Ebook Clinics in obstetrics: Part 2

CHAPTER 12

Breech Presentation
Tania G Singh

DEFINITION
• Defined as a fetus in a longitudinal lie with the buttocks or feet closest to the cervix (at the
maternal pelvic outlet)
• Commonest of all the malpresentations.

INCIDENCE
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3–4% of all deliveries

Decreases with advancing gestational age:
– 22–25% of births prior to 28 weeks gestation
– 7% of births at 32 weeks gestation
– 1–3% of births at term
Fetal abnormalities are observed in:
– 17% of preterm breech deliveries
– 9% of term breech deliveries
Cord prolapse occurs in:
– 0–2% with frank breech
– 5–10% with complete breech
– 10–25% with footling breech
– 6% in multigravidas
– 3% in primigravidas
Nuchal arms (one or both arms are wrapped around the back of the neck) are present in:
– 0–5% of vaginal breech deliveries
– 9% of breech extractions
Fetal head entrapment (results from an incompletely dilated cervix and head that lacks time to
mold to the maternal pelvis):
– 0–8.5% of vaginal breech deliveries
• Perinatal mortality:
– Increased 2–4 fold with breech presentation, regardless of mode of delivery
– Commonest causes:

- Malformations

- Prematurity

- Intrauterine demise.

404 Section 1: Long Cases

PREDISPOSING FACTORS
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Prematurity (most common cause)
Uterine malformations (septate; bicornuate uterus)
Fibroids and cysts
Polyhydramnios
Oligohydramnios
Placenta previa
Cornual or fundal placement of placenta
Fetal abnormalities (e.g. CNS malformations—anencephaly, Down’s syndrome, hydrocephalus;
myotonic dystrophy, neck masses, heart and GIT disorders)
Multiple gestation
Multiparity
Breech presentation in the previous pregnancy
Stretched and weakened uterine muscle

Short umbilical cord.

TYPES OF BREECHES
• Frank or extended breech (50–70%)—Hips flexed, knees extended (pike position). Least
associated with cord prolapse. Good dilator of the cervix
• Flexed or complete breech (5–10%)—Hips flexed, knees flexed (cannon ball position)
• Footling or incomplete (10–30%)—One or both hips or knees extended, foot presenting
• Kneeling breech—fetus is in a kneeling position, one or both legs extended at the hips and flexed
at the knees. This is extremely rare.

DIAGNOSIS
I. Physical examination
Suspect breech presentation if:
• On abdominal examination

– The presenting part,

- Feels irregular

- Is not ballotable and

- A hard round ballotable head is found in the fundus

– Fetal heart sounds are heard high in the abdomen (usually around or above the umbilicus)

– Fetal back and irregular parts are felt on sides
• On pelvic examination:

– The head is not felt in the pelvis

– Soft, globular buttocks may be felt

OR

– Bony parts like ischial tuberosities, sacrum or heel of foot may be felt

– Prominence of the heel and less mobile great toe can help identify the foot

– Thick, formed meconium may be present once the membranes are ruptured
II. Ultrasound:
• Most reliable method:

– Confirm type of breech presentation (frank, complete or footling breech)

– Estimate fetal weight


Chapter 12: Breech Presentation 405





– Exclude hyperextension of the fetal head
– Exclude placenta previa
– Assess fetal morphology.

Vaginal versus Cesarean Section for Breech Delivery (Past Scenario)
• Vaginal breech deliveries were previously the norm until 1959 when Wright proposed that all
breech presentations should be delivered abdominally to reduce perinatal morbidity and

mortality.
• Term breech Trial by Mary Hannah, Walter Hannah and Andrew Willian (2000) found cesarean
section to produce better outcomes than vaginal breech delivery but did acknowledge that it may
be due to the lost skills of operators. Therefore, the recommended mode of delivery is cesarean
section. Since then the rate of cesarean birth for the term breech has increased dramatically.
• Important considerations for vaginal breech delivery are size of fetus, presentation, attitude, size
of maternal pelvis and parity of the woman.
Case: A primigravida presents at 36 weeks period of gestation, sure of her dates, and also
corresponding with 1st trimester USG, with pain abdomen. On examination: vitals are stable. Per
abdomen examination reveals a breech fetus with uterine height corresponding to 32 weeks. Per
vaginal examination: cervix 1.5 cm dilated, 1.5 cm length, presenting part high up, with bulging
membranes. What will be your mode of delivery?
Since this is a case of severe IUGR and preterm labor with breech presentation → the ideal mode of
delivery would be by cesarean section. The other indications for the procedure are mentioned below.

