BREECH

OBSTETRICS
DR. RAYMUNDO
AUGUST 11, 2016

TERMS: *During lithotomy:

FETAL LIE  The patients right is the doctors left side
 Longitudinal  Identification as to the site of location is in the
 Transverse MOTHERS SIDE
 oblique ATTITUDE
 Relationship of the fetal long axis to that of the mother  Relationship of the different parts of the fetus to the
 Eg: if fetus is in the transverse lie - TRANSVERSE mother
 Flexion
FETAL PRESENTATION  Extension
 Portion of the fetal body that is leading towards the  In breech
uterus o Need to determine if thigh is extended or
o Cephalic – head of the baby is way down on flexed
the lower segment of the uterus o Hips- extended or flexed
 IE:can palpate the fetal head
o breech *the more premature the higher the chance it is a breech
 IE: palpate for the anal structure  Prevelance of breech presentation by gestational age
of delivery
FETAL ATTIDUTE/ POSTURE  Near term, the fetus turns
 Fetus becomes folded / bent upon itself o Spontaneously to a cephalic presentation
 Relationship of the small parts to the body of the fetus o Bulk of the butttucks seeks the more
 There are times that the fetal part is extended or spacious funds
flexed in posture
CLASSIFICATION OF BREECH
FETAL LIE  Frank (50-70%)
 Longitudal lie  Complete (5-10%)
o Cephalic  Incomplete (10-30%)
o Breech o Footling
 Transverse lie
o shoulder
 Different on attitude / posture of the fetal body
o Vertex
o Sinciput
o Brow
o Face
*position is in cephalic and would like to know occiput (where
fetal head is located in the pelvic canal)
 Upper or lower quadrant?
 Left or right side?

FETAL POSITION FRANK BREECH PRESENTATION

 Relation of an arbitrary chosen portion of the fetal  Lower extremities
presenting part to the right o Flexed at the hips
o Extended at the knees
POSITION OF TRANSVERSE LIE  Feet lie in close plroximity to the head
 Right acromion  IE: ischial tuberosities, sacrum, anus
 Dorsoanterior (RADA) and dorsoposterior (RADP)
*transverse COMPLETE BREECH
 Identify  Lower extremities
o Shoulder or acromion o Flexed at the hips
o Scapular o One/ both knees are flexed
o Left or right o Extended thighs
o Anterior or posterior baby (RADA OR RADP)
INCOMPLETE FOOTLING
DENOMINATOR AND DETERMINING POINTS  Lower extremities
 Most important o One/ both foot
 Bony fixed point on the presenting part which comes in *the more premature the baby the greater the chance that it is in
relation with the various quadrants of maternal pelvic breech
 Determining points *as the pregnancy progress there will be a change on the
o Vertex presentation- it will be more of a cephalic presentation
o Face – try to palpate for: *higher chance of cephalic presentation in TERM BABIES
 Chin -in early stage of pregnancy the uterus is shaped as if
 Mentum upside down (bigger upper than lower part (inverted truangle))
BREECH or TRANSVERSE LIE: -BASE -is in the fundal area of the uterus
 Longitudinal lie -APEX-lower segment of the uterus
 Vertex *the breech part of the fetus will always seek and position itself to
 Left occiput anterior a bulkier portion of the uterus therefore during the early stage of
 Transverse lie the pregnancy it will be at the breech part will always occupy the
o Acromion bigger area
*as the pregnancy progress the baby will position itself to a
 Breech presentation
o Sacrum cephalic presentation

REVIEW!

