1. International University of AfricaInternational University of Africa
Faculty of MedicineFaculty of Medicine
and Health Sciencesand Health Sciences
Breech 2Breech 2
Presented by:-Presented by:-
Dr. AlwaleedDr. Alwaleed
M.AlfakiM.Alfaki
Gya. &Gya. &
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2. BreechBreech
 Incidence:-Incidence:-
 3-4% at term3-4% at term
 Type:-Type:-
1.1. Complete breechComplete breech “flexed breech“flexed breech”:-”:-
- Hips and knees are both flexedHips and knees are both flexed
- 25% of cases25% of cases
- Common in multiparous womenCommon in multiparous women
- Cord prolapse is commonCord prolapse is common
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3. 22..Incomplete breechIncomplete breech
Extended or frank breechExtended or frank breech
- The legs are fully flexed at the hips andThe legs are fully flexed at the hips and
extended at the kneesextended at the knees
- 65% of cases Common in PG (-rigid65% of cases Common in PG (-rigid
abdominal wall -good uterine tone)abdominal wall -good uterine tone)
3)Footling breech3)Footling breech
- Occurs in 10% of casesOccurs in 10% of cases
- High incidence of cord prolapseHigh incidence of cord prolapse
4)Knee presentation4)Knee presentation
-rare-rare
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4. Causes of breechCauses of breech
1.1. Prematurely is the commonest causePrematurely is the commonest cause
“30-40% at 20__25 weeks”“30-40% at 20__25 weeks”
““15%at 32 weeks “.15%at 32 weeks “.
2.2. Extended legExtended leg
3.3. Fetal anomalies( hydrocephalus –Fetal anomalies( hydrocephalus –
anencephaly) .anencephaly) .
4.4. Multiple pregnancy.Multiple pregnancy.
5.5. IUFDIUFD
6.6. Short cordShort cord
7.7. Placenta previa and cornual insertion ofPlacenta previa and cornual insertion of
the placentathe placenta
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5. 8.8. Uterine abnormalities (septate,Uterine abnormalities (septate,
bicornuate ) fundal myomabicornuate ) fundal myoma
9.9. Pelvic tumorsPelvic tumors
10.10. Poly and oligohydramnios.Poly and oligohydramnios.
11.11. Multiparty and previous breechMultiparty and previous breech
deliverydelivery
12.12. IdiopathicIdiopathic
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6. DiagnosisDiagnosis
 Abdominal examination reveals theAbdominal examination reveals the
head (smoother rounder, harder andhead (smoother rounder, harder and
palatable) at the fundus.palatable) at the fundus.
 Fetal heart is best heard above theFetal heart is best heard above the
umbilicus on the side of the back.umbilicus on the side of the back.
 On vaginal examination the soft-On vaginal examination the soft-
irregular breech can be felt.irregular breech can be felt.
In complete breech the feet can alsoIn complete breech the feet can also
be felt.be felt.
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7. InvestigationInvestigation
 Ultra sound scan:-Ultra sound scan:-
- Confirm the diagnosisConfirm the diagnosis
- Exclude placenta previaExclude placenta previa
 Lateral X-Rays abdomen:-Lateral X-Rays abdomen:-
- Confirm diagnosis and type of breechConfirm diagnosis and type of breech
- Reveals major skeletalReveals major skeletal
malformationsmalformations
- Reveals degree of flexion of the headReveals degree of flexion of the head
- PelvimetryPelvimetry
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8. Complication of breechComplication of breech
 Fetal complicationsFetal complications:-:-
o Are from Asphyxia- trauma andAre from Asphyxia- trauma and
congenital malformation.congenital malformation.
o Perinatal mortality at least 5 times thatPerinatal mortality at least 5 times that
of cephalic presentationof cephalic presentation
1.1. Fetal Asphyxia due to:-Fetal Asphyxia due to:-
- Retained after coming headRetained after coming head (>10 min)(>10 min)
- Cord prolapse compression by afterCord prolapse compression by after
coming headcoming head
- Premature respirationPremature respiration
- Premature separation of the placentaPremature separation of the placenta
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9. 2.2. traumatrauma
 Fast delivery of the head beforeFast delivery of the head before
moulding with compression andmoulding with compression and
decompression of the head leads todecompression of the head leads to
intracranial Hge, tentorial tear,intracranial Hge, tentorial tear,
Fracture skull borneFracture skull borne
 Dislocation of cervical spineDislocation of cervical spine
 Fracture and epiphyseal separationFracture and epiphyseal separation
of femur. Humorous and clavicleof femur. Humorous and clavicle
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10.  Brachial plexus palsy and transBrachial plexus palsy and trans
section of the cord (erb’s palsy).section of the cord (erb’s palsy).
 Sternomastoid muscle rupture &Sternomastoid muscle rupture &
haematoma.haematoma.
 Rupture of abdominal viscera.Rupture of abdominal viscera.
