Breech Presentations

Types of Malpresentation
TRANSVERSE
In a transverse lie, a
fetus lies horizizontally
in the pelvis so that the
longest fetal axis is
perpendicular to that of
the mother.
The presenting part
is usually one of the
shoulders (acromion
process), an iliac crest,
a hand, or an elbow.
Management
If an infant is preterm and smaller
than usual, an attempt to turn the
fetus to a horizontal lie may be
made.
Most infants in transverse lie must
be born by cesarean birth, however,
because they cannot be turned and
cannot be born normally form this
wedged position.
SINCIPUT
The sinciput presentation
occurs when the larger
diameter of the fetal head
is presented. Labor
progress is slowed with
slower descent of the fetal
head.
FACE
The face presentation is
caused by hyper-extension
of the fetal head so that
neither the occiput nor the
sinciput is palpable on
vaginal examination.
Management
In the chin-anterior
position prolonged
labor is common.
Descent and delivery
of the head by flexion
may occur.
In the chin-posterior
position, however, the
fully extended head is
blocked by the sacrum.
This prevents descent
and labor is arrested.
Management
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,
augment labor with
oxytocin;
If descent is
unsatisfactory, deliver
by forceps.
If the cervix is not fully

dilated and there are
no signs of
obstruction:
augment labor with
oxytocin.
Chin-Posterior Position
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.
*Do not perform vacuum

extraction for face
presentation.
BROW
The brow
presentation is
caused by
partial
extension of the
fetal head so
that the occiput
is higher than
the sinciput.
MGT:
MGT If the fetus is alive or
dead, deliver by caesarean
section.
*Do not deliver brow
presentation by vacuum
extraction, outlet forceps
symphysiotomy.
or
Nursing Care of Clients with

Malpresentations
Observe closely for abnormal labor patterns.
Monitor fetal heart beat and contractions
continuously.
Anticipate forceps-assisted birth.
Anticipate cesarean birth for incomplete
breech or shoulder presentation.
Be prepared for childbirth emergencies such
as cesarean section, forceps-assisted
delivery, and neonatal-resuscitation.
Position pt. in Trendelenburg or knee-chest
position.
Manually raise the presenting part aseptically
Fetal Malpresentation
Pathophysiology
Anxiety
Provide client and family teaching,
Be available to client for listening and talking
Provide client support and encouragement.
Encourage client to acknowledge and express
feelings.
Encourage breathing exercises to relieve anxiety.
Fear
Provide client and family teaching,
Note for degree of incapacitation.
Stay with the client or make arrangements to have
someone else be there.
Provide opportunity for questions and answer honestly.
Explain procedures within level of clients ability to
understand and handle.
Risk for Injury

Observe closely for abnormal labor patterns.
Monitor fetal heart beat and contractions continuously
Be prepared for childbirth emergencies such as cesarean
section, forceps-assisted delivery, and neonatalresuscitation.
Maintain sterility of equipments
Anticipate forceps-assisted birth.
Anticipate cesarean birth for incomplete breech or
shoulder presentation.
Risk for infection

Stress proper hand washing techniques of all
caregivers.
Maintain sterile technique.
Cleanse incision site daily and prn.
Change dressings as needed.
Encourage early ambulation, deep breathing,
coughing, and position change.
Fetal Malposition
Refers to positions other than
an occipitoanterior position.
position
Malpositions include
occipitoposterior and
occipitotransverse positions of
fetal head in relation to
maternal pelvis.
It is usually seen in multipara
or those with lax abdominal
wall. Fetal malpositions are
assessed during labor.
Left Occipitoanterior
Rotation
(A) A fetus in cephalic presentation, LOA position. View

is from outlet. The fetus rotates 90 degrees from this
position. (B) Descent and flexion (C) Internal rotation
complete. (D) Extension; the face and chin are born
Types of Fetal Malposition

