By

Dr. Nadia Saddam AL.Assady

C.A.B.O.G

Breech presentation:
The incidence rate at term is (3-4%), but it is
commoner preterm (15% at 32 weeks) & ( 20% at 28
weeks).
etiology:
A-maternal factors:
null parity, older age, uterine abnormality, abnormal
placental site ( placenta previa), diabetes, smocking,
late or no antenatal care & white ethnicity.
B-fetal factors:
the commonest association with prematurity, fetal
anomali( hydrocephalus or neuromuscular dysfunction
causing abnormal posture or dyskinesia), IUGR,
polyhydramnios, short umblical cord, extended legs &
multiple pregnancy.

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 Clinical feature:
1-the term mother complain from subcostal
discomfort specially on the right side.
2-abdominal palpation: revel the hard, round ballot
able head at the uterine fundus & auscultation of
fetal heart sounds above the umbilicus.
3-vaginal examination: may reveal soft presenting
part the landmarks being the ischial tuberosity, the
anus & genitalia may also be palpable.
4-U/S examination: to confirm the presentation &
exclude fetal & maternal abnormalities that affect the
management.

Types of breech presentation:

a-extended (frank): the legs are flexed at hip
& extended at the knee.It occurs at (70%) of
cases &carries the lowest risk of cord prolapse
& feto pelvic disproportion.
b-flexed (complete): both hips & knee are
flexed & the buttock is the presenting part.
c-footlying ( incomplete): at least one leg
extended at hip & knee. This carries highest
risks of cord prolapse & feto pelvic
disproportion.

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 Management of Preterm breech:
There are concerns that the preterm fetus may
be more vulnerable to hypoxic injury than the
term fetus & also since the fetal head is
relatively larger than the body, in preterm
(BPD is larger than bitrochanteric diameter)
there is greater risk of entrapment of the after
coming head. However, elective C/S is
complicated by the fact that (80%) of women
in threatened preterm lobar will deliver at term
so there is significant risk of iatrogenic
prematurity if the babies delivered by C/S
before lobar is established.

Furthermore, elective preterm C/S does not

escape the risk of head entrapment, &
midline uterine incision or inverted T-
incision carry increased risk of scar rupture
in the future. It is generally, accepted that
for the fetus prior to (34 weeks), the risk
associated with prematurity & congenital
anomalies far outweigh those associated
with mode of delivery & there is no evidence
to support a policy of elective C/S for breech
presentation in preterm lobar.

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 Management of Term breech:
1-posture: knee- chest position for up to (10
minute/day) may be effective in converting breech to
cephalic one, no significant benefits from this
procedure so not routinely recommended.
2-external cephalic version:
It is an abdominal procedure by which the fetus is
turned from breech to cephalic presentation & should
be only undertaken by professional trained personal.
Benefits of ECV: reduce the incidence rate of vaginal
breech delivery & C/S rate so reduce maternal
morbidity & mortality.
Risk of ECV: transient bradycardia, abruption
placenta, cord prolapse, feto maternal hemorrhage

Indication of ECV:
1-any breech presentation after (37 completed weeks)
in other wise uncomplicated pregnancy.
2-maternal request.
Contraindication:
a-absolute C/I:
1- multiple pregnancy. 2-antepartum hemorrhage.
3-rupture membrane. 4-fetal abnormalities.
5-hyper extended head. 6-need urgent delivery
regardless the presentation e.g placenta previa.
7-need for C/S to ensure fetal wellbeing or any
suspected compromise,
b-relative C/I: 1-previous LSCS.2-maternal disease like
(HT, DM). 3-IUGR. 4-oligohydramnios.
5-maternal obesity. 6-nuchal cord

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 Procedure of ECV:
1-before starting the ECV the women should be
asked to drink plenty of fluid so this optimize liquor
volume.
2-perform CTG to confirm normal reactive pattern.
3-U/S is useful before ECV to confirm the breech,
confirm the presence of normal fetus, ensure
adequate liquor volume ,confirm placenta position,
observe the presence of nuchal cord & detail the
fetal attitude & position of fetal legs.
4- obtained informed consent , specially the risk.
5-ensure facilities for delivery by immediate C/S are
present

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 3-vaginal breech delivery:
Criteria for allowing breech vaginal delivery:
1-frank breech. 2-fetal weight < (3.8 Kg).
3-no feto pelvic disproportion & clinically adequate
pelvis.
Criteria for preclude breech vaginal delivery:
1-footlying breech. 2-fetal weight > (3.8 Kg).
3-star gazing or hyper extended fetal neck.
Risk of breech vaginal delivery:
1- low Apgar scores at birth. 2-intracranial injuries.
3-brachial plexus injuries.
4-fracture of fetal long bones.
5-soft tissues genital tract injuries to mother.

