Breech Presentation Dr Moly Sam K on 17-04-2010 Final

8/9/2019 Breech Presentation Dr Moly Sam K on 17-04-2010 Final

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BREECH PRESENTATION ANDBREECH PRESENTATION AND

DELIVERYDELIVERY

Dr.Moly Sam KDr.Moly Sam K


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IntroductionIntroduction

Definition:-Definition:-

It is a longitudinal lie where theIt is a longitudinal lie where the

podalic pole presents and thepodalic pole presents and the

denominator is sacrum.denominator is sacrum.

Commonest among allCommonest among all

mal presentationsmal presentations


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It occurs in 3 4 % of all deliveries.It occurs in 3 4 % of all deliveries.

The occurrence of breech presentationThe occurrence of breech presentationdecreases with advancing gestational age.decreases with advancing gestational age.

This presentation occurs in 25 % of birthsThis presentation occurs in 25 % of births

that occurs before 28 weeks, in 7 % ofthat occurs before 28 weeks, in 7 % of

birth that occurs at 32 weeks and 1-3 %birth that occurs at 32 weeks and 1-3 %

of birth which occurs at term.of birth which occurs at term.


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Incidence of Breech presentationIncidence of Breech presentation

Gestation (weeks)Gestation (weeks) % Breech% Breech

21 - 2421 - 24 33%33%

25 - 2825 - 28 28%28%

29 - 3229 - 32 14%14%

33 3633 36 9%9%

37 4037 40 3%3%


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Types of BreechesTypes of Breeches


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Types of breechesTypes of breeches

CompleteCompletebreechbreechororFlexed breechFlexed breech ( 5-10 % )( 5-10 % ) HipsHipsFlexed, Knees FlexedFlexed, Knees Flexed

Incomplete breechIncomplete breech:-:- a) Frank breech or Extended breech (50-70%)a) Frank breech or Extended breech (50-70%)

- Hips flexed, knees extended- Hips flexed, knees extended

b) Knee presentation extension at hip andb) Knee presentation extension at hip andflexion at kneesflexion at knees

c) Footling (10-30%) Extension at hip andc) Footling (10-30%) Extension at hip andknees, feet are presentingknees, feet are presenting

Complicated breech breech presentationComplicated breech breech presentationassociated with any fetal or maternalassociated with any fetal or maternalcomplicationscomplications

Uncomplicated breech breech presentationUncomplicated breech breech presentationwithout any other complicationswithout any other complications


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Eti lEti l


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EtiologyEtiology

MaternalMaternal

a) Multi paritya) Multi parity

( producing uterine( producing uterine

relaxations )relaxations )

b) Pelvic tumorsb) Pelvic tumorsc) Contracted pelvisc) Contracted pelvis

d) Uterined) Uterinemalformation malformation Recurrent breechRecurrent breech

presentation seen inpresentation seen inuterine anomalies.uterine anomalies.

FetalFetal

a) Prematurity a) Prematurity Commonest causeCommonest cause

b) Multiple gestationb) Multiple gestation

c) Hydramniosc) Hydramnios

d) Macrosomiad) Macrosomia

e)Hydrocephaluse)Hydrocephalusf) Anencephalyf) Anencephaly

g) Trisomieg) Trisomie

h)Myotonic dystrophyh)Myotonic dystrophy

i) Placenta previa andi) Placenta previa andcornuofundalcornuofundalattachment of placentaattachment of placenta

j) Oligoamniosj) Oligoamnios

i l iEti l ti


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Etiology continEtiology contin

IUDIUD

Extended legs When legs are extendedExtended legs When legs are extended

the kicking movements of fetus againstthe kicking movements of fetus against

uterine wall are hampered and this resultsuterine wall are hampered and this results

in persistence of breech presentationin persistence of breech presentation

G OS SDIAGNOSIS


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DIAGNOSISDIAGNOSIS

Abdominal Exmination Head felt inAbdominal Exmination Head felt in

fundusfundus 11stst Pelvic grip breech feltPelvic grip breech felt

FH heard above the umbilicus.FH heard above the umbilicus.

P/VP/V :-:-

-- Conical bag of membraneConical bag of membrane

- Presenting part high up- Presenting part high up

- Flexed breech-ischial tuberosities,- Flexed breech-ischial tuberosities,

anus, sacrum,buttocks and feet areanus, sacrum,buttocks and feet are

palpablepalpable

di idi i t


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diagnosis contn..diagnosis contn..

