Mechanism of labor in Breech

presentation
By Munkaila Adam
 outline
• Definition
• Incidence
• Types of breech
• Aetiology of breech presentation
• Diagnosis
• Management options in breech
• Mechanism of labor in breech(ED-FLICEREE)
• Complications
 Breech presentation
Dfn
• Is when the bottom of the fetus occupies the
lower pole of the uterus
Or
• when the podalic pole of fetus presents at the
pelvic brim
 Incidence of breech
• Common in preterm of about( 20% incidence),
and in multiple gestation
• at term reduces to 3-4%
 Types(varieties) of breech
2main types; 1. Complete or 2. Incomplete

1. Complete
• Flexed breech

2. Incomplete;
• Frank breech
• Footling breech presentation
• Knee presentation
 Varieties of breech
Complete breech
• Is a completely flexed breech, both at the hips
and the knee joints
• Feet is beside the bottom
• presenting part consists of two
buttocks,external genitalia and two feet
• is common in multiparae
• Is in 10% of all breechs
This a complete breech
 Incomplete breech .
Frank breech
• Known as breech with extended legs
• Both hips are flexed, but knees are extended
• Presenting part is both buttocks and the external
genitalia
• common in primigravidae
• 60-70% of all breechs
• increased prevalence in primigravida due to a tight
abdominal wall, good uterine tone and early engagement
of breech.
This a frank breech
 Incomplete-cont.
Footling presentation :
• Is either single or double footling breech
• Occurs in 25%
• the thighs and the legs are partially extended
bringing the legs to present at the brim.
 Varieties of breech--incomplete
Knee presentation:
• Baby is in kneeling position
• Thighs are extended but the knees are flexed,
bringing the knees down to present at the
pelvic brim.
• Its extremely rare
AETIOLOGY OF BREECH PRESENTATION

Aetiological factors are;

• Maternal-(pelvic- and uterine) factors
• Fetal-(placental and amniotic fluid) factors
• Hereditary factors
• Idiopathic
AETIOLOGY OF BREECH PRESENTATION

Maternal-(pelvic and uterine) factors

• Previous history of term breech
• High paritylax abdominal wall, reduced ut
tone
• Congenital uterine anomalies; septate, bicorn
• Pelvic masses; fibroids, ovarian tumors
• Contracted pelvis
AETIOLOGY OF BREECH PRESENTATION
Fetal-(placental and amniotic fluid) factors
• Prematuritiy
• Placenta previa
• Multiple gestation
• Cornual or fundal insertion of placenta
• Macrosomia
• Fetal anomalies; xsome->13, 18, 21. hydrocephalus,
anencephally
• Polyhydramnious or oligohydramnious
AETIOLOGY OF BREECH PRESENTATION

Hereditary factors.
• Study done in Norway from 1997-2004
concluded that term breech birth may be
determine by genes
• People who themselves were delivered breech
had more twice the risk of breech delivery in
their own 1st pregnancies (compared to people who
were delivered in cephalic presentation)
AETIOLOGY OF BREECH PRESENTATION

Idiopathic
• In a number of cases there is no cause
 Diagnosis of breech
• Clinical means

or

• imaging techniques;
 Diagnosis of breech

Clinical means; Uterine palpation findings

Leopolds manoeuvres will give ff findings
Fundal grip;
• Head is palpated in the fundus as round, regular hard
and ballotable mass
Lateral grip;
• lie is longitudinal,
• fetal back is felt on the maternal right or left which is
smooth, firm and regular and irregularly felt limbs on the
other side
Pelvic grip;
• The breech/podalic pole is felt in the lower Uterine
segment as a; soft, broad, irregular and nonballotable
mass
 Diagnosis of breech
• Clinical means; fetal heart auscultation
Fetal heart sounds;
• Heard at higher level than in cephalic
• Best heard above the umbilicus
 Breech diagnosis—clinical
Vaginal exmination findings;
• No hard head, no fontanels or sutures are
palpated
• Soft buttock and hard sacrum with sacral spines
feeling like strings of pearls is palpated
• Skin of buttocks is smooth and cleft is felt in
between the buttocks
• Two Ischial tuberosities and anal orifice (in
between them) are felt and are in straight line
 Breech diagnosis—clinical, cont.
Vaginal exam
• In footling breech, foot or feet can be palpated
• The foot felt is identified by the prominence
of the heel and lesser mobility of the great
toe
 Breech diagnosis—clinical, cont
Vaginal exam In labor, when membranes
rupture;
• There is fresh thick dark meconium stained
liquor in the absence of fetal distress
• If we have a fetus presenting as footling
breech or Hand presentation, how do
differentiate the foot from the hand?

