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BREECH PRESENTATION AND DELIVERY

Breech- buttocks of the fetus enter the pelvis before the


head
Breech was derived from britches, which described a cloth
covering the loins and thighs.
Breech presentation persists in only about 3-4% of singleton
deliveries

ETIOLOGY
As
term
approaches,
the
uterine
cavity
usually
accommodates the fetus in a longitudinal lie with the vertex
presenting
Factors that predispose to breech presentation:
1. gestational age
2. hydramnios
3. uterine relaxation associated with great parity
4. multiple fetuses
5. oligohydramnios
6. hydrocephalus
7. anencephaly
8. previous breech delivery
9. uterine anomalies
10. pelvic tumors
Frequency of breech delivery also increased with placenta
previa
No strong correlation has been shown between breech
presentation and a contracted pelvis
COMPLICATIONS
1. perinatal morbidity and mortality from difficult mortality
2. LBW from preterm delivery, growth restriction, or both
3. prolapsed cord
4. placenta previa
5. fetal, neonatal, an d infant anomalies
6. uterine anomalies and tumors
DIAGNOSIS

Frank breech presentation- lower extremities are


flexed at the hips and extended at the knees, and thus the feet
lie in the proximity of the head

Complete breech presentation- one or both knees are


flexed

Incomplete breech presentation- one or both hips are


not flexed and one or both knees lie below the breech, such that
a foot or knee is lowermost in the birth canal

Footling breech- incomplete breech with one or both


feet below the breech
ABDOMINAL EXAMINATION
Use of Leopold maneuver
o 1st Leopold- the hard, round, readily ballotable fetal
head is found to occupy the fundus
o 2nd- indicates the back to be on one side of the
abdomen and small parts on the other
o 3rd- if engagement has not occurred, the
intertrochanteric diameter of the fetal pelvis has not
passed through the pelvic inlet, the breech is
movable above the pelvic inlet
o 4th- the firm breech to be beneath the symphysis
Fetal heart sounds are heard loudest
slightly above the umbilicus, whereas
the engagement of the fetal head, the
heart sounds are loudest below the
umbilicus
VAGINAL EXMAINATION
Ischial tuberosities, sacrum, and anus are usually palpable
an after descent, the genitalia maybe distinguished
When labor is prolonged, the buttocks may become
markedly swollen, rendering differentiation of face and
breech very difficult- the anus may be mistaken for the
mouth and the ischial tuberosities for the malar eminences
Careful examination should be done to prevent error
o Finger encounters muscular resistance with the anus,
whereas the firmer, less yielding jaws are felt
through the mouth
o Finger, upon removal from the anus, sometimes is
stained with meconium
o
Mouth and malar eminences form a triangular
shape, whereas the ischial tuberosities and anus are
in a straight line.

The most accurate information is based on the location of


the sacrum and its spinous process which establishes
diagnosis of position and variety
In complete breech- feet maybe felt alongside the buttocks
Footling presentation- one or both feet are inferior to the
buttocks and foot can be readily identified as right or left on
the basis of the relation to the great toe
When the breech has descended farther into the pelvic
cavity, the genitalia maybe felt

IMAGING TECHNIQUES
Ultrasound- ideally be used to confirm a clinically suspected
breech presentation and to identify any fetal anomalies
In CSD, additional imaging is not indicated
In NSVD, the type of breech and the degree of flexion or
deflexion of the head is important and UTZ supplies this
information
CT scan- provide pelvic measurements and configurations at
lower doses of radiation
MRI- provides reliable information about pelvic capacity and
architecture without ionizing radiation
X-ray pelvimetry
PROGNOSIS
Both mother and fetus are at greater risk with breech
presentation compared with cephalic presentation
Obstetrical intervention will not eliminate all mortality and
long-term morbidity associated with breech presentation
MATERNAL MORBIDITY
Risk is increased even more with ER surgery instead of
elective CSD
Labor length is similar to cephalic presentation
PERINATAL MORBIDITY AND MORTALITY
Prognosis in breech is worse than when in a vertex
presentation
Major contributors to perinatal loss
a. Preterm deliver
b. Congenital anomalies
c. Birth trauma

