2. Breech Presentation Breech presentation, the most common obstetric malpresentation, complicates approximately 4% of deliveries. Breech presentation is a polar alignment of the fetus in which the fetal buttocks present at the maternal pelvic inlet.

3. Incidence The incidence of breech presentation is closely associated with birth weight. Breech presentation accounts for 4% of births overall but occurs in 15% of deliveries of low– birth-weight (<2,500 g) infants. Furthermore, the smaller the infant, the higher the incidence of breech presentation, rising to 30% among infants weighing 1,000 to 1,499 g and to 40% among those weighing <1,000 g.

4. Three types are recognized frank incomplete and complete Frank breech presentation. Complete breech presentation Incomplete breech presentation

5. CLASSIFICATION OF BREECH PRESENTATIONS 1. In frank breech presentation, the fetal hips are flexed and the knees extended so that the thighs are apposed to the abdomen and the lower legs to the chest. Frank breech presentation accounts for 60% to 65% of breech presentations; it is more common at term.

6. CLASSIFICATION OF BREECH PRESENTATIONS 2. In incomplete breech presentation, the fetus has one or both hips incompletely flexed so that some part of the fetal lower extremity, rather than the buttocks, is the most dependent part (hence the terms single footling or double footling). This presentation accounts for 25% to 35% of breech presentations and is more common among premature fetuses.

7. CLASSIFICATION OF BREECH PRESENTATIONS 3. Complete breech presentation is the least common type, accounting for about 5% of breech presentations. In this situation, the fetal hips and knees are both flexed so that the thighs are apposed to the abdomen and the legs lie on the thighs. A significant proportion of these fetuses convert to incomplete breech presentations if allowed to labor.

8. Cause Factors that predispose to breech presentation are: Fetal anomalies Head anomalies Anencephaly Hydrocephalus Chromosomal anomalies Autosomal trisomies Multiple anomaly syndromes

9. Cause Uterine Anomalies Septate Bicornuate Unicornuate Uterine overdistension Polyhydramnios Multiple gestation High parity with lax abdominal and uterine musculature

10. Conditions that cause intrauterine crowding can lead to abnormal fetal positions Bicornuate uterus Uterine malformation Multiple fetuses Uterine fibroid Uterine pathology

11. Diagnosis On abdominal examination, Leopold's first maneuver will identify the fetal head in the fundus.

12. The third maneuver reveals the softer breech over the pelvic inlet. It is useful to remember that the head narrows down to the neck before attaching to the body, whereas there is no such tapering between the buttocks and body. Auscultation of fetal heart tones usually reveals them to be most easily detected in the upper quadrants of the uterus when the fetus is in breech presentation.

13. Diagnosis - The diagnosis often is made by vaginal examination In frank or complete breech presentation, the anal orifice may be identified, with the bony prominences of the ischial tuberosities directly lateral to it. Face presentation may be difficult to distinguish from frank breech presentation on digital examination, with the fetal mouth being mistaken for the anus. It is helpful to remember that the mouth is surrounded by bone, whereas the anus is not. In incomplete breech presentations, palpation of the feet on vaginal examination is diagnostic. During labor, any presentation that is not clearly vertex by vaginal examination should be confirmed by an intrapartum ultrasound.

15. Management of Vaginal Delivery Occasionally, a patient will arrive at the hospital in the process of delivering a breech infant. In such circumstances, a vaginal delivery probably is less traumatic to both the infant and mother than a rushed cesarean under suboptimal emergency conditions. Vaginal delivery of a fetus in breech presentation requires the attendance of at least an obstetrician and an anesthesiologist. It is preferable to have a pediatrician in attendance as well. The fetal monitor should be taken to the delivery room, and monitoring should be continued until the physician is committed to a vaginal delivery. Such a commitment occurs when the fetal umbilicus passes over the mother's perineum, at which time the fetal head is in the maternal pelvis and the umbilical cord may undergo compression. Traction on the fetus before that point constitutes a total breech extraction and should be avoided.

16. The legs may then be delivered by flexing the knees and sweeping the legs out from in front of the fetus. A towel is placed around the fetal pelvis, which is then grasped, and downward traction is applied until the fetal scapulas pass under the maternal symphysis. Then, the fetal body is rotated so that the shoulders are in an anteroposterior position, and the anterior arm is flexed and swept out from under the symphysis. The fetus is then rotated 180 degrees in the direction that will keep the fetal back toward the maternal symphysis, and the other arm is swept out in a similar manner. During delivery of a breech, it is important that the fetus not be allowed to assume a position with the fetal face or abdomen toward the maternal symphysis.

