malpresentation

1. BREECH PRESENTATION
Breech presentation is one in which the lie is longitudinal and
the podalic pole presents at the pelvic brim. It is the most
common malpresentation.

2. Incidence
Gestatainal age in weeks Percentage
28 20
34 5
term 3-4
The higher incidence of breech in earlier weeks of pregnancy

3. Types: COMPLETE BREECH PRESENTATION
• More common type - 25%
• More common in multipara women
• Attitude is full flexion
• Thigh are flexed on the abdomen and the legs are flexed at the knees.
• The presenting part is buttocks, external genitalia and feet .

4. INCOMPLETE BREECH PRESENTATION
It is of three types depending of degree of extension of thighs or legs
I. FRANK BREECH
• Attitude flexed
• Thigh flexed on the trunk
• Legs Extended on the knee Joint.
• Presenting part is buttocks and external genitalia .
• More common in primigravida about 70 % due to tight abdominal wall

6. Contd. INCOMPLETE BREECH PRESENTATION
• ii. FOOTLING BREECH (10-30%)
• Both the thigh and legs are partially extended bringing
• the legs to present at the brim.

7. Contd. INCOMPLETE BREECH PRESENTATION
iii.. KNEE PRESENTATION
• Thigh are extended but the knees are flexed bringing
the knees down to the brim

8. Clinical varieties:
According to the dangers associated, breech presentation is clinically classified as:
1. Uncomplicated- It is defined as one where there is no other associated obstetric
complications apart from the breech
2. Complicated- When the presentation is associated with conditions which
adversely influence the prognosis such as prematurity, twins, contracted pelvis,
placenta previa, etc. It is called complicated breech.
Extended legs or arms, cord prolapse or difficulties countered during breech
delivery are called complicated or abnormal breech delivery nit as complicated

9. Etiology
• Prematurity: It is the most common cause of breech presentation.
• Factors preventing spontaneous version:
(a) Breech with extended legs
(b) Twins
(c) Oligohydramnios
(d) Congenital malformation of the uterus such as septate or bicornuate uterus
(e) Short cord - relative or absolute
(f) Intrauterine death of the fetus.

10. Favorable adaptation:
(a) Hydrocephalus-big head can be well accommodated in the wide fundus,
(b) Placenta previa,
(c) Contracted pelvis,
(d) Cornu-fundal attachment of the placenta-minimizes the space of the
fundus where the smaller head can be placed comfortably.

11. Contd. etiology
• Undue mobility of the fetus:
(a) Hydramnios
(b) Multiparae with lax abdominal wall
• Fetal abnormality:
• Trisomies 13, 18, 21
• anencephaly
• myotonic dystrophy of fetus alter the muscular tone and mobility

12. Prematurity: Factors preventing
spontaneous version:
Favorable adaptation Undue mobility of the
fetus
Fetal abnormality
most common
cause of breech
presentation.
• Breech with extended
legs
• Twins
• Oligohydramnios
• Congenital
malformation of the
uterus - septate or
bicornuate uterus
• Short cord
• Intrauterine death of the
fetus.
• Hydrocephalus
• Placenta previa,
• Contracted pelvis,
• Cornu-fundal
attachment of the
placenta
• Polyhydramnios
• Multiparae with lax
abdominal wall
• Fetal abnormality:
• Trisomies 13, 18, 21
• Anencephaly
• Myotonic dystrophy
of fetus

13. Etiology
Maternal factors Fetal factors Placenta/ fluidl or cord
factors
Multiparity Prematurity Placenta Previa
Uterine
Abnormalities-
Bicornate septate
uterus, uterine
fibroid
Macrosomia
Fetal Anomalies -
Hydrocephalus ,
Anencephaly, myotonic
dystrophy
Oligohydramnios or
Polyhydramnios
Contracted Pelvis Twin pregnancy Short cord
Multiple pregnancy Intrauterine fetal death
Extended legs

14. Diagnosis
Abdominal examination- Palpation and auscultation
Vaginal examination
USG
X- ray

15. Abdominal examination
Complete breech Frank breech
Fundal grip Hard globular mass suggestive of
fetal head.
Head is non ballotable
In addition to head, small parts may
be felt.
Head is non ballotable due to
splinting action of fetal limbs
Lateral grip Fetal back on one side and small
irregular parts (fetal limbs) on
other side
Less irregular parts (fetal limbs) are
felt
Pelvic Grip Broad soft irregular mass is felt
Usually not engaged
Small hard conical mass is felt
Usually engaged
Auscultation of Fetal
heart sound
Usually located higher, around
umblicus
Usually located lower and in midline
due to early engagement of breech

