BreechBreech

Management Management

By By

Dr. Khattab KAEODr. Khattab KAEO

Prof & Head of Obstetrics and Gynaecology Prof & Head of Obstetrics and Gynaecology Department Department

Faculty of Medicine, Al-Azhar University, Faculty of Medicine, Al-Azhar University, DamiettaDamietta

Breech delivery is not just a vertex delivery in reverse. The principal options are: * A trial of vaginal delivery.* Elective CS. * External cephalic version.

Mode of delivery:Mode of delivery:

CS is not a routine.CS is not a routine.

The fear of litigation, how-The fear of litigation, how-ever, greatly contributed to ever, greatly contributed to CS shift.CS shift.

More than half of breech More than half of breech presentations can be presentations can be delivered vaginally.delivered vaginally.

Vaginal delivery is associated with in-creased Vaginal delivery is associated with in-creased perinatal mortality& morbidity, while CS is perinatal mortality& morbidity, while CS is associated with increased maternal morbidity associated with increased maternal morbidity and is more costly. and is more costly.

However, the increase in perinatal mortality However, the increase in perinatal mortality &morbidity is not only related to the mode of &morbidity is not only related to the mode of delivery; prematurity, congenital delivery; prematurity, congenital malformations, PPROM and cord prolapse, all malformations, PPROM and cord prolapse, all are more common with breech presentations. are more common with breech presentations.

The rate of cerebral palsy is high regardless of The rate of cerebral palsy is high regardless of the mode of delivery. the mode of delivery.

The perinatal morbidity rate depends on the The perinatal morbidity rate depends on the quality of birth management and criteria for quality of birth management and criteria for admission to a trial of vaginal breech delivery admission to a trial of vaginal breech delivery (selection). (selection).

Modified Zatuchni-Andros scoreModified Zatuchni-Andros score for for vaginal breech delivery.vaginal breech delivery.

Selection criteria:Selection criteria: Not completely Not completely reliable. Type of breech, EFW and reliable. Type of breech, EFW and

pelvic dimensions are important pelvic dimensions are important factors. factors.

Parity is less important. Parity is less important.

Pelvimetry is not a routine. Pelvimetry is not a routine.

CS is offered for EFWs of CS is offered for EFWs of 3.75 kg.3.75 kg.

With a frank or complete breech, With a frank or complete breech, normal pelvis and EFW between 1.5 normal pelvis and EFW between 1.5 & 3.8 kg, assisted breech delivery is & 3.8 kg, assisted breech delivery is

probably as safe as a CS. probably as safe as a CS.

Exclusion criteria:Exclusion criteria: EFW <1500 g or >3800 g. It should EFW <1500 g or >3800 g. It should

be noted that the error margins in be noted that the error margins in fetal weight estimations may be fetal weight estimations may be higher with breech presentations higher with breech presentations ((1 kg). 1 kg).

Macrocephaly. Macrocephaly. Hyperextended head. Hyperextended head. Footling presentation. Footling presentation. Others like placenta praevia and Others like placenta praevia and

feto-pelvic disproportion.feto-pelvic disproportion.Ultrasound examination will Ultrasound examination will

diagnose head extension (a clear diagnose head extension (a clear indication for CS).indication for CS).

Vaginal delivery requirementsVaginal delivery requirements~ Anaesthesia is immediately available; ~ Anaesthesia is immediately available;

~ Ready access to CS. ~ Ready access to CS.

~ Continuous electronic fetal monitoring. ~ Continuous electronic fetal monitoring.

~ Two obstetricians experienced with ~ Two obstetricians experienced with breech delivery. breech delivery.

~ Two paediatricians. ~ Two paediatricians.

TechniqueTechnique - Induction & augmentation are allowed in selected cases- Induction & augmentation are allowed in selected cases- Fetal bl samples from buttocks provide an accurate - Fetal bl samples from buttocks provide an accurate

assessment of the A-B status when FHR is suspect. assessment of the A-B status when FHR is suspect. - Membranes should be kept intact and pushing should be - Membranes should be kept intact and pushing should be

delayed as long as possible. delayed as long as possible. - No interference before delivery of the umbilicus. The - No interference before delivery of the umbilicus. The

buttocks, legs and abdomen should be allowed to deliver buttocks, legs and abdomen should be allowed to deliver spontaneously. spontaneously.

