BREECH_PRESENTATION.ppt The main notions for determining the diagnosis of breech presentation • Specific features of breech presentation

DEFINITION:
• It is a longitudinal lie in which the buttocks is the
presenting part with or without the lower limbs.
Incidence:
3.5% of term singleton deliveries and about 25% of cases
before 30 weeks of gestation as most cases undergo
spontaneous cephalic version up to term

AETIOLOGY:
• In general, the foetus is adapted to the pyriform shape of
the uterus with the larger buttock in the fundus and
smaller head in the lower uterine segment.
• Any factor that interferes with this adaptation, allows free
mobility or prevents spontaneous version, can be
considered a cause for breech presentation as :

CONTI…..
1- Prematurity : due to
- relatively small foetal size,
- relatively excess amniotic fluid, and
- more globular shape of the uterus.
2- Multiple pregnancy: one or both will present by the
breech to adapt with the relatively small room.
3- Poly-and oligohydramnios.
4-Hydrocephalus

5- Intrauterine foetal death.
6-Bicornuate and septate uterus.
7- Uterine and pelvic tumours
8-Placenta praevia

TYPES:
(A) Complete breech:
- The feet present beside the buttocks as both knees and
hips are flexed.
- More common in multipara

(1) Frank breech:
- It is breech with extended legs where the knees are
extended while the hips are flexed.
- More common in primigravida.
(2) Footling presentation:
- The hip and knee joints are extended on one or both
sides.
- More common in preterm singleton breeches.
(3) Knee presentation:
The hip is partially extended and the knee is flexed on one
or both sides

BREECH_PRESENTATION.ppt The main notions for determining the diagnosis of breech presentation • Specific features of breech presentation

POSITIONS : ( 8 POSITIONS)
1- Left sacro- anterior.
2- Right sacro-anterior
3- Right sacro - posterior.
4- Left sacro-posterior.
In addition to
5 left sacro-transverse
6 Right sacro - transverse (lateral).
7 - Direct sacro- anterior
8 Direct sacro posterior

• Sacro-anterior positions are more common than sacro-
posterior as in the first the concavity of the foetal front
fits into the convexity of the maternal spines.

DIAGNOSIS:
(A) During pregnancy:
(I) Inspection:
1. A transverse groove may be seen above the umbilicus in
sacro-anterior corresponds to the neck.
2. If the patient is thin , the head may be seen as a
localised bulge in one hypochondrium.

(II) PALPATION
1. Fundal grip: the head is felt as a smooth, hard, round
ballottable mass which is often tender.
2. Umbilical grip: the back is identified and a depression
corresponds to the neck may be felt.
3. First pelvic grip: the breech is felt as a smooth, soft
mass continuous with the back. Trial to do ballottment
to the breech shows that the movement is transmitted
to the whole trunk

(III) AUSCULTATION:
• FHS is heard above the level of the umbilicus. However
in frank breech it may be heard at or below the level of
the umbilicus

(IV) ULTRASONOGRAPHY
• It is used for the following:
1. To confirm the diagnosis.
2. To detect the type of breech.
3. To detect gestational age and foetal weight:Different
measures can be taken to determine the foetal weight
as the biparietal diameter with chest or abdominal
circumference using a special equation.

4. To exclude hyperextension of the head.
5. To exclude congenital anomalies.
6. Diagnosis of unsuspected twins

(B) DURING LABOUR:
• In addition to the previous findings, vaginal examination
reveals;
1. The 3 bony landmarks of breech namely 2 ischial
tuberosities and tip of the sacrum.
2. The feet are felt beside the buttocks in complete breech.
3. Fresh meconium may be found on the examining fingers.
4. Male genitalia may be felt.

MECHANISM OF LABOUR
Delivery of the buttocks:
- The engagement diameter is the bitrochanteric diameter
10 cm which enters the pelvis in one of the oblique
diameters.
- The anterior buttock meets the pelvic floor first so it
rotates 1/8 circle anteriorly.

