Breech presentation: definition, causes, types, diagnosis and management. Lecture on Evernote: https://goo.gl/jkK9oK

1. Breech Presentation
By Ali S. Mayali

2. Seminar - 23 Oct. 2017
Overview:
•Definition, etiology and complications.
•Types.
•Diagnosis.
•Management:
• External cephalic version.
• Elective cesarean section.
• Breech delivery.

3. Breech presentation is defined as a fetus in a
longitudinal lie with the buttocks or feet closest
to the cervix.

4. Predisposing factors:
• Multiparity, pelvic tumors, congenital
uterine anomalies, contracted pelvis and
previous history of breech birth (10 %).
Maternal
• Prematurity, multiple pregnancy,
macrosomia and fetal abnormalities:
hydrocephalus, aneuploidy, neck masses,
neural tube defect, anencephaly.
Placental
• Placenta previa, polyhydramnios and
amniotic bands.Fetal

5. fetuses presenting by breech have increased
perinatal mortality and morbidity. Perinatal
mortality is increased 2- 4 folds with breech
presentations regardless of the mode of delivery.
There is also increased risk of cord accidents (i.e.
cord prolapse), CTG abnormalities and mechanical
difficulties with the delivery.

6. Types of breeches:
•Frank breech (50-70%) - Hips flexed, knees extended (pike position).
•Footling or incomplete (10-30%) - One or both hips extended, foot presenting.
•Complete breech (5-10%) - Hips flexed, knees flexed (cannonball position).

7. Diagnosis:
Diagnosis of breech presentation can be made by:
•Clinical examination
• A transverse groove may be seen above the
umbilicus in corresponds to the neck.
• If the patient is thin, the head may be seen as a
localized bulge in one hypochondrium.
Inspection
• Fundal grip: The head is felt as a smooth, hard,
round ballotable mass which is often tender.
• Pelvic grip: Small, hard and conical mass is
felt.
Palpation
• FHS is heard above the level of the umbilicus.
However in frank breech it may be heard at or
below the level of the umbilicus.
Auscultation

8. •Radiological examination.
• Confirms the clinical diagnosis.
• Detect fetal congenital abnormality and congenital anomalies of the uterus.
• Detects type of breech.
• Localizes the placenta.
• Assessment of liquor.

9. Management
Breech presentation is the most commonly encountered malpresentation and occurs in 3–4% of term
pregnancies, but is more common at earlier gestations, the percentage of breech deliveries decreases with
advancing gestational age from 22-25% of births prior to 28 weeks' gestation to 7-15% of births at 32 weeks'
gestation to 3-4% of births at term.
If a breech presentation is clinically suspected at or after 36 weeks, this should be confirmed by ultrasound
scan. The three management options available at this point should be discussed with the woman. These are
external cephalic version (ECV), vaginal breech delivery and elective cesarean section.

10. External Cephalic Version
External cephalic version (ECV) is a procedure that externally rotates the
fetus from a breech presentation to a cephalic presentation. It has been
shown to reduce the number of caesarean sections due to breech
presentations.

11. •The procedure is performed at or after 37 completed weeks’ gestation by an experienced
obstetrician at or near delivery facilities.
•ECV should be performed with a tocolytic (e.g. nifedipine) as this has been shown to
improve the success rate.
•The woman is laid flat with a left lateral tilt having ensured that she has emptied her
bladder and is comfortable.
•With ultrasound guidance, the breech is elevated from the pelvis and one hand is used to
manipulate this upward in the direction of a forward role whilst the other hand applies
gentle pressure to flex the fetal head and bring it down to the maternal pelvis.
•version is usually performed in the direction that increases flexion of the fetus and makes it
do a forward somersault
•The procedure should last no more than 10 minutes. If the procedure fails, or becomes
difficult, it is abandoned.
•Success rates vary according to the experience of the operator but in most units are
around 50% (and are higher in multiparous women who tend to have lax abdominal
musculature).

12. Contraindications to ECV:
•Placenta previa or abruptio placentae.
•Pre-eclampsia or hypertension.
•Previous caesarean or myomectomy scar on the uterus.
•History of antepartum hemorrhage.
•Multiple gestation.
•Oligohydramnios or polyhydramnios.
•Plan to deliver by caesarean section anyway.
Risks of ECV:
•Placental abruption.
•Premature rupture of membranes.
•Cord accident.
•Transplacental haemorrhage.
•Fetal bradycardia.

13. If ECV fails, or is contraindicated, and Cesarean section is nor indicated for other
reasons, then women should be counselled regarding elective Cesarean section and
planned vaginal delivery.
There is controversy on the preferred mode of delivery (vaginal delivery versus
Cesarean section) in breech delivery in relation to neonatal outcome. While CS is
supposed to be safer for the fetus, arguments against CS can be the increased risk of
maternal morbidity, risks for future pregnancies, and costs. Moreover, neonatal
respiratory distress syndrome occurs more frequently after CS compared to VD.
Many studies conclude that perinatal mortality and morbidity in the planned vaginal
breech delivery were significantly higher than with planned caesarean delivery.
See: (onlinelibrary.wiley.com/doi/10.1111/1471-
0528.13524/full, pubmed/15901272 and 24199680.

