BREECH PRESENTATION obstetrics and gynacology mbbs final year presentation , pregnancy final year mbbs normal labor breech labor complications management BREECH tdmc kerala

1. BREECH
PRESENTATION
Sarath tk
tdmc

2. BREECH PRESENTATION
 It is a longitudinal lie where the podalic pole presents & the denominator is the
sacrum.
Most common among malpresentations.
Positions:
1. Left sacroanterior (LSA)
2. Right sacroanterior (RSA)
3. Right sacroposterior (RSP)
4. Left sacroposterior (LSP)

3. TYPES OF BREECH
1. Extended/Frank breech - flexion at thighs & extension at knees;
• most common
• buttocks are the presenting part
2. Complete breech/flexed breech - Fetus maintains attitude of universal flexion with flexion at thighs &
knees
3. Incomplete breech -
• Knee presentation - extension at thighs & flexion at knees - knees are the presenting part.
• Footling breech - extension at thighs & knees - feet are the presenting part

4. 1. Complicated breech - associated with any fetal or maternal complications
• indication for caesarean section.
2. Uncomplicated breech - Without any other complications

5. AETIOLOGY
• Prematurity - most common cause
• Maternal factors -
• Multiparity - abdominal muscle & uterus relaxed
• Uterine obliquity
• Placenta Previa & cornuofundal attachment of placenta
• Uterine fibroids in lower segment
• Uterine anomalies like bicornuate, septate uterus & uterus didelphys.

6. • Fetal factors -
• Multiple pregnancy
• Congenital anomalies (hydrocephalus, myelomeningocele, Prader Will
syndrome)
• Polyhydramnios
• Oligohydramnios
• Intrauterine death
• Extended legs

7. DIAGNOSIS
• Abdominal examination -
• Head of fetus is felt in fundal grip
• Breech is felt in first pelvic grip
• Fetal heart beat heard above umbilicus
• Vaginal examination -
• Conical bag of membranes
• Presenting part is high up

8. • Flexed breech - ischial tuberosities, anus, sacrum, buttocks & feet
are palpated - after further descent, external genitalia also felt.
• Extended breech - buttocks are the presenting part & feet are not
felt.
• Footling breech - feet are the presenting part with the buttocks
higher up.
• Sacrum is usually in the anterior quadrant. Posteriorly placed
sacrum is less favorable for vaginal delivery.
• Difference of breech from face – mouth is surrounded by bones
and anus is not.

9. FLEXED Vs EXTENDED BREECH

10. PROBLEMS OF BREECH DELIVERY
• Engagement before labour is unusual - ill fitting presenting part predisposes to PROM & cord
prolapse
incidence of cord prolapse
1. flexed breech - 6%
2. footling -12%,
3. extended breech - 0.5 % ( similar to that in vertex)
• Poor dilator of cervix compared to vertex
• Smaller & more compressible parts come out first while the larger & less yielding head comes out
last.
• In flexed & footling breech, limbs may slip out before full dilation- entrapment of head- more
risk in preterm babies
• No time for head to mould

11. ULTRASOUND IN TERM
BREECH
• Confirms breech presentation & type of breech
• Rules out anomalies
• Rules out placenta praevia
• Rules out hyperextension of fetal head (stargazing fetus)
• Assessment of fetal weight & liquor
• During external cephalic version

12. MECHANISM OF LABOUR
• Most common position - left sacroanterior (LSA)
• Vaginal breech delivery – 3 stages
1. Delivery of breech
2. Delivery of shoulders
3. Delivery of head

13. • Delivery of the breech –
1. Engagement - Engaging diameter is the bitrochanteric diameter (9.5 cm)
- in LSA, this diameter is in the left oblique diameter of pelvis.
Engagement is slow.
2. Descent with increasing compaction.
3. Internal rotation - when the anterior buttock reaches the resistance of
the pelvic floor, it rotates forward through 1/8 of a circle, so that it is
behind the symphysis pubis.
4. Lateral flexion - Anterior hip appears first & impinges under the
symphysis pubis & then, by a process of lateral flexion, the posterior hip
is born over the perineum.
5. Delivery of trunk & limbs.
6. Restitution of buttocks

14. • Delivery of shoulders:
1. Engagement: The engaging diameter is the bisacromial diameter (12 cm) &
engagement takes place in the same oblique diameter as the breech.
2. Internal rotation: Anterior shoulder rotates through 1/8 of a circle & the
shoulders come to lie in the AP diameter of the pelvic outlet.
3. Birth by lateral flexion: The anterior shoulder hitches under the symphysis
pubis & is born first & then by a process of lateral flexion, the posterior
shoulder & arm are born as the baby's body is lifted up.
4. Restitution of shoulders.

15. • Delivery of head:
1. Engagement: Suboccipitofrontal diameter engages in the opposite
oblique diameter to that in which the buttocks are engaged, i.e, in the
right oblique diameter in LSA.
2. Descent with increasing flexion of head
3. Internal rotation: Occiput rotates anteriorly so that sagittal suture
lies in AP diameter.
4. Birth by flexion: Nape of neck pivots under the symphysis & the
chin, mouth, nose, forehead & occiput are born by a movement of
flexion.

