BREECH PRESENTATION

 DEFINITION
 TYPES
 INCIDENCE
 ETIOLOGY/PREDISPOSING FACTORS

 MANAGEMENT:-
 DIAGNOSIS:
 -CLINICAL PRESENTATION
 - INVESTIGATIONS
 MODE OF DELIVERY
 - CAESEREAN SECTION
 - ASSISSTED VAGINAL DELIVERY
 - EXTERNAL CEPHALIC VERSION
DEFINITION
Breech presentation is the entrance of the fetal buttocks or
lower extremities into the maternal pelvic inlet. It is the
commonest form of malpresentation.
TYPES
1. Frank or extended: hips flexed,knees extended.
2. Complete or flexed: hips flexed,knees flexed.
3. Footling or incomplete: one or both hips extended with a foot
presenting.
INCIDENCE
The incidence of breech presentation is about 25% at 28-
30weeks gestation, 15% at 32weeks gestation but by
34weeks most have undergone spontaneous version to
cephalic presentation such that at term the incidence is about
2-4%. Frank breech is the commonest type of breech
presentation, accounting for 50-70% of cases, Footling for 10-
30% of cases and complete for 5-10%.
Etiology
Idiopathic
PREDISPOSING FACTORS
Maternal:- abn. of maternal pelvis, uterine abn (bicornate uterus), low lying
pelvic tumors (fibroids, ovarian cysts) maternal diabetes .
Fetal:- Prematurity (commonest), fetal abns (hydrocephalus, cns mal. Neck
masses), multiple pregnancy, placenta praevia,short cord, abn of liquor vol
(oligo, polyhydramnios), intra-uterine fetal death.
Drugs – anticonvulsant - phenytoin

DIAGNOSIS:
Based on clinical presentation, usually an incidental finding on abdominal
examination.
Palpation:- soft, globular, non ballotable fetal part at the lower uterine pole
and a hard, rounded and ballotable part felt above the umbilicus (uterine
fundus). Difficulties in making a diagnosis by palpation arise when the
anterior abdominal wall is obese, extended legs obscure ballotment of the
fetal head with the fetus in dorso-anterior position and polyhydramnios
present.
Auscultation:- the area of greatest intensity of the fetal heart sounds is above
the level of the maternal umbilicus although if the legs are extended, the
sounds tend to be heard at a lower level.
Vaginal examination:- fetal buttock is felt, if cervix is dilated and membrane
ruptured, natal cleft is felt, feet felt alone or close to buttocks, cord may also
be felt.
INVESTIGATIONS:
• Pelvic u/scan: confirm breech presentation
- R/o PDF (fetal cong. Abn, p.praevia, multiple preg)
- Estimate fetal weight
• Pelvimetric assessment: clinical pelvimetary, x-ray pelvimetary (plain abdo
x-ray, CTScan, MRI) - Role in the management of breech is controversial:-
has not changed the incidence of c/s nor the success of V.B.D
MODE OF DELIVERY:
The management of breech presentation remains controversial due to the
associated high perinatal morbidity and mortality following breech deliveries.
Options employed to reduce the perinatal mortality and improve the
maternal and fetal outcome include: Caesarean section, vaginal breech
delivery and external cephalic version.
E.C.V
is a manipulative transabdominal conversion of an abnormal presentation to
cephalic presentation.
Arguments:
Those in favour of E.C.V say it has reduced the incidence and therefore the
risk factors associated with vaginal breech delivery or caesarean section
while those against E.C.V say its complications outweigh its benefits (eg
prelabour rupture of fetal membranes, cord prolapse, premature labour,
prematurity, fetal heart rate abnormalities, abruptio placenta, cord
entanglements, uterine rupture)
 when E.C.V is considered it is carried out only at term and after exclusion of
contraindications such as; placenta praevia, multiple pregnancy, PROM,
APH, PIH, Previous c/s, prematurity and contraindications to vaginal
delivery.
STEPS: E.C.V to be done in labour ward unit or theatre.
1. Obtain consent after explaining procedure to the woman
2. u/scan to R/O contraindications.
3. Maternal B.P measurement.
4. Fetal heart rate measurement (b/4 and after procedure):- non stress test
(CTG)
5. Tocolytics (eg salbutamol, ritodrine) for uterine relaxation.
6. Mother placed in a steep lateral position with her back supported with a
cushion or in a supine position and comfortable.
7. Breech disengaged from pelvic inlet using both hands, E.C.V carried out
when breech is above the inlet.
8. One hand on lower pole, other on upper pole, manipulate in the direction
which increases flexion of the fetus and makes it do a forward somersault,
bringing the head to the lower uterine pole.
 9. On completion of version the fetus is steadied by
lateral pressure while the mother is transferred to the
supine or semi-recumbent position.
10. Check fetal heart rate after procedure.
N/B: If procedure fails or becomes difficult, it is
abandoned.
it is easier to perform ECV in multiparous women due to
laxity of uterus and abdominal wall.
No place for E.C.V in preterm – high failure rate.
E.C.V at term is what is recommended - to allow for
spontaneous version (reversion less likely, if successful),
delivery of term baby in case of spontaneous labour or
complications that require C/S, other unidentified P.D.F
would have become obvious, associated with higher
success rate,
ECV success rate is between 25-97% of breech
presentation.
Factors influencing success of E.C.V
Maternal: parity - higher in multip
Race - higher in black women - due to late engagement
Fetal: type of breech - flexed>frank
descent of presenting part

