Breech delivery

1. Breech Presentation
Roll No. 45,46

2. Contents
● Definition
● Incidence
● Varieties
● Etiology
● Recurrent Breech
● Clinical Diagnosis
● Investigation
● Mechanism of Labour in Breech Presentation
● Complications of Vaginal Breech Delivery
● Antenatal Management
● Management of Vaginal Breech Delivery
● Management of complicated Breech Delivery

3. DEFINITION- In breech presentation, lie is
longitudinal and the podalic pole present at
the pelvic brim. It is the commonest
malpresentation
INCIDENCE:- The incidence is about 20% at 28th
week and drops to 16% at 34th week and about 3-
4% at term.
Thus in 3 out of 4 spontaneous correction into vertex
presentation occurs by 34th week.

4. VARIETIES
-Complete
-Incomplete
1) COMPLETE- The hips and
knees are flexed

5. 2) INCOMPLETE
1. Breech with extended legs
(frank breech) - Hips, thighs are
flexed, legs, knees are extended.

6. 2. footling presentation- both the thighs & legs are
partialy extended bringing the legs to present at the
brim

7. 3) Knee presentation - thighs are extended but
the knees are flexed, bringing the knee down
to present at the brim.

8. CLINICAL VARITIES
1) Uncomplicated:- It is defined as one where there is no
other associated obstetric complications apart from the
breech prematurity being excluded.
2) Complicated:- when the presentation is associated with
conditions which adversely influence the prognosis such as
prematurity, twins, contracted pelvis, placenta previa etc

9. ETIOLOGY OF BREECH PRESENTATION
1.Prematurity
2.Factor preventing spontaneous version-
- breech with extended legs
- twins
- oligohydramnios
- congenital malformation of uterus
- short cord
- IUD of fetus
3. Fetal abnormality
- Trisomies 13,18,21

10. RECURRENT BREECH
The breech presentation recurs in successive pregnancies
When it recurs in three or more consecutive pregnancies it is
called habitual or recurrent breech
The probable causes are congenital malformation of the uterus,
septate or bicornuate, and repeated cornu-fundal attachment of
the placenta

11. CLINICAL DIAGNOSIS OF BREECH PRESENTATION
Complete Breech
FUNDAL GRIP :-
Head is ballotable
Head suggested by hard and globular
LATERAL GRIP
Fetal back is to one side and the irregular
limbs
FRANK BREECH
FUNDAL GRIP
Head
Irregular small parts of the feet may be felt
by the side of the head.
Irregular parts are less felt on the side
LATERAL GRIP
Irregular parts are less felt on the side

12. PELVIC GRIP. PELVIC GRIP
Breech suggested by soft broad. Small, hard amd a conical mass is felt
and irregular mass.
Breech is usually not engaged during
pregnancy The breech is usually engaged
FETAL HEART SOUND. FETAL HEART SOUND
Usually located at a higher level round. Located at a lower level in the midline due to
about the umbilicus. Early engagement of the breech

13. DURING PREGNANCY
Soft and irregular parts are felt through the fornix
DURING LABOUR
Palpation of ischial tuberosities, sacrum and the
feel by the sides of the buttocks
The foot felt is identified by the prominence of the
heel and lesser mobility of the great toe
DURING PREGNANCY
Hard feel of sacrum is felt often mistaken
for the head
DURING LABOUR
Palpation of ischial tuberosities, anal
opening and sacrum and they are felt in
one line

14. Ultrasonography
1. It confirms the clinical diagnosis- specially in
primigravidae with engaged frank breech or with
tense
abdominal wall and irritable uterus.
2. It can detect fetal congenital abnormality and also
congenital anomalies of the uterus.
3. Type of breech (complete or incomplete).
4. It measures biparietal diameter, gestational age
and
approximate weight of the fetus.
5. It also localizes the placenta.

15. 6. Assessment of liquor volume (important for ECV).
7. Attitude of the head- flexion or hyperextension
(Important for decision making at the time of
delivery).
8. CT and MRI can be used to assess the pelvic
capacity in addition to all the above mentioned
information.

