Management of breech presentation

1. Breech Presentation

2. • Definition:
It is a malpresentation in which lie is
longitudinal and podalic pole is at pelvic brim.
It is the commonest malpresentation.
Denominator-sacrum.
• Incidence:
It is 20% at 28 weeks and drops to 3% at term

3. • It is considered as malpresentation as it
Increases maternal morbidity and perinatal
morbidity and mortality

4. Complications
1.Maternal complications
• Genital laceration
• Bleeding and sepsis
2.Fetal complications
• Injury to the brain and skull
1.Intracranial hemorrhage
2.Fracture of skull bones
3.Brain dysfunction
• Prematurity
• Congenital dislocation of hip

5. • Birth asphyxia may occur due to:
1.Prolonged compression of cord
2.Cord prolapse
3.Aspiration of liquor and vaginal secretions
4.Prolonged labour
• Fetal injuries
1.Fracture of neck,humerus,clavical,femur
2.Cervical and brachial plexus palsies
3.Hepatic rupture
4.Splenic laceration
5.Pharyngeal injury

6. Classification
• Complete breech:
Normal attitude of full flexion is maintained.
Presenting part-two buttocks,external genitalia
and two feet.
Commonly seen in multiparae

7. Complete breech

8. • Incomplete breech:
1.Frank breech:
Thighs flexed at the hip joint,legs are extended
at knee joint.
Presenting part –two buttocks and external
genitalia.
Commonly seen in primigravida

9. Frank breech

10. 2.Footling presentation:
Both thighs and legs are partially extended.
Legs are presenting part.
3.Knee presentation:
Thighs are extended,knees are flexed

11. Footling breech

13. • Clinically it is classified as
Uncomplicated breech-No other obstetric
complications.
Complicated breech-Associated with
prematurity,twins,contracted pelvis,placenta
praevia

14. Etiology
• Prematurity
• Factors preventing spontaneous version
1. Breech with extended legs
2. Twins
3. Oligohydramnios
4. Congenital malformations of uterus
5. Short cord

15. • Favourable adaptation:
1. Hydrocephalus
2. Placenta praevia
3. Contracted pelvis
• Undue motility of fetus
1. Hydramnios
2. Multipara with lax abdominal wall
• Fetal abnormality:
Trisomy 13,18,21 and myotonic dystrophy due
to alteration in muscle tone and mobility

16. Diagnosis
Clinical :
• Complete breech:
1. Fundal grip-head suggested by hard and
globular mass which is ballotable.
2. Pelvic grip-breech is suggested by soft,broad
and irregular mass,not engaged during
pregnancy

17. • Frank breech:
1. Fundal grip-head can be felt along with small
parts of feet by the side of it.Head is not
ballotable
2. Pelvic grip-small,hard and conical mass felt
suggestive of breech which is usually engaged
• Auscultation:FHS is heard above the umbilicus.

18. • Ultrasonography confirms clinical diagnosis
• It also helps in detecting any congenital
malformations of fetus,localising the
placenta,assessment of liquor volume and
attitude of fetal held

19. Mechanism of labour (sacro-anterior)
• Principle movements occur at three places
1. Buttocks
2. Shoulders
3. Head

20. Delivery of buttocks
• Engagement
• Descent
• Flexion
• Internal rotation
• Birth of Buttocks

21. Delivery of shoulders and arms
• Engagement
• Descent continuous
• Internal rotation
• Birth of shoulders
• Restitution

22. Delivery of after coming head
• Engagement
• Descent
• Flexion
• Internal rotation
• Birth of the head

24. External cephalic version
• It is a procedure where the fetus is turned from
breech presentation to cephalic presentation
• Successful version reduces the risk of caesarean
section
• The success rate -60%
• Time of version:
At 36-37weeks
Late version after 37weeks is difficult due to
increasing size of fetus and diminished liquor

26. • Successful version is likely in cases of
1. Complete breech
2. Non-engaged breech
3. Sacroanterior
4. Adequate liquor
5. Non-obese patient

