LECTURE ON MALPRESENTATION

1. D E P T O F O B S T E T R I C S 7 G Y N E C O L O G Y
F E U N R M F
BREECH DELIVERY (revised
2016)

2. BREECH DELIVERY (revised 2016)
BREECH PRESENTATION
 when the buttocks or legs of the fetus enter the
pelvis before the head
 more common remote from term
 persists at term in only 3 to 4 percent of singleton
deliveries as the fetus turns spontaneously to a
cephalic presentation as the increased bulk of the
podallic pole seeks the more spacious fundus

3. 3 CATEGORIES OF BREECH
 1.FRANK BREECH

4. 3 CATEGORIES OF BREECH
 2.COMPLETE BREECH

5. 3 CATEGORIES OF BREECH
 3. INCOMPLETE BREECH

6.  gestational age
 abnormal amnionic fluid volume
 high parity with uterine relaxation
 multifetal gestation
 fundal placental implantation
 hydrocephaly
 anencephaly
 prior breech delivery
 uterine anomalies
 pelvic tumors
 placenta previa
 prior cesarean delivery
 smoking
DIAGNOSIS
RISK FACTORS

7. ABDOMINAL EXAMINATION-LEOPOLD’S
MANEUVER

8. ABDOMINAL EXAMINATION-LEOPOLD’S
MANEUVER
 1st - hard, round, readily ballotable fetal head is found to
occupy the fundus
 2nd - indicates the back to be on one side of the abdomen and
the small parts on the other
 3rd - if engagement has not occurred—the intertrochanteric
diameter of the fetal pelvis has not passed through the pelvic
inlet—the breech is movable above the pelvic inlet
 4th - shows the firm breech to be beneath the symphysis
( after engagement )
 *Breech Presentation-Fetal heart sounds usually are heard
loudest slightly above the umbilicus
 *Cephalic presentation- the heart sounds are loudest
below the umbilicus

9. VAGINAL EXAMINATION
CATEGORIES OF BREECH
FRANK BREECH  ischial tuberosities, the sacrum, and the anus usually are
palpable
 after further descent, the external genitalia may be distinguishe
 the anus may be mistaken for the mouth and the ischial
tuberosities for the malar eminences
 the finger encounters muscular resistance with the anus
 the finger, upon removal from the anus, sometimes is stained
with meconium
 the firmer, less yielding jaws are felt through the mouth
 the mouth and malar eminences form a triangular shape,
whereas the ischial tuberosities and anus are in a straight line
 the most accurate information: the location of the sacrum and its
spinous processes, establishes the diagnosis of position and
variety
COMPLETE BREECH feet may be felt alongside the buttocks
FOOTLING BREECH one or both feet are inferior to the buttocks
foot can readily be identified as right or left on the basis of the
relation to the great toe

10. ROUTE OF DELIVERY
 Multiple factors aid determination of the
best delivery route for a mother fetus pair:
fetal characteristics
pelvic dimensions
coexistent pregnancy complications
operator experience
patient preference
 hospital capabilities

11. ROUTE OF DELIVERY:
TERM & PRETERM BREECH FETUS
 TERM BREECH FETUS:
 PLANNED VAGINAL DELIVERY:
 Increased neonatal mortality and morbidity
 causes of death were head entrapment, cerebral injury and
intracranial hemorrhage, cord prolapse, and severe asphyxia
The number of skilled operators continues to dwindle.
PLANNED CS DELIVERY: TBT & WHO: improved
perinatal outcomes compared w/ planned vag. delivery
 PRETERM BREECH FETUS:
 Between 24 & 32 wks AOG, attempted vaginal delivery>
low completion rate & higher neonatal mortality rates
Between 24 to 29 wks> no improved survival rate w/ CS
Between 32 to 37 wks> fetal weight rather than AOG most
impt
 SOGC : vaginal delivery reasonable if EFW is > 2500 g

12. DELIVERY COMPLICATIONS
 MATERNAL MORBIDITY
 genital tract lacerations: w/ vaginal delivery
& CS
 CS: added stretching of the lower uterine
segment by forceps or a poorly molded fetal
head can extend hysterotomy incisions
Vaginal delivery: vaginal wall & cervical
lacerations, extension of an episiotomy, deep
perineal tears, increased infection risks,
uterine atony from anesthesia (for uterine
relaxation); death rare