- The anterior buttock hinges below the symphysis and the
posterior buttock is delivered first by lateral flexion of the
spines followed by the anterior buttock.
- External rotation occurs so that the sacrum comes
anteriorly

DELIVERY OF THE SHOULDERS:
- The shoulders enter the same oblique diameter with the
biacromial diameter 12 cm (between the acromial
processes of the scapulae).
- The anterior shoulder meets the pelvic floor first, rotates
1/8 circle anteriorly, hinges under the symphysis , then
the posterior shoulder is delivered first followed by the
anterior shoulder.

DELIVERY OF THE AFTER-COMING
HEAD:
- The head enters the pelvis in the opposite oblique
diameter.
- The occiput rotates 1/8 circle anteriorly, in case of sacro-
anterior position and 3/8 circle anteriorly in case of
sacro- posterior position.
- Rarely, the occiput rotates posteriorly and this should be
prevented by the obstetrician

THE HEAD IS DELIVERED BY
MOVEMENT OF FLEXION IN:
1. Direct occipito-posterior (face to pubis).
2. Face mento-anterior.
3. The aftercoming head in breech presentation.
The head is delivered by extension in normal labour only
i.e. occipito - anterior positions

MANAGEMENT OF BREECH
PRESENTATION
(I) External Cephalic Version:
• It regains its importance after increased rate of
caesarean sections nowadays.
Timing:
• After the 32th weeks up to the 37th week and some
authors extend it to the early labour as long as the
membranes are intact and there is no contraindications.

VERSION IS NOT DONE EARLIER
BECAUSE:
1. Spontaneous version is liable to occur.
2. Return to breech presentation is liable to occur.
3. If labour occurs the foetus will have a lesser chance for
survival.

VERSION IS DIFFICULT AFTER 37 TH
WEEKS DUE TO :
1. Larger foetal size.
2. Relatively less liquor.
3. More irritability of the uterus.
The aim :
1. To detect cephalo-pelvic disproportion.
2. Cephalic delivery is safer for the mother and foetus.

SUCCESS RATE:
• 50-70%.
Causes of failure:
1- Large sized foetus.
2- Oligo - or polyhydramnios.
3- Short umbilical cord.
4- Uterine anomalies as bicornuate or septate uterus

5- Irritable uterus. Tocolytic drugs may be started 15
minutes before the procedure to overcome this.
6- Obesity.
7- Rigid abdominal wall.
8- Frank breech because the legs act as a splint.

CONTRAINDICATIONS:
1- Contracted pelvis.
2- Multiple pregnancy.
3- Hydrocephalus.
4- Antepartum haemorrhage.
5- Uterine scar.

6- Hypertension as the placenta is more susceptible to
separation.
7- Elderly primigravida.
8- Ruptured membranes
9-Anaesthesia during version is contraindicated as pain is a
safeguard against rough manipulations

COMPLICATIONS:
1- Accidental haemorrhage due to separation of the
placenta.
2- Rupture of membranes .
3- Preterm labour.
4- Foetal distress.
5- Cord presentation or prolapse.
6- Entangling of the cord around the foetus.
7- Isoimmunization in Rh-negative mothers due to foeto -
maternal transfusion

(II) CAESAREAN SECTION:
Indications:
1. Large foetus i.e. > 3.75 kg estimated by ultrasound.
2. Preterm foetus but estimated weight is still more than
1.25 kg.

3. Footling or complete breech :as the presenting irregular
part is not well fitting with the lower uterine segment
leading to;
- Less reflex stimulation of uterine contractions.
- Susceptibility to cord prolapse.
- Early bearing down as the foot passes through partially
dilated cervix and reaches the perineum.

4. Hyperextended head: diagnosed by ultrasound or X-ray.
5. Contracted pelvis: of any degree.
6. Uterine dysfunction

7. Complicated pregnancy with:
- Hypertension.
- Diabetes mellitus.
- Placenta praevia.
- Pre - labour rupture of membranes for ³ 12 hours.
- Post-term.
- Intrauterine growth retardation.
- Placental insufficiency

• 8. Primigravidas: breech in primigravida equals
caesarean section in opinion of most obstetricians as the
maternal passages were not tested for delivery before.