- Episiotomy is considered when crowning occurs. - Episiotomy is considered when crowning occurs. - Forefingers in the groins and thumbs on the sacrum to - Forefingers in the groins and thumbs on the sacrum to

keep the back always anterior. Rest of the fetal body keep the back always anterior. Rest of the fetal body should be delivered promptly. should be delivered promptly.

- When the scapulae appear, fingers should be placed over - When the scapulae appear, fingers should be placed over the shoulders from the back. The humerus should be the shoulders from the back. The humerus should be followed down, and each arm rotated across the chest followed down, and each arm rotated across the chest and out (Lovsett's manoeuvre). To deliver the right arm, and out (Lovsett's manoeuvre). To deliver the right arm, the fetus is rotated in anti-clockwise direction; to deliver the fetus is rotated in anti-clockwise direction; to deliver the left arm, the fetus is rotated in a clockwise direction. the left arm, the fetus is rotated in a clockwise direction. A gentle steady downward traction should be kept during A gentle steady downward traction should be kept during rotation. rotation.

- Delivery of the head by 1 of the following methods: - Delivery of the head by 1 of the following methods: * Burns-Marshall technique: The body of the fetus, * Burns-Marshall technique: The body of the fetus,

while supported to avoid sudden slipping, is left while supported to avoid sudden slipping, is left hanging down from the edge of the table. When the hanging down from the edge of the table. When the suboccipital region appears below the symphysis suboccipital region appears below the symphysis pubis, the fetus's ankles are grasped and the fetus is pubis, the fetus's ankles are grasped and the fetus is moved towards the mother's abdomen to deliver the moved towards the mother's abdomen to deliver the head in flexion. head in flexion.

* Mauriceau-Smellie-Veit technique (Jaw flexion * Mauriceau-Smellie-Veit technique (Jaw flexion –– shoulder traction): While the fetus is riding over the shoulder traction): While the fetus is riding over the obstetrician's Lt forearm, its head is maintained in obstetrician's Lt forearm, its head is maintained in flexion by the obstetrician's Lt index& middle fingers flexion by the obstetrician's Lt index& middle fingers that apply pressure on the fetus's low or upper jaw. that apply pressure on the fetus's low or upper jaw. 2 fingers of the Rt hand are hooked over the fetal 2 fingers of the Rt hand are hooked over the fetal neck grasping the shoulders, and traction is applied neck grasping the shoulders, and traction is applied downwards and backwards until the suboccipital downwards and backwards until the suboccipital region appears below the symphysis pubis, then the region appears below the symphysis pubis, then the fetus is moved towards the mother's abdomen to fetus is moved towards the mother's abdomen to deliver the head in flexion. deliver the head in flexion.

The operator uses both hands simultaneously to exert The operator uses both hands simultaneously to exert continuous downward gentle traction bilaterally on continuous downward gentle traction bilaterally on the fetal neck & on the maxilla. Suprapubic pressure the fetal neck & on the maxilla. Suprapubic pressure by an assistant maintains flexion of the head. by an assistant maintains flexion of the head.

The aftercoming headThe aftercoming head* Forceps is applied in * Forceps is applied in

a reverse direction a reverse direction to maintain flexion to maintain flexion of the head. Ideally of the head. Ideally the Pipper's forceps the Pipper's forceps with long reversed with long reversed shanks is used. shanks is used. After bringing the After bringing the suboccipital region suboccipital region below the below the symphysis pubis, symphysis pubis, the forceps is then the forceps is then elevated elevated upwardsupwards..

Breech extractionBreech extraction It is mainly indicated to deliver the 2nd twin & in It is mainly indicated to deliver the 2nd twin & in

