Lecture 6

BREACH PRESENTATION
TRANSVERSAL & OBLIQUE LIE

Prof. Vlad TICA, M.D., Ph. D.

 TYPES OF BREECH
PRESENTATION
• Frank (65%): Hips are flexed,
knees are extended
• Complete (10%): The hips and
knees are flexed
• Incomplete (25%): The feet or
knees are the lowermost
presenting part:
• Single footling: one of the
lower extremities is
lowermost.
• Double footling: Both of the
lower extremities are
lowermost
 Breech presentations:
A: Right sacrum posterior (RSP) position
B: Left sacrum anterior (LSA) position
 TYPES OF BREECH
PRESENTATION
• Frank (65%): Hips are flexed,
knees are extended
• Complete (10%): The hips and
knees are flexed
• Incomplete (25%): The feet or
knees are the lowermost
presenting part:
• Single footling: one of the
lower extremities is
lowermost.
• Double footling: Both of the
lower extremities are
lowermost
 BREECH PRESENTATION
PREDISPOSING FACTORS
• Prematurity
• Uterine abnormalities
• Malformation
• Fibroids

• Fetal abnormalities
• CNS Malformations

• Neck Masses

• Multiple gestations
• Previous breech delivery
 BREECH PRESENTATION

Gestational age in weeks % Breech

21-24 33

25-28 28

29-32 14

33-36 9

37-40 7
 BREECH PRESENTATION

DIAGNOSIS

• Palpation and ballottement

• Ultrasound

• Pelvic examination

• X-Ray studies
BREECH PRESENTATION

Leopold Maneuver
EXTERNAL CEPHALIC VERSION
MANAGEMENT
 MANAGEMENT

TYPE OF DELIVERY

• Vaginal delivery:

• Spontaneous

• Partial breech extraction

• Total breech extraction

• Cesarean delivery
 TYPES OF VAGINAL BREECH DELIVERY

• Spontaneous breech (rare): No manipulation of the

infant is necessary, other than supporting the infant

• Partial breech extraction: Fetus descend

spontaneously to where umbilicus is at the vaginal
introitus; then, the fetus is extracted completely

• 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.
 CONDITIONS ARE UNFAVORABLE FOR
BREECH DELIVERY
• Fetus weight > 3500 g

• Unfavorable pelvis – Breech delivery does not allow

sufficient time for molding of the fetal head; thus, a
platypelloid or android pelvis decreases ability fetal
head to navigate maternal pelvis

• Hyperextension of the head – increases risk of cervical

spine injury

• Footlings- incidence of umbilical cord prolapse

increases with coiling of the umbilical cord around the
legs of the fetus
 MORTALITY/MORBIDITY

• Increased birth trauma: As duration of umbilical cord

compression increases → deliver the infant more
rapidly → increasing birth trauma

• Decreased birth weight may result from preterm

delivery/growth restriction

• Incidence of prolapsed umbilical cord depends on type

of breech presentation : Footling 17%, Complete 5%,
Frank 0,5%
MECHANISM OF LABOR IN BREECH
DELIVERY
ASSISTED DELIVERY OF FRANK BREECH
ASSISTED DELIVERY OF FRANK BREECH
ASSISTED DELIVERY OF FRANK BREECH
ASSISTED DELIVERY OF FRANK BREECH

Maneuver for delivery of the

head:
• The fingers of the left hand
are inserted into the infant’s
mouth of over mandible;
• The right hand exerts
pressure on the head from
above
MAURICEAU MANEUVER
MECHANISM OF LABOR IN BREECH
DELIVERY

• Piper forceps

• Modified Prague maneuver

DELIVERY OF THE AFTERCOMING HEAD

Application of Piper forceps, employing towel sling support.

The forceps are introduced from below, left blade first.
Aiming directly and intended positions on sides of the head
DELIVERY OF THE AFTERCOMING HEAD
MODIFIED PRAGUE MANEUVER
COMPLETE OR INCOMPLETE BREECH
EXTRACTION
COMPLETE OR INCOMPLETE BREECH
EXTRACTION
BREECH EXTRACTION
 C-SECTION INDICATION

• A large fetus ( > 3.500 grams)

• A hyperextended fetus

• Uterine dysfunction

• Footling presentation

• Any degree of contraction or unfavorable shape

restriction

• Previous perinatal death or children suffering from

birth trauma
 COMPLICATIONS

1. Perinatal morbidity and mortality from difficult delivery

2. Low birthweight from preterm delivery, growth

restriction, or bot

3. Prolapsed cord

4. Placenta praevia

5. Fetal, neonatal, and infant anomalies

6. Uterine anomalies and tumors

7. Multiple fetuses

8. Operative intervention, especially cesarean delivery

TRANSVERSE OR OBLIQUE PRESENTATION
1. DEFINITION
At the end of pregnancy or during of labor,
champ of pelvic inlet is not fetal head or fetal
breech

