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1. Breech Presentation
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2.  Introduction to Breech Presentation
 Epidemiology of breech presentation
 Pathogenesis and Risk factors
 Route of Delivery
 External cephalic version - ECV
 Vaginal Breech Delivery
 Risk of recurrence
 Entrapment of after coming head
 Delivery of the hydrocephalic fetus in breech presentation
 Mature breechVs Premature breech
 Complications ofVaginal Breech Delivery
2
Contents

3. Introduction to Breech Presentation
Definition
• Definitions
– a longitudinal lie of the fetus with
• Caudal pole (buttock) @ the lower part of uterus
– Breech is palpated at the pelvic brim
• Cephalic pole (head) in the uterine fundus
• Why incidence of breech is more in early px?
– Since bigger is head in early px, but later on breech will exceed head
so –occupy fundus
3

4. Classification of Breech Presentation
Frank (pike position)
▪ Both hips - flexed
▪ both knees = extended
▪ Neither of the feet is felt
Complete (tuck position)
▪ Both hips & knees – flexed
▪ feet may be felt → above
buttock
Footling
▪ One or both hips are
extended with one or both
extended knee(s) and the
foot felt below the buttocks
4

5. • Incidence
– The prevalence of breech presentation decreases with
increasing gestational age
• In GA < 28 wk: 20 -25%; @ 32 wk: 7-16%; @ term: 3-
4%
– It is a common occurrence in early pregnancy when the
fetus is highly mobile within a relatively large
volume of amniotic fluid
– In singleton breech presentations in which the infant
weighs
• > 2500 g: (65% - frank) > (25% footling) > (10% -
complete)
• < 2500 g: (50% - footling) > (40% - frank ) > (10% -
complete)
TYPE OVERALL % OF
BREECHES
RISK OF
PROLAPSE (%)
PREMATURE
(%)
Frank 48-73 0.5 38
Complete 4.6-11.5 4-6 12
Footling 12-38 15-18 50
5
Presentation, breech, cranial diameters
• Importance of cranial flexion is
emphasized by noting the increased
diameters presented to the birth canal
with progressive deflection
• A: Flexed head
• B: Military position
• C & D: Progressive deflection

6. Stargazer (flying) fetus
• Britain - flying fetus
• fetal head - extreme hyperextension
• Occurs in perhaps 5% of term breech presentations
• vaginal delivery may result in injury to the cervical
spinal cord
– Thus, if present after labor has begun, this is an indication
for cesarean delivery
6

7. Presentation
• History
– Discomfort under the rib (due to the hard head)
– Feeling of more fetal movement in the lower segment
• Physical Examination - Leopold Maneuvers
– Head (round hard & ballotable smooth mass) - fundus
– Breech (soft, broad, indefinite and non ballotable mass) - lower
pole of uterus
– FHB - umbilicus (may be lower with engagement)
• PV
– Complete breech: feet are felt along side the buttock
– Footling breech: one or both feet are inferior to the buttock
– Ischial tuberosity and anus are in straight line
• But the malar eminence & mouth form a triangle in face presentation)
– Suckling in live fetus (but not by the anus in breech)
7

8. Workup
• Ultrasound
– Head flexion / extension: for vaginal delivery, fetal
head should not be extended
– EFW
– 80% of breech fetuses - dolichocephalic head (long,
narrow head)
• dolichocephaly is a mild cranial deformity in which the head
has become disproportionately long and narrow, due to
mechanical forces associated with breech positioning in
utero
• This change in shape is more commonly associated with
primiparity (first babies), larger babies, oligohydramnios, and
posterior placentas, all of which result in greater forces
applied to the fetal head.
8

9. • CT Pelvimetry
– is favored due to its accuracy, low radiation dose and widespread availability
– MRI is superior to CT scan
– specific measurements to permit a planned VD:
• Inlet AP diameter ≥ 10.5 cm
• Inlet transverse diameter ≥ 12 cm and
• Midpelvic interspinous diameter ≥ 10cm.
• Maternal-fetal biometry correlation to permit a planned VD
– inlet OC - BPD: ≥ 1.5 cm
– Inlet transverse diameter - BPD : ≥ 2.5 cm; and
– Midpelvis interspinous diameter - BPD : ≥ 0 mm
9

