BREECH PRESENTATION

MALPRESENTATION
Presentation: Presentation means part of the fetus which lies at the pelvic brim or in the lower
pole of uterus. Following are the presentations

1. Vertex presentation: is normal presentation and occur in 96.8% of pregnant women. In

this type of presentation, head is in lower pole of uterus or in pelvic brim. The head is
flexed.
2. Breech presentation: It is Malpresentations. It occurs in 2.5% of pregnant women The
buttocks lie in the lower pole of uterus.
3. Shoulder presentation: Its incidence is 1 in 250. It is also a type of Malpresentations. The
shoulder lie either dorso anterior or dorso posteriorly in the lower sole of uterus.

Malpresentations

Malpresentations means the fetus presents in the maternal pelvis other than vertex,
longitudinal lie and flexion attitude. The Malpresentations are:

 Breech presentation
 Face presentation
 Brow presentation
 Shoulder presentation
 Compound presentation
 Cord presentation

BREECH PRESENTATION
In breech presentation, the lie is longitudinal and the podalic pole presents at the pelvic
brim. It is the most common malpresentation. In a breech presentation, the fetus lies
longitudinally with the buttocks in the lower pole of the uterus. The presenting diameter is the
bitrochanteric (10 cm) (measured at the level of the hip joint) and the denominator is the
sacrum. This presentation occurs in approximately 3% pregnancies at term.

Incidence: The incidence is about 20% at 28th week and drops to 5% at 34th week and to 3-
49% at term. Thus in3 out of 4, spontaneous correction into vertex presentation occurs by 34th
week. The incidence is expected to be low in hospitals where high parity births are minimal and
routine external cephalic version is done in antenatal period.
Breech presentation at delivery occurs in 3 to 4 percent of pregnancies. However, before 28
weeks of gestation, the incidence is about 25 percent. As term gestation approaches, the
incidence decreases. In most cases, the fetus converts to the cephalic presentation by 34 weeks
of gestation.

DEFINITION:
In breech presentation, fetal buttocks or lower extremities present into the maternal
pelvis.

-Neelam kumara

Breech presentation is a longitudinal lie in which the buttocks is the presenting part with
or without the lower limbs

-Nima bhaskar

Breech presentation is a longitudinal lie with a variation in polarity. The fetal pelvis is the
leading pole. The denominator is the sacrum. A right sacrum anterior (RSA) is a breech
presentation where the fetal sacrum is in the right anterior quadrant of the mother's pelvis and
the bitrochanteric diameter of the fetus is in the right oblique diameter of the pelvis

Etiology

As term approaches, the uterine cavity, in most cases, accommodates the fetus best in a
longitudinal lie with a cephalic presentation. In many cases of breech presentation, no reason
for the malpresentation can be found and, by exclusion, the cause is ascribed to chance. Some
women deliver all their children as breeches, suggesting that the pelvis is so shaped that the
breech fits better than the head.

Breech presentation is more common at the end of the second trimester than near term;
hence, fetal prematurity is associated frequently with this presentation.

The causes of breech presentation are:

Fetal
 Liquor
Uterine
Placental
Pelvic
Maternal

Maternal factors:

Factors that influence the occurrence of breech presentation include

 The uterine relaxation associated with high parity

 Polyhydramnios, in which the excessive amount of amniotic fluid makes it easier for the
fetus to change position
 Oligohydramnios, in which, because of the small amount of fluid, the fetus is trapped in
the position assumed in the second trimester
 uterine anomalies;
 neoplasm’s, such as leiomyomata of the myometrium
 While contracted pelvis is an uncommon cause of breech presentation, anything that
interferes with the entry of the fetal head into the pelvis may play a part in the etiology
of breech presentation.

Fetal causes:

It includes prematurity, multiple pregnancy. Anomalies of fetus sometime restrict the fetus
to assume a vertex presentation. The malformation of fetus such as hydrocephaly,
anencephaly, meningomyocoele and congenital dislocation of hip.

Placental cases:

Placental site: There is some evidence that implantation of the placenta in either cornual-
fundal region tends to promote breech presentation. There is a positive association of breech
with placenta previa.

Liquor: polyhydramnios, oligohydramnios

Uterine causes: bicornuate uterus/ fibroid uterus

Pelvic causes: any pelvic tumors obstructing the birth canal

ETIOLOGY OF BREECH PRESENTATION

There is higher incidence of breech in earlier weeks of pregnancy. Smaller size of the fetus
and comparatively larger volume of amniotic fluid allow the fetus to undergo spontaneous
version by kicking movements until by 36th week when the position becomes stabilized. The
following are the known factors responsible for breech presentation. In a significant number of
cases, the cause remains obscure.

 Prematurity: It is the most common cause of breech presentation.