16. Abdominal examination

17. Vaginal examination
Conplete breech Frank breech
During pregnancy Soft irregular parts are felt through
vaginal fornix
Hard feel of sacrum through vaginal fornix
During Labor Ischial tuberosities, sacrum and feet Ischial tuberosities, anal opening and
sacrum in one line. In addition there may
be meconium staining of finger on
examination

18. Position of breech presentation

19. Mechanism of labor in breech presentation
• Lie is longitudinal
• Attitude is of complete flexion
• Presentation breech
• Position is left sacroanterior
• Denominator is sacrum
• Presenting part is anterior buttock [left in LSA]
• Engaging diameter is bi-trochantric diameter (10 cm)
• Principal movements occur at three places buttocks, shoulders and head

20. Delivery of buttocks
• Engagement occur in one of the oblique diameter of the inlet. The
engaging diameter is bi-trochanteric (10 cm or 4") with the sacrum directed
toward the iliopubic eminence.
• Descent occurs until the anterior buttock touches the pelvic floor.
• Internal rotation of the anterior buttock occurs through1/8th 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
Engagement occur in bisacromial diameter (12 cm) in the same oblique
diameter as that occupied by the buttocks, soon after the delivery of the
breech.
Descent occurs with internal rotation of the shoulders, bringing the
shoulders to lie in the anteroposterior 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: Untwisting of the trunk occurs
putting the anterior shoulder toward the right thigh in LSA and left thigh
in RSA. External rotation of the shoulders occurs to the same direction
because of internal rotation of the occiput through 1/8th of a circle
anteriorly and fetal trunk is now positioned as dorso anterior.

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 suboccipitofrontal (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 subocciput hinges under symphysis
pubis.
Head is born by flexion-chin, mouth, nose, forehead, vertex and
occiput appearing successively. The expulsion of the head from the
pelvic cavity depends entirely upon the bearing-down efforts.

23. Complication of vaginal breech delivery
• Maternal
1. Trauma to genital tract
2. Increased frequency of operative delivery- episiotomy, forceps and
cesarean leading to sepsis and anesthesia related complications

24. Fetal complications
Intrapartum fetal death
Injury to brain and skull-
 Intracranial hemorrhage from compression followed by decompression during
delivery of the unmolded aftercoming head. Risk is more with preterm babies
 Fracture of the skull
Birth asphyxia: It is due to
 Cord compression from aftercoming head / Cord prolapse
 Retraction of the placental site
 Premature attempt of respiration (aspiration of amniotic / vaginal fluid) while the
head is still inside
 Delayed delivery of the head / Prolonged labor

25. Contd…
Birth injuries (7%): usually found in manipulative deliveries.
 Hematoma-over the sternomastoid or over thighs.
 Fractures of femur, humerus clavicle and dislocation of the hip joint etc
 Visceral injuries - rupture of the liver, kidney, lungs and hemorrhage
 Nerve injuries- spinal cord injury, stretching of the cervical and brachial
plexus to cause either Erb's or Klumpke's palsy
 Long-term neurological damage.
Congenital malformations are doubled compared to babies with cephalic
presentation Congenital dislocation of the hip, hydrocephalus and anencephaly
are common.

27. Management
• Antenatal management- external cephalic version
• Elective cesarean section
• Assisted vaginal delivery

28. Antenatal Management
• Identify complicating factors by sonography
• External cephalic version –
Version- It is changing the transverse lie to a longitudinal
one or replacement the presenting pole by the other. If the
aim is to make the head the presenting part it is called
cephalic version and if the breech will be the presenting part
it is podalic version. It can be internal or external. External
cephalic version is done at 36-37 weeks.
Indication - breech presentation and transverse lie
Advantages - reduction in the incidence of breech presentation and
breech delivery at term, reduces need of LSCS , reduction in maternal
and fetal mortality.

29. Contraindication of ECV
• Antepartum haemorrhage ,
• Fetal factors - big baby, congenital malformations, dead fetus,
IUGR
• Multiple pregnancy
• Ruptured membrane
• Contracted pelvic ,obstetric complication
• Congenital malformations of uterus
• Abnormal cardio tocography
• Previous caesarean delivery
• Rh incompatibility
• Obstetric complications- severe preeclampsia, elderly primi, bad
obstetric history etc

30. Prerequisites
Evacuation of the bladder
Complete aseptic conditions
Cervix is fully dilated
Uterus is not tonically contracted
No previous uterine scar
Adequate liquor amnii (intact or recently ruptured
membranes)
No obstruction to vaginal delivery whether maternal as
contracted pelvis or fetal as hydrocephalus.

31. EXTERNAL CEPHALIC VERSION-
• Indications - Breech presentation and Transverse or
oblique lie
Procedure
General anaesthesia to guard against pain and give uterine
and pelvic relaxation
The patient evacuates her bladder.
She lies in a Trendelenburg position with exposed vulva to
detect any vaginal bleeding.
The fetal position is determined and FHS is auscultated.