Indications for Cesarean Section
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Large baby
Footling or kneeling breech presentation
Suspicion of an inadequacy of the pelvis
Prolonged labor
Baby with intrauterine growth restriction
Previous cesarean section
Oligohydramnios (less amniotic fluid)
Fetal anomaly incompatible with vaginal delivery
Preterm labor
Placenta previa
Associated other obstetric and medical complications where vaginal birth is contraindicated
Hyperextended fetal neck in labor (diagnosed on USG)—Star gaze sign
Obstetrician or medical personnel not well trained in vaginal breech delivery
Delay in descent of the breech any time during the 2nd stage of labor
Persistent cord presentation.

1. If you have opted for cesarean section, which manoeuvres can be performed during the
procedure? Are there any other complications associated apart from those which are
procedure related?



Manoeuvres for cesarean delivery
• Similar to those for vaginal breech delivery, including the Pinard manoeuvre, wrapping the
hips with a towel for traction, head flexion during traction, rotation and sweeping out of the
fetal arms and the Mauriceau Smellie Veit manoeuvre

406 Section 1: Long Cases



















• An entrapped head can still occur during cesarean delivery as the uterus contracts after
delivery of the body, even with a lower uterine segment that misleadingly appears adequate
prior to uterine incision
– Entrapped heads occur more commonly with preterm breeches, especially with a low
transverse uterine incision
– As a result, some practitioners opt to perform low vertical uterine incisions for preterm
breeches prior to 32 weeks gestation to avoid head entrapment and the kind of difficult
vaginal delivery to avoid which cesarean delivery was performed
– Low vertical incisions usually require extension into the corpus, resulting in cesarean
delivery for all future deliveries

– If a low transverse incision is performed and difficulty is encountered with delivery of
the fetal head, the transverse incision can be extended vertically upward (T-incision).
Alternatively, the transverse incision can be extended laterally and upward, taking great
care to avoid trauma to the uterine arteries
– A third option is the use of a short-acting uterine relaxant (e.g. nitroglycerin) in an attempt
to facilitate delivery.
Complications associated with cesarean section:
• Increased risk of pulmonary embolism
• Infection
• Bleeding
• Damage to bladder and bowel
• Slower recovery
• Longer hospitalization
• Respiratory difficulties for the baby
• Delayed bonding and breastfeeding
• Compromise of future obstetric performance.

Vaginal Breech Delivery
Precautions
• It should be a frank breech and near full-term. Any other type will not dilate the birth canal
adequately
• Head of the fetus should be flexed, with the baby’s chin on his or her chest
• Mother should have a ‘proven’ pelvis, means either she should have delivered a child previously
that was as big or bigger than breech fetus in index pregnancy or in case of primigravida, mother’s
pelvis is adequate for the weight/size of the baby at the time of planning labor
• The doctor and other medical personnel should be experienced in attending breech births
• Spontaneous and normally progressing labor
• A healthy and well mother and fetus
• It should take place in a hospital setting where there is well-maintained operation theater for
emergency cesarean section

• Epidural analgesia is not routinely recommended.
Types–mainly 3
Spontaneous breech delivery
• It is the natural expulsive action producing:
– An upward rotation of the baby’s back around the symphysis of the mother
– Simultaneous delivery of the arms and shoulders in that order, and
– An attitude of extension facilitating the delivery of the head


Chapter 12: Breech Presentation 407

• No traction or manipulation of the fetus
• Occurs predominantly in very preterm, often previable, deliveries
Assisted breech delivery
• Most common type
• There is:
– Downward traction in the direction of the birth canal
– Rotation of the shoulders into an anteroposterior position with delivery of each arm
– Followed by manual or instrumental delivery of the head
OR
The Bracht manoeuvre
• It is a variant approach to the assisted vaginal breech delivery.
Total breech extraction
• Feet are grasped, and the entire fetus is extracted
• Should be used only for a noncephalic second twin
• Should not be used for a singleton fetus because the cervix may not be adequately dilated to
allow passage of the fetal head
• Should not be routinely performed (causes extension of the arms and head)
• Birth injury rate ≈ 25%
• Mortality rate ≈ 10%

• Sometimes performed by less experienced accoucheurs when a foot unexpectedly prolapses
through the vagina
Footling breech presentation: Once the feet have delivered, never get tempted to pull the feet.
This action may precipitate head entrapment in an incompletely dilated cervix or may precipitate
nuchal arms. As long as the fetal heart rate is stable and no physical evidence of a prolapsed cord
is evident, management may be expectant while awaiting full cervical dilation.

