HNS220_:LABOUR

LECTURER:MS CAROLINE NYARIKI

GROUP2:BREECH PRESENTATION

FIDELIS MANYARA –HSN211-0026/2021

SIMON NDERITU-HSN211-0086/2021

JOB KINANGA-HSN211-0014/2021

ELIZABETH MUTHEU-HSN211-0023/2021

DAISY ANYANGO-HSN211-0076/2021

JOHN WAEMA-HSN211-0089/2020
BREECH PRESENTATION

 A breech presentation occurs when the fetal buttocks lie lowermost in the
maternal uterus and the fetal head occupies the fundus. The lie is
longitudinal, the denominator is the sacrum and the presenting diameter is
the bitrochanteric, which measures 10 cm. It is common before 37 weeks’
gestation.
Types of breech presentation

 Flexed or complete breech: the fetus sits with the thighs and knees flexed
with the feet close to the buttocks.
 • Extended or frank breech: the fetal thighs are flexed, the legs are
extended at the knees and lie alongside the trunk, with the feet near the
fetal head. This is the commonest type of breech presentation.
 • Footling presentation: one or both feet present below the fetal buttocks,
with hips and knees extended.
 • Knee presentation: one or both knees present below the fetal buttocks,
with one or both hips extended and the knees flexed.
Causes

 The most common cause is likely to be a ‘benign error of

orientation’. Other causes include:
 abnormal size and shape of the pelvis
 uterine causes
 abnormal liquor volume
 multiple pregnancy
 maternal conditions or fetal abnormalities resulting in poor
postural tone
 congenital anomalies
 Diagnosis during pregnancy
 Health history--A history of a previous breech presentation may be significant, and if the breech persists, then
referral to an obstetrician should be made and the likely cause identified.
 History of discomfort under the ribs due to the presence of the hard fetal head or describe fetal movements in the
lower pole of the uterus.
 Physical examinations with emphasis on Abdomen
 Inspection - fetal movements can be seen in the lower pole.
 Palpation- presenting part feels firm but less hard and less rounded than the head.
 breech presentations can be missed.
 A primigravida with an extended breech may simulate a cephalic presentation.
 Fetal heart sounds are heard halfway between the superior anterior iliac spine and the maternal umbilicus.
 Vaginal examination Vaginal examination may be carried out by the midwife or obstetrician to exclude a deeply
engaged head and confirm breech presentation. If the head is deeply engaged, the shoulders palpate just above
the pelvic brim and are sometimes difficult to distinguish from the breech. On vaginal examination, an extended
breech has a hard, compressed presenting part similar to a cephalic presentation, and the cleft of the buttocks
may imitate the line of the sagittal suture.
 Ultrasound helpful in:
 • confirming presentation
 • identification of fetal attitude
 • fetal weight and liquor volume estimation
 Diagnosis during labor
 In labor the presenting part may initially be high. On vaginal examination the breech feels soft and irregular and no
sutures or fontanelles are palpable. The hard sacrum and the anus should be felt and it is important to distinguish the
breech from a face presentation.
 The midwife will note that in a breech presentation the landmarks of the fetal ischial tuberosities are on either side of
the fetal anus and form a straight line. This differs from a face presentation, in which the fetal mouth and malar
prominences form a triangle.
 Fresh, ‘toothpaste like’, thick meconium may be found on the examining finger and is diagnostic of a breech
presentation. The fetal genitalia are soft and not easily recognized because they become edematous. A flexed breech,
the feet may be palpable alongside the buttocks, but these usually fall back behind the presenting part as labor
advances.
 vaginal examination
 features of the foot that distinguish it from a hand are:
 shorter digits, larger size but limited range of movements of the big toe, and the presence of a heel.
 ASSOCIATED RISKS
 complicated vagina delivery or caesarean section
 childhood handicap -a trial of labor and following an elective caesarean section.
 Poor outcomes following vaginal breech delivery, therefore, might result from some underlying condition causing
breech presentation rather than damage during delivery
 long-term neonatal morbidity between babies born by vaginal birth
 and those born by caesarean section
 Care and Management during pregnancy

