BREECH PRESENTATION & DELIVERY

Panwad Rattanasrithong INT2

Definition & Clinical importance

Definition
The presentation that the fetus is in longitudinal lie and its buttock enter the pelvis first

Incidence
3-4% of singleton deliveries 15% at 29 32 weeks

ETIOLOGY
Precipitating factor
Gestational age Great parity / Multiple fetuses (uterine relaxation) Hydramnios / Oligohydramnios Hydrocephalus / Anencephalus Previous breech delivery Uterine anomalies / Pelvic tumors Placenta previa

Types of breech

Types of breech
Frank breech : flexed at hips and
extended at knees

Complete breech : flexed at hips and

flexed at knees

Incomplete breech : one or both hips

are not flex and one or both feet or knees lie below the breech

Diagnosis

Abdominal examination
1st Leopold maneuver: ballottement
2nd Leopold maneuver: large part 3rd Leopold maneuver: movable 4th Leopold maneuver: prominence

Vaginal Examination
Palpable : both ischial tuberosities,the sacrum and the anus DDx : Face presentation (Mouth and Malar eminence) Position & Variety : Sacrum&Spinus process

Imaging Techniques
Ultrasound CT MRI

Mechanism of delivery

Mechanism of delivery
Denominator

Mechanism of delivery
Engagement Descent Internal rotation Lateral flexion External rotation Birth : breech body

head

Mechanism of delivery
Engagement

Descent

Mechanism of delivery

Internal rotation

Lateral flexion

Mechanism of delivery

External rotation

Birth : breech

Mechanism of delivery

Birth : body

head

Modes of delivery

Modes of delivery
Cesarean section Vaginal delivery
Spontaneous breech delivery Assisted breech delivery (Partial extraction) Total breech extraction

Vaginal delivery

Vaginal delivery
Entrapment of fetal head : Duhrssen incision Entrapment of fetal arm behind the neck (nuchal arm) Prolapse cord : complete 5% ,footling15%

Duhrssen incision

Vaginal delivery
Unfavorable pelvis
Gynecoid & anthropoid : favorable Platypelloid & Android : unfavorable

Vaginal delivery
Hyperextension
5 % in term breech presentation Result : Injury to C spinal cord Marked hyperextension : C/S

Vaginal delivery
Labor induction & Augmentation
No significant mortality and Apgar between infant with induced vs spontanous] Oxytocin Amniotomy CT confirm adequate pelvis

Vaginal delivery
Management of labor Establish : Membranes,labor,Fetal condition,UC Notified nursery Stage of Labor : Cx , Eff , Station ,Presentation Fetal Monitoring :
FHR q 15 min (most continue EFM) PV check cord prolapse & FHR q 5-10min (MR)

Vaginal delivery
Methods of Vaginal delivery
Spontaneous breech delivery Partial breech extraction Total breech extraction

Vaginal delivery
Assisted Breech Delivery

Vaginal delivery

The posterior hip of frank breech is delivering

Vaginal delivery
The anterior hip has now delivered and external rotation has occurred. The fetal thighs remain in flexion with extension knees.

Mode of delivery
Delivery of the legs by placing the fingers parallel with medial aspect of the femur and displacing laterally and away from midline

Mode of delivery
Delivery of the body.

Delivery of the shoulder

Cats paw method Classical method Lovset s method

Cats paw method

Cats paw method

Classical Method

Lovsets Method

Partial breech extraction or breech assisting

Delivery of the aftercoming head
Mauriceau-Smellie-veit maneuver Prague maneuver Piper forceps

Mauriceau-Smellie-Veit Maneuver

Prague maneuver

The back of the fetus fail to rotate to the anterior

Piper Forceps

Total breech extraction

Indication 1. Prolong second stage of labor 2. Twin 3. Maternal disease 4. Prolapse cord 5. Fetal distress

Total breech extraction

Contraindication 1. Cervix not fully dilated 2. CPD

Total breech extraction

The hand is introduced through the vagina &both feet of the fetus are grasped Gentle traction the feet through the vulva Breech appears at the vulva, gentle traction until the hips are delivered assisted breech delivery

Complete breech extraction begins with traction on the feet and ankles.

continues with traction on the thighs

the scapulas becomes visible and the body rotates, usually to the side of the mother

Cesarean section
Recommendation
Large fetus Contraction or unfavorable shape of pelvis Hyperextended head Delivery is indicated but not in labor Uterine dysfunction Incomplete or footling presentation

Cesarean section
Recommendation
Healthy preterm Severe fetal growth restriction Previous perinatal death or newborn complication of birth trauma A request for sterilization Lack of an experienced operator

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

Morbidity & Mortality

Perinatal Morbidity & Mortality
Preterm delivery & low birth weight & IUGR Prolapse cord 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

Intracerebral haemorrhage

Birth asphyxia

Version

Version
External cephalic version Internal podalic version

External Cephalic Version

Thank you for attention