This document provides information on breech births, including definitions, types, diagnosis, and management. It begins with an introduction defining breech birth as birth where the baby exits the pelvis feet or buttocks first instead of head first. It then describes the different types of breech presentations (complete, incomplete, frank), discusses diagnosis using clinical exams and ultrasound, and outlines the management of breech births including external cephalic version, vaginal delivery or cesarean section depending on the situation. The conclusion states that breech presentations can be effectively managed with early diagnosis and skillful techniques from obstetricians.

1. -Deepa Mishra
M. Sc. Nursing (OBG)

2. INTRODUCTION
A breech birth is the birth of a baby from a
breech presentation, in which the baby exits the
pelvis with the buttocks or feet first as opposed to
the normal head-first presentation. In breech
presentation, fetal heart sounds are heard just
above the umbilicus. In a breech presentation,
the lie is longitudinal and the podalic pole
presents at the pelvic brim. It is the commonest
malpresentation.

3. DEFINITION
It is a longitudinal lie in which the buttocks is the presenting
part with or without the lower limbs.
According to Nima Bhaskar
A breech birth is the birth of a baby from a breech
presentation, in which the baby exits the pelvis with the
buttocks or feet first as opposed to the normal head-first
presentation.
According to Wikipedia

4. INCIDENCE
3-4% of fetus present by breech at
term
5% at 34 weeks
20% at 28 weeks
20% diagnosed initially in labour
3.5% term singleton deliveries and
about 25% of cases before 30 weeks
of gestation undergo spontaneous
cephalic version up to term.

5. TYPES
Complete Breech
(Flexed Breech)
Incomplete
Breech(30-35%)

6. 1. Complete Breech (Flexed
Breech)
The normal attitude of
full flexion is
maintained.
The thighs are flexed
at the hips and the
legs at knees.
The presenting part
consists of two
buttocks, external
genitalia and two feet.
It is commonly present
in multiparae.

7. 2. Incomplete
Breech(30-35%)
Buttocks variety (70%)
Incomplete variety with
procidentia: One or more
little parts (footling,
knees) precede the
buttocks.
Sacro-anterior positions are
more common than
sacroposterior as in the first
the concavity of the fetal
front fits into the convexity
of the maternal spines

8. INCOMPLETE BREECH
Frank Breech
• It is breech with extended legs where the knees
are extended while the hips are flexed.
• More common in primigravida.
Footling Presentation
• The hip and knee joints are extended on one or
both sides.
• More common in preterm singleton breeches.
Knee Presentation
• The hip is partially extended and the knee is
flexed on one or both sides

9. TYPES OF INCOMPLETE BREECH

10. CLINICAL VARIETIES
Uncomplicat
ed
It is defined as one
where there is no
other associated
obstetric
complications apart
from the breech,
prematurity being
excluded.
Complicate
d
When the
presentation is
associated with
conditions which
adversely influence
the prognosis such
as prematurity, twins,
contracted pelvis,
placenta praevia etc.

11. POSITIONS
Left Sacroanterior
(LSA)
Left Sacroposterior
(LSP)
Left Sacrolateral
(LSL)
Right Sacroanterior
(RSA)
Right
Sacroposterior
(RSP)
Right Sacrolateral
(RSL)

12. Etiology Of Breech Presentation
Prematurity
Factors preventing
spontaneous version
Favorable adaptation
Undue mobility of the fetus
Fetal abnormality

13. DIAGNOSIS
CLINICAL
SONOGRAPHY
RADIOLOGY

14. CLINICAL
Complete Breech Frank Breech
Per Abdomen
Fundal Grip  Head- suggested by hard and
globular mass
 Head is ballottable
 Head
 Irregular small parts of the feet
may be felt by the side of the
head.
 Head is non-ballottable due to
splinting action of the legs on
the trunk.
Lateral Grip  Fetal back is to one side and the
irregular limbs to the other
 Irregular parts are less felt on the
side