General Considerations
• Continuous electronic fetal heart monitoring is preferable in the 1st stage and mandatory in the
2nd stage of labor. Descent of breech and entry of umbilical insertion into the pelvis are commonly
associated with an increased incidence of cord compression and variable decelerations
• Fetal membranes should be left intact as long as possible to act as a dilating wedge and to prevent
overt cord prolapse
• If there is inadequate progress, proceed for cesarean section
• Induction of labor:
– Not recommended for breech presentation
– Oxytocin induction and augmentation—controversial. Concerns that nonphysiologic forceful
uterine contractions could result in an incompletely dilated cervix and an entrapped head
– Oxytocin augmentation is acceptable in cases of uterine dystocia due to epidural analgesia
• Assessing full dilatation in breech presentation is more difficult than in cephalic presentation
because the fully dilated cervix does not disappear behind the cephalic crown. Instead, the
cervix remains palpable as the fetal trunk descends through it
• Avoid pushing before full dilatation
• Assess for and perform episiotomy, if required, in between contractions. Some routinely perform
episiotomy even in multiparas to prevent soft tissue dystocia
• Hands off until there is reason to assist
• Anesthesiologist and pediatrician should be informed in advance and be available if and when
required

408 Section 1: Long Cases

• Thick meconium passage is common as the breech is squeezed through the birth canal. This
is usually not associated with meconium aspiration because the meconium passes out of the
vagina and does not mix with the amniotic fluid.

Highlights of the Assisted Breech Delivery
Once the buttocks have crowned, maximize maternal bearing down efforts, upright posture and
suprapubic pressure
• After crowning, an assistant should exert gentle suprapubic pressure from above to keep the fetal
head flexed and facilitate its engagement
• The Ritgen type manoeuvre can be applied to take pressure off the perineum during vaginal
delivery.
The Original Ritgen Manoeuvre
• Delivery of the head of the fetus by pressure on the perineum while controlling the speed of
delivery by pressure with the other hand on the head
• Named after Franz von Ritgen, a German obstetrician
• No downward or outward traction should be exerted on the fetus until the umbilicus is past the
perineum.
Delivery of Legs
• Do per vaginal examination and check for the position of the legs
• If the legs are flexed, they will deliver spontaneously with the next contraction
• If the legs are extended, they are delivered by Pinard’s manoeuvre
– Flex the knee by applying gentle pressure on the popliteal fossa by index and middle fingers
and then hook it down by movement of abduction
• Use a dry towel to wrap around the hips (not the abdomen) to help with gentle downward and
outward traction, which is applied in conjunction with maternal expulsive efforts until the
scapula and axilla are visible.
Delivery of Arms
• After spontaneous delivery to the fetal umbilicus, expulsive delay despite power from above,

with or without nuchal arms may require manoeuvres involving fetal manipulation
• The Løvset and Bickenbach manoeuvres are the best described:
– Only the bony fetal pelvis and legs should be grasped to avoid damage to the fetal adrenal
glands, which are disproportionately large
– Traction on the fetus should be minimized to avoid trapped after-coming fetal parts
– As a breech fetus transits the pelvis, normal fetal tone and uterine compression keep its head
and arms flexed. Fetal manipulation prior to entrance of the elbows and chin into the pelvic
inlet can induce extension of fetal limbs and head (Moro reflex) resulting in trapped aftercoming fetal parts
– Once the scapula is visible, rotate the infant 90° and gently sweep the anterior arm out of the
vagina by pressing on the inner aspect of the arm or elbow
– Rotate the infant to 180° angle in the reverse direction, and sweep the other arm out of the
vagina
– Once the arms are delivered, rotate the infant back to 90° angle so that the back is anterior
Delivery of the Fetal Head—The Most Decisive and Fundamental Step:
• Should not take >10–15 minutes
• Various manoeuvres can be followed in practice


