by Dr. R. OMOZUAPO

1.  MANAGEMENT OF BREECH
PRESENTATION AT TERM
By: Dr. Omozuapo (MB.BS. Uniben)
1

2. outline
 Introduction
 Epidemiology
 Variety/types
 Aetiology/risk factors
 Diagnosis
 Management
 Antenatal/ECV
 Options on mode of delivery
 Methods of vaginal breech delivery
 Complicated breech delivery
 Complication
 Conclusion
 References 2

3. INTRODUCTION
 Commonest malpresentation
Occurs when the fetal pelvis or lower
extremities engage in the maternal pelvic
inlet , Or A presentation where the fetal
buttocks or feet are closest to the cervix.
 It occurs in 3-4% of all deliveries at term.
 Larger % before term
3

4. Epidemiology
Incidence Gestational
age
35% <28wks
25% 28-32wks
20% 32-34wks
8% 34-36 wks
4-5% 36wks
3-4% Term
Frank breech
presentations occur in
65% of all breech
deliveries.
Footling and complete
breech presentations
occur in 25% and 10%
respectively.
Lower in hospitals
 where ECV is done
4

5. EPIDEMIOLOGY ctd
 Breech (presentation) deliveries
increases with decreased gestational
ages.
 3-4% occur at term.
 Majority of breech revert or turn
spontaneously on or before 36weeks.
5

6. VARIETIES
 In frank breech, the hips are flexed with
extended knees bilaterally.
 In complete breech, both hips and knees
are flexed.
 In footling breech, 1 (single footling
breech) or both (double footling breech)
legs are extended below the level of the
buttocks.
6

7. VARIETIES
7

8.  Studies have shown that In singleton breech
presentations in which the infant weighs less
than 2500 g,
 50% footling breech, 40% are frank breech, 10%
complete breech.
 With birth weights of more than 2500 g,
 65% are Frank breech, 25% footling breech, and
10% complete breech.
8

9. AETIOLOGY/ RISK FACTORS
1. Prematurity: (commonest) relatively large fetal head
to body ratio.
2. Polyhydramnious/oligohydramnious
3. Pelvic tumours
4. Placenta Previa
5. Congenital anomalies of the uterus
6. Congenital anomaly of the fetus
7. Multiple pregnancy and high parity.
8. Fetal macrosomia
9. Contracted pelvis 9

10. DIAGNOSIS (during pregnancy and labour)
A. ABDOMINAL EXAMINATION
 Palpation and ballottement helps to confirm
breech presentation. On palpation, the
presenting part feels firm but not bony hard and
less rounded than the head.
 On auscultation with the Pinnard stethoscope,
the area of greatest intensity of the fetal heart
sounds will be above the level of the maternal
umbilicus although, if the legs are extended, the
sounds tend to be heard at a lower level.
10

11. B. VAGINAL EXAMINATION
 On vaginal examination
 The fetal feet may be felt close to the buttocks or
may be the sole presenting part as in a footling
breech.
 However, if no presenting part is discernable ,
further studies are necessary.
11

12. C. ULTRASOUND
 Confirmation of a diagnosis of breech
presentation is easily accomplished by
ultrasound.
 Ultrasonographic scanning by an experienced
examiner will document fetal presentation,
attitude, Est. FW, multiple gestation, location of
the placenta, and amniotic fluid volume.
 Exclude congenital anomaly, type of breech.
12

13. D. During Labour
 V. E. may reveal
 2 Ischial tuberosities and tip of the sacrum
 The feet are felt besides the buttocks in
complete breech
 Fresh meconium may be found on the
examining fingers
 Genitalia may be felt.
13

14. 14

15. Possible Positions
 Fetal sacrum as the point of reference to the maternal
pelvis.
 Eight possible: (SA), (SP), (LST), (RST), (LSA), (LSP), (RSA),
and (RSP).
15

16. MANAGEMENT OF BREECH PRESENTATION
1. ANTENATAL CARE /MANAGEMENT
 Early booking gives the obstetrician the
opportunity to evaluate the previous obstetric
performance of the patient.
 Interventions are unnecessary up to 36 completed
weeks of gestation as spontaneous version to
cephalic presentation will occur in many cases if
uterine/gross fetal abnormalities are absent.
16

17.  Radiographic pelvimetry using X-Ray, Computed
tomography, or magnetic resonance imaging should be
done to rule out women with a borderline or contracted
pelvis.
 If breech presentation persists beyond 36weeks of
gestation, external cephalic version should be
considered.
17

18. Management ctd
 During antenatal
 Identify complicating factors related
with breech
 External cephalic version, if not
contraindicated.
 Formulation of line of management, if
ECV failed or is contraindicated.
18