27. • Causes of failure of version
1. Breech with extended legs
2. Scanty liquor
3. Big baby
4. Short cord
5. Uterine malformations

28. • Complications of version
1. Premature onset of labour
2. Premature rupture of membranes
3. Placental abruption
4. Entanglement of cord around fetal part or
formation of true knot leading to impairment
of fetal circulation and fetal death

29. • Contraindications of ECV
1. Antepartum haemorrhage-risk of placental
separation
2. Multiple pregnancy
3. Congenital malformations of uterus
4. Contracted pelvis
5. Ruptured membranes
6. Previous C-section-risk of scar rupture

30. • Fetal causes:
1. Congenital malformations
2. Dead fetus
3. Hyperextension of head
4. IUGR

31. Method of delivery
• Elective caesarean section
• Vaginal breech delivery

32. Indications for Elective C-section
• Contracted, border line or abnormal pelvis
• Placenta praevia
• Large baby
• Hyperextension of head
• Footling breech
• Premature baby
• Previous caesarean section
• Elderly primigravida , BOH ,primary infertility
• IUGR

33. Management of Vaginal breech delivery
• First stage:
Vaginal examination at onset of labour and after
rupture of membranes to rule out cord prolapse
IV line with ringer solution,oral intake is avoided
Blood sent for grouping and cross matching
Adequate analgesia is given
Fetal status and progress of labour is monitored

34. • Second stage:
3 methods of vaginal breech delivery
1. Spontaneous(10%)
2. Assisted breech delivery
3. Breech extraction

35. Assisted breech delivery
• Principles:
1. Never pull from below but push from above.
2. Always keep the fetus with back anteriorly.

36. Steps
• The patient is brought to the table when the anterior
buttock and fetal anus are visible.
• Patient is placed in lithotomy position when the
posterior buttock distends the perineum.
• Liberal episiotomy when the perineum is distended
and thinned by the breech.
• Patient is encouraged to bear down
• No touch of fetus policy is adopted until buttocks are
delivered along with legs in flexed breech and the
trunk slpis upto the umbilicus

37. • Soon after the trunk upto the umbilicus is born,the
following are to be done
1.The extended legs(in frank breech) are to be decompressed
by pressure on the knees(popliteal fossa) in the manner of
abduction and flexion of thighs.
2.Umbilical cord is to be pulled down and to be mobilised to
one side of sacral bay to minimise cord compression
3.If back remains posteriorly,rotate trunk to bring the back
anteriorly.
4.Baby is wrapped with sterile towel to prevent slipping

38. Delivery of the arms
• The assistant has to place hand over the fundus and
keep a steady pressure during uterine contractions to
prevent extension of arms.
• Soon the anterior scapula is visible.
• The position of arm should be noted.
• When the arms are flexed,the vertebral border of
scapula remains parallel to the vertebral column

39. • When arms are extended,there is winging of scapula
• The arms are delivered one after the other only
when axilla is visible,by simply hooking down each
elbow with fingers

40. Delivery of after coming head
• Most crucial stage of delivery
• Time between the delivery of umbilicus to delivery of
mouth should be 5-10 min
• Various methods:
• Burn –Marshall method
• Forceps delivery
• Malar flexion and shoulder traction(modified
Mauriceau-Smellie-Veit technique)

41. Burn-Marshall method
• Baby is allowed to hang by its own weight
• The assistant is asked to give suprapubic pressure
with flat of hand in a downward and backward
direction to promote flexion of head
• When the nape of neck is visible under pubic
arch,the baby is grasped by ankles with a finger in
between two
• Maintaining a steady traction and forming a wide arc
of circle,the trunk is swung in upward and forward
direction

42. • Perineum is guarded with the left hand
• When the mouth is cleared off the vulva,there
should be no hurry.Mucus is cleared from mouth and
pharynx.