Chapter 12: Breech Presentation 409

I. Burns—Marshall technique

• For delivering the head in a breech delivery, if it does not deliver spontaneously:

– Allow baby’s body to hang until you can see the hair at the back of the neck

– Hold the feet

– Swing the feet upwards over to the mother’s abdomen

– Free the baby’s mouth and pause while you clean it

– Finish delivery by swinging the baby over the mother’s abdomen
II. Mauriceau-Smellie-Veit manoeuvre or Mauriceau manoeuvre (named after François
Mauriceau, William Smellie and Gustav Veit)

• An obstetric or emergent medical manoeuvre done by an assistant and an obstetrician to
maintain the head in a flexed position to allow its smallest diameter to pass

– Assistant: applies suprapubic pressure

– Obstetrician

Inserts left hand in the vagina

- With the index and middle finger on either side of the maxilla, gently press on it,
bringing the neck to a moderate flexion

- Left hand’s palm should rest against the fetal chest
Right hand

- Ring and little fingers placed on the baby’s right shoulder

- Middle finger in suboccipital region

- Index finger on the left shoulder

– Aim of the manoeuvre

- Neck flexion

- Traction on the fetus toward the hip/pelvis

- Suprapubic pressure to allow for delivery of the fetal head
III. Alternatively, Piper forceps can be used for head flexion

• Introduced by Edmond Piper of Philadelphia in 1927. It has long shanks and a perineal
curve

• Piper forceps are specialized forceps used only for the after-coming head of a breech
presentation

– An assistant is needed to hold the fetal body in a horizontal plane

– The operator gets on one knee to apply the forceps from below

– Unlike conventional forceps, these are not tailored to the position of the fetal head (i.e. it
is a pelvic, and not cephalic, application).

• Technique:

– The after-coming head must have descended to fill the pelvis and must be in direct
occipitoanterior position


– Assistant holds trunk of fetus upwards horizontally, so that it may be out of way as much
as possible

– Forceps blades are introduced at 4 o’clock and 8 o’clock position and made to lie against
the sides of the head through a short arc


410 Section 1: Long Cases



– Handles then lie along ventral aspect of fetus, so as to promote flexion



– Traction first made downwards and backwards till chin appears, then forceps and fetus
are carried upwards towards the mother’s abdomen

Advantages
• Very little or no traction is needed for delivery with Piper’s forceps
• Controlled delivery of head
• Flexion is well maintained
• Pull is directly applied over fetal head contrary to other manual methods, where it is applied via
vertebral column.
Precaution
• During delivery of the head, avoid extreme elevation of the body, which may result in
hyperextension of the cervical spine and potential neurologic injury.
Erich Franz Bracht Manoeuvre
• First described in 1935 by a German gynecologist for delivering the frank breech with minimal
interference
• Can be used as an alternative to assisted breach delivery mentioned above
– The breech is allowed to deliver spontaneously to the umbilicus without push or pull
– The knee-extended legs of the flexed breech are not brought down

– The body and extended legs are then grasped in both hands, with the fingers around the lower
back and the thumbs around the posterior aspect of the thighs, while the upward and anterior
rotation of the body is maintained
– When the anterior rotation is nearly complete, the baby’s body is held, not pressed, against
the mother’s symphysis using only a force equivalent to the weight of that portion of the baby
already born
– The mere maintenance of this position, added to the uterine contractions and, if necessary,
gentle suprapubic pressure by an assistant, allows the baby’s head to deliver spontaneously in
full extension.

Mode of Delivery
• Position of choice → Lithotomy.
Delivery of buttocks
• Engagement → when bitrochanteric diameter enters the pelvic inlet
• Sacrum is in the left anterior quadrant
• Bitrochanteric diameter enters the pelvic brim in the left sacroanterior position
• Further contractions will lead to descent of breech but it is usually slow
• Anterior buttocks reach the pelvic floor and rotate 1/8th of a circle (45°) into the anteroposterior
diameter (i.e. forward, downward and towards the midline)
• Anterior hip escapes under the symphysis pubis → lateral flexion occurs → posterior hip rises
and sweeps over the perineum
• Buttocks are born.
Delivery of legs
• Restitution occurs to the mother’s right → Legs will usually be born with further contractions →
Babies with legs extended might require assistance


Chapter 12: Breech Presentation 411

• When popliteal fossae present at vulva, flex knee by placing index finger in popliteal fossa

