BREECH for

the STARS

TYPES OF BREECH
PRESENTATION
Frank (65%): Hips are flexed,
knees are extended
Complete (10%): The hips and
knees are flexed
Incomplete (25%): The feet or
knees are the lowermost
presenting part:
Single footling: one of the
lower extremities is
lowermost.
Double footling: Both of the
lower extremities are
lowermost

Breech presentations:
A: Right sacrum posterior (RSP) position
B: Left sacrum anterior (LSA) position

BREECH PRESENTATION
PREDISPOSING FACTORS
Prematurity
Uterine abnormalities
Malformation
Fibroids

Fetal abnormalities
CNS Malformations
Neck Masses

Multiple gestations
Previous breech delivery

BREECH PRESENTATION

Gestational age in weeks

% Breech

21-24

33

25-28

28

29-32

14

33-36

37-40

BREECH PRESENTATION
DIAGNOSIS
Palpation and ballottement
Ultrasound
Pelvic examination
X-Ray studies

BREECH PRESENTATION
Leopold Maneuver

EXTERNAL CEPHALIC VERSION

MANAGEMENT

MANAGEMENT
TYPE OF DELIVERY
Vaginal delivery:
Spontaneous
Partial breech extraction
Total breech extraction
Cesarean delivery

TYPES OF VAGINAL BREECH DELIVERY

Spontaneous breech (rare): No manipulation of the
infant is necessary, other than supporting the infant
Partial breech extraction: Fetus descend
spontaneously to where umbilicus is at the vaginal
introitus; then, the fetus is extracted completely
Total breech extraction: The entire body is extracted.
This is indicated only if there is evidence of fetal
distress unresponsive to routine maneuvers and a
cesarean delivery is not possible.

CONDITIONS ARE UNFAVORABLE FOR

BREECH DELIVERY
Fetus weight > 3500 g
Unfavorable pelvis Breech delivery does not allow
sufficient time for molding of the fetal head; thus, a
platypelloid or android pelvis decreases ability fetal
head to navigate maternal pelvis
Hyperextension of the head increases risk of cervical
spine injury
Footlings- incidence of umbilical cord prolapse
increases with coiling of the umbilical cord around the
legs of the fetus

MORTALITY/MORBIDITY
Increased birth trauma: As duration of umbilical cord
compression increases deliver the infant more
rapidly increasing birth trauma
Decreased birth weight may result from preterm
delivery/growth restriction
Incidence of prolapsed umbilical cord depends on type
of breech presentation : Footling 17%, Complete 5%,
Frank 0,5%

MECHANISM OF LABOR IN BREECH

DELIVERY

ASSISTED DELIVERY OF FRANK

BREECH

ASSISTED DELIVERY OF FRANK

BREECH

ASSISTED DELIVERY OF FRANK

BREECH

ASSISTED DELIVERY OF FRANK

BREECH

Maneuver for delivery of the

head:
The fingers of the left hand
are inserted into the infants
mouth of over mandible;
The right hand exerts
pressure on the head from
above

MAURICEAU MANEUVER

MECHANISM OF LABOR IN BREECH

DELIVERY

Piper forceps

Modified Prague maneuver

DELIVERY OF THE AFTERCOMING HEAD

Application of Piper forceps, employing towel sling support.

The forceps are introduced from below, left blade first.
Aiming directly and intended positions on sides of the head

DELIVERY OF THE AFTERCOMING HEAD

MODIFIED PRAGUE MANEUVER

COMPLETE OR INCOMPLETE BREECH

EXTRACTION

COMPLETE OR INCOMPLETE BREECH

EXTRACTION

BREECH EXTRACTION

C-SECTION INDICATION
A large fetus ( > 3.500 grams)
A hyperextended fetus
Uterine dysfunction
Footling presentation
Any degree of contraction or unfavorable shape
restriction
Previous perinatal death or children suffering from
birth trauma

COMPLICATIONS
1. Perinatal morbidity and mortality from difficult delivery
2. Low birthweight from preterm delivery, growth
restriction, or bot
3. Prolapsed cord
4. Placenta praevia
5. Fetal, neonatal, and infant anomalies
6. Uterine anomalies and tumors
7. Multiple fetuses
8. Operative intervention, especially cesarean delivery

TRANSVERSE OR OBLIQUE
PRESENTATION
1. DEFINITION

At the end of pregnancy or during of labor,

champ of pelvic inlet is not fetal head or fetal
breech
2. VARIETY
- shoulder right in dorso-anterior
- shoulder left in dorso-anterior
- shoulder right in dorso-posterior
- shoulder left in dorso-posterior