Extended breech : - feet not felt. CanExtended breech : - feet not felt. Can

palpate both ischial tuberosities sacrumpalpate both ischial tuberosities sacrumand anus are usually palpable and withand anus are usually palpable and with

further descent external genitalia mayfurther descent external genitalia may

be distinguishedbe distinguished

-- Footling :- feet are presenting partFootling :- feet are presenting part

with buttocks high upwith buttocks high up

- Sacrum is usually in the anterior- Sacrum is usually in the anterior

quadrant.quadrant.

- D/d Face presentation- D/d Face presentation

di i tdi i t


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diagnosis contndiagnosis contn

--

Imaging Techniques :-Imaging Techniques :-

a)a)U S S - Ideal to confirm the presentationU S S - Ideal to confirm the presentation

andand

type of breechtype of breech

- To rule out anomalies placenta- To rule out anomalies placentaprevia, hyper extension of headprevia, hyper extension of head

- Assessment of fetal weight. liq.- Assessment of fetal weight. liq.

vol.vol.

- USG is helpful in ECV- USG is helpful in ECVb) CT - Pelvimetry for pelvicb) CT - Pelvimetry for pelvic

measurementsmeasurements

c) X-ray - Pelvimetry in deciding mode ofc) X-ray - Pelvimetry in deciding mode of

delivery in breech isdelivery in breech is


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PositionPosition

LSA,RSA,RSP,LSPLSA,RSA,RSP,LSPRSL, LSLRSL, LSL


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MANAGEMENTMANAGEMENT

AntepartumAntepartum

DeliveryDelivery

During laborDuring labor V i f th b hV i f th b h


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Version of the breechVersion of the breech

Spontaneous versionSpontaneous version

ECVECV

Internal podalic versionInternal podalic version

V i f th b h ECVVersion of the breech ECV


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Version of the breech - ECVVersion of the breech - ECV

Procedure whereby the presentation otherProcedure whereby the presentation other

than cephalic is converted by externalthan cephalic is converted by externalmanipulation into a cephalic presentationmanipulation into a cephalic presentation

Indications:- Breech or Shoulder presentationIndications:- Breech or Shoulder presentation

diagnosed in the last week of pregnancydiagnosed in the last week of pregnancy

Success rate 65 %Success rate 65 %Timing of ECV at 36 weeksTiming of ECV at 36 weeks

Advantage incidence of CS rate decreaseAdvantage incidence of CS rate decrease

Contraindications of ECV:- ( Absolute )Contraindications of ECV:- ( Absolute )Placenta previa, Multiple pregnancy, PROM,Placenta previa, Multiple pregnancy, PROM,

APH, PIH, Prematurity and contraindication toAPH, PIH, Prematurity and contraindication to

vaginal delivery, Significant fetal abnormality.vaginal delivery, Significant fetal abnormality.


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Contraindication ContnContraindication Contn

Relative Contraindication :-Relative Contraindication :-

Previous CSPrevious CS

IUGRIUGR

ObesityObesity

Rhesus iso-immunizationRhesus iso-immunization

Anterior placentaAnterior placenta

Grand multiparaGrand multipara

Precious babyPrecious baby

Newmans Score for ECVNewmans Score for ECV


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Newmans Score for ECVNewman s Score for ECV

ScoreScore 00 11 22

ParityParity 00 11 >> 22

Estimated fetal weight (kg)Estimated fetal weight (kg) < 2.5< 2.5 2.5-2.5-

3.53.5> 3.5> 3.5

Placental positionPlacental position anterioranterior posteriorposterior

Lateral or fundalLateral or fundalCervical dilatationCervical dilatation >> 33 1-21-2 00

Station of presenting partStation of presenting part >> -1-1 -2-2 -3-3

Because of significant overlap in scoresBecause of significant overlap in scores

between successful and unsuccessfulbetween successful and unsuccessful

ECV, this scoring system is clinically lessECV, this scoring system is clinically less

useful.useful.

ECV contnECV contn


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ECV contn.ECV contn.