 After confirmed diagnosis of breech presentation the woman must be informed to choose
her options of care. The mother's choice should be documented in her maternity record. The
options includes;
>Planned ECV
>Spontaneous or assisted vaginal breech birth
> Planned caesarian section
Spontaneous ECV
 Effectiveness has not been confirmed.
 This is done by continuous postural management so as to convert breech to cephalic
presentation.
External cephalic version.
 Is safe and effective in reducing breech presentation at birth. Tocolytics is associated with
fewer failures of ECV.
 Management during labour
First stage
 Often proceeds normally as cephalic presentation if breech is engaged in the pelvis
 Augmentation of labour is not recommended although can be given if the uterine
action is hypotonic.
 Assess and monitor the risk of early rupture of membranes and cord prolapse Incase
the breech is not engaged. Perform VE to rule out prolapse.
 Encourage upright position and ambulation in a woman labouring with breech
presentation.
 Continuous monitoring of fetal heart rate ,fetal and maternal well-being.
 Monitor and be ready to prevent the premature urge to push that occurs when the
breech descends through the cervix before the os are fully dilated. This can be
delayed by use of epidural anesthesia.
 Obstetric management of the second stage
 Full dilatation is confirmed by vaginal examination prior to allowing the woman to push.
Await the descent of the presenting part which should be visible at the perineum before
active pushing begins.
 Inform the obstetrician, anesthetist and pediatrician of the impending birth.
 In multigravida or a small preterm fetus, the delivery may be spontaneous with minimal
intervention.
 The lithotomy position may be adopted and sterile field prepared with drapes.
 Catheterization may be carried out to prevent delay and maximize the pelvic space.
 Preparation and equipment for a forceps delivery should be to hand but intervention should
only be when strictly necessary. Allow spontaneous descent and birth.
 Infiltrate with local anesthetic if needed when the buttocks distends the perineum.
 An episiotomy should only be performed if necessary to facilitate the birth.
 The buttocks should be born spontaneously.
 The baby then descends up to the umbilicus without intervention if the legs are flexed they
will deliver quite easily.
 If the cord is under tension, ease a loop down to avoid unnecessary traction
 With the next contraction, the shoulder blades appear, if the arms are flexed they will deliver
easily.
 The shoulders rotate into the antero-posterior diameter of the outlet ,the body can be tilted
towards the mother’s sacrum to facilitate delivery of the anterior shoulder. The posterior
shoulder sweeps the perineum and is aided by lifting the buttocks towards the mother’s
abdomen
 It is important that the baby is held only around the pelvic girdle and handled as little as
possible, to avoid trauma to internal structures.
 The head enters the pelvis in the transverse diameter, therefore the back is in a lateral
position until restitution and internal rotation takes place.
 When the back has turned uppermost allow the body to hang by its own weight, this
encourages flexion of the head and rotation into the anteroposterior diameter of the outlet
when it meets the resistance of the pelvic floor.
 When the nape of the neck becomes visible, deliver the head. It is essential that the head is
delivered in a controlled manner. Many obstetricians apply forceps, otherwise it the
following techniques may be used.
Assisted breech delivery
 The woman’s urinary bladder is emptied and she is placed in a lithotomy position.
 Local anaesthesia is administered when the posterior buttock distends the
perineum and an episiotomy is performed.
 During descent, the shoulders rotate anteriorly And enter the maternal pelvis in a
transverse or oblique diameter of the inlet.
 Traction is not recommended. Avoid unnecessary manipulations.(hand of the
breech rule)
 After full delivery of the buttocks, rapid Foetal delivery is recommended to
prevent progressive acidosis.
 If the fetal legs do not deliver spontaneously, insert the index finger behind the
thigh to flex the knee and abduct the leg to gently disengage them.
 The arms usually sleep out on their own and the shoulder is born on the
anteroposterior diameter of the pelvis.
 At this stage, the head is entering the transverse or oblique diameter of the pelvic
inlet.
Delivery of the head
 The head should be delivered within 5min after the delivery
of the body.
 Spontaneous delivery can occur if the head is at the pelvis
outlet. The woman changes position from a Christian prayer
position to a Muslim prayer position. This aids release of the
head facilitating its delivery.
 Alternatively, two manoeuvres can be used:
> Mauriceau–Smellie–Veit manoeuvre
>Burns–Marshall manoeuvre
Mauriceau–Smellie–Veit manoeuvre
 The baby is supported with the legs straddling the midwives left arm
 Slide 3 fingers into the vagina and feel the baby's malar bones(cheek
bones)
 Rest the index and ring finger on the cheekbones while the middle finger
applies pressure to the chin.
 The index and ring fingers of the practitioner’s right hand are hooked over
the baby’s shoulders, to apply traction, while the middle finger presses on
the occiput to aid flexion.
 An assistant may apply suprapubic pressure if needed.
 The baby's head is flexed gently and aided to the outlet. The trunk is
raised to bring the mouth into view
 Air passage is cleared and the head delivery completes the usual way.
Burns–Marshall manoeuvre
 The baby is allowed to hang for a few moments to facilitate descent and
flexion of the head.
 When the hairline comes into view, the head is ready to be delivered.
 Grasp the baby by the ankles and direct the baby's trunk upwards in a wide
angle over the woman's abdomen.
 Depress the perineum with the fingers to expose the mouth of the fetus
allowing it to be cleared of blood or mucus to enable the baby to breathe
easily.
 Proceed with the birth of the head slowly to prevent intracranial haemorrhage
due to sudden release of pressure.
 A Wrigley's forceps can be used to control the speed of which the head is born.
COMPLICATIONS OF VAGINAL BREECH PRESENTATION

