Breech presentation Lecture pp 5.3.02.pdf

Breech Presentation
Dr Maureen C. Chisembele
Consultant Obstetrician Gynaecologist
Lecturer - Eden University
Academic Head of Department Obstetrics &
Gynaecology - LMMU
Hononary Lecturer - UNZA
BScHB, MBChB, MMED Obs & Gyn (UNZA), MSc
Clinical Trials (LSHTM)

Chisembele 30.1.2023 2
Definition
The foetus lies with its buttocks in the
lower pole of the uterus in a
longitudinal lie.

Incidence
28 weeks: 25%;
Term: 2-3%;
1/3: undiagnosed during labour.

Types of breech
presentations/classification
Extended or Frank Breech (65%) - hips
flexed and legs extended;
Flexed or Complete Breech (25%) - hips and
knees are flexed and the feet are not below the
foetal buttocks;
Footling Breech - where one or both feet are
presenting as the lowest part of the foetus;
Kneeling breech - the knees are the lower
most presenting part.

Types of breech
presentations

Positions
The denominator is the sacrum:
1st position - left sacral anterior (LSA), back
anterior and to the left;
2nd position - right sacral anterior (RSA),
back is anterior and to the right;
3rd position - right sacral posterior (RSP),
back is posterior and to right;
4th position - left sacral posterior (LSP), back
is posterior and to left.

Aetiology/causes
Maternal factors
Preterm delivery;
Uterine anomalies
(bicornuate/septate);
Contracted pelvis;
Pelvic tumours
(fibroids).
Foetal factors
IUFD;
Oligo/polyhydramnios;
Multiple pregnancy;
Foetal anomalies
(hydrocephaly/anencephaly);
Placental anomalies
(praevia/cornual placenta);
Short cord;
Extended legs in the foetus.

Diagnosis
Clinical Examination:-
The foetal head is felt in the fundus as a
round hard ballotable mass;
The back is either on the left or the right as
the lie is longitudinal;
At the pelvic brim a large soft indefinite
mass is felt;
The foetal heart is heard at or above the
level of the umbilicus.

Diagnosis
Investigations:-
Ultrasound will confirm the diagnosis
and also exclude possible causes of the
breech presentation;
X-ray will also be helpful where
ultrasound is not available.

Dangers of a breech
delivery
Risk to the mother:-
Tears of the perineum, vagina, cervix &
uterus;
Dangers of emergency anaesthesia &
emergency C/S should vaginal delivery
fail.

Dangers of a breech
delivery
Risk to the foetus:-
Stillbirths;
Brachial plexus
injuries;
Transection of the
spinal cord;
Fractures;
Sternocleidomastoid
haematoma;
Injury to abdominal
organs;
Interference with
utero-placental
circulation;
Interference with
cord circulation.

Selection for vaginal
breech delivery
Pelvic shape and capacity;
There should be no other obstetric
complications;
Type of breech;
There should be adequate liquor volume &
foetal weight should not exceed 3.5kg, the BPD
should not exceed 9.5cm and there should be
no hyperextension of the foetal neck.

Selection for vaginal
breech delivery
Skilled manpower trained in vaginal
breech delivery and neonatal resuscitation
should be available;
There should be facilities available for
C/S;
Primigravidas may be allowed to
deliver vaginally after careful selection,
taking the above into consideration.

Mechanism of labour in a
breech, LSA
Descent;
Internal rotation;
Lateral flexion of the
body;
External rotation of
the sacrum;
Internal rotation of
the shoulders;
Internal rotation of
the head;
External rotation of
the body;
Birth of the head.

Mechanism of labour in a breech,
LSA cont’d

breech, LSA cont’d
Delivery of the buttocks:
The engaging diameter is the bitrochanteric
diameter 10cm which enters the pelvis in one of the
oblique diameters;
The anterior buttock meets the pelvic floor first and
rotates 1/8th of a circle anteriorly;
The anterior buttock hinges below the symphysis
pubis and the posterior buttock is delivered first by
lateral flexion of the spine followed by the anterior
buttock;
External rotation occurs so that the sacrum comes
anteriorly. 17

Delivery of the shoulders:
The shoulders enter the same oblique
diameter with the biacromial diameter
12cm (between the acromial processes of
the scapulae);
The anterior shoulder meets the pelvic floor
first and rotates 1/8th of a circle anteriorly,
hinges under the pubic symphysis then the
posterior shoulder is delivered first followed
by the anterior shoulder.
18

The head enters the pelvis in the
opposite oblique diameter;
The occiput rotates 1/8th of a circle
anteriorly in case of sacro-anterior
position and 3/8th anteriorly in case of
sacro-posterior position;
Rarely the occiput rotates posteriorly
this should be prevented by the
obstetrician. 19

The head is delivered by the movement
of flexion in:
After coming head in breech presentation;
and others:
Direct occipito-posterior (face to pubes);
Face mento-anterior.

