BREECH DELIVERY

-Deepa Mishra
M. Sc. Nursing (OBG)
INTRODUCTION
A breech birth is the birth of a baby from a
breech presentation, in which the baby exits the
pelvis with the buttocks or feet first as opposed to
the normal head-first presentation. In breech
presentation, fetal heart sounds are heard just
above the umbilicus. In a breech presentation,
the lie is longitudinal and the podalic pole
presents at the pelvic brim. It is the commonest
malpresentation.
DEFINITION
Itis a longitudinal lie in which the
buttocks is the presenting part with
or without the lower limbs.
According to Nima Bhaskar
A breech birth is the birth of a baby
from a breech presentation, in
which the baby exits the pelvis with
the buttocks or feet first as
opposed to the normal head-first
presentation.
According to Wikipedia
INCIDENCE
3-4% of fetus present by breech
at term
5% at 34 weeks
20% at 28 weeks
20% diagnosed initially in labour
3.5% term singleton deliveries
and about 25% of cases before
30 weeks of gestation undergo
spontaneous cephalic version up
to term.
TYPES

Complete Breech Incomplete

(Flexed Breech) Breech(30-35%)
1. Complete Breech (Flexed
Breech)

The normal attitude of The thighs are flexed

full flexion is at the hips and the
maintained. legs at knees.

The presenting part

consists of two It is commonly
buttocks, external present in multiparae
genitalia and two
feet.
2. Incomplete Breech(30-
35%)
Incomplete variety with
procidentia: One or
Buttocks variety (70%) more little parts
(footling, knees)
precede the buttocks.

Sacro-anterior positions
are more common than
sacroposterior as in the
first the concavity of the
fetal front fits into the
convexity of the maternal
spines
INCOMPLETE BREECH
Frank Breech
• It is breech with extended legs where the
knees are extended while the hips are flexed.
• More common in primigravida.

Footling Presentation
• The hip and knee joints are extended on one
or both sides.
• More common in preterm singleton breeches.

Knee Presentation
• The hip is partially extended and the knee is
flexed on one or both sides
TYPES OF INCOMPLETE
BREECH
 CLINICAL VARIETIES

Uncompli Complica
cated ted
When the
It is defined as
presentation is
one where there
associated with
is no other
conditions which
associated
adversely
obstetric
influence the
complications
prognosis such
apart from the
as prematurity,
breech,
twins, contracted
prematurity
pelvis, placenta
being excluded.
praevia etc.
POSITIONS

Left Sacroanterior Left Sacroposterior Left Sacrolateral

(LSA) (LSP) (LSL)

Right Right Right Sacrolateral

Sacroanterior Sacroposterior (RSL)
(RSA) (RSP)
Etiology Of Breech Presentation

Prematurity

Factors preventing
spontaneous version

Favorable adaptation

Undue mobility of the

fetus

Fetal abnormality
 DIAGNOSIS

CLINICAL
SONOGRAPHY
RADIOLOGY
CLINICAL
  Complete Breech Frank Breech
Per Abdomen
 
Fundal Grip  Head-  Head
suggested by  Irregular small
hard and parts of the feet
globular mass may be felt by
 Head is the side of the
ballottable head.
 Head is non-
ballottable due
to splinting
action of the
legs on the
trunk.
Lateral Grip  Fetal back is to  Irregular parts
one side and are less felt on
the irregular the side
CLINICAL
  Complete Breech Frank Breech
Pelvic Grip  Breech- suggested by  Small, hard and a
soft, broad and conical mass is felt
irregular mass.  The breech is usually
 Breech is usually not engaged
engaged during
F.H.S. pregnancy
• Located at a lower
 Usually located at a level in the midline
higher level round due to early
about the umbilicus engagement of the
breech