VAGINAL DELIVERY
Once the breech has passed beyond the vaginal introitus,
the abdomen, thorax, arms, and head must be delivered
promptly
With a term fetus, some degree of head molding may be
essential for it to negotiate the birth canal successfully
1. Delivery maybe delayed many times while the
aftercoming head accommodates to the maternal pelvis,
resulting in hypoxia and academia, which can become
severe; or,
2. Delivery
maybe
forced,
causing
trauma,
from
compression, traction, or both
With a preterm fetus, the disparity between the size of the
head and buttocks is even greater than with a larger fetus
Duhrssen incision maybe lifesaving in cases where the
buttocks and lower extremities of the preterm fetus will pass
through the cervix and be delivered, and yet the cervix will
not be dilated adequately
Another problem in breech: entrapment of the fetal arm
behind the neck (nuchal arm)
Frequency of cord prolapse is increased when the fetus is
small or when the breech is not frank
Soernes and Bakes confirmed that umbilical cord length is
significantly shorter in breech
Multiple coils of cord entangling the fetus are more common
with breech and these umbilical abnormalities have high
incidence of a nonreassuring fetal heart rate pattern in labor
Apgar scores, esp. at 1min, of vaginally delivered breech
infants are generally lower than those of breech infants born
with elective CSD
Compared with cephalic deliveries, umbilical artery blood pH
and HCO3 are lower, and PCO2 is higher
UNFAVORABLE PELVIS
Gynecoid (round) and anthropoid (elliptical) pelves are
favorable configurations, but platypelloid (AP flat) and
android (heart-shaped) pelves are not
HYPEREXTENSION OF THE FETAL HEAD
5% of all breech presentations
Referred to as stargazer fetus (flying foetus in Britain)

With hyperextension, vaginal delivery may result in injury to


the cervical spinal cord
An indication for CSD

FOOTLING BREECH
The possibility of compression of a prolapsed cord or a cordentangled around the extremities as the breech fills the
pelvis is a threat to the fetus
TERM FETUS
Main causes of death in vaginal deliver (Cheng and Hannah)
1. head entrapment
2. cord prolapse
3. cerebral injury
4. intracranial hemorrhage
5. severe asphyxia
PRETERM FETUS
The aftercoming head of a preterm fetus maybe trapped by
a cervix that is sufficiently effaced and dilated to allow
passage of the thorax but not of the less compressible head
o The consequences of vaginal delivery in this
circumstance:
a. Hypoxia
b. Physical trauma
CURRENT STATUS OF VAGINAL BREECH DELIVERY
ACOG concluded that, except in case of advanced labor
and imminent delivery, which are not otherwise defined,
women with persistent singleton breech presentation at
term should undergo a planned CSD
Recommendations for Delivery
CSD is commonly but not exclusively used in the ff.:
1. a large fetus
2. any degree of contraction or unfavorable shape of the pelvis
3. a hyperextended head
4. when delivery is indicated in the absence of spontaneous
labor
5. uterine dysfunction
6. incomplete or footling breech presentation
7. an apparently healthy and viable preterm fetus with the
mother I either active labor or in whom delivery is indicated
8. severe fetal growth restriction

9. previous perinatal death or children suffering from birth


trauma
10. a request for sterilization
11. lack of an experienced operator
TECHNIQUES FOR BREECH DELIVERY
LABOR AND SPONTANEOUS DELIVERY
With a cephalic presentation, once the head is delivered, the
rest of the body typically follows without difficulty
With breech, successively larger and very much less
compressible parts of the fetus are born
Engagement and descent usually take place with the
bitrochanteric diameter in one of the oblique pelvic
diameters
o Anterior hip usually descends more rapidly than the
post hip, and when the resistance of the pelvic floor
is met, internal rotation of 45 follows bringing the
ant hip toward the pubic arch and allowing the
bitrochanteric diameter to occupy the AP diameter of
the pelvic outlet
o If the post extremity is prolapsed, it rotates to the
symphysis pubis rather than the ant hip
After rotation
o Descent continues until the perineum is distended by
the advancing breech and the ant hip appears at the
vulva
o By lateral flexion of the fetal body, post hip then is
forced over the perineum, which retracts over the
buttocks, thus allowing the infant to straighten out
when the ant hip is born
o The legs and feet follows the breech and maybe born
spontaneously or with aid
After the birth of the breech
o There is slight external rotation, with back turning
anteriorly as the shoulders are brought into relation
with one of the oblique diameters of the pelvis
o Shoulders then descend rapidly and undergo internal
rotation , with the biacromial diameter occupying the
AP plane
o Ff. the shoulders, the head, which is normally flexed
upon the thorax, enters the pelvis in such a manner
to bring the post portion of the neck under the SP
o The head is then born in flexion

