BREECH

PRESENTATION
DR ISAAC KOJO AMEDIOR
OUTLINE
• CASE PRESENTATION
• INTRODUCTION
• DEFINITION
• TYPES
• INCIDENCE
• AETIOLOGICAL FACTORS
• DIAGNOSIS
• MECHANISM OF LABOUR-BREECH
• MANAGEMENT OF BREECH-ITS INDICATIONS, CONTRAINDICATION AND
COMPLICATIONS
 CASE PRESENTATION
23YRS MB

G1P0

EGA - 37WKS + 4 DAYS

EDD -23/11/23

C/O - LAP ,4/7 LOL- TODAY

HPC CLIENT WITH NO KNOWN CHRONIC ILLNESS REFEERED FROM ANC O/A OF THE ABOVE SYMPTOMS

ODQ: BPV - PFM + , EPIGASTRIC PAINS - , BLURRED VISION - DIZZINESS .HEADACHE - EASYFATIGUABILITY
-,DYSURIA - FREQUENCY + VAGINAL DISCHARGE - , FEVER - CHILLS - , VOMITING -
GYN HX :MENARCHE UNKNOWN MENSES 28 DAY WITH 5 DAYS DURATION , STI -

PAST OBS HX ; NIL OF NOTE

OBS HX : G1 INDEX PREGNANCY

BOOKING DATE 19/04/23

BOOKING BP 132/78MMHG

BOOKING HB - 7.6G/DL

BLOOD GROUP - O POSITIVE

OTHER LABS( SCAN FINDING ) - SINGLE FETUS , FHR- PRESENT , PLACENTA - POSTERIOR HIGH , PRESENTATION - FRANK
BREECH , AFI - 15.2CM , EFW- 3581G

IMP -1. FRANK BREECH IN A NULLIP AT 37WKS + 4 DAY

2.PROM

PLAN + DR MK

TO BE ADMITTED FOR AN EMERGENCY C/S

C/S MED
INTRODUCTION
• WHAT IS PRESENTATION?
It is the part of the fetus that is closest to the birth canal. There are
about three main types of presentation.
Cephalic
Breech
Shoulder presentation
DEFINITION
Breech presentation occurs when the fetus is in the longitudinal lie and
the podalic pole (legs/ buttocks )occupies the lower segment of the
uterus with the legs either extended or flexed. There are three types of
breech presentation:
Complete breech
Incomplete breech
Footling breech
TYPES
• Complete breech occurs when the fetus is in a longitudinal lie and
both the hips and knees are flexed with the buttocks as the
presenting part.
• Incomplete breech/frank breech occurs when the fetus is in a
longitudinal lie with the upper limb flexed and the lower limbs
extended with the buttocks as the presenting part.
• Footling breech occurs when the fetus is in a longitudinal lie with the
podalic pole occupying the lower pole of the uterus. Here the upper
limb is flexed but one or both lower limbs are extended downwards.
Complete breech
Frank breech
Footling breech
INCIDENCE
• Approximately 3-4% of singleton term pregnancies are
complicated by breech presentation.

• About 68% of breech in multiparous women and 36%

in primigravide become cephalic.
 INCIDENCE
• Incidence decreases with increasing gestational age
18-22 weeks : 25%
28-34 weeks : 7-8%
Term : 2.8%
AETOLOGICAL FACTORS
The foetus is adapted to the pyriform shape of the
uterus with the larger buttocks being in the uterine
fundus and the smaller head situated in the lower
uterine segment.
Any factor that: interferes with this adaptation, allows
free mobility of the foetus or prevents spontaneous
version, can be considered a cause of breech
presentation
 AETIOLOGICAL FACTORS

• Maternal /placental
Previous uterine surgery
Placenta praevia
Abnormal volume of amniotic fluid
Uterine abnormalities such as bicornuate, septate uterus
Large pelvic tumors such as uterine fibroids
• Fetal
Fetal anomalies such as hydrocephaly, anencephaly
Multiple pregnancy
Neuromuscular defect
Extended legs
Prematurity
DIAGNOSIS
Breech presentation can be diagnosed antenatally and during
intrapartum.
DIAGNOSIS- ANTENATAL

Diagnosis during antenatal care can be made

by
• History
• Physical Examination
• Investigations
HISTORY
• Identify the predisposing factors:
Previous History of a breech presentation
Previous surgery on the uterus
Multiparity
Pelvic or uterine masses
 ANTENATAL- SYMPTOMS
• She might present with no symptoms but might
complain of:
Kicking in the lower part of the abdomen
Subcostal pain or discomfort
PHYSICAL EXAMINATION
• Diagnosis is mainly made clinically using
abdominal exam(Leopold’s manoeuvre) and
vaginal examination
PHYSICAL EXAMINATION

