Breech

3rd October 2016

Sareta Dubay
Kelly-Ann John
Che-Marie Lee Kin
Sarita Sudama
Presentation Outline
• Definition
• Incidence
• Aetiology & Risk Factors
• Types of Breech Presentations
• Consequences of Breech Presentation
• Diagnosis
• Management
• External Cephalic Version
• Vaginal Breech Delivery
Definition
Breech
A malpresentation where the foetal buttocks
lies over the maternal pelvis.

The lie is longitudinal and the foetal head

is at the fundus of the uterus.
Incidence
The incidence of breech presentation decreases from about 20% at 28
weeks of gestation to 3–4% at term, as most babies turn spontaneously
to the cephalic presentation.

When compared with singleton vertex pregnancy:

The perinatal mortality rate is 3 times higher
The perinatal morbidity rate is 12 times higher
Aetiology & Risk Factors
MATERNAL MATERNAL-FOETAL FOETAL

● High parity ● Placenta praevia ● Prematurity/Preterm

● Congenital anomalies of ● Amniotic fluid (poly/ delivery (most
the uterus- oligohydramnios) common)
○ unicornuate, ● Previous breech ● Multiple gestation
bicornuate, presentation ● Abnormalities in foetal
subseptate ● Short umbilical cord tone and movement
● Uterine abnormalities
○ uterine fibroids,
extrauterine
tumours
● Pelvis (contracted)
Types of Breech Presentation
1. Frank/Extended
2. Complete/ Flexed
3. Incomplete
-Footling
/Kneeling
Frank/
Extended
Breech
• Both legs are extended such that
the foetus is staring directly at its
own feet.
• The buttocks are the presenting
part.
• Most favorable for vaginal delivery
• 60-70%
Complete/
Flexed Breech
• Legs flexed at the knees and hips so
that both the feet and buttocks are
presenting.
• Descent and engagement are difficult
• 4x greater risk of cord prolapse
after rupture of membranes than
frank breech
• 15%
Incomplete/
Footling
Breech
• One or both legs are extended
below the level of the buttocks
such that one or both legs are
presenting.
• Elective Caesarean section
recommended at term
• 15%
Consequences of a Breech
Presentation
Maternal Foetal
Difficult vaginal delivery Risk of hypoxia and trauma during
Likelihood of a Caesarean delivery
delivery Irrespective of the mode of delivery,
neonatal and long-term risks are
increased
Diagnosis of a Breech
Presentation
• Before 36 weeks gestation a breech presentation is not of much
concern unless the patient is in labour.
• If spontaneous version does not occur at term then the patient should
be counseled on this type of presentation- consequences, methods of
management and course of action to be taken.
• Breech presentations are commonly not diagnosed until labour.
Diagnosis of a Breech
Presentation
History

• Patient may complain of pain or discomfort in the fundal area.

Examination:

• Longitudinal lie
• Fundus: foetal head - hard, round, ballotable
• Presenting part: irregular and soft.
• Foetal heart: detected mostly above umbilicus.

USS

• Confirms the diagnosis

• Assess any possible growth or anatomical anomalies
Management of a Breech
Presentation 1. External Cephalic Version
(ECV)

2. Vaginal Breech Delivery

3. Caesarean Section
External Cephalic Version
• Undertaken around 37-39 weeks gestation
• Manoeuvres which manually convert the polarity from breech to cephalic
• The intention is to reduce the need for Caesarean Section.
• Should only be attempted where facilities are available for emergency
Caesarean section (if it becomes necessary, i.e. about 0.5% of cases)
• USS is performed before ECV to confirm presentation and lie of foetus and
after ECV to confirm version
• Foetal heart should be monitored
ECV Technique
1. USS is performed.
2. The patient’s bladder is emptied.
3. Powder is liberally applied to the mother’s
abdomen.
4. The breech is held with one hand which
gently elevates it away from the pelvic inlet
while simultaneously the other hand flexes
the foetal head.
5. The foetus is encouraged into a “Forward
Roll” (or less commonly, a ‘back flip’* in
order to change the polarity.
ECV Technique
After ECV

• The foetal heart is directly observed with ultrasound or auscultated.

• The introitus should be inspected for blood or liquor.

• A non-stress test (NST) should follow for at least 20 minutes.