ECVECV shouldshouldbe carried out in an area that hasbe carried out in an area that hasready access to a facility equipped to performready access to a facility equipped to perform

emergency CSemergency CS

Better to do it under USG guidanceBetter to do it under USG guidance

1. Obtain consent after explaining procedure to1. Obtain consent after explaining procedure to

the womanthe woman2. u/scan to R/O contraindications2. u/scan to R/O contraindications..

3. Maternal B.P measurement.3. Maternal B.P measurement.

4. Fetal heart rate measurement (b/4 and after4. Fetal heart rate measurement (b/4 and after

procedure):-non stress test (CTG)procedure):-non stress test (CTG)

5. Tocolytics (eg salbutamol, ritodrine) for5. Tocolytics (eg salbutamol, ritodrine) foruterine relaxation.uterine relaxation.

ECVECV C


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ECVECV ContnContn....6. Mother placed in a steep lateral position with6. Mother placed in a steep lateral position with

her back supported with a cushion orher back supported with a cushion or

in a supine position and comfortable.in a supine position and comfortable.7. Breech disengaged from pelvic inlet using both7. Breech disengaged from pelvic inlet using both

hands, E.C.V carried out when breech is abovehands, E.C.V carried out when breech is above

the inlet.the inlet.

8. One hand on lower pole, other on upper pole,8. One hand on lower pole, other on upper pole,

manipulate in the direction which increasesmanipulate in the direction which increases

flexion of the fetus and makes it do a forwardflexion of the fetus and makes it do a forward

roll, bringing the head lower uterinepole.roll, bringing the head lower uterinepole.

9. The back flip technique is then tried if9. The back flip technique is then tried if

unsuccessfulunsuccessful


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ECV contnECV contn


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ECV contn.ECV contn.

10. On completion of version the fetus is steadied10. On completion of version the fetus is steadied

by lateral pressure while the mother isby lateral pressure while the mother is

transferred to the supine or semi-recumbenttransferred to the supine or semi-recumbent

position.position.

11. Check fetal heart rate after procedure.11. Check fetal heart rate after procedure.

N/B: If procedure fails or becomes difficult, itN/B: If procedure fails or becomes difficult, it

is abandoned.is abandoned.

it is easier to perform ECV in multiparousit is easier to perform ECV in multiparouswomen due to laxity of uterus and abdominalwomen due to laxity of uterus and abdominal

wall.wall.

No place for E.C.V in preterm high failureNo place for E.C.V in preterm high failure

rate.rate.

F t i fl i th f ECVFactors influencing the success of ECV


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Factors influencing the success of ECVFactors influencing the success of ECV

Maternal: parity - higher in multipara. NormalMaternal: parity - higher in multipara. Normal

amount of liquoramount of liquor

Race : higher in black women - due to lateRace : higher in black women - due to late

engagementengagement

Fetal : Type of breech - flexed>frankFetal : Type of breech - flexed>frank

descent of presenting part notdescent of presenting part notoccurred into the pelvisoccurred into the pelvis

Failure : Diminished liquor, Excessive maternalFailure : Diminished liquor, Excessive maternal

wt., anterior placental location,wt., anterior placental location,

cervical dilatation, descent of thecervical dilatation, descent of the

breech into the pelvis and anterior orbreech into the pelvis and anterior or

posterior positioning of the fetal spine.posterior positioning of the fetal spine.

Complications of ECVComplications of ECV


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Complications of ECVComplications of ECV

Placental abruptionPlacental abruption Uterine ruptureUterine rupture

Amniotic fluid embolismAmniotic fluid embolism

Fetomaternal hemorrhage 4 %Fetomaternal hemorrhage 4 % Iso-immunizationIso-immunization

Preterm labourPreterm labour

Fetal distressFetal distress

Fetal demiseFetal demise

Fetal heart deceleration - 40 %Fetal heart deceleration - 40 %

Internal podalic ersionInternal podalic version


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Internal podalic versionInternal podalic version

This maneuver consist of turning the fetusThis maneuver consist of turning the fetus

byby

inserting a hand into the uterine cavity,inserting a hand into the uterine cavity,

seizingseizing

one or both feet and drawing themone or both feet and drawing themthrough thethrough the

cervix.cervix.

