Breech presentation, assisted breech delivery, breech extraction,mauriceau smelllie viet technique, Burns Marshall technique, forceps delivery in Breech,

1. CONDUCT OF VAGINAL
DELIVERY IN BREECH
PRESENTATION

2. TYPES
Spontaneous
Breech
Delivery
Assisted
Breech
Delivery
Total Breech
extraction

3. TRIAL OF LABOR IN BREECH
CRITERIA:
• FRANK OR COMPLETE BREECH
• TERM GESTATIONALAGE 36 TO 42 WEEKS
• ESTIMATED FETAL WEIGHT 2500 TO 3500 GRAMS
• ADEQUATE MATERNAL PELVIS
• NO MATERNAL OR FETAL INDICATION FOR A CESARIAN SECTION

4. MANAGEMENT OF FIRST STAGE OF LABOR
• BED REST
• FOETAL HEART RATE MONITORING FOR EVERY 15 MINUTES ESPECIALLY AFTER
RUPTURE OF MEMBRANES.
• VAGINAL EXAMINATION AFTER RUPTURE OF MEMBRANES.
• LABOUR IS ALLOWED TO CONTINUE PROVIDED THERE IS NO CORD PROLAPSE

5. SPONTANEOUS BREECH DELIVERY:
• THE FETUS IS EXPELLED SPONTANEOUSLY WITHOUT ANY MANIPULATION
OTHER THAN SUPPORT OF THE NEWBORN.
• MOST COMMON DURING THE DELIVERY OF A DEAD FOETUS.
• ACCOUNTS FOR ONLY 10% OF TOTAL BREECH DELIVERIES DONE.

6. ASSISTED BREECH DELIVERY:
• THE FOETUS IS DELIVERED SPONTANEOUSLY UPTO THE LEVEL OF UMBILICUS
BUT THE REMAINDER OF THE BODY IS DELIVERED WITH ASSISTANCE.
• CONSISTS OF THREE P’S:
• P- PREREQUISITES
• P- PRINCIPLES
• P- PROCEDURE

7. PREREQUISITES:
• SKILLED OBSTETRICIAN
• ANAESTHETIST
• AN ASSISTANT
• INSTRUMENTS AND SUTURE MATERIALS FOR EPISIOTOMY
• A PAIR OF OBSTETRIC FORCEPS
• APPLIANCES FOR THE RESUSCITATION OF THE BABY
• A NEONATOLOGIST

8. PRINCIPLES:
• NEVER TO RUSH.
• NEVER TO PULL BUT TO PUSH FROM ABOVE.
• ALWAYS KEEP THE BACK OF THE BABY ANTERIORLY.

9. PROCEDURE:
• PREPARATIONS
• DELIVERY OF THE BREECH
• DELIVERY OF THE SHOULDERS
• DELIVERY OF THE AFTER COMING HEAD

10. PREPARATIONS:
• PATIENT IS BROUGHT TO BED WHEN ANTERIOR BUTTOCK AND THE ANUS ARE
VISIBLE.
• KEEP IN LEFT LATERAL POSITION.
• PLACE HER IN LITHOTOMY POSITION WHEN THE POSTERIOR BUTTOCK
DISTENDS THE PERINEUM
• ANTISEPTIC CLEANING
• CATHETERISATION OF BLADDER
• LOCAL INFILTRATION ANAESTHESIA- 10ML OF 1% LIGNOCAINE

11. DELIVERY OF BREECH:
• EPISIOTOMY:
IT IS GIVEN WHEN THE “CLIMBING OF THE
BREECH” OCCURS
• PATIENT IS ASKED TO BEAR DOWN.
• NO TOUCH TO THE FOETUS POLICY IS STRICTLY
FOLLOWED.
• IF THERE IS ANY DIFFICULTY GROIN TRACTION IS
GIVEN.
• UMBILICAL CORD IS PULLED DOWN TO ONE SIDE
OF THE SACRUM TO AVOID CORD
COMPRESSION.
• AFTER THE DELIVERY OF THE UMBILICUS IF THE

12. DELIVERY OF SHOULDERS:
• WHAT TO LOOK?
POSITION OF THE SCAPULA – PARALLEL OR WINGING
INTERPRETATION – PARALLEL – FLEXED ARMS
WINGING – EXTENDED ARMS
• WHAT TO DO? (FLEXED ARMS)
THE SHOULDERS ARE TO BE DELIVERED ONE AFTER THE OTHER ONLY
WHEN ONE AXILLA IS VISIBLE.
DELIVERY IS SIMPLY DONE BY HOOKING OUT EACH ARM AT THE
ELBOW