• All Rhesus negative mothers should be given Anti-D.

Efficacy of ECV
• Success rate
• About 40% for nulliparous and about 60% for multiparous
women
• Is affected by: race, parity, uterine tone, liquor volume,
engagement of the breech and whether the head is palpable, and
the use of tocolysis
• Is increased by the use of tocolysis. This has been proven with
ritodrine, salbutamol and terbutaline. It can be given
electively or if the first attempt fails.
• Risk of spontaneous version is about 3%.
• Epidural or spinal anesthesia are not usually used.
Complications of ECV
• Foetal distress
• Feto-maternal transfusion
• Rupture of membranes
• Placental abruption
• Uterine rupture
• Amniotic fluid embolism (rare)
• Pain
• Precipitation of labour
 Contraindications to ECV
Absolute Relative
• Caesarean delivery already • SGA foetus with abnormal doppler
indicated parameters
• Antepartum hemorrhage • Foetal abnormalities
• Major uterine anomalies • Unstable lie
• Ruptured membranes • Previous Caesarean section
• Multiple pregnancy (except if twin • Maternal hypertension
A is cephalic)
• Foetal compromise
• Oligohydramnios
• Rhesus isoimmunization
• Pre-eclampsia
Vaginal Breech Delivery
● High risk delivery – institution that can facilitate emergency Caesarean section.
● An anaesthetist should be available for the delivery for 2 reasons:
○ A Caesarean section may be necessary at any time until delivery of the foetal
umbilicus.
○ General anesthesia may be required if difficulty is encountered with the
aftercoming head.
● During labour, early artificial rupture of membranes should be avoided.
● If spontaneous rupture of membranes occurs, speculum examination should be
conducted to rule out umbilical cord prolapse.
● Continuous foetal monitoring throughout labour.
● Augmentation of labour is not recommended.
● Failure of the presenting part to descend in the 2nd stage of labour may signal
feto-pelvic disproportion and recourse to Caesarean section.
Vaginal Breech Delivery:
Outline
Delivery of the buttocks ● Occurs naturally
Delivery of the legs and ● Legs flexed= Spontaneous
lower body ● Legs extended= Pinard’s manoeuvre
Delivery of the shoulder ● Lovset’s manoeuvre
Delivery of the head ● Forcep – Piper’s forcep
● Mauriceau –Smellie- Veit manoeuvre
● Burns-Marshall Method
Vaginal Breech Delivery:
Technique
• Maternal effort delayed until the buttocks are visible.
• In the active 2nd stage of labour, when anterior buttock becomes visible at the
introitus, the patient placed in lithotomy position, perineum is cleaned and
draped.
• An episiotomy is performed as the posterior buttock distends the perineum.
• After the buttocks are delivered, ensure foetal back faces upwards.
• After the umbilicus appears over the maternal perineum, a short loop of cord
may be loosened and drawn down.
Vaginal Breech Delivery:
Technique
Frank breech = Pinard’s Result:
manoeuvre: • external rotation of the thigh
• the operator may align a at the hip
finger medial to one thigh • flexion at the knee
then, the other, pressing • delivery of one and then the
laterally as the foetal pelvis is other leg
rotated away from that side.
Frank Breech:
Pinard’s
Manoeuvre
Vaginal Breech Delivery:
Technique
• The foetal trunk is then wrapped with a towel; expulsive forces from uterine
contractions results in further descent

• The arms are then hooked down by the index finger at the foetal elbow,
bringing them down to the baby’s chest.
• If the arms are extended, Lovset’s manoeuvre allows the anterior shoulder and
then the posterior shoulder to enter the pelvis and for the arm to be delivered from
below the pubic arch.