Breech may engage in the transverse diameter with the


sacrum directed ant or post
o Mechanism differs only in that internal rotation
occurs through an arc of 90 rather than 45

METHODS OF VAGINAL DELIVERY


1. Spontaneous breech delivery- infant is expelled entirely
spontaneously without any traction or manipulation other
than support of the infant
2. Partial breech extraction- infant is delivered spontaneously
as afr as the umbilicus, but the remainder of the body os
extracted or delivered with operator traction and assisted
maneuvers, with or without maternal expulsive efforts
3. Total breech extraction- entire body of the infant is
extracted by the OB
MANAGEMENT OF LABOR
Assess status of the membranes, labor, and fetal conditions
Close surveillance of the fetal HR and uterine contractions is
begun at admission
Immediate recruitment of necessary nursing, obstetrical,
and anesthesia team
Venous catheter is inserted and an infusion begun as soon
the woman arrives in the labor suite
Reasons that may require immediate access for the
administration of medications, fluids, or blood
1. ER induction of anesthesia
2. hemorrhage from lacerations or from uterine atony
Stage of Labor
Assess cervical dilatation and effacement
If labor is too far advanced, there may be not sufficient time
for an x-ray pelvimetry
Fetal Condition
Presence of fetal anomaly can be rapidly ascertained by
UTZ or radiography
Fetal Monitoring
FHR is recorded at least every 15 min
When membranes are ruptured, the risk of cord prolapse is
increased therefore, a vaginal examination should be

performed following rupture to check for cord prolapse. FHR


be monitored for the 1st 5-10 min following rupture to detect
occult cord prolapse
One-on-one nursing

Route of Delivery
Choice of abdominal or vaginal delivery is based on the type
of breech, flexion of the head, fetal size, quality of uterine
contractions , and size of the maternal pelvis
Timing of Delivery
Delivery team includes:
1. an OB skilled in the art of breech extraction
2. an associate to assist with the delivery
3. anesthesia personnel who can assure adequate
analgesia or anesthesia when needed
4. an individual trained to resuscitate the infant
Persistent fetal bradycardia is prone to develop from cord
compression with fetal further descent thru the birth canal
ASSITED FRANK BREECH DELIVERY
The frank breech should ideally be allowed to deliver
without assistance to at least the level of the umbilicus. Unless
there is considerable relaxation of the perineum, an episiotomy
should be made. The episiotomy is an important adjunct to any
type of breech delivery. As the breech progressively distends the
perineum, the posterior hip will deliver, usually from the 6 o'clock
position, and often with sufficient pressure to evoke passage of
thick meconium at this point. The anterior hip then delivers,
followed by external rotation to the sacrum anterior position. The
mother should be encouraged to continue to push, as the cord is
now drawn well down into the birth canal and likely is being
compressed with resultant fetal bradycardia. As the fetus continues
to descend, the legs are sequentially delivered by splinting the
medial aspect of each femur with the operator's fingers positioned
parallel to each femur and by exerting pressure laterally so as to
sweep each leg.
Following delivery of the legs, the fetal bony pelvis is
grasped with both hands, using a cloth towel moistened with warm
water. The fingers should rest on the anterior superior iliac crests
and the thumbs on the sacrum, minimizing the chance of fetal
abdominal soft tissue injury. Maternal expulsive efforts are used in
conjunction with continued gentle downward operator rotational
traction to effect delivery of the fetus. Gentle downward traction is