ijdcarmona 1
DIFFERENT TYPES OF BREECH side of the abdomen
1FRANK BREECH  THIRD MENEUVER: determine what is present in the
 Most common lower segment of the uterus
 Lower extremities *if ballotable structure in leopolds 1- have to
o Flexed area at the hips appreciate an irregular structure in the leopolds 3
o Extended part in the knee  FOURTH MANEUVER: appreciate the position of the
o Letter F position presenting part
o FOOT: infront of the face- because of o Engaged or not engared
extended areas of the thighs and hips o Done by: Digging the examining hand down
 IE: will not be able to appreciate foot to the pelvic cavity
o Appreciate  If the hand wont meet each
 genital area other on the lowest point of the
 anal area cavity – ENGAGED
 tuberosity *computation for fetal expected weight (STEPS:)
o Subtract11 or 12 on the computation
2 COMPLETE BREECH depending if the presenting part s engaged
 flexion at the area of the hips or not
 or one of the knees are flexed  By listening to the fetal heart tone will have an idea if
 IE: can palpate footlike structure the present station is in breech or cephalic
o Breech- UPPER QUADRANTS OF THE
3 INCOMPLETE BREECH UTERUS (area above the umbilicus)
 Footling o Cephalic- LOWER PART OF THE QUADRANT
 IE: plantar surface of the foot
BREECH FACE
*FRANK BREECH:thighs are flexed, legs are extended, thigh area REFERENCE Anus Mouth
flexed towards the abdomen, Ischial tuberosities Malar prominence
*COMPLETE BREECHflexion of the knee part Sacrum
*INCOMPLETE BREECH- different findings appreciate the foot as IE Finger encounters
the presenting part muscular
*upon IE- to check if it is the anus or the mouth upon retraction of
CASES IN WHICH A FEMALE IS MORE PRONE TO A BREECH the finger and there is meconium- ANUS
1. OLGOHYDRAMNIOS *Correlate the abdominal examination from the internal
 Small amount of amniotic fluid examination
2. HYDROCEPHALY *start with abdominal examination because it gives you an idea
3. MULTIPARA- chances that one of the babies are in before IE
breech
4. PLACENTA that are located in the fundal area DIAGNOSIS:
*a lot of cases where placenta previa was identified in UTZ and  Vaginal exam
once in labor they would be on the breech presentation o Complete breech
5. ANENCEPHALY- absence of skull o Footling breech
6. POLYHYDRAMNIOS *difference between the presence or absence of
7. EARLY OR PREMATURE BABIES the foot
8. CASES WITH HISTORY OF BREECH AND CS *if in doubt go back to LEOPOLDS maneuver
9. FEMALE WITH TUMORS *before examining finger is removed- able to tell
 Eg: myoma if it is in the left sacral finger or right sacral
 Precipitate breech posterior etc
10. FEMALE BORN TO ANOMALIES IN THE MULLERIAN  The fetal sacrum its spinous process are palpated to
DUCT DEVELOPMENT- ending with uterine anomalies establish position
11. SMOKING  Fetal positions
o Reflect relationship of fetal sacrum tu
DIAGNOSIS: maternal pelvis
By:
 Abdominal exam: fetal heart sound IMAGING TECHNIQUES:
o Leopolds maneuver  Indications
 Appreciate location of: o Take note of the presentation of the fetus
 fetal head o Measure the different parts where fetus will
 Lower part be coming out
 Back o Perform pelvimetry- make sure that there is
 extremities enough space for the presenting part of the
o Unengaged fetus to pass through
o Engaged o Assess pelvic dimentions prior to vaginal
 VAGINAL EXAM (IE) delivery (radiographic pelvimetry)
o Examine presenting part o Identify type of a breech
 Wait for the patient to go into  Hyperextended- cant pass
labor through vaginal canal
o No feet o Degree of neck flexion/ extension
o Mistaken  Stargazer fetus/ “flying fetus”
 Anus for mouth o Fetal head may be extreme hyperextension
 Ischial tuberosities o 5% of breech fetuses
o Warrant abdominal delivery
LEOPOLDS MANEUVER (review):  Sonography
 FIRST MANEUVER: Appreciate what is present in the o Sonographic fetal evaluation
fundal area of the uterus -Determine
o Rounded or Ballotable- cephalic  Gross fetal abnormalities
o Hard or irregular structure at the area of (hydrocephaly/ anencephaly)
the fundus- breech  Identify fetuses not suitable for
 SECOND MANEUVER: Back of the fetus vaginal delivery
o Location where fetal heart tone is heard  Large for gestational age /small
o Done by: Gliding the hands at the lateral for gestational age

