BREECH

PRESENTATION
Definition: When the buttock of the fetus occupy the
pelvic inlet & the head is felt in the fundus of uterus .
It is the most common types of malpresentations, The
dominator is the sacrum, the position is usually
sacro-anterior.

Incidence: Breech presentation occurs in 40% at 26th

wk, 20% at 30 wk of gestation and 3% at term.

10/99 2
Figure 21-2. Breech presentations. A: Right sacrum posterior (RSP) position. B: Left sacrum
anterior (LSA) position. (Redrawn and reproduced, with permission, from Bumm E: Grundiss zum
Studium der Geburtshilfe. Bergmann, 1922)
 THE 3 TYPES OF BREECH
PRESENTATION

• Frank : Hips are flexed, knees are

(extended) extended. It is the commonest
• Complete : The hips and knees are
(flexed) flexed
• Incomplete : The feet or knees are
the lowermost presenting
part below the buttock.
o Single footling : one of the lower extremities
is lowermost.
o Double footling : Both of the lower extremities
are lowermost
 PREDISPOSING FACTORS :
 Prematurity
 Uterine abnormalities :-Malformation(bicornute ut.); -Fibroids
Pelvic abnormality pelvic tumor

 Fetal abnormalities : -CNS Malformations;

 Multiple gestations
 Placenta previa
 Polyhydramnios, Oligohydramnios
 Multi parity ,
 Clinical presentation
Symptoms: Pain under the ribs
Indigestion
Hard mass at the hypochondrium
Fetal movements in the lower abdomen
On examination :
fundal grip is the head of the fetus with +ve
ballottement, the lie is longitudinal, pelvic
grip is occupied by the buttock.
Fetal heart sound is heard by sonicaid
above the umbilicus.
 DIAGNOSIS :
 Clinical feature (history & exam)

 Ultrasound safe and useful tool for diagnosis of breech

presentation, gestational age, viability, presence of
congenital anomalies, hyperextension of the head of the
fetus, types of the breech, presence of oligo or
polyhydramnios, multiple pregnancy, weight of the fetus to
decide the mood of delivery.

 X-Ray in late pregnancy if ULS not available

Complication of breech
Maternal complication:
Increased maternal mortality and morbidity
 Prolonged labor
 Maternal distress
 Increased manipulation and trauma to
the birth canal &PPH
 Puerperal sepsis
High incidence of C/S rate
Complication of breech
Fetal complication:
Increased fetal mortality and morbidity
 Prematurity
 P.R.O.M
 Cord prolapse (foot ling)
 Entrapment of the fetal head(Asphyxia)
 intra ventricular hemorrhage
 Fetal trauma(Brachial plexus leading to Erbs pulsy and intra
abdominal organ injury)
Management of a breech presentation at term:-
A- External Cephalic Version ( ECV ).
B- Caesarean section.
C- Vaginal delivery.

A- External Cephalic Version:

Changing the presentation of the fetus from breech to
cephalic presentation by manipulation through
anterior abdominal wall ,it reduces the number of
Caesarean section due to breech presentation.
• ECV is usually carried out by experienced obstetrician at
38 weeks of gestation in a hospital with facilities & theater
for Caesarean section available, it is mildly uncomfortable
and it is occasionally performed with tocolytics such as
ritodrin and nefidipin.
FHS should be checked before and after the procedure, if
the patient is RH –ve, anti- D should be given to the
patient.
Risks of ECV:
1- Abruptio placenta.
2- Premature rupture of membrane.
3- Cord prolapse.
4- Fetal bradycardia.
 Contra-indications
 Multiple pregnancy.
 APH, P.Previa.
 Ruptured membranes, poly or oligohydramnios.
 Significant foetal abnormalities.
 Need for CS for other indications.
 Previous scar in the uterus( C.section or myomectomy )
 Pre-eclampsia or PIH.

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 MANAGEMENT DURING LABOR

Type of Delivery
 Vaginal delivery:
 Spontaneous
 Assistedbreech
 Breech extraction

 Cesarean of delivery
 C-Section Indication

 A large or small fetus ( > 3.500 gr &< 2000)

 Extended neck
 Uterine scar (C/S , myomectomy)
 Footling presentation
 Any degree of contraction or unfavorable shape restriction
 Previous perinatal death or children suffering from birth
trauma
 Any obstetric problem: Placenta previa, gestational diabetes,
PIH and pre-eclampsia.
C- Assisted Vaginal Delivery :
Pre-requests for vaginal delivery:
1- Normal size fetus( 2.0 – 3.5 kg ).
2- Good pelvimetry assessed clinically and some times by X-
ray or MRI pelvimetry scan can also be used.
3- Flexed neck.
4- Multiparous.
5- Breech deeply engaged..
6- Obstetric unit and staff experienced in vaginal breech
delivery.
7- NO fetal congenital abnormality.
8- Extended ( Frank ) and flexed ( complete )breech.
Management of labour :
Fetal wellbeing and progress of labour should be monitored
carefully by partogram and CTG, if fetal distress was
supsected, fetal blood sampling from buttocks provides an
accurate assessment of the acid- base status .

Technique of assisted breech delivery:

Assisted breech delivery is based on the fact of hands- off i.e.
pulling on the baby should not be tried to facilitate the
delivery, fully dilation of the cervix should be diagnosed
first.
Delivery of the buttock
When the buttock will be visible in the perineum, then
preparations for the delivery are made. The buttocks will lie
in the anterio-posterior diameter. Once the anus is seen over
the fourchette an episiotomy can be done.
Delivery of the legs and lower body
If the legs are flexed they will delivered spontaneously, if they
are extended, Pinard’s maneuver is used, using a finger to
flex the knee joint& extend the hip joint. With uterine
contraction and maternal bearing down the lower limb &
body will delivered, then a loop of cord should drawn down.
Assisted Delivery of Frank Breech
Assisted Delivery of Frank Breech
Delivery of the shoulders:
The shoulders enter the pelvis in the transvers
diameter.As the anterior shoulder rotates to ant-post
diameter of outlet (clockwise) the scapula become
visible &a finger placed above the shoulder will help
to deliver the arm. As the posterior shoulder reaches
the pelvic floor,it too rotates anteriorly(anti clockwise)
.Once the scapula becomes visible,delivery of the 2nd
arm follow.
Loveset’s manoeuvre copies these natural movements
&will be used if the arms were extended .
Assisted Delivery of Frank Breech
Assisted Delivery of Frank Breech
With delivery of the shoulders, the breech should allowed to
hang for at least 1 minute so that the weight of the baby will
promote flexion of the head and the head will enter the
pelvis then application of short curved obstetric forceps to
the head is indicated, another method to deliver the head is
Mauriceau- Smellie- Veit manoeuvere (jaw and shoulder
traction method ) the baby lies on obstetrician’s arm with
downward traction being leveled on the head via fingers one
on each maxilla. Delivery will occur with first downward
and then upward movement ( as with the instrumental
delivery ).
Mauriceau Maneuver
Mechanism of Labor in Breech Delivery

Figure 21-12. Application of Piper forceps, employing towel sling support. The forceps are
introduced from below, left blade first. Aiming directly and intended positions on sides of
the head. (Reproduced, with permission, from Benson RC:Handbook of Obstetrics &
Gynecology, 8th ed. Lange, 1983)
Complete or Incomplete Breech Extraction