16. MECHANISM OF LABOUR IN BREECH PRESENTATION
Principal movement occur at three places
1) Buttocks. 2) Shoulders. 3) Head
Delivery of Buttocks
• The engagement diameter is the bitrochantric diameter 10 cm
which enters the pelvis in one of the oblique diameters.
• Descent of the buttocks occurs until the anterior buttock
touches the pelvic floor.
• Internal rotation of the anterior buttock occurs through 1/8th of a
circle placing it behind the symphysis pubis.

17. • 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

18. Delivery of Shoulders
• Bisacromial diameter (12 cm or 4 %") engages in the same
oblique diameter as that occupied by the buttocks at the brim
soon after the delivery of breech.
• Descent occurs with internal rotation of the shoulders bringing
the shoulders to lie in the antero-posterior diameter of the pelvic
outlet The trunk simultaneously rotates externally through 1/8' of a
circle.

19. • Delivery of the posterior shoulder followed by the
anterior one is
completed by anterior flexion of the delivered trunk.
• Restitution and external rotation

20. 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 suboccipito-
frontal (10 cm).
• Descent with increasing flexion occurs.

21. • Internal rotation of the occiput occurs anteriorly, through
1/8' or 2/8* of a circle placing
the occiput behind the symphysis pubis.
• Further descent occurs until the sub-occiput hinges
under the symphysis pubis.

22. The head is born by flexion- The chain, mouth, nose, forehead,
vertex and occiput appearing successively. The expulsion of the
head from the pelvic cavity depends entirely upon the bearing
efforts and not at all on uterine contractions
.
• Sacro-posterior position: The mechanism is not substantially
modified. The head has to rotate through 3/8" of a circle to bring
the occiput behind the symphysis pubis.

23. COMPLICATIONS OF VAGINAL BREECH DELIVERY
Maternal factors:-
Trauma to the genital tract
Operative vaginal delivery (episiotomy,forceps)
Cesarean section
Sepsis and anesthetic complications
Fetal factors:-
Prematurity
Birth trauma
Congenital malformation of the fetus

24. THE DANGERS TO THE BABY
-1) Intrapartum fetal death, especially with preterm babies
Injury to brain and skull:- a) intracranial hemorrhage b)
minute hemorrhage c) fracture of the birth skull
-2) Birth asphyxia :-
a) Cord compression soon after the buttocks are delivered and
also when the head enters into the pelvis. A period of more
than 10 minutes will produce asphyxia of varying degrees.
B) Retraction of the placemtal site
C) Premature attempt at respiration while the head is still inside
D) Delayed delivery of the head

25. -4) Birth injuries:-
Hematoma:- over the sternomastoid
Fractures :-the common sites are femur, humerus,
clavicle and odontoid process
Visceral injuries:- include rupture of liver, kidney ,
suprarenal glands, lungs
Nerve :- Spinal cord injury

26. Prevention of the Fetal Hazards
• The incidence of breech can be minimized by external cephalic
version where possible.
• If the version fails or is contraindicated, delivery is done by
elective caesarean section.
• A skilled obstetrician along with an organized team consisting of
a skilled anesthetist and an assistant should conduct vaginal
breech delivery.

27. ANTENATAL MANAGEMENT
It consists of
-1) Identification of the complicating factors releated with
breech
-2) External Cephalic version
-3) Formulation of the line of management
IDENTIFICATION OF COMPLICATING FACTOR
It can be detected by clinical examination, supplemented by sonography
Sonography is particularly useful to detect congenital malformation of the
fetus, the precise location of the placental site and congenital anomalies
of the uterus

28. EXTERNAL CEPHALIC VERSION
There are protagonists and antagonists to external version
Time of version ECV has been considered from 37 weeks onward. While
version in the early weeks is easy but chance of reversion is more. Late
version may be difficult because of increasing size of the fetus and
diminishing volume of liquor amnii.
Benefits of ECV
1) Reduction in the incidence of breech presentation at term
2) Reduction in the incidence of breech delivery (vaginal of cesarean) and
the associated complications
3) Reduction in the incidence of cesarean delivery by 5%

29. Successful version is likely in cases of :-
1) Complete breech
2) Non Engaged breech
3) Sacro Anterior position
4) Adequate liquor
5) Non obese patient
Causes of failure of version
1) Breech with extended legs
2) Big size baby
3) Short cord
4) Uterine malformations