ijdcarmona 2
  Sonogram uncertain
 Exclusion criteria for planned
vaginal delivery → consider CS
 ≤ 2500g
 ≥3800 to 4000g
 Evidence of growth restriction
 Biparietal diameter (BPD) is ≥
9.0-10 cm- don’t want to
maximize ischial distance-
possibility that the head will not
pass the midpart of the pelvis
 Pelvimetry
o Assess usng CT scan MRI and radiation
o MRI- has less radiation effects than other
imaging techniques
o UTZ: Weight of the fetus
o VALUES THAT WILL WARRANT VAGINAL
DELIVERY:
 Inlet- AP diameter ≥10.5 cm or
105mm
 ≤ 10cm- CS
 Bispinous diameter- ≥10 cm
 Importance- idea how
big will the fetus be
upon coming out
 Parts of the fetus
coming out
-pelvimetry values to permit vaginal deliveries
 Measurements:
o Inlet anteroposterior (AP) diameter
≥105mm
o Inlet transverss diameter ≥120mm
o Midpelvic interspinous diameter (100mm)
 Maternal fetal biometry
o Inlet obstetrical conjugate minus
ROUTE OF DELIVERIES
-vaginal or ceasarian
Factors to determine route
 Fetal characteristics
 Pelvic dimensions
 Coexistent pregnancy complications
 Operator experience
 Patient preference
 Hospital capabilities
FETAL CHARACTER
 Term breech fetus
o Term breech trial (TBT)
-lower neonatal morbidity and mortality
rates planned CS delivery for breech
o WHO
-improved perinatal outcomes associated
with planned CS delivery of termed breech
fetus
o Swedish collaborative breech study group
-lowered neonatal morbidity and mortality
rates with CS delivery
*lower morbidity and mortality in CS
 Term breech fetus
o Presentation et mode de acccouchment
(premoda study)
o No difference in coreected neonatal
mortality rates and neonatal outcomes
according to delivery mode
 Preterm breech fetus
o Planned as delivery is more advantageous
o Mother cant deliver baby at term due to
ijdcarmona
health conditions etc
o National institutes of heath (NIH)
retrospective multicenter cohort study
involving 208, 695, dervatives between 24
o 6 months old baby- survival rate will be low
o When estimated weight is more than 2500g
– more of the weight
*if unsure of the babies delivery do CS
CEASARIAN DELIVERY:
 Can make incision bigger until the baby can pass
through
 Know the presentation of the baby
 More easier than vaginal
COMPLICATIONS EITHER VAGINAL OR ABDOMINAL DELIVERY
MATERNAL MORTALITY AND MORBIDITY
 Large for gestational age baby delivered vaginally-
LACERATIONS
 Death due to aneasthetic effect
 Uterine atony due to manipulation
 Post partum hemorrhage
PERINATAL MORTALITY OR MORBIDITY
 Death of the fetus brought about by the entrapment of
the head
 Intracranial Hemorrhage leading to fetal death due to
manipulations
 ASPHYXIA- Not aware there is a time to deliver baby
 Abruptio placenta
 Damage brachial plexus leading to erbs palsy – one
hand does not move
o Baby can recover as long as it is a stretch
type of nerve
o If cut – paralysis of extremities
 Testicular damage- due to manipulation
DECISION MAKING
 CEPHALIC PRESENTATION- once head is delivered
everything will follow
o Head will fully dilate cervix to accommodate
the rest of the baby
 BREECH PRESENTATION- the next part will be larger
than the breech portion
o Needs to manipulate or do a lot of
maneuvers to deliver the structures after
breech delivery
 Induction of labor can be done in breech delivery but
never to augment delivery
o AUGMENTATION- mother is in labor and
will give something for continuous
contractions that will squeeze out the baby
 Can lead to problems
 End up with:
 Rupture of the uterus
 Fetal death
 Abruption placenta
o INDUCTIONof labor- not yet in labor but is
in 41-42 weeks
 Stimulate cervical ripening and
contraction
 Go into a latent phase of labor-
no need to augment
 But not to the active phase
FACTORS THAT WOULD FAVOR CS
 Placenta previa
 Breech that cant be delivered vaginally because of the
presence of placenta at the vaginal canal or at the
lower portion of the uterus
 Fetal anomaly- large headed fetus
 Hyperextended head
 Large babies ≥3800 to 4000g
3
  Hyperextension of the head- use pipers forceps
 Once the breech will go out- there will be passage of
meconium- indicates that there is intact anus
 Deliver- try to hold on the pelvic portion of the fetus-
makes use of the bony portion of the fetus to pull
baby out of the vaginal canal

NUCHAL ARM
 Trapped arm
 Try to put examining finger inside the vaginal canal and
follow the arm then try to hook it toward the canal
MANAGEMENT IN LABOR
 Deliver upper extremities as much as possible before
head is delivered
3 METHODS ON HOW TO DELIVER VAGINALLY
1 BREECH  Hard to deliver head with the upper extremities due to
 Spontaneous the diameter- can cause fractures
 Stay in the perineal area
MODIFIED FROG MANEUVER
 Observe and protect baby as it goes out- wait
 Deliver head with problem of rotation of the fetus
 Done if the fetal back is seen at the lower part of the
2 PARTIAL BREECH
perineum
 Let the baby go into the spontaneous delivery up to
 Majority: babies back is towards the area of the
the level of the umbilicus then do manipulation
symphysis pubis
3 TOTAL BREECH
 Try to squeeze out the baby as soon as the breech is
coming out try to hook it out the vaginal canal and do
manipulation

USE OF FORCEPS:
 To assist in delivery
 Can have sudden hyperextension at the time of
delivery

DELIVERING BREECH BY CS
 Total breech extraction done by CS

LABOR INDUCTION AND AUGMENTATION

 Always a team

VAGINAL DELIVERY
 Make sure to have intact membranes
 Principle of hands of on breeches- important! Don’t
make a lot of manipulations

MAURITIOUS NELLY HEAD MANEUVER

 Another way to deliver baby
 Support baby in arms
 Insert finger the vaginal canal and appreciate the alar
portion of the fetus with the aid of the other hand try
to hook it at the nape of the fetus and pull it n a
manner that head can be delivered

CARDINAL MOVEMENT OF LABOR DURING BREECH

 There will always be a internal rotation
 If the BPD is in cephalic presentation-
 BITROCHANTERIC diameter is the BPD in breech
o Pelvic area of the fetus will tell us if it is
engaged
 Difference:instead of fetal head- the breech will be
coming out
 The head is born on a flexed position
o Chin is closer to the chest wall
o If not in flexed- need to perform all
maneuvers that is needed

ijdcarmona 4