PREGNANCY AND DELIVERY AT BREECH PRESENTATION. FETAL MALPRESENTATIONS.

Prepared by I. Kuziv
Usually the fetal head engages in the occipito-anterior position (more often left occipitoanterior (LOA) rather than right) and then undergoes a short rotation to be directly occipitoanterior in the mid-cavity. Malpositions are abnormal positions of the vertex of the fetal head
relative to the maternal pelvis. Malpresentations are all presentations of the fetus other than
vertex.

MALPRESENTATION
Predisposing factors to malpresentation include:

Prematurity.
Multiple pregnancy.
Abnormalities of the uterus, eg fibroids.
Partial septate uterus.
Abnormal fetus.
Placenta praevia.

Breech pregnancy: Introduction

Breech pregnancy is a condition of pregnancyin which the fetus or baby is not in the
head-down position in the uterus. Breech pregnancy is common and normal in early
pregnancy as the baby grows and moves around in the uterus. However, by about 36 weeks of
pregnancy, the baby should have moved into the head-down position, the normal position for

vaginal delivery. If this has not happened, it is called a breech presentation.

In a breech pregnancy or breech presentation, the baby is positioned with the buttocks
down and the head up. The mother may or may not be aware of any symptoms of a breech
pregnancy or breech presentation. Complications of breech pregnancy that lead to breech
presentation and a vaginal breech delivery can include dicult vaginal delivery, fetal
distress, birth defects and compression of the umbilical cord. For more details on symptoms
and complications, refer to symptoms of breech pregnancy.
One of the main causes of a breech pregnancy that leads to a breech presentation is
prematurity. Risk factors for breech pregnancy that leads to a breech presentation include
having an abnormally shaped uterus, too little or too much amniotic fluid, having twins, triplets
or other multiple pregnancies, fibroids of the uterus and placenta previa.
There are several variations of a breech pregnancy orbreech presentation. These include
a frank breech presentation, in which the hips of the fetus are exed and the legs extend
straight upward with the knees straight and the feet at the head or face.
A breech pregnancy or breech presentation called a complete breech presentation occurs
when the hips and the knees of the fetus are exed. A breech pregnancy or breech
presentation called a footling breech presentation occurs when one or both of the infant's feet
cover or push through the cervix of the uterus.
A breech pregnancy that results in a breech presentation occurs in only about 3 percent
to 5 percent of pregnancies with a single infant. A breech pregnancy that results in a breech
presentation is more common in multiple pregnancies, in which there are twins, triplets or
other multiple infants.
A diagnosis of breech pregnancy and/or breech presentation is made by ultrasound. In
the later stages of pregnancy, it is often possible for a licensed physician or nurse midwife to
feel a breech presentation through the wall of a pregnant woman's abdomen. A variety of
other tests may be performed to evaluate overall health of the mother and the fetus. Tests
can include blood tests, such as a complete blood count (CBC), a chemistry panel,
urinanalysis, and blood glucose testing. Amniocentesis may also be performed for some
women.
It is possible that a diagnosis of breech pregnancy can be missed or delayed. For more
information on misdiagnosis, refer to misdiagnosis of breech pregnancy.
Breech pregnancy can be treated or addressed to minimize any complications that can
occur during labor and delivery. Treatment can include manual manipulation to turn the baby
into the correct head-down position (vertex presentation). This is called external cephalic
version.
Infants in a breech presentation that are unable to be repositioned into the vertex
position are often delivered by cesarean section. In some cases it is possible to safely deliver
an infant vaginally in abreech presentation. For more information on treatment, refer
to treatment of breech pregnancy.

Breech pregnancy: Symptoms

Many women are unaware of a breech pregnancy, especially in early pregnancywhen the
baby is small and tends to move around and shift positions often. If the infant remains in

a breech presentation and does not move into a head-down position (vertex presentation) in
late pregnancy, a woman may be able to feel the baby's head in the upper area of the
abdomen and/or possibly a lot of kicking or movement in the lower abdomen.
A breech pregnancy can often be felt through the abdomen by a licensed physician of
nurse midwife in late pregnancy. Other clinical signs of a breech pregnancy can be seen on an
imaging test called an ultrasound. These include a position in which the infant's buttocks are
down and seated against the cervix of the uterus and the head is at the top area of the uterus.

Breech presentation

Breech presentation is the most common malpresentation, with the majority discovered
before labour. Breech presentation is much more common inpremature labour.

Approximately one third are diagnosed during labour when the fetus can be directly
palpated through the cervix.

After 37 weeks, external cephalic version can be attempted whereby an attempt is made
to turn the baby manually by manipulating the pregnant mother's abdomen.

If the pelvis is normal and estimated fetal weight is 2,500-4,000 g, assisted breech
delivery
with
experienced
sta
is
believed
to
be
as
safe
asCaesarean

section;[1] approximately 50% of women aiming for vaginal delivery will achieve this.
Women who have an elective Caesarean section for a breech presentation in their rst
pregnancy have approximately a 1 in 10 chance of having an elective Caesarean section for

a breech presentation in their second pregnancy.[2]

Transverse lie

When the fetus is positioned with the head on one side of the pelvis and the buttocks in
the other (transverse lie), vaginal delivery is impossible.

This requires Caesarean section unless it converts or is converted late in pregnancy. The
surgeon may be able to rotate the fetus through the wall of the uterus once the abdominal
wall has been opened. Otherwise, a transverse uterine incision is needed to gain access to a
fetal pole.

Internal podalic version is no longer attempted.

Malposition
Occipito-posterior position

This is the most common malposition where the head initially engages normally but then
the occiput rotates posteriorly rather than anteriorly. Approximately 10% of labours begin
this way, but many correct in labour.

The occipito-posterior position results from a poorly exed vertex. The anterior fontanelle
(four radiating sutures) is felt anteriorly. The posterior fontanelle (three radiating sutures)
may also be palpable posteriorly.

It may occur because of a at sacrum, poorly exed head or weak uterine contractions
which may not push the head down into the pelvis with sufficient strength to produce correct
rotation.

Occasionally, epidural analgesia relaxes the pelvic oor such that the occiput sinks into it
instead of being pushed to the correct position.[3]
Management

As occipito-posterior position pregnancies often result in a long labour, close maternal

and fetal monitoring are required. An epidural is often recommended and it is essential that

adequate fluids be given to the mother.

The mother may get the urge to push before full dilatation but this must be discouraged.
If the head comes into a face to pubis position then vaginal delivery is possible as long as
there is a reasonable pelvic size. Otherwise, forceps or Caesarean section may be required.
Occipito-transverse position

The head initially engages correctly but fails to rotate and remains in a transverse
position.

Alternatives for delivery include:

If the second stage is reached, the head must be manually rotated with Kielland's
forceps or delivered using vacuum extraction. This is inappropriate if there is any fetal
acidosis because of the risk of cerebral haemorrhage.

Therefore, there must be immediate provision for a failure of forceps delivery to be

changed immediately to a Caesarean. The trial of forceps is therefore often performed in
theatre.

Some centres prefer to manage by Caesarean section without trial of forceps.

Face presentations

Face presents for delivery if there is complete extension of the fetal head.

Face presentation occurs in 1 in 300 deliveries.

With adequate pelvic size, and rotation of the head to the mento-anterior position,
vaginal delivery should be achieved after a long labour.

Backwards rotation of the head to a mento-posterior position requires a Caesarean

section.
Brow positions

The fetal head stays between full extension and full exion so that the biggest diameter
(the mento-vertex) presents.

Brow presentation occurs in 1 in 500 deliveries.

Brow presentation is usually only diagnosed once labour is well established.

The anterior fontanelle and super orbital ridges are palpable on vaginal examination.

Unless the head exes, a vaginal delivery is not possible, and a Caesarean section is
required.

What causes breech position during pregnancy?

There is often no clear reason why the baby did not turn head-down. In other cases, breech
position might be linked to:2
Labor that begins before the 37th week of pregnancy, before the baby is likely to turn
head-down on its own.

Twins or more. Limited space for two or more babies can prevent them from moving into
the head-down position before delivery.

Too much or too little amniotic fluid in the uterus.

Problems with the uterus, such as an oddly shaped uterus or uterine broids, which are
noncancerous growths in the uterine wall.

Stretched and weakened uterine muscle from past pregnancies.

Problems with the baby, including heart, digestive tract, and brain problems, such
as Down syndrome, anencephaly, or hydrocephalus.
BREECH PRESENTATION
Breech presentation is common remote from term. Most often, however, some time before
the onset of labor the fetus turns spontaneously to a cephalic presentation so that breech

presentation persists in only about 3 to 4 percent of singleton deliveries. For example, 3

percent of 58,334 singleton infants delivered from 1991 through 1994 at Parkland Hospital
presented as breech.

As term approaches, the uterine cavity most often accommodates the fetus in a
longitudinal lie with the vertex presenting. Factors other than gestational age that appear to
predispose to breech presentation include uterine relaxation associated with great parity,
multiple fetuses, hydramnios, oligohydramnios, hydrocephalus, anencephalus, previous breech
delivery, uterine anomalies, and pelvic tumors.

There are three types of breech presentation: complete, incomplete, and frank.
Complete breech is when both of the baby's knees are bent and his feet and bottom are
closest to the birth canal.
Incomplete breech is when one of the baby's knees is bent and his foot and bottom are
closest to the birth canal.
Frank breech is when the baby's legs are folded at up against his head and his bottom is
closest to the birth canal.
There is also footling breech where one or both feet are presenting.
Fianu and Vaclavinkova (1978) provided sonographic evidence of a much higher
prevalence of placental implantation in the cornualfundal region for breech presentations (73

percent) than for vertex presentations (5 percent). The frequency of breech presentation is also
increased with placenta previa, but only a small minority of breech presentations are
associated with a previa. No strong correlation has been shown between breech presentation
and a contracted pelvis.
A live fetus is not required for a fetus to change presentations spontaneously. One woman
admitted to Parkland Hospital at term had a fetus known to be dead, conrmed by real-time
sonography. The presentation was cephalic during the rst oxytocin induction. Three days later,
at the time of the second attempt at labor induction, the fetus was in a breech presentation.
Three days later, at the time of a third and successful induction, the fetus was again in a
cephalic presentation!
In the persistent breech presentation, an increased frequency of the following
complications can be anticipated:
(1) perinatal morbidity and mortality from difficult delivery;
(2) low birthweight from preterm delivery, growth restriction, or both;
(3) prolapsed cord;
(4) placenta previa;
(5) fetal, neonatal, and infant anomalies;
(6) uterine anomalies and tumors;
(7) multiple fetuses;
and (8) operative intervention, especially cesarean delivery.
The varying relations between the lower extremities and buttocks of breech presentations
form the categories of frank, complete, and incomplete breech presentations. With a frank
breech presentation, the lower extremities are exed at the hips and extended at the knees,
and thus the feet lie in close proximity to the head. A complete breech presentation diers in
that one or both knees are exed. With incomplete breech presentation, one or both hips are
not exed and one or both feet or knees lie below the breech, that is, a foot or knee is
lowermost in the birth canal. The frank breech appears most commonly when the diagnosis is
established radiologically near term.

Fig. 1 Longitudinal lie. Frank breech presentation.

Fig. 2 Longitudinal lie. Complete breech presentation.

