1. BREECH DELIVERY
Deepa Mishra
M. Sc. Nursing (OBG)

2. INTRODUCTION
A breech birth is the birth of a baby from a breech presentation, in which the baby exits the pelvis with the buttocks or feet first as opposed to the normal head-first presentation. In breech presentation, fetal heart sounds are heard just above the umbilicus. In a breech presentation, the lie is longitudinal and the podalic pole presents at the pelvic brim. It is the commonest malpresentation.

3. DEFINITION
It is a longitudinal lie in which the buttocks is the presenting part with or without the lower limbs.
According to Nima Bhaskar
A breech birth is the birth of a baby from a breech presentation, in which the baby exits the pelvis with the buttocks or feet first as opposed to the normal head-first presentation.
According to Wikipedia

4. INCIDENCE 3-4% of fetus present by breech at term 5% at 34 weeks
20% diagnosed initially in labour
3.5% term singleton deliveries and about 25% of cases before 30 weeks of gestation undergo spontaneous cephalic version up to term.

5. Complete Breech (Flexed Breech) Incomplete Breech(30-35%)
TYPES
Complete Breech (Flexed Breech)
Incomplete Breech(30-35%)

6. Complete Breech (Flexed Breech)
The normal attitude of full flexion is maintained.
The thighs are flexed at the hips and the legs at knees.
The presenting part consists of two buttocks, external genitalia and two feet.
It is commonly present in multiparae.

7. 2. Incomplete Breech(30-35%)
Buttocks variety (70%)
Incomplete variety with procidentia: One or more little parts (footling, knees) precede the buttocks.
Sacro-anterior positions are more common than sacroposterior as in the first the concavity of the fetal front fits into the convexity of the maternal spines

8. INCOMPLETE BREECH Frank Breech Footling Presentation Knee Presentation
It is breech with extended legs where the knees are extended while the hips are flexed.
More common in primigravida.
Footling Presentation
The hip and knee joints are extended on one or both sides.
More common in preterm singleton breeches.
Knee Presentation
The hip is partially extended and the knee is flexed on one or both sides

9. TYPES OF INCOMPLETE BREECH

10. Complicated Uncomplicated CLINICAL VARIETIES
It is defined as one where there is no other associated obstetric complications apart from the breech, prematurity being excluded.
Complicated
When the presentation is associated with conditions which adversely influence the prognosis such as prematurity, twins, contracted pelvis, placenta praevia etc.

11. POSITIONS Left Sacroanterior (LSA) Left Sacroposterior (LSP)
Left Sacrolateral (LSL)
Right Sacroanterior (RSA)
Right Sacroposterior (RSP)
Right Sacrolateral (RSL)

12. Factors preventing spontaneous version Undue mobility of the fetus
Etiology Of Breech Presentation
Prematurity
Factors preventing spontaneous version
Favorable adaptation
Undue mobility of the fetus
Fetal abnormality

13. DIAGNOSIS
CLINICAL
SONOGRAPHY
RADIOLOGY

14. CLINICAL Per Abdomen Complete Breech Frank Breech Fundal Grip
Complete Breech
Frank Breech
Per Abdomen
Fundal Grip
Head- suggested by hard and globular mass
Head is ballottable
Head
Irregular small parts of the feet may be felt by the side of the head.
Head is non-ballottable due to splinting action of the legs on the trunk.
Lateral Grip
Fetal back is to one side and the irregular limbs to the other
Irregular parts are less felt on the side

15. CLINICAL Complete Breech Frank Breech Pelvic Grip F.H.S.
Complete Breech
Frank Breech
Pelvic Grip
F.H.S.
Breech- suggested by soft, broad and irregular mass.
Breech is usually not engaged during pregnancy
Usually located at a higher level round about the umbilicus
Small, hard and a conical mass is felt
The breech is usually engaged
Located at a lower level in the midline due to early engagement of the breech
Per Vaginum  
During Pregnancy
During labour
Soft and irregular parts are felt through the fornix
Palpation of ischial tuberosities, sacrum and the feet by the sides of the buttocks
The foot felt is identified by the prominence of the heel and lesser mobility of the great toe.
Hard feel of the sacrum is felt, often mistaken for the head
 Palpation of ischial tuberosities, anal opening and sacrum only