• Sweep leg outwards abducting hip slightly
• Repeat manoeuvres with second leg → Second leg is born → Hands off—allow breech to deliver
with contractions and maternal effort.
Delivery of arms
• Engagement of shoulders occurs in left oblique diameter of the pelvis
• Anterior shoulder rotates under the symphysis
• Bisacromial diameter turns 1/8th of the circle from left oblique to anteroposterior diameter and
escapes under the symphysis pubis → Posterior shoulder sweeps the perineum → Arms will
usually be born spontaneously.
Delivery of after-coming head
• When the shoulders are at the outlet, the head is entering the pelvis
• Head enters the pelvic brim with the sagittal suture in the oblique or transverse diameter
• Occiput, which is in the left anterior quadrant of the pelvis, rotates forward, accompanied by
simultaneous external rotation of the body
• Maintain flexion of the head
• No touch—until nape of neck visible
• Head comes to the outlet with the sagittal suture in the anteroposterior diameter and the occiput
comes under the symphysis
• Sacrum rotates towards the pubis to make the back anterior
• When the nape of the neck comes under the symphysis, the chin, mouth, nose, forehead and,
finally, the occiput is born by a movement of flexion.

Complications
Fetal Complications
1. Lower Apgar scores, especially at 1 minute:
• Many advocate obtaining an umbilical cord artery and venous pH for all vaginal breech
deliveries to document that neonatal depression is not due to perinatal acidosis
2. Fetal head entrapment:
• May result from an incompletely dilated cervix and a head that lacks time to mold to the
maternal pelvis

• Occurs in 0–8.5% of vaginal breech deliveries
• The above percentage is higher with preterm fetuses (< 32 weeks), when the head is larger
than the body
• Dührssen incisions (i.e. 1–3 cervical incisions made to facilitate delivery of the head) may
be necessary to relieve cervical entrapment. However, extension of the incision can occur
into the lower segment of the uterus, and the operator must be equipped to deal with this
complication
• The Zavanelli manoeuvre has also been described, involving replacement of the fetus into
the abdominal cavity

– Fetus that has begun to show is pushed back into the vagina until it can be delivered by
cesarean section

– First described in the 1970s, it is used both for breech presentations and for cases in which
the fetus has a cephalic presentation but the shoulders are stuck

– While success has been reported with this manoeuvre, fetal injury and even fetal death
have occurred


412 Section 1: Long Cases

3. Nuchal arms (one or both the arms are wrapped around the back of the neck):
• Present in 0–5% of vaginal breech deliveries and in 9% of breech extractions
• Nuchal arms may result in neonatal trauma (including brachial plexus injuries) in 25% of the
cases
• Risks may be reduced by avoiding rapid extraction of the baby during delivery of the body
• To relieve nuchal arms when it is encountered, rotate the fetus so that the face turns towards
the maternal symphysis pubis; this reduces the tension holding the arm around the back of
the fetal head, allowing for the delivery of the arm

• Nuchal arms may be reduced by the Løvset or Bickenbach manoeuvres
4. Damage to spine or spinal cord:
Positioning the baby incorrectly while using forceps to deliver the after coming head can damage
the spine or spinal cord
Cervical spine injury
• Predominantly observed when the fetus has a hyperextended head prior to delivery
• Complete cervical spine injury can be in the form of transection or nonfunction
Cord prolapse:
• May occur in 7.4% of all breech labors
• This incidence varies with the type of breech: 0–2% with frank breech, 5–10% with complete
breech, and 10–25% with footling breech
• Cord prolapse occurs twice as often in multiparas (6%) than in primigravidas (3%)
• Cord prolapse may not always result in severe fetal heart rate decelerations because of the
lack of presenting parts to compress the umbilical cord
6. Oxygen deprivation:
• May occur from either cord prolapse or prolonged compression of the cord during birth, as in
head entrapment
• It may cause permanent neurological damage or death
7. Injury to the brain and skull:
• This may occur due to the rapid passage of the baby’s head through the mother’s pelvis
• More likely to occur in preterm babies
8. Damage to the internal organs:
• This can occur due to squeezing of the baby’s abdomen.



5.

Maternal Complications
1.
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3.
4.

Tears of the genital tract
Complications associated with cesarean section, instrumental deliveries
Infection due to manipulations
Maternal anxiety.

