Breech presentation in one of the important topic to learn

1. Breech presentation
Obstetric

2. Definition and causes
• It is when the fetus lie longitudinally in the uterus with
buttocks[breech] in the lower part of the uterus and with the
head in fundus
Causes;
• Hydramnious
• Multiple pregnancy
• Hydrocephalus
• Grand Multiparity
• Prematurity
• Contracted pelvis
• Fibroids or ovarian cyst[abdominal or pelvis tumors

3. Types of breech presentation
Divided according to fetal attitude as follows
1. Complete breech=fetal is attitude complete flexion, head and
legs are fully flexed
2. Incomplete breech with subtypes;
• Breech with extended legs[frank breech],legs extended on the
abdomen
• Footling presentation; rare one or both feet present because
thighs or legs are not fully flexed
• Knee presentation;rare,one thigh is extended, one leg is flexed
• Extended arms presentation; less common than extended legs
but are now more serious
NB; lie is longitudinal for all these breech
The denominator is sacrum

4. Six positions of breech presentation
With sacrum as the denominator;
1. Right sacro anterior position/RSA
2. Left sacro anterior position/LSA
3. Right sacro lateral position/RSL
4. Left sacro lateral position/LSL
5. Right sacro posterior position/RSP
6. Left sacro posterior position/LSP

5. Differential diagnosis of breech
presentation
• Face presentation
• Shoulder presentation
• fibroids

6. Diagnosis of breech presentation during
pregnancy
1. History of discomfort around the ribs due to fetal
head pressing the ribs
2. Per abdominal examinations;
a) Inspection-ovoid shape
b) Palpation- large soft mass felt at the pelvis brim
and round hard movable mass felt at the side of
the fundus
c) Auscultation-fetal heard sound at or above the
umbilicus in complete breech

7. Management of breech presentation
diagnosed during pregnancy
1. A breech diagnosed at 32 weeks and above-refer to doctor or hospital
Investigations; u/s reveals;
a) Singleton or multiple pregnancy
b) Size and shape of pelvis
c) Size of fetus
d) Fetal attitude note whether legs, arms or head are extends
e) Fetal abnormalities e.g. hydrocephalus, encephalic etc
2. External cephalic version, if not contraindications
3. Continue regular ANC visit i.e. every 2 weeks up to 36 weeks of gestation
and weekly from 36 weeks up to delivery
4. In Primigravida; admit mother to hospital at 38 weeks of gestation for
constant assessment to avoid dangers

8. Diagnosis of breech presentation during
labour
1. History of discomfort around the ribs areas due to
fetal head pressing on the ribs
a) Per abdominal examinations
• Inspection- the shape is ovoid
• Palpation-soft mass felt at pelvis brim and movable
hard mass around at one side of the fundus
• Auscultation-fetal heart sound at or above the
umbilicus in complete breech

9. Management of breech presentation
diagnosed during labour
• Breech involve risks to fetus and mother that may need CS so delivery has
to be conducted in hospital with theatre
1. First stage is conducted as in cephalic presentation
2. Carry out observation and record on partograph
3. Vaginal examination must be performed on admission, immediately after
the rupture of membrane for the following reasons;
• To exclude cord Prolaspe
• To determine the dilatation of cervical os
• To find out whether the breech is complete or incomplete
i. In case of complete breech a high, soft, irregular mass presents with feet
lying alongside the buttocks. Sacrum and coccyx may be felt. The anal
sphincter grip the examining finger [meconium on the examining finger
confirm breech presentation

10. ii. In case of incomplete breech-if the legs are extended
no feet are felt but external genitalia of the fetus is
easily felt and distinguished
iii. In footling presentation, there may be doubt whether it
is Prolaspe of the arms or footling breech.the foot may
appear at the vulva while cervix is partially dilated or
iv. If the legs are extended and fetus is small, the breech
may slip through incomplete dilated cervix. Leading to
serious danger of fetal head being trapped by the
cervix when the fetus is partially delivered leading
to torn cervix and severe intra partum hemorrhage

