
 Pudendal block with perineal infiltration/ epidural
analgesia is done
 Episiotomy:
 To straighten birth canal
 To facilitate intravaginal manipulation and forceps
delivery
 To minimize head compression
 Patient is encouraged to bear down as it ensure
flexion of head and safe descent

38. Delivery of trunk
 ‘NO TOUCH’ policy till buttocks and legs
are delivered and the trunk slips up to
umbilicus
 After the trunk up to the umbilicus is born:
 The extended legs are delivered by
abduction at knees
 Umbilical cord is pulled down and
mobilized to one side to minimize
compression
 If back remain posterior, rotate the trunk
anteriorly
 The baby is wrapped in sterile towel
 To prevent slipping when held
 To facilitate manipulation

39. Delivery of
the arms
 Assistant apply pressure on
fundus to prevent extension of
arms
 Position of arm is noted
 If flexed, vertebral border of
scapula is parallel to vertebral
column
 If extended, there is winging of
scapula
 Arm is delivered when one axilla
is visible by hooking down elbow
with a finger
 Baby should be held by feet over
the sterile towel during delivery of
arm

40. Delivery of Head
 Time gap between delivery of umbilicus and
mouth: 5 – 10 minutes
 Methods:
a) Burns- Marshall method
b) Forceps delivery
c) Modified Mauriceau- Smellie- Veit technique

41. a)Burns- Marshall method
 Baby: allowed to hang by its weight
 Assistant: downward, backward
suprapubic pressure to promote
head flexion
 Right hand: grasp ankles with a
finger in between ( when nape of
neck is visible under pubic arch)
 Trunk is swung upward,forward till
mouth is cleared off the vulva
 Depress the trunk to deliver the rest
of head
 Left hand: guard the perineum

42. b)Forceps
delivery
 Baby: allow to hang by its weight
 Assistant:
 give suprapubic pressure
 raises legs of child when occiput is against pubic
symphysis
 Piper forceps is used
 Head is delivered slowly (>1 min) to reduce
compression-decompression

43. c)Modified
Mauriceau-
Smellie- Veit
technique
 Aka malar flexion and shoulder
traction
 Baby: placed on supinated left
hand with limbs hanging
 Assistant: give suprapubic
pressure
 Left hand: middle and index
fingers are placed on malar bones
to maintain head flexion
 Right hand:
 Ring and little fingers on right
shoulder
 Index finger on left shoulder
 Middle finger on sub-occipital
region
 Downward, backward traction is
given till nape of neck is visible
 Upward, forward traction to
release face and brow
 Depressed to release occiput and
vertex

44.  Resuscitation of baby if asphyxiated
 3rd stage: uneventful
 Preterm breech
 ECV not recommended
 CS done when fetal weight < 1.5kg

45. Complicated
Breech
Delivery

46. Arrest of buttocks
1. At Outlet
 Causes
 Outlet contraction
 Big baby and
extended legs
 Weak uterine
contraction
 Rigid perineum
 Contracted pelvis/ big
baby – CS
 In absence of
contracted pelvis/ big
baby:
 Episiotomy, fundal
pressure with groin
traction
 Groin traction
 Index finger is
placed in groin fold
and traction is given
towards trunk till
delivery of the knee

47. 2. In the Cavity
( at/ above ischial spine)
 Causes
 Contracted pelvis
 Big baby
 Weak uterine
contraction
 Trial of breech – when
cervix fully
dilated,breech should
descent down to
perineum
 If fail,
 CS- best treatment
 Pinard’s Maoeuvre-
frank breech
 Pinard’s Manoeuvre
 Middle and index
fingers are carried
up to popliteal fossa,
then exert pressure
and leg is abducted
 Fetal foot is grasped
at ankle and pulled
down

48. Arrest of shoulders
 Cause: extended arm with
lateral/dorsal (nuchal)
displacement due to faulty
technique
 Diagnosis:
 By observing winging of scapula
 Absence of flexed limbs in front
of chest
 Management:
 Lovset’s maneuver
 Classical ( intrauterine
manipulation under GA)
 Left hand:introduced along sacral
curve( baby pulled slightly
upwards), posterior arm is
pushed over fetal head
 Right hand:introduced along
sacral curve( baby’s trunk is
depressed), anterior arm is
delivered from anterior aspect
 Nuchal displacement
of arm
 Flexed at elbow,
extended at
shoulder
 Trunk is rotated 180
towards fingers of
trapped arm  draw
elbow forward 
Lovset’s Maneuvre

49. Lovset’s Maneuvre
 Advantages:
 Wider applicability
 No intrauterine
manipulation
 Effective for all arm
displacement
 No general anesthesia
needed
 Principle:
 When anterior shoulder
is above pubic
symphysis, posterior
shoulder is below sacral
promontory. When
posterior shoulder is
rotated forward, it will
appear below pubic
symphysis.
 Baby grasped using
both hands by femoro-
pelvic grip
 Start only when inferior
angle of anterior
scapula is visible under
pubic arch
1. Baby lifted slightly and
rotated 180 with
downward traction,
then hooked out
2. Trunk rotated in
reverse and anterior
arm is hooked out.

50. Arrest of head
 At the brim
 Causes: deflexed head, contracted pelvis, hydrocephalus
 malar flexion with shoulder traction with suprapubic pressure
(only in deflexed head) or craniotomy ( contracted pelvis,
hydrocephalus)
 In the cavity
 Causes: deflexed head,contracted pelvis
 Delivery by forceps or malar flexion with shoulder traction
(only in deflexed head)
 At the outlet:
 Causes: rigid perineum, deflexed head
 Episiotomy with forceps/ malar flexion and shoulder traction

51. Delivery of head
through incompletely
dilated cervix
 Causes: premature
baby, footling
presentation, hasty
breech delivery
 Management:
 Shoe-horn method-
cervix is pulled up while
trunk traction is made
by malar flexion and
shoulder traction
 Duhrssen’s incision at
2,6 and 10 o’clock
position on cervix
 Perforation of head
(dead baby)

52. Occipito-posterior
head
 Usually in
spontaneous breech
delivery
 Grasp fetal trunk and
head with hands
positioned like that in
malar flexion and
shoulder traction, then
rotate to bring them
anteriorly
 In premature baby,
 (Prague Maneuver)-
head is delivered face
to pubis by reverse
malar flexion and
shoulder traction
 Forceps

53. Conclusion
 External Cephalic Version
 Management
 Assisted breech delivery
 Buttocks: knee abduction
 Shoulders: hooking down elbow
 Head: Burns-Marshall method, Forceps delivery,
Malar flexion and shoulder traction
 Complicated breech delivery
 Buttocks: groin traction, Pinard’s Maneuver
 Shoulders: Classical, Lovset’s Maneuver
 Head:Malar flexion and shoulder traction, Shoe-
horn method, Duhrssen’s method, Prague Method

54. Reference