• Inspection : No abnormal findings

• Palpation: Using the Leopold’s maneuver
• Fundal Grip – Hard, round and mobile structure ,
felt in the uterine fundus and occasionally in the
midline.
• Pawlick’s grip – firm but not bony hard
(buttocks), less rounded than head.
PHYSICAL EXAMINATION
• Auscultation – Fetal heart is usually located at a
higher level; around the umbilicus. When the legs are
extended as in frank breech, it may be heard lower in
the midline due to early engagement.
 PHYSICAL EXAMINATION
COMPLETE BREECH FRANK BREECH

FUNDAL GRIP Head—suggested by hard and globular Irregular small parts of the feet may be felt
mass by the side of the head
Head is ballotable Head is non-ballotable due to splinting
action of legs on the trunk

LATERAL Fetal back is to one side and the Irregular parts are less felt on the side
irregular limbs to the other

PELVIC GRIP Soft, broad and irregular mass. Breech Breech is usually engaged.
is usually not engaged during pregnancy

FETAL HEART Usually located at a higher level round Located at a lower level in the midline due
about the umbilicus to early engagement of the breech
 INVESTIGATIONS
Confirmation of breech presentation is by
• Pelvic ultrasonography.
PELVIC ULTRASONOGRAPHY
• Excludes aetiologic factors and gives added information on the
state of the fetus
• Confirms diagnosis of breech presentation, type of breech
presentation, detects fetal congenital abnormalities as well as
abnormalities of the uterus, estimated fetal weight, biparietal
diameter and gestational age. It also localizes the placenta and
assesses liquor volume.
 INTRAPARTUM
• Diagnosis is made intrapartum mainly by vaginal
examination.
• Late in pregnancy, if cervix is slightly dilated breech
presentation can be confirmed by feeling:
• Presenting part feels less hard and rounded than the
head, no palpable sutures
• Inter gluteal cleft (with membranes ruptured)
• Meconium-stained examining finger
• Foetal sacrum with spines feeling like a ‘string of pearls’
• Foot may be felt in footling breech
INTRAPARTUM -VAGINAL
EXAMINATION
NB – possibility of mistaking lower extremity features on VE
with that of upper body.
• Foot and hands mistaken for each other.
• Fetal anal orifice may be mistaken for mouth in face
presentation
• Buttocks mistaken for caput succedaneum
• Sacrum mistaken for a hard head
MECHANISM OF LABOUR-BREECH
• Lie – Longitudinal
• Presentation – Breech
• Attitude – Complete flexion
• Position – L or R sacro- anterior or posterior
• Presenting part – L or R buttock
• Diameter - Sacrum
MECHANISM OF LABOUR(CONT..)
SACRO ANTERIOR POSITION
The principal movements occur at the buttocks, shoulders and the
head. Each of the three components undergo cardinal movements as
those of normal mechanism - Flexion, descent & engagement of the
breech
The engaging diameter is bitrochanteric (10 cm) with the sacrum
directed toward the iliopubic eminence
MECHANISM OF LABOUR (CONT...)
• Descent of the buttocks occurs until the anterior buttock
touches the pelvic floor.
• Internal rotation of the anterior buttock occurs through
45⁰ placing it behind the symphysis pubis
• Lateral flexion of the trunk occurs until the anterior hip
hinges under the symphysis pubis which is released first
followed by the posterior hip.
MECHANISM OF LABOUR
• 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
• Bisacromial diameter (12 cm) engages in the same
oblique diameter as that occupied by the buttocks
at the brim.
 MECHANISM OF LABOUR
• Descent occurs with internal rotation of the shoulders
bringing the shoulders to lie in the anteroposterior diameter
of the pelvic outlet. The trunk simultaneously rotates
externally through 45⁰.
• Delivery of the posterior shoulder followed by the anterior
one is completed by anterior flexion of the delivered trunk.
• Engagement of the head 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 suboccipitofrontal (10 cm).
MECHANISM OF LABOUR
• Descent with increasing flexion occurs
• Internal rotation of the occiput occurs anteriorly,
through 45⁰ or 90⁰ placing the occiput behind the
symphysis pubis
• Head is delivered by flexion—The expulsion of the
head from the pelvic cavity depends entirely upon
the bearing-down efforts and not at all on uterine
contractions
MANAGING BREECH LABOUR
Three modalities of managing breech labour
• External cephalic version
• Vaginal breech delivery
• Assisted vaginal delivery
• Total breech extraction (usually done for retained
2nd twin)
• Caesarean section
 EXTERNAL CEPHALIC VERSION
External cephalic version is the trans-abdominal
manipulation of a breech-presenting fetus into a
cephalic presentation. It is a procedure that externally
rotates the fetus from a breech presentation to a
cephalic presentation.
It is considered to be a safe and effective procedure to
convert babies from breech to vertex position. It is
usually performed after 37 weeks of gestation when
the fetus is unlikely to turn by itself.
Easier to perform and likely to be successful
if
• Patient is multiparous
• Adequate amount of liquor is present
• Station of the breech is above the pelvic
brim
• Pregnancy is singleton
• Use of tocolytic
INDICATIONS
• Unengaged
• Fetus not too small <2.5 kg or too big > 3.5kg
• Mother and baby should be in good health
• Mother should have adequate pelvis
 CONTRAINDICATIONS
• Absolute
• When vaginal delivery is contraindicated.
• Antepartum haemorrhage or vaginal bleeding within the
last 7 days
• Non-reassuring fetal status shown by abnormal CTG
readings
• Fetus with a hyperextended head
• Ruptured membranes
• Multiple pregnancy, except in the delivery of the second
twin
• Significant fetal or uterine anomalies
 CONTRAINDICATIONS
• Relative
• Intrauterine growth restriction (IUGR) in association
with abnormal umbilical artery Doppler index
• Severe pre-eclampsia
• Oligohydramnios/Polyhydramnios
• Multiple pregnancy, except in the delivery of the
second twin
• Significant fetal or uterine anomalies
PRECAUTIONS
• Procedure should be performed in a labour or delivery
unit.
• An operating room should be ready in case the need
arises for an emergency caesarean section.
• Ultrasound scan should be done to assess fetal
position, amniotic fluid level, placenta location.
• Fetal testing with a nonstress test or biophysical
profile should be done
• ECV should be performed with a tocolytic
 External cephalic version
• The procedure is performed at or after 37 completed
weeks
• The woman is laid flat with a left lateral tilt having
ensured that she has emptied her bladder and is
comfortable.
• With ultrasound guidance, the breech is elevated from
the pelvis and one hand is used to manipulate this
upward in the direction of a forward role, while the
other hand applies gentle pressure to flex the fetal head
and bring it down to the maternal pelvis
ECV - PRECAUTIONS
• A fetal heart rate trace must be performed before and after the
procedure

