Obestric and Gynecological Nursing topic

2. BREECH
PRESENTATION
PRESENTED BY:
Diksha Jinde
M.Sc. (N) 1st Yr

3. Introduction

4. •A breech birth is the birth of a baby
from breech presentation, in which the
baby exists the pelvis with the
buttocks or feet first as opposed to the
normal head- first presentation.

5. •In breech presentation, fetal heart
sounds are heard just above the
umbilicus. In a breech presentation,
the lie is longitudinal and the poddalic
pole presents at the pelvic brim. It is
the commonest malpresentation.

6. Definition

7. •The presentation that the fetus is
in longitudinal lie and the podalic
pole presents at pelvic brim.

8. Incidence:

9. • 20% at 28th week
• Drops to 5% at 34th week
• 3-4% at term
• Thus 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

10. Types

12. Complete Breech (Flexed breech)
•Flexed at hips and flexed at knees
•The presenting part consists of two
external genitalia and two feet.
•It’s commonly present in multipara

13. •Incomplete Breech
•Due to varying degree of extension of
thighs or legs at podalic pole
•3 possible varieties:
1) Frank breech (breech with extended
legs)
2) Footling presentation(25%)
3) Knee presentation.

14. 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

15. Footling Presentation(25%)
•Both the thighs and legs are partially
extended bringing legs to present at
brim.
Knee Presentation
•Thighs are extended but knees are
flexed, bringing the knees down to
present at the brim.

16. Clinical Varieties

17. Uncomplicated Breech
• Defined as one where there is no other
associated obstetric complication apart
from breech, prematurity being excluded.

18. Complicated Breech
• When presentation is associated with
conditions which adversely influence
prognosis such as prematurity, twins,
contracted pelvis, placental previa, etc.

19. Etiology

21. I) Prematurity: Commonest cause of
breech presentation.
II) Factors preventing spontaneous
version :
• a) Breech with extended legs
• b) Twins
• c) Oligohydromnios
• d) Congenital malformation of uterus
• e) Short cord
• f) Intrauterine death of foetus

22. III) Favourable adaptation:
• Hydrocephalous; big head can be well
accommodated in wide fundus
• Placenta previa
• Contracted pelvis
• Corn fundal attachment of placenta;
minimizes the space of fundus where
smaller head can be placed comfortably.

23. IV) Undue mobility of foetus:
• Hydramnios
• Multiparae with lax abdominal wall
V)Foetal abnormality:
a) Trisomy’s 13,18, 21
b) Anencephaly
c) Myotonic dystrophy due to alteration of
foetal muscular tone and mobility.

25. A)Clinical
i) Per abdomen
a. Fundal Grip
• Complete Breech: Head suggested by hard
and globular mass, Head is ballotable
• Frank breech: Head , Irregular small parts
of the feet may be felt by the side of the
head , Head is non- ballotable due to
splinting action of the legs on the trunk.

26. b. Lateral grip
• Complete Breech: Fetal back is to one side
and the irregular limbs to the other
• Frank Breech: Irregular parts are less felt
on the side
c. Pelvic Grip
• Complete Breech: Breech suggested by
soft, broad and irregular mass, Breech is
usually not engaged during pregnancy
• Frank Breech: Small, hard and a conical
mass is felt, The breech is usually engaged.

27. d) Foetal heart rate
•Complete Breech: Usually located at a
higher level round about the umbilicus
•Frank Breech: Located at a lower
level in the midline due to early
engagement of the breech

28. ii) Per Vaginal
a) During Pregnancy
• Complete breech: Soft and irregular parts are felt
through the fornix.
• Frank Breech: Hard feel of the sacrum is felt,
often mistaken for the head.
b)During labour
• Complete Breech: Palpation of ischial tuberosity,
sacrum and feet by the sides of the buttocks.
• Frank Breech: Palpation of ischial tuberosity,
anal opening & sacrum only.

29. b) Sonography
• Confirms the clinical diagnosis
• Detect fetal congenital abnormality and
also congenital anomalies of the uterus.
• Type of breech
• It measures biparital diameter, gestational
age and estimated weight of the fetus.
• Localizes the placenta.
• Assessment of liquor volume
• Attitude the head

30. Management of
Breech
Presentation

31. •Management during pregnancy
•After 36 weeks
Spontaneous version
External cephalic version
•If persisted till 34 weeks . Then
ultrasound scan to exclude;
abnormality, Polyhydramnios,
placenta previa.
•By completed 37 weeks External
cephalic version.

32. External cephalic version
• The right hand lifts the breech out of the
pelvis. The left hand makes the head
follow the nose. Flexion of head and back
is maintained throughout.
• Flexion is continued. The left hand brings
the head downwards. The right hand
pushes the breech upwards.
• Pressure is exerted on head and breech
simultaneously until the head is lying at the
pelvic brim.

34. Complications :
•Knotting of the umbilical cord
•Separation of placenta
•Rupture of the membranes

35. Contraindications:
•Pre- eclampsia
•Multiple pregnancy
•Oligohydramnios
•Ruptured membrane

36. II) Management during
labour
• First stage during the first stage of labour,
the midwife should make all the usual
observation.
• Vaginal examination should be done as
soon as the membranes rupture.
• Preparation for delivery
• Second Stage when the breech is
distending the perineum, the patient should
be given position.

37. • Delivery of the buttocks it is done by
maternal efforts.
• Delivery of shoulders The weight of the
buttocks will bring the shoulders down to
the pelvic floor where they will rotate into
the antero -posterior diameter of the outlet.
The baby is grasped at the iliac crests and a
downward traction may be used when the
patient is pushing to aid the expulsion of
the shoulders.

38. • Delivery of the after-coming head This is
the most critical stage of the delivery. If the
after coming head is delivered too hastily it
results in intracranial injury and
subsequent death of the foetus.
• After coming the head of the breech can be
delivered by the Burns- Marshall
technique, by the use of obstetric forceps
and by Mauriciceu- Smellie- Viet
technique.

39. Burns- Marshall technique
•The baby is allowed to hang down
with the back uppermost at the vulva ,
for about two minutes.
•This encourages descent and flexion
of the head and allows head to be born
as far as the nape of the neck.

40. • When the sub occipital area appears at the
pubic arch the legs of the baby are grasped
and the midwife exerts a firm outward
traction and the body is lifted towards the
mothers abdomen.
• The fetal head is delivered by movement of
flexion.
• At this stage the left hand of the midwife is
used to guard the perineum and to prevent
the head being delivered too quickly.

41. Complications of Breech
Delivery
1) Maternal complications
•Risk of operative intervention
•Risk of infection due to manipulations
•Extensions of episiotomy
•Postpartum haemorrhage

42. 2) Fetal complications
•Preterm delivery
•Low birth weight
•Cord prolapse
•Birth asphyxia
•Fetal injuries

43. Conclusion

44. •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
manoeuvres and skilful observation of
the obstetrician.

45. Reference:

46. 1)Maternity Nursing,
Family, New born and women’s Health care,
19th edition, Editor A.V Raman, Page No. 314-316.
2)Myles Textbook For Midwives,
Page No. 133-136.
3)A textbook for midwives in the tropics
OA OJO ENANG BASSEY BRIGGS
Second edition
Published by Jaypee Brothers, Page No. 269-278.