or

• when you have a compound presentation,

how will we identify the feet and the hands?
Note that; in footling breech or hand presentation
the foot can be distinguished from the hand by ff;
• Foot has a heel which is prominent and forms
almost 90 degrees to the ankle joint
• The hand has therna and hypotherna eminence
which is less prominent compare to the heel.
• The therna eminence is also in straight line
(180degrees) to the wrist joint
• The big toe cannot be abducted from the next
toe, whilst the thumb can be abducted long away
from the index finger
 Note; differentiation of breech from face presentation in labor

Careful vaginal examination;

• the finger encounters muscular resistance
with the anus,
• whereas the firmer, less yielding jaws are felt
through the mouth.
• Furthermore, the finger, upon removal from
the fetal anus, sometimes is stained with
meconium
 Note; differentiation of breech from face presentation

• The mouth and malar eminences form a

triangular shape,
• whereas the two ischial tuberosities and anus
are in a straight line.
 Diagnosis of breech
Imaging
• An Obstetric Ultrasound scan will confirm
and identify type of breech
• Other imagings are; CT-Scan, MRI, X-ray
 ANTENATAL MANAGEMENT(MGT) OF
BREECH
Breech clinically diagnosed ;
• Antenatal mgt involve; the usual or routine
antenatal monitoring till 36weeks, then at this
gestation if the breech persists, then we do ff;

1. Identification of the complicating factors related

to breech presentation.

2. Formulation of the next line of management,

 Antenatal mgt of breech, cont.

Identification of the complicating factors related with breech

presentation.
• by clinical examination, supplemented by
sonography(ultrasound scan);
Scan to determine;
• Type of breech
• Confirm GA
Exclude;
• fetal anomaly,
• Star gazer fetus(hyperextended head)
• previa,
• multiple gestation,
• nuchal cord or cord around the fetal body, other pelvic
pathologies
 Antenatal mgt of breech, cont.
To discuss options of management of breech
with the couple and obtain informed concern
Options of management include
• 1. Planned c-section
• 2. External Cephalic Version(ECV)
• 3. Planned vaginal breech delivery
 Management options for breech, cont.
Sequential questions to ask
• Is there any condition that mandates
caesarean-section? If yes, then do elective cs
• If there is no such condition, is there
contraindication to ECV?
• If there is no contraindication to ECV, then ECV
is performed
• If ECV fails, is there contraindication to trial of
breech labor, including patient’s informed
concern?
 Management options for breech, cont.

Indication for c-section for breech

• Previous macrosomia
• Previous difficult delivery/ or previous stillbirth
• Index pregnancy fetal weight (EFW)> 3.5kg
• Footling or kneeling breech
• Hyperextended fetal neck(star gazing fetus) or
forward looking fetus
• Inadequate pelvis
• IUGR
• Serious medical complication, eg severe preeclamp
• Lack of experience in vaginal breech delivery
 Management options for breech
• If there is no indication for C/S
• And no contraindication for ECV,
• then perform ECV under tocolysis, and review
patient weekly, untill she goes into
spontaneous labor, and deliver vertex (in
cephalic presentation)
 Management options for breech
Contraindication for ECV
Absolute
• Other indications for CS, eg major previa, elderly nullip etc.
• Multiple pregnancy
• APH
• Fetal anomalies
• Fetal distress
• ROM
• Oligohydramnious
• Nuchal cord
Relative
• preclamplsia., prev-C/S, IUGR, maternal obesitiy
 Management ops for breech
• If there is contraindication for ECV,
• then consider trial of vaginal breech delivery.
• And when trial of vaginal breech delivery fails,
then do emergency C/S
 Management of breech, if ECV fails or is
contraindicated
• The pregnancy is to be continued with usual
ANC visits
• Spontaneous version may occur
if the breech persists, assessment of the case is
to be done with respect to;
• associated complicating factors
• size of the baby
• pelvic capacity– clinical pelvimetry
 Management of breech, if ECV fails or is
contraindicated
If vaginal breech delivery is considered, the ff
factors should also be considered in the facility
trying to undertake breech delivery;
• Skills on vaginal breech delivery
• Equipment for fetal monitoring in labor, including
electronic fetal monitor
• Functioning theatre, anesthesia, blood bank and
NICU services
• Expertise for C/S and neonatal resuscitation
Other Criteria to be fulfilled for vaginal breech
delivery are;
• Average fetal weight (between 1.5 and 3.5
kg),
• Flexed fetal head,

