Complete breech

Introduction

A fetus is said to be in a breech presentation when the

buttocks of the baby are presenting first at the bottom
of the uterus, and the head is in the upper part, or
fundus of the uterus.
A breech birth is the birth of a baby from a breech
presentation. In the breech presentation the baby
enters the birth canal with the buttocks or feet first as
opposed to the normal head first presentation.
A malpresentation of the FETUS at near term or
during OBSTETRIC LABOR with the fetal cephalic
pole in the fundus of the UTERUS.
BREECH PRESENTATION occurs when the buttocks
and/or the feet are the presenting parts.
Usually a few weeks before birth, most babies will
move into delivery position, with their head moving
near the birth canal. If this does not happen, the baby's

buttocks and/or feet will be in place to be delivered

first. This is called a breech presentation.
Incidence of breech presentation

Breech presentation occurs in 3-4% of all deliveries. The

percentage of breech deliveries decreases with advancing
gestational age.
1. Gestational age 21 to 24 weeks: 33% breech
2. Gestational age 25 to 28 weeks: 28% breech
3. Gestational age 29 to 32 weeks: 14% breech
4. Gestational age 33 to 36 weeks: 9% breech
5. Gestational age 37 to 40 weeks: 7% breech
Risk Factors
6. Prematurity
7. Multiple pregnancies
8. Polyhydramnios or oligohydramnios
9. Uterine abnormalities
10. Fetal abnromalities (e.g. hydrocephaly,
anencephaly, Down Syndrome and other congenital
abnormalities)
11. Macrosomia
12. Twin Gestation
Causes

Certain factors can encourage a breech presentation.

Prematurity is likely the chief cause. Twenty five percent of
fetuses are in the breech position at 32 weeks gestation; this
drops to three percent at term. The increasing size of the
fetus near term traps the fetus into the head down position
normally. Pregnancies ending in preterm birthsimply recruit
more breeches before they can turn to head down.
There is no such conform causes of breech presentation.
But the following circumstances favour breech
presentation.

In subsequent
pregnancies(Due to lack of
tone in uterus)
In multiples pregnancies
When there is history of
premature delivery
In an abnormal shaped uterus
or a uterus with abnormal
growths, such as fibroids.
Contracted pelvis
For women with placenta
previa
Polyhydramnious/
oligohydramnious
Hydrocephaly
Relative or absculate short
cord

Types of breeches
There are four main categories of breech births:
Complete breech (10-15%) ( Hips flexed, knees flexed
(cannonball position).)
The baby's hips and knees are flexed so that the baby is
sitting crosslegged, with feet beside the bottom. The
presenting part consists of two buttocks, external
genitalia and two feet. It is commonly present in
multiparae.
Frank breech (Breech with extended legs) The breech
presents with the hips flexed and legs extended on the
abdomen (with feet near the ears). 65-70% of breech
babies are in the frank breech position. . The frank
breech presentation is the most common and the safest
position for a baby to be in if a vaginal delivery is to be
attempted.
Footling breech (35-45%) ( One or both hips
extended, foot presenting.)
One or both feet come first, with the bottom at a higher
position. This is rare at term but relatively common with
premature fetuses.
Kneeling breech - the baby is in a kneeling position,
with one or both legs extended at the hips and flexed at
the knees. This is extremely rare.

(Incomplete: This is due to varying degrees of extension of

thighs or legs at the podalic pole eg Frank breech, Footling
breech, Kneeling breech.)

Diagnosis
During antenatal period
A few weeks prior to the due date, the health care provider
may place his/her hands on the mother's lower abdomen to
locate the baby's head, back, and buttocks. If they think the
baby is in a breech position, an ultrasound may be used to
confirm. Special x-rays can also determine the baby's
position and measure the pelvis to determine if a vaginal
delivery of a breech baby may be attempted.
On abdominal palpation

Longitudinal Fetal Lie

Firm lower pole
Limbs to one side
Hard head at uterine fundus. Head may be obscured by
maternal ribs

Auscultation
Breech Fetal heart best heard above Umbilicus
Diagnosis During labour

On abdominal examination, the head is felt in the

upper abdomen and the breech in the pelvic brim.
Auscultation locates the fetal heart higher than
expected with a vertex presentation. Breech Fetal heart
best heard above Umbilicus
On vaginal examination
o

o
o
o
o

Thick, dark meconium is normal.

