OBSTETRICS 2

1S-5 | CEU-SOM A & B

BREECH DELIVERY
LEILANI C. CHAVEZ - COLOMA, MD

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

Figure 1. Leopold's Maneuvers

I. OVERVIEW
OBJECTIVES
II. CLASSIFICATION/ TYPES OF BREECH
v To define the different types of breech presentation.
v To discuss how clinical examination and imaging techniques can v FRANK
diagnose breech presenting fetuses. Ø Flexed at the hips and
v To discuss the different routes of delivering a breech and its extended at the knees
complications
v To discuss the different maneuvers done in delivering a breech.

DIAGNOSE BREECH

1. DO LEOPOLD’S MANEUVER (abdominal palpation during PE)

Ø LM1 – Which part occupies the fundus?
Ø LM2 – Which side is the fetal back palpated? Figure 2. Frank breech presentation
Ø LM3 – Presenting part (above the pelvic inlet)
Ø LM4 – Breech beneath the Pubic symphysis
v COMPLETE
Ø Both hips are flexed
ST
U REMEMBER: 1 3 maneuvers (LM1-LM3) the position of OR one or both knees
the examiner is facing the patient, while in LM4, the examiner are flexed
faces the feet of the patient.
2. DO INTERNAL EXAMINATION (IE)/PELVIC EXAM
v U Use fingers to palpate and usually 2 different presentations are
interchanged, namely:
Ø BREECH – Ischial tuberosity, Anus
§ U You will be able to palpate the trochanter and the anus
on a straight line (Sabi ni doc sa recording, trochanter Figure 3. Complete breech
pero yung nakalagay sa ppt, ischial tuberosity, so…) presentation
Ø FACE – Malar eminences, Mouth
§ U You will be able to palpate the important parts, malar
eminences and mouth on a triangular position v INCOMPLETE
Ø One or both hips are
extended OR one or
both knees or feet lie
below the breech. A
foot or knee is
lowermost the birth
canal

Figure 4. Incomplete breech

presentation

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.

DEPENDING ON THE AOG:

v STARGAZING FETUS a. 20 - 25 weeks (periviable fetuses) – consensus
Ø An incomplete breech with one or both feet below the breech (Raju, 2014) support that routine CS does not
Ø U Of the term breech fetuses, the neck may be extremely improve neonatal and neurological outcomes
hyperextended in perhaps 5% ¨ U Why? Because these are periviable, they
are so small. There won’t be disproportion in
FLYING FETUS the fetal head yet and fetal trunk
v With a transverse lie and with similar hyperextension of the b. 23 - 28 weeks – ACOG 2017 states considerations
fetal neck for CS at 23 weeks and recommends CS at 25
weeks.
¨ U 23 – 28 weeks, we recommend caesarean
III. RISK FACTORS section because of the disproportion over the
head and the breech. You might have a
v Aids in the early recognition complication of an entrapment of the
v Early Gestational Age aftercoming head. Magdedeliver na simula sa
Ø U Because it hasn’t stabilized the position buttocks up to the scapular area but the head
v Extremes of AFV won’t because the head is usually bigger. The
Ø U For those with polyhydramnios, there will be a lot of weight recommended is < 2500 grams.
movements for the fetus and it will be floating for the rest of Because > 2500 – 3500/3800 is an
the gestational age equalization or proportionate size of the head
v Multifetal Gestation and the trunk.
v Hydrocephaly/ Anencephaly c. 24 - 32 weeks – (Reddy and associates 2012)–
Ø Congenital anomalies on the part of the fetus attempting vaginal delivery yielded low success
v Structural Uterine Abnormalities/ Pelvic Tumors rates, higher mortality rates vs CS.
v Imperative to check on this d. 32 - 37 weeks – CS vs vaginal shows similar
v U Makes the space difficult for the fetus to be on a cephalic perinatal mortality rates but LESS composite
position mortality and severe morbidity.
v Placenta Previa ¨ U No definite recommendation, consider fetal
Ø U Placenta implants down near the cervix, the head will favor weight rather than age of gestation.
more to occupy the fundus because of implanted placenta
below
v MFMC SOGC (Maternal Fetal Medicine Committee,
v Previous Breech
Society of Obstetricians and Gynecologists of Canada) –
Ø Recurrence rate for a second breech presentation is 10%
vaginal breech delivery, reasonable if weight is > 2500
Ø For a subsequent third breech is 28%
gms for singleton pregnancies.
v It is different for twins.
IV. ROUTE OF DELIVERY Ø U You don’t plan a vaginal delivery if there is a
malpresented fetus in a multifetal pregnancy
v U There are complications in the different routes of delivery, like
in vaginal delivery of a breech presenting fetus, it may cause
cervical spinal cord injury on the neonate.
v Consider multiple factors to determine the BEST for the MOTHER- VII. COMPLICATIONS OF DELIVERY
FETUS pair
Ø Gestational Age MATERNAL FETAL
§ Whether term or preterm v Genital tract lacerations v Prematurity
Ø Fetal characteristics v Deep perineal tears v Congenital anomalies
§ if there is anomaly, the fetal lie v Infections v Cord prolapse
Ø Maternal pelvic dimensions v Uterine atony v Fractures (e.g. spinal cord
Ø Coexistent pregnancy complications injuries)
§ Like diabetes, hypertension v Soft tissue injuries
Ø Provider expertise
Ø Patient preference/consent v U Sometimes for breech presenting fetuses, hip dysplasia is
Ø Hospital capabilities inherent

