abnormal presentation

1. Breech Presentation
Dr. Abd El-Naser Abd El-Gaber Ali
Assistant professor of Obestet & Gynecol

2. Malpresentations

3. Definition
This is a malpresentation where the
podalic pole presents at the pelvic
inlet.
The lie is longitudinal
The denominator is sacrum
 Incidence
 3.5 % of fetus present by breech at
term

4. Types of breeches
 Frank breech (50-70%) - Hips flexed,
knees extended
 Complete breech (5-10%) - Hips
flexed, knees flexed
 Incomplete (Footling or knee
presentation) (10-30%)

6. Types of Breech
Frank Complete Footling

8. Positions
 Anterior
-right sacroanterior (common)
- direct sacroanterior
– -left sacroanterior
 Posterior
--right sacroposterior
-- direct Sacroposterior
- -left sacroposterior
 Transverse Right and Left sacrotransverse

9. Breech presentations:
A: Right sacrum posterior (RSP) position
B: Left sacrum anterior (LSA) position

11. Etiology
1-Fetal Factors
2-Maternal factors
3- Idiopathic = 20%

12. 1-Fetal Factors
 Prematurity
 Extension of legs
 IUFD
 Hydrocephalus
 Multiple pregnancy
 Short cord
 Chromosomal aberrations affect fetal
tone and movement as down syndrome
and myotonic dystrophy

13. 2-Maternal factors
 Polyhydramnios
 Oligohydramnios
 Uterine malformations as septum ,
bicornuate
 Fundal myoma
 Placenta previa
 multiparity

14. Diagnosis of Breech
 History
Abdominal examination
Fetal heart sounds
Vaginal examination
Investigations

15. Investigations
 Routine antenatal investigations
 US
– Anomalies
– Head extension (star gazing or flying
fetus)
– Maturity
– Site and grade of placenta, AF volume
– Multiple gestation
– Confirming fetal presentation

16. Investigations
X-ray abdomen (history)
–Skeletal anomalies
–Extended head (angle between
mandible and cervical spine >105)
–Pelvimetry
–Multiple gestation

17. Mechanism of labor
Delivery of lower limbs and
buttocks
Delivery of shoulders and arms
Delivery of aftercoming head

18. Management during pregnancy
External cephalic version

19. Types of Vaginal breech delivery
 Spontaneous
 Assisted
 Total breech extraction

20. .

22. .

23. …….

27. Complicated breech delivery
 Arrest of buttock
 Arrest of the shoulders
 Arrest of aftercoming head

28. Arrest of buttock at pelvic inlet
Causes and management
 Contracted pelvis = CS
 Large fetus =CS
 Uterine atony = Oxytocin if failed CS

29. Arrest of buttock at pelvic outlet
Causes and management
 Extension of legs = Groin traction –
bringing down legs
 Large fetus = CS
 Contracted outlet = CS
 Rigid perineum = generous episiotomy
 Uterine atony = Oxytocin if failed CS

30. Arrest of the shoulders
Causes and management
Extension of arms : Treated by
Classical method - Lovset technique
Nuchal displacement: treated rotation of
trunk in direction of tips of the fingers
of displaced hand

31. Arrest of aftercoming head
 Aetiology
A- Causes in head
 Large head - Hydrocephalus
 Extension of head
 Posterior rotation of occiput
B- Causes in the passages
 Contracted pelvis
 Incompletely dilated cervix
 Rigid perineum

32. Management of arrest of
aftercoming head
 C P or large head symphysiotomy if fetus
alive or cranitomy if fetus is dead
 Hydrocephalus = taped vaginally by spinal
needle or trocar
 Extension of the head
a – Burns Marshall technique
b- Jaw flexion shoulder traction
c- Forceps application

33.  Posterior rotation of the occiput
a- Anterior rotation of fetus
b- Jaw flexion shoulder traction (face
to pubis)
c- Prague technique
Rigid perineum = episiotomy
Incompletely dilated cervix = cervical
incision if fetus alive or craniotomy if
fetus is dead

34. Indications of CS in breech
 Contracted pelvis
 Placenta previa
 Large baby
 Hyperextension of head
 Footling presentation
 Previous CS

35. Breech Complications
Fetal complications
A- Fatal complications
B- Non Fatal complications

36. A- Fatal fetal complications
 Intracranial hemorrhage
 Fracture dislocation of cervical spine
 Asphyxia (Anoxia <6min not harmful, 6-12
min brain stem necrosis with motor and
behaviour changes, >17 min=Death
 Rupture of abdominal viscera as liver
and spleen

37. B- Non Fatal Fetal complications
Fracture clavicle
Fracture humerus or femur
Dislocation of lower jaw
Brachial plexus palsy
Hematoma or rupture of
sternomastoid muscle

38. Maternal complications
 PROM and cord prolapse
 Prolonged labor and maternal
exhusion
 Obstructed labor
 Uterine atony
 Post partum hemorrhage
 Puerperal sepsis
 Perineal lacerations
 Cervical lacerations

39. Transverse Lie
and
Unstable Lie

40. Transverse lie ( shoulder
presentation):
 Incidence:
0.3% of all
deliveries.

41. Transverse lie.
The shoulder of
the fetus is to the
mother's right,
and the back is
posterior.

42. Aetiology of transverse &
unstable Lie:
1. Polyhydramnios causing an increased
ratio of fluid to fetus.
2. Something preventing the
engagement of the head in the pelvis.
3. Placenta praevia.
4. Fibroids.
5.Contracted pelvis.
6. Abnormal shape of uterus
(subseptate or arcuate uterus).
7. Second twin.
8. Grand multiparity (5+).