Occipitoposterior Position
Arrested labor may
occur when the head does
not rotate and/or descend.
Delivery may be
complicated by perineal
tears or extension of an
episiotomy.
Occipitotransverse
Position
It is the incomplete
rotation of OP to OA
results in the fetal head
being in a horizontal or
transverse position (OT).
Left Occipitoposterior
Rotation
(A) Fetus in cephalic

presentation LOP
position. View is
from outlet. The
fetus rotates 135
degrees from this
position. (B) Descent
and flewion. (C) In
ternal rotation
beginning. Because
of the posterior
position, the head
will rotate in a
longer arc than if it
were in an anterior
position. (D) Internal
rotation complete.
(E) Extension; the
face and the chin
are born. (F)
External rotation;
the fetus rotates to
place the shoulder in
an anteroposterior
position
Maternal risks:
prolonged labor
potential for
operative delivery
extension of
episiotomy,
3rd or 4th degree
laceration of the
perineum.
Maternal
symptoms:
Intense back pain in
labor
Dysfunctional labor
pattern
prolonged active phase
secondary arrest of
dilatation
arrest of descent
Diagnosis:
Abdominal examination the lower part of the abdomen is
flattened, fetal limbs are palpable anteriorly and the fetal
flank.
Vaginal examination the posterior fontanelle is toward the
sacrum and the anterior fontanelle may be easily felt if the
head is deflexed
Ultrasound
Nursing MGT
Encourage the mother to lie on her side from the
fetal back, which may help with rotation.
Pelvic rocking may
Knee chest position
help with rotation.
may facilitate rotation.
Apply sacral counter pressure with heel of hand to

relieve back pain.
Continue support and encouragement:
Keep client and family informed progress.
Praise clients efforts to maintain control.
Management
If there are signs of obstruction or the
fetal heart rate is abnormal at any
stage,
stage deliver by caesarean section.
If the membranes are intact,
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,
obstruction
augment labor with oxytocin.
If the cervix is fully dilated but there is
no descent in the expulsive phase,
phase
assess for signs of obstruction.
Management
dilated and if:
the leading bony edge
of the head is above
-2 station, perform
caesarean section;
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;
If the bony edge of the
fetal head is at 0 station,
deliver by vacuum
extraction or forceps.
Management
SYMPHYSIOTOMY
A surgical procedure in
which the cartilage of the
symphysis pubis is divided
to widen the pelvis
allowing childbirth when
there is a mechanical
problem.
Currently the
procedure is rarely
performed in developed
countries, but is still
routine in developing
countries where cesarean
section is not always an
option.
Management
Forceps - provides traction
or a means of rotating
the fetal head.
Risks: fetal ecchymosis or
edema of the face,
transient facial paralysis,
maternal lacerations, or
episiotomy extensions.
Vacuum extraction Provides traction to shorten

the second stage of
labor.
Risks: newborn
cephalhematoma, retinal
hemorrhage and
intracranial hemorrhage.
Nursing Diagnoses:
Impaired gas exchange
Encourage the mother to lie on her side from the fetal back,
which may help with rotation.
Knee chest position may facilitate rotation.
Pelvic rocking may help with rotation.
Monitor FHB appropriately
Be prepared for childbirth emergencies such as cesarean
section, forceps-assisted delivery, and neonatal-resuscitation.
Pain
Encourage relaxation with contractions.
Apply sacral counter pressure with heel of hand to relieve
back pain.
Provide comfortable environment.
Teach breathing exercises for use during early labor until client
receives pharmacologic relief.
Monitor physical response for example, palpitations/rapid pulse
Nursing Diagnoses:
Fatigue
Assess psychological and physical factors that may affect
reports of fatigue level
Monitor physical response for example, palpitations/rapid pulse
Monitor fetal heart beat and contractions continuously.
Refraining from intervening with client during contraction.
Anxiety
Keep client and family informed progress.
Provide support during labor through personal touch and
contact. These methods convey concern.
Continue support and encouragement.
Make the client feel she is somewhat in control of her situation.
Provide client and family teaching.
Identify clients perception of the threat presented by the
situation.
Fetal Malposition
Pathophysiology
SHOULDER DYSTOCIA
(Sh.D)
Shoulder dystocia
obstetricnightmare
Definition
Shoulder dystocia (Sh. D)
- is the inability to deliver the fetal shoulders after
delivery of the head, without the aid of specific
maneuvers (ie. other than gentle downward
traction on the head) .
Definition
Objective definition :
Mean head-to-body delivery