15. CLINICAL
Complete Breech Frank Breech
Pelvic Grip
F.H.S.
 Breech- suggested by soft, broad and
irregular mass.
 Breech is usually not engaged during
pregnancy
 Usually located at a higher level round about
the umbilicus
 Small, hard and a conical mass is felt
 The breech is usually engaged
• Located at a lower level in the midline due to
early engagement of the breech
Per Vaginum
During Pregnancy
During labour
 Soft and irregular parts are felt through the
fornix
 Palpation of ischial tuberosities, sacrum and
the feet by the sides of the buttocks
 The foot felt is identified by the prominence
of the heel and lesser mobility of the great
toe.
 Hard feel of the sacrum is felt, often mistaken
for the head
• Palpation of ischial tuberosities, anal
opening and sacrum only

16. Ultrasonography
1. It confirms the clinical diagnosis-specially
in primigravidae with engaged
frank breech or with tense abdominal wall
and irritable uterus.
2. It can detect fetal congenital
abnormality and also congenital anomalies
of the uterus.
3. Type of breech (complete or
incomplete).
4. It measures biparietal diameter,
gestational age and approximate weight of
the fetus.
5. It also localizes the placenta.
6. Assessment of liquor volume (important
for ECV).

17. DURING PREGNANCY
Inspection
• A transverse
groove may be
seen above the
umbilicus in
sacro-anterior
corresponds to
the neck.
• If the patient is
thin, the head may
be seen as a
localized bulge in
one
hypochondrium
Palpation
• Fundal Grip: The
head is felt as a
smooth, hard,
round ballottable
mass which is often
tender.
• Umbilical Grip: The
back is identified
and a depression
• First pelvic Grip:
The breech is felt
as a smooth, soft
mass continues
with the back. Trial
to do ballottement
to the breech
shows that the
movement is
transmitted to the
whole trunk.
Auscultatio
n
FHS is heard above
the level of the
umbilicus. However
in frank breech it
may be heard at or
below the level of
the umbilicus.
Ultrasonograp
hy
• To confirm the
diagnosis.
• To detect the type of
breech.
• To detect gestational
age and foetal
weight: Different
measures can be
taken to determine
the foetal weight as
the biparietal
diameter with chest
or abdominal
circumference using
a special equation.
• To exclude
hyperextension of
the head.
• To exclude
congenital
anomalies.
• Diagnosis of

18. DURING LABOUR
 The 3 bony landmarks of breech namely 2 ischial tuberosities
and tip of the scarum.
 The feet are felt beside the buttocks in complete breech.
 Fresh meconium may be found on the examining fingers.
 Male genitalia may be felt.

19. MECHANISM OF LABOUR
Delivery of the
buttocks
Shoulders
Head

20. Delivery of Buttocks
• The engagement diameter is the bitrochantric diameter 10 cm which enters the pelvis
in one of the oblique diameters.
• Descent of the buttocks occurs until the anterior buttock touches the pelvic floor.
• Internal rotation of the anterior buttock occurs through 1/8th of a circle placing it behind
the symphysis pubis.
• Further descent with lateral flexion of the trunk occurs until the anterior hip hinges
under the symphysis pubis which is released first followed by the posterior hip.
• Delivery of the trunk and the lower limbs follow.
• Restitution occurs so that the buttocks occupy the original position as during
engagement in oblique diameter.

21. Delivery of Shoulders
• Bisacromial diameter (12 cm or 4 ¾”) engages in the same oblique
diameter as that occupied by the buttocks at the brim soon after the
delivery of breech.
• Descent occurs with internal rotation of the shoulders bringing the
shoulders to lie in the antero-posterior diameter of the pelvic outlet. The
trunk simultaneously rotates externally through 1/8th of a circle.
• Delivery of the posterior shoulder followed by the anterior one is
completed by anterior flexion of the delivered trunk.
• Restitution and external rotation :

22. Delivery of Head
• Engagement occurs either through the opposite oblique diameter as that
occupied by the buttocks or through the transverse diameter. The engaging
diameter of the head is suboccipito-frontal (10 cm).
• Descent with increasing flexion occurs.
• Internal rotation of the occiput occurs anteriorly, through 1/8th or 2/8th of a
circle placing the occiput behind the symphysis pubis.
• Further descent occurs until the sub-occiput hinges under the symphysis pubis.
• The head is born by flexion- The chain, mouth, nose, forehead, vertex and
occiput appearing successively. The expulsion of the head from the pelvic cavity
depends entirely upon the bearing efforts and not at all on uterine contractions.
• Sacro-posterior position: The mechanism is not substantially modified. The head has
to rotate through 3/8th of a circle to bring the occiput behind the symphysis pubis.