Factors Leading to Adverse Effects on the Fetal Outcome
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Older mothers
Footling presentation
Hyperextended fetal head
Low birth weight
Prolonged labor
Nonexperienced clinician.


Chapter 12: Breech Presentation 413

Vaginal Versus Cesarean Delivery (Present Scenario)

• After 37 weeks gestation, options for the mode of delivery should be discussed with both the
parents explaining the risks in detail
• Prematurity, which is the greatest risk factor associated with intraventricular hemorrhage,
should not be misinterpreted for trauma during delivery
• For estimated fetal weight ≥ 3.5 kg, cesarean delivery should be opted for because of the concern
for entrapment of the unmolded head in the maternal pelvis, although data to support this
practice are limited
• A frank breech presentation is preferred when vaginal delivery is attempted. Complete breeches
and footling breeches are still candidates for vaginal delivery, as long as the presenting part is
well applied to the cervix and both obstetrical and anesthesia services are readily available in the
event of a cord prolapse
• The fetus should show no neck hyperextension on antepartum ultrasound imaging. Flexed or
military position is acceptable
• Vaginal breech delivery after one prior cesarean delivery is not contraindicated, though larger
studies are not available on it. Studies showing success of vaginal breech delivery with prior
one cesarean section are available but simultaneously complications like nuchal arm, brachial
plexus injury, uterine dehiscence with subsequent hysterectomy have also been reported in
literature.

Primigravida Versus Multiparous
• It had been commonly believed that primigravida with a breech presentation should have a
cesarean delivery, although no data (prospective or retrospective) support this view
• The only documented risk related to parity is cord prolapse, which is 2-fold higher in parous
women than in primigravid women.

EXTERNAL CEPHALIC VERSION
• Transabdominal manual rotation of a fetus presenting as breech into a cephalic presentation

Historical Considerations
• Initially popular in the 1960s and 1970s, ECV virtually disappeared with time, after reports of

fetal deaths following the procedure.

Prerequisites for ECV
1. Written and informed consent (explaining the risks, need for emergency cesarean section or
induction of labor, adverse effects of tocolytics)
2. Recent USG (preferably on day of ECV) to confirm the presentation, rule out congenital
anamolies, to note placental location and for adequacy of amniotic fluid
3. Performed in the labor room with immediate approach to the operation theater
4. Adequate pelvis
5. Average size baby weight
6. Reassuring NST
7. Adequate amniotic fluid


414 Section 1: Long Cases

8.
9.
10.
11.
12.
13.
14.
15.
16.
17.

Relaxed uterus
Appropriate gestational age
Skilled operator

Breech should not be engaged
Patient should be on IV fluids PREFERABLY but not necessary (NPO, at least 4–6 hours prior to
the procedure)
Immediate measures for emergency cesarean section (blood availability, OT, anesthetist,
pediatrician)
No other obstetric or medical complication
Some prefer to have an assistant to help turn the fetus, elevate the breech out of the pelvis or to
monitor the position of the baby with ultrasonography
Excessive force should not be used at any time, as this may increase the risk of fetal trauma
No consensus has been reached regarding how many ECV attempts are appropriate at one
time.

Period of Gestation
• 35–36 weeks in nulliparous
• From 37 weeks in multiparous.

Candidates for ECV
•
•
•
•




Fetus in breech presentation
Reassuring fetal heart rate tracings
No contraindications to vaginal delivery at ≥ 36 weeks gestation
Usually not performed on preterm breeches because:
– They are more likely to undergo spontaneous version to cephalic presentation

– They are more likely to revert to breech after successful ECV (approximately 50%)
– If complications occur, they will result in preterm neonate (iatrogenic prematurity).

Contraindications
Absolute Contraindications
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Inadequate pelvis
Multiple gestation with a breech-presenting fetus (except in delivery of the 2nd twin)
Vaginal bleeding (within the past 1 week)
Major fetal anamoly
Contraindications to vaginal delivery (e.g. active herpes simplex virus infection, placenta previa)
Nonreassuring fetal heart rate tracing
Premature rupture of membranes
Other obstetric complications (severe preeclampsia, maternal cardiac disease, etc.)
Cord around the fetal neck.

