Abnormalities of labour (breech)

1. BREECH PRESENTATION

2. CONTENTS
• Definition
• Classification
• Etiology
• Diagnosis
• Complications
• Mechanism of Labour
• Management

3. Fetus in longitudinal lie and the podalic pole or the buttocks present
with the legs extended or flexed

4. INCIDENCE
Gesatational Age (in weeks) Percentage
28 25%
32 7%
Term 3-4%

5. CLASSIFICATION

6. ETIOLOGY
• MATERNAL FACTORS
• Multiparity
• Uterine Anomalies
• Fibroid Uterus
• FETAL FACTORS
• Multiple pregnancy
• Fetal anomalies
• Hydrocephalus
• Fetal neuromuscular d.o
• PLACENTAL AND AMNIOTIC
FLUID FACTORS
• Placenta previa
• Cornuofundal placenta
• Relative/ Absolute Increase in
AF
• Prematurity
• Polyhydramnios

7. COMPLICATIONS OF BREECH
PRESENTATION
• Fetal Complications
• Inherent problems in the fetus
• Complications in delivery
• Cord Accidents
• Birth Asphyxia
• Entrapment of after coming
head
• Birth trauma
• Maternal Complications
• Increased Cesarean delivery
• Genital tract injuries

8. DIAGNOSIS
• Abdominal Examination
• Ultrasound
• Pelvic Examination

9. ABDOMINAL EXAMINATION

10. VAGINAL EXAMINATION

12. ULTRASOUND

13. MECHANISM OF LABOUR
• Denominator - sacrum
• Engaging Diameter - Bitrochanteric diameter (9.5 cm)
• Positions - 6

15. MECHANISM OF LABOUR

16. MANAGEMENT
• Antenatal Period
• External Cephalic Version
• Performed at 36-37 weeks
• Pre-requisites
• Higher Success Rates
• Multiparous lady
• Good liquor volume
• Average fetal weight
• Complete Breech

17. ECV- PROCEDURE

18. ECV - COMPLICATIONS
• Fetal bradycardia
• Placental Abruption
• Fetomaternal Haemorrhage
• Uterine rupture

19. MANAGEMENT OF BREECH AT TERM
• Mode of Delivery
• Elective Cesarean Section
• Estimated fetal wt <3.5 kg
• Footling Breech
• Hyperextended head (Stargazing fetus)
• Complicated Breech
• Placenta previa
• Contracted pelvis

20. VAGINAL BREECH DELIVERY
•Spontaneous breech (rare): No manipulation of the infant is necessary,
other than supporting the infant
•Assisted breech delivery: Fetus descend spontaneously upto the
umbilicus then, the rest of the fetus is extracted using additional
manouvres
•Total breech extraction: The entire body is extracted. This is indicated
only if there is evidence of fetal distress unresponsive to routine
maneuvers and a cesarean delivery is not possible

21. VAGINAL BREECH DELIVERY
• Criteria for patient selection
• Complete/ Frank Breech
• EFW- 2-3.5 kg
• Flexed head
• Uncomplicated Breech

22. ASSISTED BREECH DELIVERY
• Obstetrician skilled in breech delivery
• Facilities for EFM
• Neonatologist on call
• Facilities for 24 hour C section
• Forceps for after coming head

23. GENERAL GUIDELINES
• Patient and attenders to be counselled
• Informed written consent
• IOL - not recommended
• Late ARM
• Oxytocin Augmentation - usually avoided
• Maintain Partogram

24. PROCEDURE

26. DELIVERY OF AFTER COMING HEAD

27. MAURICEAU- SMELLIE- VEIT TECHNIQUE

28. PIPERS FORCEPS

29. DIFFICULTIES DURING ASSISTED BREECH
DELIVERY
Extended Legs –
Pinard’s Manouvre

30. EXTENDED ARMS- LOVSET MANOUVRE

31. BRINGING DOWN POSTERIOR ARM

32. NUCHAL ARM

33. ENTRAPMENT OF AFTER COMING HEAD
DUHRSSEN’S INCISION

34. POSTERIOR ROTATION OF HEAD- PRAGUE
MANOUVRE

35. BIRTH INJURIES DURING BREECH
DELIVERY
• Tentorial tears
• Intracranial Haemorrhage
• Brachial plexus injury
• Spinal cord injuries
• Fracture of clavicle, humerus, femur
• Depressed fracture skull
• Injury to external genitalia
• Injury to abdominal viscera