10. Epidemiology of breech presentation
• Breech presentation
– complicates 3–4% of all pregnancies at term
• more common at GA remote from term
• 7% of pregnancies at 32 wks
• 25% of pregnancies of < 28 wks
– This is since fetal poles are of similar bulk earlier in
pregnancy
10

11. Pathogenesis and Risk factors
• Near term,
– fetus typically turns spontaneously to a cephalic presentation
• Because the increasing bulk of buttocks seeks more spacious fundus
(best fit in the intrauterine space)
• So a normally proportioned active fetus in a normal volume of amniotic
fluid adopts the cephalic presentation near term
• If any of these variables are disrupted by
» underlying maternal, fetal, or placental conditions,
– then breech presentation becomes more likely
• In most pregnancies, however, breech presentation appears to be a chance
occurrence
• Abnormalities of the uterus and/or fetus account for < 15 % of breech
presentations
11

12. Risk Factors
• Altered intrauterine contour or
volume:
– Uterine anomalies (eg, bicornuate or septate
uterus)
– Space occupying lesions (eg, uterine
leiomyomata)
– Placental abnormalities (eg, placenta previa,
cornual placenta)
– Multiparity resulting in a lax abdominal wall
and more rounded intrauterine space
– Extremes of amniotic fluid volume
(polyhydramnios, oligohydramnios)
– Contracted maternal pelvis
– Prior cesarean delivery
• Altered fetal shape:
– Fetal anomaly (eg, anencephaly, hydrocephaly,
sacrococcygeal teratoma, neck mass)
– Extended fetal legs
• Impaired fetal mobility:
– Crowding from multiple gestation
– Neurologic impairment
– Short umbilical cord
– Fetal asphyxia
– fetal genetic disorders
• Trisomies 13, 18, and 21
• Potter syndrome; and myotonic dystrophy
• Prior breech delivery: Recurrence
rate for
– 2nd pregnancy is 10 % and
– 3rd pregnancy is 27 %
• Smoking may be a Modifiable cause
12

13. Route of Delivery
• Controversies on Planned CD
– Some say → it lower risk of perinatal mortality
– Others report that it isn’t associated with a reduction in maternal and fetal risks
• ACOG (2012b) currently recommends
– The decision regarding the mode of delivery should depend on → experience of the
health care provider
– “planned vaginal delivery of a term singleton breech fetus
• may be reasonable @ hospital level
• Breech presentation shouldn’t be allowed to labor unless
– Anesthesia coverage is immediately available
– Cesarean delivery can be undertaken promptly
– Continuous FHR monitoring is used, and
– Delivery is attended by experienced care provider (one pediatrician and two
obstetricians)
13

14. Go for
Vaginal Breech delivery
• Complete / frank breech
• Adequate maternal pelvis
• Flexed neck
• EFW : 2.5 -3.8 kg
• written informed consent
• Presence of a skilled care provider
• Zatuchni-Andros score ≥ 4
• Rapid CD is possible
• Good progress is maintained in labor
Cesarean delivery
• Incomplete or footling breech
– Why? Poor dilator + higher risk of cord
prolapse
• EFW is <1500 or >4000 g
• hyperextended head
• Uterine dysfunction – b/c
augmentation is not possible
• Lack of an experienced operator of
VD
• Prior cesarean delivery
• Zatuchni-Andros score <4
• Arrest of progress
14
• Contraindications to breech vaginal delivery include
which of the following?
– A. Frank breech B. Complete breech
– C. Hyperextended head D. Aftercoming breech
presenting twin

15. Zatuchni-Andros score
• Prognostic index for vaginal delivery in breech presentation at
term
• based on 6 clinical variables
• Zatuchni - Andros score < 4
– accurately predict poor outcomes ➔ CD
15

