What are the types of breech presentation?
1- complete breech
- flexed hips & flexed knees
2- incomplete breech
- Frank breech -> flexed hips & extended knees
- Footling -> partial extension of the hip & knee on one or both sides
- Knee -> extension of the hip & flexion of the knee
What are the causes of breech presentation?
Passages
- placenta Previa
- uterine fibroid
- uterine anomalies (bicornuate or septate)
Passenger
- prematurity
- polyhydramnios/oligo
- hydrocephalus
- frank breech -> legs act as splint
- twins
- IUFD
- macrosomia
What is the mechanism of labor in sacro-anterior position?
BUTT
1- bitrochanteric diameter (10cm) enters oblique diameter of pelvis
2- anterior butt reaches pelvis floor first & rotates anteriorly
3- anterior butt hinges below symphysis pubis & posterior butt is delivered first by lateral flexion of the spine
SHOULDER
4- biacromial diameter (12cm) enters oblique pelvis
5- anterior shoulder reaches pelvic floor first & rotates anteriorly
6- anterior shoulder hinges below symphysis pubis
7- posterior shoulder is delivered first by lateral flexion of spine
HEAD
8- head enters in opposite oblique diameter
9- occiput reaches pelvic floor first & rotates anteriorly
10- occiput hinges below the symphysis pubis
11- head is delivered in flexion
How is delivery of sacro-posterior position completed?
1- anterior butt & shoulder rotate anteriorly (45 degrees)
2- occiput rotates anteriorly (135 degrees)
3- occiput hinges below symphysis pubis
4- head is delivered in flexion
How is breech presentation diagnosed during pregnancy?
INSPECTION
- localized bulge in hypochondrium (head)
PALPATION
- fundal grip: head is felt
- umbilical grip: detect position of back
- pelvic grip: buttock is felt
AUSCULTATION
- FHS above the level of umbilicus
ULTRASOUND
- confirm diagnosis
- fetal head hyperextension -> angle between the fetal mandible & cervical spine is more than 105 degrees
- detect associated OB conditions
What should be done in vaginal examination of breech presentation during labour?
1- presenting part is diagnosed by palpating 3 body prominences -> 2 ischial spines + tip of sacrum)
- in complete breech feet are felt
2- dilatation of cervix -> slow
3- exclude contracted pelvis + ROM + cord prolapse
How is frank breech diagnosed during labour?
May be confused with cephalic
1- fundal level is lower (early engagement)
2- fundal grip: ballotment of the head is restricted due to extended legs
3- fetal heart sounds are at or below umbilicus due to early engagement of breech
Vaginal examination
- feet are not felt beside butt
Commoner in primigravida
How is breech presentation managed during pregnancy?
1- External cephalic version (36-37 weeks)
2- Depending on success of ECV
- If successful -> trial of vaginal delivery
- if failed -> C section
What is the reason behind the specific timing for ECV?
not before 36 weeks because
- breech may recur
- spontaneous cephalic version may occur
- preterm labour may occur
Not after 37 because
- less liquor
- uterus becomes more irritable
What are the complications of ECV?
- separation of placenta
- rupture of membranes & preterm labour
- Rh iso-immunization
What are the contraindications for ECV?
1- if C section is already indicated
2- antepartum hemorrhage
3- hypertension -> placental separation
4- diabetes -> macrosomic baby
5- Twins
When is Caesarian delivery indicated?
- any degree of contracted pelvis
- fetal weight > 3.5 kg OR < 1.5 kg
- footling presentation -> to avoid cord prolapse or head entrapment
- hyperextension of the fetal head
- placenta Previa
- other OB indications
How is breech presentation managed during labour?
1st Stage
1- rest & proper analgesia
2- combat uterine inertia
3- avoid PROM
4- continuous monitoring of uterine contractions & FHR
5- partogram
2nd Stage
- decision of what type of delivery will be taken here
1- spontaneous breech delivery: only if she has good contractions
2- assisted breech delivery
3- breech extraction
What is the most common method of assisted breach delivery?
1- avoid traction before full cervical dilatation
2- episiotomy when perineum is fully distended by butt
3- legs are hooked out opposite to hip joints without any traction
4- pull down loop of umbilical cord to avoid compression & detect pulsation
5- when anterior scapula appears under symphysis pubis -> each arm is delivered by hooking finger in elbow & sweeping arm in front of chest
6- back is rotated anteriorly to keep it under symphysis pubis to ensure anterior rotation of occiput
Why is an episiotomy mandatory in breech delivery when perineum is distended by buttock?
- to decrease amount of lateral flexion of fetal spine
- to avoid perineal tears
- to avoid compression & decompression
What are the different methods for delivery of the after-coming head?
1- Burns-Marshall’s method -> only when occiput appears under symphysis infant is held from feet & body is lifted towards mothers abdomen
2- Jaw flexion-Shoulder traction method -> jaw flexion by left hand & shoulder traction by right hand
3- Pipers forceps -> prevents stretch of fetal head so it promotes flexion
- protects head from injury & sudden compression decompression
4- Kristeller maneuver -> gentle fundal pressure during contractions by assistant
- guides head into pelvis & maintains flexion
What are the indications for breech extraction?
- prolonged 2nd stage of labour
- maternal distress
- maternal disease
- prolapse pulsating cord
- frank breech
What is the difference between assisted breech delivery & breech extraction?
ASSISTED
- no traction applied to legs until delivery of butt
- epidural or spinal
EXTRACTION
- traction is applied to legs to deliver butt
- entire delivery is done under general anesthesia
What is the technique for breech extraction?
- In complete breech -> traction on both legs
- In frank breech -> bring down leg by Pinard’s method
What are the complications of breech delivery in mother?
- early ROM
- prolonged labour -> uterine inertia or arrested delivery
- birth canal injuries
- postpartum hemorrhage
- puerperal sepsis
What are the fetal complications that may occur with breech delivery?
FATAL
- intracranial hemorrhage
- fracture of cervical spine
- asphyxia -> cord compression & premature stimulation of respiration
- injury of abdominal organs
NON-FATAL
- fracture of femur & humerus
- dislocation of hip joint
- brachial plexus palsy
- sternomastoid rupture
How is fetal intracranial hemorrhage avoided?
- fundal pressure only during contractions
- generous episiotomy
- vitamin K IM: given to mother early
- forceps delivery
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Physiological changes during pregnancy11
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Prenatal care 1 & 224
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Prenatal diagnosis14
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OB imaging10
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Ectopic Pregnancy17
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Vesicular Mole20
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Hypertensive states with pregnancy22
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GIT disorders22
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Thyroid Disorders17
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Thrombo-embolic disorders26
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Cardiac diseases19
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Peripartum cardiomyopathy6
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Anemia in pregnancy14
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DM with pregnancy19
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Urinary system disorders & epilepsy20
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Placenta Previa16
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Placental abruption8
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Post term pregnancy8
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IUGR12
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IUFD11
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Polyhydramnious & Oligohydramnious15
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Multifetal pregnancy0
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Rh isoimmunization18
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PPROM & Chorio-amnionitis20
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Preterm labour6
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Induction of labour11
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Management of normal labour21
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Mechanism of labour17
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Assessment of fetal wellbeing30
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labour dystocia14
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occipito-posterior position12
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breech presentation22
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face brow shoulder12
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operative delivery16
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shoulder dystocia9
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cord presentation7
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VBAC6
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perineal tears & birth injuries17
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Postpartum Hemorrhage22
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Puerperium24
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Infectious Diseases31
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Contracted Pelvis & Cephalopelvic Disproportion12