• After delivery of the arms, the baby is allowed to hang at the vulva so that the
effect of gravity leads to further descent of the foetal head.
Lovset’s
Manoeuvre
Lovset’s
Manoeuvre
Vaginal Breech Delivery:
Technique
Delivery of the aftercoming head should be gentle and controlled to avoid rapid
decompression → intracranial bleeding via

1. Mauriceau-Smellie-Veit Manoeuvre

2.Forceps
Delivery of the
Head
1) Mauriceau- Smellie- Veit
Manoeuvre
When the nape of the neck is visible,
delivery is achieved by placing 2 fingers
of the right hand over the maxilla and
two fingers of the left at the back of the
head to flex it and maternal pushing is
encouraged.
If this fails to deliver the head
2) Forceps should be applied before
the next contraction.
Delivery of the
Head
The Burns-
Marshall
Manoeuvre
• While standing on one side of
the mother, the baby’s feet are
held and outward traction is
exerted
• The baby is taken through an arc
towards the mother’s abdomen
• Note:
• there is no control of delivery of
head → possible cerebral
complications
• Incorrect method → over
-extension of neck
Complications of Vaginal Breech
Delivery
• Cord prolapse and compression
• Fractures to the upper and lower limbs, ribs and pelvis
• Dislocation of the hip joint
• Visceral trauma eg liver, spleen and adrenals
• Brachial plexus injury
• Intracranial hemorrhage
• Sternocleidomastoid injury eg torticollis
• Occipital diastasis from excessive pressure on the occiput
• Stretching and spasm of the vertebral arteries
Complications
of Vaginal
Breech
Delivery
Contraindications to a Vaginal
Breech Delivery
• Clinically inadequate pelvis
• Footling or kneeling breech presentation
• Large baby (> 3500g)
• Growth- restriction (<2000g)
• Other contraindications to vaginal birth e.g. placenta praevia, foetal compromise
• Previous caesarean section
• Hyperextended foetal neck in labour (USS)
• Absence of a clinician trained in vaginal breech delivery
Sources
Textbook of Obstetrics, Roopnarinesingh (3rd
Edition)

RCOG Guideline 20b: Management of Breech

Presentation
Questions?
Case
History
You are asked to see a woman in the antenatal clinic. She is 37 years old and pregnant with her 3rd
child. Her previous children were both born by vaginal delivery after induction of labour for post
dates.
First-trimester ultrasound confirmed her menstrual dates and she is now 37 weeks. At her last
appointment at 36 weeks’ gestation, the midwife suspected that the baby was in a breech
presentation. An appointment has been made for an ultrasound assessment and to discuss the
situation.

Examination
Blood pressure is 140/85 mmHg and abdominal examination suggests a breech presentation with
the sacrum not engaged.
Case
Questions
• What are the options available to the
woman?
• What management would you
recommend in this case?
• What are some of the causes of breech
presentation?
Case: Answer
At 30 weeks the incidence of breech
presentation is around 14 per cent, but is
only 2–4% by term.

The 3 options available are:

1. external cephalic version
2. elective Caesarean section
3. vaginal breech delivery.
All 3 options should be discussed with the
woman and her partner with important
counselling points.
Case: Answer
Vaginal Breech Delivery:
• found to be less safe for singleton
term fetuses than planned Caesarean
section
• carries a high chance of necessitating
an emergency
• needs an experienced obstetrician
with continuous fetal heart monitoring
and ideally an epidural
• should only be allowed if the labour
progresses spontaneously –
augmentation of breech labour is
generally not recommended
• contraindicated with placenta praevia,
large baby, footling breech or
maternal condition such as pre-
eclampsia
External Cephalic Version:
• involves using external manipulation of the
fetus, encouraging the baby to turn to the
cephalic presentation by way of pressure on
the maternal abdomen
• is often performed after giving a uterine
relaxant such as salbutamol
• carries a very small chance of abnormal fetal
heart rate during or after the procedure which
could necessitate an emergency Caesarean
section
• has approximately 50 % success rate overall
• some fetuses revert to breech position even
after successful external cephalic version
• contraindicated with previous C- section, other
uterine surgery, pre-eclampsia, intrauterine
growth retardation, oligohydramnios
• can be painful
Caesarean Section:
• is safer than vaginal breech
delivery
• is suitable where
contraindications exist to external
cephalic version
• can be planned for in advance,
which women may find more
convenient
• does not necessarily mean a
woman would need a Caesarean
section for any future pregnancy.
Case: Answer
In this case the woman should be recommended external cephalic version as soon as possible, with
options for an elective Caesarean section or possible trial of breech delivery if this is unsuccessful.

Postnatal paediatric review should focus on the baby’s hips, with a neonatal ultrasound arranged
within 6 weeks to rule out congenital hip dislocation (10–15 times more common in breech
presentation).