16. External cephalic version - ECV
• Indications: Breech presentation,Transverse lie
• Gabbe
– ECV is recommended at 36 to 37 weeks to help
diminish the risk of adverse outcome
• RCOG & ACOG Recommends: all women at
≥ 36 weeks of gestation
– RCOG,ACOG, KNOV & NVOG
– Earlier ECV (34 to 35 weeks) - reduce cesarean
delivery rate, but the safety of ECV performed
before 36 weeks is less well-established
– Version during labor — safe option
• Ancillary measures to enhance success
– Tocolysis, epidural or spinal analgesia
– Vibroacoustic stimulation,Amnioinfusion, Maternal
hydration
• Success rate : 35 to 86%, with an average of 58
percent
Contraindication for ECV
• Footling breech
• Presence of an indication for CS
• Presence of compounding factors such
as:
– Previous CS, Multiple pregnancy, Elderly
primigravidity, Infertility
– Bad obstetrics history
– Polyhydramnious, Oligohydramnious
– PROM, IUGR, IUFD
– Congenital fetal abnormality
– Rh-isoimmunization
– Maternal cardiac disease, Hypertension,
Obesity, Consent declined
– Uterine malformation
– Cord completely encircling the fetal neck
16
• Which of the following is the only tocolytic agent shown in a randomized trial to increase the
success rate of external cephalic version?
– A. Ritodrine B.Terbutaline C. Nitroglycerin D. Magnesium sulfate

17. • Prerequisites
– Gestational age > 36 weeks including early labor
– Intact fetal membranes
– adequate amniotic fluid
– Reassuring fetal condition
– No contraindication for vaginal delivery
Factors That
• Increase Success of ECV
– Increasing parity
– Ample amnionic fluid
– Unengaged fetus
– Tocolysis
• Decrease Success
– Engaged fetus
– Tense uterus
– Inability to palpate head
– Obesity
– Anterior placenta
– Fetal spine anterior or posterior
– Labor
17

18. • Failed ECV: Version attempts should be discontinued, if there is
– Excessive maternal discomfort
– Persistent abnormal FHR
– After a maximum of three attempts
• Complications of ECV
– Abnormal FHR usually transient – commonest (4.7%)
– Feto maternal hemorrhage
– Emergency cesarean delivery during labor is increased following
successful ECV than in spontaneous cephalic presentation
– Vaginal bleeding and placental abruption
– Fracture of the baby’s femur
18

19. VAGINAL BREECH DELIVERY
First stage of labor
• Partograph
– If the cervicogram crosses the
alert line, consider hydration; avoid
augmentation of labor
– Cesarean delivery is undertaken if
the action line is approached
• Avoid ARM
• Meconium is common with breech
labors
– Not - sign of fetal asphyxia
• Continuous epidural analgesia, is
advocated
Second stage
• Three Methods of Vaginal Delivery
1. Spontaneous
2. Assisted / partial breech
extraction
3. Total breech extraction
19

20. 20
2) Assisted (partial) BE
1) Spontaneous breech delivery
3) Total breech extraction
Three ways of Vaginal Beech Delivery
Spontaneous expulsion
no traction or
manipulation
Only support of the
newborn
Spontaneously till umbilicus
remainder of the body
▪ Traction +
▪ assisted maneuvers ±
▪ maternal efforts
Body + Arms + Head
The entire body is
extracted by the
obstetrician
Trunk & legs + Body + Arms
+ Head

21. • For vaginal delivery, spontaneous onset of labor is expected
• Labor Induction and Augmentation
– controversial
• some protocols avoid augmentation, whereas others recommend it only for
hypotonic contractions
– avoided though there is no convincing evidence
– at Parkland Hospital
• Amniotomy induction is practiced
• Avoid oxytocin induction or augmentation
21

22. Total Breech extraction
• It is delivery of the baby with no assistance from the mother. It serves as an
alternative to CS in desperate conditions.
• Indications
– Fetal distress in 2nd stage of labor
– Cord prolapse or entanglement around the leg
– Need for expedite delivery of the 2nd twin
– Footling breech- with advanced labor with fully dilated cervix (better managed by C/S in
other conditions).
• Preconditions
– Fully dilated cervix
– No mechanical obstruction or fetopelvic disproportion
– No uterine scar
– No grand multiparity
22