Fig. 3 Longitudinal lie. Incomplete, or footing, breech presentation.

Classification of breech presentations

ABDOMINAL EXAMINATION
Typically, with the rst Leopold maneuver, the hard, round, readily ballottable fetal head is

found to occupy the fundus (Fig. 4). The second maneuver indicates the back to be on one side
of the abdomen and the small parts on the other. On the third maneuver, if engagement has
not occurredthat is, if the intertrochanteric diameter of the fetal pelvis has not passed
through the pelvic inletthe breech is movable above the pelvic inlet. After engagement, the
fourth maneuver shows the rm breech to be beneath the symphysis. Fetal heart sounds are
usually heard loudest slightly above the umbilicus, whereas with engagement of the fetal head
the heart sounds are loudest below the umbilicus.
Fig. 4 Palpation in left
sacroanterior position. A.
First maneuver. B. Second
m a n e u v e r . C.
Third
maneuver.
D.
Fourth
maneuver.
VAGINAL EXAMINATION
With the frank breech
presentation, both ischial
tuberosities, the sacrum,
and the anus are usually
palpable, and after further
descent,
the
external
genitalia
may
be
distinguished.
Especially
when labor is prolonged,
the buttocks may become
markedly
swollen,
rendering dierentiation of
face and breech very
dicult; the anus may be
mistaken for the mouth,
and the ischial tuberosities
for the malar eminences.
Careful
examination,
however, should prevent
this error, because the
nger
encounters
muscular resistance with
the anus, whereas the
rmer, less yielding jaws
are felt through the mouth.
Furthermore, the nger,
upon removal from the anus, is sometimes stained with meconium. The mouth and malar
eminences form a triangular shape, while the ischial tuberosities and anus are in a straight line.
The most accurate information, however, is based on the location of the sacrum and its spinous
processes, which establishes the diagnosis of position and variety.
In complete breech presentations, the feet may be felt alongside the buttocks, and in
footling presentations, one or both feet are inferior to the buttocks (Fig. 18). In footling
presentations, the foot can readily be identified as right or left on the basis of the relation to the

great toe. When the breech has descended farther into the pelvic cavity, the genitalia may be
felt.

Fig. 5. Double-footling breech presentation in labor with membranes intact. Note possibility of
umbilical cord accident at any instant, especially after rupture of membranes.
X-RAY, COMPUTED TOMOGRAPHY, AND ULTRASONIC EXAMINATIONS.
Sonography should ideally be used to conrm a clinically suspected breech presentation
and to identify, if possible, any fetal anomalies. If cesarean delivery is planned, x-rays are not
indicated. If, however, vaginal delivery is considered, the type of breech presentation is of
considerable importance. Radiation exposure may be reduced considerably by using computed
tomographic pelvimetry (Kopelman and associates, 1986). These imaging techniques can be
used to provide information regarding the type of breech presentation, presence or absence of
a flexed fetal head, and pelvic measurements.
The role of x-ray pelvimetry in deciding mode of delivery for breech presentation is
controversial (Morrison and co-authors, 1995). Cheng and Hannah (1993) comprehensively
surveyed the literature on breech delivery at term and reviewed 15 studies in which x-ray
pelvimetry was used and 2 studies in which CT pelvimetry was used as one of the criteria for
allowing vaginal delivery. They concluded that interpretation of the role of x-ray pelvimetry was
complicated because pelvic dimensions for allowing labor varied among studies. Most authors,
however, found no correlation between radiological pelvic measurements and the outcome of
labor, while only one study (Ohlsn, 1975) demonstrated that the incidence of complicated
labor rose with decreasing pelvic capacity.
Delivery presentation describes the way the baby (fetus) is positioned to come down the
birth canal for delivery.
THE DELIVERY PROCESS
The delivery process is described in terms of fetal station, lie, attitude, and presentation.
Fetal station:
This is the relationship between the presenting part of the baby -- the head, shoulder,
buttocks, or feet -- and two parts of the mother's pelvis called the ischial spines. Normally the

ischial spines are the narrowest part of the pelvis. They are a natural measuring point for the
delivery progress.
If the presenting part lies above the ischial spines, the station is reported as a negative
number from -1 to -5 (each number is a centimeter). If the presenting part lies below the ischial
spines, the station is reported as a positive number from +1 to +5. The baby is said to be
"engaged" in the pelvis when it is even with the ischial spines at 0 station.
Fetal lie:
This is the relationship between the head to tailbone axis of the fetus and the head to
tailbone axis of the mother. If the two are parallel, then the fetus is said to be in a longitudinal
lie. If the two are at 90-degree angles to each other, the fetus is said to be in a transverse lie.
Nearly all (99.5%) fetuses are in a longitudinal lie.
Fetal attitude:
The fetal attitude describes the relationship of the fetus' body parts to one another. The
normal fetal attitude is commonly referred to as the fetal position. The head is tucked down to
the chest, with arms and legs drawn in towards the center of the chest. Abnormal fetal
attitudes may include a head that is extended back or other body parts extended or positioned
behind the back. Abnormal fetal attitudes can increase the diameter of the presenting part as it
passes through the pelvis, increasing the difficulty of birth.
Fetal presentation:
Cephalic (head-first) presentation:
Cephalic presentation is considered normal and occurs in about 97% of deliveries. There
are different types of cephalic presentation, which depend on the fetal attitude.
Rarely, the fetus' head is extended back, and the chin, face, or forehead will present rst
depending on the degree of extension. This is a more dicult delivery, because this is not the
smallest part of the fetus' head. It may result in a need for cesarean delivery.
A cesarean delivery may be recommended for any of the fetal positions other than
cephalic.
Breech presentation:
Breech presentation is considered abnormal and occurs about 3% of the time. A complete
breech presentation occurs when the buttocks present rst, and both the hips and knees are
exed. A frank breech occurs when the hips are exed so the legs are straight and completely
drawn up toward the chest. Other breech positions occur when either the feet or knees come
out first.
Shoulder presentation:
The shoulder, arm, or trunk may present rst if the fetus is in a transverse lie. This type of
presentation occurs less than 1% of the time. Transverse lie is more common with premature
delivery or multiple pregnancies.
BIOMECHANISM OF LABOR IN BREECH PRESENTATION
I moment the internal breech rotation. The breech rotates and the fetal intertrochanteric
diameter from one of oblique size of the pelvic inlet to anteteroposterior size of the pelvic
outlet.
II moment the lateral exion of the body. The anterior hip is stemmed against the pubic arc.

By lateral exion of the fetal body the posterior hip is forced over the anterior margin of the
perineum. Then anterior hip is born.
III moment the internal shoulders rotation. After the birth of the breech, there is the slight
external rotation as a result of the descends and rotations of the shoulders. The shoulders
rotates on the pelvic floor and diameter biacromialis occupies anteroposterior diameter of the
pelvic outlet.
IV moment the lateral flexion the body in the thoraco-brachial part. The shoulders are born.
V moment the internal rotation of the head. The rotation begins when the fetal head descends
from the plane of greatest pelvic dimensions to the least pelvic dimensions (midpelvis). The
rotation is complete when the head reaches the pelvic floor, the sagittal suture is in the
anteroposterior diameter of the pelvic outlet and the small fontanel is under the symphysis.
VI moment the flexion of the fetal head. The head fixes with its fossa suboccipitalis to the
inferior margin of symphysis pubis and flexes. The face, forehead, vertex, and occiput are born.

Figure Fetal head engages in left occipito-anterior position (top) then descends into midcavity and rotates to full occipito-anterior (bottom)
THE MANUAL AIDS IN BREECH PRESENTATIONS
The manual aid by Tsovyanov I in frank breech presentations.
The aim of the manual aid: to prepare the maternal ways to the delivery of the head and
shoulders and to keep the normal attitude of the fetus.
In the frank breech presentation the fetus extremities are flexed at the hips and extended at
the knees and thus the feet lie in close proximity to the head. The circumference of the thorax
with the crossing on it arms and legs is larger than circumference of the head and the aftercoming head deliveries easily.
The technique. The aid begins after the delivery of the buttocks. The obstetricians hands are
applied over the buttocks, the thumbs placed on the fetus sacrum and other fingers on the
legs. The doctor gently supports the legs to avoid its flexion. If the normal attitude of the fetus
is keeping the head deliveries easy.
The classic manual aid on the labor in complete and incomplete breech presentation.
The aim of the classic manual aid: to help of the shoulders and the head delivery.
The classic manual aid begins when the lower angular of the anterior scapula became visible.
There are 4 moments of the classic manual aid.

I moment the delivery of the posterior arm. The posterior shoulder must be delivered first.
The feet are grasped in one hand and drawn upward over the groin of the mother toward which
the ventral surface of the fetus is directed; in this manner, leverage is exerted upon the
posterior shoulder, which slides out over the perineal margin, usually followed by the arm and
hand.
II and III moment the external trunk rotation and the freeing the posterior arm. The aim of this
moment is the reverse of the anterior shoulder to the sacrum and the delivery of second arm.
The obstetrician applies his hand on the lateral sides of the fetus trunk and rotates it. The
direction of the movement must be in this way: the occiput must go under the symphysis pubis.
When the posterior shoulder and arm appears at the vulva the doctor put two fingers into the
vagina, the fingers passed along the humorous until the elbow is reached. The fingers are now
used to splint the arm, which is swept downward and delivered through the vulva.
IV moment the freeing of the head. After the shoulder are born, the head usually occupies an
oblique diameter of the pelvic with the occiput directed anteriorly. The fetal head may then be
extracted by the method of Mauriceau-Levret. Employing the Mauriceau-Levre maneuver to
help flex the head, the doctors middle finger of one hand are applied into the fetal mouth,
while the fetal body rests upon the palm of the hand and fore arm, which is straddled the fetal
legs. Two fingers of the operators other hand are then hooked over the fetal neck and grasping
the shoulders, downward traction is applied until the suboccipital region appears under the
symphysis. The body of the fetus is then elevated toward the mother abdomen, and the mouth,
nose, brow and the occiput emerge over the perineum. Gentle traction should be exerted by
the fingers over the shoulders.
The manual aid by Tsovyanov II in footling presentations.
The aim of the manual aid: To perform the footling presentation to the incomplete breech and
to prepare the maternal ways to the delivery of the head and shoulders.
The doctor covers the area of the vulva with the sterile napkin and puts up resistance to the
delivery of the feet. The feet are flexing and the footling presentation becomes incomplete
breech presentation. Than the delivery manage as in incomplete breech presentation.
To try the minimize infant mortality and morbidity, cesarean section is now commonly used.
The indications to the cesarean section:
1.