time > 60 seconds
PATHOPHYSIOLOGY
Shoulder dystocia results from
a size discrepancy between
the fetal shoulders and the
pelvic inlet when:
1.The bisacromial diameter is large
relative to the biparietal diameter
2.Pelvic prim is flat rather
than gynecoid
.
SHOULDER
DYSTOCIA
0.15-1.7%,
Risk
factor;macrosomia,diabetes,h
istory of SD,prolonged2th
stage of labor,maternal
obesity,multiparity,postterm.
50%SDnorisk factor
Sono
Complications of Sh D
1.Maternal
2.Fetal
Maternal Complications (25%)

1. Postpartum hemorrhage
11%
2. Vaginal laceration
19%
3. Perineal tears 2nd&3rd
4%
4. Cervical laceration
2%
Fetal Complications of Sh D
Brachial plexus injuries,
Fractures of the humerus, and
Fractures of the clavicle
are the most commonly reported
injuries associated with shoulder
dystocia
Traction combined with fundal
pressure
-has been associated with a high
rate of brachial plexus injuries
and fractures
Fewer than 10% of

deliveries complicated by
shoulder dystocia will result
in a persistent brachial
plexus injury.
Fetal Complications
Head shoulder interval >
7min.
Brain injury
(sensitivity & specificity :70 %)

With hypoxic fetus it is much
shorter
Can shoulder dystocia

be predicted
RISK FACTORS FOR SHOULDER

DYSTOCIA
Antenatal:
Excessive maternal weight gain
Macrosomia
G. diabetes
Short stature
Post term

DYSTOCIA
Intrapartum:
1. Protracted or arrested active phase
2. Protracted or failure of descent of
head
3. Need for midpelvic assisted delivery

DYSTOCIA
Most of the prenatal and antenatal risk factor

are interrelated with fetal macrosomia. So the
main risk factor is:
Fetal
Macrosomia
MANAGEMENT
(Within5- 7 minutes)
.
Management
1-Suprapubic pressure
2-McRobert manoeuver
3- Woods corkscrew .
4-Rubens manoeuver
5-Delivery of P. shoulder
6-Zavanelli
7-All fours
8-Cleidotomy
9-symphysiotomy
ACOG Issues Guidelines

Recommendation 1991
1-Call for help: assistants,
anesthesiologist
2-Initial gentle attempt of traction.
3-Generous episiotomy.
4-Suprapubic pressure.

Recommendation 1991
5-The Mc Roberts
manoeuvre
(Exaggerated hyper
flexion of the thighs
upon the abdomen.)
&
Suprapubic pressure
in the direction of the
Foetal face
McRoberts manoeuvre: X ray pelvimetry study
No increase in pelvic dimensions.

Decrease in the angle of pelvic inclination P=0.001
Straightening of the sacrum P= 0.04%
Tends to free the impacted anterior shoulder
Gherman et al Obstet Gynecol 95:43 ,2000
ACOG Issues Guidelines Recommendation 1991
If Mc Roberts failed:
6-Woods manoeuvre:
The hand is placed
behind the posterior
shoulder of the fetus.
The shoulder is
rotated progressively 180 d in a corkscrew manner so
that the impacted anterior shoulder is released. .