V. TERM BREECH FETUS VIII. DECISION-MAKING SUMMARY

v Studies by Hannah 2000 (term breech trial) revealed that CS v ACOG 2016b recommendations for the mode of delivery for breech
delivery is favored vs vaginal delivery, and resulting to less depends on:
neonatal morbidity. Ø expertise of the provider
v Additional study by WHO (Lumbiganon 2010) – favors CS and Ø planned vaginal delivery should be under equipped hospital
found that with planned CS vs vaginal delivery, there was setting
improved perinatal outcome Ø following set guidelines POGS (Philippine Obstetrical and
v In Contrast, other studies (Hofmeyr, 2015a ; Goffinet 2006; Michel Gynecological Society).
2011; Eide et al 2005) support vaginal delivery as a suitable option Ø consent of patient (discussed prior to delivery)
at term. (no significant difference in the neonatal outcome) v MINIMUM Requirements for a planned vaginal delivery:
v Despite all debates: At least in the US rates of planned vaginal 1. Adequate pelvis (birth canal sufficiently large)
delivery attempts DECLINED

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

DELIVERY OF THE AFTERCOMING HEAD

v Index and middle fingers over the maxilla to flex the head while
body rests on the forearm. (MAURICEAU maneuver)
v Specialized forceps (Piper) may be used to deliver the after coming
head.
v Modified Prague maneuver
Ø U Hold the fetal neck and grasp the foot then push the feet
towards the maternal abdomen slowly and gently to flex the
head

Figure 7. Cardinal Movements of Labor and Delivery

XII. PARTIAL BREECH EXTRACTION Figure 11. Forceps delivery of the aftercoming head
v Larger and less compressible parts are born first.
v Episiotomy is an important adjunct to delivery (especially if
perineum is not tested yet)
v Assisted (maneuvers) delivery after fetal body at the level of
umbilicus has spontaneously been delivered.
Ø External rotation of the sacrum to anterior position (mother
encouraged to push as fetus descends until legs are
accessible
Ø Do Pinard’s maneuver
U Wherein we press the popliteal fossa so that the legs will
flex and then try to deliver grasping the foot out of the
perineum
U First maneuver is the Pinard’s
Figure 12. Delivery of the aftercoming head using Mauriceau maneuver

Figure 13. Delivery of the aftercoming head using

the modified Prague maneuver

1S-4 DISORDERS OF AFV & ABNORMALITIES OF PLACENTA, FETAL MEMBRANES & CORD ESTUYE • HO • JAVIER • RAMOS • ROCHA
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 HEAD ENTRAPMENT

Figure 15. Complete breech extraction

Figure 14. Duhrssen incision begins with traction on the feet and ankles

Figure 16. External cephalic version

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

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