44. Forceps delivery
• Baby is allowed to hang by its own weight aided by
suprapubic pressure
• When occiput lies against pubic symphysis,an assistant
raises the legs of child as much to facilitate
introduction of blades from below
• The forceps pull maintains an arc which follows the axis
of birth canal
• Pipers forceps is used for this condition
• The head should be delivered slowly to reduce
compression and decompression forces that lead to
intracranial bleeding

46. Malar flexion and shoulder traction
• Baby is placed on the supinated left forearm with
limbs hanging on either side
• The middle and index fingers of the left hand are
placed over the malar bones on either side
• This maintains the flexion of the head
• The ring and the little finger of the pronated right
hand are placed over the child`s right shoulder,the
index finger is placed over left shoulder and middle
finger over sub-occipital region

47. • Traction is now given in downward and backward
direction till the nape of the neck is visible under
pubic arch.
• Assistant gives suprapubic pressure during the period
to maintain flexion.
• Thereafter the fetus is carried in upward and forward
direction towards the mothers abdomen releasing
face,brow and lastly trunk is depressed to release
occiput and vertex.

48. Modified Mauriceau-Smellie-Veit
technique

49. Management of complicated breech
delivery
Breech may be arrested at
1. At outlet
2. In cavity
3. At brim

50. Arrest at outlet
• Causes
1. Big baby with extended legs
2. Weak uterine contractions
3. Rigid perineum
4. Outlet contraction

51. • Management:
• If the outlet is contracted and baby is big-
Caesarean section
• If the outlet is not contracted and there is no
fetopelvic disproportion-Liberal episiotomy
and fundal pressure with or without groin
traction

52. Midcavity arrest
• Causes :
1. Contracted pelvis
2. Weak uterine contractions
3. Big baby
• Management-Caesarean section is treatment
of choice

53. Frank breech extraction
(Pinards maneuver)
• It is done to convert a frank presentation to a
footling presentation by intrauterine manipulation
• The middle and the index fingers are carries upto the
popliteal fossa
• It is then pressed and abduction so that the fetal leg
is flexed
• The fetal foot is then grasped at the ankle and breech
extraction is done

54. Pinards maneuver

55. Lorset`s maneuver
• It is used in correction of extended arms
• Procedure:
• The baby is grasped,using both hands by
femuropelvic grip keeping the thumbs parallel
to the vertebral column.
• The manoeuvre should start only when the
inferior angle of anterior scapula is visible
underneath the pubic arch

56. Procedure
• The baby is lifted slightly to cause lateral flexion.
• The trunk is rotated through 1800 keeping the
back anteriorly and maintaining downward
direction
• This will bring the posterior arm to emerge under
pubic arch which is then hooked up
• The trunk is then rotated in the reverse direction
keeping the back anterior to deliver the anterior
shoulder under pubic symphysis

57. Lorset`s maneuver
• Procedure:
• Baby trunk is made to rotate with downward traction
holding the baby at iliac crest so that posterior
shoulder comes below the pubic symphysis
• Arm is delivered by flexing the shoulder followed by
hooking at the elbow and flexing it followed by
bringing down the of the forearm

58. • The same procedure is repeated by reverse rotation
of 180 degrees so that anterior shoulder comes
below the symphysis pubis.

59. Lorset`s maneuver

60. Arrest of After-coming head
At brim
• Causes:
1. Deflexed head
2. Contracted pelvis
3. Hydrocephalus
• Management:
If arrest is due to deflexed head-malar flexion and
shoulder traction.
If arrest is due to hydrocephalus-perforation of head

61. In cavity
• Causes:
1. Deflexed head
2. Contracted pelvis
• Management
Delivery of head by forceps

62. At outlet
• Causes
1. Rigid perineum
2. Deflexed head
• Management
Liberal episiotomy followed by forceps delivery

63. Term breech trial(Hannah trial)
• In case of breech presentation perinatal mortality,
neonatal mortality or serious neonatal morbidity (as
a composite outcome) was significantly lower in the
planned caesarean section group of patients
compared to the planned vaginal delivery group.

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