3. 3
External cephalic version and Internal podalic
version
• With version, fetal presentation is altered by physically substituting one pole
of a longitudinal presentation for the other, or converting an oblique or
transverse lie into a longitudinal presentation.
• Manipulations performed through the abdominal wall that yield a cephalic
presentation are termed external cephalic version.
• Manipulations accomplished inside the uterine cavity that yield a breech
presentation are designated internal podalic version.
4. 4
• External cephalic version (ECV) reduces the rate of noncephalic presentation
at birth, and its success rate is 50 to 60 percent
• For women with a transverse lie, the overall success rate is significantly higher.
• In general, ECV is attempted before labor in a woman who has reached 370/7
weeks’ gestation (ACOG 2020).
• This threshold aims to balance risks of fetal immaturity and the greater
amnionic fluid volume seen in early-term pregnancies, which aids turning.
5. 5
• In support of this, one systematic review found that ECV done before 370/7
weeks raised ECV success rates but did not lower the ultimate cesarean delivery
rate and increased the risk of latepreterm birth.
Before 37wks, breech presentation also still has a high likelihood of correcting
spontaneously.
If ECV is performed too early, time may allow a reversion back to breech
If attempts at version cause a need for immediate delivery, complications of iatrogenic
early-term delivery generally are not severe.
6. 6
Contraindications to ECV
• If any contraindication to vaginal delivery , such as with placenta previa, classic
CD Scar, 2CD scar…
• Relative contraindications are early labor, 1LUSCD scar, oligohydramnios,
ruptured membranes, known nuchal cord, structural uterine abnormalities,
IUGR, multifetal gestation, Infertility Bad obstetrics history, Uterine
malformation and prior abruption or its risk factors, Congenital fetal
abnormality, Polyhydramnious
7. 7
• Several factors can improve the chances of an ECV attempt. These are
• multiparity,
• unengaged presenting part,
• nonanterior placenta,
• Nonobese patient, and
• abundant amnionic fluid (yet,neither a preprocedural 2-L intravenous fluid
bolus nor amnioinfusion raised ECV success rates).
• Decrease Success
• Engaged fetus
• Tense uterus
• Inability to palpate head
• Obesity
• Anterior placenta
• Fetal spine anterior or posterior
• Labor
9. 9
Complications
• small but real complications are placental abruption, preterm labor, and fetal
compromise.
• Bradycardia is common during or following ECV, but emergent cesarean rates
are ≤0.5 percent.
• Uterine rupture, fetomaternal hemorrhage, alloimmunization,
amnionic fluid embolism, and maternal or fetal deaths are rare
• Overall, compared with expectant management, perinatal morbidity and
mortality rates are not greater with ECV
• Even after successful ECV, several reports suggest that the cesarean delivery rate
does not completely revert to the baseline the vertex presentations.
• Specifically, dystocia, malpresentation, and NRFHRP may be more common in
these fetuses who have undergone successful ECV
10. 10
• 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
12. 12
Vaginal Breech delivery
Vaginal 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
• EFW is <1500 or >4000 g
• hyperextended head
• Uterine dysfunction
• Lack of an experienced operator of
VD
• Prior cesarean delivery
• Zatuchni-Andros score <4
• Arrest of progress
13. 13
• First stage of labor
• follow with 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
15. 15
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 crevics
22. 22
head-to-body delivery interval > 60 seconds, which was two SD above the mean value
(24 seconds)
Although promising, this definition has not been studied extensively and further
investigation is needed to validate its use for diagnosis of shoulder dystocia and determine
the optimum threshold for predicting adverse neonatal outcomes
23. 23
Risk Factors
High birth weight > 4 kg
Estimated risk of shoulder dystocia
– EFW > 5000 g + No diabetes: >20%
– EFW > 4500 g + DM: ~ 15%
Diabetes mellitus – 2 reasons
– Higher risk of macrosomia
– chest-to-head and shoulder-to-head ratios are
increased
in IDMs
Previous shoulder dystocia
– recurrence - 10 – 25%
– Recurrent shoulder dystocia is more likely when
o Current EFW > previously affected pregnancy
o Prepregnancy weight > previously affected
pregnancy
o Gestational weight gain > previously affected
pregnancy
Postterm pregnancy
– higher birth weights with advancing
gestational age
Male fetal sex
Maternal obesity & excessive
gestational weight gain
Maternal demographics; Advanced
maternal age
24. 24
Management of Shoulder Dystocia
• obstetric emergency; goal of management
to prevent fetal asphyxia & permanent Erb's palsy or death
Avoiding maternal physical injury (eg, bone fractures, maternal trauma)
• Call for help—mobilize assistants and anesthesia and pediatric personnel. Initially, a gentle
attempt at traction is made. Drain the bladder if it is distended
• Check for and release a tight nuchal cord, if present.
• Drain a distended bladder, if present.
• Position the patient with her buttocks flush with the edge of the bed to provide optimal access
for executing maneuvers to effect delivery
• Generous episiotomy
• Avoid excessive neck rotation, head and neck traction, and fundal pressure because this
