Breech Delivery

Fetal pole is of similar bulk earlier in pregnancy
 Therefore, maybe be breech in early
pregnancy
May continue as Breech presentation in:
15% at 29-32 weeks
3-4% at term deliveries
Williams Obstetrics 25th Edition, Copyright © 2018 by McGraw-Hill Education

Near term, the fetus turns/rotates
within the uterus
Bulk of the buttocks seeks the more
spacious fundus
Therefore, spontaneously converted to
cephalic presentation

Classification of breech
presentations

• Complete breech (5-10%)
• Incomplete breech (10-30%)
 Footling breech
• Frank breech (50-70%)

1. Frank Breech
Legs are extended at
the Knees
Feet in close
proximity to face
Thighs flexed at the hip

1. Frank Breech – IE
Ischial Tuberosity and
Anus (palpable in a
straight line)
Sacrum

2. Complete Breech
Thighs flexed at the hip
One/Both legs are flexed
at the knee Feet lie
ALONGSIDE
the buttocks

2. Complete Breech – IE
Feet felt
ALONGSIDE the
buttocks
Sacrum is the
presenting part

3. Incomplete Breech
One/Both Thighs
Extended at the hip
Foot is the presenting part

3. Incomplete Breech – IE
Feet is felt as
presenting part

Risk Factors
associated with breech presentations

Breech – Dr Ali S Mayali https://www.slideshare.net/3lisadeq/breech-presentation-81103930

Other factors:
l Prior cesarean delivery
l Maternal diabetes
l Short umbilical cord
l Uterine anomalies
l Fundal placental implantation
l Smoking

l Uterine anomalies
l Placenta previa
l Fundal placental implantation
l Pelvic tumors (space
occupying lesions- myoma)
l High / grand multiparity with
uterine relaxation
l Previous breech delivery
l Smoking

Diagnosis
of breech presentations

l Inspection
l Auscultation
l Percussion
l Palpation --> Leopold maneuvers
l Vaginal Examination
l Imaging Techniques

1. Leopold maneuvers
First maneuver
l hard, round, ballotable
fetal head
occupies the fundus
Second maneuver
l back to be on one side of
the abdomen and the small
parts on the other
Imagetakenfrom:
http://mtresources.tripod.com/Tre
atments/maneuvers.htm

Third maneuver, if not
engaged
l breech is movable above the
pelvic inlet
Fourth maneuver
l After engaged, firm breech to
be beneath the symphysis
Imagetakenfrom:
http://mtresources.tripod.com/Tre
atments/maneuvers.htm

2. Vaginal Examination
Frank Breech
• Ischial Tuberosity and Anus
(palpable in a straight line)
• Sacrum
• External genitalia
Complete Breech
• Foot ALONGSIDE the buttocks
Incomplete Breech (Footling)
• Foot felt BEFORE the buttocks

3. Imaging techniques
Identify:
• Type of Breech
• Neck flexed or extended
• Maternal Pelvimetry
(to know whether safe to attempt a
vaginal delivery)

Ultrasound
Look for …
l Gross fetal abnormalities-
hydrocephaly/anencephaly
l Neck flexion / extension
l Fetal weight and BPD
estimation
X-Ray
If fetal attitude is uncertain after the ultrasound
May attempt vaginal delivery if:
1. No gross abnormalities
2. Flexed neck
3. 2500-3800g estimated
weight
4. No growth restriction
5. BPD is <10cm

CT Scan / MRI
They are
superior in
assessing
Pelvic
dimensions
May attempt vaginal delivery if:
1. Inlet AP diameter ≥10.5cm
2. Inlet Transverse diameter ≥12cm
3. Midpelvic interspinous diameter ≥10cm

May attempt vaginal delivery if
(Maternal-Fetal Biometry)
1. Inlet Obstetrical conjugate – BPD ≥1.5cm
2. Inlet Transverse diameter – BPD ≥2.5cm
3. Midpelvic interspinous diameter – BPD ≥0cm

Route of Delivery
for breech presentations

Term Breech
• May attempt vaginal delivery (in Frank)
• Planned C-section
• Emergency C-section
Preterm Breech (32-37 weeks)
• Planned C-section
• Emergency C-section
Extremely Premature Breech (<24-25 weeks)
• No emergency C-section