Operation is followed by breech extractionOperation is followed by breech extraction

Indications:- Transverseli of 2Indications:- Transverseli of 2ndnd of twinof twin

DURING LABOURDURING LABOUR


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DURING LABOURDURING LABOUR

Management of term breech :-Management of term breech :-

CSCS

Vaginal breech deliveryVaginal breech delivery Indication of CS:-Indication of CS:-

a)a) All complicated breechAll complicated breech

b)b) Contracted or borderline pelvisContracted or borderline pelvis

c)c) Weight of the baby more than 3.5 kgWeight of the baby more than 3.5 kg

d)d) Severe IUGRSevere IUGR

e)e) Hyper extension of fetal headHyper extension of fetal head

f)f) Footling or knee presentationFootling or knee presentationg)g) Flexed breechFlexed breech

h)h) Preterm with wt. less than 1.5 kgPreterm with wt. less than 1.5 kg


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Nowadays individualization of cases toNowadays individualization of cases to

decide on elective CS or Vaginal delivery isdecide on elective CS or Vaginal delivery is

reasonable standard of care in modernreasonable standard of care in modern

obstetric practice. At CS the baby shouldobstetric practice. At CS the baby should

be delivered in exactly the same as it isbe delivered in exactly the same as it is

during a Vaginal delivery.during a Vaginal delivery.

VAGINAL BREECH DELIVERYVAGINAL BREECH DELIVERY


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VAGINAL BREECH DELIVERYVAGINAL BREECH DELIVERY

Three types ofThree types of

vaginal breechvaginal breech

deliveries:-deliveries:-

1.1. Spontaneous breech deliverySpontaneous breech delivery2. Assisted breech delivery2. Assisted breech delivery

3.Total breech extraction3.Total breech extraction

Criteria for VD or CSCriteria for VD or CS


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Criteria for VD or CSCriteria for VD or CS

VDVD

FrankFrank

GA>34wGA>34w

FW=2000-3500grFW=2000-3500gr

Adequate pelvisAdequate pelvis

Flexed headFlexed head

Nonviable fetusNonviable fetus

No indicationNo indication

Good progress laborGood progress labor

CSCSFWFW

3500gr3500gr

FootlingFootlingSmall pelvisSmall pelvis

Deflexed headDeflexed head

Arrest of laborArrest of labor

GA24-34wGA24-34w

Elderly PGElderly PG

Inf or poor historyInf or poor history

Fetal distressFetal distress

Mechanism of LabourMechanism of Labour


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Denominator SacrumDenominator Sacrum

Commonest position - LSACommonest position - LSA



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Engagement

Descent

Internal rotation

Lateral flexion

External rotation

Birth : breech - body

head

EngagementEngagement


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EngagementEngagementDescent with increasing compactionDescent with increasing compaction

Engaging diameter is

bitrochanteric 10cm. Engagementoccurs in left Obliquediameter of pelvis.

Internal rotationInterna rotat on


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Internal rotationInterna rotat onLateral flexionLateral flexion

Anterior buttockstouches the pelvic floor,

it rotates through 1/8 ofcircle so it is behindpubic symphysis.Anterior hip appearsfirst & impinges underthe Sym. Pubis and bylateral flexion, the post.

hip is born

External rotationExternal rotation


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External rotationExternal rotation

Birth - BreechBirth - Breech

Birth - Body- HeadBirth - Body- Head


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Birth Body Headody ead

Delivery of shoulder engagingdiameter is bisacromial diameter12 cm. Engagement occurs in thesame oblique diameter as thebreech

Head eng. dia. Suboccipitobregmatic dia. 9.4 cm in the oppositeoblique dia. to that in which thebuttocks engaged.

V B DV B D


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V B DV B D

Spontaneous breech delivery The fetus is expelledSpontaneous breech delivery The fetus is expelledentirely spontaneously without any traction orentirely spontaneously without any traction ormanipulation.manipulation.

