This document provides information on breech presentation and delivery. It defines breech presentation as when the fetus is in longitudinal lie and its buttocks enter the pelvis first. It discusses the types of breech presentations including frank, complete, and incomplete breech. It describes the mechanisms, risks, and methods of both vaginal and cesarean breech deliveries. Key points include that vaginal breech delivery can be attempted for selected cases using techniques like partial or total breech extraction, but cesarean section is recommended when there are risk factors like a large fetus or unfavorable pelvis. Both maternal and neonatal risks are outlined.

1. BREECH PRESENTATION
&
DELIVERY
Panwad Rattanasrithong INT2

2. Definition & Clinical
importance

3. Definition
The presentation that the fetus is in
longitudinal lie and its buttock enter the
pelvis first

4. Incidence
3-4% of singleton deliveries
15% at 29 – 32 weeks

5. ETIOLOGY
Precipitating factor
Gestational age
Great parity / Multiple fetuses (uterine
relaxation)
Hydramnios / Oligohydramnios
Hydrocephalus / Anencephalus
Previous breech delivery
Uterine anomalies / Pelvic tumors
Placenta previa

6. Types of breech

7. Types of breech
Frank breech : flexed at hips and
extended at knees
Complete breech : flexed at hips and
flexed at knees
Incomplete breech : one or both hips
are not flex and one or both feet or knees
lie below the breech

10. Diagnosis

11. Abdominal examination
1st Leopold maneuver: ballottement
2nd Leopold maneuver: large part
3rd Leopold maneuver: movable
4th Leopold maneuver: prominence

12. Vaginal Examination
Palpable : both ischial tuberosities,the
sacrum and the anus
DDx : Face presentation (Mouth and
Malar eminence)
Position & Variety : Sacrum&Spinus
process

13. Imaging Techniques
Ultrasound
CT
MRI

14. Mechanism of delivery

15. Mechanism of delivery
Denominator

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

17. Mechanism of delivery
Engagement
Descent

18. Mechanism of delivery
Internal rotation Lateral flexion

19. Mechanism of delivery
External rotation Birth : breech

20. Mechanism of delivery
Birth : body head

21. Modes of delivery

22. Modes of delivery
Cesarean section
Vaginal delivery
Spontaneous breech delivery
Assisted breech delivery
(Partial extraction)
Total breech extraction

23. Vaginal delivery

24. Vaginal delivery
Entrapment of fetal head : Duhrssen
incision
Entrapment of fetal arm behind the neck
(nuchal arm)
Prolapse cord : complete – 5% ,footling-
15%

25. Duhrssen
incision

26. Vaginal delivery
Unfavorable pelvis
Gynecoid & anthropoid : favorable
Platypelloid & Android : unfavorable

27. Vaginal delivery
Hyperextension
5 % in term breech presentation
Result : Injury to C spinal cord
Marked hyperextension : C/S

28. Vaginal delivery
Labor induction & Augmentation
No significant mortality and Apgar
between infant with induced vs spontanous]
Oxytocin
Amniotomy
CT confirm adequate pelvis

29. Vaginal delivery
Management of labor
Establish : Membranes,labor,Fetal
condition,UC
Notified nursery
Stage of Labor : Cx , Eff , Station ,Presentation
Fetal Monitoring :
FHR q 15 min (most continue EFM)
PV check cord prolapse & FHR q 5-10min (MR)

30. Vaginal delivery
Methods of Vaginal delivery
Spontaneous breech delivery
Partial breech extraction
Total breech extraction

31. Vaginal delivery
Assisted Breech Delivery

32. Vaginal delivery
The posterior hip of frank
breech is delivering

33. Vaginal delivery
The anterior hip
has now
delivered and
external rotation
has occurred. The
fetal thighs
remain in flexion
with extension
knees.

34. Mode of
delivery
Delivery of the
legs by placing
the fingers
parallel with
medial aspect of
the femur and
displacing
laterally and away
from midline

35. Mode of
delivery
Delivery of the body.

36. Delivery of the shoulder
Cats paw method
Classical method
Lovset ‘s method

37. Cats paw method

38. Cats paw method

39. Classical
Method

40. Lovset’s Method

41. Partial breech extraction or
breech assisting
Delivery of the aftercoming head
Mauriceau-Smellie-veit maneuver
Prague maneuver
Piper forceps

42. Mauriceau-Smellie-Veit Maneuver

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

44. Piper Forceps

45. Total breech extraction
Indication
1. Prolong second stage of labor
2. Twin
3. Maternal disease
4. Prolapse cord
5. Fetal distress

46. Total breech extraction
Contraindication
1. Cervix not fully dilated
2. CPD

47. Total breech extraction
The hand is introduced through the vagina
&both feet of the fetus are grasped
Gentle traction the feet through the vulva
Breech appears at the vulva, gentle
traction until the hips are delivered
assisted breech delivery

48. Complete
breech
extraction
begins with
traction on the
feet and ankles.

49. continues with
traction on the
thighs

50. the scapulas
becomes
visible and the
body rotates,
usually to the
side of the
mother

51. Cesarean section
Recommendation
Large fetus
Contraction or unfavorable shape of pelvis
Hyperextended head
Delivery is indicated but not in labor
Uterine dysfunction
Incomplete or footling presentation

52. Cesarean section
Recommendation
Healthy preterm
Severe fetal growth restriction
Previous perinatal death or newborn
complication of birth trauma
A request for sterilization
Lack of an experienced operator

53. Morbidity & Mortality
Maternal Injuries
Risk : Operative intervention
Manipulations : Risk infection
Intrauterine maneuvers : Rupture of the
uterus +/- lacerations of Cx
Extensions of the episiotomy
Uterine atony , Postpartum hemorrhage

54. Morbidity & Mortality
Perinatal Morbidity & Mortality
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

55. Intracerebral haemorrhage

56. Birth asphyxia

57. Version

58. Version
External cephalic version
Internal podalic version

59. External Cephalic Version

60. Thank you for attention