32. Contd….
One hand is applied externally to the fetal head and the
other on its buttock, the two poles are approximated to flex
the fetus and rotation is done by the two hands
simultaneously to bring the head lower down.
The FHS is auscultated again, if there is fetal distress lasting
for more than 5 minutes, the fetus is returned back to its
previous position as the cord might be coiled or entangled
around the neck.
If neither vaginal bleeding nor fetal distress results, an
abdominal binder is applied to fix the new position and re-
examined twice weekly. If the original presentation returned
again, the procedure of version can be repeated.
version, pulled through the cervix while the other hand is assisting the version externally.<br
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33. Complication of ECV
• Umbilical cord entanglement
• placenta abruption
• preterm labor
• premature rupture of membranes
• rupture of uterus
• Feto-maternal bleed and Rh isoimmunization

34. Elective Cesarean Section
In which the operation is pre arranged time during pregnancy.
Indications are-
• Big baby (>3.5 kg) or small baby (<1.5 kg)
• Fetal distress
• Hyperextended head
• Footling presentation
• IUGR
• Contracted pelvis
• Any associated obstetric or medical complications

35. Assisted vaginal breech delivery-
management
• INDICATION - Average fetal weight, flexed fetal head, adequate
pelvis, without any medical or obstetrical complication
(uncomplicated breech)
MANAGEMET OF FIRST STAGE
• Vaginal examination at onset of labor and soon after rupture of
membranes
• Check vital sign
• Monitor FHS and progress of labor
• Empty bladder

36. contd…
• Start IV Fluid (RL)
• Blood grouping and cross matching
• Analgesics if required
• Oxytocin infusion for augmentation of labor if needed

37. Management of second stage
• Spontaneous vaginal delivery (10%): No manipulation of fetus is
required other than supporting the fetus. This is not preferred.
• Assisted breech: The delivery of the fetus till umbilicus is
spontaneous, after that various methods are used to assist delivery of
rest of the fetus. This method should be employed in all cases.
• Breech extraction (partial or total): When part or the entire body of
the fetus is extracted by the obstetrician. This is done only in cases
when fetal distress is present and caserean is not possible of when
fetus is dead

38. Assisted breech
• Prerequisites:
It should be conducted by a skilled obstetrician. The following are to be kept ready
beforehand :
(1) Anesthetist to administer anesthesia as and when required
(2) An assistant to push down the fundus during contraction
(3) Instruments and suture materials for episiotomy
(4) A pair of obstetric forceps for the aftercoming head, if required
(5) Articles for resuscitation of baby
(6) Neonatologist
(7) Facilities for caserean available

39. Principles of conduction of assisted vaginal breech delivery:
• Never to rush
• Never to pull from below, but push from above
• Always keep the fetal back anteriorly

40. Conduction of assisted breech delivery
• The patient is brought to the table when the anterior buttock and fetal
anus are visible.
• She is placed in lithotomy position when the posterior buttock distends
the perineum.
• To avoid aortocaval compression, the woman is tilted laterally using a
wedge under the back.
• Antiseptic cleaning of perineum is done.
• Bladder is emptied with an "in and out" catheter (K-90).

41. • Pudendal block is done along with perineal infiltration if no epidural has been
used.
• Episiotomy is done to facilitate intravaginal manipulation, for use of forceps and
to minimize compression of the aftercoming head. Women is encouraged to bear
down to maintain flexion of head and aid in descent.
• “No touch policy till buttocks are delivered and trunk slips up to umbilicus.
• Presence of meconium or meconium-stained amniotic fluid is common during
breech delivery and is not necessarily a sign of foetal distress
• Once the umbilicus is out, the rest of the delivery must be completed within 3
minutes, otherwise compression of the cord will deprive the infant of oxygen.
Do not touch the infant until the shoulder blades appear to avoid triggering the
respiratory reflex before the head is delivered.
– Monitor the position of the infant's back; impede rotation into posterior position.

42. Contd…
• Now extended legs (in frank breech) are decomposed by pressure on
the knees (popliteal fossa) in a manner of abduction and flexion of the
thighs. The umbilical cord is moved to one side of the sacral bay to
minimize compression. If the back remains posteriorly, rotate the
trunk to bring the back anteriorly. The baby is wrapped with a sterile
towel to prevent slipping when held by the hands and to facilitate
manipulation, if required.

43. • Delivery of the arms: The assistant is asked to place a hand over the
fundus and keep a steady pressure during uterine contractions to
prevent extension of the arms. Soon, the anterior scapula is visible.
The position of the arm should be noted. If the vertebral border of the
scapula remains parallel to the vertebral column then arms are flexed
and if there is winging of the scapula (parallelism is lost) arms are
extended. The arms are delivered one after the other only when one
axilla is visible, by simply hooking down each elbow with a finger.