17. COMPLICATIONS
• Maternal:
o Increased chance of operative delivery & anaesthesia  maternal mortality
& morbidity.
• Perinatal -
o Perinatal mortality increased even with caesarean section
o Causes are:
1. Prematurity
2. Congenital anomalies (two & a half times that in cephalic presentation)
3. Birth trauma
4. Birth asphyxia - cord prolapse/cord compression, prolonged delivery,
entrapment of after coming head

18. PRETERM BREECH
• They share most of the problem of term breech but to higher degree.
• Management
• Caesarean section is preferred.
• Vaginal delivery can be done if fetal weight > 1.5 kg and GA >32 weeks.
• Supervised by experienced obstetrician
• Epidural analgesia - prevent pushing prior to full dilatation.
• Head gets entrapped - Duhurssen's incisions done

19. MANAGEMENT OF TERM BREECH
There are mainly 5 techniques of management of a term breech:
1. Elective caesarean section
2. External cephalic version
3. Assisted breech delivery
4. Emergency caesarean section
5. Breech extraction

20. ELECTIVE C-SECTION
Planned procedure performed at 39 weeks gestation.
Definite indications:
1. All complicated breech pregnancies (preeclampsia, GDM etc)
2. Contracted or borderline pelvis
3. Large babies (> 3500 g)
4. Severe intrauterine growth restriction
5. Hyperextension of fetal head
6. Footling or knee presentation
7. Previous C-section
8. Lack of an obstetrician experienced in assisted breech delivery.

21. Requisites during C-section:
 Baby should be delivered in exactly the same way as in a vaginal
delivery.
 As in vaginal delivery, the fetal bony pelvis & not the soft parts
should be grasped.

22. EXTERNAL CEPHALIC VERSION
• Procedure whereby the presentation other than cephalic, is converted by
external manipulation into a cephalic presentation.
• Carried out in breech presentation in well selected cases & has a success rate
of about 65%.
• Reduces the chance of breech birth & C-section
• Performed after 36 weeks gestation.

23. Contraindications:
1. Multiple pregnancy
2. Antepartum hemorrhage
3. Uteroplacental insufficiency as in IUGR or preeclampsia
4. Ruptured membranes
5. Previous C-section
6. Contracted pelvis & uterine anomalies
7. Need for C-section due to other indications like medical disorders

24. Procedure:
• Only done in a place with ready access to perform an emergency C-section,
preferably in the labour ward.
• Ultrasound is done to confirm the presentation, type of breech, adequacy of
liquor & to rule out placenta praevia & anomalies
• Continuous fetal monitoring
• Maternal rate is also checked
• A reactive NST should precede the procedure.
• Anaesthesia is best avoided
• Tocolytics like terbutaline can be used as IV infusion or subcutaneously.

25. • Each hand grasps one fetal
pole
• Fetal buttocks are gently
elevated from the maternal
pelvis & displaced laterally
• Then the buttocks are guided
gently towards the fundus while
the head is directed to the
pelvis.
• The trunk should be kept well
flexed during the procedure.
• NST is repeated after version

26. • Procedure is stopped if there is pain, fetal distress or multiple
attempts fail.
• Anti - D to be given to Rh -ve nonimmunized women
• Version is not attempted if the breech is deeply engaged.
• Observation for atleast 1 hr after the procedure
• Version can be reattempted if the presentation reverts to breech

27. • Factors associated with successful version:
1. Multiparity
2. Flexed breech
3. Adequate liquor
• Complications:
1. Fetal distress
2. Preterm labour
3. Premature rupture of membranes
4. Abruption
5. Fetomaternal hemorrhage
6. Amniotic fluid embolism
7. Uterine rupture (rare)

28. ASSISTED BREECH DELIVERY
Ideal cases for vaginal delivery:
1. Average sized fetus with well flexed head on ultrasound
2. Normal pelvis
3. No maternal or fetal indications for C-section
4. Spontaneous onset of labour
5. Extended breech - better suited

29. Prerequisites:
1. Obstetrician skilled in assisted breech delivery
2. Facility to perform emergency C-section
3. Informed consent of the woman
4. Pediatrician skilled neonatal resuscitation

30. Scoring system:
• to assess the prognosis for successful vaginal delivery
• Zatuchini-Andros scoring system is most popular
• A score of 3 or less is an indication for C-section
• Higher scores can be kept for vaginal delivery

31. First stage:
 PV done to ascertain
• type of breech,
• cervical dilatation,
• intactness of membranes
• assess the pelvis.
 Patient advised to take nothing by mouth & is given parental fluids.
 Maintain intact membranes until complete dilatation.
 When membranes rupture, PV is done to rule out cord prolapse.
 Progress of labour is monitored by a partogram
 If there is failure to progress or PROM -most likely cause is subtle
fetopelvic disproportion & oxytocin is better avoided - C section is
preferable here.

