Breech presentation occurs when the fetus lies longitudinally with the pelvic or podalic pole presenting at the birth canal instead of the head. It has an incidence of 3-15% depending on gestational age. There are various types of breech including complete, frank, and footling. Breech delivery can be managed through external cephalic version, vaginal delivery, or cesarean section depending on the fetal position and other risk factors. Vaginal breech delivery requires skilled assistance and maneuvers to safely deliver the fetus in stages starting with the buttocks and hips, shoulders, and finally the head. Complications for mother and baby can include injuries if not properly managed.

1. MRS. SONY SARA P.J
ASSO. PROFESSOR
MSC (N),OBSTETRICS AND GYNECOLOGICAL NURSING
GANGA COLLEGE OF NURSING
COIMBATORE

2. BREECH PRESENTATION

3. Content Overview
• Introduction
• Definition
• Incidence
• Types of breech
• Causes of breech
• Diagnosis
• Management of breech
• Mechanism of breech delivery
• Assisted breech delivery
• Prognosis

4. Introduction
• Normally, the increasing bulk of the buttocks seeks
the more spacious fundus. There are various
possible positions. In that the right sacro anterior
is most common due to the presence of sigmoid
colon in the left quadrant of the maternal pelvis
• Breech presentation persist at term in 3 to 4% of
singleton deliveries.

5. Definition – Breech Presentation
Breech presentation is when the lie of the baby
is longitudinal and pelvic or Podalic pole of foetus
presents at the brim and cephalic pole at the fundus.

6. Incidence
Depends on the gestational age
• Before term between 28-36weeks (10-15%)
• After 37 completed weeks (3%)

7. Types
Complete
Breech/Flexed Breech
Presentation Frank Breech
Footling Presentation
Knee Presentation
Incomplete Breech

8. Types (Cont..)
Knee Presentation

9. Aetiology
Maternal Factors
Fetal Factors
Placental and Amniotic Fluid
Factors

10. Maternal Factors
Multiparity
Uterine Anomalies
Fibroid Factors

11. Fetal Factors
Multiple Pregnancy
Short cord Intrauterine death
Fetal Anomalies

12. Placental And Amniotic Fluid Factors
Placenta praevia
Cornufundal
placenta
Prematurity Polyhydramnios

13. Diagnosis
• Abdominal examination
• Ultrasonography
• Pelvic examination

14. Abdominal Examination

15. Ultrasonography
• It confirms the clinical diagnosis
• It helps to detect fetal congenital anomalies
• To find out type of breech
• It helps to localise the placenta
• Assessment of liquor
• Attitude of the head

16. Vaginal Examination
S.No Types Breech Cephalic
1. Frank breech Ischial Tuberosity, Scarum,
Anus,External Genitalia
Fetal sutures and
Fontanalles
Muscular resistance of anus
with or without Meconium
Less yielding jaws
Straight line : Ischial
Tuberosity & Anus
Triangular : Malar
Eminences & Mouth
2. Complete
breech
Feet along side the buttocks
3. Footling One or both feet Inferior t the
buttocks

17. Clinical Examination

18. Positions

19. Mechanism of Labour
• Lie : Longitudinal
• Presentation : Breech
• Presenting parts : Anterior part of the Left
buttocks.
• Attitude : Complete Flexion (Complete Breech),
Flexion of hip and Extension of knee(Frank Breech)
• Denominator : Sacrum
• Positions : Left & right sacro anterior (LSA & RSA),
right & left sacro posterior (RSP and LSP)

20. Cont..
Delivery of Buttocks & lower limbs
• Engagement
• Descent
• Internal rotation of breech
• More descent with Lateral flexion
• Birth of buttocks
• Restitution
Delivery of Shoulders & arms
• Engagement
• Descent
• Internal rotation of shoulders
• Birth of shoulders by lateral flexion
• Restitution
• External rotation

21. Cont..
Delivery of After coming Head
• Engagement
• Descent
• Flexion
• Internal rotation
• Birth of head by flexion

22. Cont..

23. Cont..
Delivery of the buttocks :
 Engagement :
• The engaging diameter is “bi-trochanteric diameter”
(10cm)
• It is passes the pelvic brim, the breech is engaged.
 Descent :
• It occurs until the buttocks reaches the pelvic floor.
 Internal Rotation :
• It occurs 1/8th of the circle until it comes under the
Symphysis Pubis.