• No any other (medical or obstetric)

complications
 NB; ZATUCHINI-ANDROS SCORE
breech(another criteria for vaginal br del, >4 favorable )
score
parameters 0 1 2
parity 0 1 2
GA 39+ 38 <37
EFW >3500g 2500-3500g <2500
Previous breech 0 1 2
delivery
Cx-dilatation(cm) 2 3 >4
station -3 -2 -1
Management ops for vaginal breech
• Options for vaginal breech delivery;
• 1. spontaneous breech delivery-
• 2. assisted breech delivery
• 3. total breech extraction
• 4. partial breech extraction
 Management ops for breech
Spontaneous breech delivery;
• no traction or any manipulation is applied to deliver the
baby
Assisted breech delivery;
• infant is allowed to deliver up to the umbilicus, then its
assisted by certain techniques for complete delivery
Total breech extraction;
• baby is totally extracted without the maternal efforts
Partial breech extraction;
• baby is delivered up to umbilicus, then its extracted
 NOTE;
Total breech extraction is only, used for delivery of ;
• noncephalic second twin,
• breech with extended legs arrested at the cavity or at the
outlet
• and should not be used for singleton breech as the cx is not
fully dilated for passage of fetal head;
• The only other use in singleton breech are; acute fetal
distress or cord prolapse with fully dilated cx,.when access to
c/s in time is impossible
 Management of trial of breech labor; Assisted
Breech Delivery in labor
Mgt Steps from 1st stage to 2nd stage of labor;
Counsel the client and admit to Labor Ward

• Get IV access with 16G cannula and take blood for;

FBC, GXM
• Start N/S infusion slowly
• Put patient on patograph
• Monitor FH every 15min with fetal stethosc or on
CTG
Mgt of trial of breech labor; Assisted Breech
Delivery in labor-1st -2nd stg
• Do not do ARM, leave the membrane to form a
dilating wedge and to prevent cord prolapse
• Exclude cord prolapse as soon as membranes
rupture
• When patient start to bear down or fetal
buttocks is seen, do VE to confirm full cervical
dilatation
• If not fully dilated discourage patient from
bearing down
 Mgt of trial of breech labor; Assisted Breech Delivery
in labor

Steps from 2nd stage to delivery of umbilicus and legs.

Allow the baby to deliever up to the umbilicus;
• 1.Neonatologist and anesthetist must be present
• 2.Put patient in litothomy position when the
posterior buttock distends the perineum
• 3.Empty the bladder with a catheter
• 4.Perform episiotomy if perineum is unyielding
• 5.Encourage patient to push with the contractions,
but avoid traction(pulling) up to this
stage(trunk)----’NON TOUCH(hands up) principle’
• when the navel(umbilicus) is now born, gently
pull down the cord to prevent compression
• check for cord pulsation every 2mins
• Check to see if the legs are in the vagina
• in frank breech, the extended legs are brought
out by pinard manoeuvre, (by applying pressure
on the popliteal fossa( knee joint) in a manner of
abduction and flexion of the thighs bringing the legs out
of vagina)
• NB; all above are performed without pulling on the baby—”hands up’ or “no touch”
technique up to level of Navel or trunk
 NB; Pinard’s maneuver
• is done by intrauterine manipulation to
convert a frank breech to a footling breech

• the middle and the index fingers are carried

up to the popliteal fossa of fetus . It is then
pressed and abducted so that the fetal leg is
flexed. The fetal foot is then grasped at the
ankle and brought out
Pinard manueovre
Mgt steps from delivery Navel(trunk) and legs to
delivery of shoulders
After delivery of the trunk, we monitor till the
shoulders start appearing,
• Rotate the trunk to bring the back anteriorly (sacro-
anterior)
• Wrap baby with a sterile towel to prevent slipping
when held by the hands and to facilitate
manipulation, if required
• Do not pull on the trunk, allow it to hang till the
shoulder(angle of scapula) appears
Mgt steps in the delivery of Shoulders and Arms
• When the scapulae are delivered, then allow the
arms to deliver spontaneously
• If spontaneous delivery of Arms are unduly
delayed, then Loveset manoevre or internal
manipulation is used to deliver the extended Arms

