dr. Udin Sabarudin

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MECHANISM OF LABOR IN BREECH PRESENTATION
dr. Udin Sabarudin Department of Obstetrics
Gynecology Medicine School of Padjadjaran
University Bandung
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THE 3 TYPES OF BREECH PRESENTATION

• Frank (65) Hips are flexed, knees are
  extended.
• Complete (10) The hips and knees are
  flexed
• Incomplete (25) The feet or knees are
  the lowermost presenting part.
• o Single footling one of the lower
  extremities is lowermost.
• o Double footling Both of the lower
  extremities are lowermost

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Figure 21-2. Breech presentations. A Right
sacrum posterior (RSP) position. B Left sacrum
anterior (LSA) position. (Redrawn and reproduced,
with permission, from Bumm E Grundiss zum
Studium der Geburtshilfe. Bergmann, 1922)
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PREDISPOSING FACTORS

• Prematurity
• Uterine abnormalities -Malformation
  -Fibroids
• Fetal abnormalities -CNS Malformations
• -Neck Masses
• Multiple gestations
• Previous breech delivery

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Gestational age and frequency of breech birth
Gestational age in weeks Breech
21-24 33
25-28 28
29-32 14
33-36 9
37-40 7
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DIAGNOSIS

• Palpation and ballottement
• Ultrasound
• Pelvic examination
• X-Ray studies

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Leopold Maneuver
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External Cephalic Version

• T

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MANAGEMENT DURING LABOR

• Type of Delivery
• Vaginal delivery
• Spontaneous
• Partial breech extraction
• Total breech extraction
• Cesarean of delivery

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Management
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Three types of vaginal breech delivery exist

• Spontaneous breech (rare) No manipulation of
  the infant is necessary, other than supporting
  the infant.
• Partial breech extraction Fetus descend
  spontaneously to where umbilicus is at the
  vaginal introitus then, the fetus is extracted
  completely.
• Total breech extraction The entire body is
  extracted. This is indicated only if there is
  evidence of fetal distress unresponsive to
  routine maneuvers and a cesarean delivery is not
  possible.

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Conditions are unfavorable for breech delivery

• Fetus weight more than 3500 g
• Unfavorable pelvis Breech delivery does not
  allow sufficient time for molding of the fetal
  head thus, a platypelloid or android pelvis
  decreases ability fetal head to navigate maternal
  pelvis
• Hyperextension of the head increases risk of
  cervical spine injury
• Footlings- incidence of umbilical cord prolapse
  increases with coiling of the umbilical cord
  around the legs of the fetus

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MORTALITY/MORBIDITY

• Increased birth trauma As duration of umbilical
  cord compression increases ? deliver the infant
  more rapidly ? increasing birth trauma
• Decreased birth weight may result from preterm
  delivery/growth restriction
• Incidence of prolapsed umbilical cord depends on
  type of breech presentation Footling 17,
  Complete 5, Frank 0,5
  

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Mechanism of Labor in Breech Delivery
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Assisted Delivery of Frank Breech
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Assisted Delivery of Frank Breech
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Assisted Delivery of Frank Breech
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Assisted Delivery of Frank Breech
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Assisted Delivery of Frank Breech
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Assisted Delivery of Frank Breech
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Assisted Delivery of Frank Breech
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Mechanism of Labor in Breech Delivery
Figure 21-5. Maneuver for delivery of the head.
The fingers of the left hand are inserted into
the infants mouth of over mandible the right
hand exerts pressure on the head from above.
(Modified and reproduced, with permission, from
Benson RCHandbook of Obstetrics Gynecology,
8th ed. Lange, 1983)
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Mauriceau Maneuver
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• Delivery of the Aftercoming Head
• Piper forceps
• Modified prague maneuver

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Mechanism of Labor in Breech Delivery
Figure 21-12. Application of Piper forceps,
employing towel sling support. The forceps are
introduced from below, left blade first. Aiming
directly and intended positions on sides of the
head. (Reproduced, with permission, from Benson
RCHandbook of Obstetrics Gynecology, 8th ed.
Lange, 1983)
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Forceps to Aftercoming Head
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Modified Prague Maneuver
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Complete or Incomplete Breech Extraction
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Complete or Incomplete Breech Extraction
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Complete or Incomplete Breech Extraction
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Complete or Incomplete Breech Extraction
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Breech Extraction
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C-Section Indication

• A large fetus ( gt 3.500 gr )
• A Hyperextended fetus
• Uterine dysfunction
• Footling presentation
• Any degree of contraction or unfavorable shape
  restriction
• Previous perinatal death or children suffering
  from birth trauma

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COMPLICATIONS
1. Perinatal morbidity and mortality from
difficult delivery 2. Low birthweight from
preterm delivery, growth restriction, or both 3.
Prolapsed cord 4. Placenta previa 5. Fetal,
neonatal, and infant anomalies 6. Uterine
anomalies and tumors 7. Multiple fetuses 8.
Operative intervention, especially cesarean
delivery
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Thank You