30. DANGERS OF VERSION:-
1) Premature onset of labour
2) Premature rupture of the membranes
3) Placental abruption and bleeding
4) Entanglement of the cord round the feet part or formation of a true
knot leading to impairment of fetal circulation and fetal death
5) Increased chance of fetomaternal bleed and alloimmunization
6) Amniotic fluid embolism
7) Rupture of uterus
CONTRAINDICATIONS OF ECV
Antepartum hemorrhage
Fetal causes:- hypertension of head, large fetus, dead fetus
Multiple pregnancy
Ruptured membranes :- drainage of liquor
Contracted pelvis
Previous cesarean delivery

31. Management, if version fails
To perform an elective cesarean section
To allow spontaneous labor to start and vaginal breech delivery to occur
Induction of labour is not usually recomended
The indications of CS in breech are:-
1) Big baby , small baby (>3.5kg to <1.5kg)
2) Hypertension of head
3) Footling presentation
4) Suspected pelvic contraction
Vaginal breech delivery :-
1) Average fetal weight
2) Flexed fetal head
3) Adequate pelvis
4) Without any other complications

32. 5) Availability of facilities for emergency cesarean section
Facilities for continuous labor monitoring
6) Presence of obstetrician experienced with vaginal breech delivery
7) Frank breech is preferred
8) zatuchin-andros score >4

33. Name- Itika Sharma
Roll No.- 19046
Management of breech
presentation

34. Management of vaginal breech delivery
● First stage : similar to normal labor. Spontaneous onset of labor
increases the chance of successful vaginal delivery
● Vaginal examination-
A) At the onset of labor for pelvic
assessment.
B) Soon after rupture of the membranes to exclude cord prolapse .
● An intravenous line is sited with ringer's solution,blood is sent for
group and cross matching .
● Adequate analgesia - epidural is preferred.
● Fetal status and progess of labor are monitored.
● Oxytocin infusion .

35. ● Indications of cesarean section : a) cases seen for
the first time in labor with presence of complications.
b) Arrest in the progress of labor .
c) Nonreassuring FHR pattern( fetal distress)
d) cord presentation or prolapse.
Second stage : three methods of vaginal breech delivery:
1. Spontaneous
2. Assisted breech
3. Breech extraction : Indications: a ) delivery of second
twin after IPV.

36. b)cord prolapse
C) Extended legs arrested at the cavity or at the
outlet.

37. Assisted Breech Delivery
●Breech delivery should be conducted by a skilled
obstetrician.
●The following are to be kept ready : A) An Anesthetist .
B)An assistant - to push down the fundus during
contraction.
C) Instruments and suture materials for episiotomy
D)a pair of obstetric forceps for the aftercoming head , if
required.
E)Appliances for resuscitation of the baby . F )

38. Principles in conduction :
1.Never to rush
2.Never pull from below but push from
above.
3.Always keep the fetus with the back
anteriorly.
It is expected that good uterine contractions
and maternal expulsive forces will maintain the
flexion of the fetal head and result in descent
and safe delivery .

39. Never to rush and never to pull - early Aggressive
and hasty pull affects breech delivery adversely by :
A ) entrapment of the aftercoming fetal head through
the incompletely dilated cervix.
B) Traction from below results in deflection of the
head posing longer occipitofrontal diameter (
11.5 cm ) at the pelvic inlet.
C) increased risk of nuchal displacement of
arms.

40. Steps:
●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 ( 15 degrees) using a wedge under the back.
●Antiseptic cleaning is done ,bladder is emptied with an “ in and
out “ catheter.
●Pudendal block is done along with perineal infiltration if
no epidural has been used earlier.

41. ● Episiotomy: it should be made in all cases of primigravidae and
selected multiparae.
Advantages :
°to straighten the birth canal which especially facilitates the delivery
of breech with extended legs where lateral flexion is inadequate.
° To facilitate intravaginal manipulation and for forceps delivery.
° to minimise compression of the aftercoming head .
The best time for episiotomy is when the perineum is distended
and thinned by the breech as it is climbing the perineum.