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 The procedure of breech vaginal delivery:
the principle of vaginal breech delivery is to allow
the spontaneous delivery of the fetus through the
combination of uterine activity & maternal expulsive
efforts, operator intervention should be limited to a
few well trained maneuvers with injudicious traction
on the fetal body or limbs avoided at all costs, not
only can traction lead to direct injury such
interventions may also increase displacement of the
fetal limbs from their normal attitude increasing the
relative disproportion between fetus & pelvis that
may already exist.

Management during the 1st stage of lobar:

1-lobar should be conducted within setting that
allows rapid intervention by C/S if needed.
2-the diagnosis of lobar & presentation of the fetus
by breech should be confirmed IV access established
& fetal monitoring started.
3-epidural anesthesia may be recommended in order
to prevent involuntary expulsive efforts prior to full
cervical dilatation & to permit emergency delivery by
C/S however epidural is not essential.
4-the use of oxytocin should be discouraged because
any failure of progression is indication for C/S
specially for breech.

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 Management during the 2nd stage:
It is begins with full cervical dilatation & visualization
of the fetal anus at the perineum & must be managed
by operator trained in the delivery of breech. There
are 3 option for breech delivery ,
1-spontaneous breech delivery .
2-assissted breech delivery.
3-breech extraction.
1-the patient is adopted lithotomy position.
2-pudendal block can be provided if there is no
epidural in situ.
3-episiotomy may be performed to facilitate
manipulation of the after coming head.

4-the breech should be allow to deliver

spontaneously to the level of umbilicus, a loop of
cord is then brought down to minimize the risk of
traumatic delivery.
5-once the legs & abdomen have emerged the fetus
allowed to hang from the perineum until the scapula
seen & the arms are usually folded across the fetal
chest & require nothing to deliver them.
6-if the arms are extended over the fetal head so
used Lovset,s maneuver to free them . In this case,
the fetus is grasped over the bony pelvis with your
thumb along the sacrum & turned so as to bring the
posterior arm anterior. So elbow appear below the
symphysis pubis & than the arm delivered by
sweeping it across the fetal body & this maneuver
repeated for other hand.

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 7-nuchal arm these are lying above & behind the fetal
head( flexed at elbow & extend at shoulder) so it is a
consequence of inappropriate traction on the breech, so
we can used modified Lovset,s maneuver ( rotating the
fetal back in the direction of trapped arm, thus forcing
the elbow towards the fetal face over the fetal head
once free so traditional Lovset,s maneuver may then be
performed.
8-the fetus then allowed to hang from the vulva for a
few seconds until the nape of neck is visible at vulva,
this allow the head to descend in the pelvis & avoid the
complication of hyperextension that can occur with
traction at this stage. the duration of the time from
appearance of umbilicus to fetal mouth clearing the
perineum is( 10-15 min).

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 Delivery of fetal head:
a-Burns-Marshall technique:
the operator ,s assistant should grasp the ankle of the
fetus & raise the body above the mother abdomen, this
promotes flexion of fetal head & encourages it into the
A-P diameter of pelvic outlet so allow spontaneous
delivery of fetal head without further intervention.
b-Mauriceau-Smelli-Veit maneuver:
with the fetus supported on the right arm of the
operator, the middle finger is placed in the fetal throat &
the forefinger & ring finger are placed either on the
malar eminences, pressure is applied to the fetal tongue
to encourage the flexion of the head.

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 Thus present the sub occipito- bregmatic diameter to
the pelvis.
c-forceps application used straight forceps like
Kielland forceps.
Head entrapment:
1-Mc Robert,s manoevure:
the body of the fetus should be turned sideways &
suprapubic pressure applied to increase flexion &
encourage entry through the pelvic inlet in the
occipito-lateral position.
2-Dehursson,s incision: incising the cervix at 4, 8,
o'clock if descent occur before full cervical dilatation
is achieved.
3-craniotomy & delivery of the head by C/S.

Notes: pediatrician should always be present at

delivery & documentation of all events.
Breech extraction:
The only indication is to deliver the 2nd twin by
foot extraction in fully dilated cervix.
C/S:
Performing C/S does not prevent the possibility
of birth injuries like abdominal organs, spine &
brain injury.

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