ASSISTED BREECH DELIVERY
by Dr.SUBHA MS OG
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DEFINITION
Breech presentation is defined as a fetus in a
longitudinal lie with the buttocks or feet
occupy the lower segment of the uterus.
BREECH
PRESENTATION
Types:
1. Flexed or complete breech
2. Extended or frank breech
3. Incomplete breech
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Frank breech or extended breech (70%):
Here, both the thighs are flexed against the abdomen
but the legs are extended at the knee so that the lower
limbs lie along the ventral surface of the baby’s trunk.
It is more common in nulliparous women.
Complete breech (5–10%):
Here, the fetus maintains the attitude of universal
flexion with the thighs flexed at the hips and the legs at
the knees.
More commonly seen in multiparous women.
Incomplete breech presentation:
Knee presentation: The thigh is extended at the hip, but
the leg is flexed at the knee.
Footling presentation: The thigh is extended at the hip
and the leg at the knee.
Associated with a high risk of cord prolapse and
therefore, is an indication for cesarean section.
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Breech presentation: 3% of all deliveries.
INCIDENCE At 28 weeks of gestation: 25%.
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FETAL FACTORS UTERINE FACTORS
• Prematurity • Oligohydramnios
• Congenital abnormalities • Placenta previa
• Multiple gestation • Maternal alcohol abuse
• Skeletal or neuromuscular • Use of anticonvulsants
malformations • Uterine anomalies
• Extended legs • Uterine fibroids
• Placenta previa
• Cornuofundal implantation of placenta
• Contracted pelvis
• Pelvic tumours
ETIOLOGY UNIVERSITIES PRESS PVT. LTD
DIAGNOSIS
Abdominal palpation
The cephalic pole will be felt at the fundus of
POSITION the uterus.
The lateral grip will reveal the presence of the
S back on one side and the limbs on the other.
Left sacroanterior (most
common) Pelvic grip: Large breech is felt at the lower
Right sacroanterior (RSA) pole.
Right sacroposterior (RSP)
Left sacroposterior (LSP) Auscultation
The fetal heart will be heard above the level of
the umbilicus, either to its right or left,
depending upon the position of the back.
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Vaginal examination
A breech presentation is detected on vaginal examination by the palpation of
the ischial tuberosities on either side, with the anus in the middle and the
sacrum behind.
In a complete breech, the feet can be felt beside the buttocks.
In an extended breech, the feet are not felt.
In the footling presentation, one or both feet may be felt hanging in the vagina.
Sometimes, the external genitalia may be felt.
When a finger is introduced into the anus, the grip of the sphincter is usually
felt; there may also be staining with meconium. The anus and the ischial
tuberosities form a straight line, distinguishing the breech from the face.
Imaging techniques
USG: Presentation, type of breech, congenital anomalies, location of the
placenta, hyperextended or deflexed head, adequacy of liquor and cord
presentation are determined.
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MANAGEMEN
T Contraindications for external cephalic version
Absolute contraindications
Multiple pregnancy
Antenatal period: External APH, placenta previa
cephalic version (ECV) Ruptured membranes
Method of converting a Significant fetal abnormalities
breech presentation into a When there is a need for CS for other
cephalic presentation by
external manipulation. indications
The advantages of ECV Known uterine anomalies
are that it is safe, non- Relative contraindications
invasive, relatively easy to Scarred uterus
perform and relatively
painless for the mother IUGR
and it may reduce the Severe pre-eclampsia
need for a cesarean
section. Rh-isoimmunisation
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ECV is performed starting
from 36 weeks in a nullipara
and 37 weeks in a
multiparous woman.
The procedure is successful
in nearly 60% of cases.
Successful: Vaginal
delivery.
If not successful, it can be
repeated at weekly intervals.
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If ECV is repeatedly unsuccessful: Elective
cesarean section or assisted vaginal breech
delivery at the onset of labour.
Anti-D immunoglobulin must be given if
the mother is Rh-negative.
Complications: Abruption, preterm labour,
preterm premature rupture of membranes,
fetal distress and cord entanglement.
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Breech with other obstetrical
problems or previous cesarean
section
Severe IUGR
Oligohydramnios
INDICATIONS FOR
CESAREAN DELIVERY Fetal weight >3.5 kg
Inadequate pelvis
Hyperextended head
Footling/knee presentation
An obstetrician inexperienced in
conducting an assisted vaginal
breech delivery
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MECHANISM OF
LABOUR
Compared to the vertex presentation, labour in breech
presentation is more complicated because progressively
larger and less compressible parts of the fetus are delivered.
The chances of cord prolapse and premature rupture of
membranes are also high.
Labour in breech presentation consists of three stages—
delivery of the breech, delivery of the shoulders and the
delivery of the head.
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DELIVERY OF THE
BREECH
Engagement
In breech, the denominator is the sacrum,
and the engaging diameter is the
bitrochanteric diameter, which is 9.5 cm.
Descent with compaction
When labour begins, the first movement is
descent with compaction.
Compaction means that every part of the
fetal body becomes a little more flexed; this
movement is akin to the flexion noted in
vertex presentation.