No hard head palpated in pelvis
Fontanels and Sutures not palpable
Soft buttocks palpated with hard irregular sacrum
Feet may be presenting part in pelvis
Complete breech

Frank breech

Per abdomen
Fundal grip

Head suggested by
Irregular small part of the feet
hard and globular mass may be felt by the side of the
head.
Head is ballotable

Head is non ballotable due to

splinting action of the legs on
the trunk

Lateral grip
Fetal back is to one
side and the irregular
limbs to the other

Irregular parts are less felt on

the side.

Breech suggested by
soft, broad and
irregular mass.

Small hard and conical mass is

felt

Pelvic grip

F.H.S.

Breech is usually not

engaged during
pregnancy.

The breech is usually engaged.

Usually located at a
higher level round
about the umbilicus.

Located at a lower level in the

middle due to early engagement
of the breech.

Per vaginam Palpation of ischial

Palpation of ischial tuberosities,
tuberosities, sacrum
anal opening and sacrum only.
and feet by the sides of
the buttocks.

Management

During antenatal Period:

o Evaluate for cause in all breech presentation
o Consider postural Exercises for patient
Technique 1: Knee chest
Knee-chest position for 15 minutes
Repeat 3 times daily for 5 days
Consider pelvic rocking while performing
Technique 2: Deep trendelenburg position
Patient supine with hips elevated 9-12 inches
Perform 10 minute, once to twice daily
Consider pelvic rocking while performing
o Identification of the complicating factors related
with breech presentation
o External cephalic version, if not contraindicated
o Formulation of the line of management, if the
version fails or is contraindicated. The pregnancy is
to be continued with usual check up.Two methods
of delivery can be planned.
To perform an elective CS.
To allow spontaneous labour to start and vaginal
delivery to occur.
Management during labour
Footling or Incomplete Breech

-Cesarean Section
Frank or Complete Breech
-Attempt External Cephalic Version if:

breech presentation is present at or after 37 weeks

(before 37 weeks, a successful version is more
likely to spontaneously revert back to breech
presentation);
vaginal delivery is possible;
membranes are intact and amniotic fluid is
adequate;
There are no complications (e.g. fetal growth
restriction, uterine bleeding, previous caesarean
delivery, fetal abnormalities, twin pregnancy,
hypertension, fetal death).

-If external version is successful, proceed with normal

childbirth
-If external version fails proceed with vaginal breech
delivery (see below) or caesarean section.
Complete Breech with foot protruding through cervix
Dangerous! (Very high risk)
Emergent Cesarean section

VAGINAL BREECH DELIVERY

Three types of vaginal breech deliveries are described, as

follows:
Spontaneous breech delivery: No traction or
manipulation of the infant is used. This occurs
predominantly in very preterm deliveries.
Assisted breech delivery: This is the most common type
of vaginal breech delivery. The infant is allowed to
spontaneously deliver up to the umbilicus, and then
maneuvers are initiated to assist in the delivery of the
remainder of the body, arms, and head.
Total breech extraction: The fetal feet are grasped, and
the entire fetus is extracted. Total breech extraction
should be used only for a noncephalic second twin; it
should not be used for singleton fetuses because the
cervix may not be adequately dilated to allow passage of
the fetal head. If the feet prolapse through the vagina,
treat expectantly as long as the fetal heart rate is stable to
allow the cervix to completely dilate around the breech.
Total breech extraction for the singleton breech is
associated with a birth injury rate of 25% and a mortality
rate of approximately 10%.

Ideally, every breech delivery should take place in a

hospital with surgical capability.
A vaginal breech delivery by a skilled health care
provider is safe and A vaginal delivery may be
attempted for a baby in the breech position if:

The baby is in a frank breech position its hips are

bent and its legs extend up.
Fetus is not too large or the baby is small enough
(usually under 8 pounds) to pass easily through the
vagina.
Adequate clinical pelvimetry
The pregnant woman has no previous
caesarean section for cephalopelvic
disproportion and no obstetrical problems,
such as placenta previa, that might complicate
the delivery.
The pregnant woman's pelvis is a normal or above
average size.
The baby has already descended well into the
pelvis as labor begins.
The baby's head is tucked down toward its chest not extended.