Per Vaginum  
During Pregnancy  Soft and irregular
parts are felt through
During labour the fornix
 Palpation of ischial
tuberosities, sacrum
and the feet by the
sides of the buttocks
 Hard feel of the
sacrum is felt, often
mistaken for the head
•  Palpation of ischial
tuberosities, anal
opening and sacrum
only
Ultrasonography
1.It confirms the clinical diagnosis-
specially in primigravidae with
engaged frank breech or with
tense abdominal wall and irritable
uterus.
2. It can detect fetal congenital
abnormality and also congenital
anomalies of the uterus.
3. Type of breech (complete or
incomplete).
4. It measures biparietal diameter,
gestational age and approximate
weight of the fetus.
5. It also localizes the placenta.
DURING PREGNANCY
Inspectio Auscultat Ultrasonogra
Palpation
n ion phy

• A transverse • Fundal Grip: The • To confirm the

groove may be head is felt as a FHS is heard diagnosis.
seen above the smooth, hard, above the level • To detect the type
round of the of breech.
umbilicus in • To detect
sacro-anterior ballottable mass umbilicus.
which is often However in gestational age
corresponds to and foetal
the neck. tender. frank breech it weight: Different
• If the patient is • Umbilical Grip: may be heard at measures can be
The back is or below the taken to
thin, the head identified and a
may be seen as level of the determine the
depression umbilicus. foetal weight as
a localized • First pelvic Grip: the biparietal
bulge in one The breech is diameter with
hypochondrium felt as a chest or
smooth, soft abdominal
mass continues circumference
using a special
with the back.
equation.
Trial to do • To exclude
ballottement to
hyperextension of
the breech
DURING LABOUR

 The 3 bony landmarks of breech namely 2 ischial tuberosities

and tip of the scarum.
 The feet are felt beside the buttocks in complete breech.
 Fresh meconium may be found on the examining fingers.
 Male genitalia may be felt.
 
MECHANISM OF LABOUR

Delivery of the
buttocks

Shoulders

Head
Delivery of Buttocks
• The engagement diameter is the bitrochantric diameter 10 cm
which enters the pelvis in one of the oblique diameters.

• Descent of the buttocks occurs until the anterior buttock touches

the pelvic floor.

• Internal rotation of the anterior buttock occurs through 1/8 th of a

circle placing it behind the symphysis pubis.
• Further descent with lateral flexion of the trunk occurs until the
anterior hip hinges under the symphysis pubis which is released
first followed by the posterior hip.

• Delivery of the trunk and the lower limbs follow.

• Restitution occurs so that the buttocks occupy the original

position as during engagement in oblique diameter.
Delivery of Shoulders
• Bisacromial diameter (12 cm or 4 ¾”) engages in the
same oblique diameter as that occupied by the buttocks at
the brim soon after the delivery of breech.

• Descent occurs with internal rotation of the shoulders

bringing the shoulders to lie in the antero-posterior
diameter of the pelvic outlet. The trunk simultaneously
rotates externally through 1/8th of a circle.

• Delivery of the posterior shoulder followed by the

anterior one is completed by anterior flexion of the
delivered trunk.

• Restitution and external rotation :

Delivery of Head
• Engagement occurs either through the opposite oblique diameter as
that occupied by the buttocks or through the transverse diameter. The
engaging diameter of the head is suboccipito-frontal (10 cm).

• Descent with increasing flexion occurs.

• Internal rotation of the occiput occurs anteriorly, through 1/8th or

2/8th of a circle placing the occiput behind the symphysis pubis.