Recommendation 1991
7-Delivery of the
posterior arm :
.
By inserting a hand
into the posterior
vagina and ventrally
rotating the arm at
the shoulder
delivery
over the
perineum
BREECH BIRTH
Techniques
Olusile M. Vaginal Breech birth.

www.
cetl.org.uk/learning/breechbirth/breechbirth/data/downloads/breechbirth-print.pdf
Types of breech
Extended or frank breech-occurs in 60%-70% of breech births, least associated
with cord prolapse

www.
Flexed or complete breech

www.
Footling or incomplete Breech-one or both legs may be extended

www.
Delivery
Avoid pushing before full dilatation
Assess for and perform episiotomy if
required when anus stays in view
between contractions
Hands off until there is reason to assist
Position of choice: all fours
www.
Sacrum (bitrocanteric diameter 10 cms) enters the pelvic brim in the left
sacro-anterior position

www.
Descent of the presenting part with contractions and flexion

www.
Anterior buttocks reaches pelvic floor and rotates 1/8th of a circle into the
anterior posterior diameter

www.
Anterior buttock escapes under the symphysis pubis and posterior buttock
sweeps perineum

www.
Buttock are born. Restitution occurs to mothers right. Legs will usually be born
with further contractions. Babies with legs extended might require assistance.

www.
When popliteal fossae present at vulva flex knee by placing index finger in
popliteal fossa.

www.
Sweep leg outwards abducting hip slightly

www.
Repeat manoeuvres with second leg

www.
Second leg is born

www.
Hands off allow breech to deliver with contractions and maternal effort

www.
Shoulders (bisacromial diameter 11 cms) now enter the pelvis in the left
oblique diameter

www.
Anterior shoulder rotates 1/8 and escapes under synphysis pubis

www.
Posterior shoulder sweeps perineum. Arms will usually be born spontaneously

if flexed across chest.

www.
Looping of cord no longer advocated. Some advocate 15 min from delivery of

buttocks to delivery of head to prevent effects of cord compression.

www.
Where arms are extended Loveset manoeuvre will be performed to assist

the delivery

www.
Place hands around thighs with thumbs over buttocks pointing along spine

www.
Rotate through 180 degrees with back uppermost applying gentle traction

www.
Locate arm and sweep across face and down chest to deliver.

www.
Repeat manoeuvre to deliver second arm

www.
Locate arm and sweep across face and down chest to deliver

www.
Once arms delivered hands off

www.
Head enters pelvic brim in the oblique or transverse diameter

www.
Occiput rotates forward accompanied by simultaneous external rotation of

body to back uppermost

www.
Hands off, allow breech to deliver until nape of neck visible

www.
Deliver head using Mauriceau Smellie Viet Manoeuvre

www.
Drape baby over forearm placing 2 fingers on the malar eminencies

(cheekbones)

www.
Place index finger of other hand on occiput of baby to maintain flexion

www.
Apply gentle traction and deliver baby in a controlled manner maintaining

flexion of the fetal head at all times.

www.
Once delivery is complete:

www.
Baby can be put down so cord can be clamped and cut

www.
Baby can be handed to mother

www.
Royal Women's Hospital Clinical

Practice Guidelines (CPGst
Royal Women's Hospital Clinical Practice Guidelines

www.thewomens.org.au/BreechManagementofBreechPresentat
ion










Example of assisted breech

birth
Fischer R.Breech Presentation.

www.emedicine.com/med/topic3272.htm











Types of vaginal breech delivery:
1. Spontaneous breech delivery

2. Assisted breech delivery
3. Breech extraction
Mechanism
of delivery:
External Cephalic Version

In delivery room
NPO and ready for c/s
CTG & USS
Tocolytic
Head down position
Dislodge breech then
gently turn around
Uss and CTG after procedure.
Mode
of delivery:
1.
Vaginal:
Criteria:
a) Frank or complete breech presentation

b) Gestational age > 36 weeks
c) Estimated foetal weight b/n 2.5-3.5 kg
d) Foetal head must be flexed
e) Adequate maternal pelvis, x-ray or ct pelvimetry ???
f) No other obstetric complications, privacy/s, pet etc
g) Preferably epidural analgesia
UMBILICAL CORD
PROLAPSE
Umbilical Cord Prolapse