case of prolapsed pulsating cord with the case of prolapsed pulsating cord with the breech engaged & the cervix is fully dilated. It breech engaged & the cervix is fully dilated. It can be accomplished by moderate traction by can be accomplished by moderate traction by a finger in each groin (or the anter. groin a finger in each groin (or the anter. groin alone, but not the post. groin alone). If alone, but not the post. groin alone). If moderate traction does not effect delivery, moderate traction does not effect delivery, breech de-composition i.e. converting the breech de-composition i.e. converting the frank breech into footling. 2 fingers are frank breech into footling. 2 fingers are carried up along the anterior thigh to the knee carried up along the anterior thigh to the knee to push it away from the midline by pressing to push it away from the midline by pressing on the popliteal fossa. Spontaneous flexion on the popliteal fossa. Spontaneous flexion usually follows, and the foot is grasped & usually follows, and the foot is grasped & brought down (Pinard manov If we bring the brought down (Pinard manov If we bring the posterior leg, the anter buttock may override posterior leg, the anter buttock may override the symphysis pubis. This is contrary to the symphysis pubis. This is contrary to extended arms where we can bring the extended arms where we can bring the posterior arm first (introducing the hand along posterior arm first (introducing the hand along concavity of the sacrum is easier). If the concavity of the sacrum is easier). If the anterior arm overrides the symphysis pubis, anterior arm overrides the symphysis pubis, there is no great problem because we can hold there is no great problem because we can hold the trunk and rotate it 180the trunk and rotate it 180 to bring the anter. to bring the anter. arm posteriorly then delivering it.arm posteriorly then delivering it.

Breech extraction (Cont.)Breech extraction (Cont.)The ankles are held with the 2nd finger lying between The ankles are held with the 2nd finger lying between

them & gentle downward traction is exerted. them & gentle downward traction is exerted. As the legs emerge, successively higher portions are As the legs emerge, successively higher portions are

grasped. grasped. A cardinal rule is to employ steady, gentle, downward A cardinal rule is to employ steady, gentle, downward

rotational traction until the lower 1/2 of the scapulas rotational traction until the lower 1/2 of the scapulas are delivered outside the vulva - making no attempt are delivered outside the vulva - making no attempt at delivery of the shoulders and arms before that. at delivery of the shoulders and arms before that.

The anter shoulder & arm are released & delivered firstThe anter shoulder & arm are released & delivered first The body of the fetus is then rotated in the reverse The body of the fetus is then rotated in the reverse

direction to deliver the other shoulder and arm. direction to deliver the other shoulder and arm. If trunk rotation is unsuccessful, the posterior shoulder If trunk rotation is unsuccessful, the posterior shoulder

must be delivered first. The feet are grasped and must be delivered first. The feet are grasped and drawn upward over the inner thigh of the mother drawn upward over the inner thigh of the mother toward which the ventral surface of the fetus is toward which the ventral surface of the fetus is directed. Then, by depressing the body of the fetus, directed. Then, by depressing the body of the fetus, the anterior shoulder emerges beneath the pubic the anterior shoulder emerges beneath the pubic arch, thereafter, the back tends to rotate arch, thereafter, the back tends to rotate spontaneously in the direction of the symphysis. spontaneously in the direction of the symphysis.

Complicated vaginal breech deliveryComplicated vaginal breech delivery

Arrest of the buttocks at the pelvic outletArrest of the buttocks at the pelvic outlet Extension of the legs is the main cause Extension of the legs is the main cause

because they interfere with lateral because they interfere with lateral flexion of the spine. flexion of the spine.

This can be managed by Pinard manoev. or This can be managed by Pinard manoev. or by groin traction. by groin traction.

Groin traction is performed by putting the Groin traction is performed by putting the index finger in the anterior groin for index finger in the anterior groin for traction during uterine contractions. This traction during uterine contractions. This may be helped by fundal pressure. When may be helped by fundal pressure. When the posterior groin canbe reached the posterior groin canbe reached traction is made on both groins, down-traction is made on both groins, down-ward and backward until the anterior ward and backward until the anterior groin appears below the symphysis groin appears below the symphysis pubis, and then upward to deliver the pubis, and then upward to deliver the posterior buttock. Traction should be posterior buttock. Traction should be directed towards the trunk not the thigh directed towards the trunk not the thigh to avoid fracture of the femur. to avoid fracture of the femur.