16. Ultrasonography
1. It confirms the clinical diagnosis- specially in primigravidae with engaged frank breech or with tense abdominal wall and irritable uterus.
2. It can detect fetal congenital abnormality and also congenital anomalies of the uterus.
3. Type of breech (complete or incomplete).
4. It measures biparietal diameter, gestational age and approximate weight of the fetus.
5. It also localizes the placenta.
6. Assessment of liquor volume (important for ECV).
7. Attitude of the head- flexion or hyperextension (Important for decision making at the time of delivery).
8. CT and MRI can be used to assess the pelvic capacity in addition to all the above mentioned information.

17. DURING PREGNANCY Inspection Palpation Auscultation Ultrasonography
A transverse groove may be seen above the umbilicus in sacro-anterior corresponds to the neck.
If the patient is thin, the head may be seen as a localized bulge in one hypochondrium
Inspection
Fundal Grip: The head is felt as a smooth, hard, round ballottable mass which is often tender.
Umbilical Grip: The back is identified and a depression
First pelvic Grip: The breech is felt as a smooth, soft mass continues with the back. Trial to do ballottement to the breech shows that the movement is transmitted to the whole trunk.
Palpation
FHS is heard above the level of the umbilicus. However in frank breech it may be heard at or below the level of the umbilicus.
Auscultation
To confirm the diagnosis.
To detect the type of breech.
To detect gestational age and foetal weight: Different measures can be taken to determine the foetal weight as the biparietal diameter with chest or abdominal circumference using a special equation.
To exclude hyperextension of the head.
To exclude congenital anomalies.
Diagnosis of unsuspected twins.
Ultrasonography

18. DURING LABOUR
The 3 bony landmarks of breech namely 2 ischial tuberosities and tip of the scarum.
The feet are felt beside the buttocks in complete breech.
Fresh meconium may be found on the examining fingers.
Male genitalia may be felt.

19. Delivery of the buttocks
MECHANISM OF LABOUR
Delivery of the buttocks
Shoulders
Head

20. Delivery of Buttocks
The engagement diameter is the bitrochantric diameter 10 cm which enters the pelvis in one of the oblique diameters.
Descent of the buttocks occurs until the anterior buttock touches the pelvic floor.
Internal rotation of the anterior buttock occurs through 1/8th of a circle placing it behind the symphysis pubis.
Further descent with lateral flexion of the trunk occurs until the anterior hip hinges under the symphysis pubis which is released first followed by the posterior hip.
Delivery of the trunk and the lower limbs follow.
Restitution occurs so that the buttocks occupy the original position as during engagement in oblique diameter.

21. Delivery of Shoulders
Bisacromial diameter (12 cm or 4 ¾”) engages in the same oblique diameter as that occupied by the buttocks at the brim soon after the delivery of breech.
Descent occurs with internal rotation of the shoulders bringing the shoulders to lie in the antero-posterior diameter of the pelvic outlet. The trunk simultaneously rotates externally through 1/8th of a circle.
Delivery of the posterior shoulder followed by the anterior one is completed by anterior flexion of the delivered trunk.
Restitution and external rotation :

22. Delivery of Head
Engagement occurs either through the opposite oblique diameter as that occupied by the buttocks or through the transverse diameter. The engaging diameter of the head is suboccipito-frontal (10 cm).
Descent with increasing flexion occurs.
Internal rotation of the occiput occurs anteriorly, through 1/8th or 2/8th of a circle placing the occiput behind the symphysis pubis.
Further descent occurs until the sub-occiput hinges under the symphysis pubis.
The head is born by flexion- The chain, mouth, nose, forehead, vertex and occiput appearing successively. The expulsion of the head from the pelvic cavity depends entirely upon the bearing efforts and not at all on uterine contractions.
Sacro-posterior position: The mechanism is not substantially modified. The head has to rotate through 3/8th of a circle to bring the occiput behind the symphysis pubis.

