DELIVERY TECHNIQUES IN ABNORMAL PRESENTATION

KAREEN N. REFORMA, MD, FPOGS, FPSUOG

BREECH PRESENTATION
Buttocks or lower extremity presenting
Cephalic pole occupies the fundus

With the frank breech presentation, both ischial

tuberosities, the sacrum, and the anus are
palpable
External genitalia may be distinguished

Types of Breech

Complete breech hips flexed, knees flexed (5 10%)

Incomplete breech one or both hips extended and
one or both feet lie below the breech (10 30%)
Frank breech hips flexed, knees extended (50 70%)
Incomplete Breech

Single footling

Double footling

Incidence
3 4% of singleton deliveries at term
Increases with decreasing gestational age
7 10% at 32 weeks
25 35% at <28 weeks
Predisposing factors
Prematurity
Abnormal amniotic fluid volume (Polyhydramnios,
oligohydramnios)
Uterine relaxation associated with great parity
Multifetal gestation
Hydrocephaly
Anencephaly
Previous breech delivery
Placenta previa
Fundal placental implantation
Uterine anomalies
Pelvic tumors
Leopold Maneuvers

Vaginal Examination

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Breech Positions
Fetal positions are designated as left sacrum
anterior (LSA), right sacrum anterior (RSA), left
sacrum posterior (LSP), right sacrum posterior
(RSP), or sacrum transverse (ST) to reflect the
relationship of the fetal sacrum to the maternal
pelvis.

Route of Delivery
Vaginal Delivery vs Cesarean Section
Fetal characteristics
Pelvic dimensions
Coexistent pregnancy complications
Operator experience
Patient preference
Hospital capabilitites
Imaging Techniques
Ultrasound confirms suspected breech; type of breech
and neck angle
CT Scan/MRI pelvic dimensions and configuration
X-ray pelvimetry
Hannah Breech Trial
a multicenter randomized clinical trial conducted
in 2000, involving term fetuses in frank or
complete breech presentations
1041 women randomly assigned to planned
cesarean and 1042 to planned vaginal delivery
Overall, planned cesarean delivery was
associated with a lower risk of perinatal mortality

DELIVERY TECHNIQUES IN ABNORMAL PRESENTATION

KAREEN N. REFORMA, MD, FPOGS, FPSUOG

compared with planned vaginal delivery3 per

1000 versus 13 per 1000.
Planned cesarean delivery was also associated
with a lower risk of serious neonatal morbidity
1.4 versus 3.8 percent.
Maternal complications were similar between the
groups.
Note: Main causes of death head entrapment, cerebral
injury and intracranial hemorrhage, cord prolapse and
severe asphyxia
The decision regarding the mode of delivery
should depend on the experience of the health care
provider and that planned vaginal delivery of a term
singleton breech fetus may be reasonable under hospitalspecific protocol guidelines.
Committee Opinion No. 340
American College of Obstetricians and
Gynecologists (2006)
Recommendations for Delivery
Cesarean delivery is commonly, but not exclusively, used
in the following circumstances:
1. A large fetus
2. Any degree of contraction or unfavorable shape of the
pelvis determined clinically or with CT pelvimetry
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 in 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
Maternal Morbidity
Increased rate of maternal morbidity due to
higher frequency of operative delivery
Genital tract lacerations
Uterine rupture due to intrauterine maneuvers,
especially with a thinned lower uterine segment,
or delivery of the aftercoming head through an
incompletely dilated cervix
Uterine atony, postpartum hemorrhage
Increased risk of infection
Perinatal Morbidity and Mortality
Perinatal mortality is increased to 2-4 fold
Preterm delivery
Congenital anomalies (6.3% vs 2.4%)

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Birth trauma (vaginal breech delivery)

- fracture of the humerus, clavicle, femur
- brachial plexus injury
- spoon-shaped depression, skull fracture
- fetal neck injury
- Cord prolapse
Management of Labor
Assessment of cervical dilatation, effacement,
station and status of the membranes
Surveillance of fetal heart rate
Monitor uterine contractions and progress of
labor
Immediate recruitment of necessary staff :
1. An obstetrician skilled in the art of breech
extraction
2. An associate to assist with the delivery
3. Anesthesia personnel who can ensure
adequate analgesia or anesthesia when needed
4. An individual trained in newborn resuscitation
Techniques for Breech Delivery
Three Methods of Vaginal Delivery :
1. Spontaneous breech delivery
- The fetus is expelled entirely spontaneously
without any traction or manipulation other than
support of the newborn.
2. Partial breech extraction
- The fetus is delivered spontaneously as far as
the umbilicus, but the remainder of the body is
extracted or delivered with operator traction and
assisted maneuvers, with or without maternal
expulsive efforts.
3. Total breech extraction
The entire body of the fetus is extracted by the
obstetrician.
Partial Breech Extraction

DELIVERY TECHNIQUES IN ABNORMAL PRESENTATION

KAREEN N. REFORMA, MD, FPOGS, FPSUOG

2.
3.