Relative Contraindications
• Polyhydramnios (associated with spontaneous reversion)
• Oligohydramnios

Chapter 12: Breech Presentation 415

•
•
•
•
•

Fetal growth restriction
Small for gestational age fetus with abnormal doppler
Uterine malformation
Scarred uterus
Unstable lie (in cases where induction is not planned).

Controversial Candidates
• Women with prior uterine incisions
• Performing ECV on a woman in active labor.

Procedure
•
•
•
•
•
•

In delivery room
Before ECV, foot-end elevation (of bed) to help disengage the breech
Sprinkle powder over the abdominal wall → mother’s skin can get very red and sore
Scan to confirm breech and position of fetal back

NST to be performed before and after the procedure
Tocolytics-β sympathomimetics, slow IV or bolus subcutaneous routes can be used (ritodrine,
terbutaline, salbutamol) but not with glyceryl trinitrate, as a patch or sublingually or with
nifedipine
• If rhesus negative → anti-D Ig given
• If successful → followed either by induction of labor (keeping in mind the unengaged head and
unripe cervix) or the patient can be discharged
• If unsuccessful → can wait (expectant management allows the possibility of spontaneous
version) or cesarean section, especially if regional anesthesia given, minimizing the risk of
second regional anesthesia.

Success Rate
•
•
•
•









Range from 30–80%
Overall success rate of 25–40% for nulliparas and 60% for multiparous women
Performance of ECV decreases the cesarean delivery rate by ≈ 50%
Improved success rates occur with:
– Multiparity

– Earlier gestational age
– Frank (versus complete or footling) breech
– Transverse lie
– Thinner patients
– Posterior placenta
– Adequate amniotic fluid volume
– Skill of the practitioner (≈ 30–80% of attempts will be successful, depending on the case
selection).

Note:
• As the incidence of breech presentation is only 3–5% of all deliveries, decreasing the cesarean
delivery rate for breeches by 50% will have only a marginal impact on the overall cesarean section
rate.


416 Section 1: Long Cases
Newman score (to predict ECV success)
Add 0 points

Add 1 point

Add 2 points

Parity

0

1

>2

Dilatation

>3 cm

1–2 cm

0 cm

EFW

<2500

2500–3500

>3500

Placenta

Anterior

Posterior

Fundal/lateral

Station

> –1

–2

< –3

• Score < 2 → 0% successful
• Score> 9 → 100% successful.

Risks
Common Risks
• Alterations in fetal parameters:
– Fetal bradycardia and subsequent nonreactive NST → both are transient
– Alterations in umbilical artery and middle cerebral artery waveforms and an increase in
amniotic fluid volume:

- Occurs in ≈ 12–40% of cases

- Believed to be a vagal response to head compression with ECV

- Usually resolves within a few minutes after cessation of the ECV attempt

- Not usually associated with adverse sequelae for the fetus
• Unsuccessful ECV
• 35% report mild-to-moderate discomfort during procedure
• Failure of induction, if induced immediately after ECV with unengaged head and unriped cervix.

Uncommon Risks
•
•
•
•
•

•
•
•
•
•
•

Spontaneous reversion to breech (<5%)
Dizziness and palpitations from tocolysis (4%)
High pain score (≈ 5%)
Fetomaternal hemorrhage (0–5%)
Cord entanglement (< 1.5%)
Precipitation of labor
Premature rupture of membranes
(<1%)
Abruptio placentae
Profound fetal bradycardia
Fractured fetal bones
Possibility of emergency cesarean section–0.5% (e.g. because of placental abruption following
the procedure)
• Small increase in instrumental delivery.

Tocolytics
• Data regarding the benefit of intravenous or subcutaneous beta-mimetics in improving ECV
rates are conflicting
• Whether tocolysis should be used routinely or selectively is still unclear.


Chapter 12: Breech Presentation 417

Regional Anesthesia
Regional analgesia, either epidural or spinal, may be used to facilitate external cephalic version
(ECV) success.

Advantages
• When analgesia levels similar to that for cesarean delivery are given, it allows relaxation of the
anterior abdominal wall, making palpation and manipulation of the fetal head easier
• Eliminates maternal pain that may cause bearing down and tensing of the abdominal muscles
• After successful ECV, epidural can be removed and the patient sent home to await spontaneous
labor or labor is induced (as per indication)
• If ECV is unsuccessful, patient can proceed to cesarean delivery under her current anesthesia, if
fetal lung maturity has been documented.