13. DELIVERY OF THE POSTERIOR SHOULDER:

14. DELIVERY OF THE ANTERIOR SHOULDER:

15. DELIVERY OF THE AFTER COMING HEAD:
• CRUCIAL PART OF BREECH DELIVERY.
• THE INTERVAL BETWEEN THE DELIVERY OF THE UMBILICUS TO THE DELIVERY
OF THE HEAD SHOULD BE 5 – 10 MINUTES.
• METHODS TO DELIVER THE AFTER COMING HEAD
• MAURICEAU SMELLIE VEIT TECHNIQUE (MODIFIED)
• BURNS-MARSHALL METHOD
• FORCEPS DELIVERY

16. MODIFIED MAURICEAU-SMELLIE-VEIT
TECHNIQUE
BABY IS PLACED OVER THE SUPINATED LEFT FORE ARM WITH LIMBS HANGING ON EACH SIDE
THE INDEX AND MIDDLE FINGER OF THE LEFT HAND ARE PLACED OVER THE MALAR EMINENCES
OF THE BABY
THIS MAINTAINS THE FLEXION OF THE HEAD
THE RING AND LITTLE FINGERS OF THE PRONATED RIGHT HAND ARE PLACED ON THE BABY’S
RIGHT SHOULDER
AND INDEX FINGER IS KEPT OVER LEFT SHOULDER
MIDDLE FINGER IS PLACED ON THE SUB OCCIPITAL REGION TRACTION IS GIVEN IN DOWNWARD
AND BACKWARD DIRECTION TILL THE NAPE OF THE NECK IS VISIBLE UNDER THE PUBIC ARCH
SUPRAPUBIC PRESSURE IS GIVEN BY THE ASSISTANT

17. MODIFIED MAURICEAU-SMELLIE-VEIT
TECHNIQUE

18. BURNS-MARSHALL METHOD:
BABY IS ALLOWED TO HANG ON ITS OWN WEIGHT
THE ASSISTANT IS ASKED TO GIVE SUPRAPUBIC PRESSURE WITH A FLAT HAND IN A
DOWNWARD AND BACKWARD DIRECTION
THIS IS TO PROMOTE THE FLEXION OF THE HEAD
WHEN THE NAPE OF THE NECK IS VISIBLE UNDER PUBIC ARCH
ANKLES OF THE BABY ARE GRASPED WITH A FINGER IN BETWEEN
MAINTAINING A STEADY TRACTION A WIDE ARC OF A CIRCLE IS FORMED BY
SWINGING THE TRUNK UPWARD AND FORWARD DIRECTION
LEFT HAND IS PLACED OVER THE PERINEUM TO SUCCESSIVELY SLIP OFF FROM
THE FACE OF THE BABY

19. FORCEPS DELIVERY:
THE HEAD SHOULD BE BROUGHT AS LOW DOWN AS
POSSIBLE
WHEN THE OCCIPUT LIES AGAINST THE BACK OF THE
PUBIC ARCH
THE ASSISTANT RAISES THE LEGS OF THE BABY TO
FACILITATE THE INTRODUCTION OF FORCEPS FROM
BELOW
THE HEAD SHOULD BE DELIVERED SLOWLY TO AVOID
DECOMPRESSION AND COMPRESSION OF THE HEAD
WHICH MAY CAUSE INTRACRANIAL BLEEDING

20. ADVANTAGES:
• DELIVERY CAN BE CONTROLLED BY GIVING PULL DIRECTLY ON THE HEAD NOT
THROUGH NECK
• ADEQUATE FLEXION OF THE HEAD IS ALWAYS ENSURED
• MUCUS CAN BE SUCKED OUT FROM THE MOUTH MORE EFFECTIVELY

22. TOTAL BREECH EXTRACTION
• RARELY DONE THESE DAYS
• ONE OF THE FEW INDICATIONS WHERE IT MAY BE FOLLOWED ARE, DELIVERY OF
SECOND TWIN AFTER IPV AND DELIVERY OF EXTENDED LEGS ARRESTED AT THE
CAVITY OR OUTLET.
• A HAND IS INTRODUCED THROUGH THE VAGINA AND BOTH FEET OF THE FETUS ARE
GRASPED
• WITH GENTLE TRACTION, THE FEET ARE BROUGHT THROUGH THE INTEROITUS.
• THE TRACTION IS CONTINUED AND SUCCESSIVE PARTS ARE GRASPED AND
EXTRACTED UNTIL THE BUTTOCKS EMERGE AND THE BODY ROTATES ANTERIORLY.
• THE REMAINING STEPS ARE COMPLETED AS IT IS DONE FOR ASSISTED BREECH
DELIVERY.