13.  Prognosis worsefor fetuses in breech because
of increased incidence of preterm delivery,
congenital anomalies and birth trauma.
 Common injuries: fractures of the humerus,
clavicle, & femur. Traction may separate
scapular, humeral or femoral epiphysis
 Upper extremity paralysis, Erb or Duchenne
spoon shaped depression or actual fractures
of the skull; spinal cord injury or vertebral
fracture; testicular injury,
 Umbilical cord prolapse; hip dysplasia
Perinatal Morbidity & Mortality

14. IMAGING TECHNIQUES
 The head of a breech presenting fetus does
not undergo appreciable molding during
labor.
 Thus, to avoid head entrapment following
delivery of the breech:
1. pelvic dimensions should be assessed
before vaginal delivery
2. fetal size, type of breech, & degree of neck
flexion or extension should be identified.
 The ff. imaging techniques will help:

15. IMAGING TECHNIQUES
1..ULTRASOUND-
 to identify fetuses not suitable for vaginal delivery
 to help ensure that a CS is not performed under emergency
conditions for an anomalous fetus w/no chance of survival
 to identify head flexion, extension; EFW <2500 & >3800 to
4000 g, evid of FGR, BPD > 90 to 100 mm are used as
exclusion criteria for vaginal delivery
2. TWO VIEW RADIOGRAPHY of abdomen to determine head inclination
3. CT SCAN
 accurate; widely available, & will provide PELVIC MEASUREMENTS and
configuration at lower doses of radiation than standard radiography;
 Possible vaginal delivery: inlet AP dia >/= 105 mm, GTI >/= 120 mm
& midpelvic IS >/= 100 mm. Or maternal/fetal biometric correlations
4. .MRI
 provides reliable information about pelvic capacity and architecture
without ionizing radiation, but it is not always readily available

16. DECISION MAKING SUMMARY
>> Risks vs benefits weighed & discussed w/
the patient preferably before labor
>> For a favorable outcome w/ any breech
delivery:
1. the birth canal must be sufficiently large
to allow passage of the fetus w/o trauma
2. cervix must be fully dilated, and if not,
CS is the more appropriate method if
suspected fetal compromise develops

17. Factors Favoring Cesarean Delivery of the
Breech Detus
 Lack of operator experince
 Patient request for CS delivery; Prior CS
 Large fetus > 3800 to 4000 g
 Apparently healthy & viable preterm fetus
 Severe fetal growth restriction
 Fetal anomaly incompatible w/vaginal deliv
 Prior perinatal death or neonatal birth
trauma
 Incomplete or footling breech presentation
 Hyperextended head; Pelvic contraction

18. Management of Labor & Delivery:
Methods of Vaginal Delivery
 3 GENERAL METHODS OF BREECH DELIVERY
 Spontaneous breech delivery. The fetus is expelled
entirely spontaneously without any traction or
manipulation other than support of the newborn.
 Partial breech extraction. The fetus is delivered
spontaneously as far as the umbilicus, but the remainder
of the body is extracted or delivered with operator
traction and assisted maneuvers, with or without
maternal expulsive efforts.
 Total breech extraction. The entire body of the infant
is extracted by the obstetrician.

19. LABOR INDUCTION AND
AUGMENTATION
 controversial in women with breech
presentation
 In many studies, orderly labor progression is
associated with improved rates of successful
vaginal delivery & neonatal outcome.
Thus, some protocols avoid augmentation;
others recommend it only for hypotonic
contractions
At Parkland Hospital- CS is preferred to
oxytocin induction or augmentation in
women w/ viable fetus

20. MANAGEMENT OF LABOR
 Rapid assessment of status of the membranes,
labor, and fetal condition.
 Close surveillance of fetal heart rate and uterine
contractions.
 Recruitment of necessary staff: an OB skilled in
the art of breech extraction, an associate to assist
w/ the delivery, anesthesia personnel, & staff
skilled in newborn resuscitation
 IV catheter infusion in preparation for
anesthesia induction/ resuscitation ff the
possibility of hemorrhage

21.  In planning for the route of delivery: assess
the cervical dilatation & effacement, station
& type of breech presentation.
>> Obtain pelvimetry if labor is not too far
advanced.
>> Satisfactory progress in labor is the best
indicator of pelvic adequacy
>> Sonographic assessment of fetal
biometry,head flexion & fetal anatomy is
completed
MANAGEMENT OF LABOR

22. >> Ultimately, the choice of abdominal or
vaginal delivery is based on the factors
favoring CS.
>> during the first stage of labor: monitor FHR
every 15 minutes or continuously
>> with membrane rupture, the cord prolapse
risk is increased when the fetus is small or
NOT in frank breech
>> vaginal exam should be done ff rupture &
monitoring of FHR for 15 minutes
MANAGEMENT OF LABOR