 Factors preventing spontaneous version: (a) Breech with extended legs, (b) Twins, (c)
Oligohydramnios, (d) Congenital malformation of the uterus such as septate or
bicornuate uterus, (e) Short cord, relative or absolute, (f) Intrauterine death of the fetus.
 Favorable adaptation: (a) Hydrocephalus-big head can be well accommodated in the
wide fundus, (b) Placenta previa, (c) Contracted pelvis, (d) Cornu-fundal attachment of
the placenta minimizes the space of the fundus where the smaller head can be placed
comfortably.
 Undue mobility of the fetus: (a) Hydramnios, (b) Multiparae with lax abdominal wall.
 Fetal abnormality: Trisomies 13, 18, 21, anencephaly and myotonic dystrophy due to
alteration of fetal muscular tone and mobility. .

Recurrent breech: On occasion, the breech presentation recurs in successive pregnancies.

When it recurs in three or more consecutive pregnancies, it is called habitual or recurrent
breech. The probable causes are congenital malformation of the uterus, septate or bicornuate,
and repeated cornu-fundal attachment of the placenta.

Types of breech presentation:

 Complete
 Incomplete
 Breech with extended legs (frank breech)
 Footling presentation
 Knee presentation

Complete (Flexed breech): The normal attitude of full flexion is maintained. Thighs are flexed at
hips and legs at knees. The presenting part consists of two buttocks, external genitalia and two
feet. It is commonly present in multiparae (10%).

Incomplete: This is due to varying degrees of extension of thighs or legs at the podalic pole.

Three varieties are possible:

Breech with extended legs (Frank breech): In this condition, thighs are flexed on the trunk and
legs are extended at the knee joints. The presenting part consists of the two buttocks and
external genitalia only. It is commonly present in primigravidae, about 70%. The increased
prevalence in primigravida is due to right abdominal wall, good uterine tone and early
engagement of breech.

Footling presentation (25%): Both thighs and legs are partially extended bringing the legs to
present at brim.

Knee presentation: Thighs are extended but the knees are flexed, bringing the knees down to
present at the brim. The latter two varieties are not common.

Clinical varieties: In an attempt to find out the dangers inherent to breech, breech presentation
is clinically classified as:

(1) Uncomplicated-It is defined as one where there is no other associated obstetric

complication apart from the breech, prematurity being excluded.

(2) Complicated--When the presentation is associated with conditions which adversely

influence the prognosis such as prematurity, twins, contracted pelvis, placenta previa, etc. It is
called complicated breech. Extended legs, extended arms, cord prolapse or difficulty
encountered during breech delivery should not be called complicated breech but are called
complicated or abnormal breech delivery.

Diagnosis of breech presentation

 Clinical
 Sonography

Per abdomen complete breech frank breech

Fundal grip  Head suggested by  Head

hard and globular  Irregular small parts of
mass the feet may be felt by
 Head is ballottable the side of the head
Lateral grip  Head is nonballottable
 Fetal back is to one due to splinting action
side and the irregular of the legs on the
Pelvic grip limbs to the other trunk
 Breech--suggested by  Irregular parts are less
soft, broad and felt on the side
irregular mass  Small, hard and a
 Breech is usually not conical mass is felt
engaged during  The breech is usually
FHS pregnancy engaged
 Usually located at a  Located at a lower
level in the midline
 higher level round due to early
about the umbilicus engagement of the
breech
Per vaginam

During pregnancy  Soft and irregular parts  Hard feel of the

are felt through the sacrum is felt, often
fornix mistaken for the head
During labour  Palpation of ischial  Palpation of ischial
tuberosities, sacrum tuberosities, anal
and the feet by the opening and sacrum
sides of the buttocks only
The foot felt is
identified by the
prominence of the
heel and lesser
mobility of the great
toe

Ultra Sonography:

ULTRASONOGRAPHY is most informative.

1. It confirms the clinical diagnosis-especially in -especially in primigravidae with engaged

frank breech or with tense abdominal wall and irritable uterus.
2. It can detect fetal congenital abnormality and also congenital anomalies of the uterus.
3. Type of breech (complete or incomplete).
4. It measures biparietal diameter, gestational age and estimated weight of the fetus.
5. It also localizes the placenta.
6. Assessment of liquor volume (important for ECV)
7. 7) Attitude of the head -flexion hyperextension (important for decision making at the
time of delivery). CT and MRI can be used to assess the pelvic capacity in addition to all
the above-mentioned information

POSITIONS OF BREECH PRESENTATION:

Sacrum is the denominator of breech and there are four positions. In anterior
positions, sacrum is directed toward iliopubic eminences and in posterior positions; sacrum is
directed to sacroiliac joints. The positions are:
  First position-left sacroanterior (LSA)-being the most common
 Second position- right sacroanterior (RSA)
 Third position-right sacroposterior (RSP) and
 Fourth position--left sacroposterior (LSP),

MECHANISM OF LABOR IN BREECH PRESENTATION

SACROANTERIOR POSITION:

In the mechanism of breech delivery, the principal movements occur at three places-
buttocks, shoulders and the head. The first two successive parts to be born are bigger but more
compressible while the head because of nonmolding due to rapid descent, presents difficulties.
Each of the three components undergo cardinal movements as those of normal mechanism.