(III) VAGINAL DELIVERY:
Prerequisites:
1. Frank breech.
2. Estimated foetal weight not more than 3.75 kg.
3. Gestational age : 36-42 weeks

4. Flexed head.
5. Adequate pelvis.
6. Normal progress of labour by using the partogram.
7. Uncomplicated pregnancy.
8. Multiparas.
9. An experienced obstetrician.
10. . In case of intrauteine foetal death

N.B.
During vaginal delivery, prematures are more susceptible
to:
- hypoxia,
- trauma, and
- retained after-coming head as the partially dilated cervix
allows the passage of the body but the less
compressible relatively larger head will be retained

MANAGEMENT OF VAGINAL BREECH
DELIVERY:
• First stage: as other malpresentations.
• Second stage: The foetus may be delivered by one of
the following methods:

(I) SPONTANEOUS BREECH DELIVERY:
• This is rarely occurs in multipara with adequate pelvis,
strong uterine contractions and small sized baby. The
baby is delivered spontaneously without any assistance
but perineal lacerations may occur

(II) ASSISTED BREECH DELIVERY:
- This is the method of delivery in far majority of cases.
- The assistance is indicated for delivery of the shoulders
and after-coming head and the infant is allowed to be
delivered up to the umbilicus spontaneously.

(1) DELIVERY OF THE BUTTOCKS:
- The golden rule is to "Keep your hands off".
- The patient is asked to bear down during uterine
contractions and relax in between until the perineum is
distended by the buttocks

- An episiotomy is done especially in primigravida to avoid
much lateral flexion of the spines, perineal lacerations
and intracranial haemorrhage due to sudden
compression and decompression of the aftercoming
head.
- The legs are hooked out but without traction

- When the umbilicus appears, a loop of the cord is hooked
to prevent traction or compression of the cord and detect
its pulsation.
- The foetus is covered with warm towel to prevent
premature stimulation of respiration

(2) DELIVERY OF THE SHOULDERS:
- Gentle steady downward traction is applied to the foetal
pelvic girdle during uterine contractions with gradual
rotation of the foetus to bring the shoulders in the antero-
posterior diameter of the pelvis.
- When the anterior scapula appears below the symphysis,
both arms are delivered by hooking the index finger at
the elbow and sweep the forearm across the chest of the
foetus

- The back is rotated anteriorly.
- Kristeller manoeuvre: gentle fundal pressure is done
during uterine contractions to guide the head into the
pelvis and maintain its flexion.

(3) DELIVERY OF THE AFTER -COMING
HEAD:
• It is delivered by one of the following methods:

(A) JAW FLEXION- SHOULDER TRACTION
(MAURICEAU- SMELLIE -VIET) METHOD:
- Two fingers of the left hand, (as originally described) or
better on the malar eminencies (the maxillae) to avoid
dislocation of the jaw.
- The index and ring finger of the right hand are placed on
each shoulder while the middle finger is pressing against
the occiput to promote flexion and act as a splint for the
neck , preventing hyperextension and hence cervical
spine injury.

- Traction is commenced downwards and backwards till the
nape of the foetus appears, the body is lifted towards the
mother’s abdomen

(B) BURNS - MARSHALL’S METHOD:
• The foetus is left hanging so that its weight exerts gentle
downwards and backwards traction. When the nape
appears, grasp the feet and left the body towards the
mother’s abdomen.

(C) FORCEPS:
- Piper’s forceps is more suitable than the ordinary forceps
as it has a perineal but not pelvic curve and has longer
shanks. It is applied from the ventral aspect of the
foetus.
- Traction is applied downwards and backwards till the
nape appears, then downwards and forwards to deliver
the head by flexion

- FORCEPS DELIVERY HAS THE
FOLLOWING ADVANTAGES
1. It promotes flexion of the head.
2. Traction is applied on the head and not on the neck.
3. It prevents sudden compression and decompression of
the head.
4. It protects the head from compression by pelvic bones or
rigid perineum

(III) BREECH EXTRACTION:
Indications:
1. Maternal or foetal distress.
2. Prolonged second stage.
3. To shorten the second stage in maternal respiratory and
heart diseases.
4. Prolapsed pulsating cord with fully dilated cervix

TECHNIQUE:
Like assisted breech delivery except that:-
i) It is done under general anaesthesia.
ii) Both legs are bringing down.
iii) Traction on the legs is done helped by fundal pressure
to deliver the breech and the trunk.
iv) The after - coming head is delivered by jaw flexion -
shoulder traction or forceps.