11. 4. Monitor the mother carefully in order to avoid
premature pushing
5. Ensure empty bladder through out labour
6. Prepare for delivery paying emphasis to being
prepare for;
• Performing episiotomy
• Receiving asphyxiated baby

12. Breech delivery
3 types of breech delivery are;
1. Spontaneous breech delivery-little assistant from birth
attendant i.e. in complete breech[burns Marshall
method/manoeuevre
2. Assisted breech delivery; buttocks are born
spontaneously, but assistance is necessary for
delivery of extended legs or arms
3. Breech extraction; a manipulation carry out by doctor
to quicken delivery in emergency to save life of fetus

13. Second stage of labour in breech delivery
3 cardinal rules to follow during second stage of
labour;
1. Always confirm second stage of labour by vaginal
examination
2. Ensure empty bladder-pass a urine catheter
3. Place mother in a lithotomy position at the edge of
the bed

14. Mechanism of labour in breech delivery
• Lie is longitudinal
• Position is sacro-anterior
• Attitude is complete flexion
• Presentation is breech
• Denominator is sacrum
• Presenting part is anterior buttock
• The bitrochanteric diameter measuring 10 cm enters in
the oblique diameter of the maternal pelvic brim with
the sacrum pointing at the left or right ilio-pectoneal
eminence

15. Mechanism of breech cont..
1. Descent takes place with increasing compaction due to
increased flexion of limbs
2. Internal rotation of the buttocks-anterior buttock reaches the
pelvic floor first and rotates 1/8 of the circle forward along
right or left side of the pelvis. The bitrochanteric is now in
the antero posterior diameter of the pelvis outlet
3. Lateral flexion of the body-the anterior buttock escape under
the symphysis pubis, the posterior buttock sweeps the
perineum and the buttocks are born by a movement of the
lateral flexion
4. Restitution of the buttocks-the anterior buttock turns slightly
to the mother’s right side

16. Mechanism of labour in breech cont…
5. Internal rotation of the shoulders-the shoulders[bi cranium
diameter,12cm] enter in the oblique diameter of the pelvic brim.
The anterior shoulder rotates 1/8 of the pelvic circle along the right
side of the maternal pelvis and escape under the symphysis pubis.
The posterior shoulder sweeps the perineum and the shoulders
are born
6. Internal rotation of the head-the head enters the transverse
diameter of the pelvic brim. The occiput rotates forwards along the
left side and sub occipital region[nape of the neck]shows under the
surface of symphysis pubis
7. External rotation of the body- the body turns so that the back is
upper most a movement which is accompanied by internal rotation
of the head
8. Birth of the head-the chin, face and sinciput sweep the perineum
and the head is born by flexion

17. Position for delivery
• When the buttocks are bulging place the mother in
lithotomy position with buttocks at the edge of the bed
and two pillows under her head
• Perform vaginal examination to confirm second stage of
labour
• Clean the vulva under aseptic precautions
• Perform an episiotomy to widen perineum
• Encourage the mother to push during uterine
contractions

18. Delivery of complete breech [burns
Marshall method]
Delivery of the body;
i. Dressed up with sterile gown, gloves and gum boot as birth
attendant[co or midwife or dr] and stand at the foot of the
bed
ii. Buttocks are expelled by unaided, bearing down effort by
the mother. The buttocks curve upwards, the feet
disengage at the vulva and with the same contraction the
baby is born as far as the umbilicus
iii. A loop of the cord is pulled down, to avoid traction on the
umbilicus-cord must be handled gentle to avoid inducing
spasm of the blood vessels
iv. Feel for the elbows at the chest where the should be in
complete flexed breech. Wait calmly for the next uterine
contraction; do not hurry the delivery of the baby