combined with an initial 90-degree rotation of the fetal pelvis


through one arc and then a 180-degree rotation to the other to
effect delivery of the scapulas and arms.
The depicted rotational and downward traction maneuvers
will decrease the occurrence of persistent nuchal arms, which can
complicate all vaginal breech deliveries, prevent further descent,
and increase fetal-newborn trauma and morbidity. These
maneuvers are frequently most easily effected with the operator at
the level of the maternal pelvis and with one knee on the floor.
When the scapulas are clearly visible, delivery is then completed as
subsequently described for the complete or incomplete breech.
FRANK BREECH EXTRACTION
This procedure involves manipulation within the birth canal
to convert the frank breech into a footling breech. The procedure is
accomplished more readily if the membranes have ruptured
recently, and it becomes extremely difficult if considerable time has
elapsed since escape of amniotic fluid. In such cases, the uterus
may have become tightly contracted over the fetus, and
pharmacological relaxation by general anesthesia, IV MgSO4, or a
beta-mimetic such as terbutaline (250 ug SC) maybe required.
Breech decomposition is accomplished by the maneuver
attributed to Pinard (1889). It aids in bringing the fetal feet within
reach of the operator. Spontaneous flexion usually follows, and the
foot of the fetus is felt to impinge on the back of the hand. The fetal
foot then may be grasped and brought down.
COMPLETE OR INCOMPLTE BREECH EXTRACTION
1. Complete breech extraction begins with traction on the
feet and ankles.
2. Complete breech extraction continues with traction on
the thighs. A warm, moist towel is most often applied
over the fetal parts to reduce slippage from vernix as
traction is applied.
3. Breech extraction continues, the scapulas become
visible and the body rotates, usually to the side of the
mother to which it was originally directed.
4. As breech extraction continues, upward traction is
employed, effecting delivery of the posterior shoulder.
This is followed by delivery of the posterior arm (inset).
5. Breech extraction continues with delivery of the anterior
shoulder by downward traction. The anterior arm then
may be freed the same way as the posterior arm

A cardinal rule in successful breech extraction is to employ


steady, gentle, downward rotational traction until the lower
halves of the scapulas are delivered outside the vulva,
making no attempt at delivery of the shoulders and arms
until one axilla becomes visible. Failure to follow this rule
frequently will make an otherwise easy procedure difficult.
The appearance of one axilla indicates that the time has
arrived for delivery of the shoulders. It makes little
difference which shoulder is delivered first, and there are
two methods for delivery of the shoulders.
Unfortunately, the process is not always so simple, and it is
sometimes necessary first to free and deliver the arms.
These maneuvers are less likely to be required if rotational
traction is employed and attempts to deliver the shoulders
until an axilla becomes visible are avoided. Attempts to
free the arms immediately after the costal margins
emerge should be avoided.

DELIVERY OF THE AFTERCOMING HEAD


1.Mariceau Maneuver
The index and middle finger of one hand are applied over
the maxilla, to flex the head, while the fetal body rests on the palm
of the hand and forearm . The forearm is straddled by the fetal
legs. Two fingers of the other hand then are hooked over the fetal
neck, and grasping the shoulders, downward traction is applied
until the suboccipital region appears under the symphysis. Gentle
suprapubic pressure simultaneously applied by an assistant helps
keep the head flexed. The body then is elevated toward the
maternal abdomen, and the mouth, nose, brow, and eventually the
occiput emerge successively over the perineum. It is emphasized
that with this maneuver, the operator uses both hands
simultaneously and in tandem to exert continuous
downward gentle traction simultaneously on the fetal neck
and on the maxilla. At the same time, appropriate suprapubic
pressure applied by an assistant is helpful in delivery of the head.
2.Prague Maneuver
Rarely, the back of the fetus fails to rotate to the anterior.
When this occurs, rotation of the back to the anterior may be
achieved by using stronger traction on the fetal legs or bony pelvis.
If the back still remains oriented posteriorly, extraction may be
accomplished using the Mauriceau maneuver and delivering the
fetus back down. If this is impossible, the fetus still may be
delivered using the modified Prague maneuver, which, as practiced