Management of labour
The principles of management are:-
Intelligent observation;
Avoidance of unnecessary interference;
Prompt action, carried out with manual
dexterity;
The avoidance of foetal injury & hypoxia.

The first stage of labour is conducted as
in a vertex presentation;
The foetal heart should be auscultated
before, during and for 15 secs after each
contraction.

A vaginal examination should always be
done immediately after the membranes
rupture to check for cord which may
prolapse;
No pushing should occur until the
buttocks are bulging at the vulva .

Methods of delivering a
breech vaginally
Spontaneous;
Assisted vaginal breech delivery;
Breech extraction.

25
Assisted vaginal breech
delivery
The breech is assisted at certain
stages of the delivery by medical
staff
There cervix should be fully dilated and
there should be uterine contractions;
The breech should be left alone until the
perineum is distended and thinned;
A generous episiotomy should then be
performed.

delivery
Usually the breech delivers
itself with a little help by
unhooking of the limbs if they
are extended (Pinards’
Manoeuvre);
The patient then pushes until
the trunk is born;
The cord is pulled down to
free it from being compressed;
The trunk should not be
pulled down unnecessarily.

delivery - extended hands
No attempt should be
made to deliver an arm
until the scapular and
one axilla are seen;
The Lovsets
Manoeuvre is then
employed to deliver both
arms if they are
extended.

delivery - extended hands

delivery
However, the weight of the buttocks will
bring the shoulders down on to the pelvic
floor, where they will rotate into the A-P
diameter of the outlet.

delivery
The expulsion of the shoulders can be assisted
by downward traction;
The baby is grasped by the iliac crests and
when the anterior shoulder escapes, the
buttocks are elevated to allow the posterior
shoulder and arm to pass over the perineum;
The back must not be turned uppermost until
the shoulders have been born.

delivery
When the nuchal region is seen, delivery
of the head may proceed by various
manoeuvres such as Burns Marshall,
Mauriceau-Smellie-Veit, Prague and
even obstetric forceps (Pipers).

Mauricea-Smellie-Veit
Employed in cases of an extended
head:
The baby lies astride the left arm with
the palm supporting the chest;
The first and third fingers of the left
hand are on the malar bones to flex the
head (some, place the middle finger in the
mouth to aid flexion).

The first two fingers of the right hand
hooked over the shoulders, pull in a
downward direction;
Traction on the shoulders should not be
excessive (can cause Erb's palsy);
Controlled traction is exerted in a downward
direction as the head descends in the curved
birth canal.

Traction is continued in an outward direction
until the suboccipital area appears (if upward
traction is carried out too soon, fracture of the
neck could be inflicted);
Traction is then exerted in an upward direction
to expedite birth of the head;
The nose and mouth are free so the airway is
cleared;
The vault is delivered slowly.

Burn’s Marshall
As soon as the shoulders are born, the
baby is allowed to hang by its own
weight, which brings the head down to
the pelvic floor on which the occiput
rotates forwards;
This encourages the descent and flexion
of the head and allows the head to be
born as far as the nape of the neck.

Burn’s Marshall
When the suboccipital area appears at
the pubic arch, the legs of the baby are
grasped and a firm outward traction is
exerted and the body is lifted towards the
mother's abdomen;
The head is delivered by the movement
of flexion.

Burn’s Marshall
At this time the left hand of the attendant
is used to guard the perineum to prevent
the head being delivered quickly;
As soon as the mouth and nose are free
an assistant sucks out all the mucus from
the airway.

Burn’s Marshall

Prague manoeuver
The back of the foetus fails to rotate to the
anterior;
When the occiput rotates posteriorly and the
head extends, the chin hangs above the
symphysis pubis;
Foetus is grasped from its feet and flexed
towards the mother's abdomen, while the other
hand is doing simultaneous traction on the
shoulders to deliver the head by flexion.
40

Prague manoeuver

Delivery by forceps (Piper)

External Cephalic Version
(ECV)
The foetus is turned to a head
presentation by manipulation
through the mother’s abdominal wall
The presenting part must be free;
The uterus must neither be tense nor
irritable;
There must be sufficient liquor.