19. Delivery of complete breech cont….
Delivery of the shoulders;
i. The weight of the buttocks will bring the shoulders down on to the pelvic
floor, where they will rotates into the anterior posterior diameter of the
pelvic outlet
ii. Assist the expulsion of the shoulders by using pull downward traction and
encouraging the mother to push
iii. Gently grasp the baby by the iliac crests[thumbs on the sacrum avoiding
to compress the adrenal glands]
iv. When the anterior shoulder escapes, elevates the buttocks to allow the
posterior shoulder and the arm to pass over the perineum
v. The back must not be turned uppermost, until the shoulders have been
born. In order to allow the head to descend down through transverse
diameter of the pelvis. If the back is turned up this time the head will enter
the antero posterior diameter of the brim extended; the shoulders may
become impacted at the outlet leading to extensive perineal tear

20. Delivery of complete breech cont….
Delivery of the head; as soon as the shoulders are born the baby is allow to
hang by its weight for one or two minutes, which bring the head down to the
pelvis floor on which the occiput rotates forward
i. The back is now uppermost-gradually the neck elongates, the hair line
appears
ii. With the left hand grasp the baby feet and take it up by an arc of 180
degree until the mouth and the nose are free at the mother’s vulva baby
being held up side down
iii. Right hand guards the perineum
iv. Wipe the mouth and the nose with gauze swabs to remove mucus or use
another form of mucus extractor[sucker]
v. Deliver the rest of the head by using the right hand to deliver the vault
very slowly over 2-3 minutes to avoid sudden compression and release of
the head which may lead to intra cranial injury
vi. Mother is encourage to breath in and out until completion of delivery of
the head
vii. Cut the cord and show the baby to the mother, quickly place the baby in a
cot or resuscitation table according to APGAR score

21. Delivery of the breech with extended
head[mauriceau-smell-veit maneuver]
• If the hair line does not appear after the baby is allowed to hang
for 1-2 minutes, that us an indication the head is extended
• Use mauriceau-smell-veit method by jaw flexion and shoulder
traction movement
Method;
a) Place the baby astride your left arm
b) With the left hand middle finger on the tongue and other two
fingers on the check bone on either side help to flex the head
c) The first two fingers of the right hand are placed over the
shoulders and the chest when the nose and the mouth are free,
clear airway
d) Hold the legs with the fore finger between ankles
e) The right hand deliver vault of the head slowly

22. Delivery of breech with extended legs
Methods;
a) Pass the right hand along the thigh to the knee
joint
b) Flex the knee by pushing in the popliteal space
towards the body
c) Bending the leg sideways deliver the leg
d) Deliver second leg flexing in opposite direction

23. Delivery of breech with extended arms[
Lovest movement]
Methods; it is a combination of rotation and downward traction
by;
a) Grasping the baby by pelvis with thumbs on the sacrum
b) Apply traction downwards and the same time rotate the
body half a circle 180 degree to bring the posterior arm to
the anterior
c) Deliver the arm in front of the face to flex the arm
d) Rotate the baby half circle in opposite direction to bring the
other arm Anteriorly and delivery the arm in front of the face
to flex the arm
e) The rotation movement must be with the back uppermost

24. Complications of breech presentation
To the mother;
1. Injuries to the birth canal
2. Assisted instrumental delivery which could be;
forceps delivery or caesarian section and
anesthesia complications
3. Obstructed labour

25. Complication of breech cont….
To the baby;
1. Cord Prolaspe-very common in flexed or footling breech
2. Birth injuries which may be;
a) fracture or dislocation of baby’s
b) part, Erb’s palsy due to damage of brachial plexus by twisting of the neck
c) Trauma to internal organs e.g. spleen rupture during grasping of abdomen
d) Damage to adrenal glands
e) Damage to spinal cord as spine fracture etc
f) Intracranial hemorrhage as a result of rapid delivery of the head with on
time to mould or due to hypoxia
g) Fetal hypoxia; result from cord Prolaspe or premature separation of
placenta or delay delivery of head
h) Soft tissue injury; oedema and bruising of genitalia due to prolonged
cervix pressure cutting off blood supply and footling breech with the foot
lying at the vulva and become oedema and discolored due to cut of blood
supply