17. If the breech infant is delivering so rapidly that cesarean birth is not feasible, the aftercoming head usually delivers spontaneously. Should this not occur, delivery of the fetal head with Piper forceps may be necessary. An assistant must support the fetal body during application of these forceps. The temptation to elevate the fetal body to provide better visualization must be resisted, because this maneuver hyperextends the neck. Rather, the fetal body should be supported parallel to the floor

18. The application is pelvic rather than cephalic, with the forceps being applied to the lateral aspects of the maternal pelvis, not wandered around from the posterior using landmarks on the fetal head, as would be done in vertex presentation. Controlled delivery of the fetal head is then accomplished, with suctioning of the fetal airway as soon as the mouth passes over the perineum. Breech delivery with Piper forceps to the after-coming head. Note that the infant's body is being supported parallel to the floor.

19. The hips of the frank breech are delivering over the perineum. The anterior hip usually is delivered first. Delivery of the body. The hands are applied, but not above the pelvic girdle. With thumbs over the sacrum, gentle downward traction is accomplished until the scapulas are clearly visible.

22. Piper forceps for delivery of the aftercoming head: The fetal body is held elevated using a warm towel and the left blade of forceps is applied to the aftercoming head. The right blade is applied with the body still elevated. Forceps delivery of the aftercoming head. Note the direction of movement shown by the arrow.

23. Perinatal Mortality Perinatal mortality is higher in breech presentation than in vertex. 64% of deaths among term infants in breech presentation are due to malformations or infection Trauma to the head is a significant risk in both term and premature infants who present as a breech, regardless of the route of delivery. Unlike the situation in vertex presentation, in which the fetal head is in the maternal pelvis for hours or days during which molding can occur, the after-coming head of the breech fetus must come through the pelvis as is—there is no time for molding.

24. Perinatal Mortality When extracting a breech presentation, damage to fetal muscles, soft tissue, and viscera may occur. Likewise, delivery may be associated with nerve injury if the arms are not delivered properly, especially if there are nuchal arms. Finally, trauma to the cervical spinal cord may occur with delivery of a breech fetus with hyperextension of the neck. Asphyxia may be caused by prolapse of the umbilical cord past the body, as the head will compress the cord against the cervix and pelvic soft tissues.

25. Antepartum Management Breech presentation diagnosed before 32 weeks gestation should be managed expectantly. Recently, it has been confirmed that a significant percentage of preterm fetuses in abnormal presentations (breech, transverse and oblique) spontaneously convert to vertex presentation as the gestation approaches term. Breech presentation that persists into the late third trimester should be evaluated by an ultrasound examination for congenital anomalies. When a breech presentation persists beyond 32 weeks gestation, some obstetricians have recommended attempts at converting the presentation to vertex by external cephalic version (ECV).

26. VERSION With this procedure, fetal presentation is altered by physical manipulation, either substituting one pole of a longitudinal presentation for the other, or converting an oblique or transverse lie into a longitudinal presentation. According to whether the head or breech is made the presenting part, the operation is designated cephalic or podalic version, respectively. With external version, the manipulations are performed exclusively through the abdominal wall. With internal version, they are accomplished inside the uterine cavity.

27. Transverse Lie (Shoulder Presentation) When the long axis of the fetus lies perpendicular to that of the mother, the condition is termed a shoulder presentation or transverse lie. This malpresentation complicates 1 in 300 births.

28. Definitions In transverse lie, the fetal head lies in one maternal iliac fossa and the buttocks in the other. A better term for this would be transverse presentation, but this term is avoided, as it often is confused with transverse position of vertex presentation. Because the fetal shoulder usually lies over the pelvic inlet, the formal term is shoulder presentation, which should be considered synonymous with transverse lie.

30. Definitions The fetal position is described with the fetal acromion used as a reference point and is termed left or right acromion, according to which side of the mother the fetal shoulder is directed. Because the fetal back may be directed anteriorly, posteriorly, superiorly, or inferiorly, the additional qualifying terms: dorsum superior, dorsum anterior, and so on are used as well.

31. Definitions So, if a fetus with its head on the mother's left and its back toward the mother's head would be described as left acromion dorsum superior. If one fetal pole lies in a maternal iliac fossa and the other pole lies in the opposite upper quadrant of the uterus, the lie is said to be oblique or unstable.

32. Cause The most common causative factors of shoulder presentation are high parity with lax abdominal wall and uterine musculature as well as conditions in which the fetus is small in relation to the volume of the uterus (i.e., prematurity and polyhydramnios). Shoulder presentation also may be caused by anything that prevents descent of a fetal pole into the maternal pelvis, such as pelvic contraction, placenta previa, lower uterine segment myoma, or an ovarian tumor in the cul-de-sac. These conditions should be kept in mind for any patient who presents with a transverse lie, but especially in the patient of low parity who has this malpresentation at or near term.

33. Diagnosis The diagnosis of shoulder presentation usually can be made by physical examination of the maternal abdomen with the fetal head and buttocks palpable in the iliac fossas and no fetal pole at the pelvic inlet. A very high or unreachable presenting part on vaginal examination suggests transverse lie. All such findings should be confirmed by ultrasound.