(ECV)
The abdominal wall must be thin and
relaxed;
The CTG must be reactive;
The patient must know what you are
doing and should give consent for the
procedure.

(ECV)

(EVC)
Contraindications:-
PIH;
APH;
Previous uterine scar;
Rhesus
Isoimmunization;
Ruptured
membranes;
IUGR;
Multiple pregnancy;
Elderly primigravid;
Foetal Abnormality.

(EVC)
Complications:-
Premature labour;
Placental abruption;
Ruptured uterus;
Foetal distress.
ECV has allowed a reduction of breech
presentation at term from 2-5% to 1-2%.

Caesarean section for
breech presentation
Breech presentation
+ another obstetric
problem;
IUGR;
BPD is large
(>9.5cm) or foetal
weight over 3.5kg;
Footling breech;
Hyperextension of
the foetal head
regardless of the type
of breech;
Multiparas with poor
obstetric history;
H/O infertility;
Primigravids over
35years of age.

breech presentation cont’d
Women should be informed that routine
caesarean section for breech presentation in
spontaneous preterm labour is not
recommended;
The mode of delivery should be individualised
based on the stage of labour, type of breech
presentation, foetal wellbeing and availability of
an operator skilled in vaginal breech delivery.

A trial of labour should be precluded in
the presence of medical or obstetric
complications;
There is insufficient evidence to support
C/S for the delivery of the first and second
twin;
If the second twin is non-vertex, vaginal
delivery is considered safe.

Women should be informed that the evidence is
limited, but that planned caesarean section for a twin
pregnancy where the presenting twin is breech is
recommended;
Routine emergency caesarean section for a breech
first twin in spontaneous labour, however, is not
recommended;
The mode of delivery should be individualised based on
cervical dilatation, station of the presenting part, type of
breech presentation, foetal wellbeing and availability of
an operator skilled in vaginal breech delivery.
51

2017 RCOG guidelines for
management of term breech
Women with a breech presentation at
term should be offered external
cephalic version (ECV) unless there is
an absolute contraindication;
They should be advised on the risks and
benefits of ECV and the implications for
mode of delivery.

management of term breech cont’d
Women should be informed that planned caesarean
section leads to a small reduction in perinatal mortality
compared with planned vaginal breech delivery;
Any decision to perform a caesarean section needs to be
balanced against the potential adverse consequences
that may result from this;
Selection of appropriate pregnancies and skilled
intrapartum care may allow planned vaginal breech birth
to be nearly as safe as planned vaginal cephalic birth.

Women should be informed that planned vaginal
breech birth increases the risk of low Apgar
scores and serious short-term complications, but
has not been shown to increase the risk of long-
term morbidity;
Women should be informed that planned
caesarean section for breech presentation at
term carries a small increase in immediate
complications for the mother compared with
planned vaginal birth.
54

Women should be informed that maternal complications
are least with successful vaginal birth;
Planned caesarean section carries a higher risk, but the
risk is highest with emergency caesarean section
which is needed in approximately 40% of women
planning a vaginal breech birth;
Women should be informed that caesarean section
increases the risk of complications in future
pregnancy, including the risks of opting for vaginal birth
after caesarean section, the increased risk of
complications at repeat caesarean section and the risk
of an abnormally invasive placenta.
55

Where a woman presents with an unplanned
vaginal breech labour, management should
depend on the stage of labour, whether factors
associated with increased complications are
found, availability of appropriate clinical
expertise and informed consent;
Women near or in active second stage of labour
should not be routinely offered caesarean
section.

All maternity units must be able to
provide skilled supervision for vaginal
breech birth where a woman is admitted
in advanced labour and protocols for this
eventuality should be developed.
57
Chisembele 30.1.2023

References
Dewhurst. Postgraduate textbook of Obs
& Gyn. 5th Edition, 1995
Myles M Textbook for Midwives. 9th
Edition, 1981
RCOG Guidelines. Guideline No 20.
Revised April 2017.
Saunders W.B. High Risk Pregnancy,
Management Options. 2nd Edition, 2000.

Breech presentation Lecture pp 5.3.02.pdf

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