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Internal rotation
This descent with compaction drives the breech down
through the pelvis until the anterior buttock reaches the
floor of the pelvis.
Then, the second movement - internal rotation takes
place - anterior buttock moves towards the symphysis
pubis through one-eighth of a circle, regardless of
whether the sacrum is in the anterior or posterior
position.
Lateral flexion
It is only by lateral flexion that the breech is able to
pass through the cavity and present at the outlet.
The breech then distends the perineum, after which,
the body and limbs are born
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Delivery of the shoulders
The engaging diameter at the shoulder is the
bisacromial diameter which is 12 cm, and it engages
in the same left oblique diameter as the breech.
Internal rotation—the anterior shoulder hitches
against the symphysis pubis, and by lateral flexion,
the posterior shoulder sweeps over the perineum
and is born first, the anterior shoulder following later.
Delivery of the head
After the shoulders have descended, the head
engages in the opposite oblique diameter with
suboccipitofrontal diameter (10.5 cm).
Further descent of the head with increasing flexion.
Flexion—the head is born.
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Spontaneous breech delivery:
the infant is expelled
spontaneously without any
assistance or manipulation -
extreme preterm babies.
CONDU
Assisted breech delivery: In
CT OF assisted breech delivery, the
VAGINA fetus is delivered
L spontaneously up to the
BREECH umbilicus; the rest of the baby
is delivered by various
DELIVER manoeuvres.
Y Total breech extraction: a
routine breech extraction is
not favoured and is
recommended only when
there is a definite indication.
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With the descent of the breech
to the pelvic floor, the pain
increases in intensity and
frequency and the breech
appears at the vulval outlet.
ASSISTED BREECH At this stage, the patient should
DELIVERY be brought to the edge of the
board and kept in lithotomy
position.
If the woman is not on epidural,
pudendal block anesthesia is
given, and the bladder is
catheterised.
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When the baby’s anus is visible at the vulval outlet
between contractions - ‘breech climbing the perineum’
a liberal mediolateral episiotomy is performed.
At this stage, the ‘hands-off approach’ should be
practiced until the baby is born to the level of umbilicus.
At this stage, there should not be any attempt to apply
traction on the fetus. The obstetrician must ensure that
the baby’s back is facing him. Cord should be kept to
one side to prevent it from being compressed.
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The baby should be covered in a warm towel to avoid early breathing attempts and
aspiration of the amniotic fluid.
The body of the baby should be steadied around the pelvic girdle with a femoropelvic
grip.
With further efforts on the part of the woman, the axillary folds of the baby come into
view under the symphysis.There should not be any attempt to deliver the shoulder until
the scapula and one axilla are visible. The posterior arm is usually born first, followed
by the anterior arm.
If the arm is not flexed, and if there is delay, the Lovset manoeuvre is used to deliver
the arms.
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The baby is held by the femoropelvic grip and rotated
with gentle traction until the posterior shoulder
becomes anterior and comes under the symphysis
pubis.
A finger is passed along the arm down to the elbow,
which is then flexed. As a result, the hand drops down.
LOVSET The baby is then rotated again so that the other
shoulder comes under the symphysis and the same
MANOEUVR manoeuvre is repeated.
E The child hangs from the vulval outlet with its back
directly facing the obstetrician - facilitates entry of the
head into the pelvis by flexion and by the action of
gravity.
Should further assistance be required, it is provided
by moderate suprapubic pressure on the head to
promote flexion and descent.
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DELIVERY OF THE
HEAD
Once the hairline is seen under the symphysis, with the assistant applying
suprapubic pressure to maintain flexion, with steady traction on the feet,
swings the fetus in an arc over the mother’s abdomen - Marshall–Burns
technique.
This manoeuvre has the potential to make the head hyperextended and
cause injury to the cervical vertebra and the spinal cord.
The head can also be kept flexed by jaw flexion and shoulder traction—
the Mauriceau–Smellie–Veit manoeuvre.
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DELIVERY
OF THE
HEAD
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Delivery of the after-coming head by forceps
Piper’s forceps
An assistant carries the body of the child forward, towards the mother’s
abdomen, and the operator introduces the blades, one on either side of the head,
and then applies steady traction
In cases where the occiput is posterior- apply the forceps from above the
child’s body
Advantages
Delivery of the head can be controlled, and sudden exit of the head can be
avoided
promotes flexion and prevents traction and injury to the neck and cervical
vertebra
The space created by the forceps allows the baby to breathe
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Indications for cesarean section in labour
Cord prolapse in first and early second stage of
labour
Fetal distress
MANAGEMENT
Failure to progress in the first and second stages of
OF THE THIRD labour
STAGE OF High breech and failure to descend
LABOUR
Impacted breech
Prophylactic use of The uterine incision should be adequate; if necessary,
oxytocics prior to the it can be converted to an inverted T or J-shaped
completion of the delivery incision.
is not recommended. When the lower uterine segment is not well-formed,
further difficulties will be encountered. Uterine
relaxants may be required just before delivering the
baby. The risk is even higher for preterm babies.
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Complications
Encountered During
Breech Delivery
1. Premature rupture of the membranes and
imperfect dilatation of the cervix
Very common feature - complete breech and footling
presentation.
