A BREECH PRESENTATION

BY
ARAMBAM ARUNA
BREECH – DELIVERY

Definition: The baby lie longitudinally with the buttocks in the lower pole of the uterus
Varieties/ Type

1.Complete breech
2. Incomplete breech- Frank breech/ breech with extended leg
- Footling breech
- Knee presentation
• Complete breech: The fetal attitude is complete flexion, the thigh are flex at the hip and leg are
flex at the knee. presenting part consist of 2 buttock, external genitalia and 2 feet
Incomplete breech:
• Breech with extended leg/ Frank breech: The thigh are flex on the trunk and leg are extended at
the knee joint. Presenting part consist of buttock and genitalia only
• Footling breech: Both thigh and leg are partially extended bringing the legs to present at the
pelvic brim
• Knee presentation: Thigh are extended but the knees are flexed bringing the knees to present at
the pelvic brim

ETIOLOGY:
• higher incidence of breech in early week of pregnancy
• Factor responsible for BP are- Prematurity
• Factor preventing spontaneous VERSION ( breech with extended leg,twins, oligohydramnios,
short cord, IUD of fetus, congenital malformation of uterus e.g septed uterus
 • Favourable adaptation( hydrocephalus, contracted pelvis, placenta praevia, cornufundal
attachment of placenta)
• Fetal abnormalities(trisomies 13, 18, 21 MYOTONIC DYSTROPHY
DIAGNOSIS:
• Clinical diagnosis( ultrasonography, radiography)
• Abdominal palpation: lie longitudinal with soft and irregular presentation which is usually felt using
pelvic grip-I, at the fundus hard round mass suggestive of head, women may complain discomfort
at the rib while lying down due to pressure of head on the diaphragm.
• Auscultation: if breech has not pass through the pelvic brim, the FHS can be clearly heard above
the umbilicus, when the breech has decend in to the pelvis the FHS can heard at low level.
• Vaginal examination: Palpation of the ischeal tuberosities on either side with the anus in the
middle and the sacrum behind.The breech feel soft and irrigular with no suture.
• USG- to confirm clinical diagnosis, to detect fetal congenital abnormalies, to localise the placenta,
to assist the liquor volume
Mechanism Of Labour:
• The criteria are
• Lie- longitudinal
• Attitude-complete flexion
• Presentation- breech
• Position- Left sacro anterior/right sacro anterior
• Denominator-sacrum
• Presenting part-anterior left buttock
Left sacro anterior- the bitrochanteric diameter 10cm enter the pelvis in the left oblique diameter of
pelvic brim, sacrum point to the left iliopectineal eminence
a. Compaction- decent take place with increase compaction, owing to the increase flexion of limbs

b.Internal rotation of buttocks-the anterior left buttock reaches the pelvic floor 1st and rotate forward
1/8th of a circle along the right side of pelvis to lie underneath the symphysis pubis. The bitrochanteric
diameter is now in anterior posterior diameter of pelvic outlet

c. Lateral flexion of the body: the anterior buttock escapes under the symphysis pubis and posterior
buttock sweep the perineum and buttock are born by movement of lateral flexion.

d. Restitution of the buttock- anterior buttock turns slightly to the mother right side
e. Internal rotation of shoulder- shoulders enter the pelvis in the same oblique diameter as the buttock
i,e left oblique diameter. The anterior shoulder rotate forward 1/8th of a circle along the right side of
pelvis and escape under the symphysis pubis. The posterior shoulder sweep the perineum and shoulder
are born.
f. Internal rotation of the head: the head enter the pelvis with sagittal suture in the transverse diameter
of the brim.the occiput rotate forward along the left side and the suboccipital region that comes under
the symphysis pubis.

g. External rotation of body: at the same time of internal rotation of head, the body also turns so that
the back is uppermost

h.Birth of head: the chin face and sinciput sweep the perineum and head is born in a flexed attitude

• ANTENATAL MANAGEMENT OF BREECH PRESENTATION:

• 1.Identification of coplicating factor.
• 2. External cephalic version
• 3. Formulation of line of management
•
1.Identification of coplicating factor: complicting factors can be detected by clinical examination,
USG & by radiography

2. External cephalic version: It is a manipulative procedure design to change the lie or to bring the
favourable pole to the lower pole of the uterus
Time: Ideal time is considered to be 35-37week, while version in earlier week can cause reversion later
week may be difficult because of increase size of fetus.
• MANAGEMENT OF VAGINAL BREECH DELIVERY
1ST STAGE
• Vaginal examination is indicated at the onset of labour and soon after the rupture of membrane
• IV fluid started with ringer solution
• Adequate analgesia
• Oxytocin infusion and augmentation of labour.
• Bed rest
• Careful monitoring.
2nd STAGE- 3 method
• Spontaneous- the expulsion of the fetus occurs with very little assistance. It usually happen in
multi gravida with small baby.
• Assisted breech delivery- the delivery of the foetus is by assistant from the beginning to the end.