(I) ARREST OF THE BUTTOCKS AT THE
PELVIC BRIM:

(II) ARREST OF THE BUTTOCKS AT THE
PELVIC OUTLET

GROIN TRACTION:
a- Living foetus :
- traction is done by the index or the index and middle
fingers put in the anterior groin in a downward and
backward direction.
- The traction is done towards the trunk to avoid dislocation
of the femur.

- Traction is done during uterine contractions and aided by
fundal pressure.
- When the posterior buttock appears traction is done by
the 2 index fingers in both groins in a downward and
forward direction

B- DEAD FOETUS:
Groin traction is done by breech hook.
Bringing down a leg (Pinard’s method):
- Under general anaesthesia.
- Press by 2 fingers in the popliteal fossa of the anterior leg
to flex it then grasp the ankle and bring it down.This will
prevent the anterior buttock from over-riding the
symphysis pubis.
- If the posterior leg was brought down first it must be
rotated anteriorly with the trunk then bring the other leg
which is now becomes posterior

N.B. THE FOOT HAS THE FOLLOWING
FEATURES DIFFERENTIATING IT FROM
THE HAND:
1-Presence of the heel.
2- Absence of the mobile thumb.
3- The toes are shorter than the fingers

(III) ARREST OF THE SHOULDERS:

CLASSICAL METHOD:
- Under epidural or general anaesthesia.
- As there is more space posteriorly, bring down the
posterior arm first by using 2 fingers pressing against the
cubital fossa and sweep the arm in front of the foetal
body to avoid fracture humerus.
- The anterior arm is then brought down by the same
manoeuvre. If this is difficult rotate the body180o to
make the anterior arm posterior and bring it down.

LÖVSET METHOD:
- Under epidural or general anaesthesia.
- Gentle downward and backward traction is applied to the
foetus by grasping its pelvis till the inferiora ngle of the
anterior scapula appears, the foetal trunk is rotated 180o
to bring the posterior shoulder anteriorly emerging
beneath the symphysis pubis. So the arm can be
brought down.
- The trunk is again rotated 180o in the opposite direction
to bring the other shoulder anteriorly emerging beneath
the symphysis so the second arm can be brought down.

- The back should be kept always anterior during rotation.

(IV) ARREST OF THE AFTER - COMING
HEAD:

PRAGUE MANOEUVRE:
- When the occiput rotates posteriorly and the head
extends, the chin hangs above the symphysis pubis.
- Foetus is grasped from its feet and flexed towards the
mother’s abdomen, while the other hand is doing
simultaneous traction on the shoulders to deliver the
head by flexion

COMPLICATIONS OF BREECH
DELIVERY:
(A) Maternal:
1. Prolonged labour with maternal distress.
2. Obstructed labour with its sequelae may occur as in
impacted breech with extended legs.
3. Laceration especially perineal.
4. Postpartum haemorrhage due to prolonged labour and
lacerations.
5. Puerperal sepsis

(B) FOETAL:
(I) Foetal mortality :
Is about 4% in multipara and 8% in primigravida which may be
due to:
1. Intracranial haemorrhage : is the commonest cause of death
due to sudden compression and decompression of the head
as there is no gradual moulding of the head.
This can be avoided by:
a) Forceps delivery of the after -coming head.
b) Episiotomy.
c) Slow delivery of the head.
d) Vitamin K to the mother early in labour.

2. Fracture dislocation of the cervical spines prevented by
avoiding lifting the body towards the mother’s abdomen
until the nape appears below the symphysis.
3. Asphyxia due to:
i- Cord prolapse or compression by the head.

ii- Premature stimulation of respiration leading to inhalation
of mucus, liquor or blood. This can be avoided by
covering the body of the foetus with warm towels during
delivery.
• 4. Rupture of an abdominal organ : from rough
manipulations avoided by grasping the foetus from its
hips only.

(II) NON-FATAL INJURIES:
1. Fracture femur, humerus or clavicle.
2. Dislocation of joints or lower jaw.
3. Injury to the external genitalia.
4. Brachial plexus injury.
5. Lacerations to the sternomastoid muscles.

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