34. Mechanism and Course of Labor The tiny fetus in transverse lie may deliver by the mechanism of conduplicato corpore, in which the fetal body doubles up on itself and the fetal head and buttocks enter the maternal pelvis simultaneously. This often is associated with rupture of fetal abdominal viscera. If the fetal weight is greater than approximately 800 g, there is no mechanism of labor. Uterine contractions will wedge the fetal shoulder into the maternal pelvis, and eventually the membranes will rupture and the fetal arm will prolapse into the vagina. Such a condition is termed a neglected transverse lie. If labor is permitted to continue, there will be progressive thinning of the lower uterine segment, a Bandl retraction ring will form, the uterus will rupture, and eventually both the fetus and the mother will die.

35. Management Shoulder presentations that are diagnosed before term should be managed expectantly, as most will convert to polar presentations before labor. If the patient is not at term but the cervix is significantly dilated (>3 cm), hospitalization at bed rest should be considered because the incidence of cord prolapse in such a patient is 10% to 15% should spontaneous rupture of membranes occur. If the patient is at term (37 or more completed weeks gestation), external version may be attempted.

36. Management If the version is successful and the cervix favorable, induction of labor may be undertaken immediately. External version also may be attempted in early labor, provided the membranes are intact and no fetal part has entered the pelvis. Before any version attempt, ultrasound should be used to rule out placenta previa or pelvic masses precluding a successful external version.

37. Management If the patient is in active labor or has ruptured membranes and the fetus is of a gestational age to be considered viable, delivery should be by cesarean. Because of exceedingly high morbidity and mortality for both the mother and fetus, there is no role for internal version and extraction in the management of transverse lie in singleton gestation. Because the lower uterine segment may be poorly developed, vertical uterine incisions are often necessary. If, however, the fetus can be manipulated to a polar presentation after opening the abdomen but before entering the uterus, a low transverse incision may be performed. This usually is possible only if the membranes are still intact.

38. Management The patient with a neglected transverse lie is an obstetric emergency. Usually she is septic, and often the fetus has died. If the uterus is still intact, it is exceedingly thin because of the prolonged duration of contractions. Some patients will be completely dilated on arrival at the hospital, but the temptation to try vaginal maneuvers such as internal version must be resisted, as this often will result in uterine rupture and may lead to maternal death. Such patients should have basic laboratory studies, coagulation indices, and blood cultures obtained. Rapid intravenous hydration and antibiotic therapy should be instituted, type-specific blood should be available, and the patient should be taken promptly to the operating room for a cesarean delivery. Cesarean hysterectomy often is the best procedure for such patients, especially if the uterus has ruptured or is grossly infected. In the past, various vaginal fetal destructive procedures were described for treating the neglected transverse lie with a dead fetus. Given that obstetricians today have almost no training in such procedures, they should be abandoned in favor of cesarean delivery, even in the face of a dead fetus.

39. Versions

40. External Cephalic Version For breech fetuses near term, the American College of Obstetricians and Gynecologists recommends that version should be offered and attempted whenever possible. Its success rate ranges from 35 to 86% with an average of 58% For women with a transverse lie, the overall success rate is significantly higher.

41. Indications In general, external version is attempted before labor in a woman who has reached 36 weeks’ gestation with a breech fetus. Before this time, a breech presentation still has a high likelihood of correcting spontaneously. And, if performed too early, time may allow a return back to breech.

42. Contraindications Version is contraindicated if vaginal delivery is not an option. Examples include placenta previa or nonreassuring fetal status. Other contraindications include: rupture of membranes known uterine malformation multifetal gestation recent uterine bleeding.

43. Complications Conversion back to breech, and risks of the procedure itself. Risks include: placental abruption uterine rupture fetomaternal hemorrhage alloimmunization preterm labor fetal compromise,even death maternal death due to amnionic fluid embolism

45. Technique Sonographic examination is performed to confirm nonvertex presentation, document amnionic fluid volume adequacy, exclude obvious fetal anomalies if not done previously, and identify placental location. External monitoring is performed to assess fetal heart rate reactivity. Anti-D immune globulin is given to Rh- D negative women. A forward roll of the fetus usually is attempted first. Each hand grasps one fetal pole, and the fetal buttocks are elevated from the maternal pelvis and displaced laterally

46. Internal Podalic Version This maneuver is used only for delivery of a second twin. With the membranes preferably still intact, a hand is inserted into the uterine cavity to turn the fetus manually. The operator seizes one or both feet and draws them through the fully dilated cervix, while using the other hand transabdominally to push the upper portion of the fetal body in the opposite direction as shown in This is then followed by breech extraction

47. Internal podalic version. Upward pressure on the head by an abdominal hand is applied as downward traction is exerted on the feet.

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