23.  Vaginal delivery requires skilled participation by the
obstetrician for a favorable outcome
 Engagement & descent of the breech ( w/ bitrochanteric
dia in the oblique pelvic diameter)>>anterior hip
descends more rapidly>> internal rotation of 45
degrees>>anterior hip toward the pubic
arch>>bitrochanteric dia at AP dia of the pelvic outlet
Descent continues>>perineum distended by the breech
>>anterior hip appears at the vulva>>lateral flexion of
fetal body>>posterior hip forced over the perineum which
retracts>>allowing the infant to straighten out when the
anterior hip is born>> legs & hips follow the breech &
born spontaneouly or may require aid.
CARDINAL MOVEMENTS WITH BREECH
DELIVERY

24. Cardinal Movements with Breech
Delivery
 After the birth of the breech>>slight external
rotation>>back turns anteriorly>>shoulders into an
oblique pelvic diameter>>shoulders descend
rapidly>>internal rotation w/ the bisacromial dia >>AP
plane>>head enters the pelvis in one of oblique dia
>>rotates >> posterior portion of the neck under
symphysis pubis
 The mechanism of labor in the transverse position is the
same except that internal rotation is thru an arc of 90
rather than 45 degrees.

25. Partial Breech Extraction
 The breech is allowed to deliver spontaneously to the
umbilicus >> draws the umbilicus and attached cord into
the pelvis which stretches & compresses the cord. Thus,
the abdomen, thorax, arms, & head must be delivered
promptly spontaneously or assisted.
 The posterior hip will deliver at 6 o’clock
position>> anterior hip delivers>>external
rotation to sacrum anterior position

26. Partial Breech Extraction
 As the fetus continues to descend>>legs sequentially
delivered by splinting the medial aspect of each femur, &
by exerting pressure laterally to sweep each leg away from
the midline>> fetal bony pelvis grasped w/ both hands
using moist towel ( fingers should rest on the anterior
superior iliac crests & thumbs on the sacrum)
>>gentle downward traction aided by maternal
pushing>>lower halves of scapula visible>>fetal back
turns to side of mother to w/c it was originally
directed>>shoulder delivery ( 2 methods)
>> these rotational & downward traction maneuvers will
decrease the persistence of nuchal arm >>the back of the
fetus rotates in the direction of symphysis>>head is
delivered

27. ASSISTED FRANK BREECH DELIVERY

28. ASSISTED FRANK BREECH DELIVERY

29. ASSISTED FRANK BREECH DELIVERY

30. ASSISTED FRANK BREECH DELIVERY

31. ASSISTED FRANK BREECH DELIVERY

32. FRANK BREECH EXTRACTION

33. FRANK BREECH EXTRACTION

34. COMPLETE/INCOMPLETE BREECH
EXTRACTION

35. COMPLETE/INCOMPLETE BREECH
EXTRACTION

36. COMPLETE/INCOMPLETE BREECH
EXTRACTION

37. COMPLETE/INCOMPLETE BREECH
EXTRACTION

38. COMPLETE/INCOMPLETE BREECH
EXTRACTION

39. COMPLETE/INCOMPLETE BREECH
EXTRACTION

40. DELIVERY OF THE AFTERCOMING
HEAD
 1.MAURICEAU

41. MAURICEAU MANEUVER
 index and middle finger of one hand are applied over the
maxilla, to flex the head, while the fetal body rests on the
palm of the hand and forearm.
 The operator’s forearm is straddled by the fetal legs.
 Two fingers of the other hand then are hooked over the
fetal neck, and grasping the shoulders, downward traction
is applied until the suboccipital region appears under the
symphysis.
 Gentle suprapubic pressure simultaneously applied by an
assistant helps keep the head flexed. The body then is
elevated toward the maternal abdomen, and the mouth,
nose, brow, and eventually the occiput emerge
successively over the perineum.

42.  It is emphasized that with this maneuver, the
operator uses both hands simultaneously and
in tandem to exert continuous downward
gentle traction simultaneously on the fetal
neck and on the maxilla.
 At the same time, appropriate suprapubic pressure
applied by an assistant is helpful in delivery of the
head

43. DELIVERY OF THE AFTERCOMING
HEAD
 2.PRAGUE MANEUVER

44.  the back of the fetus fails to rotate to the anterior.
 When this occurs, rotation of the back to the anterior
may be achieved by using stronger traction on the
fetal legs or bony pelvis.
 If the back still remains oriented posteriorly,
extraction may be accomplished using the Mauriceau
maneuver and delivering the fetus back down.
 If this is impossible, the fetus still may be delivered
using the modified Prague maneuver, which, as
practiced today, consists of two fingers of one hand
grasping the shoulders of the back-down fetus from
below while the other hand draws the feet up over the
maternal abdomen

