Breech presentation and child delivery

1. BREECH
PRESENTATI
ON AND
DELIVERY

2. contents
 Definition
 Types
 Causes and risk factors
 Diagnosis
 Management
 Complications

3. DEFINITION
Breech presentation is a malpresentation whereby the buttock or feet present or
lead the way through the birth canal.
Incidence
3-4% of fetuses present by breech at term
7% at 32 weeks
25% at 28 weeks
2% diagnosed in labour
Therefore, breech presentation is commonly associated with prematurity.

4. Causes and risk factors
 Uterine abnormalities eg, congenital abnormal uterus
 Uterine masses such as uterine fibroid, adenomyosis, placenta
praevia
 Multiple pregnancy
 Prematurity
 Small For Gestation (SFG) babies
 Fetal anomaly
 Grandmultiparity
 Polyhydramnios

5. Types of breech delivery
 Frank –hips flexed and knees extended
 Complete – both hips and knees flexed
 Incomplete/ Footling –knee/s or hip/s partially flexed ( feet or one foot
presents)
FRANK
BEECH
COMPLETE
BREECH
FOOTLING OR INCOMPLETE
BREECH

6. ASSESSMENT OF BREECH PRESENTATIONS
 Sacrum is the denominator in assessing the
fetal Position in breech presentation.
 The most common position is ( left sacral
anterior).
 The bitrochanteric diameter ( the transverse
diameter between the great trochanters of
the fetus) presents and measures 10cm.
LSA
position

7. mechanism
Descent and
engagement at a
bitrochantric diameter
Internal rotation at 45 degrees
bringing the anterior hip to the pubic
arch ( bitrochanteric diameter at an
anteroposterior diameter.
Anterior hip appears at
the vulva, followed by
posterior hip after
lateral flexion of the
body.
Delivery of legs and feet.
Slight external
rotation – back
turns in anteriorly
Shoulders rotate to
a bi-acromial
diameter

8. HEAD IS THEN BORN IN FLEXION

9. Diagnosis
 Presentation feels soft and irregular or buttock or feet palpable during
vaginal examination
 Longitudinal lie
 Hard round ballotable head felt at the fundus or upper abdomen
 Fetal heart audible higher up the abdomen ( above the umbilicus)
 Feet prolapsed at the vulva
 USS at the hospital
 Soft presentation with irregular edges.

10. Management
 ECV ( External Cephalic Version ) at 37 weeks or more.
 Vaginal breech delivery
 Caeserean section

11.  ECV should be offered at term pregnancy
 Success rate increased with:
 multiparity
 adequate liquor
 station of breech above the pelvic brim

12. METHODS OF BREECH DELIVERY
Vaginal breech delivery is accomplished by one of three methods.
1. Spontaneous breech delivery, the fetus is expelled entirely without
any traction or manipulation other than support of the newborn.
2. Partial ( or assisted ) breech delivery, the fetus is delivered
spontaneously as far as the umbilicus, but the remainder of the
body is delivered by provider traction and assisted maneuvers, with
or without maternal expulsive efforts.
3. Total breech extraction, the entire fetal body is extracted by the
provider.

13. VAGINAL DELIVERY
Cervix fully dilated with fetal
anus visible at the vulva.
Put the woman in a lithotomy
position

14. Breech Delivery
Delivery of the breech should be
‘hands off’
Legs and abdomen are born
spontaneously.

15. Breech Delivery
Ensure that the fetal back
rotates uppermost by
carefully grasping the fetal
pelvis with fingers & thumbs.
Leg delivery may need knee
flexion by pressure in
popliteal fossa

16. Breech Delivery
The fetus should be allowed to
hang once the legs and
abdomen have emerged until
the wings of the scapula are
seen.

17. Lovset’s Manoeuvre
Grasp the fetus around the bony
pelvis with the thumbs across
the sacrum.
The fetal back should then be
turned through 180 degrees until
the posterior arm comes to lie
anteriorly…….

18. Lovset’s Manoeuvre
The elbow will appear below
the symphysis pubis and the
arm is delivered by sweeping
it across the fetal body.
The manoeuvre is repeated in
reverse to deliver the other
arm.

19. Breech Delivery
Allow the fetus to hang from
the vulva until the nape of
the neck is visible.
Then carry out Mauriceau-
Smellie-Veit maneuver

20. Management
 No action until 37-38 weeks of gestation
 Exclude fetal anomalies
 Placenta previae
 Multiple pregnancy
 Offer external cephalic version (ECV)
Should not be attempted if there are risks

21. Delivery
 Assisted Vaginal Breech delivery
 Elective Caesarean Section (CS)
 Emergency CS
 Selection for vaginal delivery
 Average fetal weight not more than 3.5kg
 Normal pregnancy
 No growth restriction
 Willing parents
 Experienced staff, Midwife, Obstet, neonatologist,
anesthetist

22. Assisted vaginal breech delivery
 Close supervision
 Epidural analgesia
 Progress of labour
Second stage of labour, can be dangerous
Observe for delivery of the breech,
Hands off
 Help is needed if the arms are extended above the head
 Lovset’s maneuver to deliver the arms and shoulders
 Delivery of head, forceps or head traction jaw flexion
 Mauriceau Smellie Veit maneuver to deliver the entrapped head.

23. Mauriceau- smellie veit manouvre

24. Caesarean section (C/S)
 C.Section should be done in the presence of
 BIG baby
 Bad obstetric history
 High risk woman
 Previous c.section
 The woman refuses to have breech vaginal birth
 • Footling breech – the riskiest breech (after Coming head often gets stuck!)
 Studies have proven that C/S is the safest method of delivery in breech
presentations and is also associated with less risk of urinary incontinence.

25. complications
 Fetal complications
1. Intracranial injury
2. With the head descending fast through the
birth canal during labour, this results in rapid
compression and decompression leading to
intracranial injury.
3. Ashpyxia if delivery delayed
4. Traumatic injury. –fractures humerus,
clavicle,femur
5. Apneoa –the placenta separates in the second
stage while the head is in the pelvis which may
lead to airway obstruction from blood loss
following placental separation.
MATERNAL
COMPLICATIONS
1. Cord prolapse - due to
an ill-fitting presenting
part
2. Perineal tears,