Management of Breech

Presentation
By
Dr Dambo
 Introduction
• The management of breech presentation is an
area of intense controversy.
• A variety of committed opinions have been
expressed on every aspect of management
from the mode of delivery (once a breech always
a cesarean section) to the place of external
cephalic version in modern management.
• The most fundamental shift in opinion over the
last 10-15 years has been the realization that
breech presentation may well be a bad
prognostic variable of itself hence caution.
• Management involves:-
-History taking
-Physical examination
-Laboratory investigations
-Treatment
Based on clinical presentation, usually an
incidental finding on abdominal examination.

Palpation:- soft
- globular,
- non ballotable fetal part at the lower
uterine pole
- and a hard, rounded and ballotable
part felt above the umbilicus (uterine fundus).
- Difficulties in making a diagnosis by
palpation arise when the anterior abdominal wall
is obese and polyhydramnios present.
Auscultation:- the area of greatest intensity
of the fetal heart sounds is above the level
of the maternal umbilicus although if the
legs are extended, the sounds tend to be
heard at a lower level.
Vaginal examination:- fetal buttocks,
ischial tuberosities, the sacrum and the
anus are felt, if cervix is dilated and
membrane ruptured, feet felt alone or
close to buttocks, cord may also be felt.
INVESTIGATIONS:
• Pelvic u/scan: confirm breech presentation
- R/o PDF (fetal cong. Abn, p.praevia,
multiple preg)
- Estimate fetal weight
• Pelvimetric assessment:
clinical pelvimetary, x-ray pelvimetary
(plain abdo x-ray, CTScan, MRI) –
Role in the management of breech is
controversial:- has not changed the
incidence of c/s
MODE OF DELIVERY:
The management of breech presentation
remains controversial due to the
associated high perinatal morbidity and
mortality following breech deliveries.
Options employed to reduce the perinatal
mortality and improve the maternal and
fetal outcome include:-
-Caesarean section
-vaginal breech delivery
-External cephalic version (E.C.V)
E.C.V
is a manipulative transabdominal
conversion of an abnormal presentation to
cephalic presentation.
Arguments:
Those in favour of E.C.V say it has
reduced the incidence and therefore the
risk factors associated with vaginal breech
delivery or caesarean section.
While those against E.C.V say its
complications outweigh its benefits
- prelabour rupture of fetal membranes
-cord prolapse
-premature labour,
- prematurity
-fetal heart rate abnormalities
-abruptio placenta
-cord entanglements
-uterine rupture
when E.C.V is considered it is carried out only at term and after
exclusion of contraindications such as; placenta praevia, multiple
pregnancy, PROM, APH, PIH, Previous c/s, prematurity and
contraindications to vaginal delivery.
STEPS: E.C.V to be done in labour ward unit or theatre.
1. Obtain consent after explaining procedure to the woman
2. u/scan to R/O contraindications.
3. Maternal B.P measurement.
4. Fetal heart rate measurement (b/4 and after procedure):- non
stress test (CTG)
5. Tocolytics (eg salbutamol, ritodrine) for uterine relaxation.
6. Mother placed in a steep lateral position with her back supported
with a cushion or in a supine position and comfortable.
7. Breech disengaged from pelvic inlet using both hands, E.C.V
carried out when breech is above the inlet.
8. One hand on lower pole, other on upper pole, manipulate in the
direction which increases flexion of the fetus and makes it do a
forward somersault, bringing the head to the lower uterine pole.
9. On completion of version the fetus is steadied by lateral
pressure while the mother is transferred to the supine or
semi-recumbent position.
10. Check fetal heart rate after procedure.
N/B: If procedure fails or becomes difficult, it is
abandoned.
it is easier to perform ECV in multiparous women due to
laxity of uterus and abdominal wall.
No place for E.C.V in preterm – high failure rate.
E.C.V at term is what is recommended - to allow for
spontaneous version (reversion less likely, if successful),
delivery of term baby in case of spontaneous labour or
complications that require C/S, other unidentified P.D.F
would have become obvious, associated with higher
success rate,
ECV success rate is between 25-97% of breech
presentation.
Factors influencing success of E.C.V
Maternal: parity - higher in multiparity
Race - higher in black women -
due to late engagement
Fetal: type of breech - flexed>frank
descent of presenting part
CAESAREAN SECTION:

Due to the high perinatal mortality and

morbidity associated with breech presentation,
the global trend now for breech delivery is C/S