TRANSVERSE OR OBLIQUE
PRESENTATION
3. ETIOLOGY
Mistake of accommodation: the grand cause of
transverse position is multipara (relax of uterine wall)
Other cause can hydramnios, previa tumor, shortness
umbilical cord
Uterine malformation

TRANSVERSE OR OBLIQUE
PRESENTATION
4. CLINICAL
Inspection
The uterus is developing transverse or oblique
Palpation
Hands explored base part of uterus on of pelvic
inlet can not contact fetal pole
At middle of uterus fundus have no fetal pole

TRANSVERSE OR OBLIQUE
PRESENTATION
At lateral face of uterus (right or left) can contact with
fetal pole or breech
Multipara are rare on same plan of transverse
Uterus malformation, the two poles can contact at
same higher at uterine body (back in anterior)
In dorso-posterior, abdominal wall perception fetal
limps

TRANSVERSE OR OBLIQUE
PRESENTATION

TRANSVERSE OR OBLIQUE
PRESENTATION
Auscultation:
the fetal cardiac sound can receive a bite under
umbilical at cephalic side
Digital exam:
during pregnancy: the excavation is empty
(fingers are not contact the presentation)

TRANSVERSE OR OBLIQUE
PRESENTATION
During labor: if membranes are not rupture, the sac
amniotic fluid is big volume (can not evaluation the
presentation)
After rupture of membranes, the fingers are
perception:
. Shoulder and acromial protrusion
. Axillary furrow

TRANSVERSE OR OBLIQUE
PRESENTATION
At profound permit contact:
. Costal
. Scapula
In some cases, superior limp fall down in excavation,
vaginal, vulva with character cyanosis and edema
The thumb turn to thigh of mother same name with of
shoulder that present

TRANSVERSE OR OBLIQUE
PRESENTATION
Diagnostic of variety: must to know head, breech,
back, shoulder (right or left) situate at pelvic inlet
When the hand is out side of vulva, sign of thumb
confirm the diagnosi
X-ray: necessary in all cases, it confirme diagnostic
Ultrasound: same of x-ray and position of placenta

TRANSVERSE OR OBLIQUE
PRESENTATION
5. DELIVERY
A. Ovular phenomenon:
The precocity of membranes rupture is favorable by
character of amniotic fluid sac (big volume in cervical
canal)
Uterus is empty of amniotic fluid and cord prolapses

TRANSVERSE OR OBLIQUE
PRESENTATION

TRANSVERSE OR OBLIQUE
PRESENTATION
B. Mechanic phenomenon:
First time: weakness, head orient opposite trunk
(vertical). The shoulder is in center of basin.
Superficial exam, the presentation return
longitudinal
Second time: engage of shoulder
Third time: stop of progression (enclave).

TRANSVERSE OR OBLIQUE
PRESENTATION
C. Plastic phenomenon:
is at region of shoulder, neck, back
D. Physiologic phenomenon:
the dilatation of cervix is trouble: cause of dynamic
abnormal and ovular infection
The cervix is edema, thick
Lower segment still thick not contact with
presentation

TRANSVERSE OR OBLIQUE
PRESENTATION
The uterine contraction is the trouble: the contraction
is normal until rupture of membrane but the
progression of presentation is stopped
First irregular, then inertia or hypertonia with
hypercinesis
The consequence of retraction is:
Death of the fetus: the retraction provoke
diminution of blood fluid trans placenta and
infection

TRANSVERSE OR OBLIQUE
PRESENTATION

Uterine rupture:
the retraction of the myometrium of uterine body
provoke lower segment stretch (lower segment
rupture)

TRANSVERSE OR OBLIQUE
PRESENTATION
6. TREATMENT:
A. During of pregnancy:
- the surveillance of presentation is every days
- it can external version for cephalic presentation or
breech presentation at pelvic inlet (multipara)
- primipara: cesarean section at the end of
pregnancy

TRANSVERSE OR OBLIQUE
PRESENTATION

TRANSVERSE OR OBLIQUE
PRESENTATION

TRANSVERSE OR OBLIQUE
PRESENTATION
B. During of labor:
Primipara:
cesarean section
Multipara:
The membrane is intact:
Complete dilatation of cervix: artificial rupture of
membrane and internal version
Dilatation is incomplete: conservation of
membrane until complete dilatation

TRANSVERSE OR OBLIQUE
PRESENTATION
The membranes are ruptured:
Uterus is soft (not retracted) & fetus is alive:
cesarean section if incomplete dilatation
internal version if complete dilatation
Uterus is retracted:
Fetus is alive: cesarean section
Fetus is dead: embryotomy

TRANSVERSE OR OBLIQUE
PRESENTATION
Uterus is ruptured:
after laparotomy and extraction of fetal mort and
placenta, the operation must suture of rupture or
hysterectomy