• Breech extraction- when the entire body of the fetus is extracted by obstetrician with minimum
aid, it is rarely done this day because it may produce trauma to fetus and mother( the indication
are- maternal and fetal distress, cord prolapse, extended leg arrested in cavity or outlet, following
an internal version
ASSISTED BREECH DELIVERY
Principle:
• Never be in hast
• Never pull from below but push from above
• Always keep the fetus with back anteriorly
Steps:
• place the women in lithotomy position, when the buttock are distending the perineum
• swab the vulva and drape with the sterile towel
• catheterise the bladder
• episiotomy
• encourage to push with contraction and buttock are delivered spontaneously
• if the leg are flexed, the feet disengage at the vulva and baby is born as far as the umbilicus
• a loop of cord is gently pulled down to avoid traction on the umbilicus
Delivery of the shoulder:
• wrap a small towel around the baby hip which preserve warm and improve the grip on the
slippery skin.
• The midwife now grasps the baby by the iliac crests with her thumbs held parallel over the
sacrum and tilts the baby towards the maternal sacrum in order to free the anterior shoulder.
•

• When the anterior shoulder has escape the buttock are lifted towards the mother’s abdomen to
enable the posterior shoulder and arm to pass over the perineum.
• As the shoulders are born the head enters the pelvic brim and decend through the pelvis with
sagittal suture in transverse diameter.
Delivery of after coming head:
• when the back has been turn the infant is allow to hang from the vulva with out any support.
• The baby weight bring the head on to the pelvic floor on which the occiput rotate forward.
• The sagittal suture is now in anterior posterior diameter. The baby can be allowed to hang for 1
or 2 mint.
• Delivery of head can be employed by- forcep delivery, Burns Marshall method, Malar flexion
and shoulder traction(Mauriceau smellie veit technique)

• Forcep delivery- forcep should be apply to the after coming head to achieved a controlled
delivery

Burns Marshall method-

• Baby is allowed to hang by its own weight.

• The assistant is ask to give a supra pubic pressure in a downward and backward direction,
• when the nape of head is visible under the pubic arch, the baby is grasp by the ankle with a finger
in between the two maintaining a steady traction and forming a wide arch of circle, The trunk is
swung in upward and forward direction.
• The left hand is to be place over the perineum in order to prevent sudden escape of head and
airway should be clear off
MALAR FLEXION AND SHOULDER TRACTION( Modified Mauriceau Smellie Veit
technique)

- the baby is placed on the supinated left forearm with the limbs hanging on either sides.
- The middle and the index finger of the left hand are placed over the malar bone on either
sides( this maintain flexion of the head)
- The ring finger and little finger of the pronated right hand are placed on the child’s right shoulder
- The index finger is placed on the left shoulder and the middle finger is placed on the sub –
occipital region.
- Traction is now given in downward direction till the nape of the neck is visible under the pubic
arch.
- The assistant gives suprapubic pressure during the period to maintain flexion.
- The fetus is carried in upward and forward direction toward the mother’s abdomen releasing the
face , bro and lastly the trunk is depressed to release the occiput and vertex

RESUSCITATION OF THE BABY: the baby may be asphyxiated and need to be resuscitated

THIRD STAGE : the placenta is expelled out soon after delivery of the head. If prophylactic ergometrine
is to be given, it should be administered IV with the crowning of the head

MANAGEMENT OF COMPLICATED BREECH DELIVERY:

The breech may be arrested
- at the outlet
- in the cavity
- at the brim
Arrest at the outlet big size baby with leg extended, weak uterine contraction, outlet contraction,
rigid perineum.
Management: caesarean section
Arrest at or above the level ob ischial spines ( contracted pelvis, weak uterine contraction,
big baby)
Management –
- caesarean section
- Frank breech extraction ( pinard’s manaeuver)
 -

- The Pinard maneuver may be needed with a frank breech to facilitate delivery of the legs but only
after the fetal umbilicus has been reached.
- Pressure is exerted in the popliteal fossa of the knee with middle and the index finger. Flexion of
the knee follows, and the lower leg is swept medially and out of the vagina.
- The fetal foot is then grasped at the ankle and breech extraction is accomplished.
- 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

EXTENDED ARMS:
PRINCIPLE:

- Because of the curve birth canal, when the anterior shoulder remains above the symphysis pubis,
the posterior shoulder will be below the sacral promontory.
- If the fetal trunk is rotated keeping the back anterior and maintaining a downward traction, the
posterior shoulder will appear below the symphysis pubis.

PROCEDURE:

When the umbilicus is born and shoulder are in anterior posterior diameter the baby is grasps by iliac
crest with thumb over the sacrum, downward traction is applied until the axial is visible.
STEPS:
i. The trunk is rotated through 180º keeping the back anterior and maintaining a downward
traction. This will bring the posterior arm to emerge under the pubic arch.
ii. The trunk is then rotated in reverse direction keeping the back anterior to deliver the anterior
shoulder under the symphysis pubis

DELAY IN DELIVERY OF HEAD / ARREST OF THE AFTER COMING HEAD:

If the arrest is due to deflexed head delivery is to be done by

- malar flexion and shoulder traction ,
- forcep should not be apply if the head is high
If the arrest is due to contracted pelvis/ Hydrocephalus
 - perforation of head is done.

COMPLICATION:

- IMPACTED BREECH: Labour become obstructed when the fetus is dispropertionally large the
size of the maternal pelvis.
- CORD PROLAPSE:it is common in Footling presentation, as these have ill fitting presentation, in
these the prolase leg may become oedema or discoloured
- BIRTH INJURY:Superficial tissue damage, oedema of baby genitalia by pressure, fracture of
humerous, clavicle, femur, dislocation of shoulder/ hip, spinal cord damage( by bending the baby
backward over the mother symphysis pubis), erb’s palsy( when brachial plexus is damage- by
twisting the baby neck), trauma to internal organ(rupture liver/ spleen during grasping of baby
abdomen), intracranial injury( by rapid delivery of the head)
- FETAL HYPOXIA- due to cord compression and cord prolapse
- PREMATURE SEPARATION OF THE PLACENTA- Retraction begin while the head is still in the
vagina and placenta begin to separated
- MATERNAL TRAUMA- In operative vaginal deliver.