Breech presentation and a large fetus (the weight of the fetus estimated 3700 g and
more).
2.
Breech presentation and any degree of contraction or unfavorable shape of the pelvis.
3.
Breech presentation and deflexed head.
4.
Breech presentation and uterine dysfunction.
5.
Breech presentation and previous perinatal death of children suering from birth
trauma.
6.
Breech presentation and fetal hypoxia.
Prognosis. Both mother and fetus are at greater risk with breech presentation compared
with cephalic presentation, but to nowhere near the same degree. In an analysis of 57,819
pregnancies in the Netherlands, Schutte and colleagues (1985) reported that even after
correction for gestational age, congenital defects, and birthweight, perinatal mortality was
higher in breech than in cephalic infants. They concluded that it may be possible that breech
presentation is not coincidental but is a consequence of poor fetal quality. If this were true,

then medical intervention may be unlikely to reduce perinatal mortality associated with breech
presentation. This possibility had been suggested earlier by Hytten (1982) and by Susuki and
Yamamuro (1985). This concept was strengthened by the report of Nelson and Ellenberg
(1986), who observed that one third of children with cerebral palsy who were in a breech
presentation at birth had major noncerebral malformations.
Because of the greater frequency of operative delivery, including cesarean delivery, there is a
higher maternal morbidity and slightly higher mortality for pregnancies complicated by
persistent breech presentation (Collea and co-authors, 1980). This risk is likely increased even
more if an emergency operation is performed instead of an elective cesarean delivery
(Bingham and Lilford, 1987). Labor is usually not prolonged; Hall and Kohl (1956) reported the
median duration of labor to be 9.2 hours for nulliparas and 6.1 hours for multiparas.
The prognosis for the fetus in a cephalic presentation is considerably worse than when in a
vertex presentation. The major contributors to perinatal loss are preterm delivery, congenital
anomalies, and birth trauma. Brenner and associates (1974) provided a careful analysis of the
characteristics and perils to the fetus from breech presentation. They determined the overall
mortality rate for 1016 breech deliveries to be 25 percent compared with 2.6 percent for
nonbreech deliveries at the University Hospitals of Cleveland. At every stage of gestation, they
identied antepartum, intrapartum, and neonatal deaths to be signicantly greater among
breeches, and the average Apgar scores to be lower for those who survived. During the latter
half of pregnancy, the birthweight at any gestational age was somewhat less for breech infants.
Congenital abnormalities were identied in 6.3 percent of breech deliveries compared with 2.4
percent of nonbreech deliveries.
Tank and associates (1971) examined the character of serious traumatic vaginal delivery. At
autopsy, the organs most frequently found to be injured were, in order of frequency, the brain,
spinal cord, liver, adrenal glands, and spleen. It is of interest that, in retrospective analysis of
cases of idiopathic adrenal calcication, breech delivery was very common. Other injuries
from vaginal delivery included the brachial plexus; the pharynx, in the form of tears or
pseudodiverticula from the obstetricians nger in the mouth as part of the Mauriceau
maneuver; and the bladder, which might be ruptured if distended. Traction might injure the
sternocleidomastoid muscle and, if not appropriately treated, lead to torticollis.
PROBLEMS WITH VAGINAL DELIVERY
Delivery of the breech draws the umbilicus and attached cord into the pelvis, which compresses
the cord. Therefore, once the breech has passed beyond the vaginal introitus, the abdomen,
thorax, arms, and head must be delivered promptly. This involves delivery of successively less
readily compressible parts. With a term fetus, some degree of head molding may be essential
for it to negotiate the birth canal successfully. In this unfortunate circumstance, the
alternatives with vaginal delivery are both unsatisfactory: (1) delivery may be delayed many
minutes while the aftercoming head accommodates to the maternal pelvis, but hypoxia and
acidemia become severe; or (2) delivery may be forced, causing trauma from compression,
traction, or both.
With a preterm fetus, the disparity between the size of the head and buttocks is even greater
than with a larger fetus. At times, the buttocks and lower extremities of the preterm fetus will
pass through the cervix and be delivered, and yet the cervix will not be dilated adequately for
the head to escape without trauma (Bodmer and associates, 1986). In this circumstance,
Dhrssen incisions of the cervix may be attempted. Even so, trauma to the fetus and mother
may be appreciable, and fetal hypoxia may prove harmful. Another mechanical problem with
breech delivery is entrapment of the fetal arm behind the neck. A nuchal arm complicates up
to 6 percent of vaginal breech deliveries and is associated with increased neonatal mortality

(Cheng and Hannah, 1993).

The frequency of cord prolapse is increased when the fetus is small or when the breech is not
frank. In the report by Collea and colleagues (1978), the incidence with frank breech
presentation was about 0.5 percent, which is similar to the incidence (0.4 percent) reported for
cephalic presentations (Barrett, 1991). In contrast, the incidence of cord prolapse with footling
presentation was 15 percent, and it was 5 percent with complete breech presentation.
Soernes and Bakke (1986) conrmed earlier observations that the umbilical cord length is
signicantly shorter in breech compared with cephalic presentations. Moreover, multiple coils
of cord entangling the fetus are more common in breech presentations (Spellacy and
associates, 1966). These umbilical cord abnormalities likely play a role in the development of
breech presentation as well as the relatively high incidence of a non-reassuring fetal heart rate
pattern in labor. For example, Flanagan and co-workers (1987) selected 244 women with a
variety of breech presentations (72 percent were frank breech) for a trial of labor, and there
was a cord prolapse in 4 percent. Fetal distress not due to cord prolapse was diagnosed in
another 5 percent of women selected for vaginal delivery. Overall, 10 percent of the women
identified for vaginal birth underwent cesarean deliveries for fetal jeopardy in labor.
Apgar scores, especially at 1 minute, of vaginally delivered breech infants are generally lower
than when elective cesarean delivery is performed (Flanagan and co-workers, 1987). Similarly,
neonatal cord blood acidbase values are signicantly dierent for vaginally delivered breech
infants. Christian and Brady (1991) reported that umbilical artery blood pH was lower, PCO2
higher, and HCO3 lower compared with cephalic deliveries. Socol and colleagues (1988),
however, concluded that cesarean delivery improved Apgar scores but not acidbase status.
Flanagan and co-workers (1987) emphasized that ultimate infant outcome for breech birth was
not worsened by these significant differences in Apgar scores or acidbase status at birth.
Unfavorable Pelvis.
Because there is no time for molding of the aftercoming head, a
moderately contracted pelvis that had not previously caused problems in delivery of an
average-size cephalic fetus might prove dangerous with a breech. Rovinsky and colleagues
(1973) urged not only accurate measurements of the pelvic dimensions but also precise
evaluation of the pelvic architecture rather than reliance on pelvic indexes. Gynecoid (round)
and anthropoid (elliptical) pelves are favorable congurations, but platypelloid
(anteroposteriorly flat) and android (heart-shaped) pelves are not.

Fig. 6. Hyperextension of Fetal Head

In perhaps 5 percent of term breech presentations, the fetal head may be in extreme
hyperextension (Fig. 19). In these, vaginal delivery may result in injury to the cervical spinal
cord. In general, marked hyperextension after labor has begun is considered an indication for
cesarean delivery (Svenningsen and associates, 1985).
Induction of labor in women with a breech presentation is defended by some and condemned
by others. Brenner and associates (1974) found no signicant dierences in mortality rates and
Apgar scores between cases with induced and those with spontaneous labor. In oxytocinaugmented labor, however, infant mortality rates were higher, and Apgar scores were lower.
Gimovsky and Paul (1982) observed that augmentation of labor was followed by vaginal
delivery in only 2 of 9 women, both multiparous. Moreover, one of the two deliveries resulted in
entrapment of the aftercoming fetal head. The general policy at Parkland Hospital is to resort to
cesarean delivery, rather than use oxytocin to induce or augment labor, unless the fetus is
previable or has a severe anomaly.
The possibility of compression of a prolapsed cord or a cord entangled around the extremities
as the breech fills the pelvis, if not before, is a threat to the fetus.
With a preterm fetus, the aftercoming head may be trapped by a cervix that is suciently
eaced and dilated to allow passage of the thorax but not the less compressible head. The
consequences of vaginal delivery in this circumstance all too often have been both hypoxia and
physical trauma, both of which are especially deleterious to the preterm infant. Thus, delivery
of the apparently healthy but very small fetus by cesarean is generally recommended.
Cheng and Hannah (1993) conducted a systemic search of the world literature regarding term
breech delivery and found 82 reports published in English between 1966 and 1992. A total of 24
studies were selected for analysis because these compared planned vaginal delivery with
planned cesarean section for the term, singleton breech fetus. The eects of planned vaginal
delivery on perinatal mortality, corrected for lethal congenital anomalies and antepartum fetal
death. The corrected perinatal mortality rate ranged from 0 to 48 per 1000 births and was
higher among infants in the planned vaginal delivery groups.
All but two deaths were in the groups of women allowed to labor and deliver vaginally. The
main causes of death were head entrapment, cerebral injury and hemorrhage, cord prolapse,

and severe asphyxia. Cheng and Hannah (1993) observed that the overall neonatal mortality
and morbidity resulting from trauma were increased signicantly in the planned vaginal
delivery groups, with a typical odds ratio of 3.86. They suggested that until a well-designed
randomized trial with sucient statistical power is performed, planned cesarean delivery
should be strongly considered for persistent breech presentation at term. Similarly, Giord and
co-workers (1995) performed a meta-analysis of outcomes after term breech delivery and
observed that, given many methodological limitations of published studies, their analysis
suggested an increased risk of injury or death after a trial of labor.
Only 2 of the 24 reports reviewed by Cheng and Hannah (1993) and Giord and co-workers
(1995) were randomized trials, and both were from the same institution. Collea and colleagues
(1980) reported the results of 200 women with frank breech fetuses at term. Almost half of
these women were excluded from further consideration because of possible fetopelvic
disproportion based on x-ray pelvimetry. A total of 60 infants were eventually delivered
vaginally, and all survived, although two sustained brachial plexus injuries. There were no
perinatal deaths, but half of the 148 women who had cesarean deliveries experienced
signicant morbidity compared with only 7 percent of 60 women who were delivered vaginally.
Gimovsky and colleagues (1983) later evaluated 105 nonfrank breech fetuses and reported
similar ndings. Although these two trials concluded that vaginal breech delivery was relatively
safe, only 110 fetuses were actually allowed a trial of labor after careful selection. As
emphasized by Eller and Van Dorsten (1995), this small number would not provide sucient
statistical power to demonstrate dierences in uncommon adverse outcomes such as perinatal
death and birth injury.
There are no randomized studies regarding delivery of the preterm breech fetus. Penn and
colleagues (1996) attempted such a study in 26 hospitals in England and discontinued the trial
after 17 months because only 13 patients could be recruited. Retrospective studies have
yielded conicting results. Bowes and colleagues (1979) and Main and co-workers (1983) found
that infants born by cesarean section had a better prognosis. Others concluded that vaginal
delivery did not signicantly increase perinatal mortality (Olshan and co-workers, 1984; Rosen
and Chik, 1984; Westgren and co-workers, 1985a, c). The National Institute of Child Health and
Human Development Neonatal Research Network (Malloy and co-workers, 1991) collected data
on 437 very-low-birthweight breech infants admitted to seven neonatal intensive care centers.
After adjusting for several variables, the risk of intraventricular hemorrhage and neonatal death
was not signicantly aected by the mode of delivery for breech fetuses weighing less than
1500 g. A similar analysis was reported from the Netherlands (Gravenhorst and co-workers,
1993). Perinatal follow-up data were collected on 899 live-born singleton, nonanomalous infants
with gestational age less than 32 weeks and birthweight less than 1500 g. Statistical analysis
failed to conclusively resolve whether cesarean delivery was advantageous.
Eller and Van Dorsten (1995) recently surveyed the centers in the MaternalFetal Medicine
Units Network to determine the feasibility of resolving the controversy regarding route of
delivery by a randomized clinical trial. Virtually all participating obstetricians in the Network
agreed that clear scientic evidence was needed to determine if mode of delivery of the breech
aects outcome. Performing the needed investigation was judged to be not feasible, however,
because the number of skilled operators with the ability to safely deliver breech fetuses
continues to dwindle and medicolegal concerns make it dicult to train residents to perform
such deliveries. Indeed, at least two other groups of investigators, who have attempted trials of
breech delivery, concluded that such studies were likely impossible (Penn and Steer, 1990;
Zlatnik, 1993).
What then is standard of care for delivery of term and preterm singleton breech presentations

