Breech 17

BREECH
PRESENTATION
AND DELIVERY
By Lorraine Patal
Clinical Tutor ( Obs & Gyn)
2019
LEARNING OUTCOMES
• At the end of the lecture the students will
• Define breech presentation.
• Describe the three types of breech presentations
• Outline the risk factors of breech preenttion
• Describe ways of diagnosing breech presentation
• Describe the manuevres used in breech childbirth.
• List all fetal and maternal complications associated with breech
presentations and delivery.
CONTENTS
• Definition
• Types
• Causes and risk factors
• Diagnosis
• Management
• Complications
DEFINITION
breech presentation is a malpresentation whereby the buttock or feet present or lead

the way through the birth canal.
Incidence
• 3-4% of fetuses present by breech at term
• 7% at 32 weeks
• 25% at 28 weeks
• 2% diagnosed in labour
• therefore, breech presentation is commonly associated with prematurity.
CAUSES AND RISK FACTORS
• Uterine abnormalities eg, congenital abnormal uterus
• Uterine masses such as uterine fibroid, adenomyosis, placenta praevia
• Multiple pregnancy
• Prematurity
• Small For Gestation (SFG) babies
• Fetal anomaly
• Grandmultiparity
• Polyhydramnios
TYPES OF BREECH DELIVERY
• Frank –hips flexed and knees extended
• Complete – both hips and knees flexed
• Incomplete/ Footling –knee/s or hip/s partially flexed ( feet or one foot
presents)
COMPLETE FOOTLING OR INCOMPLETE

FRANK BEECH
BREECH BREECH
ASSESSMENT OF BREECH PRESENTATIONS
• Sacrum is the denominator in assessing the
fetal Position in breech presentation.
• The most common position is ( left sacral
anterior).
• The bitrochanteric diameter ( the transverse
diameter between the great trochanters of the
fetus) presents and measures 10cm.
LSA position
MECHANISM
Descent and engagement
at a bitrochantric
diameter
Internal rotation at 45 degrees bringing

the anterior hip to the pubic arch (
bitrochanteric diameter at an
anteroposterior diameter.
Anterior hip appears at Slight external

the vulva, followed by rotation – back
posterior hip after lateral turns in anteriorly
flexion of the body.
Shoulders rotate to
Delivery of legs and feet. a bi-acromial
diameter
HEAD IS THEN BORN IN FLEXION
DIAGNOSIS
• Presentation feels soft and irregular or buttock or feet palpable during vaginal
examination
• Longitudinal lie
• Hard round ballotable head felt at the fundus or upper abdomen
• Fetal heart audible higher up the abdomen ( above the umbilicus)
• Feet prolapsed at the vulva
• USS at the hospital
• Soft presentation with irregular edges.
MANAGEMENT
• ECV ( External Cephalic Version ) at 37 weeks or more.

• Vaginal breech delivery
• Caeserean section
• ECV should be offered at term pregnancy
• Success rate increased with:

• multiparity
• adequate liquor
• station of breech above the pelvic brim
METHODS OF BREECH DELIVERY
Vaginal breech delivery is accomplished by one of three methods.

1. Spontaneous breech delivery, the fetus is expelled entirely without any
traction or manipulation other than support of the newborn.
2. Partial ( or assisted ) breech delivery, the fetus is delivered
spontaneously as far as the umbilicus, but the remainder of the body is
delivered by provider traction and assisted maneuvers, with or without
maternal expulsive efforts.
3. Total breech extraction, the entire fetal body is extracted by the
provider.
VAGINAL DELIVERY
Cervix fully dilated with fetal

anus visible at the vulva.
Put the woman in a lithotomy

position
BREECH DELIVERY
Delivery of the breech should be

‘hands off’
Legs and abdomen are born
spontaneously.
BREECH DELIVERY
Ensure that the fetal back

rotates uppermost by carefully
grasping the fetal pelvis with
fingers & thumbs.
Leg delivery may need knee
flexion by pressure in popliteal
fossa
BREECH DELIVERY
The fetus should be allowed to

hang once the legs and abdomen
have emerged until the wings of
the scapula are seen.
LOVSET’S MANOEUVRE
Grasp the fetus around the bony

pelvis with the thumbs across the
sacrum.
The fetal back should then be turned
through 180 degrees until the
posterior arm comes to lie
anteriorly…….
LOVSET’S MANOEUVRE
The elbow will appear below the

symphysis pubis and the arm
is delivered by sweeping it
across the fetal body.
The manoeuvre is repeated in
reverse to deliver the other
arm.
BREECH DELIVERY
Allow the fetus to hang from

the vulva until the nape of
the neck is visible.
Then carry out Mauriceau-
Smellie-Veit maneuver
MANAGEMENT
• No action until 37-38 weeks of gestation
Exclude fetal anomalies

Placenta previae
Multiple pregnancy
Offer external cephalic version (ECV)
Should not be attempted if there are risks
DELIVERY
• Assisted Vaginal Breech delivery
• Elective Caesarean Section (CS)
• Emergency CS
• Selection for vaginal delivery
Average fetal weight not more than 3.5kg
Normal pregnancy
No growth restriction
Willing parents
Experienced staff, Midwife, Obstet, neonatologist,
anesthetist
ASSISTED VAGINAL BREECH DELIVERY
• Close supervision
• Epidural analgesia
• Progress of labour
Second stage of labour, can be dangerous
Observe for delivery of the breech,
Hands off
Help is needed if the arms are extended above the head
 Lovset’s maneuver to deliver the arms and shoulders
Delivery of head, forceps or head traction jaw flexion
Mauriceau Smellie Veit maneuver to deliver the entrapped head.
MAURICEAU- SMELLIE VEIT MANOUVRE
CAESAREAN SECTION (C/S)
• C.Section should be done in the presence of

BIG baby
Bad obstetric history
High risk woman
Previous c.section
The woman refuses to have breech vaginal birth
• Footling breech – the riskiest breech (after Coming head often gets stuck!)
• Studies have proven that C/S is the safest method of delivery in breech presentations
and is also associated with less risk of urinary incontinence.
COMPLICATIONS
• Fetal complications
MATERNAL COMPLICATIONS
1. Intracranial injury
2. With the head descending fast through the birth 1. Cord prolapse - due to an
canal during labour, this results in rapid
ill-fitting presenting part
compression and decompression leading to
intracranial injury. 2. Perineal tears,
3. Ashpyxia if delivery delayed
4. Traumatic injury. –fractures humerus,
clavicle,femur
5. Apneoa –the placenta separates in the second
stage while the head is in the pelvis which may
lead to airway obstruction from blood loss
following placental separation.
• End of presentation
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BREECH

breech presentation is a malpresentation whereby the buttock or feet present or lead

COMPLETE FOOTLING OR INCOMPLETE

Internal rotation at 45 degrees bringing

Anterior hip appears at Slight external

• ECV ( External Cephalic Version ) at 37 weeks or more.

• Success rate increased with:

Vaginal breech delivery is accomplished by one of three methods.

Cervix fully dilated with fetal

Put the woman in a lithotomy

Delivery of the breech should be

Ensure that the fetal back

The fetus should be allowed to

Grasp the fetus around the bony

The elbow will appear below the

Allow the fetus to hang from

• No action until 37-38 weeks of gestation

Exclude fetal anomalies

• C.Section should be done in the presence of

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