BREECH PRESENTATION AND DELIVERY

- when the buttocks of the fetus enter the pelvis before the head, the
presentation is BREECH.

Predisposing Factors:
-hydramnios -high parity with uterine relaxation -multiple fetuses
-oligohydramnios -hydrocephaly -anencephaly -previous breech
delivery -uterine anomalies -placenta previa -fundal placental implantation
-pelvic tumors
Definitions: -Frank breech-the lower extremities are flexed at the hip and
extended at the knees and thus the feet lie in closed proximity to the head.
-Complete breech presentation-the lower extremities are flexed at the hip
and one or both knees are flexed.
-Incomplete breech presentation-one or both hips are not flexed and one or
both feet or knees lie below the breech, such that a foot or knee is lowermost in
the birth canal.
-Footling breech presentation-is an incomplete breech with one or both
feet below the breech.

Diagnosis:
1. History: Patient feels fetal movement in the lower abdomen and may
complain of painful kicking against the rectum.
2. P.E.
a. abdominal exam-On Leopold’s maneuver:
L1- fetal head L2- no cephalic prominence L4- breech
FHT- heard loudest at or near umbilicus
b. vaginal exam:
-presenting part is soft and irregular. The anal orifice and the
ischial tuberosities are in a straight line.
3. Diagnostic Aids
Sonography-the best confirmation of a suspected breech
presentation. It can also provide information regarding the breech type and neck
angle. Other methods- CT scan, MRI, Pelvimetry
COMPLICATION:
- prolapsed cord - placenta previa - congenital anomalies
- Uterine anomalies and tumors - difficult delivery
-Increased maternal and perinatal morbidity
PROGNOSIS:
Maternal Morbidity:
- genital tract laceration include - uterine rupture
- laceration of the cervix and vaginal walls - extension of episiotomy and
deep perennial tears - anesthesia used- may lead to sufficient uterine
relaxation may lead to –
postpartum hemorrhage - increase risk of infection
Maternal mortality may even increase
Perinatal Morbidity and Mortality
- The major contributors to perinatal loss are preterm delivery,
congenital anomalies, and birth trauma.
-fetal injuries are associated with vaginal breech delivery/ difficult
cesarean delivery-includes fracture of the humerus and clavicle, more serious
problems however may follow separation of the epiphyses of the scapula, humerus
or femur. -upper extremity paralysis may follow pressure on the brachial
plexus by the finger in exerting traction, but more frequently it is cause by
overstretching the neck while freeing the arms.
-skull fractures
-fetal neck injury
-testicular injury (anorchia )
Recommendation for delivery:
CESAREAN DELIVERY-is commonly used in the following circumstances;
1. a. large fetus
2. any degree of contraction or unfavorable shape of the pelvis determined
clinically or with CT –pelvimetry
3. a hyperextended head
4. when delivery is indicated in the absence of spontaneous labor
5. uterine dysfunction- some would used oxytocin augmentation
 6. Incomplete or footling breech presentation
7. an apparently healthy and viable preterm fetus with the mother in either
active labor or in whom delivery is indicated.
8. sever fetal growth restriction
9. previous perinatal death or children suffering from birth trauma
10. a request for sterilization
11. lack of experienced operator

TECHNIQUES FOR BREECH DELIVERY

-vaginal delivery requires skilled participation for a favorable outcome.

METHODS OF VAGINAL DELIVERY

-spontaneous vaginal delivery. The fetus is expelled entirely spontaneously
without any traction or manipulation other than support of the newborn.
-partial breech extraction. The fetus is delivered spontaneously as far as
the umbilicus, but the remainder of the body is extracted or delivered with
operator traction and assisted maneuvers, with or without maternal expulsive
efforts.
-total breech extraction. The entire body of the fetus is extracted by the
obstetrician.
LABOR INDUCTION AND AUGMENTATION-CONTROVERSIAL
Management of labor
-rapid assestment
Immediate recruitment of necessary staff should include;
- an obstetrician skilled in the art of breech extraction
- an associate to assist with the delivery
- anesthesia personnel who can ensure adequate analgesia or anesthesia when
needed
- an individual trained newborn resuscitation
Vaginal delivery-precautions
-partial breech extraction is preferred. Complete breech extraction only in
specific indications eg.- second of twin.
- proper and adequate anesthesia
 -preserve BOW as long as possible, rupture only if cervix is fully dilated
- empty the bladder. Keep head well flexed with suprapubic pressure during
extraction .
-pipers forceps should be on hand. Apply pipers forceps either electively or
after an attempt with mauriceau’s maneuver.
-refrain from undue haste or delay in delivery.
-in case of nuchal arm, rotate the body, towards the direction of the
forearm to be delivered.
-duhrssen’s incision is resorted to when aftercoming head is arrested by
incompletely dilated cervix.
-manual extraction of placenta is frequently elected to fascilitate 3 rd stage (
if under GA)
-manual exploration of the lower uterine segment and ocular inspection of
the cervix and vagina to detect lacerations.
-POD should be at the DR during delivery.
Analgesia and anesthesia-must provide sufficient relaxation so as to allow
intrauterine manipulation.
VERSION;
-is a procedure I which the fetal presentation is altered by physical
manipulation , either substituting one pole of a longitudinal presentation to the
other , or converting an oblique or transverse lie into a longitudinal presentation.
EXTERNAL CEPHALIC VERSION-
Purpose
-correct the breech presentation to a vertex
- lower the incidence of breech presentation in labor
-decrease the cesarean section rate and
-decrease the perinatal morbidity that may be associated with vaginal
breech delivery.
Factors that modify the success ECV
Increase success -increasing parity -ample amniotic fluid
-unengaged fetus - tocolysis
Decrease success - engaged fetus -tense uterus -inability to palpate head
 - obesity - anterior placenta -fetal spine
anterior or posterior -labor

PROCEDURE:
- forward roll of the fetus is attempted , each hand grasps one of the fetal
poles and the buttocks are elevated from the maternal pelvis and displaced
laterally. The buttocks are then gently guided toward the fundus, while the head is
directed toward the pelvis.
- if forward roll is unsuccessful backward flip is attempted.
- version attemps are discontinued for excessive discomport, persistently
abnormal FHR-or after multiple failed attempts.