Breech Presentation & its Mx
• Definition:is a polar alignment of the fetus in
which the fetal buttocks present at the maternal
• Types:frank, incomplete, and complete.
• The fetal hips are flexed and the knees
extended so that the thighs are apposed to
the abdomen and the lower legs to the chest
The buttocks are the most dependent part of
• In incomplete breech presentation, the fetus
has one or both hips incompletely flexed so
that some part of the fetal lower extremity,
rather than the buttocks, is the most
dependent part (hence the terms single
footling or double footling).
• The fetal hips and knees are both flexed so
that the thighs are apposed to the abdomen
and the legs lie on the thighs.
• A significant proportion will change to
incomplete in labor.
• Described with the fetal sacrum as the
Thus, it is right sacrum anterior,right
sacrum posterior,right sacrum transverse,&
• Uterine overdistension
• High parity with lax abdomen and uterine
Leopold’s first-head in the fundus
Leopold’s third-no tapering b/n the buttocks
and the body
Auscultation-FHR in the upper quadrants
• Vaginal –frank:anal orifice,ischial
tuberosities and no feet.
-Complete:anal orifice,ischial tuberosities &
feet above the buttock
-Incomplete:one or more feet/knees felt
• Ultrasound:in difficult cases and to see
associated anomalies,weight estimation and
• Feared and serious complication in breech.
• Four fold higher than cephalic.
• Trauma:no time for molding leading to head
:hyperextension of neck leads to
• Asphyxia:cord prolapse(0.4%,5%,10%)
• Less than 36weeks
-expectant as spontaneous version to
cephalic is common.
-ultrasound for possible anomalies
• Greater than 36weeks
-ECV(External Cephalic Version)
• External cephalic version (ECV) is a third
alternative to vaginal delivery or cesarean delivery
for the breech fetus
• Success with ECV varies from 60 to 75 percent
• The mechanical goal is to squeeze the fetal vertex
gently out of the fundal area to the transverse and
finally into the lower segment of the uterus.
• Contraindications:Indications for cesarean
delivery irrespective of fetal presentation (eg,
Nonreassuring fetal monitoring test
Hyperextended fetal head
Significant fetal or uterine anomaly
Mechanism of labor
• enters the pelvic inlet in one of the diagonal
• Engagement: the bitrochanteric diameter
beyond the inlet by vaginal examination, the
presenting part may be at -2 to -4 station.
• At the levator ani muscular sling, internal
rotation brings the bitrochanteric diameter into the
anteroposterior (AP) axis of the pelvis.
• The breech at the outlet emerge, first as a
sacrum transverse, then rotating to sacrum
• Crowning occurs when the bitrochanteric
diameter passes under the pubic symphysis.
As the infant emerges, rotation begins,
usually toward a sacrum anterior position.
• A spontaneous breech delivery is one in which
the entire infant delivers vaginally without manual
• The assisted breech delivery( partial breech
extraction.) In this delivery, the fetus is allowed to
deliver by the forces of uterine contractions and
maternal bearing-down efforts until the fetal
umbilicus has passed over the mother's perineum.
After this, delivery of the legs, trunk, and arms are
assisted manually; the head may be delivered
manually or with forceps.
• A complete breech extraction, in which
manual assistance is applied by traction in
the groins or on the lower extremities
before delivery of the buttocks.
• Contraindicated in singleton breech
Assisted breech deliv…
• Criteria - No contraindication to vaginal birth (eg,
- Absence of fetal anomaly
- fetal weight 2000 g –4000g
- GA 36 weeks or more
- Flexed fetal head, No hyperextension
-Normal progress of labor
-Continuous fetal heart rate monitoring
- Staff skilled in breech delivery and facilities
available for safe emergency cesarean
-The membranes are left intact because spontaneous
rupture of the membranes is more likely to be
followed by cord prolapse due to the irregular
outline of the breech..
-Oxytocin infusion may be used for inadequate
uterine activity in latent phase of labor. In the
active phase may be an indicator of fetopelvic
disproportion augmentation is not recommended
once active labor has commenced .
Steps in assisted breech delivery
• The body is allowed to deliver
spontaneously up to the level of the
• After the umbilicus has been reached,
pressure is applied to the medial aspect of
the knee, which causes flexion and
subsequent delivery of the lower leg.
• The fetal trunk is then wrapped with a towel
to provide secure support of the body
• When the scapulae appear at the outlet, the
operator may slip a hand over the fetal
shoulder from the back , follow the humerus
to effect delivery of forearms.
• Delivery of the head by performing the
• EFW <1,500 or >4,000 g
• Footling presentation
• Small pelvis
• Hyperextended fetal head
• Absence of expertise
• Nonreassuring fetal heart rate pattern
• Arrest of progress