43. Diagnosis
1 - Abdominal examination—
the head is in one flank and the
buttocks in the other.
2 -Vaginal examination—the pelvis is
empty of presenting parts.
3- Investigation: ultrasound scan
confirms diagnosis

44. Management of transverse lie in pregnancy
and labour:
 1- Before 36 weeks, The position is usually
self-curing.
 2- Past 37 weeks in a multiparous patient,
admission to hospital should be advised,
where ECV is done.
 3- Should the woman go to term with the
fetus still in a transverse position,
management may be by either of the
following:
 ECV(external cephalic version) is done in
the labour ward and induction of labor.
 Labour follows in the normal fashion.
 An elective Caesarean section

45. Management:
4 Occasionally a woman is admitted in
mid or late labor with a transverse lie.
contractions lead to impaction of
shoulder,
Treatment must be by immediate caesarean
section even if the fetus is dead because of
the risk of uterine rupture.

46. Complication of Transverse
and Unstable lie:
 Cord or hand prolapse.
 Obstructed labour .
 Uterine rupture.
 Difficult intra operative delivery of
the fetus.
 Birth trauma ( erbs pulsy).
 Postpartum haemorrhage.

47. Unstable Lie:
 Unstable Lie is defined as a condition in
which at any time after the beginning of
38 weeks of pregnancy, the fetal lie is
oblique or transverse and the presentation
is varies..

48. Another definition:
 Unstable lie refers to the frequent
changing of fetal lie and presentation
in late pregnancy (usually refers to
pregnancies > 37 weeks.
 Lie refers to the relationship between the
longitudinal axis of the fetus and that of
its mother, which may be longitudinal,
transverse or oblique.

49. Contributing factors :
 High parity
 Placenta praevia
 Polyhydramnios
 Pelvic contracture 0r fetal macrosomia
 Pendulous abdomen
 Uterine abnormalities (e.g. bicornuate
uterus or uterine fibroids).
 Fetal anomaly (e.g. tumours of the neck
or sacrum, hydrocephaly, abdominal
distension)

50. Associated risk factors
 Cord presentation or prolapse if
membranes rupture or at the onset of
labour
 Fetal hypoxia if left unattended in
labour
 Shoulder presentation and transverse lie in
labour
 Uterine rupture

51. Diagnosis :
 Usually made when a varying fetal lie
is found on repeated clinical
examination in the last month of
pregnancy .

52. Management :
85 % of fetal lies will become
longitudinal before rupture of
the membranes or labour .
 Abdominal palpation to assess for
polyhydramnios
Pelvic examination as indicated
(assess pelvic size and shape)

53. Management:
 Inform woman of need for prompt
admission to hospital if membranes
rupture or when labour starts
 Hospital admission from 37 weeks
onwards is recommended
 May attempt external version to cephalic
presentation in early labour with access to
facilities for immediate delivery if indicated

54. Intrapartum management
Vaginal and pelvic assessment :
 Establish presentation
 Exclude cord presentation
 Assess if polyhydramnios
 Assess cervical dilatation
 If the lie is longitudinal
 Normal labour management

55. Intrapartum management
 If the lie is not longitudinal
 Consider external version to correct
lie
 ARM(artificial rupture of membrane)
should be done with caution
 If the lie is not longitudinal and
cannot be corrected
 Caesarean section is considered.

56. External cephalic
version

57. External cephalic version
 Advantages
 Indications (breech, Transverse or oblique
lie (at 36wks)
 Time 36-38wks
 Technique
 Causes of failure
 Complications
 Contraindications

58.  EXTERNAL CEPHALIC VERSION (ECV)
This is the trans-abdominal manual rotation
of the fetus into a cephalic presentation.

59. PROCEDURE:
 Prepare for the possibility of caesarean
delivery.
 Perform a non-stress test – to confirm
fetal well being.
 Perform the ECV, in or near a delivery
suite
No anesthesia or analgesia
Rotation is intermittent
Vagina is bared for detection of bleeding
 After ECV, repeat the non-stress test.
 Administer Rh immune globulin to women
who are Rh- negative

60. RISKS:
 Precipitation of labour or premature
rupture of membranes
 Abruptio placentae
 Feto-maternal haemorrhage
 Cord entanglement
 Fractured fetal bones

61. CONTRAINDICATIONS:
 Multiple gestations
 Contra indications to vaginal delivery
(e.g. herpes simplex virus
infection, placenta praevia)
 Non reassuring fetal heart rate
tracing

63. Thank you