Prof. Abdulhafid Abudher
MBBch,DGO,MD,FABOG,FRCOG
Definetion
 This is a malpresentation where the podalic pole
presents at the pelvic inlet.
 The lie is longitudinal
 The denominator is sacrum
Various positions
 Anterior
 RSA-right sacroanterior (common)
 SA-sacroanterior
 LSA-left sacroanterior
 Posterior
 RSP-right sacroposterior
 SP- Sacroposterior
 LSP-left sacroposterior
Incidence
 At term
 29-32 weeks
 Accounts for
2.2% to3.7%
up to 25%
4.8% of all births in USA (Haugley 1985)
Types of Breech (Seed and Cafalo 1982)
 Complete 5-12%
 Frank
48-73%
 Incomplet 10-30%
 Footling
 Kneeling
Etiology
 Predisposing Factors
 Abnormal uterine shape
 Excessive fetal mobility
 Interference in fetopelvic relationship
1-Maternal factors
2-Placental,Liquor and cord factors
3-Fetal Factors
Maternal Factors
 Cephalopelvic disproportion at the pelvic inlet
 Soft tissue dystocia
 Congenital uterine anomalies
 Grand multipara
 Anticonvulsants and maternal alcohol intake (Robertson
1984)
Placental,Liqure,Cord Factors
 Placenta previa
 Cornufundal implantation of placenta(fainu and
vaclavinkova 1978)
 Polyhydramnios
 Oligohydramios
 Very long or very short cord
Fetal Factors
 Multiple gestation
 Congenital anomalies
 Prematurity
 Large baby
 Postdate
 Intra uterine fetal death
 Fetal aneuploidy (Zhang and Schingle 1993)
Diagnoses of Breech
 Abdominal examination
 Fetal heart sounds
 Vaginal examination
 Ultrasound examination
Mechanism of labour
 Delivery of lower limbs and buttocks
 Delivery of shoulders and arms
 Delivery of aftercoming head
Delivery of lower limbs and
buttocks
 Engagement
 Descent
 Flexion
 Internal rotation
 Birth of Buttocks
Delivery of shoulders and arms
 Engagement
 Descent continuous
 Internal rotation
 Birth of shoulders
 Restitution
Birth of after coming head
 Engagement
 Descent
 Flexion
 Internal rotation
 Birth of the head
Mechanism of labour in other
positions
 Sacroanterior position
 Sacroposterior position
 Moulding
Investigations
 Routine antenatal investigations
 US
 Anomalies
 Head extension
 Maturity
 Site and grade of placenta
 Adequacy of liquor
 Multiple gestation
 Confirming fetal presentation
Investigations
 X-ray abdomen (history)
 Skeletal anomalies
 Maturity
 Pelvimetry
 Multiple gestation
Management during pregnancy
 External cephalic version
 Trial of labour
 Caesarean delivery
Vaginal breech delivery
 Spontaneous
 Assisted
 Total breech extraction
Indications for trial of labour
 Frank breech
 Gestational age 36 to 42 weeks
 Estimated fetal weight 1500 to 3900 grm
 Flexed fetal BPD less than 9.5
 Adequate maternal pelvis
Breech Vaginal Delivery
 First Stage
 Second stage
 Episiotomy
 Assisted

Lovset’s maneuver
 Aftercoming head






Kristellar’s maneuver
Bracht’s maneuver
Wigand-Martin maneuver
Mauriceau-Smellie-Veit maneuver
Forceps delivery (Savage’s maneuver)
Occipto-posterior position


Rotating face posterior
Prague maneuver
Total breech extraction
 Rapid delivery -FD
 Pre-requisites:
 No fetopelvic disproportion
 Fully dilated cervix
 Empty balder and rectum
 Anesthesia
 Good assistance
Hyper extension of the head
 Etiology
 Spasm or congenital shortening of the extensors
muscles of neck
 Umbilical cord looped around the neck
 Congenital tumors of the neck ,teratoma or cystic
hygroma
 Uterine anomalies
 Placental tumors
Hyper extension of the head
 Diagnosis
 X-ray (star gazing foetus)
 Ultrasound (measurement of the craniospinal angle)
• Risk of spinal cord damage



Excessive longitudinal stretching
Extreme flexion of neck during delivery
Marked tortion
Indications for elective C/S






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


Contracted, border line or abnormal pelvis
Placenta previa
Large baby
Hyperextension of head
Footling breech
Premature baby
Previous caesarean section
Elderly primgavida , BOH ,primary infertility
IUGR
BPD more than 9.5 cm
Prognosis for breech presentation
 Maternal
 Genital laceration
 Bleeding
 Fetal
 Injury to the brain and skull



Intracranial hemorrhage
Fracture of skull bones
Brain dysfunction
 Prematurity
 Congenital anomalies




Congenital dislocation of hip
Hydrocephaly
Anencaphaly
meningomyelocele
Prognosis for breech presentation
 Birth asphyxia may occur due to:
 Prolonged compression of cord
 Cord prolapse
 Aspiration of liquor and vaginal secretions
 Prolonged labor
 Fetal injuries
 Fracture of neck,humerus,clavical,femur
 Cervical and brachial plexus palsies
 Hepatic rupture
 Splenic laceration
 Adrenal gland rupture
 Pharyngeal injury