Posteriorly rotated headPosteriorly rotated head

Prague technique:Prague technique: Rarely, the back of Rarely, the back of the fetus fails to rotate to the anterior. the fetus fails to rotate to the anterior. Rotation may, then, be achieved by Rotation may, then, be achieved by using stronger traction on the fetal using stronger traction on the fetal bony pelvis. If the back still remains bony pelvis. If the back still remains posteriorly, the fetus still may be posteriorly, the fetus still may be delivered using the modified Prague delivered using the modified Prague manoeuvre. It consists of grasping the manoeuvre. It consists of grasping the shoulders of the back-down fetus by shoulders of the back-down fetus by two fingers of one hand, from below, two fingers of one hand, from below, while the other hand draws the feet up while the other hand draws the feet up over the maternal abdomen.over the maternal abdomen.

Extended armsExtended arms It usually occurs due to traction before full dilatation of the Cx.It usually occurs due to traction before full dilatation of the Cx.

Classical method:Classical method: UGA, the poster. arm is brought UGA, the poster. arm is brought down first. A hand is passed along the arm to the down first. A hand is passed along the arm to the cubital fossa, & 2 fingers press to flex the forearm. If cubital fossa, & 2 fingers press to flex the forearm. If there is no enough space anteriorly, we can hold the there is no enough space anteriorly, we can hold the trunk & rotate it 180trunk & rotate it 180 to bring the anterior arm to bring the anterior arm posteriorly then delivering it by the same procedure. posteriorly then delivering it by the same procedure. Lovsett's technique:Lovsett's technique: This is the method of choice This is the method of choice because there is no need for anaesthesia or to pass because there is no need for anaesthesia or to pass the hand into the vagina. The fetus is grasped by the the hand into the vagina. The fetus is grasped by the pelvic girdle. Traction is applied downward until the pelvic girdle. Traction is applied downward until the inferior angle of the anter scapula appears below the inferior angle of the anter scapula appears below the symphysis pubis. Then, the fetus is rotated 180symphysis pubis. Then, the fetus is rotated 180 to to bring the post shoulder below the symphysispubis bring the post shoulder below the symphysispubis where the arm can be brought down Then, the fetus where the arm can be brought down Then, the fetus is rotated 180is rotated 180 in the opposite direction to bring the in the opposite direction to bring the other shoulder anterior below the symphysis pubis other shoulder anterior below the symphysis pubis where the other arm can be brought down too. where the other arm can be brought down too. During rotation shoulders descend for few Cms During rotation shoulders descend for few Cms which are enough to assist delivery. During rotation which are enough to assist delivery. During rotation the fetal back should always remain anterior. the fetal back should always remain anterior.

Nuchal displacement of the armNuchal displacement of the armIt results from rotating the trunk in the It results from rotating the trunk in the

wrong direction during delivering the wrong direction during delivering the extended arm. Treatment is by rotating extended arm. Treatment is by rotating the trunk at least 90the trunk at least 90 in the direction of in the direction of the tips of fingers of the displaced hand the tips of fingers of the displaced hand until the fetal back is directed toward until the fetal back is directed toward one side of the pelvis. During rotation, one side of the pelvis. During rotation, the arm will usually be forced to an the arm will usually be forced to an extended position by the pressure from extended position by the pressure from the pelvic brim. The arm is, then, swept the pelvic brim. The arm is, then, swept downward over the face and chest. downward over the face and chest.

Double nuchal arms Double nuchal arms

Caesarean sectionCaesarean section Indications = exclusion criteria for vaginal Indications = exclusion criteria for vaginal

breech delivery + other indications for CS breech delivery + other indications for CS e.g. previous 2 CS, placenta praevia, etc. e.g. previous 2 CS, placenta praevia, etc.

It should be emphasized that CS is indicated It should be emphasized that CS is indicated with any degree of pelvic contraction. This with any degree of pelvic contraction. This is because with term fetus some degree of is because with term fetus some degree of head molding may be essential to head molding may be essential to negotiate the birth canal successfully. In negotiate the birth canal successfully. In breech presentation, once the breech has breech presentation, once the breech has passed beyond the vaginal introitus, the passed beyond the vaginal introitus, the abdomen, thorax, arms & head should be abdomen, thorax, arms & head should be delivered promptly. This involves delivery delivered promptly. This involves delivery of successively less compressible parts.of successively less compressible parts.

CS due to only breech presentation is CS due to only breech presentation is followed by >80% possibility of vaginal followed by >80% possibility of vaginal delivery of the next pregnancy if the delivery of the next pregnancy if the presentation is vertex. presentation is vertex.

ThankThank you you