 ↑↑ incidence of malformationincidence of malformation
Maternal complicationMaternal complication:-:-
 genital track lacerationgenital track laceration
 Postpartum haemorrhagePostpartum haemorrhage
 Danger of emergency anaesthesiaDanger of emergency anaesthesia
and C/Sand C/S
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11. ManagementManagement
(mode of delivery)(mode of delivery)
1.1. Elective caesareanElective caesarean section.section.
• Breech presentation associated withBreech presentation associated with
any other obstetric adverse factorsany other obstetric adverse factors
is generallyis generally delivereddelivered by C/S :-by C/S :-
• fetal weight >3.5kgfetal weight >3.5kg
• footling breechfootling breech
• Hyperextension of the headHyperextension of the head
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12. - Any degree of pelvic contraction &- Any degree of pelvic contraction &
abnormal shapeabnormal shape
- Associated pregnancy complications likeAssociated pregnancy complications like
APH, PIH diabetes . BOHAPH, PIH diabetes . BOH
2.2. External cephalic version:-External cephalic version:-
- Changing the breech to cephalic by transChanging the breech to cephalic by trans
abdominal manipulation.abdominal manipulation.
- Usually done after 36 week.Usually done after 36 week.
- Risks are 1% mortality –ruptureRisks are 1% mortality –rupture
memebranes with preterm labour-memebranes with preterm labour-
abruptio placenta- cord accident- fetoabruptio placenta- cord accident- feto
maternal transfusion- rupture uterus )maternal transfusion- rupture uterus )
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13.  Contraindication:- (indication of c/s –Contraindication:- (indication of c/s –
APH- PIH-scar uterus- multipleAPH- PIH-scar uterus- multiple
pregnancy- congenital malformation ofpregnancy- congenital malformation of
the uterus –B.O.H- elderly PG –rupturethe uterus –B.O.H- elderly PG –rupture
membrane - IUFD-IUGR.membrane - IUFD-IUGR.
 Cause of failure of ECV. Are (extensionCause of failure of ECV. Are (extension
of the les –large fetus. Undiagnosedof the les –large fetus. Undiagnosed
twins- short cord-scanty liquor-irritabletwins- short cord-scanty liquor-irritable
uterus- uterine anormalies –rigiduterus- uterine anormalies –rigid
abdominal wall- obesity –engagedabdominal wall- obesity –engaged
breech).breech).
3.3. Vaginal breech deliveryVaginal breech delivery
1. spontaneous ,1. spontaneous ,
2. assisted breech delivery2. assisted breech delivery
3. breech extraction)3. breech extraction)
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14. 1/1/ assisted breech deliveryassisted breech delivery
Delivery particularly of the head isDelivery particularly of the head is
usually assisted to a varying degreeusually assisted to a varying degree
this involves gentle manipulation tothis involves gentle manipulation to
control and guide the fetus duringcontrol and guide the fetus during
the mother’s expulsive effort so thatthe mother’s expulsive effort so that
the delivery is affected withthe delivery is affected with
minimum of trauma and maximum ofminimum of trauma and maximum of
safetysafety..
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15.  Acceptable if:-Acceptable if:-
- Pelvis normal in size and in shapePelvis normal in size and in shape
- Fetal weight about 3.5kg or lessFetal weight about 3.5kg or less
- Flexed headFlexed head
- No other obstetric complicationNo other obstetric complication
 Should be under taken in fullyShould be under taken in fully
equipped hospitalequipped hospital
 Fist stageFist stage :-managed as high risk:-managed as high risk
labour (NPO- I.V fluid –pain relief-labour (NPO- I.V fluid –pain relief-
maternal & fetal monitoring)maternal & fetal monitoring)
 Second stageSecond stage:-:- lithotomy or modifiedlithotomy or modified
lithotomy position –episiotomy.lithotomy position –episiotomy.
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16.  Delivery of after coming headDelivery of after coming head..
1-1- forceps:-forceps:- more safe –because ofmore safe –because of
controlled delivery of headcontrolled delivery of head
2- Buns- marshall’s technique :-2- Buns- marshall’s technique :-
The baby is grasped by the ankles withThe baby is grasped by the ankles with
maintained traction and is swung throughmaintained traction and is swung through
a wide arc towards the mother abdomen.a wide arc towards the mother abdomen.
3- jaw flexion- shoulder traction3- jaw flexion- shoulder traction
(mauriceau –smellie veit technques(mauriceau –smellie veit technques--
not recommended –traction may causenot recommended –traction may cause
brachial –plexus injury)brachial –plexus injury)
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17. 2/2/ spont breech delivery:-spont breech delivery:-
- Should not be allowed- Should not be allowed
- Occur rarely except in multiparousOccur rarely except in multiparous
patient, in preterm labourpatient, in preterm labour
- Carry high perinatal mortality &Carry high perinatal mortality &
morbidity.morbidity.
-
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18. 3/ breech extraction:-3/ breech extraction:-
- Delivery of the fetus with no assistanceDelivery of the fetus with no assistance
from the motherfrom the mother
- Indication :- in second stage of labourIndication :- in second stage of labour
- -fetal distress-fetal distress
- Cord prolapseCord prolapse
- Delay of delivery of second twinDelay of delivery of second twin
- Maternal distressMaternal distress
- Should be done in the theatre & only if:Should be done in the theatre & only if:
- No Cephalo pelvic disproportionNo Cephalo pelvic disproportion
- Cervix fully dilatedCervix fully dilated
- Patient adequately anaesthetizedPatient adequately anaesthetized
- Enough liquor. To allow manipulationEnough liquor. To allow manipulation
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