Etiology
1-275 deliveries
Classification
Complete: cord is seen or palpated ahead of
presenting part (OB Emergency)
Fundic: cord felt through intact membranes
ahead of presenting part
Occult: hidden or not visible at any time during
course of labor
Definition: umbilical cord that lies

below/beside presenting part

Precipitating
factors:
Long umbilical cord
Abnormal location
on placenta
Small or preterm
infant
Polyhydramnios
Multiple gestation
Precipitating
factors:
Amniotomy before
fetal head is
engaged
IUPC placement
External cephalic
version

Clinical Manifestations:
Cord observed or palpated
Bradycardia following ROM
Repetitive, variable decelerations that
do not respond to medical intervention
(e.g. amnioinfusion)
Prolonged decelerations (>15 bpm
lasting 2 mins or longer yet <10 mins)

Nursing interventions:
Assess fetal viability
Call for assistance
Relieve pressure from cord (usually presenting part)
Continuous manual relief of pressure from presenting part
Avoid excessive manipulation of cord
Re-position client: Trendelenburg, modified Sims, or kneechest
Prepare for emergency delivery
Administer oxygen by mask 10-12 L/min
Fill maternal bladder with 500-700 cc NS
Continuous fetal monitoring
Possible neonatal resuscitation (notify neonatal team per
hospital protocol)

Aim of Medical management:
Immediate delivery of viable infant
Hallmark treatment: C-section

Breech Presentations

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Types of Malpresentation

If the cervix is not fully

If the cervix is not fully

*Do not perform vacuum

Nursing Care of Clients with

Risk for Injury

Risk for infection

(A) A fetus in cephalic presentation, LOA position. View

Types of Fetal Malposition

(A) Fetus in cephalic

Apply sacral counter pressure with heel of hand to

If the operator is not

Vacuum extraction Provides traction to shorten

Mean head-to-body delivery

Maternal Complications (25%)

3. Perineal tears 2nd&3rd

Fewer than 10% of

(sensitivity & specificity :70 %)

Can shoulder dystocia

RISK FACTORS FOR SHOULDER

RISK FACTORS FOR SHOULDER

RISK FACTORS FOR SHOULDER

Most of the prenatal and antenatal risk factor

ACOG Issues Guidelines

ACOG Issues Guidelines

McRoberts manoeuvre: X ray pelvimetry study

No increase in pelvic dimensions.

ACOG Issues Guidelines Recommendation 1991

ACOG Issues Guidelines

Olusile M. Vaginal Breech birth.

Olusile M. Vaginal Breech birth.

Flexed or complete breech

Olusile M. Vaginal Breech birth.

Footling or incomplete Breech-one or both legs may be extended

Olusile M. Vaginal Breech birth.

Olusile M. Vaginal Breech birth.

Descent of the presenting part with contractions and flexion

Olusile M. Vaginal Breech birth.

Olusile M. Vaginal Breech birth.

Olusile M. Vaginal Breech birth.

Olusile M. Vaginal Breech birth.

Olusile M. Vaginal Breech birth.

Sweep leg outwards abducting hip slightly

Olusile M. Vaginal Breech birth.

Repeat manoeuvres with second leg

Olusile M. Vaginal Breech birth.

Second leg is born

Olusile M. Vaginal Breech birth.

Olusile M. Vaginal Breech birth.

Olusile M. Vaginal Breech birth.

Anterior shoulder rotates 1/8 and escapes under synphysis pubis

Olusile M. Vaginal Breech birth.

Posterior shoulder sweeps perineum. Arms will usually be born spontaneously

Olusile M. Vaginal Breech birth.

Looping of cord no longer advocated. Some advocate 15 min from delivery of

Olusile M. Vaginal Breech birth.

Where arms are extended Loveset manoeuvre will be performed to assist

Olusile M. Vaginal Breech birth.

Olusile M. Vaginal Breech birth.

Olusile M. Vaginal Breech birth.

Olusile M. Vaginal Breech birth.

Repeat manoeuvre to deliver second arm

Olusile M. Vaginal Breech birth.

Olusile M. Vaginal Breech birth.