External cephalic version (ECV) involves manually rotating the fetus from a breech position to a head-down position before labor. It has a success rate of 50-60% and is generally attempted before 37 weeks. Complications are rare but include placental abruption, preterm labor, and fetal compromise. Internal podalic version involves manually rotating the fetus to a breech position inside the uterus. Vaginal breech delivery can be attempted if certain criteria are met, but carries risks. Shoulder dystocia is a obstetric emergency that occurs when the fetal shoulders become lodged behind the pubic bone. Risk factors include high birth weight, diabetes, and previous shoulder dystocia. Management

1. External cephalic version and Internal podalic
version; Assisted breech delivery and delivery of
shoulder dystocia
Dr.Alelign

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Outline
•External cephalic version
•Complications of ECV
•IDV

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External cephalic version and Internal podalic
version
• With version, fetal presentation is altered by physically substituting one pole
of a longitudinal presentation for the other, or converting an oblique or
transverse lie into a longitudinal presentation.
• Manipulations performed through the abdominal wall that yield a cephalic
presentation are termed external cephalic version.
• Manipulations accomplished inside the uterine cavity that yield a breech
presentation are designated internal podalic version.

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• External cephalic version (ECV) reduces the rate of noncephalic presentation
at birth, and its success rate is 50 to 60 percent
• For women with a transverse lie, the overall success rate is significantly higher.
• In general, ECV is attempted before labor in a woman who has reached 370/7
weeks’ gestation (ACOG 2020).
• This threshold aims to balance risks of fetal immaturity and the greater
amnionic fluid volume seen in early-term pregnancies, which aids turning.

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• In support of this, one systematic review found that ECV done before 370/7
weeks raised ECV success rates but did not lower the ultimate cesarean delivery
rate and increased the risk of latepreterm birth.
Before 37wks, breech presentation also still has a high likelihood of correcting
spontaneously.
If ECV is performed too early, time may allow a reversion back to breech
If attempts at version cause a need for immediate delivery, complications of iatrogenic
early-term delivery generally are not severe.

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Contraindications to ECV
• If any contraindication to vaginal delivery , such as with placenta previa, classic
CD Scar, 2CD scar…
• Relative contraindications are early labor, 1LUSCD scar, oligohydramnios,
ruptured membranes, known nuchal cord, structural uterine abnormalities,
IUGR, multifetal gestation, Infertility Bad obstetrics history, Uterine
malformation and prior abruption or its risk factors, Congenital fetal
abnormality, Polyhydramnious

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• Several factors can improve the chances of an ECV attempt. These are
• multiparity,
• unengaged presenting part,
• nonanterior placenta,
• Nonobese patient, and
• abundant amnionic fluid (yet,neither a preprocedural 2-L intravenous fluid
bolus nor amnioinfusion raised ECV success rates).
• Decrease Success
• Engaged fetus
• Tense uterus
• Inability to palpate head
• Obesity
• Anterior placenta
• Fetal spine anterior or posterior
• Labor

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• Prerequisites
Gestational age > 36 weeks
Intact fetal membranes
adequate amniotic fluid
Reassuring fetal condition
No contraindication for vaginal delivery

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Complications
• small but real complications are placental abruption, preterm labor, and fetal
compromise.
• Bradycardia is common during or following ECV, but emergent cesarean rates
are ≤0.5 percent.
• Uterine rupture, fetomaternal hemorrhage, alloimmunization,
amnionic fluid embolism, and maternal or fetal deaths are rare
• Overall, compared with expectant management, perinatal morbidity and
mortality rates are not greater with ECV
• Even after successful ECV, several reports suggest that the cesarean delivery rate
does not completely revert to the baseline the vertex presentations.
• Specifically, dystocia, malpresentation, and NRFHRP may be more common in
these fetuses who have undergone successful ECV