19. External Cephalic Version (ECV)
 ECV is a transabdominal manipulative
procedure of converting breech to
cephalic presentation
 Popular in 1960s & 1970s
 Disappeared thereafter due to report of
fetal death
 Re-introduced in 1980 in America and
now became increasingly popular
19

20. External cephalic version
 Done to bring favorable cephalic pole
into the lower pole of the uterus
 Mean Success rate is 60%
 ≥36wks
 Less chance of spontaneous reversion
 If complications arise, delivery of a
term infant can be accomplished.
20

21. Contraindications
 Engaged presenting part
 hyperextended head
 Abnormal CTG
 Premature rupture of membrane
 Antepartum hemorrhage
 Placenta previa
 Uterine anomalies
 Multiple gestation, Previous CS delivery
 Obstetric complications: severe pre-eclampsia, obesity,
elderly primigravida, IUGR
21

22. Successful version likely in
 Complete breech
 Non-engaged
breech
 Sacro-anterior
position
 Adequate liquor
 Non-obese patient
Failed version likely in:
 Frank breech
 Scanty liquor/big
baby
 Mechanical –obesity,
irritable uterus
 Short cord
 Uterine
malformations
22

23. ADVANTAGES
 Reduces breech incidence at
term
 Reduces breech delivery
incidence
 Reduces CS
23

24. Newman’s scoring system for ECV
0 1 2
Parity 0 1 ≥2
Placenta Ant Post Lateral, fundal
Cervical Dilatation >3cm 1 – 2cm 0
EFW <2.5Kg 2.5 – 3.5Kg >3.5Kg
station -1 - 2 - 3
24

25. Procedure
 Informed consent
 USS guidance – confirms diagnosis and adequate liquor
 A reactive NST, FHR auscultation, Empty bladder,
 If desired admin tocolytic
 Position of patient: supine, thighs slightly flexed, and
abdomen fully exposed.
 Lubricant should be applied per abdomen.
 Fetal presentation, position of back and limbs are
checked
25

26. Forward roll movt.
 Step 1
 Mobilize breech using both hands
towards which back of fetus lie.
 Right hand: grasp podalic pole
 Left hand: grasp head.
26

27. Step 2
 L: Pressure exerted to head to
push breech
 R: Pressure in opposite direction to
guide vertex
 Intermittent pressure given till lie
becomes transverse
 FHR is checked.
27

28. Step 3
 Changing of hands
 Intermittent pressure exerted till head
is brought to lower pole of uterus.
28

29.  Patient is observed for 30minutes to 1 hr
 Allow FHR to settle down
 Note any bleeding PV/PROM
 Patient is advised for follow up, to report any
vaginal bleeding /leakage and Rh-neg woman
is given 300ug anti D Ig immunoglobulin.
29

30. COMPLICATIONS OF ECV
Complications are rare, occurs in 1-2% of all
ECVs
1. Preterm labour
2. Fetal distress
3. Fetal demise
4. Placental abruption
5. Uterine rupture
6. Rupture of membranes and cord prolapse
7. Fetomaternal heamorrhage
30

31.  It is advised that the procedure (ECV) be
performed in a facility where immediate
caesarean section or delivery can be
performed
.
 Following the procedure, external fetal heart
rate monitoring should be continued for 1
hour to ensure stability of the fetus.
31

32.  If ECV failed/contraindicated
 Continue with usual check up
 Assess again based on
 maternal age
 Associated complicating factors
 Size of baby
 Pelvic capacity
Then clinical assessment of the pelvis is
done to plan the method of delivery.
32

33. OPTIONS ON MODE OF DELIVERY OF
BREECH
 Vaginal breech delivery
 Spontaneous
 Assisted VBD
 Breech extraction
 Ceasarean section
33

34. DECISION ON MODE OF DELIVERY
The decision regarding mode of delivery must be
individualized.
Delivery is either by vaginal route or Caesarean section.
In the past (before 1980’s), virtually all viable singleton
breech presentations were delivered vaginally.
C/S was reserved for specific fetal indications- Fetal
distress, cord prolapse or maternal indications such as
placenta praevia, abruption placentae or failure of progress
of labour.
34

35. However, breech newborn/ infants delivered
vaginally had a higher fold morbidity and mortality
rate compared to the cephalic presentations.
 Caesarean delivery for breech presentation has
now become much more common in breech
presentation , with lower rates of perinatal
morbidity and mortality.
35

