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Breech Delivery
Breech Delivery
OUTLINE
I. OVERVIEW
A. Objectives
B. Diagnose Breech
II. CLASSIFICATION/ TYPES OF BREECH
III. RISK FACTORS
IV. ROUTE OF DELIVERY
A. Term Breech Fetus
B. Preterm Breech Fetus
V. COMPLICATIONS OF DELIVERY
VI. DECISION-MAKING SUMMARY
VII. IMAGING TECHNIQUES
VIII. LABOR & DELIVERY MANAGEMENT
IX. SPONTANEOUS BREECH DELIVERY
X. PARTIAL BREECH EXTRACTION
XI. REFERENCES
DIAGNOSE BREECH
1S-4 DISORDERS OF AFV & ABNORMALITIES OF PLACENTA, FETAL MEMBRANES & CORD ESTUYE • HO • JAVIER • RAMOS • ROCHA
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v FOOTLING VI. PRE-TERM BREECH FETUS
Ø An incomplete breech
with one or both feet v No randomized trials done regarding delivery of preterm breech
below the breech. fetuses.
Ø U A subtype of v Planned caesarean delivery is favored and confers a survival
incomplete breech advantage compared with planned vaginal delivery.
1S-4 DISORDERS OF AFV & ABNORMALITIES OF PLACENTA, FETAL MEMBRANES & CORD ESTUYE • HO • JAVIER • RAMOS • ROCHA
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§ Consider for dystocia apart from the normal pattern of
delivery, you have to consider the passenger (fetus), the
passageway and the uterine contractions.
2. Cervix is fully dilated (10 cm)
v U We recommend spontaneous/assisted breech vaginal delivery
not the complete breech vaginal delivery where you try to expel
using manually the maneuvers. It should be assisted/partial breech
extraction.
v In PRETERM fetuses, the breech is smaller than the aftercoming
head, thus the HEAD of a breech presenting fetus does not
undergo molding during labor.
v CONSIDERATIONS: (for vaginal breech delivery)
Ø fetal size/ weight
Figure 5. Pelvic Inlet
Ø type of breech (with nuchal arm)
Ø degree of neck flexion or extension X. LABOR & DELIVERY MANAGEMENT
§ U Whether immature or a term fetus, if it is
hyperextended, don’t try to deliver vaginally. v Breech labor generally proceeds slower than labor in cephalic
Ø adequacy of the pelvis presenting fetuses.
Ø fetal anomalies v U Hindi nga nagmomold yung head eh. So the soft part doesn’t
v SONOGRAPHY: follow after the head as compare to cephalic presenting fetuses
Ø SEFW (sonographic estimated fetal weight) 1. Vaginal Breech delivery
§ If >2500/< 3800g, then vaginal delivery is possible § Spontaneous – no manipulation
§ If more than 3800, do CS
• U Let the baby expel spontaneously and is
Ø U By ultrasound: supported only by the provider
§ If the biparietal diameter (fetal head) is >90-100mm
§ Partial – expelled up to the umbilicus, then maneuvers
planned vaginal delivery is not recommended
done after.
v U We consider pelvimetry not just clinically but we can do it using § Total – not usually done (extracted fully by provider)
pelvic CT scan. We consider the measurement of the pelvic inlet,
1. Labor induction/augmentation (U using oxytocin or
the AP diameter, transverse diameter vs. the biparietal diameter of
uterotonics) – not recommended
the fetal head.