32. Second stage:
1. Delivery of breech
 Once the cervix is completely dilated & breech is visible at the outlet,
patient is brought to the edge of the delivery table & placed in lithotomy
position.
 An IV infusion should be maintained & oxytocin added if needed.
 Pudendal block anaesthesia can be given if she is not having an epidural.
 Bladder is catheterised.
 When the breech is climbing the perineum, a liberal mediolateral
episiotomy is given.
 Usually, the breech is delivered on its own up to the umbilicus.
 Premature traction is avoided - At the most, the legs are hooked out
gently.

33. • Key points:
 Baby's back should always be anterior
Baby should be held only by femeropelvic grip -
fingers on the ASIS & thumbs on the sacrum.
A loop of cord should be drawn down to avoid
compression.
Baby should be wrapped in a warm towel to
avoid premature breathing efforts due to tactile
stimulation.

34. 2. Delivery of shoulders:
The assistant exerts suprapubic pressure on the head to
maintain flexion while shoulders & arms are delivered by
lateral flexion of the body.
• Lovset manoeuvre –
 inferior angle of anterior scapula is seen, baby is grasped by
femeropelvic grip & the trunk rotated through 180°, so that the
back faces anteriorly
 downward traction is applied when the previously posterior
shoulder becomes anterior & emerges under the public arch -
this is then hooked out
 trunk is rotated in reverse direction & anterior shoulder is
delivered out.
 reduces the incidence of nuchal arms & extended arms.

36. • Delivery of aftercoming head:
Usually, the back turns anteriorly spontaneously. Rarely, the back may turn
posteriorly - this should be anticipated & the back should be rotated anteriorly to
prevent the head rotating face to pubis.
1. Burns Marshall manoeuvre
2. Mauriceau Smellie Viet manoeuvre
3. Forceps

37. 1. Burns Marshall manoeuvre:
When the occiput (identified by the hairline) is
seen under the symphysis pubis, steady traction
is given on the feet & the baby is swung in an
arc towards the mother's abdomen - by
simultaneous suprapubic pressure (Kristellar
manoeuvre), the head is born in flexion.

38. 2. Mauriceau Smellie Viet manoeuvre:
The fetal body rests upon the palm of the hand and the left forearm & the index & middle fingers of
the same hand are applied over the malar bones to flex the head. 2 fingers of the right hand are hooked
over the fetal neck & grasping the shoulders, downward traction is applied until the suboccipital region
appears beneath the symphysis pubis. Simultaneous gentle suprapubic pressure keeps the head flexed.

40. 3. Forceps for the after coming head:
• Piper forceps or any straight forceps - used.
• The baby's body is wrapped in a towel including
the arms, and the body is raised out of the way
by an assistant.
• Then, forceps is applied from below the body.
• Attempts at elevating the body should be
resisted as this can cause extension of the neck -
the fetal body should be supported parallel to
the floor & the operator should drop to his
knees during application of forceps.
• Traction is exerted & the head extracted slowly.
• only done when the head is in the pelvis.

41. • Advantages of forceps:
1. It provides controlled delivery of the head
2. Traction is on the head rather than on the neck
3. It retracts the vaginal walls allowing the baby to breathe

42. Complications of assisted breech delivery
1. PROM:
2. Cord prolapse
3. Dysfunctional labour
4. Extended arms: arms are kept extended over the baby's head. Lovset manoeuvre is tried
or else one hand is introduced along the back of the fetus & slowly pressure is exerted
on the elbow - then the arm will flex & can be brought down.
5. Nuchal arms: Extension at the shoulder & flexion at the elbow - forearm is trapped
behind the fetal head - trunk is rotated through 90ﾟin the direction in which the hand is
pointing
6. Entrapment of aftercoming head: Duhurssen's incisions/ cervical dilatation with iv
nitroglycerin/ breech extraction/ Replacement of fetus high into the vagina & uterus,
followed by C-section (Zavanelli manoeuvre)

43. 7. Chin to pubis rotation: Rare - Prague manouvre used - fingers placed
over the shoulders from behind & outward & upward traction made ,
other hand grasps the legs & the body is swung over the mother's
abdomen - occiput is born over the perineum; this is traumatic to the
baby, so it is entertaining use GA to dislodge the chin & rotate the face
posteriorly & the back anteriorly - then flex the chin & deliver the head
with forceps.
8. Impacted breech - C-section done regardless of level of impaction

44. EMERGENCY C-SECTION
Indications
1. Cord prolapse
2. Failure to progress
3. Maternal or fetal distress
4. Impacted breech

45. BREECH EXTRACTION
• When the cervix is fully dilated & immediate breech delivery is warranted -
fetal or maternal distress or cord prolapse.
• Entire body is delivered vaginally under GA without any effort by the
patient.
• Main indication – delivery of second twin after internal podalic version.