36. CRITERIA FOR VAGINAL OR CAESAREAN DELIVERY IN
BREECH PRESENTATION
FACTORS SUPPORTING VAGINAL DELIVERY
1. Frank breech presentation
2. Estimated gestational age of 36weeks or more
3. EFW of 2.5 to 3.5kg
4. Flexed fetal head
5. Adequate maternal pelvis (as determined by CT
pelvimetry)
6. No maternal or fetal indication for C/S
7. Previable fetus
8. Documented lethal fetal congenital anomalies
9. Presentation of patient (mother) in advanced labour
with no fetal or maternal distress
36

37. FACTORS SUPPORTING CAESAREAN SECTION
1. Estimated fetal weight ≥3.5kg or < 1.5kg
2. Contracted or borderline maternal pelvis
3. Deflexed or hyperextended fetal head
4. Prolonged rupture of membranes
5. Unengaged presenting part
6. Mother with infertility problems
7. Elderly Primigravida
8. Poor or bad obstetric history
9. Premature fetus (gestational age of 26 to 36weeks)
10. Footling breech
11. Fetus with variable heart rate deceleration on
electronic fetal monitoring.
37

38. VAGINAL BREECH DELIVERY METHODS
 Obstetricians who contemplate performing a vaginal
breech delivery should be experienced in the
manoeuver and should be assisted by 3 physicians:
1. An experienced Obstetrician who will assist with the
delivery.
2. A Neonatologist to resuscitate the newborn.
3. An Anaesthesiologist to ensure that the patient is
comfortable and cooperative during labour and
delivery and for possible reversion to CS.
38

39. METHODS OF VAGINAL BREECH DELIVERY:
1. SPONTANEOUS - Usually occurs in a
multigravida with a small baby.
2. ASSISTED VAGINAL BREECH DELIVERY
The fetus is delivered with the assistance of the
obstetrician. It should be encouraged in all
cases.
39

40. 3. BREECH EXTRACTION
 When the entire body of the fetus is extracted
by the obstetrician with minimal or no aid from
the mother.
 It is carried out under anaesthesia in case of
fully dilated cervix with maternal/ fetal distress,
cord prolapse and conversion to CS.
 It is done very infrequently these days in a live
baby.
40

41. Mechanism of labour in breech
 Principal movts at
 Buttocks
 Shoulders
 Head
41

42. SPONTANEOUS VAGINAL DELIVERY: the buttocks
42
• The diameter of engagement: oblique diameters of the
inlet. The engaging diameter is bi-trochanteric with the
sacrum directed towards the ilio-pubic eminence.
When the diameter passes through the pelvic brim, the
breech is engaged. • Descent of the buttocks occurs until
the anterior buttock touches the pelvic floor. • Internal
rotation of the anterior buttock occurs placing it behind
the symphysis pubis. Descent with lateral flexion of the
trunk occurs until the anterior hip hinges under the pubis
sym. which is released first followed by the posterior hip.•
Delivery of the trunk and the lower limbs follow.

43. The shoulders
 Bisacromial diameter engages in the transverse
diameter at the brim soon after the delivery of the
breech.
 • Descent occurs with internal rotation of the shoulders
bringing the shoulders to lie in the anteroposterior
diameter of the pelvic outlet. The trunk rotates
externally • Delivery of the posterior shoulder followed
by the anterior one is completed by anterior flexion of
the delivered trunk. • Restitution and external rotation:
the fetal trunk is now positioned as dorso-anterior.
43

44. The head
 Engagement occurs through the same oblique
diameter as that occupied by the buttocks. The
engaging diameter of the head is
suboccipitofrontal. • Descent with increasing
flexion occurs. • Internal rotation of the occiput
occurs anteriorly, placing the occiput behind the
symphysis pubis. • Further descent occurs until
the subocciput hinges under the symphysis pubis.
 • The head is born by flexion.
44

45. 45

46. ASSISTED VAGINAL BREECH DELIVERY
 Breech delivery should be conducted by a skilled
obstetrician.
 The following are to be ready before hand when
planning an assisted breech delivery in addition to
the requirements for the conduction of normal
labour:
1. Anaesthetist , An assistant, Nurses / midwives,
Paediatrician (Neonatologist)
2. GXM blood
46

47. 3. Pudendal block and infiltration of the perineum
or epidural anaesthesia
4. Instruments and suture materials for
episiotomy.
5. A breech towel,
6. A pair of Piper’s forceps for the after coming
head
7. Appliances for neonatal resuscitation.
47

48. Principles In Conduction Of Assisted Vaginal
Breech Delivery
A. Never rush delivery
B. Never pull from below but push from above.
C. Always keep the fetus with the back anteriorly.
 Aggressive and hasty pull affects breech delivery
adversely by causing:
I. Entrapment of the after coming fetal head through
the incompletely dilated cervix.
II. Nuchal arm
III. Deflexed head 48

