Breech delivery

1. BREECH DELIVERY
Vineeth S Chimkode
Final year mbbs
MRMC

2. BREECH PRESENTATION
IN BREECH PRESENTATION , THE LIE IS LONGITUDINAL AND
THE PODALIC POLE PRESENTS PRESENTS AT THE PELVIC BRIM.
IT IS THE MOST COMMON MALPRESENTATION.
INCIDENCE: THE INCIDENCE IS ABOUT 20% AT 28TH WEEK
AND DROPS TO 16% AT 32-34TH WEEK AND TO 3-4% AT
TERM.
THUS IN 3 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 LESS AND ROUTINE EXTERNAL CEPHALIC VERSION
IS DONE IN ANTENATAL PERIOD

3. VARIETIES
THERE ARE TWO VARIETIES OF BREECH
PRESENTATION:
 COMPLETE
INCOMPLETE
• 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%).

4. INCOMPLETE: THIS IS DUE TO VARYING DEGREE OF EXTENSION OF THIGHS OR
LEGS AT THE PODALIC POLE. THREE VARIETIES ARE:
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 parts
consists of the two buttocks and external genitalia only. It is commonly
present in primigravidae, about 70%.
FOOTLING PRESENTATION(25%): both thighs and legs are partially extended
bringing the legs to present at brim. More commonly seen in preterm
deliveries.
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.

6. • 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
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

7. Favourable adaptation: (a) hydrocephalus –big head can be
well accommodated in the wide fundus, (b) placenta previa , (c)
contracted pelvis
Undue mobility of the fetus: (a) hydramnios , (b)multiparae
with lax abdominal wall
Fetal abnormality: Trisomies 13 ,18, 21 anencephaly and
myotonic dystrophydue to alteration of fetal muscular tone and
mobility.

8. • DIAGNOSIS OF BREECH PRESENTATION
 CLINICAL
SONOGRAPHY
THE DIAGNOSTIC FEATURES OF A COMPLETE
BREECH AND A FRANK BREECH ARE GIVEN IN
A TABULATED FORM:

9. Table :
Complete breech Frank breech
Per abdomen
Fundal grip • Head-suggested by hard and globular
mass.
• Head is ballotable.
• Head.
• Irregular small parts of the feet may be felt by
the side of the head.
• Head is nonballotable due to splinting action of
the legs on the trunk.
Lateral grip • Fetal back is to one side and the irregular
limbs to the other.
• Irregular parts are less felt on the side.
Pelvic grip • Breech-suggested by soft, broad and
irregular mass. Breech is usually not
engaged during preg- nancy.
• Small, hard and a conical mass is felt.
• The breech is usually engaged.
FHS • Usually located at a higher level round
about the umbilicus.
• Located at a lower level in the midline due
to early engagement of the breech.
Per vaginam
During pregnancy and labor • Soft and irregular parts are felt through the
fornix.
• Palpation of ischial tuberosities, sacrum and the
feet by the sides of the buttocks.
• Hard feel of the sacrum is felt, often
mistaken for the head.
• Palpation of ischial tuberosities, anal
opening and sacrum and they are felt in
one line.
Chance of cord prolapse • 5% • 0.5% (Note: In cephalic presentation, the
chance of cord prolapse is 0.4%).

10. •ULTRASONOGRAPHY
ULTRASONOGRAPHY is most informative. (1) It confirms the
clinical diagnosis-especially in primigravidae with engaged frank
breech or with tense abdominal wall and irritable uterus; (2) It can
detect fetal congenital abnomality 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) Attitude of the head -flexion
or hyperextension of the extension (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.

11. • POSITIONS: Sacrum is the denominator of breech and
there are four positions. In anterior positions, sacrum is
directed toward iliopubic eminences and in posterior e
breech positions, sacrum is directed to sacroiliac joints.
The positions are:
• (1) First position-Left Sacroanterior (LSA)-being the most
common;
• (2) Second position- Right Sacroanterior (RSA)
• (3) Third position-Right Sacroposterior (RSP);
• (4) Fourth position-LeftSacroposterior (LSP).

12. 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 undergoes cardinal movements as
those of normal mechanism.

13.  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 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.

14. SHOULDERS
Bisacromial diameter (12 cm or 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 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.

15. 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. The expulsion of the head from
the pelvic cavity depends entirely upon the bearing-down efforts
and, not at all, on uterine contractions.

18. Assisted Vaginal Breech delivery Cesarean delivery
Frank breech presentation. Unfavorable factors-fetal: Unengaged
podalic pole, footing breech.
Gestational age: >34 weeks.
 Estimated fetal weight 2000-3500 g.

Fetal head: Flexed.
 Pelvis is deemed adequate.
 Women admitted in advanced labor with
no fetal or maternal contraindications for
assisted vaginal breech delivery. POCO
Estimated fetal weight >3500 g or <1500
g.
Fetal head: Deflexed/ hyperextended.
 Pelvic inadequacy suspected.
 Women:
Elderly.
 Poor obstetric history.
 Pregnancy following ART.
 Non-reassuring FHR on EFM.