14. Although evidence suggests that it is probably safer for breech babies to be delivered by
caesarean section, there is still a place for a vaginal breech delivery in certain circumstances
(e.g. maternal choice).

15. Vaginal breech delivery
Three types of vaginal breech deliveries are described, as follows:
1. Spontaneous breech delivery: No traction or manipulation of the infant is used.
2. Assisted breech delivery: This is the most common type of vaginal breech delivery. The
infant is allowed to spontaneously deliver up to the umbilicus, and then maneuvers are
initiated to assist in the delivery of the remainder of the body, arms, and head.
3. Total breech extraction: The fetal feet are grasped, and the entire fetus is extracted. Total
breech extraction should be used only for a noncephalic second twin; it should not be
used for a singleton fetus because the cervix may not be adequately dilated to allow
passage of the fetal head. Total breech extraction for the singleton breech is associated
with a birth injury rate of 25% and a mortality rate of approximately 10%.

16. Management of labor
First stage:
• The fetal membranes should be left intact as long as possible to act as a dilating wedge
and to prevent overt cord prolapse.
• Electronic fetal monitoring is recommended throughout labor.
• There should be no evidence of feto-pelvic disproportion with a pelvis clinically thought
to be adequate and an estimated fetal weight of <3,500 g.
• Oxytocin induction and augmentation are controversial. In many previous studies,
oxytocin was used for induction and augmentation, especially for hypotonic uterine
dysfunction. However, others are concerned that nonphysiologic forceful contractions
could result in an incompletely dilated cervix and an entrapped head.
• An anesthesiologist and a pediatrician should be immediately available for all vaginal
breech deliveries. A pediatrician is needed because of the higher prevalence of neonatal
depression and the increased risk for unrecognized fetal anomalies. An anesthesiologist
may be needed if intrapartum complications develop and the patient requires
anesthesia (e.g. retained placenta).
• If there is any delay, the fetus is best delivered by an emergency caesarean section.

17. Second stage labor:
A vaginal breech delivery should be characterized by ‘masterly inactivity’ (handsoff).
Problems are more likely to arise when the obstetrician tries to speed up the process by
pulling on the baby, and this should be avoided.
•Don't be in a hurry and wait for spontaneous labor. Allow this passive phase to last for 60
to 90 minutes. Once active pushing begins, its duration is limited to no more than 60
minutes, unless delivery is imminent.
•Never pull from below and let the mother expel the fetus by her own effort with uterine
contractions.
•Always keep the fetus with its back anterior.

18. Delivery of the buttocks: Occurs naturally.
The buttocks will lie in the anterior– posterior diameter. Once the anterior buttock is delivered and the
anus is seen, an episiotomy can be cut.
Some recommend episiotomy as an important adjunct to any vaginal breech delivery (Cunningham,
2014). However, vaginally parous women with a relaxed introitus and a small-to-average sized fetus are
unlikely to benefit from an episiotomy.

19. Delivery of the legs and lower body: If the legs are flexed, they will deliver spontaneously. If extended,
they may need to be delivered using Pinard’s manoeuvre.
The posterior hip is usually born first over the intact or incised perineum. In easy cases, no assistance by
the operator is necessary or desirable. Once the anterior hip delivers, the operator can encourage the
dorsum of the fetus to rotate anteriorly and prepare to assist delivery of the legs. Even this minimal amount
of interference is sometimes unnecessary when the woman is pushing effectively.

20. Delivery of the shoulders: Loveset's maneuver:
A. Once the lower scapulas are visible, the fetal trunk is rotated 90 degrees clockwise.
B. To deliver the right arm, the fetal torso should then be rotated 180 degrees counterclockwise.

21. Delivery of the right arm using the first two fingers of the operator’s left hand over
the right shoulder and parallel to the humerus is illustrated in the figure below.
Downward pressure will sweep the arm across the chest and out. Digital pressure
transverse to the long axis of long bones risks fracture and should be avoided.

22. Delivery of the head: Mauriceau-Smellie-Veit maneuver:
• The fetal face is directed toward the floor and the ventral surface of the fetal body
rests on the operator’s forearm.
• Place the first and second fingers of one hand over the maxillary eminences. The
other hand is positioned over the fetal back with the index and third finger arched over
the shoulders and the middle finger is extended against the occiput to aid flexion.
• If this manoeuvre proves difficult, forceps need to be applied. An assistant holds the
baby’s body upwards while the forceps are applied in the usual manner.

23. The following video demonstrates the second stage labor:
(URL included)
Complications: What are the two leading reasons that lead to intrapartum cesarean
delivery of a well-selected breech?
Thank you.