§ Only for imminent deliveries, with uterine hypotonia.
v U For example, If the transverse minus the biparietal is ³ 25 mm,
we can try to consider vaginal delivery. But if it is lesser, we cannot. LABOR MANAGEMENT
Meaning, the passageway is not adequate as compared to the
fetus. v Be sure proper personnel/ providers are present
Ø skilled provider
FACTORS FAVORING CAESAREAN DELIVERY OF THE Ø anesthesiologist
BREECH FETUS Ø pediatrician to resuscitate the newborn as necessary
v Lack of operator experience in delivering vaginally Ø a capable associate/assistant to the provider
Ø U The maneuvers are the same both for delivering v Continuous monitoring of: Electronic monitoring
vaginally and CS kaya lang if hindi ka expert and you are Ø Fetal heart tones every 15 mins
not sure that you will be able to avoid complications, don’t Ø Uterine contractions
try. v The bag of water is assessed.
v Patient’s request Ø U It should be ruptured prior to the delivery of the breech
v Large fetus: > 3800 to 4000g v The progress of labor is monitored.
v Healthy and viable preterm fetus in active labor with indications Ø U Because anytime that there would be disruption of the
of delivery normal course of labor or might be labor dysfunction then you
v Severe fetal growth restriction should abort the plan - vaginal delivery of that breech and
v Fetal anomaly that may obstruct vaginal delivery proceed to CS
v Prior perinatal death or neonatal birth trauma v IV line access to mother provided.
v Incomplete or footling breech always delivered via CS v Preference to epidural anesthesia (regional)
v Hyperextended head v Watch out for complications like cord prolapse.
v Pelvic contraction determined clinically or by imaging (CT, MRI,
plain film radiography) – see measurements. XI. SPONTANEOUS BREECH DELIVERY
v Previous CS
CARDINAL MOVEMENTS:
IX. IMAGING TECHNIQUES v Engagement/ descent of the BITROCHANTERIC diameter
v At Parkland Hospital, CT pelvimetry is used v Internal rotation of the anterior hip or breech towards the pubic arch
v Specific measurements to allow vaginal delivery v Lateral flexion of the fetal body. Legs and feet follow the breech.
Ø Pelvic INLET: v External rotation, back turning anteriorly. (internal rotation of the
§ AP diameter - ³ 10.5cm bisacromial AP plane)
§ Transverse diameter - ³ 12.0cm Ø U Back of the fetus: towards the arch of pubic symphysis
Ø MID Pelvis - Interspinous distance - ³ 10cm v Head is born in flexion (sharply flexed)
v Maternal – fetal biometry (Sonography)
1. AP inlet (obstetrical conjugate) minus BPD - ³ 15mm
2. Transverse minus BPD - ³ 25mm
3. Interspinous minus BPD - ³ 0mm
1S-4 DISORDERS OF AFV & ABNORMALITIES OF PLACENTA, FETAL MEMBRANES & CORD ESTUYE • HO • JAVIER • RAMOS • ROCHA
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v Following delivery of the fetal legs, bony pelvis grasped with both
hands likeso in Figure 9
v Maternal expulsive efforts are again encouraged/used in
conjunction with steady, gentle downward traction to affect delivery
– until scapula are visible
v The arms are delivered (Lovesett maneuver) – sweep arms
downward across the chest
Figure 6. The hips of the frank breech are delivering over the perineum. Anterior hip
usually delivers first.
Figure 9. Figure 10
1S-4 DISORDERS OF AFV & ABNORMALITIES OF PLACENTA, FETAL MEMBRANES & CORD ESTUYE • HO • JAVIER • RAMOS • ROCHA
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HEAD ENTRAPMENT
v Do Zavanelli maneuver
Ø U Wherein we put back everything and do the CS with
anesthesia and for as long as there’s a maternal support and
neonatal stability
v Duhrssen incision
Ø U Where we cut to give more space aside from the episiotomy
Ø U 2 o’clock and 10 o’clock incision with anesthesia and
stability of both maternal and fetal
Other Forms:
Ø COMPLETE Breech extraction..
Ø External cephalic version (ECV)
IV. REFERENCES
th
Ø Williams Obstetrics, 25 Edition (Cunningham et al)
Ø Dr. Coloma’s PPT
Ø Notes and Recordings of OB2 Trans Team
1S-4 DISORDERS OF AFV & ABNORMALITIES OF PLACENTA, FETAL MEMBRANES & CORD ESTUYE • HO • JAVIER • RAMOS • ROCHA
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