• Further descent occurs until the sub-occiput hinges under the

symphysis pubis.
• The head is born by flexion- The chain, mouth, nose, forehead,
vertex and occiput appearing successively. The expulsion of the head
from the pelvic cavity depends entirely upon the bearing efforts and
not at all on uterine contractions.
• Sacro-posterior position: The mechanism is not substantially
modified. The head has to rotate through 3/8 th of a circle to bring the
occiput behind the symphysis pubis.
PROGNOSIS

MATERNAL

FETAL
The Fetal Dangers
• Intracranial Haemorrhage
• Asphyxia
• Injuries

Prevention of the Fetal Hazards

• The incidence of breech can be minimized by
external cephalic version where possible.
• If the version fails or is contraindicated, delivery is
done by elective caesarean section.
• A skilled obstetrician along with an organized team
consisting of a skilled anesthetist and an assistant
should conduct vaginal breech delivery.
• Vaginal manipulative delivery should be done by a
skilled person with utmost gentleness, specially
during delivery of the head.
 Identificati
on of the
complicatin
g factors

ANTENATAL
MANAGEME
NT

Formulati
on of the External
line of cephalic
manage version
ment
 External Cephalic Version

Indications:

Procedure

Preliminaries

Benefits of External Cephalic Version

Causes of failure of version

Dangers of Version

Management, if version fails or is contraindicated

ELECTIVE CAESARIAN SECTION

Indications for During First

caesarian Stage

Cases seen first time in

Big Baby (estimated fetal
labour with presence of
weight>3.5 kg)
complications
Arrest in the progress of
Hyperextension of the head
labour

Footling presentation (risk of

Non-reassuring FHR pattern
cord prolapse)

Suspected pelvic contraction Cord presentation or prolapse

Any obstetrical or medical

complications
VAGINAL BREECH DELIVERY

Management of
Indications for vaginal
Vaginal Breech
breech delivery
Delivery

Adequate pelvis First Stage

Average fetal weight (1.5-3.5

Second Stage
kg)
Flexed head and without any
other complications
ASSISTED BREECH DELIVERY

Preliminaries for
Principles in
conduction of
conduction
normal labour

Anaesthetist to administer
anaesthesia as and when Never to rush
required
An assistant to push down the Never pull from below but push
fundus during contractions. from above

Instruments and suture Always keep the fetus with the

materials for episiotomy back anteriorly.

A pair of obstetric forceps for

the after coming head, if required.

Appliances for revival of the

baby, if asphyxiated
ASSISTED BREECH DELIVERY

Delivery of the after

Steps Third Stage
coming head

Patient is to be placed in
lithotomy position when the Burn-Marshall
posterior buttock distends method
the perineum.
To avoid aortocaval Forceps
Malar delivery
Flexion and
compression
Shoulder traction
Antiseptic cleaning (modified Mauriceau-
Smellie- Veit
Pudendal block
Resuscitation
technique) of the
baby
Episiotomy

Patient is encouraged to bear

down
Soon after the trunk upto the
umbilicus is born

Delivery of the arms

 Delayed in
Descent of
the Breech

MANAGEMENT OF
COMPLICATED
BREECH DELIVERY

Arrest of the
Extended
After-coming
Arms
Head
Delayed in Descent of the Breech

Arrested at the Outlet

In the absence of outlet

contraction and feto-
pelvic disproportion

Arrest of the breech at or

above the level of ischial
spines

Frank Breech Extraction

(Pinard’s Maneuver)
Extended Arms
Extended arms is due to faulty technique in delivery
using unnecessary traction, forgetting the principle of
‘never pull but push from above’

Diagnosis is made by noting the winging of the scapula

and absence of the flexed limbs in front of the chest.

Management :

The management calls for the urgent delivery of the

arms, first the posterior and then the anterior one.

The delivery of the arm may be accomplished by

adopting any one of the following methods:

Classical

Lovset
 Arrest of After Coming Head

At the Brim

In the Cavity

At the Outlet

Delivery of the head through an incompletely

dilated cervix

Occipito- posterior position of the head through an

incompletely dilated cervix
CONCLUSION:
The incidence of Breech
presentation expected to be low in hospitals
where high parity births are minimal and
routine external cephalic version done in
antenatal period. Breech presentation can
be managed by early diagnosis and
effective management strategies. By using
different maneuvers and skillful observation
of the obstetrician.