42. ● The patient is encouraged to bear down as the
expulsive forces from above ensure flexion of the fetal
head and safe descent.
No touch to the fetus - until the buttocks are delivered
along with the legs in flexed breech and the trunk
slips up to umbilicus .
● Extended legs are decomposed by pressure on
the knees - abduction and flexion of the thighs.
● Umbilical cord - pull down and mobilize to one
side of the sacral bay to minimize compression
● - rotate the trunk to bring the back anteriorly.
● Baby is wrapped with a sterile towel to prevent
slipping .

43. Delivery of the arms :
●Assistant places a hand over the fundus
,keeps a steady pressure during uterine contractions to
prevent extension of the arms.
●When anterior scapula is visible - note
position of arm
●Arms flexed - vertebral border of scapula is parallel to
vertebral column.
●Arms extended - winging of scapula.
●When axilla is visible - hook down each elbow with a
finger.

45. Delivered of the aftercoming head -
Time between delivery of umbilicus to delivery of mouth should
be 5 - 10 min .
1.Burns Marshall method : baby is allowed to hang by its own
weight.
Assistant gives suprapubic pressure with flat hand -
downward and backward direction.( more toward sinciput)
This promotes flexion of the head- favorable diameter is
presented to pelvic cavity.
When the nape of the neck is visible under the public arch
- baby is grasped by the ankles with a finger in between the two .

46. ● Maintain a steady traction ,forming a wide arc - the trunk is
swung in upwards and forward direction .
● Left hand is to guard the perineum .
● When mouth is cleared off the vulva - mucus of the mouth and
pharynx is cleared.
● Trunk is depressed to deliver rest of the head.

47. Forceps delivery :
Advantages - 1. Delivery is controlled by giving pull directly on
the head.
2. Flexion is better maintained.
3. Mucus from mouth is sucked out more effectively.
Head is brought as low down as possible .
When occiput lies against the back of the symphysis pubis. -
raise the legs of the child - to facilitate introduction of blades from
below.
Forceps pull maintain an arc - follows the axis of the birth canal.

48. ● Ordinary forceps are quite effective.
● Piper forceps - absent pelvic curve .
● Head should be delivered slowly ( 1 min) to
reduce compression - decompression forces.

49. Malar flexion and shoulder traction ( modified
mauriceau- smellie- veit technique) :
●The baby is placed on the supinated left forearm
with the arms hanging on either sides.
●Middle and index fingers of the left hand are
placed over the malar bones on either sides - this
maintains flexion of the head.
●Ring and little finger of the pronated right hand are
placed on the child's right shoulder ,the index finger -
on the left shoulder, middle finger - on the
suboccipital region.

50. ● Traction is now given in downward and backward
direction till the nape of the neck is visible under the
pubic arch.
● Assistant gives suprapubic pressure during the period
to maintain flexion .
● The fetus is carried in upwards and forwards direction
towards the mother’s abdomen releasing the face and
brow.
● The trunk is depressed to release the occiput and
vertex.

51. Resuscitation of the baby : the baby may be
asphyxiated and need to be resuscitated.
Third Stage : placenta is expelled out soon after the
delivery of the head .
Prophylactic oxytocin - should be administered im
following delivery of the head .
Preterm breech: ECV with preterm breech
presentation is not recommended.
CS is commonly done when fetal weight is less than
1500 g.

52. Management of complicated Breech Delivery
Delay in descent of the breech : breech may be arrested
at : a) at the outlet. b ) in the cavity . c ) at the brim
●Arrested at the outlet : causes : 1. Big size baby with
extended legs.
2. Weak uterine contractions
3. Rigid perineum.
4. Outlet contraction.
Management: Cesarean section is the method of choice .-
outlet is contracted or big baby .

53. In the absence of outlet
contraction and fetopelvic
disproportion : liberal episiotomy
and fundal pressure with or without
groin traction - is effective.
Index finger is placed in the groin
fold and traction ( along with uterine
contraction ) is exerted more toward
the trunk than the femur.

54. ● Arrest of the breech at or above the level of
ischial spines : causes : 1. Pelvic contraction.
2. Big baby
3. Weak uterine contraction.
Treatment- Cesarean section
● When cervix is fully dilated - breech should
descend down to the perineum. - called as
Trial of breech .- if it fails to occur ,fetopelvic
disproportion is likely.