today, consists of two fingers of one hand grasping the shoulders of


the back-down fetus from below while the other hand draws the
feet up over the maternal abdomen.
3.Forceps to Aftercoming Head
Specialized forceps can be used to deliver the aftercoming
head. Piper forceps,or divergent Laufe forceps may be applied
electively or when the Mauriceau maneuver cannot be
accomplished easily. The blades of the forceps should not be
applied to the aftercoming head until it has been brought into the
pelvis by gentle traction, combined with suprapubic pressure, and
is engaged. Suspension of the body of the fetus in a towel
effectively holds the fetus and helps keep the arms out of the way.
ENTRAPMENT OF THE AFTERCOMING HEAD
Durhrssen incisions
Zavanelli maneuver- CSD after replacement of the infant
back into the uterus- to deliver a healthy 2590 g infant with
head entrapment
Sy,physiotomy- used to widen the ant pelvis
ANALGESIA AND ANESTHESIA
Analgesia for episiotomy and intravaginal manipulationspudendal block and local infiltration of the perineum
o NO+O2 inhalation= further relief from pain
o If general anesthesia is needed, it can be induced
quickly with thiopental plus a muscle relaxant and
maintained with NO
General anesthesia with a halogenated agent maybe
required in cases of increased uterine tone
MORBIDITY AND MORTALITY
MATERNAL INJURIES
Complicated vaginal breech deliveries are associated with
increased maternal risks
Manual manipulations within the birth canal increase the
risk of infection
Intrauterine maneuvers or delivery of the aftercoming head
thru an incompletely dilated cervix may cause rupture of the
uterus, lacerations of the cervix, or both.
Manipulations may also lead to extensions of the episiotomy
and deep perineal tears

FETAL

Anesthesia may cause uterine atony and postpartum


hemorrhage
INJURIES
Fracture of the humerus, clavicle, and femur
Neonatal perineal tears- complication of spinal electrode use
Hematomas of the SCM (usually disappear spontaneously)
More serious problems: separation of the epiphyses of the
scapula, humerus, or femur
Paralysis of the arm may follow pressure on the brachial
plexus by fingers in exerting traction but more frequently
caused by overstretching the neck while freeing the arms
Spoon-shaped depressions or actual fractures of the skull
may result when fetus is extracted forcibly thru a contracted
pelvis
Testicular injury from vaginal delivery may result in anorchia

VERSION
A procedure in which the fetal presentation is altered by
physical manipulation, either substituting one pole of a
longitudinal presentation for the other or converting an
oblique or transverse lie into a longitudinal presentation
Cephalic or podalic version
External version- the manipulations are performed
exclusively thru the abdominal wall
Internal version- they are accomplished inside the uterine
cavity
EXTERNAL CEPHALIC VERSION
Indication: When breech presentation is recognized prior to
labor in woman who has reached 36 weeks gestation
If version results in the need for immediate delivery,
complication of iatrogenic preterm delivery are not severe
Contraindications:
o Placenta previa
o Nonreassuring fetal status
o Prior uterine incision
Factors Associated with Successful Version
1. Increasing parity- most consistent factor associated with
success of external cephalic version
2. Fetal presentation
3. Amount of amniotic fluid


1.
2.
3.
4.
5.
6.

4. Gestational age
Determinants of failed version:
diminished amniotic fluid
maternal obesity
anterior placenta
cervical dilatation
descent of breech into the pelvis
ant or post positioning of the fetal spine

//gheraldrbermudez
3A Medicine 082309

Transverse Lie
women with transverse lie are excluded from analysis of
breech version bec the overall success rate approaches to
90%
Tocolysis
Terbutaline, 250 ug SC
Conduction Analgesia
According to the American College of Obstetricians and
Gynecologists (2000), there is not enough consistent
evidence to recommend conduction analgesia routinely.
Other Methods
Moxibustion- burning the herbal preparation moxa to
generate heat to stimulate acupuncture point BL67- to
promote spontaneous breech version
Acoustic stimulation- to startle breech fetuses to shift their
spines laterally
Complications
Placental abruption, uterine rupture, amniotic fluid
embolism, fetomaternal hemorrhage, isoimmunization,
preterm labor, fetal distress, fetal demise
INTERNAL PODALIC VERSION
This maneuver is used only for delivery of a second twin. It
consists of the insertion of a hand into the uterine cavity to turn the
fetus manually. The operator seizes one or both feet and draws
them through the fully dilated cervix while using the other hand to
transabdominally push the upper portion of the fetal body in the
opposite direction. The operation is followed by breech extraction.