23. Cardinal movements of Breech VD
• Engagement ➔Descent ➔ Internal rotation ➔
Lateral Flexion ➔ External rotation ➔ internal
rotation (restitution) ➔ Expulsion
• Engagement
– Usually with bitrochanteric diameter (Right
SacrumTransverse)
• Engagement of the buttocks usually occurs in
the oblique or transverse diameter of the
pelvic brim
• Internal rotation
– As buttocks reached at pelvic floor → internal
rotation (45 degrees) ➔
• bringing the anterior hip toward the pubic arch and
• allowing the bitrochanteric diameter to occupy the
AP diameter of the pelvic outlet
• Late second stage - lateral flexion of the
trunk around the pubic symphysis
– Crowning occurs when the bitrochanteric
diameter (10cm) passes under the pubic symphysis
23
Breech typically enters the inlet with the
bitrochanteric diameter aligned with one
of the diagonal diameters, with the
sacrum as the point of designation in the
other diagonal diameter

24. Mechanism and conduct of labor and vaginal delivery
1) Trunk and legs
Pinard maneuver
– Frank breech decomposition
– Two fingers are inserted along one extremity to the
knee
– ➔ exerting Pressure laterally combined with opposite
rotation of the fetal pelvis results in flexion of the knee
and delivery of each leg
Complete breech:Traction on the feet and ankles
24
2) Delivery of the body
• thumbs over the sacrum ➔ gentle downward traction until
scapulas are clearly visible
• Rushing the delivery of the trunk may
– result in cervical retraction
– encourage deflexion of the neck
• presentation of the larger occipitofrontal fetal cranial profile to the pelvic inlet →
catastrophic
– increase risk of a nuchal arm

25. 3) Delivery of Arms & Shoulder
Lovset’s maneuver
– The classical method of bringing down an arm
– Trunk is rotated through 180° keeping the back
anterior and maintaining a downward traction
• clockwise rotation assists delivery of the left arm
• counterclockwise assists delivery of the right arm,
– Counterclockwise rotation from RSA to right
sacrum transverse (RST) along with gentle
downward traction effects delivery of the right
scapula
25
Nuchal Arm
• One or both fetal arms occasionally may be
found around the back of the neck—the nuchal
arm—and impacted at the pelvic inlet.
• Reduction of nuchal arm
– rotating the fetus through half a circle CCW so that
the friction exerted by the birth canal will draw the
elbow toward the face

26. 4) Delivery of Head
• Once both arms have been
delivered ➔ With further
maternal expulsive forces
alone, spontaneous controlled
delivery of the fetal head often
occurs
• If not, delivery may be
accomplished with a
– Manually slip the cx over the
occiput
– Mauriceau-Smellie-Veit
maneuver (MSV)
– Modified Prague maneuver
– Piper forceps
26
Mauriceau-Smellie-Veit maneuver (MSV)
• Index and middle finger of one hand over the maxillae to
flex the head
• Two fingers of the other hand hooked over the fetal neck
• Gentle suprapubic pressure (Credes manuever) → by
assistant
• Body of fetus elevated toward maternal abdomen

27. Modified Prague maneuver
• Extraction of the head in a persistent OP
– Rarely, the back of the fetus fails to rotate to the anterior.
• Two fingers of one hand grasping the shoulders of the back - down fetus from
below while the other hand draws the feet up and over the maternal abdomen
27
Piper forceps, or divergent Laufe forceps
• applied electively or when the Mauriceau
maneuver cannot be accomplished easily.
• Piper forceps have a downward arch in the
shank to accommodate the fetal body and lack
a pelvic curve
Piper forceps for delivery of the aftercoming head
A. The fetal body is held elevated using a warm towel and the
left blade of forceps is applied to the aftercoming head
B. The right blade is applied with the body still elevated
C. Forceps delivery of the aftercoming head. Note the direction
of movement shown by the arrow

28. • Burn’s marshall maneuver
– The newborn is allowed to hang by its own weight
– assistant - give suprapubic pressure with the flat of hand in a downward and backward
direction, the pressure is to be exerted more towards the sinciput
– aim is to promote flexion of the head so that favorable diameter is presented to the
pelvic cavity
– Not more than 1–2 minutes are required to achieve this
28
• Duhrssen`s incision
– If the fetus is preterm and the cervix is effaced, but incompletely dilated,
the cervical os can be surgically enlarged
– At 2,10,6 o’clock
– Rarely done
• Wigand maneuver: Like MSV but differs that an assistant not needed to apply
suprapubic pressure & one hand put on the suprapubic area to provide suprapubic
pressure
• Bracht maneuver
– Suspension of the fetus against the maternal symphysis
• Zavanelli maneuver: replacement of the fetus into the uterus followed by CS if
vaginal delivery failed
• Abdominal rescue: A low transverse hysterotomy is performed to allow
transabdominal manual rotation of the anterior shoulder to the oblique diameter
→ vaginal delivery
• Symphysiotomy

