breech presentation

1. Breech presentation
Dr
Ayman Shehata

2. Definition
Breech presentation is
the presentation in which
the fetus is in longitudinal
lie and its buttock is the
lower most part .

3. Incidence
 28 weeks…25%
 Term 2-3%
 1/3 are undiagnosed in labour

4. classifications
 Frank breech (65%): where the hips are
flexed and legs extended
 Complete breech (25%): where the hips and
knees are flexed and the feet are not below the
level of the fetal buttocks
 Footling breech: where one or both feet are
presenting as the lowest part of the fetus
 Kneeling: kneesare the lowermost presenting
part

6. Kneeling presentation

7. Positions
the denominate is the sacrum:
 First position;
left sacro-anterior (back anterior and to left).
 Second position;
right sacro-anterior (back anterior and to right).
 Third position;
right sacro-posterior (back posterior and to right).
 Fourth position;
left sacro-posterior (back posterior and to left).

8. Etiology

9. Maternal factors
 Polyhydraminos
 Oligohydramnios
 Uterine anomalies (bicornuate, septate)
 Space occupying lesions (e.g fibroids)
 Placental abnormalities (praevia, cornual)
 Multiparity (in particular grand multiparas)
 Contracted pelvis

10. Fetal factors
 Prematurity
 Fetal anomalies (e.g neurological,
hydrocephalus, anenecephaly)
 Multiple pregnancy
 Fetal death
 Short umbilical cord
 Extended legs; because they splint the trunk,
and so interfere with spontaneous cephalic
version.

11. Mechanism of delivery
 Engagement
 Descent
 Internal rotation
 Lateral flexion
 External rotation
 Birth : breech then body then head

12. Diagnosis of Breech
 Clinical examination:
 abdominal
 vaginal
 Radiological examination:
 x-ray
 ultrasound scan
 CT
 MRI

13. Clinical Diagnosis
Abdominal examination
 Palpation
1. Fundal grips; the head is felt with its
characters.
2. Pelvic grip; the breech is felt, with its
characters.
 Auscultation
The fetal heart sounds are head just at, or above
the level of the umbilicus.

14. Vaginal examination
1. Slow dilatation of cervix, sausage-chapel bag of fore-
waters, and liability to premature rupture of the
membrane and prolapse of the cord.
2. After rupture of the membranes, the presenting part is
felt, that is , the two buttocks with the anus in between ,
the genitalia on one side and the sacral spines on the
opposite side.
3. In case of complete breech, the feet are felt on the
same level as the buttocks.
4. In case of breech with extended legs, the buttocks only
are felt. In case of footling presentation, the feet are at
a lower level than the buttocks. In case of knee
presentation, the knees are a lower level than the
buttocks.

15. Imaging Techniques
 Ultrasound
 CT
 MRI

16. US breech

17. Management of Breech

18. BREECH PRESENTATION
Management during pregnancy
After 36 weeks
Spontaneous version External cephalic version

19. Management of breech
 Management During Pregnancy:
 If persisted till 34 weeks…. Then ultrasound
scan to exclude; abnormality, Ployhydramnios,
placenta praevia.
 By completed 37 weeks External Cephalic
Version:

20. Version
 External cephalic version
 Internal podalic version

21. External Cephalic Version

22. In delivery room
NPO and ready for c/s
CTG & USS
Tocolytic
Head down position
Dislodge breech then
gently turn around
US and CTG after procedure.

24. Internal podalic version

25. Risks of External Cephalic Version
 Placental abruption
 Premature rupture of the membranes
 Cord accident
 Transplacental haemorrhage(remember anti-D
aministration in Rhesus-negative women)
 Fetal bradycardia

26. Contraindications of External Cephalic
Version
 Absolute
contraindication:
 Previous scar on the
uterus
 Placenta praevia
 Unexplained APH
 Pre-eclampsia
 Multiple pregnancy
 Relative
contraindications:
 Rhesus
isoimmunisation
 Elderly primigravida
 IUGR
 Oligohydramnios
 Polyhydramnios

27. Management during labour
Cesarean section
Vaginal delivery
Spontaneous breech delivery
Assisted breech delivery
Total breech extraction

28. Indications of vaginal delivery
a) Frank or complete breech presentation
b) Gestational age > 36 weeks
c) Estimated foetal weight b/n 2.5-3.5 kg
d) Foetal head must be flexed
e) Adequate maternal pelvis, x-ray or ct
pelvimetry
f) No other obstetric complications.

29. Management during labour
During labour:
1. If there is contracted pelvic, and fetus is
living and good; do caesarean section.
2. First stage
Rest in bed and avoid repeated vaginal examination to
prevent premature rupture of the membranes. But
vaginal examination is done after rupture of
membranes to exclude cord prolapse.

30. Partial breech extraction or
Assisted breech delivery
Second stage :
Delivery of the aftercoming head
 Burns Marshall method
 Mauriceau-Smellie-veit maneuver
 Prague maneuver
 Piper forceps

31. Burns Marshall Method

32. Mauriceau-Smellie-Veit Maneuver

33. Prague maneuver
The back of the fetus fail to rotate to the anterior

34. Piper Forceps

35. Total breech extraction
Indication
1. Prolonged second stage of labor
2. Twins
3. Maternal disease
4. Prolapsed cord
5. Fetal distress

36. Total Breech Extraction

37. Cesarean section
Indications:
 Large fetus
 Contraction or unfavorable shape of pelvis
 Hyperextended head(Star gazing)
 Uterine dysfunction
 Incomplete or footling presentation
 Primigravida

38. Indications of Cs in Breech
 Healthy preterm
 Severe fetal growth restriction
 Previous perinatal death or newborn
 complication of birth trauma
 Lack of an experienced operator

39. Complications of Breech
Delivery
Maternal complications
 Risk of Operative intervention
 Risk of infection due to Manipulations
 Intrauterine maneuvers : Rupture of the
uterus +/- lacerations of Cx
 Extensions of the episiotomy
 Uterine atony , Postpartum hemorrhage

40. Complications cont.
Fetal complications
 Preterm delivery & low birth weight & IUGR
 Prolapse cord
 Birth aphyxia
 Fetal Injuries
 Fx of humerous and clavicle
 Fx of femur
 Hematomas of sternocleidomastoid
 Separation of epiphyses of scapular,humerus or femur
 Brachial plexus
 Avulsion of upper C-spine
 Skull Fx , intracerebral injury

41. THAN
K
YOU