• Vaginal/cervical lacerations
• Extension of episiotomy 
later causing infections
• Anesthesia causing uterine
relaxation, leading to
Uterine atony and hence
Postpartum hemorrhage
• Fetal head entrapment,
intracranial bleeds
• Fractures of fetal humerus,
femur, clavicle, skull
• Hip dysplasia
• Brachial plexus injury
• Cervical spine injuries due
to neck hyperextension
• Umbilical cord prolapse 
Asphyxiation
• Testicular injury
• Maternal/fetal death
Complications associated with vaginal delivery:

Vaginal Delivery:
Spontaneous breech delivery
l The fetus is expelled entirely spontaneously
without any traction or manipulation other than
support of the newborn
Partial breech extraction
l The fetus is delivered spontaneously as far as the
umbilicus
l The remainder of the body is extracted or
delivered with traction and assisted maneuvers
Total breech extraction
l The entire body of the fetus is extracted by the
obstetrician

When the bag of waters is ruptured:
There is a increased chance of cord prolapse,
especially in
SGA, Complete and Incomplete Breech
Management of RBOW:
• Vaginal examination to make sure there is no
cord prolapse
• FHT monitoring for 5-10 mins following
RBOW

Partial Breech Extraction
Steps in Delivery (Frank Breech):
1. HANDS OFF – Wait for the baby to
deliver until the Umbilicus
Rawa Muhsin https://www.youtube.com/watch?v=gmnr_MTyKwc

Pinard Maneuver:
Press on the popliteal fossa to
flex the knee
Hence, deliver both legs

Deliver the cord to prevent cord
compression

Sweep across baby’s face to
deliver one arm

In case of a nuchal arm …
Lovset Maneuver:
Rotate baby to aid the delivery
of the other arm

Sweep across baby’s face to
deliver the other arm

Delivery of
aftercoming head
1st Hand:
Baby’s maxilla lifted by index
finger + middle finger
Rest the baby’s body on the
hand + forearm
2nd hand:
Use index finger + middle
finger to grasp the baby’s
shoulder
Assistant: (Crede Maneuver)
Apply suprapubic pressure
1. Mauriceau-Smellie-Veit
maneuver

Delivery of
aftercoming head
2. Burns-Marshall
maneuver
Feet are grasped and with
gentle traction swept in a slow
arc over the maternal
abdomenRawa Muhsin https://www.youtube.com/watch?v=gmnr_MTyKwc

Delivery of
aftercoming head
2. Burns-Marshall
maneuver
Feet are grasped and with
gentle traction swept in a slow
arc over the maternal
abdomen

Delivery of
aftercoming head
3. Piper Forceps
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

In case of Head Entrapment …
1. Duhrssen incision
The incompletely dilated cervix is cut at 2 o’clock,
which is followed by a second incision at 10 o’clock
(and another at 6 o’clock if needed)
Theincisionsaresoplaced as to minimize bleeding
from the laterally located cervical branches of the
uterine artery

2. Symphysiotomy
• Surgically divides the intervening symphyseal
cartilage and much of its ligamentous support to
widen the symphysis pubis up to 2.5 cm
• Indication:
Cesarean section is not available or unsafe for
the mother
• Complication:
Serious maternal pelvic or urinary tract injury

3. Zavanelli maneuver
• replacement of the fetus higher into the vagina
and uterus, followed by cesarean delivery, can
be used to rescue an entrapped breech fetus
that cannot be delivered vaginally

Both twins are in breech
presentation
Twin A is vertex, but Twin B is breech
• Vaginal of Twin A
then.
• External cephalic version
• Breech extraction
• C-section for the Twin B (vaginal-plus-C-section
If both twins were breech
• C-section
https://www.ijrcog.org/index.php/ijrcog/article/view/572/528

If Twin A is breech, Twin B is cephalic
• C-section
• Vaginal delivery can be considered as an
option for first twin breech specially in
multigravida – but is associated with an
increased chances of Locking/Locked
Twin
Leading twin in breech presentation, is routine caesarean section
necessary?
Lopamudra B. John, Reddi Rani P., Seetesh Ghose (Vol5 No2, 2016)
https://www.ijrcog.org/index.php/ijrcog/article/view/572/528

MULTIPLE PREGNANCY Supervisor : Prof. Salah Roshdy https://slideplayer.com/slide/6979329/

Breech Delivery

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