ASSISTED BREECH

DELIVERY

Dr. Swati singh

Department of Obs. & Gyn.
UDUTH SOKOTO NIGERIA
 Outlin
e
• Introduction
• Incidence
• Types
• Aetiology
• Management of vaginal breech delivery
• Criteria for assisted breech delivery
• Principles of assisted breech delivery
• Steps in assisted breech delivery
• Complication
• Conclusion
Introduction
• The subject of breech presentation especially
the aspect of breech deliveries has always
evoked intense interest among obstetricians.
• The term breech was derived from the word
‘Britches’ which is a cloth used to cover the
loins and thighs.
• Breech presentation therefore occurs when
the fetal pelvis or lower extremities present in
the maternal pelvis.
• Breech delivery is a major issue in obstetric
practice because of the attendant high fetal
morbidity and mortality.
Incidence
• Breech is most common malpresentation
in pregnancy
• The incidence of breech varies with
gestational age
• It is 30%-40% at 20-25 weeks of
gestation
• 25% at 28-30 weeks
• 15% at 32 weeks
• 2% - 3% at term
• 2.6% in Ibadan by Fawale.et. al,2001
• 2.4% in Ile-Ife by Shittu et. al 2001.
• UDUTH it was 2.4% (Tunau K 2007 part 2
book).
Types
• Frank or extended breech: 65%
cases
• Complete or flexed or full breech:
10%
• Footling breech or incomplete
breech:
Aetiology
• Cause is unknown but any fetomaternal
condition which prevent the spontaneous
version will result in a breech presentation
• Fetal
– Prematurity – It is the commonest cause
– Multiple pregnancy
– Fetal abnormalities e.g. hydrocephalus,
anencephaly, neck masses & aneuploidy
Aetiology
• Maternal
– Multiparity
– Polyhydramnios or oligohydramnios
– Pelvic tumours
– Congenital uterine anomalies e.g.
bicornuate or septate uterus

• Placental
– Placenta praevia
– Cornual implantation of placenta
Management option of
breech delivery

• External cephalic version

• Elective CS
• Assisted breech delivery
Criteria for vaginal breech
delivery
• No feto-pelvic disproportion pelvis must
be adequate
• No maternal complicating factors like-
Heart ds. Severe pre-eclampsia, abruptio
and precious pregnancy
• Estimated fetal wt. < 3.5kg
• Favorable fetal attitude eg. Frank breech
• Availability of an experienced
obstetrician, An assistant,
Anaesthesiologist & paediatrician
Management of vaginal breech delivery
First stage
• Vaginal exam. is indicated
– At the onset of labour for pelvic
assessment
– Soon after rupture of membrane to
exclude cord prolapse
• An intravenous line should be
established
• Adequate analgesia
• Fetal status and progress of labour are
monitored
Management of 2nd stage
• There are 3 methods of vaginal
breech delivery
– Spontaneous
– Assisted breech delivery
– Breech extraction
Principles of assisted breech
delivery
• Don’t rush: aggressive and hasty pull may
cause entrapment of after coming head
through the incompletely dilated cervix
• Always keep the fetus with the back
anteriorly
• Delivery of after coming head (don’t
pull from below but suprapubic
pressure can be applied)
Steps in assisted breech delivery

• Patient is transferred to the delivery

couch when in 2nd stage.
• Antiseptic cleaning is done, bladder
is emptied.
• She is placed in lithotomy position
when the post. Buttock distend the
perineum
• Pudendal block and episiotomy is
given when climbing the perineum
Steps in assisted breech delivery

• Patient is encourage to
bear down with each
uterine contraction.
• The ‘no touch of the
fetus’ policy is adapted
until the buttock are
delivered along with the
legs in flexed breech &
the trunk slips up to the
umbilicus
Steps in assisted breech delivery
• When the trunk has been
delivered upto the level of
the umbilicus.
– The extended legs in frank
breech are to be delivered
by the pressure on the knees
(popliteal fossa) in the
manner of abduction and the
flexion of the thighs. Further
flexion can be obtained by
gradually reaching for the
ankle, grasped and eased
out the foot.
Steps in assisted breech delivery

• Umbilical cord is then freed to avoid tension

on it
• The baby is wrapped with a sterile towel to
prevent slipping when held by the
 Steps in assisted breech delivery
• Delivery of the arm
– A steady traction is applied
at the hips till the ant.
Scapula is visible, the
position of the arm should be
noted
– The Flexed arm delivered
one after the other by simply
hooking down elbow with a
finger across the face
 Delivery of the
arm
• Extended arm
– If the arms are
extended
adduction and
flexion of the
shoulder followed
by extension at
the elbow helps to
bring down the
forearm and hand.
– ‘Lovset maneuver’
 Delivery of the arm
• ‘Lovset maneuver’ is resorted to
where the posterior shoulder,
which is below the level of the
sacral promontory, is brought
anterior below the symphysis
pubis by rotating the fetus
clockwise by holding the baby
with the thumbs on the sacrum
and index fingers on the anterior
superior iliac spines. After
delivery of the shoulder which
has come anterior the fetus is
turned in the anticlockwise
direction to enable descent of the
opposite shoulder. The arm is
then delivered
Delivery of the after coming
head
• This is the most crucial stage of the
delivery
• The time between delivery of the
umbilicus to delivery of mouth should
preferably be 5 – 10 min.
• Various methods of delivery.
– Mauriceau-smellie-veit maneuvre
– Burn-Marshall method
– Forceps delivery
Mauriceau-Smellie-Viet
maneuver
• A Mauriceau-Smellie-Viet
maneuver follows. The fetus
is placed abdomen down on
the operator's right arm. The
left hand supports the fetal
neck. The index and middle
fingers of the right hand are
placed on the fetal maxilla to
help maintain flexion of the
head. The assistant may
apply suprapubic pressure to
deliver the after-coming head
Burn-Marshall method
• The procedure here is to gently sweep the
baby’s limbs and truck over the mother’s
abdomen
• By holding both legs and applying traction
downwards & upwards with the back of the
baby’s trunk & limbs sweeping an arc over
the mother’s abdomen, the fetal mouth and
nostrils are brought in view.
• These orifices are suctioned to clear airways
of fluid and the remaining part of the head is
delivered
 Forceps delivery
• Forceps may
be used to
facilitate
delivery of the
after-coming
head.
Maintenance
of head flexion
is crucial.
Traction is not
required.
•Use of forceps
may be helpful in
a nulligravida or
when the fetus is
small and at term
(less than 2500
g).
•The Piper
forceps and
Elliott forceps are
specially
designed for this
task. Because the
fetal head is
visible and
should be aligned
as in an occiput
Complication

• Maternal
– Increase frequency of operative
delivery including CS, the morbidity is
increased
– The risk of trauma to genital tract,
episiotomy, forceps, haemorrhage
and infection. causes maternal
morbidity and mortality
Complication
• Fetal
– Prematurity
– Dislocation of the jaw and the joint
– Birth asphyxia
• Cord compression and cord prolapse
• Prolong labour
• Entrapment of after coming head
– Intracranial hemorrhage
– Injury to the abdominal organ
– Fracture of the bones (humerus, clavicle, femur and neck)
– Nerve injuries ( cervical plexus, brachial plexus, spinal cord)
Conclusion

• Breech presentation at any

gestational age is associated with
a higher perinatal morbidity and
mortality than vertex presentation
irrespective of mode of delivery
• It is with a view to minimizing this
high perinatal morbidity and
mortality that the knowledge and
skill of assisted breech delivery
are highly desirable.