CAESAREAN SECTION:

Due to the high perinatal mortality and morbidity associated

with breech presentation, the global trend now for breech
delivery is C/S
Recent randomised controlled trial (mary hannah in canada)
has shown that planned c/s is better than V.B.D, however in
our society where there is an aversion for c/s, and where
women with previous c/s attempt vaginal delivery to avoid
repeat c/s outside the hospital with the possible risk of uterine
rupture, liberal c/s for breech delivery is not justified.
INDICATIONS FOR C/S IN BREECH
PRESENTATION:
1. Previous c/s
2. P.I.H
3. B.O.HX
4. Previous infertility
5. Contracted pelvis
6. Primigravida breech with inadequate
pelvis
7. Elderly primigravida
8. Preterm breech,
9. Footling breech
V.B.D
In modern obstetric practise there is no place for S.V.B.D
A.V.B.D is the choice of delivery but in well selected cases
(women properly assessed:- R/O P.D.F, C/I to V.D)
Scoring index for A.V.B.D:- Andros-Zatuchni Scoring index
Parameters of index:- Parity, gestational Age, Previous V.B.D,
estimated fetal weight, cervical dilatation and station
Zatuchi-Andros scoring index is used in labour.
STEPS IN A.V.B.D:-
• Transfer to 2nd stage room when fully dilated
• Place in lithotomy position and cleanse lower abdomen,
vulva, vagina and thighs with swabs soaked in hibitane
soln.
• Apply sterile drapes to isolate the vulva
4. Empty bladder with a plastic catheter and repeat V.E to
confirm full cervical dilatation.
5. With each contraction she is encouraged to bear down
while the descent of the breech is observed without
interference
6. The perineum is infiltrated with 10mls of 1% xylocaine
7. A left mediolateral episiotomy is given as the breech
distends the perineum, the descent of the baby allowed to
continue until the umbilicus and popliteal fossa become
visible
8. Each extended lower limb is delivered by the pinard’s
manoeuvre (pressure applied with two fingers to the popliteal
fossa to flex the knee and gently abduct and flex the thigh)
9. Mother encouraged to bear down until the trunk, up to the
scapula becomes visible, cord pulsation checked and a loop
of cord pulled down to prevent cord compression
10. Baby gently held by the groin and trunk rotated 90o in one
direction with a downward traction applied and the back
facing upwards to deliver the anterior shoulder (lovset
maneouvre for extended arms)
11. Procedure repeated in the opposite direction, with a rotation
of 1800 to deliver the posterior shoulder.
12. Mother further encouraged to bear down until the hair lines
is visible (the nape of the neck become visible) under the
pubic symphysis
13. The aftercoming head is delivered by one of the following
methods:
- Mauriceau-Smellie-Veit manoeuvre (jaw flexion and
shoulder traction)
- Burns Marshall
- Obstetric forceps (piper’s)
The most important aspect of V.B.D is delivery of the
aftercoming head
 Zatuchni Andros scoring index(1965)
parameter Score 0 Score 1 Score 2

parity 0 1 >2

Gestational age 39+ 38 < 37

(weeks)
Previous vag 0 1 2
breech delivery
Estimated fetal > 4.0 3.5-4.0 < 3.5
weight (kg)
Cervical os 2 3 >4
dilatation (cm)
Station of -3 -2 -1
presenting part
• Score 0-4 - Caesarean • Score > 5 – allow vaginal
delivery recommended breech delivery
 Newman’s score for ECV

Score 0 1 2 Because of significant

overlap in scores
between successful
Parity 0 1 >2 and unsuccessful
ECV, this scoring
system is clinically
less useful
Estimated < 2.5 2.5-3.5 > 3.5
fetal weight
(kg)
Placental anterior posterior Lateral or
position fundal

Cervical >3 1-2 0

dilatation

Station of > -1 -2 -3
presenting
part
 BREECH EXTRACTION:
No maternal effort in V.B.D (breech extraction)
Mother under general anaesthesia
INDICATIONS:
- Retained 2nd twin with breech presentation
- Transverse lie (do prior internal podalic version,
then breech extraction)
- I.U.F.D with breech presentation
COMPLICATIONS OF A.V.B.D
- Trauma to fetal head (I.C.H)
- Fractured limbs (clavicular #, humerus #, shoulder
dislocation)
- Dislocation of the neck
 Other methods of achieving
spontaneous version
• Mousi Burston manouvre used by the
chinese – where they burn a herb on the
patient feet to achieve version.
• Elkin’s manouvre – patient is advised to
be in repeated knee-chest position to
encourage spontaneous