Examine the woman regularly and record progress on

a partograp.
If the membranes rupture, examine the woman
immediately to exclude cord prolapse.
Note: Do not rupture the membranes.
If the cord prolapses and delivery is not imminent,
deliver by caesarean section.

If there are fetal heart rate abnormalities (less than 100

or more than 180 beats per minute) or prolonged
labour, deliver by caesarean section.
Note: Meconium is common with breech labour
and is not a sign of fetal distress if the fetal heart
rate is normal.

The woman should not push until the cervix is fully dilated.
Full dilatation should be confirmed by vaginal
examination.

CAESAREAN SECTION FOR BREECH

PRESENTATION

A caesarean section is safer than vaginal breech

delivery and recommended in cases of:
- Double footling breech;
- Small or malformed pelvis;
- Very large fetus;
- Previous caesarean section for cephalopelvic
disproportion;
- Abnormal uterine contraction
- Maternal and fetal distress

- Hyper extended or deflexed head.

Note: Elective caesarean section does not improve the
outcome in preterm breech delivery.

COMPLICATIONS
Mother
Rupture of uterus may occur during version.
Prolonged labour
Premature Rupture of Membranes
Obstructed labour due to impacted breech.
Cord prolapse may occur, particularly in the
complete, footling, or kneeling breech. This is caused
by the lowermost parts of the baby not completely
filling the space of the dilated cervix.
Traumatic post partum haemorrhage
Baby
Lower Apgar scores, especially at 1 minute, are
more common with vaginal breech deliveries.
Oxygen deprivation may occur from either cord
prolapse or prolonged compression of the cord
during birth, as in head entrapment
Injury to the brain and skull may occur due to the
rapid passage of the baby's head through the
mother's pelvis.

 Birth trauma as a result of extended arm or head,

incomplete dilatation of the cervix or cephalopelvic
disproportion.
Broken neck.
Edematous external genitalia in male.
.
Technique and tips for assisted vaginal breech delivery
Leave the fetal membranes intact as long as possible to act
as a dilating wedge and to prevent overt cord prolapse.
Oxytocin induction and augmentation are controversial. In
many previous studies, oxytocin was used for induction and
augmentation, especially for hypotonic uterine dysfunction.
However, others are concerned that nonphysiologic forceful
contractions could result in an incompletely dilated cervix
and an entrapped head.
An anesthesiologist and pediatrician should be present for
all vaginal breech deliveries. A pediatrician is needed
because of the higher prevalence of neonatal depression
and the increased risk for unrecognized fetal anomalies. An
anesthesiologist may be needed if intrapartum
complications develop and the patient requires general
anesthesia.
Perform an episiotomy when the breech delivery is
imminent. This is advocated by many authors for all breech
deliveries, even in multiparas, to prevent soft tissue
dystocia (see Images 2-3).

The Pinard maneuver may be needed with a frank breech to

facilitate delivery of the legs, only after the fetal umbilicus
has been reached. Pressure is exerted against the inner
aspect of the knee. Flexion of the knee follows, and the
lower leg is swept medially and out of the vagina. No
traction should be exerted on the infant until the fetal
umbilicus is past the perineum, after which time maternal
expulsive efforts should be used along with gentle
downward and outward traction of the infant until the
scapula and axilla are visible (see Image 4).
Use a dry towel to wrap around the hips (not the abdomen)
to help with gentle traction of the infant (see Image 5). An
assistant should exert transfundal pressure from above to
keep the fetal head flexed.
Once the scapula is visible, rotate the infant 90 and gently
sweep the anterior arm out of the vagina by pressing on the
inner aspect of the elbow (see Images 6-7). Rotate the
infant 180 in the reverse direction, and sweep the other
arm out of the vagina. Once the arms are delivered, rotate
the infant back 90 so that the back is anterior (see Image
8).
The fetal head should be maintained in a flexed position
during delivery to allow passage of the smallest diameter of
the head. The flexed position can be accomplished by using
the Mauriceau Smellie Veit maneuver, in which the
operator's index and middle fingers lift up on the fetal
maxillary prominences, while the assistant applies
suprapubic pressure (see Image 9).