23. PROGNOSIS
MATERNAL
FETAL

24. Prevention of the Fetal Hazards
The Fetal Dangers
Intracranial Haemorrhage
Asphyxia
Injuries
Prevention of the Fetal Hazards
The incidence of breech can be minimized by external cephalic version where possible.
If the version fails or is contraindicated, delivery is done by elective caesarean section.
A skilled obstetrician along with an organized team consisting of a skilled anesthetist and an assistant should conduct vaginal breech delivery.
Vaginal manipulative delivery should be done by a skilled person with utmost gentleness, specially during delivery of the head.

25. Formulation of the line of management
ANTENATAL MANAGEMENT
Identification of the complicating factors
External cephalic version
Formulation of the line of management

26. External Cephalic Version
Indications:
Procedure
Preliminaries
Benefits of External Cephalic Version
Causes of failure of version
Dangers of Version
Management, if version fails or is contraindicated

27. ELECTIVE CAESARIAN SECTION
Indications for caesarian
Big Baby (estimated fetal weight>3.5 kg)
Hyperextension of the head
Footling presentation (risk of cord prolapse)
Suspected pelvic contraction
Any obstetrical or medical complications
During First Stage
Cases seen first time in labour with presence of complications
Arrest in the progress of labour
Non-reassuring FHR pattern
Cord presentation or prolapse

28. VAGINAL BREECH DELIVERY
Indications for vaginal breech delivery
Adequate pelvis
Average fetal weight ( kg)
Flexed head and without any other complications
Management of Vaginal Breech Delivery
First Stage
Second Stage

29. ASSISTED BREECH DELIVERY
Preliminaries for conduction of normal labour
Anaesthetist to administer anaesthesia as and when required
An assistant to push down the fundus during contractions.
Instruments and suture materials for episiotomy
A pair of obstetric forceps for the after coming head, if required.
Appliances for revival of the baby, if asphyxiated
Principles in conduction
Never to rush
Never pull from below but push from above
Always keep the fetus with the back anteriorly.

30. ASSISTED BREECH DELIVERY
Steps
Patient is to be placed in lithotomy position when the posterior buttock distends the perineum.
To avoid aortocaval compression
Antiseptic cleaning
Pudendal block
Episiotomy
Patient is encouraged to bear down
Soon after the trunk upto the umbilicus is born
Delivery of the arms
Delivery of the after coming head
Burn-Marshall method
Forceps delivery
Malar Flexion and Shoulder traction (modified Mauriceau-Smellie- Veit technique)
Resuscitation of the baby
Third Stage

31. MANAGEMENT OF COMPLICATED BREECH DELIVERY
Delayed in Descent of the Breech
Extended Arms
Arrest of the After-coming Head

32. Delayed in Descent of the Breech
Arrested at the Outlet
In the absence of outlet contraction and feto-pelvic disproportion
Arrest of the breech at or above the level of ischial spines
Frank Breech Extraction (Pinard’s Maneuver)

33. Extended Arms
Extended arms is due to faulty technique in delivery using unnecessary traction, forgetting the principle of ‘never pull but push from above’
Diagnosis is made by noting the winging of the scapula and absence of the flexed limbs in front of the chest.
Management :
The management calls for the urgent delivery of the arms, first the posterior and then the anterior one.
The delivery of the arm may be accomplished by adopting any one of the following methods:
Classical
Lovset

34. Arrest of After Coming Head
At the Brim
In the Cavity
At the Outlet
Delivery of the head through an incompletely dilated cervix
Occipito- posterior position of the head through an incompletely dilated cervix

35. CONCLUSION:
The incidence of Breech presentation expected to be low in hospitals where high parity births are minimal and routine external cephalic version done in antenatal period. Breech presentation can be managed by early diagnosis and effective management strategies. By using different maneuvers and skillful observation of the obstetrician.