in the United States? Despite the inadequacy of scientic evidence as discussed, most breech
presentations are delivered by cesarean section. Green and colleagues (1982) estimated that
about 90 percent of breech presentations of all gestational ages undergo cesarean delivery.
There are centers in the United States, however, in which perhaps half of breech presentations
are safely delivered vaginally. For example, 44 percent of breeches weighing 1500 g or more
and 60 percent of those less than 1500 g are safely delivered vaginally at the Chicago Lying-in
Hospital (Brown and co-authors, 1994; Cibils and colleagues, 1994). At Parkland Hospital, the
route of delivery is individualized to clinical circumstances by the attending faculty physician.
Women with selected frank breech presentations of about 2000 g or more but less than about
3500 g are frequently oered planned vaginal delivery. Nonetheless, 85 percent of all singleton
breech presentations in 1995 were delivered by cesarean section. We are of the view that
individualized cesarean or vaginal delivery are both reasonable and acceptable in current

obstetrical practice.
Media file 2: Assisted vaginal breech delivery. Thick meconium passage is common as
t h e breech is squeezed through the birth canal. This is usually not associated with
meconium aspiration because the meconium passes out of the vagina and does not mix
with the amniotic fluid.
Media le 3: Assisted vaginal breech delivery. The Ritgen maneuver is applied to take
pressure o the perineum during vaginal delivery. Episiotomies are often performed for
assisted vaginal breech deliveries, even in multiparous women, to prevent soft tissue
dystocia.
Media le 4: Assisted vaginal breech delivery. No downward or outward traction is
applied to the fetus until the umbilicus has been reached.

Media le 5: Assisted vaginal breech delivery. With a towel wrapped around the fetal
hips, gentle downward and outward traction is applied in conjunction with maternal
expulsive eorts until the scapula is reached. An assistant should be applying gentle
fundal pressure to keep the fetal head flexed.

Media le 6: Assisted vaginal breech delivery. After the scapula is reached, the fetus
should be rotated 90 in order to deliver the anterior arm.

Media le 7: Assisted vaginal breech delivery. The anterior arm is followed to the
elbow, and the arm is swept out of the vagina.

Media le 8: Assisted vaginal breech delivery. The fetus is rotated 180, and the
contralateral arm is delivered in a similar manner as the rst. The infant is then rotated
90 to the backup position in preparation for delivery of the head.
Media file 9: Assisted vaginal breech delivery. The fetal head is maintained in a exed
position by using the Mauriceau maneuver, which is performed by placing the index and
middle ngers over the maxillary prominence on either side of the nose. The fetal body is
supported in a neutral position, with care to not overextend the neck.
Media le 10: Piper forceps application. Piper forceps are specialized forceps used
only for the after-coming head of a breech presentation. They are used to keep the fetal
head exed during extraction of the head. An assistant is needed to hold the infant while
the operator gets on one knee to apply the forceps from below.
Media le 11: Assisted vaginal breech delivery. Low 1-minute Apgar scores are not
uncommon after a vaginal breech delivery. A pediatrician should be present for the
delivery in the event that neonatal resuscitation is needed.
Media le 13: Ultrasound demonstrating a
fetus
in
breech
presentation
with
a
hyperextended head (ie, "star gazing").

EXTERNAL CEPHALIC VERSION

Whenever a breech presentation is recognized during the third trimester, an attempt may
be made to substitute a cephalic presentation by external version. This procedure, well known
to our obstetrical predecessors, has received renewed interest in the past two decades
coincidental with the availability of ultrasound, electronic fetal monitoring, and eective
tocolytic agents. It is likely that these developments have improved the maternal and fetal
safety of external version compared with prior obstetrical eras.
Van Dorsten and co-workers (1981) rekindled interest in this procedure in the United States.
They used ultrasound, fetal monitoring, and a b-agonist for uterine relaxation in 25 pregnancies
randomized to receive external version between 37 and 39 weeks and compared outcomes

with 23 similar pregnancies managed without version. Almost 70 percent of versions were
successful, resulting in a 30 percent cesarean delivery rate compared with 75 percent when
version was not attempted. It is estimated that an active program of breech version could
reduce the expected 3 to 4 percent breech presentation rate at delivery by about half (Laros
and colleagues, 1995).

Fig. 7 Hypothetical results of a trial of external cephalic version for breech presentation derived
from 1339 published patients. (From Zhang J, Bowes WA, Fortney JA. Ecacy of external
cephalic version: A review. Obstet Gynecol. 82:306, 1993. Modied with permission from the
American College of Obstetricians and Gynecologists.
Can a breech presentation be changed?
It is preferable to try to turn a breech baby between the 32nd and 37th weeks of
pregnancy. The methods of turning a baby will vary and the success rate for each method can
also vary. It is best to discuss the options with the health care provider to see which method
he/she recommends.
Medical Techniques:
External Version: External version is a non-surgical technique to move the baby in the
uterus. In this procedure, a medication is given to help relax the uterus. There might also be
the use of ultrasound to determine the position of the baby, the location of the placenta and the
amount of amniotic uid in the uterus. Gentle pushing on the lower abdomen can turn the baby
into the head-down position. Throughout the external version the babys heartbeat will be
closely monitored so that if a problem develops, the health care provider will immediately stop
the procedure. External version has a high success rate. However, this procedure becomes
more difficult as the due date gets closer.
Chiropractic Care: The late Larry Webster, D.C., of the International Chiropractic
Pediatric Association, developed a technique that enabled chiropractors to reduce stress on the
pregnant womans pelvis leading to the relaxation of the uterus and surrounding ligaments. A
more relaxed uterus makes it easier for a breech baby to turn naturally. His technique is known
as the Webster Breech Technique.
The July/August issue of the Journal of Manipulative and Physiological Therapeutics

reported and 82% success rate for the Webster Technique. Further, the results of the study
suggest that it is preferable to perform the Webster Technique in the 8th month of pregnancy.
Natural Techniques:
The following risk-free techniques, often suggested by physical therapist, Penny Simkin,
can be tried at home for free:
The Breech Tilt: Using large, rm pillows, raise the hips 12 or 30cm o the oor for 1015 minutes, three times a day. It is best to do this on an empty stomach when your baby is
active. In this technique, try to concentrate on the baby without tensing your body, especially
in the abdominal area.
Using Music: We know that babies can hear sounds outside the womb. Consequently,
many women have used music or taped recordings of their voice to try to get their baby to
move towards the sound! Placing headphones on the lower part of your abdomen and playing
either music or sounds of your voice can encourage babies to move towards the sounds and
out of a breech position.
Some homeopathic remedies have also been found to be successful in correcting breech
positions. If interested, you can contact your local holistic practitioner about the possibility of
using of Moxibustion or Pulsatilla to correct a breech position.
Vaginal delivery versus cesarean for breech birth?
Most health care providers do not believe in attempting a vaginal delivery for a breech
position. However, some will delay making a nal decision until the woman is in labor. The
following conditions are considered necessary in order to attempt a vaginal birth:

The baby is full-term and in the frank breech presentation

The baby does not show signs of distress while its heart rate is closely

monitored.

The process of labor is smooth and steady with the cervix widening as the baby

descends.
The health care provider estimates that the baby is not too big or the mothers
pelvis too narrow for the baby to pass safely through the birth canal.

Anesthesia is available and a cesarean delivery possible on short notice

What are the risks and complications of a vaginal delivery?

In a breech birth, the babys head is the last part of its body to emerge making it more
dicult to ease it through the birth canal. Sometimes forceps are used to guide the babys
head out of the birth canal. Another potential problem iscord prolapse. In this situation the
umbilical cord is squeezed as the baby moves toward the birth canal, thus slowing the babys
supply of oxygen and blood.
In a vaginal breech delivery, electronic fetal monitoring will be used to monitor the babys
heartbeat throughout the course of labor. A cesarean delivery may be an option if signs develop
that the baby may be in distress.
When is a cesarean delivery used with a breech presentation?
Most health care providers recommend a cesarean delivery for all babies in a breech
position, especially babies that are premature. Since premature babies are small and more
fragile, and because the head of a premature baby is relatively larger in proportion to its body,

the baby is unlikely to stretch the cervix as much as a full-term baby. This means that there
might be less room for the head to emerge.

Zhang and co-authors (1993) reviewed 25 selected reports on external cephalic version
published between 1980 and 1991. Shown in Figure 20, and based on data derived from their
review, are hypothetical results if all women with otherwise normal pregnancies and with
singleton breech presentations had attempted external cephalic version at 35 to 37 weeks.
Several points are noteworthy: (1) external cephalic version is successful in 65 percent of
cases; (2) if version succeeds, almost all fetuses stay in the cephalic presentation, and viceversa; and (3) ultimately, and despite version attempts, 37 percent of women identied to have
late pregnancy breech presentations will require cesarean delivery. Zhang and co-workers
(1993) estimated that universal application of external cephalic version could reduce the
overall cesarean rate by no more than 2 percent.

PROCEDURE

From 30-32 weeks -correcting gymnastics in breech presentations

Prepare for the possibility of cesarean delivery. Obtain a type as well as an anesthesia
consult. The patient should have nothing by mouth for at least 8 hours prior to the procedure.
Perform an ultrasound to conrm breech, check growth and amniotic uid volume, and rule out
anomalies associated with breech.
Perform a nonstress test (biophysical prole as backup) prior to ECV to conrm fetal wellbeing.
Perform ECV in or near a delivery suite in the unlikely event of fetal compromise during or
following the procedure, which may require emergent delivery.
ECV can be performed with 1 or 2 operators. An assistant may help turn the fetus, elevate
the breech out of the pelvis, or monitor the ultrasound position of the baby.
ECV is accomplished by judicious manipulation of the fetal head toward the pelvis while the
breech is brought up toward the fundus. Attempt a forward roll rst and then a backward roll if
the initial attempts are unsuccessful. No consensus has been reached regarding how many ECV
attempts are appropriate at one time.

Following an ECV attempt, whether successful or not, repeat the nonstress test (biophysical
prole if needed) prior to discharge. Also, administer Rh immune globulin to women who are
Rh-negative. Some physicians induce labor following successful ECV. However, as virtually all of
these recently converted fetuses are unengaged, many practitioners will discharge the patient
and wait for spontaneous labor to ensue, thereby avoiding the risk of a failed induction of labor.
In those with an unsuccessful ECV, the practitioner has the option of sending the patient
home or proceeding with a cesarean delivery. Expectant management allows for the possibility
of spontaneous version. Alternatively, cesarean delivery may be performed at the time of the
failed ECV, especially if regional anesthesia is used (see Regional anesthesia). This would
minimize the risk of a second regional analgesia. However, be aware of the small risk for
iatrogenic respiratory distress syndrome, especially when delivery is prior to 37 weeks'
gestation.