In modern obstetric practise there is no place forIn modern obstetric practise there is no place forS.V.B.DS.V.B.D

A.V.B.D is the choice of delivery but in well selectedA.V.B.D is the choice of delivery but in well selectedcases ( women properly assessed:- R/O F P D, &cases ( women properly assessed:- R/O F P D, &other C/I to V.D )other C/I to V.D )

Scoring index for A.V.B.D:- Andros-Zatuchni ScoringScoring index for A.V.B.D:- Andros-Zatuchni Scoringindexindex

Parameters of index:- Parity, gestational Age, PreviousParameters of index:- Parity, gestational Age, PreviousV.B.D, estimated fetal weight, cervical dilatationV.B.D, estimated fetal weight, cervical dilatationand stationand station

Zatuchi-Andros scoring index is used in labourZatuchi-Andros scoring index is used in labour

Zatuchni Andros Scoring Index (1965)Zatuchni Andros Scoring Index (1965)


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Zatuchni Andros Scoring Index (1965)Zatuchni Andros Scoring Index (1965)

parameterparameter Score 0Score 0 Score 1Score 1 Score 2Score 2

parityparity 00 11 >> 22Gestational age (weeks)Gestational age (weeks) 39+39+ 3838 4.0> 4.0 3.5-3.5-4.04.0< 3.5< 3.5

Cervical os dilatation (cm)Cervical os dilatation (cm) 22 33 >> 44

Station of presenting partStation of presenting part - 3- 3 - 2- 2 - 1- 1

Score - 0 to 4 = CSScore - 0 to 4 = CS

Score - 5 or more allow Vaginal breechScore - 5 or more allow Vaginal breech

deliverydelivery

STEPS IN A V B DSTEPS IN A V B D


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STEPS IN A.V.B.DSTEPS IN A.V.B.D

1.1. Transfer to 2Transfer to 2ndnd

stage room whenstage room whenfullyfully

dilateddilated

2.2. Place in lithotomy position andPlace in lithotomy position andcleansecleanse

lower abdomen, vulva, vagina andlower abdomen, vulva, vagina and

thighsthighswith swabs soaked in betadine soln.with swabs soaked in betadine soln.

3. Apply sterile drapes3. Apply sterile drapes

Steps in A V B DSteps in A V B D


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Steps in A V B DSteps in A V B D

4.4. Empty bladder with a plastic catheter and repeat V.E toEmpty bladder with a plastic catheter and repeat V.E toconfirm full cervical dilatation.confirm full cervical dilatation.

5. With each contraction she is encouraged to bear down while5. With each contraction she is encouraged to bear down while

the descent of the breech is observed without interferencethe descent of the breech is observed without interference6. The perineum is infiltrated with 10mls of 1% xylocaine6. The perineum is infiltrated with 10mls of 1% xylocaine

7. A right mediolateral episiotomy is given as the breech7. A right mediolateral episiotomy is given as the breechdistends the perineum, the descent of the baby allowed todistends the perineum, the descent of the baby allowed tocontinue until the umbilicus and popliteal fossa becomecontinue until the umbilicus and popliteal fossa becomevisiblevisible

8. Each extended lower limb is delivered by the pinards8. Each extended lower limb is delivered by the pinardsmanoeuvre (pressure applied with two fingers to the poplitealmanoeuvre (pressure applied with two fingers to the poplitealfossa to flex the knee and gently abduct and flex the thigh)fossa to flex the knee and gently abduct and flex the thigh)

9. Mother encouraged to bear down until the trunk, up to the9. Mother encouraged to bear down until the trunk, up to the

scapula becomes visible, cord pulsation checked and a loop ofscapula becomes visible, cord pulsation checked and a loop of

cord pulled down to prevent cord compressioncord pulled down to prevent cord compression

10. Baby gently held by the groin and trunk rotated 9010. Baby gently held by the groin and trunk rotated 90oo in onein one


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10. Baby gently held by the groin and trunk rotated 9010. Baby gently held by the groin and trunk rotated 90 in onein one

direction witha downward traction applied and the back facingdirection witha downward traction applied and the back facing

upwards to deliver the anterior shoulder (lovset maneouvre forupwards to deliver the anterior shoulder (lovset maneouvre forextended arms)extended arms)

11. Procedure repeated in the opposite direction, with a rotation of 18011. Procedure repeated in the opposite direction, with a rotation of 18000

totodeliver the posterior shoulder.deliver the posterior shoulder.

