The document discusses breech presentation, including definition, types, risk factors, diagnosis, and management. It provides details on the epidemiology of breech births as well as techniques for external cephalic version, vaginal breech delivery, and cesarean section. Complications are outlined for both mother and baby.

1. By
Abdulwahid Korane
Jabir Aden Abdi

2.  Definition
 Epidemiology
 Types of Breech
 Risk factors
 Diagnosis
 Management
 Complication

3.  Breech presentation is when the fetal buttocks or lower
extremities present first into the maternal pelvis.
 The lie is longitudinal, and the head is found in the fundus..
 Breech Birth is a birth of a baby from a breech presentation, in
which the baby exits the pelvis with the buttocks or feets first
as opposed to normal head first presentation.

4.  Its The commonest abnormal presentation .
 Occurs 3-4% of all pregnancies and increases with decreasing
gestational age.
 7-10% at 32 Wks.
 25- 35% at at < 28 Wks.
 Normal in preterm when the fetus is more mobile, therefore it
should not be taken as abnormal until late pregnancy.

5. 1. Frank breech: Occurs (70%)when both fetal
thighs are flexed and both lower extremities
are extended at the knees. Its more common
in PG.
2. Complete breech: (20%)both knees and hips
are flexed, feet not below the level of
buttocks.
Common in Multipara .
3. incomplete or footling breech: (10%)The hip and
knee joints are extended on one or both sides.
There is High Risk of cord and Foot prolapse.

7. Breech presentations:
A: Right sacrum posterior (RSP)
position
B: Left sacrum anterior (LSA) position

8.  MATERNAL
 Uterine and Pelvic tumors.
 Polyhydramnios and Oligohydramnios.
 Uterine anomalies
 Placental anomaly like praevia
 Breech Presentation In previous pregnancy.
 Contracted pelvis
 Multiparty especially Grand multiparas.

9.  FETAL
 Prematurity
 IUFD
 Macrosomia
 Fetal Anomalies such as Hydrocephalus, Anencephally.

10. INSPECTION: Abdomen appears asymmetrical,, Difficult to feel
Fetal part, There is positive fluid thrill.
PALPATION: longitudinal lie, Hard at the fundus, and broad at the
lower pole.
Complains of discormfort under the ribs due to pressure of the
head on diaphragm.
AUSCULTATION: FHS heard above the umbilicus.
With legs extended breech descents into the pelvis easily making
the fetal heart to be heard at a lower level.
V/E: soft buttock felt, feet is in the pelvis.
ULTRASOUND: Confirms Breech presentation.

11.  External Cephalic Version ( ECV)
 Vaginal Breech Birth
 Caesarean Section

12.  External cephalic version (ECV) is a method for manually turning a breech
or transverse presentation into a cephalic one. It is performed from 36wks
in nulliparous women and 37wks in multiparous ones. The intention is to
reduce the need for delivery by CS.

METHOD/PROCEDURE
• 1.Do an U/S to Exclude fetal anomalies, Confirm presentation and Attitude
of fetal head.
• After USS, The woman is lied flat with a left lateral tilt (ensure her bladder
is empty) and she's comfortable.
• Breech is elevated from the pelvis and one hand used to manipulate this
upward in the direction of a forward role while the other hand applies gentle
pressure to flex the fetal head and bring it down to the maternal pelvis.

13. Procedure is uncomfortable for the mother and shouldn't’ exceed 10 minutes.
If procedure becomes difficult, its abandoned. Fetal heart rate trace must be performed before
and after the procedure and Anti-D is administered if the woman is rhesus negative.
2.PELVIMETRY to assess the Sacral Curve and measure the outlet and inlet.
3.HISTORY TAKING to exclude Contraindications Criteria For ECV, if not contraindicated do an
ECV.
Facilitation: success rates are increased by the use of tocolysis (anti-contraction),such as
salbutamol,nifedipine, nitroglycerine, indomethacin given either electively or
if a first attempt fails. Epidural or spinal analgesia are not usually used.
Safety: approximately 0.5% will require immediate delivery by CS due to fetal heart rate
abnormalities or vaginal bleeding. Theoretical or minor risks include pain, precipitation of labor,
placental abruption, fetomaternal hemorrhage, and cord accidents. The chances of CS during
labor are slightly higher than with a fetus that has always been cephalic.


15. CONTRAINDICATIONS OF ECV
ABSOLUTE
• Fetal abnormality e.g. hydrocephalus
• Placental Previa ( Low lying)
• Amniotic fluid
abnormality(Oligohydramnios )
• Suspected IUGR
• Previous caesarean or myomectomy
scar on the uterus.
• PROM
•
RELATIVE
Multiple gestation
Maternal hypertension.
COMPLICATIONS OF ECV
• Premature labor
• Premature rupture of the
membrane.
• Hemorrhage
• Fetal Distress
• Baby may turn Back to
Breech after ECV has been
done.