• ECV should be performed with a tocolytic

PROCEDURE
• If unsuccessful,
• CS
• Vaginal breech delivery
COMPLICATIONS
• Placental abruptio
• Uterine rupture
• Immediate emergency CS
• Cord accidents (Compression/prolapse)
• Fetal bradycardia
• Feto-maternal haemorrhage
• Rupture of membranes
• Spontaneous reversion to breech presentation
VAGINAL BREECH DELIVERY
REQUIREMENTS FOR VAGINAL BREECH DELIVERY
• Average fetal weight: 2.5kg - 3.6kg
• Non-footling breech
• Ruled out hyperextended neck of foetus
• Adequate pelvis
• Availability of an experienced obstetrician
• Absence of any other high risk obstetric factors
FIRST STAGE OF LABOUR
• History and Assessment
• Monitor the active phase of labour with a partograph
• Monitor FHR every 15min or with a CTG monitor
• Secure I/V access; Blood for GXM
• Involve Paediatrician, Anaesthetist, Senior Obstetrician
• Exclude cord prolapse immediately membranes rupture
• If patient starts to bear down before full cervical dilatation, she should
be discouraged from doing so
• Typically breech labour is not augmented to prevent head entrapment
• Adequate analgesia (Epidural/Pudendal block) given
• Deliver via C/S if labour crosses action line on partograph.
 SECOND STAGE OF LABOUR
Delivery is done in this order
• Delivery of the legs and umbilicus
• Delivery of the shoulders and arms
• Delivery of the aftercoming head

• NB: Episiotomy is performed when necessary, rather

than routinely
 DELIVERY OF LEGS

• Flexed Breech
• If the legs are flexed, they will deliver spontaneously.
• Feet & legs present, and may be eased out as they appear and will
deliver spontaneously
• Frank Breech
• Legs are extended, may need to be delivered using the Pinard’s
manoeuvre.
• This involves inserting 2 fingers into the vagina to gain access to the legs
and applying pressure at the popliteal fossa to aid flexion of the legs.
• A loop of cord should gently be pulled down to avoid traction on the
umbilicus
DELIVERY OF SHOULDERS AND ARMS
• The uterine contractions and weight of the body will bring the
shoulders down to the pelvic floor.
• The shoulders will rotate into the A-P diameter of the outlet and as
the anterior shoulder rotates, the scapula becomes visible
• Place a finger on the clavicle of the anterior arm and sweep down
along the humerus to free the arm
• Once the anterior shoulder has been delivered, the buttocks are lifted
towards the mother’s abdomen to enable the posterior shoulder and
arm to pass over the perineum.