23. MATERNAL
FETAL
PROGNOSIS

24. The Fetal Dangers
• Intracranial Haemorrhage
• Asphyxia
• Injuries
Prevention of the Fetal Hazards
• The incidence of breech can be minimized by external
cephalic version where possible.
• If the version fails or is contraindicated, delivery is done
by elective caesarean section.
• A skilled obstetrician along with an organized team
consisting of a skilled anesthetist and an assistant should
conduct vaginal breech delivery.
• Vaginal manipulative delivery should be done by a skilled
person with utmost gentleness, specially during delivery
of the head.

25. Identification of
the complicating
factors
ANTENATAL
MANAGEMEN
T
External
cephalic
version
Formulation
of the line of
management

26. External Cephalic Version
Indications:
Procedure
Preliminaries
Benefits of External Cephalic Version
Causes of failure of version
Dangers of Version
Management, if version fails or is contraindicated

27. ELECTIVE CAESARIAN SECTION
Indications for
caesarian
Big Baby (estimated fetal
weight>3.5 kg)
Hyperextension of the head
Footling presentation (risk of cord
prolapse)
Suspected pelvic contraction
Any obstetrical or medical
complications
During First Stage
Cases seen first time in labour with
presence of complications
Arrest in the progress of labour
Non-reassuring FHR pattern
Cord presentation or prolapse

28. VAGINAL BREECH DELIVERY
Indications for vaginal
breech delivery
Adequate pelvis
Average fetal weight (1.5-3.5 kg)
Flexed head and without any
other complications
Management of Vaginal
Breech Delivery
First Stage
Second Stage

29. ASSISTED BREECH DELIVERY
Preliminaries for conduction
of normal labour
Anaesthetist to administer
anaesthesia as and when
required
An assistant to push down the fundus
during contractions.
Instruments and suture materials
for episiotomy
A pair of obstetric forceps for the
after coming head, if required.
Appliances for revival of the baby, if
asphyxiated
Principles in conduction
Never to rush
Never pull from below but push from
above
Always keep the fetus with the back
anteriorly.

30. Steps
Patient is to be placed in
lithotomy position when the
posterior buttock distends the
perineum.
To avoid aortocaval compression
Antiseptic cleaning
Pudendal block
Episiotomy
Patient is encouraged to bear
down
Soon after the trunk upto the
umbilicus is born
Delivery of the arms
Delivery of the after
coming head
Burn-Marshall method
Forceps delivery
Malar Flexion and
Shoulder traction
(modified Mauriceau-
Smellie- Veit technique)
Resuscitation of the baby
Third Stage
ASSISTED BREECH DELIVERY

31. Delayed in
Descent of
the Breech
MANAGEMENT OF
COMPLICATED
BREECH DELIVERY
Extended
Arms
Arrest of the
After-coming
Head

32. Delayed in Descent of the Breech
Arrested at the Outlet
In the absence of outlet
contraction and feto-pelvic
disproportion
Arrest of the breech at or above
the level of ischial spines
Frank Breech Extraction
(Pinard’s Maneuver)

33. Extended arms is due to faulty technique in delivery using
unnecessary traction, forgetting the principle of ‘never pull but push
from above’
Diagnosis is made by noting the winging of the scapula and absence
of the flexed limbs in front of the chest.
Management :
The management calls for the urgent delivery of the arms, first the
posterior and then the anterior one.
The delivery of the arm may be accomplished by adopting any one of
the following methods:
Classical
Lovset
Extended Arms

34. Arrest of After Coming Head
At the Brim
In the Cavity
At the Outlet
Delivery of the head through an incompletely dilated
cervix
Occipito- posterior position of the head through an
incompletely dilated cervix

35. CONCLUSION:
The incidence of Breech presentation
expected to be low in hospitals where high parity
births are minimal and routine external cephalic
version done in antenatal period. Breech
presentation can be managed by early diagnosis
and effective management strategies. By using
different maneuvers and skillful observation of the
obstetrician.