SUCCESS RATE
Success rates vary widely but range from 35-86% (average, 58%). Improved success rates
occur with multiparity, with earlier gestational age, with frank breech presentation, with a
transverse lie, and in African American patients. Opinions dier regarding the inuence of
maternal weight, placental position, and amniotic uid volume, but these factors may also
inuence success rates. Be prepared for an unsuccessful ECV; version failure is not necessarily
a reflection of the skill of the practitioner.
Zhang reviewed 25 studies of ECV in the United States, Europe, Africa, and Israel. The
average success rate in the United States was 65%. Of successful ECVs, 2.5% reverted to
breech presentation (other estimates range from 3-5%, while 2% of unsuccessful ECVs had
spontaneous version to cephalic presentation (other estimates range from 12-26%) prior to
labor. Spontaneous version rates depend on the gestational age when the breech is discovered,
with earlier breeches more likely to have spontaneous version.
The performance of an ECV decreases the cesarean delivery rate for breech by
approximately 50%. Because breech presentations complicate only 3-5% of all deliveries,
decreasing the cesarean delivery rate for breeches by 50% will have only a marginal impact on
the overall cesarean delivery rate.
Hofmeyr and Kulier reviewed 5 randomized clinical trials of ECV versus no ECV at term. ECV
was associated with a signicant reduction in noncephalic births (relative risk [RR], 0.38; 95%
condence interval [CI], 0.18-0.8) and a reduction in cesarean delivery for breech (RR, 0.55;
95% CI, 0.33-0.91).
While most studies of ECV have been performed in university hospitals, Cook showed that
ECV has also been eective in the private practice setting. Of 65 patients with term breeches,
60 were offered ECV. ECV was successful in 32 (53%) of the 60 patients, with vaginal delivery in
23 (72%) of the 32 patients. Of the remaining breech fetuses believed to be candidates for
vaginal delivery, 8 (80%) had successful vaginal delivery. The overall vaginal delivery rate was
48% (31 of 65 patients), with no significant morbidity.
COST ANALYSIS
In 1995, Giord et al performed a cost analysis of 4 options for breech presentations at
term: (1) ECV attempt on all breeches, with attempted vaginal breech delivery for selected

persistent breeches; (2) ECV on all breeches, with cesarean delivery for persistent breeches; (3)
trial of labor for selected breeches, with scheduled cesarean delivery for all others; and (4)
scheduled cesarean delivery for all breeches prior to labor.
ECV attempt on all breeches with attempted vaginal breech delivery on selected persistent
breeches was associated with the lowest cesarean delivery rate and was the most costeective approach. The second most cost-eective approach was ECV attempt on all breeches,
with cesarean delivery for persistent breeches.
RISKS
Uncommon risks of ECV include fractured fetal bones, precipitation of labor or premature
rupture of membranes, abruptio placentae, fetomaternal hemorrhage (0-5%), and cord
entanglement ( <1.5%). A more common risk of ECV is transient slowing of the fetal heart rate
(in as many as 40% of cases). This risk is believed to be a vagal response to head compression
with ECV. It usually resolves within a few minutes after cessation of the ECV attempt and is not
usually associated with adverse sequelae for the fetus.
Women with breech presentation, reassuring fetal heart rate tracings, and no
contraindications to vaginal delivery at 36 weeks' gestation and beyond are usually candidates
for ECV (see Contraindications below).
ECV is usually not performed on preterm breeches because they are more likely to undergo
spontaneous version to cephalic presentation and are more likely to revert to breech after
successful ECV (approximately 50%). Studies of preterm ECV did not show a dierence in the
rates of breech presentations at term or overall rates of cesarean delivery. Additionally, if
complications of ECV were to arise that warranted emergent delivery, it would result in a
preterm neonate with its inherent risks.
CONTRAINDICATIONS
Absolute contraindications for ECV include multiple gestations with a breech presenting
fetus, contraindications to vaginal delivery (eg, herpes simplex virus infection, placenta previa),
and nonreassuring fetal heart rate tracing.
Relative contraindications include polyhydramnios or oligohydramnios, fetal growth
restriction, uterine malformation, and fetal anomaly.
CONTROVERSIAL CANDIDATES
Women with prior uterine incisions may be candidates for ECV, but data are scant. In 1991,
Flamm et al attempted ECV on 56 women with one or more prior low transverse cesarean
deliveries. The success rate of ECV was 82%, with successful vaginal births in 65% of patients
with successful ECVs. No uterine ruptures occurred during attempted ECV or subsequent labor,
and no significant fetal complications occurred.
Another controversial area is performing ECV on a woman in active labor. In 1985, Ferguson
and Dyson reported on 15 women in labor with term breeches and intact membranes. Four
patients were dilated greater than 5 cm (2 women were dilated 8 cm). Ritodrine was used for
acute tocolysis, and intrapartum ECV was attempted. ECV was successful in 11 of 15 patients,
with successful vaginal births in 10 patients. No adverse eects were noted. Further studies are
needed to evaluate the safety and efficacy of intrapartum ECV.

TOCOLYTICS
Data regarding the benet of intravenous or subcutaneous beta-mimetics in improving ECV
rates are conflicting.
In 1996, Marquette et al performed a prospective, randomized, double-blinded study on 283
subjects with breech presentations between 36 and 41 weeks' gestation. Subjects received
either intravenous ritodrine or a placebo. The success rate of ECV was 52% in the ritodrine
group versus 42% in the placebo group (P = .35). When only nulliparous subjects were
analyzed, signicant dierences were observed in the success of ECV (43% vs 25%, P <.03).
ECV success rates were signicantly higher in parous versus nulliparous subjects (61% vs 34%,
P <.0001), with no additional improvement with ritodrine.
In 2004, Hofmeyr reviewed 6 trials of tocolysis prior to ECV and concluded that routine
tocolysis resulted in fewer failures of ECV (RR, 0.74; 95% CI, 0.64-0.87). Sublingual
nitroglycerine was not found to be useful.
Whether tocolysis should be used routinely or selectively is still unclear.
REGIONAL ANESTHESIA
Regional analgesia, either epidural or spinal, may be used to facilitate ECV success. When
analgesia levels similar to that for cesarean delivery are given, it allows relaxation of the
anterior abdominal wall, making palpation and manipulation of the fetal head easier. Epidural
or spinal analgesia also eliminates maternal pain that may cause bearing down and tensing of
the abdominal muscles. If ECV is successful, patients can be induced with the epidural in place
or the epidural can be removed and the patient sent home to await spontaneous labor. If ECV is
unsuccessful, a patient can proceed to cesarean delivery under her current anesthesia.
The main disadvantage is the inherent risk of regional analgesia, which is considered small.
Additionally, lack of maternal pain could potentially result in excessive force being applied to
the fetus without the knowledge of the operator.
In 1994, Carlan et al retrospectively analyzed 61 women who were at more than 36 weeks'
gestation and had ECV with or without epidural. The success rate of ECV was 59% in the
epidural group and 24% in the nonepidural group (P <.05). In 7 of 8 women with unsuccessful
ECV without epidural, a repeat ECV attempt after epidural was successful. Of the epidural
group, 86% had obstetrical intervention (induction or cesarean delivery) immediately after the
ECV. No effects on maternal or perinatal morbidity or mortality occurred.
In 1997, Schorr et al randomized 69 subjects who were at least 37 weeks' gestation to
either epidural or control groups prior to attempted ECV. Those in whom ECV failed underwent
cesarean delivery. The success rate of ECV was 69% in the epidural group and 32% in the
control group (RR, 2.12; 95% CI, 1.24-3.62). The cesarean delivery rate was 79% in the control
group and 34% in the epidural group (P = .001). No complications of epidural anesthesia and
no adverse fetal effects occurred.
In 1999, Dugo et al randomized 102 breech subjects who were at more than 36 weeks'
gestation with breech presentations to either spinal anesthesia or a control group. All subjects
received 0.25 mg terbutaline subcutaneously. The success rate of ECV was 44% in the spinal
group and 42% in the nonspinal group, which was not statistically significant.
It would hence appear that epidural analgesia, though not spinal, is associated with a

higher success rate of ECV. Further studies are needed to confirm these initial findings.
ACOUSTIC STIMULATION
Johnson and Elliott performed a randomized, blinded crossover trial on 23 subjects to
compare acoustic stimulation prior to ECV with a control group when the fetal spine was in the
midline (directly back up or back down). Of those who received acoustic stimulation, 12 of 12
fetuses shifted to a spine-lateral position after acoustic stimulation, and 11 (91%) underwent
successful ECV. In the control group, 0 of 11 shifts and 1 (9%) successful ECV ( P <.0001)
occurred. After crossover to the alternate modality, all 10 fetuses in the control group in whom
ECV initially failed shifted to a spine-lateral position following acoustic stimulation and 8 of
these had successful ECV, compared with 0 of 1 ECV successes in the acoustic stimulation
group that crossed over to the control group.
VAGINAL DELIVERY RATES AFTER SUCCESSFUL VERSION
The rate of cesarean delivery ranges from 0-31% after successful ECV.
In 1994, a retrospective study by Egge et al of 76 successful ECVs matched with cephalic
controls by delivery date, parity, and gestational age failed to note any signicant dierence in
the cesarean delivery rate (8% in ECV group, 6% in control group).
In 1997, Lau et al compared 154 successful ECVs to 308 spontaneously occurring cephalic
controls (matched for age, parity, and type of labor onset) with regard to the cesarean delivery
rate. Cesarean delivery rates were higher after ECV (16.9% vs 7.5%, P <.005) because of
higher rates of cephalopelvic disproportion and nonreassuring fetal heart rate tracings. This
may be related to an increased frequency of compound presentations after ECV.
Immediate induction of labor after successful ECV may also contribute to an increase in the
cesarean delivery rate due to failed induction in women with unripe cervices and unengaged
fetal heads.
Vaginal breech delivery requires an experienced obstetrician and careful counseling for the
parent(s). Although studies on the delivery of the preterm breech are limited, the recent
multicenter term breech trial found an increased rate of perinatal mortality and serious
immediate perinatal morbidity.
Parents must be informed about potential risks and benets to the mother and neonate for
both vaginal breech delivery and cesarean delivery. The likelihood is high that the trend will
continue toward 100% cesarean delivery for term breeches and that vaginal breech deliveries
will no longer be performed.
ECV is a safe alternative to vaginal breech delivery or cesarean delivery, reducing the cesarean
delivery rate for breech by 50%. The ACOG, in its 2000 Practice Bulletin, recommends oering
ECV to all women with a breech fetus near term. Consider adjuncts such as tocolysis, regional
anesthesia, and acoustic stimulation to improve ECV success rates. Before performing a
delivery or ECV on a mother whose fetus is in a breech presentation, assess for any underlying
fetal abnormalities or uterine conditions that may result in a malpresentation
FACTORS ASSOCIATED WITH SUCCESSFUL VERSION
The most consistent factor associated with the success of external cephalic version is parity
(Zhang and colleagues, 1993). Gestational age is also important; the earlier external version is
performed, the more likely it will be successful. Conversely, the more remote from term
external version is performed, the higher the rate of spontaneous reversion (Westgren and

colleagues, 1985b). Other reported, albeit controversial, determinants of unsuccessful version