4.

5.
Total Breech Extraction

forearm. The forearm is straddled by the fetal

legs.
Two fingers of the other hand are hooked over
the fetal neck.
Grasping the shoulders, downward traction is
applied until the suboccipital region appears
under the symphysis.
Gentle suprapubic pressure is simultaneously
applied by an assistant to help 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.

Modified Prague Maneuver

Two fingers of one hand grasp
the shoulders of the back-down
fetus from below while the
other hand draws the feet up
over the maternal abdomen
Used when fetal back fails to
rotate anteriorly
Piper Forceps
The fetal body is held elevated using a warm
towel and the
blade of forceps applied to the aftercoming head. The
blades should
not be applied until the fetal head has been brought into
the pelvis by gentle traction, combined with suprapubic
pressure, and is engaged.

A cardinal rule in successful breech extraction is

to employ steady, gentle, downward rotational traction
until the lower halves of the scapulas are delivered,
making no attempt at delivery of the shoulders and arms
until one axilla becomes visible.
Delivery of the Aftercoming Head
Mauriceau Maneuver

1.

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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

Entrapment of the Aftercoming Head

Duhrssen incisions
Make an incision at 2 oclock
position of the cervix ,
followed by a second incision
at 10 o'clock. Infrequently,
an additional incision is
required at 6 oclock.
The incisions are so placed
so
as to minimize bleeding from the laterally located
cervical branches of the uterine cavity.
Other Alternatives:

DELIVERY TECHNIQUES IN ABNORMAL PRESENTATION

KAREEN N. REFORMA, MD, FPOGS, FPSUOG

1. Intravenous nitroglycerin (usually 100 g)

- provides cervical relaxation for relief of head
entrapment
2. General anesthesia
3. Zavanelli maneuver
- Cesarean delivery after replacement of the
entrapped fetus back into the uterus
- used as a last resort
4. Symphysiotomy
- used to widen the anterior pelvis
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
External version - the manipulations are performed
exclusively through the abdominal wall
Internal version - manipulations are accomplished
inside the uterine cavity
External Cephalic Version
Should be considered when a breech
presentation is recognized prior to labor in a
woman who has reached 36 weeks gestation
After 36 weeks :
- likelihood of spontaneous version is low
- complications of iatrogenic preterm delivery
generally are
not severe
Contraindications
Version is contraindicated if vaginal delivery is
not an option :
- Placenta previa
- Nonreassuring fetal status
- A prior uterine incision (although in small
studies external version was not associated with
uterine rupture in women who had previously
undergone Cesarean delivery)
Factors That May Modify the Success of External
Cephalic Version
Increase Success
Increasing parity
Ample amnionic fluid
Unengaged fetus
Tocolysis
Decrease Success
Engaged fetus
Tense uterus
Inability to palpate head
Obesity

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Anterior placenta
Fetal spine anterior or posterior
Labor

External cephalic version should be carried out in

an area that has ready access to a facility
equipped to perform emergency cesarean
deliveries
Sonographic examination is performed to confirm
nonvertex presentation and adequacy of
amnionic fluid volume, to exclude obvious fetal
anomalies if not done previously, and to identify
placental location.
External monitoring is performed to assess fetal
heart rate reactivity.

Techniques
1. A forward roll of the fetus usually is attempted first.
2. Each hand grasps one of the fetal poles, and the
buttocks are elevated from the maternal pelvis and
displaced laterally.
3. The buttocks are then gently guided toward the
fundus, while the head is directed toward the pelvis.
4. If the forward roll is unsuccessful, then a backward flip
is attempted.

Version attempts are discontinued for excessive

discomfort, persistently abnormal fetal heart
rate, or after multiple failed attempts.
The nonstress test is repeated after version until
a normal test result is obtained

Tocolysis
For uterine relaxation
Impact on success is controversial
250 ug of terbutaline subcutaneously prior to
attempted version
Conduction Analgesia
According to the American College of
Obstetricians and Gynecologists (2000), there is
not enough consistent evidence to recommend
conduction analgesia routinely for external
version.
Complications
Placental abruption

DELIVERY TECHNIQUES IN ABNORMAL PRESENTATION

KAREEN N. REFORMA, MD, FPOGS, FPSUOG
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Uterine rupture
Fetomaternal hemorrhage
Isoimmunization
Preterm labor
Fetal compromise
Death

Internal Podalic Version

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Used only for delivery of a second twin

The fetus is turned to a breech presentation by
inserting the 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 transabdominally to push the
upper portion of the fetal body in the opposite
direction, followed by breech extraction.