Alternatively, Piper forceps can be used to maintain the

head in a flexed position (see Image 10). In many early
studies, routine use of Piper forceps was recommended to
protect the head and to minimize traction on the fetal neck.
Piper forceps are specialized forceps that are placed from
below the infant and, unlike conventional forceps, are not
tailored to the position of the fetal head (ie, pelvic, not
cephalic, application). The forceps are applied while the
assistant supports the fetal body in a horizontal plane.
During delivery of the head, avoid extreme elevation of the
body, which may result in hyperextension of the cervical
spine and potential neurologic injury (see Images 12-13).

(Enlarge Image)

Media file 1: Footling breech

presentation. Once the feet have
delivered, one may be tempted to pull
on the feet. However, a singleton
gestation should not be pulled by the
feet because this action may
precipitate head entrapment in an
incompletely dilated cervix or may
precipitate nuchal arms. As long as
the fetal heart rate is stable and no
physical evidence of a prolapsed cord
is evident, management may be
expectant while awaiting full cervical
dilation.

(Enlarge Image)

(Enlarge Image)

Media file 2: Assisted vaginal breech

delivery. Thick meconium passage is
common as the breech is squeezed
through the birth canal. This is
usually not associated with
meconium aspiration because the
meconium passes out of the vagina
and does not mix with the amniotic
fluid.
Media file 3: Assisted vaginal breech
delivery. The Ritgen maneuver is
applied to take pressure off the
perineum during vaginal delivery.
Episiotomies are often performed for
assisted vaginal breech deliveries,
even in multiparous women, to
prevent soft tissue dystocia.
Media file 4: Assisted vaginal breech
delivery. No downward or outward
traction is applied to the fetus until
the umbilicus has been reached.

(Enlarge Image)
Media file 5: Assisted vaginal breech
delivery. With a towel wrapped
around the fetal hips, gentle
downward and outward traction is
applied in conjunction with maternal
expulsive efforts until the scapula is

(Enlarge Image)

reached. An assistant should be

applying gentle fundal pressure to
keep the fetal head flexed.
Media file 6: Assisted vaginal breech
delivery. After the scapula is reached,
the fetus should be rotated 90 in
order to deliver the anterior arm.

(Enlarge Image)
Media file 7: Assisted vaginal breech
delivery. The anterior arm is followed
to the elbow, and the arm is swept out
of the vagina.
(Enlarge Image)

(Enlarge Image)

Media file 8: Assisted vaginal breech

delivery. The fetus is rotated 180,
and the contralateral arm is delivered
in a similar manner as the first. The
infant is then rotated 90 to the
backup position in preparation for
delivery of the head.
Media file 9: Assisted vaginal breech
delivery. The fetal head is maintained
in a flexed position by using the
Mauriceau maneuver, which is
performed by placing the index and

(Enlarge Image)

(Enlarge Image)

middle fingers over the maxillary

prominence on either side of the
nose. The fetal body is supported in a
neutral position, with care to not
overextend the neck.
Media file 10: Piper forceps
application. Piper forceps are
specialized forceps used only for the
after-coming head of a breech
presentation. They are used to keep
the fetal head flexed during
extraction of the head. An assistant is
needed to hold the infant while the
operator gets on one knee to apply
the forceps from below.

Media file 11: Assisted vaginal breech

delivery. Low 1-minute Apgar scores are
not uncommon after a vaginal breech
delivery. A pediatrician should be present
(Enlarge Image) for the delivery in the event that neonatal
resuscitation is needed.
Media file 12: Assisted vaginal
breech delivery. The

2. Management

Conclusions
Vaginal breech delivery requires an experienced
obstetrician and careful counseling for the parent(s).
Although studies on the delivery of the preterm breech are
limited, the recent multicenter term breech trial found an
increased rate of perinatal mortality and serious immediate
perinatal morbidity.
Parents 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 term
breeches and that vaginal breech deliveries will no longer
be performed.
ECV is a safe alternative to vaginal breech delivery or
cesarean delivery, reducing the cesarean delivery rate for
breech by 50%. The ACOG, in its 2000 Practice Bulletin,
recommends offering ECV to all women with a breech
fetus near term. 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, assess
for any underlying fetal abnormalities or uterine conditions
that may result in a malpresentation.