3. Incidence
• Thus in 3 out of 4, spontaneous correction into vertex
presentation occurs at 34th week.
• The incidence is low in hospitals where high parity births are
minimal and routine cephalic version is done in antenatal
period.
5. Complete ( Flexed breech )
• flexed at hips and flexed at
knees.
• the presenting part consists
of two buttocks, external
genitalia and two feet.
• it’s commonly present in
multiparae(10%).
6. Frank breech ( breech with
extended legs )
• the thighs are flexed on the
trunk and the legs are
extended at the knee joints.
• the presenting part consists of
two buttocks and external
genitalia only.
• commonly present in
primigravidae (70%); due to
tight abdominal wall, good
uterine tone and early
engagement of breech.
7. Etiology
• Smaller size of fetus and comparatively larger volume
of amniotic fluid allow the fetus to undergo
spontaneous version by kicking movements until by
36th week when the position becomes stabilized.
• Known factors responsible for breech presentation:
»Prematurity
»Factors preventing spontaneous version
»Favorable adaptation
»Undue mobility of fetus
»Fetal abnormality
8. • Prematurity: commonest cause of breech
presentation.
• Factors preventing spontaneous version:
a) breech with extended legs
b) Twins
c) Oligohydramnios
d) Congenital malformation of uterus like
septate or bicornuate uterus
e) Short cord; relative or absolute
f) Intrauterine death of fetus
9. • Favourable adaptation:
a) Hydrocephalus; big head can be well
accommodated in wide fundus
b) Placenta praevia
c) Constricted pelvis
d) Cornufundal attachment of placenta; minimizes
the space of fundus where smaller head can be
placed comfortably.
• Undue mobility of foetus:
a) Hydramnios
b) Multiparae with lax abdominal wall
10. Diagnosis
ABDOMINAL EXAMINATION
• No head is felt at the lower end and a hard,
rounded knob is ballottable at the upper end
of the uterus.
VAGINAL EXAMINATION
• Confirms there is no head in the pelvis.
INVESTIGATIONS
• Ultrasound scan confirms the situation.
11. Clinical Varieties
Uncomplicated Breech
• defined as one where there
is no other associated
obstetric complications
apart from breech,
prematurity being excluded
Complicated Breech
• when presentation is associated
with conditions which adversely
influence prognosis such as
prematurity, twins, contracted
pelvis, placental praevia etc.
• Extended legs, extended arms,
cord prolapse or difficulty during
breech delivery should not be
called complicated breech but are
called abnormal or complicated
breech delivery.
12. Management of a breech presentation
in pregnancy
1. From about 37 weeks onwards external
cephalic version (ECV) is worth trying.
• External cephalic version is a process by which a
breech baby can sometimes be turned from
buttocks or foot first to head first. It is usually
performed after about 37 weeks. It is often
reserved for late pregnancy because breech
presentation greatly decreases with every week
13. ECV
• If it works, the woman should be seen weekly to
ensure the fetus stays as a cephalic presentation.
• If it fails, the woman should be counseled about
the route of delivery.
• Version is performed using external manual
pressure to lift the presenting part out of the
pelvis and then turning the fetus around to a
cephalic presentation.
• Success rate 40-80%. Depends on cases and
obstetrician skills
14. ECV Procedure
• Place woman in semi-
lateral position
• Use a powder to allow
free movement of
hands and get a firm
grip
• Administer salbutamol
200 micrograms IV to
relax the uterus
15. ECV
• Confirm fetal wellbeing
whether ECV was
successful or not
• By doing a non-stress
cardiotocographic test
• If the mother’s blood
group is RH neg: 100
micrograms anti-D IG
serum must be given
after attempting ECV
16. Risks
ECV complications:
• Rupture of membranes
• Abruptio placentae
• Tightening of loop of
umbilical cord
• Feto-maternal hemorrhage
• Ruptured uterus (rare)
Contraindications to doing ECV
• Pregnancy < 37 weeks
• Rupture of Membranes
• Antepartum hemorrhage
• Multiple pregnancy
• Other Indication for C/S
• HIV seropositivity
Relative Contraindications
• Previous C/S
• Suspicion of placenta
insufficiency
• HT disorder in pregnancy
18. Vaginal Breech Delivery
• In a breech delivery, the head (the largest part of the fetus)
is coming last and it is too late to wait and see if this fits the
pelvis. Therefore an estimate of the chances of delivery has
to be made on the ultrasound measurements.