1. Lie is longitudinal
2. Attitude is one of the complete flexion
3. Presentation is breech
4. Position is left sacroanterior
5. Denominator is the sacrum
6. Presenting part is the left (anterior) buttock
7. Bitrochanteric diameter (10CM), enters the pelvis in the left oblique diameter of the
brim
8. Sacrum points to the left iliopectoneal eminence
A. Descend takes place initially with increasing compaction, owing to increased flexion of
the limbs. Descend then occurs throughout.
B. Engagement of the hips takes place in an LSA position with the sacrum in the left
anterior portion of the mother's pelvis and bitrochanteric diameter in the left oblique
diameter of the mother's pelvis.
C. Internal rotation of the buttocks: The anterior buttock reaches the pelvic floor first and
rotates forwards 45° (1/8th of a circle) along the right side of the pelvis to lie
underneath the symphysis pubis. The bitrochanteric diameter is now in the
anteroposterior diameter of the outlet.
D. Birth of the buttocks by lateral flexion: The anterior buttock escapes under the
symphysis pubis, the posterior buttock sweeps over the perineum and the buttocks are
born by a movement of lateral flexion
E. Restitution of the buttocks: The anterior buttock turns slightly to the mother's right
side.
F. Internal rotation of the shoulders: The shoulders enter the pelvis in the same left
oblique diameter. The anterior shoulder rotates 45° (1/8th of a circle) along the right
side of the pelvis and escapes under the symphysis pubis.
G. External rotation of the buttocks: With the internal rotation, of the shoulders, the
delivered body also 1 rotates and sacrum returns to a left sacrotransverse (LST) position
from an LSA position.
H. Birth of the shoulders takes place by lateral flexion: When born spontaneously, the
anterior shoulder impinges beneath the symphysis pubis and serves as the pivotal point
for the lateral flexion necessary for the delivery of the posterior shoulder via the curve
of Carus. Birth of the anterior shoulder then follows as the body straightens out.
I. Internal rotation of the head: The head enters the pelvis with the sagittal suture in the
transverse diameter of the brim. The occiput rotates forward along the left side and
suboccipital region (nape of the neck) impinges on the under surface of the symphysis
pubis.
J. External rotation of the body takes place simultaneously. The body turns so that the
back of the baby is upward and the baby is facing down.
K. Birth of the head by flexrion: The chin, face and sinciput sweep over the perineum and
the head is born in a flexed attitude.
Buttocks:

 The diameter of engagement of the buttock is one of the oblique diameters of the inlet.
The engaging diameter is bitrochanteric (10 cm or 4) with the sacrum directed toward
the iliopubic eminence. When the diameter passes through the pelvic brim, the breech
is engaged.
 Descent of the buttocks occurs until the anterior buttock touches the pelvic floor.
 Internal rotation of the anterior buttock occurs through 1/8th of a circle placing it
behind the symphysis pubis.
 Further descent with lateral flexion of the trunk occurs until the anterior hip hinges
under the symphysis pubis which is released first followed by the posterior hip.
 Delivery of the trunk and the lower limbs follow.
 Restitution occurs so that the buttocks occupy the original position as during
engagement in oblique diameter.

Shoulders:

 Bisacromial diameter (12 cm or 4 3/4") engages in the same oblique diameter as that
occupied by the buttocks at the brim soon after the delivery of the breech.
 Descent occurs with internal rotation of the shoulders bringing the shoulders to lie in
the anteroposterior diameter of the pelvic outlet. The trunk simultaneously rotates
externally through 1/8th of a circle.
 Delivery of the posterior shoulder followed by the anterior one is completed by anterior
flexion of the delivered trunk.
 Restitution and external rotation: Untwisting of the trunk occurs putting the anterior
shoulder toward the right thigh in LSA and left thigh in RSA. External rotation of the
shoulders occurs to the same direction because of internal rotation of the occiput
through 1/8th of a circle anteriorly. The fetal trunk is now positioned as dorsoanterior.

Head:

 Engagement occurs either through the opposite oblique diameter as that occupied by
the buttocks or through the transverse diameter. The engaging diameter of the head is
suboccipitofrontal (10 cm).
 Descent with increasing flexion occurs.
 Internal rotation of the occiput occurs anteriorly, through 1/8th or 2/8th of a circle
placing the occiput behind the symphysis pubis.
 Further descent occurs until the subocciput hinges under the symphysis pubis.
  Head is born by flexion--chin, mouth, nose, forehead, vertex and occiput appearing
successively. Ihe expulsion of the head from the pelvic cavity depends entirely upon the
bearing-down efforts and not at all on uterine contractions.

Sacroposterior position: In sacroposterior position, the mechanism is not substantially

modified. The head has rotate through 3/8th of a circle to bring the occiput behind the
symphysis pubis.

Types of Breech Delivery

 Spontaneous breech delivery: The delivery occurs with little assistance from the
attendant.
 Assisted breech delivery: The buttocks are born spontaneously, but some assistance is
provided for delivery of extended legs or arms and the head
 Breech extraction: This is a manipulative delivery performed by an obstetrician to
hasten delivery in an emergency, such as the fetal distress.
 BREECH

PRESENTATION