49. Traction from below may result in deflection of
the fetal head causing longer occipito-frontal
diameter at the pelvic inlet.
49

50. STEPS
 The patient is placed in lithotomy position (and
tiltled laterally using a wedge under the back to
avoid aortocarval compression) when the breech
starts distending the perineum and the fetal anus is
visible.
 Antiseptic cleaning is done as well as draping.
 The urinary bladder is emptied with an in and out
catheter.
 Local anaesthesia is administered
50

51.  Episiotomy is performed and delivery is
allowed by maternal efforts alone up to the
umbilicus.
 Px is encouraged to bear down as it ensures
flexion of head and safe descent.
 The ‘no touch of the fetus’ policy is adopted
until the buttocks are delivered along with the
legs in flexed breech and the trunk slips up to
the umbilicus.
51

52. Delivery of trunk
 For the extended breech, the buttock is
palpated to reach the popliteal fossa and a
gentle depression is made (PINARD
MANOUVRE) followed by delivery of the
flexed leg. Same is repeated for the
second limb
 Umbilical cord is gently pulled down and
mobilized to one side to minimize
compression.
 Ensure a dorsoanterior position of the
fetal back
52

53.  The fetus in dorsoanterior position is allowed to
hang on its weight.
Delivery is allowed to continue until the inferior
border of the scapula is seen
Position of the arm is noted.
Arm is delivered when one axilla is visible by
hooking down elbow with a finger
53

54. Delivery of the arms
 If flexed, vertebral border of the scapula is parallel to
the vertebral column. Reach out for the shoulder and
then the arm which will be delivered. Same is done
for the contralateral limb.
 If extended, there is winging of the scapula. Reach out
for the shoulder, and then the cubittal fossa. With a
gentle depression(LOVSET MANOUVRE) on it, there is
flexion followed by sweeping of the arm over the
chest and then subsequent delivery. Same is done for
the contralateral limb. 54

55. Delivery of the head
 This is done when the nape of the neck
is seen.
 Methods of delivery of the aftercoming
head include;
 Mauriceau-Smellie-Veit technique
 Burns Marshall method
 Forceps delivery
55

56. MAURICEAU- SMELLIE -VEIT TECHNIQUE
(JAW FLEXION AND SHOULDER TRACTION)
 This technique is named after 3 great obstetricians
who described the use of the grip independently.
 The baby is placed on the supinated left forearm
with the limbs hanging on either side.
 The middle and index fingers of the left hand are
placed over the malar bones on either side. This
maintains the flexion of the head.
 The ring and little fingers of the pronated right hand
are placed on the child's right shoulder, the index
finger is placed on the left shoulder while the middle
finger is placed on the sub-occipital region.
56

57. 57

58. Burns Marshall method
 Baby allowed to hang by its weight
 Assistant: downward, backward,
suprapubic pressure to promote
head flexion.
 Right hand: grasp ankles with a
finger in between (when nape of
neck is visible under the pubic arch)
 Trunk is swung upward and forward
till mouth is cleared off the vulva
 Depress the trunk to deliver the
rest of the head
 Left hand: guides the perineum.
58

59. Forceps delivery
 Baby allowed to hang by its weight
 Assistant
 Give suprapubic pressure
 Raises legs of child when occiput is against
pubic symphysis.
 Piper forceps is used by the most skilled
personnel.
59

60.  Complicated breech delivery
60

61. Arrest of buttocks
1. At the outlet
Causes
 Big baby and extended
legs
 Weak uterine contraction
 Rigid perineum
 Contracted pelvis/ Big
baby ---CS
 In absence of contracted
pelvis and big baby do an
episiotomy, fundal
pressure with groin
traction
 Groin traction
Index finger is placed in
groin fold and traction is
given towards trunk till
delivery of the knee. 61

62. Arrest of the buttocks
2. In the cavity (Ischial
spine)
 Pinnards maneuver
 CS
 Pinnards manouver
 Middle and index
fingers are carried
up to popliteal
fossa, then exert
pressure and leg is
abducted. Fetal
foot is grasped at
ankle and pulled
down.
62

63. Arrest at the shoulder:
classical manouvre
 Baby is grasped using both hands by
femoro-pelvic grip
 Start only when inferior angle of ant.
Scapular is visible under the pubic arch.
 then lift baby slightly and rotate 1800 with
downward traction and deliver post arm.
 Trunk is rotated in reverse and ant. arm is
delivered.
63