45. FORCEPS TO AFTERCOMING HEAD
 PIPER FORCEPS –specialized forceps used to deliver the
aftercoming head.
 The blades of the forceps should not be applied to the
aftercoming head until it has been brought into the pelvis
by gentle traction, combined with suprapubic pressure,
and is engaged. Suspension of the body of the fetus in a
towel effectively holds the fetus and helps keep the arms
out of the way.
 A.The fetal body is elevated using a warm towel and the
left blade of the forceps is applied to the aftercoming head.
 B. The right blade is applied with the body still elevated.
 C. Forceps delivery of the aftercoming head.

48. ENTRAPMENT OF THE AFTERCOMING
HEAD
 With small preterm fetuses, the incompletely
dilated cervix will constrict around the neck
and impede delivery of the aftercoming head
 With gentle traction on the fetal body, the
cervix, at times, may be manually slipped
over the occiput.
If not successful, Duhrssen incisions may be
done at 2, 10 & at times 6 o’clock positions on
the cervix. Other alternatives: nitroglycerin
100 ug, halogenated agents (G.A)
Zavanelli maneuver> replacement of fetus
into the vagina & uterus >> CS

49. DUHRSSEN INCISION

50. ANALGESIA AND ANESTHESIA
 Anesthesia for breech decomposition and
extraction must provide sufficient relaxation
to allow intrauterine manipulations
 EPIDURAL ANALGESIA- may provide
sufficient relaxation to allow intrauterine
manipulations but increased uterine tone
may render the operation more difficult.
 GENERAL ANESTH-may be required to relax
the uterus as well as to provide analgesia

51. VERSION
 Procedure in which the fetal presentation is
altered by physical manipulation, either
substituting one pole of a longitudinal
presentation for the other or converting an
oblique or transverse lie into a longitudinal
presentation
 PODALIC VERSION-the breech is made the
presenting part for the delivery of 2nd of twin
 EXTERNAL CEPHALIC VERSION- for breech
fetuses near term, manipulations are
performed exclusively through the
abdominal wall

53. INDICATIONS OF EXTERNAL CEPHALIC
VERSION
 If breech presentation is recognized prior to
labor in a woman who has reached 36 weeks'
gestation, external cephalic version should be
considered.
 Contraindications:
 1. if vaginal delivery is not an option
 2. rupture of membranes
 3. uterine malformations
 4. multifetal gestation
 5. recent vaginal bleeding
 6. prior uterine incision( relative contraind)

54. FACTORS ASSOCIATED WITH
SUCCESSFUL VERSION
 multiparity
 abundant amnionic fluid
 unengaged presenting part
 fetal size 2500 to 3000 g
 posterior placenta
 nonobese patient

55. TECHNIQUE
 UTZ is performed to confirm nonvertex
presentation and adequacy of amnionic fluid
volume, to rule out obvious fetal anomalies if
not done previously, and to identify placental
location
 External monitoring is performed to assess
fetal heart rate reactivity.
 The nonstress test is repeated after version
until a normal test result is obtained

56.  FORWARD ROLL
 Each hand grasps one of the fetal poles, and
the buttocks are elevated from the maternal
pelvis and displaced laterally.
 The buttocks are then gently guided toward
the fundus, while the head is directed
toward the pelvis
 BACKWARD FLIP

57.  CONDUCTION ANALGESIA- increased success
with version when epidural analgesia is used
ACOG> not enough evidence to recommend
conduction analgesia routinely for external
version
 TOCOLYSIS- uterine relaxation with a
tocolytic agent such as betamimetics
(terbutaline),ritodrine, salbutamol, calcium
channel blockers (nifedipine), nitric oxide
donors (nitoglycerin )
 ACOG > recommends 250 g terbutaline SC
before version attempt

58. COMPLICATIONS
 1.placental abruption
 2.uterine rupture
 3.amnionic fluid embolism
 4.fetomaternal hemorrhage
 5. alloimmunization
 6.preterm labor
 7.fetal distress
 8.fetal demise

59. INTERNAL VERSION
 accomplished inside the uterine cavity
 used only for delivery of a second twin

60. INTERNAL VERSION
 insertion of a hand into the uterine cavity to turn
the fetus manually.
 the operator seizes one or both feet and draws
them through the fully dilated cervix while using
the other hand to transabdominally push the
upper portion of the fetal body in the opposite
direction.
 The operation is followed by breech extraction

61. THANK YOU!