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• Failed ECV: Version attempts should be discontinued, if there is
Excessive maternal discomfort
Persistent abnormal FHR
After a maximum of three attempts
• Complications of ECV
Abnormal FHR usually transient – commonest (4.7%)
Feto maternal hemorrhage
Emergency cesarean delivery during labor is increased following
successful ECV than in spontaneous cephalic presentation
Vaginal bleeding and placental abruption
Fracture of the baby’s femur

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Internal Podalic version/IPV

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Vaginal Breech delivery
Vaginal Delivery
• Complete / frank breech
• Adequate maternal pelvis
• Flexed neck
• EFW : 2.5 -3.8 kg
• written informed consent
• Presence of a skilled care provider
• Zatuchni-Andros score ≥ 4
• Rapid CD is possible
• Good progress is maintained in
labor
Cesarean delivery
• Incomplete or footling breech
• EFW is <1500 or >4000 g
• hyperextended head
• Uterine dysfunction
• Lack of an experienced operator of
VD
• Prior cesarean delivery
• Zatuchni-Andros score <4
• Arrest of progress

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• First stage of labor
• follow with Partograph
 If the cervicogram crosses the alert line, consider hydration;
avoid augmentation of labor
– Cesarean delivery is undertaken if the action line is approached
• Avoid ARM
• Meconium is common with breech labors
– Not - sign of fetal asphyxia
• Continuous epidural analgesia, is advocated

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Second stage

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Total Breech Extraction
• It is delivery of the baby with no assistance from the mother. It serves as
an
alternative to CS in desperate conditions.
• Indications
Fetal distress in 2nd stage of labor
Cord prolapse or entanglement around the leg
Need for expedite delivery of the 2nd twin
Footling breech- with advanced labor with fully dilated cervix (better managed by
C/S in
other conditions).
• Preconditions
Fully dilated crevics

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Mechanism and conduct of labor and breech
vaginal delivery

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Shoulder Dystocia

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head-to-body delivery interval > 60 seconds, which was two SD above the mean value
(24 seconds)
Although promising, this definition has not been studied extensively and further
investigation is needed to validate its use for diagnosis of shoulder dystocia and determine
the optimum threshold for predicting adverse neonatal outcomes

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Risk Factors
High birth weight > 4 kg
Estimated risk of shoulder dystocia
– EFW > 5000 g + No diabetes: >20%
– EFW > 4500 g + DM: ~ 15%
Diabetes mellitus – 2 reasons
– Higher risk of macrosomia
– chest-to-head and shoulder-to-head ratios are
increased
in IDMs
Previous shoulder dystocia
– recurrence - 10 – 25%
– Recurrent shoulder dystocia is more likely when
o Current EFW > previously affected pregnancy
o Prepregnancy weight > previously affected
pregnancy
o Gestational weight gain > previously affected
pregnancy
Postterm pregnancy
– higher birth weights with advancing
gestational age
Male fetal sex
Maternal obesity & excessive
gestational weight gain
Maternal demographics; Advanced
maternal age

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Management of Shoulder Dystocia
• obstetric emergency; goal of management
to prevent fetal asphyxia & permanent Erb's palsy or death
Avoiding maternal physical injury (eg, bone fractures, maternal trauma)
• Call for help—mobilize assistants and anesthesia and pediatric personnel. Initially, a gentle
attempt at traction is made. Drain the bladder if it is distended
• Check for and release a tight nuchal cord, if present.
• Drain a distended bladder, if present.
• Position the patient with her buttocks flush with the edge of the bed to provide optimal access
for executing maneuvers to effect delivery
• Generous episiotomy
• Avoid excessive neck rotation, head and neck traction, and fundal pressure because this

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• Initial Procedures
McRoberts maneuver
McRoberts maneuver with suprapubic pressure
Delivery of the posterior arm
• Secondary Procedures
Woods screw maneuver;
Rubin maneuver
 Woods & Rubin maneuver
Clavicular fracture
• Procedures of Last Resort
Gunn-Zavanelli-O'Leary maneuver
Abdominal rescue
Symphysiotomy

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References
• William’s 26th Edition
• Gabbe, 7th Edition
• Practical OBGYN Notes, 2021, 1st Edition

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Thank You