16.  TYPE OF DELIVERY
• Vaginal delivery:
•Spontaneous
•Partial breech extraction
•Total breech extraction
• Cesarean delivery

17. • Spontaneous breech (rare): No manipulation of the infant is necessary, other than supporting the infant.
• It occurs predominantly in very preterm deliveries.
• Partial breech extraction: Fetus descend spontaneously to where umbilicus is at the vaginal introitus; then,
maneuvers are initiated to assist in the delivery of the remainder of the body, arm and the head of the fetus is
extracted completely
• Total breech extraction: The entire body of fetus is extracted. This is indicated only if there is evidence of fetal
distress unresponsive to routine maneuvers and a cesarean delivery is not possible.

18. PREREQUISITES FOR VAGINAL BREECH DELIVERY
• Presentation should either be extended( hip flexed, knees extended) or flexed
(hips flexed, knees flexed but feet not below the fetal buttocks)
• No previous Caesarean Section For Cephalopelvic disproportion.
• The fetus should not be too large.
• Ensure Adequate Clinical pelvimetry.
• Should be in a Hospital with Facilities for Caesarean Section.
• Ensure adequate analgesia
• Spontaneous descent and expulsion to the umbilicus should occur with
maternal pushing only.
• Episiotomy may be considered once the anterior buttock and anus are
crowning.
• Experienced Obstetricians.
• In IUFD

19.  Large Baby
 Prime Gravida
 Previous C-Section
 Advanced Maternal age
 Small pelvis on pelvimetry
 Poor Obstetric history
 Footling Breech

20.  Call for:
 1. Experienced midwife
 2. Obstetric Registrar
 3.Neonatal Registrar
 4. Anesthetic Registrar

21.  Set IV Lines.
 Obtain blood for CBC, Grouping and Cross matching.
 Continuous cardiotocography(CTG) Monitoring.
 Empty the Bladder and Rectum.
 Consider Epidural analgesia.
 Put the patient in lithotomy.
 Do V/E to confirm Cervical dilatation and look for cord
presentation.

22.  1.Delivery of buttocks, leg and lower body
 Once the buttocks have entered the vagina tell the woman she can
bear down with the contractions.
 Maternal expulsion delivers the frank breech from the lower birth
canal, while the contractile forces of the uterus maintain flexion of
the foetal head.

23.  Let the buttocks deliver until the lower back and
then the shoulder blades are seen.
 Gently hold the buttocks in one hand but do not
pull.
 If the legs do not deliver spontaneously, deliver
one leg at a time, Its called Pinard’s manoeuvre.
 Do this by splinting the thigh whilst flexing and
abducting the hip.

24.  At this point the breech should hang downwards, while maternal
efforts expel the infant until the lower border of the scapula is visible
below the pubic arch.
 Wrap the baby in a sterile towel or cotton wool and hold by the hips.
 Do not hold the baby by the flanks or abdomen as this may cause
kidney or liver damage.
 Gentle support by the clinician ensures the back does not rotate
posteriorly.

25.  For delivery of the shoulders and arms, the clinicians thumbs overlie
the sacrum with the fingers around the iliac crests, so that the hands
cradle the foetal pelvis.

26.  Allow the arms to disengage spontaneously one by one. Only assist
if necessary.
 If the foetal arms have not become extended, the clinician passes
the index and middle fingers over the shoulder, and sweeps the left
arm medially across the chest, thus delivering it. Repeat for the right
arm.

27.  If the foetal arms have extended, the clinician applies Lovset's
manoeuvre.

28.  The clinician rotates the body with the back uppermost, 180 degrees.
 The posterior shoulder has been rotated anteriorly, and lies beneath the symphysis
Pubis.
 The clinician hooks the arm downwards, then rotates the body back 180 degrees, to
deliver the other arm in the same manner.
 If the baby’s body cannot be turned to deliver the arm that is anterior first, deliver the
shoulder that is posterior.
 Hold and lift the baby up by the ankles.

29.  Move the baby’s chest towards the woman’s inner leg. The
shoulder that is posterior should deliver.

30.  Lay the baby back down by the ankles. The shoulder that is anterior
should now deliver.
 Gentle elevation of the foetal trunk allows the clinician to access to
the foetal airway. You must avoid over-extension, because of the risk
of fetal cervical injury, and hyperextension of the foetal head.

31.  Deliver the head by the Mauriceau Smellie Veit
manoeuvre.
 Lay the baby face down with the length of its body over
your hand and arm.
Place the first and third fingers of this hand on the baby’s
cheekbones and place the second finger beneath the chin,
ease the cheeks down and flex the head.
Use the other hand to grasp the baby’s shoulders.

32.  With two fingers of this hand, gently flex the baby’s head towards the
chest while applying downward pressure on the chicks to bring the
baby’s head down until the hairline is visible.
 Pull gently to deliver the head.

33. MATERNAL
 Prolonged labor with maternal distress.
 Obstructed labor.
 Laceration especially perineal Tear.
 PPH due to prolonged labor and lacerations.
 Puerperal sepsis.

34. FOETAL
 Cord prolapse.
 Birth trauma as a result of extended arm or head, incomplete
dilatation of the cervix or CPD .
 Asphyxia from cord prolapse, cord compression, placental
detachment or arrested head.
 Damage to abdominal organs.
 Broken neck.