29. Internal Podalic Version / IPV
• only for delivery of a second twin
– Approximately 1/3rd of all twin gestations
present as cephalic/breech
• Indications
– alternative to cesarean section - when a life-
threatening condition arises
premature placental separation resulting
maternal hemorrhage
fetal distress,
prolapsed umbilical cord
• It consists of the insertion of a hand into the
uterine cavity to turn the fetus manually to
breech in transverse lie or oblique lie
• Contraindicated
– If there is ROM
– If oligohydramnios is present
29
Internal podalic version and extraction
A: Feet are grasped
B: Baby is turned; hand on abdomen pushes
head toward uterine fundus
C: Feet are extracted
D: Torso is delivered. From this point onward,
procedure is the same as for uncomplicated
breech delivery

30. Risk of recurrence
• After
– If one: 9%
– If two: Risk is 25%
– If three: Risk is 40%
30

31. Entrapment of after coming head
• The common causes are
– premature baby
– macerated baby
– footling presentation
– hasty delivery of breech before the cervix is fully dilated
• Gynecoid and anthropoid pelvis are favorable for the aftercoming head (Dutta 8th)
• This is the most crucial stage of the delivery.
• The time between the delivery of umbilicus to delivery of mouth should preferably be 5–10 minutes
• There are various methods of delivery for the aftercoming head
• Each one is quite safe and effective in the hands of an expert, conversant with that particular
technique
• The following are the common methods employed
– Burns-Marshall method
– Piper forceps is especially designed (absent pelvic curve)
– Malar flexion and shoulder traction (modified Mauriceau-Smellie-Veit technique)
31

32. • Delivery of the aftercoming head by malar flexion and
shoulder traction
– (A) original MSV
– (B) Modification (preferred)
32

33. Delivery of the hydrocephalic fetus in breech presentation
• Viable breech fetus with significant hydrocephaly
– delivery should be by cesarean to avoid head entrapment
– A transverse incision in the lower segment may be too small so it is preferable to use a
vertical lower segment incision, which may have to be extended into the upper segment.
• Nonviable fetus with hydrocephaly
– vaginal breech birth is preferable
– If head entrapment occurs during spontaneous labor
• calvarium can be decompressed and collapsed by Cephalocentesis
– Cephalocentesis
• With a wide-bore spinal needle
• perform when the head is fixed at the pelvic brim than when it is mobile in the upper segment
• Transvaginally / transabdominally
33

34. Mature breechVs Premature breech
• Mature breech (U 2018)
– planned cesarean delivery for breech presentation between 39 and 41 weeks of gestation or in
early labor to
• Allow maximum time for spontaneous cephalic version and
• Minimize risk of respiratory problems in the neonate
– A low transverse hysterotomy incision is adequate in most cases
• Premature breech
– The preterm lower uterine segment may be very narrow, making delivery through a transverse
lower uterine incision difficult. Several solutions have been suggested:
• Make a vertical uterine incision
• Administer a uterine relaxant just before opening the uterus
• Give halothane to relax the uterus.The potential to cause hepatotoxicity has led to a decrease in its use.
– Whichever incision is used, the fetus must be delivered gently and atraumatically
– Forceps, if the appropriate size is available, are useful for the aftercoming head
34

35. Complications of Vaginal Breech Delivery
• Fetal complications
– Increased perinatal mortality and morbidity
– Cord-prolapse (more frequent in footling breech)
– Birth traumas
• Brachial plexus laceration
• spinal cord injury, with neck fracture
• fracture of femur, humorous or clavicle
• Intra cranial hemorrhage
– Asphyxia due to cord prolapse, abruptio placenta, arrested head
• Maternal complications:
– Operative deli very
– Lacerations of the vagina & cervix
– Post partum endometritis
35