12. Mother further encouraged to bear down until the hair lines is visible12. Mother further encouraged to bear down until the hair lines is visible(thenape of the neck become visible) under the pubic symphysis(thenape of the neck become visible) under the pubic symphysis

13. The aftercoming head is delivered by one of the following methods:13. The aftercoming head is delivered by one of the following methods:

- Burns Marshall Technique- Burns Marshall Technique

- Mauriceau-Smellie-Veit manoeuvre (jaw flexion and shoulder traction)- Mauriceau-Smellie-Veit manoeuvre (jaw flexion and shoulder traction)

- Obstetric forceps (pipers)- Obstetric forceps (pipers)

The most important aspect of V B D is delivery of after coming head.The most important aspect of V B D is delivery of after coming head.


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Classical MethodClassical Method


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Lovsets MethodLovsets Method

- -- -


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ManeuverManeuverThe index and middle finger of one hand areThe index and middle finger of one hand are

applied over the maxilla, to flex the head,applied over the maxilla, to flex the head,

while fetal body rests upon the palmwhile fetal body rests upon the palmof the hand and forearm.of the hand and forearm.

The two fingers of other hand then hookedThe two fingers of other hand then hooked

over the fetal neck and grasping shoulders,over the fetal neck and grasping shoulders,downward traction is applied until subdownward traction is applied until suboccipital region appears under the symphysis.occipital region appears under the symphysis.

Give gentle supra pubic pressure to flex theGive gentle supra pubic pressure to flex thehead. The body of the fetus is then elevatedhead. The body of the fetus is then elevatedtowards the maternal abdomen and the headtowards the maternal abdomen and the headis deliverdis deliverd

i S lli iM i S lli V it


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Mauriceau-Smellie-VeitMauriceau-Smellie-Veit

ManeuverManeuver


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Piper ForcepsPiper Forceps

Prague ManeuverPrague Maneuver


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Prague ManeuverPrague Maneuverback of the fetus fail to rotateback of the fetus fail to rotate

to the anteriorto the anterior

Prague maneuverPrague maneuver


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Prague maneuverPrague maneuver It is used for delivery of the after comingIt is used for delivery of the after coming

head in case of failure of fetal trunk to rotatehead in case of failure of fetal trunk to rotate

anteriorly. Two fingers of one hand graspinganteriorly. Two fingers of one hand grasping

the shoulders of the back-down fetus, fromthe shoulders of the back-down fetus, from

below, while the other hand draws the feetbelow, while the other hand draws the feet

up over maternal abdomenup over maternal abdomen

1936 )1936 )


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1936 )1936 ) The breech is allowed to deliver spontaneously upThe breech is allowed to deliver spontaneously up

to the umbilicus.to the umbilicus.

The fetal body is then held, but not pressed,The fetal body is then held, but not pressed,

against the maternal symphysis. This forceagainst the maternal symphysis. This force

is meant to be the equivalent of gravity.is meant to be the equivalent of gravity.

The suspension of the fetus in this positionThe suspension of the fetus in this positioncoupled with the effects of uterine contractionscoupled with the effects of uterine contractions

and moderate suprapubic pressure by anand moderate suprapubic pressure by an

assistant, results in spontaneous delivery.assistant, results in spontaneous delivery.

C li ti f b hComplications of breech


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Complications of breechComplications of breech

deliverydelivery Morbidity & Mortality Maternal Injuries

Risk : Operative intervention

Manipulations : Risk infection Intrauterine maneuvers : Rupture of the

uterus +/- lacerations of Cx

Extensions of the episiotomy

Uterine atony , Postpartum hemorrhage

Perinatal Morbidity & Mortality


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Perinatal Morbidity & Mortality Preterm delivery & low birth weight & IUGR Birth aphyxia

Fetal Injuries Fx of humerous and clavicle

Fx of femur

Hematomas of sternocleidomastoid Separation of epiphyses of scapular,humerus or

femur Brachial plexus Avulsion of upper C-spine Skull Fx , intracerebral injury

PROM & Cord Prolapse- Incidence of Cord Prolapse inflexed breech is 6 % & footling is 12 %. Extended

breech only 0.5% ( Vertex 0.4 % )

In flexed & footling limbs may slipout before fulldilatation and can cause entrapment of head.


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Perinatal mortality isPerinatal mortality is

increased 2- to 4-fold withincreased 2- to 4-fold with

breech presentation,breech presentation,

regardless of the mode ofregardless of the mode of

delivery.delivery.