44. Delivery of aftercoming head
Most crucial stage of delivery. There are three methods commonly used.
A. Burns Marshall method-
• Allow baby to hang by its weight. An assistant puts downward, backward
suprapubic pressure to
promote flexion of head.
• When nape of neck is visible under pubic arch grasp
the fetus with finger of right hand in between ankles and
swing the trunk in upward, forward motion till mouth is
cleared off the vulva, simultaneously guarding vulva with left
hand.
Now depress the trunk to deliver the rest of the head.

46. • B. Forceps delivery:
The head must be in the cavity. With forceps delivery can be
controlled by giving pull directly on the head and the force is not
transmitted through the neck.
The head should be brought as low down as possible by allowing the
baby to hang by its own weight and supra pubic pressure. When the
occiput lies against the back of the symphysis pubis, an assistant
raises the legs of the child to facilitate introduction of the blades from
below. Piper forceps is especially designed (absent pelvic curve) for
use in this condition. The head should be delivered slowly (over 1
minute) to reduce sudden compression decompression leading to
intracranial hemorrhage.

47. Forceps delivery

48. C. Malar flexion and Shoulder traction ( Mauriceau smellie veit
technique)
• Baby is placed on supinated left hand with limbs hanging on both sides.
Middle and index fingers of left hand are placed on malar bones to maintain
head flexion.
• Pronated right hand is placed on fetal back with ring and little finger on
right shoulder, index finger on left shoulder and middle finger at sub
occiput.
• Downward ,backward traction is given till nape of neck is visible under
pubic arch.

49. • Thereafter, the fetus is carried in upward and forward direction toward
the mother's abdomen releasing the face, brow. Now the trunk is
depressed to release the occiput and vertex.
• Resuscitation of the baby: The baby may be asphyxiated and need to
be resuscitated.

50. Management of third stage of labor
• The placenta is usually expelled out soon after delivery of the head .
• •If Ergometrine / oxytocin is to be given, it should be administered
IV with crowning of the head.
Management of forth stage of labor
• Emotional support
• Rest, sleep and ambulation
• Care of bowel and bladder
• Care of vulva and episiotomy wound and antisepsis
• Care of breast and Diet

51. Complicated breech delivery
• Three problems commonly encountered are-
• Delay in descent of the breech
• Extended arms
• Arrest of aftercoming head

52. Delay in descent of the breech
• At outlet
Causes Management
Contraction at outlet Caserean section
big baby with extended legs Caserean section
Rigid perineum and Weak uterine
contraction
Libera episiotomy , fundal pressure with or
without groin traction

53. Delay in descent of the breech
• In the cavity.
• Pinard's maneuver -is done by intrauterine manipulation or
decomposition of breech to convert a frank breech to a footling breech.
In this maneuver, middle and index fingers are carried up to the
popliteal fossa. It is then pressed and abducted so that the fetal leg is
flexed. The fetal foot is then grasped at the ankle and breech extraction
is accomplished.
Pelvic contraction, big baby, weak uterine contraction Caserean section
If labor has progressed, cervix is fully dilated and breech has
descended till perineum
Trial of breech

55. Extended arms
One or both the arms may be stretched along the side of the head or lie behind the neck (nuchal displacement).
Causes- faulty technique in delivery, use of unnecessary traction, forgetting the principle of 'never pull but push from above’.
Diagnosis – winging of scapula
Management- delivery of arms by classical or Lovset’s maneuver
LOVSET'S MANEUVER: It is preferred over classical method due to its wider applicability, almost nil Intrauterine
manipulation, no need of general anesthesia and a single manipulation is effective to all types of displacement of the arms.
Principles: Because of the curved birth canal, when the anterior shoulder remains above the symphysis pubis, the posterior
shoulder will be below the sacral promontory. If the fetal trunk is rotated keeping the back anterior and maintaining a
downward traction, the posterior shoulder will appear below the symphysis pubis.
Procedure: The baby (wrapped in a warm dry towel) is grasped, using both hands by Malposition, and trunk is rotated in the
reverse direction keeping the back anterior to deliver the erstwhile anterior shoulder under the symphysis pubis

56. Arrest of aftercoming head
At the brim: In the cavity: At the outlet
Causes of arrest are-
• deflexed head
• contracted pelvis
• Hydrocephalus
Management-
• If head is deflexed head -
malar flexion and shoulder
traction
• If pelvis is contracted or
hydrocephalus -
perforation of head
Causes of arrest are –
• deflexed head
• contracted pelvis
Management-
• Forceps delivery is effective in
both the cases.
• Malar flexion and shoulder
traction may be effective only
in deflexed head.
Causes of arrest are-
• rigid perineum
• deflexed head
Management-
• Episiotomy and forceps
application in rigid perineum
• Malar flexion and shoulder
traction in deflexed head.