Recent randomised controlled trial (Mary

Hannah in Canada) has shown that planned c/s
is better than V.B.D, however in our society
where there is an aversion for c/s, and where
women with previous c/s attempt vaginal
delivery to avoid repeat c/s outside the hospital
with the possible risk of uterine rupture, liberal
c/s for breech delivery is not justified.
INDICATIONS FOR C/S IN BREECH
PRESENTATION:
1. Previous c/s
2. P.I.H
3. B.O.HX
4. Previous infertility
5. Contracted pelvis
6. Primigravida breech with inadequate pelvis
7. Elderly primigravida
8. Preterm breech,
9. Footling breech
 Vaginal Breech Delivery
• 3 options
-Spontaneous vaginal breech delivery
-Assisted breech delivery
-Total breech extraction
 Vaginal breech delivery
In modern obstetric practise there is no place for
S.V.B.D
A.V.B.D is the choice of delivery but in well
selected cases (women properly assessed:-
R/O P.D.F, C/I to V.D)
Scoring index for A.V.B.D:- Zatuchni-Andros
breech Scoring index
Parameters of index:- Parity, cervical dilatation,
Previous V.B.D, gestational age, estimated fetal
weight, and station of the presenting part.
STEPS IN A.V.B.D:-
• Transfer to 2nd stage room when fully dilated
• Place in lithotomy position and cleanse lower
abdomen, vulva, vagina and thighs with swabs
soaked in hibitane soln.
• Apply sterile drapes to isolate the vulva

4. Empty bladder with a plastic catheter and repeat

V.E to confirm full cervical dilatation.
5. With each contraction she is encouraged to bear
down while the descent of the breech is
observed without interference
6.The perineum is infiltrated with 10mls of 1%
xylocaine
7. A left mediolateral episiotomy is given as
the breech distends the perineum, the
descent of the baby allowed to continue
until the umbilicus and popliteal fossa
become visible
8. Each extended lower limb is delivered
by the pinard’s manoeuvre (pressure
applied with two fingers to the popliteal
fossa to flex the knee and gently abduct
and flex the thigh)
9. Mother encouraged to bear down until the
trunk, up to the scapula becomes visible,
cord pulsation checked and a loop of cord
pulled down to prevent cord compression

10. Baby gently held by the groin and trunk

rotated 90o in one direction with a
downward traction applied and the back
facing upwards to deliver the anterior
shoulder (lovset maneouvre for extended
arms)
11. Procedure repeated in the opposite
direction, with a rotation of 1800 to deliver
the posterior shoulder.
12. Mother further encouraged to bear down until
the hair lines is visible (the nape of the neck
become visible) under the pubic symphysis
13. The aftercoming head is delivered by one of
the following methods:
- Mauriceau-Smellie-Veit manoeuvre (jaw
flexion and shoulder traction)
- Burns Marshall
- Obstetric forceps (piper’s)
The most important aspect of V.B.D is
delivery of the aftercoming head
 Zatuchni Andros scoring index(1965)
parameter Score 0 Score 1 Score 2

parity 0 1 >2

Gestational age 39+ 38 < 37

(weeks)
Previous vag 0 1 2
breech delivery
Estimated fetal > 4.0 3.5-4.0 < 3.5
weight (kg)
Cervical os 2 3 >4
dilatation (cm)
Station of -3 -2 -1
presenting part
• Score 0-4 - Caesarean delivery recommended
• Score > 5 – allow vaginal breech delivery
• At times in preterm breech presentation
the incompletely dilated cervix may cause
aftercoming head to be entrapped.
-Gentle downward traction on the
shoulders combined with fundal pressure
by an assistant may effect delivery.
-If this fails Duhrssen`s incisions is
considered, which is incision made at 6
o`clock on the cervix with addition if
necessary at 2 and 10 o`clock.
BREECH EXTRACTION:
No maternal effort in V.B.D (breech extraction)
Mother under general or regional anaesthesia
INDICATIONS:
- Retained 2nd twin with breech presentation
- Transverse lie (do prior internal podalic
version, then breech extraction)
- I.U.F.D with breech presentation
COMPLICATIONS OF A.V.B.D
- Trauma to fetal head (I.C.H)
- Fractured limbs (clavicular #, humerus #,
shoulder dislocation)
- Dislocation of the neck
 Other methods of achieving
spontaneous version
• Mousi Burston manouvre used by the
chinese – where they burn a herb on the
patient feet to achieve version.
• Elkin’s manouvre – patient is advised to
be in repeated knee-chest position to
encourage spontaneous version
 Conclusion
• Vaginal breech delivery requires an experienced
obstetrician and careful counseling for the
parent(s).
• Patients must be informed about potential risks
and benefits to the mother and neonate for both
vaginal breech delivery and cesarean delivery.
The likelihood is high that the trend will continue
toward 100% cesarean delivery for breeches
and that vaginal breech deliveries will no longer
be performed.
 Conclusion Contd
• ECV is a safe alternative to vaginal breech
delivery or cesarean delivery, reducing the
cesarean delivery rate for breech by 50%.
Consider adjuncts such as tocolysis, regional
anesthesia, and acoustic stimulation to improve
ECV success rates. Before performing a delivery
or ECV on a mother whose fetus is in a breech
presentation, evaluate why the fetus is breech.
The position may represent a marker for an
underlying fetal anomaly.
Thank you