24. Cont..
 Further descent with lateral flexion of the trunk.
 Delivery of the trunk and the lower limbs follows.
 Restitution occurs.
Delivery of the shoulders :
 The engaging diameter of the shoulder is “Bi-
Sacromial diameter” is 12cm.
 Internal rotation of the shoulder occurs 1/8th of
the circle.
 Delivery of the posterior shoulder followed by
anterior one.
 Restitution and External Rotation.

25. Cont..
Delivery of the head:
 The engaging diameter is either through the
opposite oblique diameter is “Sub Occipito
Frontal”(10cm)
 Descent with Increasing flexion.
 Internal rotation of the occiput occurs 1/8th of the
circle.
 Further descent takes place.
 The head is born by lateral flexion.

26. Management
Antenatal management
 External cephalic version
* Performed at 36-37weeks
* Follow prerequisites
* It has higher success rates in
- Multiparous
- Adequate AF
- Average Fetal Weight
- Complete Breech

27. External Cephalic Version

28. ECV- Complications
• Fetal bradycardia
• Placental abruption
• Fetomaternal haemorrhage
• Uterine rupture.

29. Management of Breech at Term
• Mode of delivery
• Elective caesarean section
– Estimated fetal weight <3.5kg
– Footling breech
– Hyperextended head
– Complicated breech
– Placenta Praevia
– Contracted pelvis.

30. Vaginal Breech Delivery
 Spontaneous Breech: No manipulation of infant
is necessary
 Assisted Breech delivery: Fetus descend
spontaneously up to the umbilicus then, the rest of
the fetus is extracted using additional manoeuvres.
 Total Breech Extraction: The entire body is
extracted. This is indicated only if there is evidence
of fetal distress unresponsiveness to routine
manoeuvers and a caesarean delivery is not
possible.

31. Cont..
• Criteria for patient selection
Complete/Frank breech
EFW : 2-3.5kg
Flexed head
Uncomplicated Breech

32. Assisted Breech Delivery
Principles :
1. Never to rush
2. Never pull from below but push from above
3. Always keep the fetus with the back anteriorly.
Prerequisites:
1. A skilled Obstetrician
2. Anaesthetist
3. An assistant- for fundal pressure
4. Instruments, suture materials for episiotomy
5. Resuscitation articles – baby if asphyxiated
6. Neonatologist

33. Cont..
General guidelines :
• Patient and attenders to be counselled
• Informed written consent
• IOL-not recommended
• Late ARM
• Oxytocin augmentation – usually avoided
• Maintain Partogram

34. Maneuvers used in Delivery of After
Coming Head

35. Burns Marshall Method

36. Forceps Delivery

37. Malar Flexion and Shoulder Traction

38. Management of Complicated Breech
• Delay in descent of the breech
– At the outlet
– In the cavity
– At the brim
• Causes may be :
 Pelvic contraction
 Big baby
 Weak uterine contraction

39. Frank Breech Contraction (Pinard’s
Maneuver)

40. Extended Arms - Lovset’s Maneuver

41. Bringing down posterior arm

42. Nuchal arm

43. Posterior rotation of arm – Prague
Manoeuver

44. Complications
Fetal complications Maternal complications
• Intrauterine fetal death
• Intracranial haemorrhage
• Birth asphyxia
• Birth injuries
 Haematoma
 Fractures
 Visceral injuries
 Nerve injury
 Long term
neurological damage
• Increased Caesarean
delivery
• Genital tract injuries

45. Conclusion
• In view of insignificant difference in the
fetomaternal outcome balanced decision about
mode of delivery on case by case basis will go a
long way in improving both fetal and maternal
outcome.

46. Reference
• D.C.Dutta,”Textbook of Obstetrics including Perinatology and
Contraception". Seventh Edition.
• Jacob, Annamma (2009). A Comprehensive Textbook of Midwifer
y. Second Edition. New Delhi: Jaypee Brothers
Medical Publishers.
• J.B. Sharma, “Midwifery & Gynaecological Nursing” Avichal
Publishing company:1st edition
• www.ncbl.nlm.nih.gov breech presentation: overview