2. VARIETY
- shoulder right in dorso-anterior
- shoulder left in dorso-anterior
- shoulder right in dorso-posterior
- shoulder left in dorso-posterior
TRANSVERSE OR OBLIQUE PRESENTATION

3. ETIOLOGY
• Mistake of accommodation: the grand cause of
transverse position is multipara (relax of uterine wall)

• Other cause can hydramnios, previa tumor, shortness

umbilical cord

• Uterine malformation
TRANSVERSE OR OBLIQUE PRESENTATION

4. CLINICAL

• Inspection
• The uterus is developing transverse or oblique

• Palpation
• Hands explored base part of uterus on of pelvic
inlet can not contact fetal pole
• At middle of uterus fundus have no fetal pole
TRANSVERSE OR OBLIQUE PRESENTATION

• At lateral face of uterus (right or left) can contact with

fetal pole or breech

• Multipara are rare on same plan of transverse

• Uterus malformation, the two poles can contact at

same higher at uterine body (back in anterior)

• In dorso-posterior, abdominal wall perception fetal

limps
TRANSVERSE OR OBLIQUE PRESENTATION
TRANSVERSE OR OBLIQUE PRESENTATION

• Auscultation:
• the fetal cardiac sound can receive a bite under
umbilical at cephalic side

• Digital exam:
• during pregnancy: the excavation is empty
(fingers are not contact the presentation)
TRANSVERSE OR OBLIQUE PRESENTATION

• During labor: if membranes are not rupture, the sac

amniotic fluid is big volume (can not evaluation the
presentation)

• After rupture of membranes, the fingers are

perception:
. Shoulder and acromial protrusion
. Axillary furrow
TRANSVERSE OR OBLIQUE PRESENTATION

• At profound permit contact:

. Costal
. Scapula

• In some cases, superior limp fall down in excavation,

vaginal, vulva with character cyanosis and edema

• The thumb turn to thigh of mother same name with of

shoulder that present
TRANSVERSE OR OBLIQUE PRESENTATION

• Diagnostic of variety: must to know head, breech,

back, shoulder (right or left) situate at pelvic inlet
• When the hand is out side of vulva, sign of thumb
confirm the diagnosi

• X-ray: necessary in all cases, it confirme diagnostic

• Ultrasound: same of x-ray and position of placenta

TRANSVERSE OR OBLIQUE PRESENTATION

5. DELIVERY
A. Ovular phenomenon:
The precocity of membranes rupture is favorable by
character of amniotic fluid sac (big volume in cervical
canal)
Uterus is empty of amniotic fluid and cord prolapses
TRANSVERSE OR OBLIQUE PRESENTATION
TRANSVERSE OR OBLIQUE PRESENTATION

B. Mechanic phenomenon:
• First time: weakness, head orient opposite trunk
(vertical). The shoulder is in center of basin.
Superficial exam, the presentation return
longitudinal

• Second time: engage of shoulder

• Third time: stop of progression (enclave).

TRANSVERSE OR OBLIQUE PRESENTATION

C. Plastic phenomenon:
• is at region of shoulder, neck, back

D. Physiologic phenomenon:
• the dilatation of cervix is trouble: cause of dynamic
abnormal and ovular infection
• The cervix is edema, thick
• Lower segment still thick not contact with
presentation
TRANSVERSE OR OBLIQUE PRESENTATION

• The uterine contraction is the trouble: the contraction

is normal until rupture of membrane but the
progression of presentation is stopped

• First irregular, then inertia or hypertonia with

hypercinesis

• The consequence of retraction is:

• Death of the fetus: the retraction provoke

diminution of blood fluid trans placenta and
infection
TRANSVERSE OR OBLIQUE PRESENTATION

• Uterine rupture:

• the retraction of the myometrium of uterine body

provoke lower segment stretch (lower segment
rupture)
TRANSVERSE OR OBLIQUE PRESENTATION

6. TREATMENT:

A. During of pregnancy:
- the surveillance of presentation is every days
- it can external version for cephalic presentation or
breech presentation at pelvic inlet (multipara)
- primipara: cesarean section at the end of
pregnancy
TRANSVERSE OR OBLIQUE PRESENTATION
TRANSVERSE OR OBLIQUE PRESENTATION
TRANSVERSE OR OBLIQUE PRESENTATION

B. During of labor:

• Primipara:
• cesarean section

• Multipara:
• The membrane is intact:
• Complete dilatation of cervix: artificial rupture of
membrane and internal version
• Dilatation is incomplete: conservation of
membrane until complete dilatation
TRANSVERSE OR OBLIQUE PRESENTATION

• The membranes are ruptured:

• Uterus is soft (not retracted) & fetus is alive:

• cesarean section if incomplete dilatation
• internal version if complete dilatation

• Uterus is retracted:
• Fetus is alive: cesarean section
• Fetus is dead: embryotomy
TRANSVERSE OR OBLIQUE PRESENTATION

• Uterus is ruptured:

• after laparotomy and extraction of fetal mort and

placenta, the operation must suture of rupture or
hysterectomy