include diminished amnionic uid volume, excessive maternal weight, anterior placental
location, cervical dilatation, descent of the breech into the pelvis, and anterior or posterior
positioning of the fetal spine (Newman and colleagues, 1993, Zhang and co-authors, 1993).
Remarkably, Johnson and Elliott (1995) used fetal acoustic stimulation to startle breech fetuses
to shift their spines laterally for successful external version! Fernandez and co-workers (1996)
randomized 103 women with term antepartum singleton breech presentations to receive
terbutaline 250 mg subcutaneously or placebo. Use of terbutaline signicantly enhanced the
success of external cephalic version from 27 to 52 percent. Marquette and colleagues (1996)
reported similar results using ritodrine infusions.
Women with a transverse lie are usually excluded from analyses of breech version because the
overall success rate approaches 90 percent (Newman and colleagues, 1993).
TECHNIQUE
External cephalic version is typically carried out in a labor and delivery unit (Newman and
colleagues, 1993), although Kornman and colleagues (1995) have performed selected versions
in an oce setting. Real-time ultrasonic examination is performed to conrm nonvertex
presentation, the adequacy of amnionic uid volume (vertical pocket of 2 cm or greater), fetal
measurements consistent with term gestation, and estimated fetal weight; to rule out obvious
fetal anomalies; and to identify placental location. A nonstress test is performed to assess fetal
heart rate reactivity. Terbutaline sulfate, 250 mg, is given subcutaneously and version
attempted 20 minutes later. Forward roll of the fetus is usually attempted rst and the back
ip technique is then tried if unsuccessful. Version attempts are discontinued for excessive
discomfort, persistently abnormal fetal heart rate, or after multiple failed attempts. D-immune
globulin is given to D-negative, unsensitized women. The nonstress test is repeated after the
version until a normal test result is obtained. This process takes about half a day and may cost
as much as $1700 (Newman and colleagues, 1993).
According to Zhang and colleagues (1993), there have been no reported fetal deaths in the
United States resulting directly from external version since 1980. Reported
nonfatal
complications include fetal heart rate decelerations in almost 40 percent of fetuses (Phelan and
co-workers, 1984) and fetomaternal hemorrhage in 4 percent (Stine and colleagues, 1985).
Petrikovsky and colleagues (1987) reported a case of fetal brachial plexus injury after a
successful external version. Stine and co-workers (1985) reported a maternal death due to
amnionic fluid embolus.
MALPOSITIONS AND MALPRESENTATIONS
Malpositions are abnormal positions of the vertex of the fetal head (with the occiput as the
reference point) relative to the maternal pelvis. Malpresentations are all presentations of the
fetus other than vertex.
PROBLEM
The fetus is in an abnormal position or presentation that may result in
prolonged or obstructed labour.

GENERAL MANAGEMENT

Make a rapid evaluation of the general condition of the woman including vital
signs (pulse, blood pressure, respiration, temperature).

Assess fetal condition:

- Listen to the fetal heart rate immediately after a contraction:

- Count the fetal heart rate for a full minute at least once every 30 minutes during the
active phase and every 5 minutes during the second stage;
- If there are fetal heart rate abnormalities (less than 100 or more than 180 beats per
minute), suspect fetal distress.
- If the membranes have ruptured, note the colour of the draining amniotic fluid:
- Presence of thick meconium indicates the need for close monitoring and possible
intervention for management of fetal distress;
- Absence of uid draining after rupture of the membranes is an indication of reduced
volume of amniotic fluid, which may be associated with fetal distress.

Provide encouragement and supportive care.

Review progress of labour using a partograph.

Note: Observe the woman closely. Malpresentations increase the risk for uterine rupture
because of the potential for obstructed labour.
DIAGNOSIS
DETERMINE THE PRESENTING PART
The most common presentation is the vertex of the fetal head. If the vertex is not
the presenting part, see Table S-12.

Symptoms and Signs

Figure

BROW PRESENTATION is caused by partial extension of the fetal head

so that the occiput is higher than the sinciput (Fig S-16).

FIGURE S-16

On abdominal examination, more than half the fetal head is above the
symphysis pubis and the occiput is palpable at a higher level than the
sinciput.
On vaginal examination, the anterior fontanelle and the orbits are felt.
For management
FACE PRESENTATION is caused by hyper-extension of the fetal head so
that neither the occiput nor the sinciput are palpable on vaginal
examination (Fig S-17 and Fig S-18).

FIGURE S-17

On abdominal examination, a groove may be felt between the occiput

and the back.
On vaginal examination, the face is palpated, the examiners finger
enters the mouth easily and the bony jaws are felt.

FIGURE S-18

For management

FIGURE S-19

COMPOUND PRESENTATION occurs when an arm prolapses alongside

the presenting part. Both the prolapsed arm and the fetal head present
in the pelvis simultaneously (Fig S-19).
For management

BREECH PRESENTATION occurs when the buttocks and/or the feet are
the presenting parts.

FIGURE S-20

On abdominal examination, the head is felt in the upper abdomen and

the breech in the pelvic brim. Auscultation locates the fetal heart higher
than expected with a vertex presentation.
On vaginal examination during labour, the buttocks and/or feet are
felt; thick, dark meconium is normal.
For management
FIGURE S-21
COMPLETE (FLEXED) BREECH PRESENTATION
occurs when both legs are flexed at the hips and knees (Fig S-20).
FRANK (EXTENDED) BREECH PRESENTATION
occurs when both legs are flexed at the hips and extended at the knees
(Fig S-21).
FOOTLING BREECH PRESENTATION occurs when a leg is extended at
the hip and the knee (Fig S-22).

FIGURE S-22

TRANSVERSE LIE AND SHOULDER PRESENTATION occur when the

long axis of the fetus is transverse (Fig S-23). The shoulder is typically
the presenting part.

FIGURE S-23

On abdominal examination, neither the head nor the buttocks can be

felt at the symphysis pubis and the head is usually felt in the flank.
On vaginal examination, a shoulder may be felt, but not always. An
arm may prolapse and the elbow, arm or hand may be felt in the vagina.
For management
If the vertex is the presenting part, use landmarks of the fetal skull to determine
the position of the fetal head (Fig 9).

Figure 9 Landmarks of the fetal skull

DETERMINE THE POSITION OF THE FETAL HEAD

The fetal head normally engages in the maternal pelvis in an occiput transverse
position, with the fetal occiput transverse in the maternal pelvis (Fig 10).
Figure 10 Occiput transverse positions

With descent, the fetal head rotates so that the fetal occiput is anterior in the
maternal pelvis (Fig S-11). Failure of an occiput transverse position to rotate to an occiput
anterior position should be managed as an occiput posterior position.

Figure 11. Occiput anterior positions

An additional feature of a normal presentation is a well-exed vertex (Fig. 12), with

the fetal occiput lower in the vagina than the sinciput.
Figure 12. Well-flexed vertex

If the fetal head is well-flexed with occiput anterior or occiput transverse (in
early labour), proceed with delivery.

If the fetal head is not occiput anterior , identify and manage the malposition
(Table 11).

Diagnosis of malpositions

Symptoms and Signs

OCCIPUT POSTERIOR POSITION occurs when the fetal occiput is posterior
in relation to the maternal pelvis (Fig S-13 and Fig S-14).

Figure
FIGURE S-13

On abdominal examination, the lower part of the abdomen is flattened,

fetal limbs are palpable anteriorly and the fetal heart may be heard in the
flank.
On vaginal examination, the posterior fontanelle is towards the sacrum and
the anterior fontanelle may be easily felt if the head is deflexed.
For management
FIGURE S-14

OCCIPUT TRANSVERSE POSITION occurs when the fetal occiput is

transverse to the maternal pelvis (Fig S-15). If an occiput transverse position
persists into the later part of the first stage of labour, it should be managed
as an occiput posterior position.

FIGURE S-15

If the fetal head is not the presenting part or the fetal head is not wellflexed, identify and manage the malpresentation (Table 12).

MANAGEMENT
OCCIPUT POSTERIOR POSITIONS
Spontaneous rotation to the anterior position occurs in 90% of cases. Arrested labour may
occur when the head does not rotate and/or descend. Delivery may be complicated by perineal
tears or extension of an episiotomy.

If there are signs of obstruction or the fetal heart rate is abnormal (less
than 100 or more than 180 beats per minute) at any stage, deliver by caesarean section.

If the membranes are intact, rupture the membranes with an amniotic hook
or a Kocher clamp.

If the cervix is not fully dilated and there are no signs of

obstruction, augment labour with oxytocin.

If the cervix is fully dilated but there is no descent in the expulsive

phase, assess for signs of obstruction (Table 10):
- If there are no signs of obstruction, augment labour with oxytocin.

If the cervix is fully dilated and if:

- the fetal head is more than 3/5 palpable above the symphysis pubis or the leading
bony edge of the head is above -2 station, performcaesarean section;
- the fetal head is between 1/5 and 3/5 above the symphysis pubis or the leading
bony edge of the head is between 0 station and -2 station:
- Delivery by vacuum extraction and symphysiotomy;
- If the operator is not proficient in symphysiotomy , perform caesarean section;
- the head is not more than 1/5 above the symphysis pubis or the leading bony edge of
the fetal head is at 0 station, deliver by vacuum extraction or forceps.
BROW PRESENTATION
In brow presentation, engagement is usually impossible and arrested labour is common.
Spontaneous conversion to either vertex presentation or face presentation can rarely occur,
particularly when the fetus is small or when there is fetal death with maceration. It is unusual
for spontaneous conversion to occur with an average-sized live fetus once the membranes
have ruptured.

If the fetus is alive, deliver by caesarean section.

If the fetus is dead and:

- the cervix is not fully dilated , deliver by caesarean section;
- the cervix is fully dilated:
- Deliver by craniotomy;
- If the operator is not proficient in craniotomy , deliver by caesarean section.
Do not deliver brow presentation by vacuum extraction, outlet forceps or
symphysiotomy.
FACE PRESENTATION
The chin serves as the reference point in describing the position of the head. It is
necessary to distinguish only chin-anterior positions in which the chin is anterior in relation to
the maternal pelvis (Fig 24 A) from chin-posterior positions (Fig 24 B).
Figure 24. Face presentation

Prolonged labour is common. Descent and delivery of the head by exion may occur in the
chin-anterior position. In the chin-posterior position, however, the fully extended head is
blocked by the sacrum. This prevents descent and labour is arrested.
CHIN-ANTERIOR POSITION

If the cervix is fully dilated:

- Allow to proceed with normal childbirth;
- If there is slow progress and no sign of obstruction (Table 10 ), augment labour with
oxytocin;
- If descent is unsatisfactory, deliver by forceps.

If the cervix is not fully dilated and there are no signs of

obstruction, augment labour with oxytocin. Review progress as with vertex presentation.
CHIN-POSTERIOR POSITION

If the cervix is fully dilated, deliver by caesarean section.

If the cervix is not fully dilated, monitor descent, rotation and progress. If
there are signs of obstruction, deliver by caesarean section.

If the fetus is dead:

- Deliver by craniotomy;
- If the operator is not proficient in craniotomy, deliver by caesarean section.
Do not perform vacuum extraction for face presentation.
COMPOUND PRESENTATION
Spontaneous delivery can occur only when the fetus is very small or dead and macerated.
Arrested labour occurs in the expulsive stage.