Congenital malformationCongenital malformation6%6%

RisksRisks


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RisksRisks

Lower Apgar scorsLower Apgar scors

An entrapped headAn entrapped head

Nuchal armsNuchal arms

Cervical spine injuryCervical spine injury

Cord prolapseCord prolapse

,

Entrapment of the after coming headEntrapment of the after coming head


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Occurs in case of delivery of theOccurs in case of delivery of thesmall pre term fetuses. The body ofsmall pre term fetuses. The body of

the fetus is delivered through anthe fetus is delivered through anincompletely dilated cervix and it willincompletely dilated cervix and it willnot allow delivery of the after comingnot allow delivery of the after cominghead.head.

Bracht Maneuver may be tried.Bracht Maneuver may be tried. Duhrssen incisions can be made inDuhrssen incisions can be made in

the cervix.the cervix. Under GAUnder GA Replacement of the fetus higher in toReplacement of the fetus higher in to

the vagina and uterus followed by CS (the vagina and uterus followed by CS (

Abdominal rescue by CS )Abdominal rescue by CS )


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Birth AsphyxiaBirth Asphyxia

Total breech extraction


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Total breech extraction

Entire body of the infant is

extracted by theObstetrician

Indication of Total breech ExtractionIndication of Total breech Extraction


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1. Prolong second stage of labor

2. 2nd of the Twin

3. Cord Prolapse complicates the late2nd

stage

4. Fetal distress

Contraindication of TotalContraindication of Total


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Contraindication of TotalContraindication of Total

breech extractionbreech extraction

Cervix not fully dilated

2. FPD


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Pi t 3 A i t dPi t 3 A i t d


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Picture 3. AssistedPicture 3. Assistedvaginal breechvaginal breechdelivery: The Ritgendelivery: The Ritgen

maneuver is appliedmaneuver is appliedto take pressure offto take pressure offthe perineum duringthe perineum duringvaginal delivery.vaginal delivery.Episiotomies often areEpisiotomies often are

cut for assistedcut for assistedvaginal breechvaginal breech

deliveries, even indeliveries, even inmultiparous women,multiparous women,

to prevent soft-tissueto prevent soft-tissuedystocia.dystocia.
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: Once the feet have delivered,

there may be temptation topull on the feet. However, thisshould never be done with asingleton gestation because it

may precipitate an entrappedhead in an incompletelydilated cervix or it mayprecipitate nuchal arms. Aslong as the fetal heart rate is

stable and no physicalevidence of a prolapsed cordexists, expectant managementmay be followed, awaiting full

cervical dilatation.

Footling breech presentationFootling breech presentation
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Picture 5. Assisted vaginal breech delivery: Witha towel wrapped around the fetal hips, gentle

downward and outward traction is applied inconjunction with maternal expulsive efforts untilthe scapula is reached. An assistant should beapplying gentle fundal pressure to keep the

fetal head flexed.

Picture 9. Assisted vaginal breech delivery: The fetal headis maintained in a flexed position by using the Mauriceau-
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is maintained in a flexed position by using the Mauriceau-Smellie-Veit maneuver, which is performed by placing theindex and middle fingers over the maxillary prominence

on either side of the nose. The fetal body is supported in aneutral position with care to not overextend the neck.

icture 6 Assisted vaginal breech delivery:


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icture 6. Assisted vaginal breech delivery:fter the scapula is reached, the fetus shoule rotated 90 in order to delivery thenterior arm.


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Picture 8. Assisted vaginal breech delivery: Thefetus is rotated 180 and the contralateral arm is


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fetus is rotated 180 , and the contralateral arm isdelivered in a similar manner as the first. Theinfant is then rotated 90 to the back-up position in

preparation for delivery of the head.

Picture 12 Assisted vaginal


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Picture 12. Assisted vaginalbreech delivery - The

neonate after birth


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icture 11. Assisted vaginal breech delivery: Low 1-minute Apgar scores are notncommon after a vaginal breech delivery. A pediatrician should be present forhe delivery in the event that neonatal resuscitation is needed.

Pi t 10 Pi f li ti Pi


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Picture 10. Piper forceps application: Pipers arespecialized forceps used only for the aftercoming

head of a breech presentation. They are used tokeep the head flexed during extraction of the fetalhead. An assistant is needed to hold the infantwhile the operator gets on one knee to apply the

forceps from below.


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Breech Presentation Dr Moly Sam K on 17-04-2010 Final

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