1.Extended Arms
 Occurs when the baby’s arms are not flexed across the chest, hence stretched up alongside the head.
 It is not possible for the head and arms to enter the pelvis together. Arms must come first and then the
head.
 Best achieved by Lovset's manoeuvres.
 With the baby in a right sacrolateral position, the manoeuvre depends on the fact that the posterior
shoulder is below the sacral promontory and anterior shoulder above the symphysis pubis.
 The practitioner grasps the baby’s thighs with thumbs over the sacrum, and, being careful to avoid
pressure above the pelvic girdle, which could cause abdominal injury, pulls the baby gently downwards,
at the same time turning him, back upwards, through a half circle (180 degrees).
 The former posterior shoulder now becomes anterior and is released under the symphysis pubis, while
at the same time; the other shoulder is brought into the pelvic cavity.
 The baby is then turned back through a half circle in the opposite direction and the other arm is
released in the same way.
 This procedure does not require an anaesthetic.
2. Extended head
.

 After the birth or the shoulders, the baby is allowed to hang from the vagina to facilitate descent and
flexion of the head.
 If the neck and hairline are not visible within few seconds, the most likely reason is extension of the head
 Use Mauriceau-Semellie-Veit manoeuvres
 The manoeuvre involves a combination of jaw flexion and shoulder traction and can be used for any
breech delivery, but is of particular value when the fetal head is extended and forceps may be difficult to
apply.
 The practitioner supports the baby with the legs straddling their left arm, three fingers slide into the
vagina, feeling for the baby’s cheekbones (malar bones).
 Originally, the middle finger was inserted into the baby’s mouth in order to maximize traction but this is
not recommended as it can result in dislocation of the jaw.
 Instead, the ring and index fingers rest on the cheekbones while the middle finger applies pressure to the
chin.
 The index and ring fingers of the practitioner’s right hand are hooked over the baby’s shoulders, to apply
traction, while the middle finger presses on the occiput to aid flexion.
 An assistant may apply suprapubic pressure if needed.
 As gently as possible, the baby’s head is flexed and aided through the pelvic cavity to the outlet, after
which the trunk is raised to bring the mouth into view.
 The air passages are then cleared and the birth of the head completed in the usual way.
3.Entrapment of the foetal head
 Occurs when the breech is delivered and the cervix is not fully dilated and traps
the foetal head.
 It’s an emergency.
 McRobert’s manoeuvres can be used to facilitate release of foetal head.
 Hyperflex maternal hips (knees to chest position) and tell the patient to
stop pushing.
 This widens the pelvic outlet by flattening the sacral promontory and
increasing the lumbosacral angle.