Replacement of the prolapsed arm is sometimes possible:

- Assist the woman to assume the knee-chest position (Fig 25);
- Push the arm above the pelvic brim and hold it there until a contraction pushes the head
into the pelvis.
- Proceed with management for normal childbirth.
Figure 25. Knee-chest position

If the procedure fails or if the cord prolapses, deliver by caesarean section.

BREECH PRESENTATION
Prolonged labour with breech presentation is an indication for urgent caesarean section.
Failure of labour to progress must be considered a sign of possible disproportion (Table S-10)
The frequency of breech presentation is high in preterm labour.
EARLY LABOUR
Ideally, every breech delivery should take place in a hospital with surgical capability.

Attempt external version if:

- breech presentation is present at or after 37 weeks (before 37 weeks, a successful
version is more likely to spontaneously revert back to breech presentation);
- vaginal delivery is possible;
- membranes are intact and amniotic fluid is adequate;
- there are no complications (e.g. fetal growth restriction, uterine bleeding, previous
caesarean delivery, fetal abnormalities, twin pregnancy, hypertension, fetal death).

If external version is successful, proceed with normal childbirth.

If external version fails, proceed with vaginal breech delivery (see below)
or caesarean section.
VAGINAL BREECH DELIVERY

A vaginal breech delivery by a skilled health care provider is safe and feasible
under the following conditions:
- complete (Fig S-20) or frank breech (Fig 21);
- adequate clinical pelvimetry;
- fetus is not too large;
- no previous caesarean section for cephalopelvic disproportion;
- flexed head.

Examine the woman regularly and record progress on a partograph.

If the membranes rupture, examine the woman immediately to exclude cord

prolapse.
Note: Do not rupture the membranes.

If the cord prolapses and delivery is not imminent, deliver by caesarean

section.

If there are fetal heart rate abnormalities (less than 100 or more than 180
beats per minute) or prolonged labour, deliver by caesarean section.
Note: Meconium is common with breech labour and is not a sign of fetal distress if the
fetal heart rate is normal.

The woman should not push until the cervix is fully dilated. Full dilatation
should be confirmed by vaginal examination.
CAESAREAN SECTION FOR BREECH PRESENTATION

A caesarean section is safer than vaginal breech delivery and recommended in

cases of:
- double footling breech;
- small or malformed pelvis;
- very large fetus;
- previous caesarean section for cephalopelvic disproportion;
- hyperextended or deflexed head.
Note: Elective caesarean section does not improve the outcome in preterm breech
delivery.
COMPLICATIONS
Fetal complications of breech presentation include:

cord prolapse;

birth trauma as a result of extended arm or head, incomplete dilatation of the

cervix or cephalopelvic disproportion;

asphyxia from cord prolapse, cord compression, placental detachment or

arrested head;

damage to abdominal organs;

broken neck.
TRANSVERSE LIE AND SHOULDER PRESENTATION

If the woman is in early labour and the membranes are intact, attempt
external version:
- If external version is successful, proceed with normal childbirth;
- If external version fails or is not advisable, deliver by caesarean section (page P-43).

Monitor for signs of cord prolapse. If the cord prolapses and delivery is not
imminent, deliver by caesarean section.
Note: Ruptured uterus may occur if the woman is left unattended .
In modern practice, persistent transverse lie in labour is delivered by caesarean
section whether the fetus is alive or dead.
T h e transverse lie is the condition when the long axis of the fetus is approximately
perpendicular to that of the uterus. When it forms an acute angle, an oblique lie results. An
oblique lie is usually only transitory, however, for either a longitudinal or transverse lie
commonly results when labor supervenes. For this reason, the oblique lie is termed unstable lie.

Oblique lie

Transverse lie

Persistent transverse lie

An unstable lie is one in which the presenting part alters from week to week. It may be
either a transverse or oblique lie or possibly a breech presentation. These are relatively
uncommon events but are found in association with the following conditions:
1. Grand multipara. This is by far the commonest factor, due to the lax uterine and
abdominal walls, which prevent the splinting effect found in women with lesser parity.
2. Polyhydramnios. The volume of uid distends the uterus and allows the fetus to swim like
a goldfish in a bowl often taking up an oblique or transverse lie.
3. Prematurity. Here there is a relative excess of uid to the fetus. If preterm labour occurs,
the fetus may be found to have a transverse lie.
4. Subseptate uterus. The septum prevents the fetus from turning in utero.
5. Pelvic tumors such as broids and ovarian cysts may not only prevent the lower pole
from engaging, but cause it to take up a transverse lie.
6. Placenta praevia. This usually prevents engagement of the presenting part. Because of
this it may present with the fetus in an oblique or transverse lie.

7. Multiple pregnancies may present with a transverse lie. If this does occur, it is more
common in the second twin.
Diagnosis of the transverse and oblique lies:
1.
The external inspection shows than the abdomen is unusually wide from side to side,
whereas the fundus of the uterus extends scarcely above the umbilicus.
2. On palpation, with the first maneuver no fetal pole is detected in the fundus.
3.
On the second maneuver, a ballottable head is found in one side of uterus and the
breech in other.
4.
The third and fourth maneuvers are negative unless labor is well advanced and the
shoulder has become impacted in the pelvis.
5.
When the fetal head is situated in the left side of the uterus the rst position of the
fetus is identied. When the fetal head is situated in the right side of the uterus the second
position is recognized.
6. On vaginal examination, in the early stages of labor, the side of the thorax, if it can be
reached, may be recognized above the pelvic inlet. When the dilatation is further advanced, the
scapula and the clavicle are distinguished on opposite sides of the thorax. Later in the labor,
the shoulder becomes tightly wedged in the pelvic canal, and a hand and arm frequently
prolapse into the vagina and through the vulva.
Management of transverse and oblique lie. It is not uncommon for the fetus to have a
transverse lie until about the 32nd week of pregnancy. If the transverse lie persists after this
time a cause should be determined. An ultrasound examination should be done to exclude
placenta praevia, ovarian tumor or broid and if either of these conditions are present an
elective cesarean section should be performed at 38-39 weeks of gestation. The ultrasound is
also used for identifying twins and a subseptate uterus, whilst a vaginal examination will
confirm a pelvic tumor.
The main risk of a transverse or oblique lie is in association with preterm rupture of the
membranes and cord prolapse. When diagnosed the state of the cervix should be checked. If
the cervix is dilated, the patient should be admitted to hospital. If, however, the cervix is closed
and the membranes are intact the patient may be reviewed on a regular basis. If no easily
identiable cause is found, attempted external cephalic version can be made after 34 weeks. In
grand multipara patients, the fetus will usually turn easily but will often swing back to an
abnormal lie. If the abnormal lie persists or constantly reoccurs, the woman should be admitted
to hospital by the 38th week. If external version is successful at this stage and the patient's
cervix is favorable then articial rupture of the membrane can be performed with the head held
over the pelvic brim and an oxytocin drip commenced to augment uterine activity. If the
cephalic presentation is maintained, labor may be allowed to continue.
Management of transverse or oblique in labor - cesarean section must be performed.
Complications of a transverse lie. If a mother goes into labor with a transverse or
oblique lie, several catastrophes may occur. Because this occurs more commonly in
multiparous women and their uterine activity is often much stronger, rupture of the uterus is
more likely. When the membranes rupture there is a greatly increased danger of cord prolapse,
prolapse of the arm- persistent transverse lie occur. If the fetus is alive cesarean section
immediately, if die fetal destroying operation.
DEFLEXED PRESENTATIONS

Fig. 8 Longitudinal lie. Cephalic presentation. Differences in attitude of fetal body in (A) vertex,
(B) sinciput, (C) brow, and (D) face presentations. Note changes in fetal attitude in relation to
fetal vertex as the fetal head becomes less flexed.
The deexed vertex presentation. The deexed vertex presentation is a I degree of
head extension.
Diagnosis. The diagnosis of the deexed vertex presentation bases on the results of the
vaginal palpation: the sagittal suture, the large and the small fontanels on the same level. The
fetal head presents with a fronto-occipital diameter, a leader point is the large fontanel.
The cardinal movements of labor in deflexed vertex presentation are:

deflexion;

internal rotation;

flexion;

extension;

internal rotation of the fetal body and external rotation of the fetal head.
1.
Deflexion. The sagittal suture is in the transverse or oblique size of the pelvic inlet.
The head fixes to the inlet and some deflexed. The large fontanel becomes the leader point.
2 .
Internal rotation. This movement is a manner that the occiput gradually moves
from its original position posteriorly towards the sacrum os. The rotation is complete when the
head reaches the pelvic floor; the sagittal suture is in the anteroposterior diameter.
3.
Flexion of the head. Flexion begins when the head xes by its root of the nose (the
rst xing point) to the inferior margin of symphysis pubis. The exion nishes when the
occiput comes to the tip of sacrum and the second fixing point forms.
4.
Extension of the head. After internal rotation and exion the fetal head closely
touched with the area of the occiput to the tip of the sacrum. The head extends and deliveries.
5.
Internal rotation of the fetal trunk and external rotation of the fetal head .
This moment realizes as in anterior occiput presentation.
The brow presentation is a II degree of extension.
With the brow presentation, that portion of the fetal head between the orbital ridge and
the frontal suture presents at the pelvic inlet. The fetal head thus occupies a position midway
between full exion (occiput) and full extension (mentum or face). Except when the fetal head
is very small or the pelvis is unusually large, engagement of the fetal head and subsequent
delivery cannot take place as long as the brow presentation persists.
Diagnosis. The diagnosis of the brow presentation bases on the results of the external
obstetrics examination and vaginal palpation. The brow presentation may be recognized by
abdominal palpation when both the occiput and chin can be easily palpated. The reliable
information can be felt by the vaginal examination: the frontal suture, the large fontanel, orbital

ridges, eyes, and root of the nose. The nose and mouth can not be palpable.
The fetal head presents with a mento-occipital diameter, a leader point is the middle of the
frontal suture.

Fig.9 Brow posterior presentation.

The delivery at term in brow presentation is impossible. The preterm delivery, when the
fetus is small is possible and the characteristically deforms of the head occurred. The caput
succedaneum is over the fore head and may be so extensive that identication of the brow by
palpation is impossible.
If the labor is possible the cardinal movements in brow presentation are:
1 .
Deflexion. The frontal suture is in the transverse size of the pelvic inlet. The head
fixes to the inlet and deflexed. The middle of the frontal suture becomes the leading point.
2.
Internal rotation.
3.
Flexion of the head.
4.
Extension of the head.
5.
Internal rotation of the fetal trunk and external rotation of the fetal head .
Face presentation.
In the face presentation, the head is hyperextended so that the occiput is in contact with
the fetal back and the chin (mentum) is presenting part.
Diagnosis. By abdominal palpation the occiput, the chin and the angle between the fetal
back and the occiput can be easily palpated. The fetal heart sound are the loudest from the
side of the fetal thorax. On vaginal palpation, the distinctive features of the face presentation
are the mouth, nose, the malar bones, and the orbital ridges.
Face presentation is rarely observed above the pelvic inlet. The brow generally presents
and is converted to a face presentation after further extension of the head during descent
through the pelvis.
The cardinal movements of labor in face posterior presentation are:
1.
Deflexion. The face linea is in the transverse size of the pelvic inlet. Descent is
brought about by the same factors as vertex presentation. The head presented its vertical
diameter. The chin is the leading point.
2 .
Internal rotation. The object of internal rotation of the face is to bring the chin

under the symphysis. Only in this way the neck subtend the posterior surface of the symphysis
pubis. If the chin rotates directly posteriorly, the birth of the head is impossible.
3.
Extension of the head. After the rotation and descent, the chin and mouth appear
at the vulva, the undersurface of the chin presses against the symphysis, and the head is
delivered by exion. The nose, eyes, brow and occiput then appeared in succession over the
anterior margin of the perineum.
4 .
Internal rotation of the fetal trunk and external rotation of the fetal head.
The shoulders are born as in vertex presentations.