64. Nuchal arms
Excessive downward traction on the body results in
a single or double nuchal arm because of the rapid
descent of the body, leading to extension of 1 or
both arms, which become lodged behind the neck.
Rotate the body 1800 to bring the elbow toward
the face. Identify the humerus and deliver by
gentle downward traction (Lovset).
64

65. Nuchal Arm ctd
 For double nuchal arm, rotate the fetus
counterclockwise to dislodge and deliver the
right arm and rotate clockwise to deliver the
left arm.
 If unsuccessful, insert a finger and identify the
humerus, and extract the arm, resulting in
fracture of the humerus or clavicle.
65

66. Delivery of the head through incompletely
dilated cervix
 Causes: footling presentation ,
hasty breech delivery
Management:
Dührssën’s incision at 2,6,and 10
O’ clock position on the cervix
66

67. Arrest of the head
 At the outlet:
causes: rigid perineum
Episiotomy or forceps or MSV, Burns
Marshall, or symphysiotomy or CS
67

68. Occipito-posterior head
 Usually in spontaneous breech delivery
 Grasp fetal trunk and head with hands positioned
like that in malar flexion and shoulder traction,
(MSV) then rotate to bring them anteriorly.
 (prague manuevre ) head is delivered face to
pubis by reverse malar flexion and shoulder
traction.
 Forceps
68

69. Management of unbooked breech in labour
 Presents as emergency, no prior clinical
assessment
 Prior unskilled interference can compound the
clinical problem.
 Careful clinical assessment by the most
experienced member of the team is necessary
before decision on management can be taken.
69

70. Maximum score is 11
Score >7 predict good prognosis for vaginal
delivery
0 1 2
PARITY 0 1
GA 39+wks 38wks 37wks
DILATATION 2cm 3cm 4cm
PREVIOUS BREECH 0 1 2
STATION -3 -2 -1
EFW 3.6kg 3.2-3.6kg <3.2kg
ZATUCHNI ANDROS PROGNOSTIC SCORING INDEX
70

71. Deflexion of the head
Hyperextension of the head is defined as deflexion or
extension of the head posteriorly beyond the longitudinal
axis of the fetus. Deflexion causes impaction of the
occipital portion of the head behind the pubic symphysis,
which may lead to fractures of the cervical vertebrae,
lacerations of the spinal cord, epidural and medullary
hemorrhages, and perinatal death.
If head deflexion is diagnosed prior to delivery, caesarean
section should be performed to avert injury.
71

72. COMPLICATIONS
Maternal
 Increased operative
delivery
 Increase genital tract
trauma, sepsis,
anaesthetic
complications
Fetal
 Perinatal trauma
 Perinatal death
 Birth ashyxia
 Intra cranial hemorrhage
 Birth injuries
 Heamatoma–sternomastoid
/thighs
 Fracture–femur, humerus,
clavicle, odontoid process
 Visceral injuries
 Nerve–erbs, klumpke 72

73. COMPLICATIONS
Fetal cntd
 Factor influencing fetal
risk: skill of obstetrician,
Wt of the baby, legs
position, Type of pelvis
Prevention of fetal
hazards
 Minimise breech
incidence by ECV
 Delivery by CS
 Vaginal breech
delivery by skilled
obsterician,
anaesthetist,
neonatologist.
73

74. Conclusion
 ECV
 Assisted breech delivery
 Buttocks: knee abduction
 Shoulders: hooking down elbow
 Head: burns-marshall method, forceps delivery, malar
flexion and shoulder traction.
• Complicated breech delivery
 Buttocks/LL: groin traction, Pinnard’s manouvre
 Shoulders/UL: Classical, lovset’s manouvre
 Head: MSV, Burns Marshall, Forceps, Dührssën’s
method, Prague method.
 C/S
74

75. VIDEO
75

76. References
 Alarab M, Regon C, et al: Singleton Vaginal Breech Delivery at Term: still a
safe option. ObstGynacol 103: 43-44
 Alan H. D et al (2013).Malpresentation and Cord Prolapse. Current Diagnosis
& Treatment Obstetrics and Gynecology 11th Ed. 19, 583-599.
 Albrechsten S, Rasmussen S, Reigstad H et al: Evaluation Protocol for
Selecting Fetuses in Breech Presentation for Vaginal Delivery or CS. Amj.
Obstetric Gynecol 177:586-588
 American College of Obstetricians and Gynecologists. External Cephalic
Version. ACOG Practice Bulletin No. 13. Washington, DC: ACOG; 2000.
 Dr. Amerijoye. Senior Registrar, Obstetrics and Gynaecology Dept, FETHI,
EKITI.
 Gary Cunningham F., et al (2014).Breech Presentation Williams Obstetrics
24,574-583.