• As the posterior arm reaches the pelvic floor, it will rotate into the A-P
diameter and may be delivered in the same way as the first
• When the elbows are not felt on the chest after the umbilicus is born,
a diagnosis of extended arms can be made.

• Extension of the arms occurs because the baby was inappropriately

pulled at some point during delivery
• A delay in delivery from this point will lead to hypoxia of the foetus

• This can be overcome by using the Lovset's manoeuvre

Lovset's manoeuvre : Hold baby’s pelvis in a sterile towel at the iliac
crest with your thumbs on the sacrum, giving a downward traction till
the axilla of the baby is seen. The body is then rotated 180 degrees
maintaining a downward traction and keeping the back uppermost, the
posterior shoulder now becomes the anterior, you then insert your two
fingers into the vagina to splint the humerus to bring down the elbow
to deliver the anterior arm, and in the same way to deliver the next
arm
DELIVERY OF THE HEAD
• Delivery of the head is the most important part of the conduct of
vaginal breech delivery
• Once delivery of the shoulders have been achieved, delivery of the
head should not take longer than 5min, to avoid hypoxia.
• An assistant places his/her hand above the pubic symphysis and gently
presses the fetal head posteriorly and towards the pelvic brim to keep
it flexed and aid its descent through the pelvis until it’s engaged.
• Appearance of the hairline is a confirmation that all of the head is in
the pelvic cavity. From this point on, blood flow in the cord is
presumed to have ceased.
Any one of the following 3 methods can be used to deliver the
aftercoming head:

• Mauriceau-Smellie-Veit

• Burns-Marshall or Liverpool

• Piper Forceps (obstetrics forceps)

Delivery of the head
• Mauriceau-Smellie-Veit manoeuvre (with fetus resting on hand and
forearm, the operator's index and middle fingers lift up the fetal
maxillary prominences and an assistant applies suprapubic pressure)
• The Burns-Marshall method (feet are grasped and with gentle traction
swept in a slow arc over the maternal abdomen).
• Forceps delivery.
Mauriceau–Smellie–Veit manoeuvre
Piper forceps Delivery
PROBLEMS WITH DELIVERY OF THE
AFTERCOMING HEAD
• Delayed descent of the after-coming head:
If there is undue delay in the descent of the aftercoming head,
suprapubic pressure on head with flat of palm might deliver the baby.
• Extended Head
If neck and hairline are not visible after the baby has been allowed to
hang, the head is probably extended. Intervention is by the use of
forceps or Mauriceau-Smellie-Veit manouevre
. Head entrapment
• An acute emergency which usually occurs when the parturient pushes
through an undilated cervix . Usually occurs in preterm delivery or in
a multiparous patient. Speed is needed if the baby has to be saved.
• If the baby is normal and still alive, its pelvis should be grasped and
gentle traction should be exerted on it; this causes the cervix to dilate
and deliver the baby.
• Another technique is to perform Duhrsen’s incision on the cervix at 2,
6 and 10 o’clock positions to allow the baby to pass through the
cervix.
• The 3 and 9 o'clock positions should be avoided due to the risk of
entering the cervical vessels and causing hemorrhage.
 CAESAREAN SECTION DELIVERY
Elective C/S
• Estimated fetal weight >3.6kg
• Hyperextended head
• Footling presentation
• Associated obstetric/medical complication
• Pelvic inadequacy
• Absence of expertise for delivery
Emergency C/S
• Arrest of progress
• Fetal distress
• Cord prolapse
 COMPLICATIONS OF BREECH DELIVERY
Maternal
• Risk of operative delivery and its associated complications
• Risk of infections from maneuvers
• Intrauterine manoeuvres → Rupture of uterus
• Extension of episiotomy
• Genital tract injuries such as vaginal or cervical tears, extension of
episiotomy
• Postpartum haemorrhage
• FOETAL COMPLICATIONS

• Impacted breech
• Cord prolapse/ wrapped around neck
• Birth injuries e.g neck/ shoulder dislocation
• Foetal distress
• Foetal hypoxia → brain damage
• Premature separation of the placenta
• Spinal cord & brachial plexus injuries
• Seizures
• Cerebral palsy
CONCLUSION
Breeches are at increased risk whatever management is employed
ECV is a simple procedure that should be used more than it is
Good evidence now exists that planned C/S is safer for the term
breech than an attempt at vaginal delivery
Management of breech - a highly skilled procedure and this skill must
never be lost. It should be learned by all!
THANK YOU!!!!!