Fig. 10 Biomechanism of labor in face posterior presentation

In the vast majority of deliveries near term the fetus presents by the head, with the best fit
into the lower pelvis in the occipito-anterior position. However, although the head is presenting,
it may be not in an occipito-anterior but in an occipito-posterior or transverse position. In a few
cases the head is grossly deflexed so that the brow or even the face can present.
In other instances, it is not the head that is at the lower pole of the uterus but the
buttocks, or breech (from the old English brecbreeches or buttocks). The fetus many even lie
transversely so that no pole is in relation to the pelvic inlet. A fetus in this position is
undeliverable vaginally; both transverse lies and breech presentations are much more common
if the woman enters labour in the earlier weeks of pregnancy (22-28 weeks of gestation).
All these
management.

malpresentations

and

malpositions

need

careful

diagnosis

and

skilful

Malpositions
Normal mechanism
Usually the fetal head engages in the left (less commonly, right) occipito-anterior position
and then undergoes a short rotation to be directly occipito-anterior in the mid-cavity.
Occipito-posterior position

This is the commonest malpresentation. The head engages in the left or right occipitotransverse position, and the occiput rotates posteriorly, rather than into the more favourable
occipito-anterior position. The reasons for the malrotation are often unclear. A at sacrum or a
head that is poorly exed may be responsible; alternatively, poor uterine contractions may not
push the head down into the pelvis strongly enough to produce correct rotation; epidural
analgesia might sometimes relax the pelvic oor to an extent that the fetal occiput sinks into it
rather than being pushed to rotate in an anterior direction. The diagnosis is determined
clinically by vaginal examination.
The best management is to await events, preparing the woman and sta for a long labour.
Progress should be monitored by abdominal and vaginal assessment, and the mothers
condition should be watched closely. Good pain relief with an epidural and adequate hydration
are required.
The mother may have an urge to push before full dilation, but the midwife should
discourage this. If the occiput comes directly into the posterior position (face to pubis) a vaginal
delivery is possible if the pelvic diameters are reasonable.

Figure If, instead of the normal curve, the sacrum is straightened (shaded area), the
anterior-posterior diameter in mid-cavity is reduced (A-A), thus hindering head rotation in this
zone

Occipito-transverse position
The head engages in the left or right occipito-transverse position, but then rotation to
occipito-anterior fails to occur and the head remains in the transverse position. If the second
stage is reached the head must be manually rotated, rotated with appropriate forceps (namely,
those with no pelvic curvefor example, Kiellands forceps), or delivered using vacuum
extraction.
Such vaginal deliveries must not be undertaken if there is any acidosis (fetal blood pH
<7.15) as cerebral haemorrhage may result. They are now often undertaken in the operating
theatre (trial of forceps) so that a rapid change to caesarean section can be made if there is
any diculty. Some obstetricians have abandoned these more dicult vaginal deliveries in
favour of caesarean section.

Figure Three methods of delivering a baby in occipito-transverse position in the second

stage of labour: (a) vacuum extraction with a linear pull, so allowing rotation to occur according
to the pelvic anatomy; (b)rotation and extraction with Kiellands ...

Face and brow positions

If there is a complete extension of the fetal head, the face will present for delivery. Labour
will be longer, but if the pelvis is adequate and the head rotates to a mentoanterior position, a
vaginal delivery can be expected. If the head rotates backwards to a mentoposterior position a
caesarean section is needed.
In a brow presentation the fetal head stays between full extension and full exion so that
the biggest diameter (the mento-vertex 13 cm) presents. This is usually only diagnosed once
labour is well established. Unless the head exes, a vaginal delivery is not possible, and a
caesarean section is required.

Figure Left: Abdominal features of a face presentation; the head is felt on the same side as
the back and is often not engaged. Right: Abdominal features of a brow presentationboth the
sinciput and the occiput are equally palpable on each side of the ...
Malpresentations
Breech
This is the commonest malpresentation. It is usually discovered before labour, although
one third are not diagnosed until during labour, when vaginal examinations allow a more

precise diagnosis to be made, especially as the cervix dilates and allows direct palpation of the
presenting part of the fetus. Current opinion holds that in late pregnancy, external cephalic
version should be oered, with the use of tocolytics in nulliparous women to relax the uterus.
This procedure is successful in 40% of nulliparous women, and 60% of multiparous women if
performed after 38 weeks. If breech presentation persists, preparations for delivery are made.
Delivery should be in a hospital with an experienced midwife and obstetrician actively involved.
An anaesthetist and paediatrician should be available.
All women with malpresentations and malpositions should be delivered in
hospital
Vaginal delivery of breech presentation
The mother should be in the lithotomy position (laterally tilted to avoid supine

hypotension)

The bladder should be emptied

An anaesthetist and a paediatrician should be present

An episiotomy is advisable

The breech, legs, and abdomen should be allowed to deliver spontaneously (the
legs can be assisted by flexing)

The shoulders can be encouraged to deliver by rotation of the trunk (Lvsetts

manoeuvre)

Delivery of the head should be controlled manually or with forceps

With a normal pelvis and the fetuss weight estimated by ultrasonography to be 25004000 g, assisted breech delivery in experienced hands is probably as safe as a caesarean
section. These days many women with a breech presentation choose to have a caesarean
section as they think this is the safest method of delivery. In the past doctors have led them to
believe this, but meta-analyses of randomised controlled trials do not substantiate this view. Of
those women who aim for a vaginal delivery, about half will succeed. Before 32 weeks,
caesarean section is commonly performed for a breech presentation, although the evidence of
its eectiveness even at this gestation is not strong; the operation can be technically dicult,
leading to maternal complications (see next article).
Breech delivery is an art that all those practising obstetrics need to learn, with supervision
by senior practitioners, because unexpected breech deliveries still occur.
Transverse lie
When the fetus is lying sideways with the head in one ank and the buttocks in the other,
it cannot be born vaginally. Unless it converts or is converted in late pregnancy, a caesarean
section is required. After opening the abdominal wall, the surgeon may be able through the wall
of the uterus to rotate the fetus so that it then becomes a longitudinal lie. If not, the uterine
incision must be so placed transversely to allow access to a fetal pole.
Nowadays internal podalic version is not often attempted in transverse lies; a
caesarean section is thought to be safer, although it can be a difficult operation

Figure Transverse lie with subseptate uterus and low lying placenta
Prolapsed umbilical cord
If the presenting part of the fetus does not t the pelvis after membrane rupture, the
umbilical cord can slip past and present at the cervix, or actually prolapse into the vagina. If
such an event is diagnosed in labour, the woman should be transferred straight to a hospital,
preferably in a steep lateral or knee chest position with a midwife holding up the presenting
part with ngers in the vagina, to stop it compressing the umbilical cord during contractions. A
caesarean section is needed urgently.
If the cord is found ahead of the presenting part before membrane rupture, the
membranes should be ruptured articially only if full preparations for an emergency caesarean
section have been made. The cord often slips to one side of the head and disappears when the
membranes rupture.

A prolapsed umbilical cord is common in breech deliveries. This happens when part of the
umbilical cord slips down through the cervix before the baby does. The cord is then compressed
during contractions, which cuts down on blood ow to the baby. An emergency cesarean
section is usually needed.

Figure Prolapsed cord into the vagina after membrane rupture with a high head
Shoulder dystocia
After delivery of the head the hardest part of delivery is usually over, but occasionally the
shoulders are slightly broader than usual, with a bisacromial diameter greater than 10 cm. The
shoulders usually adopt the antero-posterior axis to negotiate the outlet. If the shoulders are
still above the brim at this stage, no advance occurs. The babys chest is trapped within a
vaginal cuirass. Although the nose and mouth are outside, the chest cannot expand with
respiration. There is currently no way of predicting this problem reliably. The fth annual report
from the condential inquiry into stillbirths and deaths in infancy (1998) considers the problem
well.
Shoulder dystocia: best delivery method
Flex and abduct the mothers thighs as much as possible (the McRoberts
procedure) and then depress the babys head towards the mothers anus, with an assistant
applying suprapubic pressure

If this does not work, then manual rotation of the baby through 180 by vaginal and
abdominal pressure may succeed

Cleidotomy or symphysiotomy is the last resort and should be attempted only by an

experienced obstetrician

Multiple pregnancies
Multiple pregnancies are increasing in frequency in Britain, mainly as a result of infertility
treatment (both ovarian stimulation and in vitro fertilisation). Nearly all multiple pregnancies
are now diagnosed early by ultrasound examination. Some twins, however, die and are
absorbed in the rst half of pregnancy (the disappearing twin syndrome). When pregnant with
twins, most women go into labour early at about 37 weeks. The woman should be in labour in a
hospital with a special care baby unit. With no complicating factors, the mother can go into
spontaneous labour provided that the rst twin is lying longitudinally. It is wise to have an
intravenous line running. Labour usually proceeds rapidly; although each fetus is small, the
total content of the uterus is large. The fetal heart rates of each twin should be monitored
separately; some cardiotocographs allow this to be shown on a single chart. An anaesthetist
should be present at delivery, and an epidural makes delivery of the second twin easier if there
is a malpresentation (which occurs in 5-15% of cases). Paediatricians also should be present at
the second stage of labour.
Multiple births in United Kingdom, 1995

Type
of
No of multiple births (rate per
Ratio of multiple to
multiple birth
1000 maternities*)
singleton births
Twins

9 889 (13.6)

Triplets
Quadruplets
Total

318 (0.4)
10 (0.0001)
10 217 (14.0)

1:73
1:2282
1:72 563
1:71

Data supplied by Multiple Births Foundation.

*A maternity is any pregnancy that results in the birth of at least one live baby; the total
number of maternities in 1995 was 725 638.
Conclusions
Women with a fetus with an abnormal presentation or position should be
transferred to hospital for the best care

Problem cases should be anticipated

Emergencies during an apparently normal labour need the immediate attention of a

skilled obstetrician

Prepared protocols ensure that all members of the labour ward team know their
function and what should be done

After the rst twin is delivered, the cord should be clamped and the lie of the second twin
assessed carefully. This can be done clinically, but ultrasound scanning is more reliable. If the
lie is not longitudinal, it should be made so by an external cephalic or internal podalic version.
Unless uterine contractions return within 15 minutes, stimulation of the uterus with dilute
oxytocin should be started, with an aim of delivering the second twin 25-45 minutes after the
rst. If there is any diculty in delivery of the second twin, or if this twin develops a
bradycardia, a vacuum extraction (in a cephalic presentation) or a breech extraction, if the
fetus is lying the other way, can be performed. Internal podalic version and breech extraction is
usually easy in this situation. It is not necessary to resort automatically to a caesarean section.