• It is wise to deliver most breech presentations by 41 weeks.
If the woman has not gone into spontaneous labour before
this time then induce or do an elective Caesarean section.
• If there is any other variation from normal, many
obstetricians will deliver a breech presenting baby by
elective Caesarean section at 38–39 weeks.
19. Conducting a Breech Delivery:
Precautions
• Labour to be conducted in a hospital with C/S facilities
• IV infusions must be set up with large bore cannulas
• Continuous electronic fetal monitoring
• Epidural anaesthesia may be beneficial
• Latent phase not to exceed 8 hours
• Partogram-monitored labour progress not to be less
than 1cm/hour of cervical dilatation in the active phase
• Oxytocin Augmentation is not allowed
• An experienced midwife or Obstetrician must be
available
20. • C/S preferred mode of delivery
• Some women may present in 2nd stage, when
it may be too late to do a C/S
• Lithotomy position is preferred
• Others
21. Management of a breech presentation
in labour
FIRST STAGE
1. Increased risk of early rupture of the
membranes. When they do a vaginal
examination should exclude a prolapse of the
cord.
2. An epidural anaesthetic is a good method of
pain relief as the normal delivery can rapidly
be changed to an operative one if necessary
(but is not mandatory).
22. Second Stage
1. Delivery is by the most senior obstetrician or midwife available
with an anaesthetist and a paediatrician close to the labour ward.
2. A propped up dorsal position of the mother is the easiest to
manage. The labour bed should be capable of breaking in the
middle for delivery of the baby’s body, so that the mother can
assume a lithotomy position.
3. The buttocks progress down the birth canal and, when on the
point of crowning, an episiotomy may be required. The baby is
rotated to sacroanterior. Chin to Pubis delivery should be avoided
at all costs.
4. The baby will often progress as far as the umbilicus with the
mother’s own expulsive efforts. The legs are assisted down,
especially if extended.
5. Commonly, the arms are flexed across the chest and so delivery
occurs readily with the next contraction.
23. If the arms are extended they have to be manipulated down.
After delivery of the body, it is allowed to hang and traction may be
gently applied to the legs until the suboccipital region appears
under the maternal pubis.
The head is delivered slowly by placing one finger in the baby’s
mouth or gently flexing the head with forceps, the blades applied to
either side of the fetal head from the front of the body which is
held up by an assistant. The rest of the head is slowly delivered, not
allowing any sudden decompression which could result in pressure
alterations inside the skull and so cause intracerebral venous
bleeding.
The head should not be allowed to pop out as sudden
decompression of the skull may cause intracranial injuries.
24. Maneuvers to assist delivery of the
fetal head
• Several methods have been described to
primarily prevent the head from popping out
of the vaginal canal.
Mauriceau-Smellie Veit method
Burns-Marshall method
Forceps delivery
Loveset maneuver
26. Third stage
• Syntometrine is given with the delivery of the
head for there is an increased risk of PPH.
• The placenta is delivered as described in
normal labour.
27. Risks to the fetus of breech delivery
• Intracranial damage
• Hypoxia at the time of delivery (too slow
delivery of the head).
• Cord Prolapse (poorly fitting presenting part)
• Physical injury (obstetric maneuvers)
28. References
• Diana Hamilton, 2004. Obstetrics and
Gynaecology Lecture Notes. Second edition.
Blackwell Publishing Inc
• Cronje H.S, Cilliers J, Pretorius M, 2011.
Clinical Obstetrics, a South African
perspective. Van Schaik Publishers Inc
Editor's Notes
The development of anti-D antibodies generally results from feto-maternal haemorrhage (FMH) occurring in rhesus D (RhD)-negative women who carry an RhD-positive fetus.
