Breech

Breech presentation

Incidence of breech presentation at term is 3%,but much more common before term. There are three types : 1-The commonest is extended[frank] breech in which both hips are flexed &knees are extended. 2-Less common is flexed [complete]breech in which the legs are fully flexed at both hips&knees.


3-The least common is footling breech in which the foot present at the cervix.

Predisposing factors

In most instances it occurs by chance with no underlying abnormality.

1-Uterine factors

Fibroids congenital abnormalities like bicornuate uterus uterine surgery oligo or polyhydramnios placental position like praevia or cornual implantation.

Fetal factors

Prematurity multiple pregnancy congenital abnormalities as anencephaly neuromuscular conditions

DiagnosisDuring pregnancy

By abdominal examination :The hard ,sphyrical&ballotable fetal head is felt in the fundal region of the uterus. The fetal heart sounds are heard at level slightly above maternal umbilicus


During labour After rupture of membranes additional informations obtained by vaginal examination.In case of flexed breech afoot may present ,with extended breech the rounded buttocks resemble fetal head but the hardness of bone&sutures are abscent,anus&sacrum are identified.

Management at term

Antenatally If there is any associated complication as fetal compramise or pre eclampsia elective c/s is offered.If there is no complications three options are available: ECV Trial of vaginal breech delivery C/S

External cephalic vertion[ECV]

Means changing fetal presentation by manual pressure through mother abdominal wall.It may be performed at 36-37 weeks with facilities for emergency c/s near by.CTG is carried out before&after ECV,ultrasound may be helpful&tocolytics should be used if the uterus does not feel well relaxed.


The first step is to disengage the breech from pelvic brim&pushed upward with fingers of both hands,then pushed upwards&laterally with one hand while the other hand presses on the head&increased its flexion with steady pressure,when the long axis of the fetusis brought across the long axis of the uterus the version is succeed.

Contraindications to ECV

Placenta praevia oligo or polyhydramnios history of APH previous c/s or myomectomy scar in the uterus multiple gestation pre eclampsia or hypertension plan to deliver by c/s

Risks of ECV

Placental abruption PROM cord accident transplacental haemorrage fetal bradycardia



Elective caesarean section
It should be considered in the presence of other obstetric problem as diabetes,hypertention&placenta previa when major congenital abnormality of fetus has been excluded. Also c/s indicated in multiparous with poor obstetric history


In patients with subfertility In primegravida over 35 years of age c/s must be considered when the fetus is growth restricted If disproportion is suspected When biparietal diameter is large If estimated fetal weight =or>4 kg Footling breech When hyperextended head is diagnosed


In patient with previous c/s vaginal delivery only be considered when malpresentation is the only complication present,the uterine scar should be assessed by ultrasound ,the fetus must beof average weight.

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Vaginal breech delivery

Every effort is made to prove that the pelvis is normal in shape&size by clinical pelvimetry which may be confirmed by x-ray or computed tomography .the presentation should be either frank or complete,there is increased mortality &morbidityin footling breech due to increase incidence of cord prolapse &entrapment of fetal head by the incompletely dilated cervix.


There should be no evidence of cephalopelvic disproportion with adequate pelvis,estimated fetal weight should be less than4000gram by clinical&ultrasound measurment. There should be no evidence of hyperextention of the fetal head&fetal abnormalities is excluded as ascitis or hydrocephaly.

Complications of vaginal breech delivery

Cord prolapse especially in footling&flexed breech Difficulty in delivering the head :If sudden uncontrolled delivery of head result in intracranial haemorrhage&delay in delivering it result in hypoxia or asphyxia. Difficulty in delivering shoulders may cause damage to brachial plexus or liver. So perinatal mortality &morbidity is higher in vaginal breech delivery than vertex.

Mechanism of labour

The bitochanteric diameter [10]cm usually engaged in the transverse or oblique diameter of pelvic brim with the sacrum anterior.During labour the breech descends into the pelvic cavity&internal rotation brings the bitrochanteric diameter into the anteroposterior diameter of pelvic outlet.


The breech is born by lateral flexion of trunk,the child then strightens as the anterior hip is born,legs&feet following.As the shoulders enter the brim in oblique or transverse diameter undergoes its internal rotation to bring `them into anteroposterior diameter of the outlet,the head will rotate until the posterior part of neck become fixed under subpubic arch&the head born by flexion,the chin,mouth,nose,forehead,vertex& occiput appear succesively.


Posterior rotation of the occiput occurs infrequently &then the head is delivered by face-to-pubis.


Vaginal breech delivery can be divided to three types: 1-Spontaneous delivery:that is without interference it has high risks of complications. 2-Assisted delivery 3-Breech extraction:This is indicated in delivering second twin,by catching fetal feet&traction to complete delivery without maternal efforts.

Management of vaginal breech delivery[assisted breech delivery]

First stage: The conduct of first stage of labour is similar to that of vertex presentation,epidural anesthesia is advised,poor progress may occur if the sacrum is posterior or if there is poor fit between the flexed breech&lower segment,this may result in early rupture of membranes that necessate vaginal examination to exclude cord prolapse.


Poor progress may also be due to bigger baby than expected,oxytocin infusion is usually not advised. In the first stage if: poor progress fetal distress maternal distress cord prolapse caesarean section is indicated.


Second stage: Vaginal examination is made to confirm full dilatation of the cervix,when the breech reach pelvic floor&distend the perineum,the mother should be placed in lithotomy position&episiotomy is performed. In flexed breech the feet&legsmay be eased out as they appear from vagina.



In frank breech the extended legs may need to be flexed by pressure in the popliteal fossa before bringing them down. Arrest of breech in the second stage means that the baby is too big for maternal pelvis&c/s is the best choice.

With delivery of the umbilicus asmall loop of the cord is pulled &cardiac pulsation is felt,if there is no pulsation delivery is expediated.Afinger is inserted into the vagina to make certain that the arms are lying folded in the chest.As the body descend the inferior angle of anterior scapula become visible ,the anterior arm is gently hooked out then posterior arm can be released.


Occasionally the arms are extended which require delivery by Lovset’s manoeurre,this relies on fact that the posterior shoulder will lie belowthe level pelvic brim when the anterior shoulder lie behind symphysis pubis.By downward traction the angle of scapula can be seen ,the pelvic girdle&thighs are firmly held with both hands&fetus is turned through 180 degree with the back anterior while moderate traction is maintained so the posterior arm is brought anteriorly &hooked out with afinger.

Therafter the fetus is again rotated through 180 degrees in the opposite direction with back anterior, the other arm will appear under pubic arch&easily can be delivered.After delivery of shoulders the flexed head normally enters the pelvis which usually occur if the body is hanged downward for one minute&undergo internal rotation.


The obstetric forceps can be used,the baby is lifted upward&the blades of the forceps are applied beneath to deliver the head with moderate traction.


Very rarely the fetal head cannot be made to enter pelvic brim so the nape cannot be seen,this can be managed by jaw&shoulder traction method,by passing left hand infront of fetal chest when one finger pressedon the jaw to produce flexion while other hand passed along the back until the index &middle fingers curved over the shoulders to exert traction,the head is drown down by traction on the shoulders.