Affects the fetal prognosis adversely.
In a partially dilated cervix, sometimes the foot slips
out into the vagina in flexed breech - Should NPT
extract the breech.
Such attempts will often end in tears in the cervix,
difficulties in delivering the arms and head ending most
often in stillbirth.
It is far better to deliver the baby by cesarean section.
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2. Head entrapment:
Most feared complications - common with preterm
breech vaginal delivery.
The cord will be compressed by the cervix gripping
the head of the baby.
Complica If the cervix is rigid and unyielding, then a
tions Dührssen’s incision is given at the 4 o’clock and 7
Encounte o’clock positions, so that the cervix opens sufficiently
to allow the delivery of the head.
red 3. Prolapse of the cord
During 0.5–1% in frank breech
Breech 4–5% in complete breech
Delivery 10% in knee and footling presentations.
Indication for immediate delivery of the baby if it is
viable by cesarean section or breech extraction to
save the child.
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Complications
Encountered During
Breech Delivery
4. Extended arms
This can be dealt with by the Lovset’s maneuver - deliver the
posterior arm first.
First, the baby should be held up to one side by its feet and a hand
passed into the vagina into the hollow of the sacrum and along the
side of the baby’s arm till its elbow is reached; this is now flexed and
brought down in front of the baby’s body.
Once the posterior arm is delivered, the anterior one can be delivered.
5. Nuchal position of the arms (hand behind the occiput)
This is not a common complication.
The diagnosis is made when the obstetrician notices that the medial
border of the scapula is not parallel to the spine.
The treatment is to rotate the baby in the direction in which the
fingers are pointing. The arms will drop down.
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6. Difficulty in aftercoming head
Because the bitrochanteric diameter is less
than the biparietal diameter—9.25 cm vs. 9.4
cm and the after-coming head does not have
time for moulding.
Complica
Causes: hyperextended fetal head,
tions undiagnosed disproportion between the
Encounte head and the pelvic brim and delivery
red through an undilated cervix.
During The Marshall–Burns technique is often
successful. if the flexion of the head is
Breech maintained by an assistant applying gentle
Delivery suprapubic pressure during the process of
delivery.
Forceps application to deliver the after-
coming head is also effective.
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MAURICEAU–SMELLIE–VEIT
METHOD
The fetus is supported by the left forearm,
and the index and middle finger are
applied over the maxilla to flex the head,
and the index or middle fingers of the right
hand are then slipped over the clavicles
from behind.
Downward traction is applied until the
nape of the neck appears, and the fetus is
swung up over the mother’s abdomen.
Suprapubic pressure over the head is
combined with the manoeuvre.
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Occasionally, the back and the occiput may be directed posteriorly -
grip the shoulders with two fingers of one hand - pull the baby
backwards, so that the forehead is fixed against the posterior surface
of the symphysis pubis - carry the trunk upwards onto the mother’s
abdomen.
c
If there is still a difficulty in delivery, forceps may be applied.
Deep tears of the perineum are inevitable, and it is preferable to
perform a prophylactic episiotomy.
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Complications
Encountered During
Breech Delivery
7. Extended legs:
Pinard’s manoeuvre: The gloved hand is introduced into the
vagina and the fingers are guided along the posterior aspect of
the thigh to reach the knee.
Gentle pressure is then exerted in the popliteal space - leg will
flex at the knee.
The foot is then grasped and brought down to the vulva.
8. Impacted breech
Impaction of the breech can occur when the breech is extended
- common cause is a disproportion between the size of the
breech and the pelvis.
If within 30 minutes of full cervical dilatation, descent has not
occurred to the outlet, cesarean section should be performed.
Such impaction may also occur at the outlet - episiotomy and
traction with a finger in the groin.
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PROGNOSIS
For the mother
Maternal morbidity - increased operative interventions.
For the baby
Complicated breech: Prematurity,
pre-eclampsia/eclampsia, antepartum hemorrhage, fetal
abnormalities, contracted pelvis and maternal diseases
like hypertension, cardiac disease.
Uncomplicated breech: There are no pre-existing adverse
factors, but complications can occur during the delivery.
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Cephalhematoma
Intracranial hemorrhage with rapid and
uncontrolled delivery of the head
Medullary coning
Injury to the brachial plexus or spinal cord
PERINATAL Facial nerve paralysis
LOSS AND Fracture clavicle, long bones, femur or
FETAL humerus
INJURIES Tearing of lumbar muscles
Crush syndrome effect on the kidney
Injury to intra-abdominal organs
Injury to the sternomastoid muscle
Soft tissue injury
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Breech extraction involves the delivery of the entire
fetus by the clinician without any efforts from the
woman.
Rarely carried out when urgent delivery is needed in
the second stage of labour.
Indications:
Fetal distress/cord prolapse
BREECH Maternal distress
EXTRACTI Second of twins is presenting as transverse lie -
ON under general anaesthesia, internal podalic version
with breech extraction is carried out
Breech presentation in twin pregnancy
First twin is breech - cesarean section
Second of the twin is a breech - vaginal breech
delivery
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MANAGEMENT
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