55. Frank breech extraction : ( Pinard’ s maneuver ) : done
by intrauterine manipulation- for breech decomposition)
To convert a frank breech to a footling breech.
●This is possible when the membranes have ruptured recently.
●The middle and the 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 grasped at the ankle and breech extraction
is accomplished.

57. Extended Arms : one or both the arms may be fully
stretched along the side of the head or lie behind the
neck ( nuchal displacement).
Cause : faulty technique in delivery - using
unnecessary traction .( NEVER PULL BUT PUSH
FROM ABOVE )
●Arrest occurs with the delivery of the trunk up to the
costal margins.
●Diagnosis is made by noting the winging of
the scapula and absence of the flexed limbs in

58. Management: urgent delivery of the arms ,first the
posterior, then the anterior one .
Methods :
A)Lovset ‘s Maneuver :Advantages:
1.Wider applicability- it can be applied even when
classical method becomes difficult.
2.Intrauterine manipulation is nil.
3.A single manipulation is effective to all types of
displacement of the arms .
4.General anesthesia is usually not needed.

59. 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.

60. Procedure : The baby ( wrapped in a warm dry
towel ) is grasped ,using both hands by
femoropelvic grip keeping the thumbs parallel to
the vertebral column .
The maneuver should start only when the inferior
angle of the anterior scapula is visible underneath
the pubic arch .

61. Step - 1 :
The baby is lifted slightly to
cause lateral flexion .
●The trunk is rotated through 180
degree keeping the back anterior
and maintaining a downwards
traction .
●The posterior arm then
emerges under the pubic arch
which is then hooked out .

62. Step - 2 :
The trunk is then rotated in
the reverse direction
keeping the back anterior to
deliver the erstwhile anterior
shoulder under the
symphysis pubis.

63. Nuchal displacement of arm : arm is flexed
at the elbow and extended at the shoulder and
lies behind the fetal head .
●After grasping the baby at the pelvic girdle
with thumbs along the sacrum,the trunk is
rotated 180 degree toward the fingertips of the
trapped arm.
●This draw the elbow forward and render it
amenable to lovset ‘s maneuver.
●If this fails,the arm is forcibly extracted by
hooking.

64. Classical method :
●Same principle as with lovset’ s maneuver.
●It needs intrauterine manipulation while the patient is
under general anesthesia.
●Left hand is introduced along the curve of the sacrum
while the baby is pulled Slightly upward.
●With firm pressure over the humerus, the posterior arm
is pushed over the baby's face.
●The extended anterior arm is delivered from the anterior
aspect by introducing the right hand.
The baby's trunk is depressed Towards the perineum.

65. Arrest of the aftercoming Head
▪︎ at the brim : causes : 1. Deflexed Head
2. Contracted pelvis
3. Hydrocephalus.
Management: Deflexed Head: delivery is completed by malar
flexion and shoulder traction along with the suprapubic pressure by
the assistant.
Head is negotiated through the brim in the transverse diameter
and rotated in the cavity.
●Contracted pelvis or Hydrocephalus- perforation of the head.

66. ▪︎In the cavity: causes : 1. Deflexed head
2. Contracted pelvis .
Management: delivery of the head by forceps.
▪︎ At the outlet : causes: 1. Rigid perineum
2. Deflexed head .
Episiotomy is followed by forceps application or malar
flexion and shoulder traction .
Delivery of the head through an incompletely dilated
cervix : causes : 1) premature baby
2 ) macerated baby

67. 3 ) footling presentation
4) hasty delivery of breech before the cervix is
fully dilated.
Management: Alive baby : cervix is to be
pushed up while traction of the fetal trunk is
made by malar flexion and shoulder traction.
●Duhrssen’s incision can be made at 2 and
10 o’ clock position on the cervix.
Baby dead : perforation of the head is better
than hoping for full dilatation of the cervix.

68. ● Occiput posterior position of the head :
fetal trunk and head are rotated to bring them
anteriorly.
● The fetal trunk and the head are to be
grasped ,the hand and the fingers are
positioned like that in malar flexion and
shoulder traction.

69. Thank you