• The arms are also delivered one after the other by

simply hooking down each elbow with a finger
when the axilla is visible
 NB; LOVSET’S MANEUVER
• Its an intrauterine manipulative method of bringing
down an extended arm in breech.
• Step—1: The trunk is rotated through 180° clockwise,
keeping the back anterior and maintaining a
downward traction to bring the posterior arm under
the pubic arch which is then hooked out
• Step—2: The trunk is then rotated anticlockwise to
deliver the anterior shoulder under the symphysis
pubis
Delivery of the after-coming head:
• most crucial stage of breech delivery
• Delivery of the head should not last longer
than 5min
Methods for delivery of after-coming head
• Burns-Marshall method(BM-Method);
• modified Mauriceau-Smellie-Veit
technique(MSV Technique)
• Forceps delivery:
 Delivery of the after-coming head:

Burns-Marshall method
• Allow baby to hang by its own weight
• assistant is asked to give suprapubic pressure
with the flat of hand in a downward and
backward direction
• When the nape of the neck is visible, the ankles
are grasped and the trunk is swung in upward
and forward direction to deliver the head
BURNS-MARSHALL METHOD
 modified Mauriceau-Smellie-Veit technique
Malar flexion and shoulder traction
• The baby is placed on the supinated left forearm
• The middle and the index fingers of the left hand
are placed over the malar bones on either sides to
maintain flexion on the head
• The ring and little fingers of the pronated right
hand are placed on the child’s right shoulder, the
index finger is placed on the left shoulder and the
middle finger is placed on the sub-occipital region
• Traction is now given in downward and backward
direction to deliver the head
MSV-technique
 Forceps delivery delivery of after-coming
head of breech
• Piper forceps
 ENTRAPMENT OF THE AFTERCOMING HEAD
Methods that may be employed;
Do episiotomy and do any of the ff.
• malar flexion and shoulder traction along with
suprapubic pressure(MSV
• Intravenous nitroglycerine to relax the cx
• Zavanelli’s maneuver(push baby back and perform c/s)
• Duhrssen incisions on the cervix at 10 and 2olclock,
• Use of forceps
• If IUFD, or hydrocephalus, then, perforation of head
to collapse it for easy delivery
 Mechanism of labor in breech
• Principal movements occur at three levels;
buttocks, shoulders and the head.
Buttocks
• It engages is one of the oblique diameters of the
pelvic inlet
• Engaging diameter is bi-trochanteric (10 cm)
with the sacrum toward ilio-pubic eminence
• When this diameter passes through the pelvic
brim, the breech is engaged.
 Mechanism of action in breech--buttock

• Descent occurs until the anterior buttock touches

the pelvic floor
• Internal rotation of the anterior buttock occurs
placing the anterior buttock behind the symphysis
pubis
• Further descent with lateral flexion of the trunk
occurs until the anterior hip is delivered followed
by the posterior hip
• Then Delivery of the trunk and the lower limbs
follow
• Finally Restitution occurs
 Mechanism of action in breech--Shoulders
• Bisacromial diameter (12 cm) engages in the
same oblique diameter soon after the delivery
of the buttocks
• Descent occurs with internal rotation bringing
the shoulders to lie in the anteroposterior
diameter of the pelvic outlet.
• Delivery of the posterior shoulder followed by
the anterior one by anterior flexion of the trunk
• Then Restitution and external rotation occur
putting the anterior shoulder towards the right
or left maternal thigh
 Mechanism of action in breech--Head
• Engagement occurs through oblique or
transverse diameter
• Engaging diameter is suboccipitofrontal (10
cm)
• Descent with increasing flexion occurs
• Internal rotation of the occiput occurs placing
the occiput behind the symphysis pubis
• Further descent occurs until the subocciput
hinges under the symphysis pubis.
• The head is born by flexion
 Complication of breech delivery
maternal
• increased frequency of operative delivery
• trauma to the genital tract
• Sepsis because frequency of manipulation
• anesthetic complications
Fetal;
• Increased perinatal morbidity and mortality
• Preterm delivery and prematurity
• Premature rupture of membranes
• Congenital anomalies
Birth truma;
• brain, spinal cord, liver and spleen, adrenals
• Brachial plexus injury(C5C6;Erb’s palsy. C8,T1-
Klumpke’s paralysis
Intrapartum asphyxia
• Entraped head, cord prolapse, cord compresion
• Abruptio placenta
• Thank you