Disadvantages
• Inherent risk of regional analgesia, which is considered small
• Lack of maternal pain could potentially result in excessive force being applied to the fetus
without the knowledge of the operator.

Acoustic Stimulation
• Data is scant, though a study conducted, comparing acoustic stimulation prior to ECV with a
control group when the fetal spine was in the midline, showed 100% results in shifting of fetus to
a spine lateral position after stimulation and 91% had successful ECV.

Amnioinfusion
• Amnioinfusion to facilitate ECV cannot be recommended at this time as studies have not proved
its efficacy.

Cesarean Section Rates after Successful Version
Ranges from 0–31% after successful external cephalic version (ECV)
Following factors can be attributed

1. Labor dystocia
2. Increased frequencies of compound presentations after ECV
3. Can revert back to breech
4. Failed induction in women with unripe cervices and unengaged fetal heads
5. Nonreassuring NST after ECV
6. Cephalopelvic disproportion.

Breech Delivery with Hydrocephalic Head
• Most favorable method in case of hydrocephaly because after-coming head is so easily deflated
• Baby delivered till body and arms, the body is then pulled down and transverse incision is made
over the highest available cervical spine of fetus
• Straight metal catheter, then introduced into the spinal canal and thrust through the foramen
magnum to drain excess cerebrospinal fluid
• Becomes even easier when spina bifida is present
• After deflation, delivery is quickly completed
• When baby can be salvaged, cesarean section is the choice.


418 Section 1: Long Cases

1.







What are the risks associated with preterm breech?
Risks

• Intrapartum asphyxia
• Cord prolapse
• Entrapment of after-coming head
– Delivery of the trunk through an incompletely dilated cervix can lead to head entrapment
during a preterm breech delivery. Therefore, lateral incisions of the cervix should be
considered
• Routine cesarean section is not recommended for preterm breech.

2. What is Zatuchni-Andros Scoring system or Breech Index Scoring system?
It is a prognostic scoring system to decide mode of delivery in breech presentation.
Factor

Score
Add 0 points

Add 1 point

Add 2 points

Parity

0

1

2

Gestational age

≥ 39 weeks

37–38 weeks

36–37 weeks

Previous breech > 2.5 kg

0

1

≥2

Estimated fetal weight

> 3.5 kg

3–3.5 kg

< 2kg

Cervical dilatation

2

3

≥4

Station of breech

–3 and above

–2

–1 or lower








Assessment is to be made at the onset of labor
Total score = 11
Score 0–3 → LSCS
Score 4–5 → careful review and to proceed with caution
Score > 5 → reasonable chance for successful vaginal delivery
One point should be subtracted for footling breeches, as they are somewhat difficult to manage.

3. Describe the Westin scoring system.
It is used for selecting the mode of delivery in breech.
Parameters
0
Inlet, AP diameter
Inlet, Transverse diameter
Outlet, AP diameter
Outlet, Interspinous diameter
Intertuberous diameter

Sum of outlet
Estimated weight (g)
Presentation

<11.5
<12.5
<10.5
<10
<10
<32.5
<1500, >4000
Double footling

Soft parts

Unripe cervix and
rigid pelvic floor
None

Previous deliveries

Score
1
11.5–12
12.5–13
10.5–11
10–10.5
10–11
32.5–33.5
1500–2000

Complete breech,
single footling
Unripe cervix or rigid
pelvic floor
Uncomplicated
breech

2
>12
>13
>11
>10.5
>11
>33.5
2000–3500
Frank
Ripe cervix and
relaxed pelvic floor
Uncomplicated
breech


Chapter 12: Breech Presentation 419






•

•
•
•

Total score = 20
If all the parameters of the pelvis are included → score of >12 is safe for vaginal delivery
Score ≤ 12 → indication for cesarean section
But many parameters are based on pelvimetry, which is not done routinely.

4.





Enumerate the incidence and causes of hyperextended head in breech.
Hyperextended neck is defined as an angle of extension > 90° (‘Star-gazing’ fetus)
• Can be discovered on antepartum radiographs
• Its persistence is an indication for cesarean section
• Incidence ≈ 5%.

Causes

1. Primary posture

2. Multiple loops of nuchal cord

3. Fetal neck masses

4. Torticollis

5. Uterine myomas/septa.



Note:
• ‘Flying fetus’ → refers to hyperextended head of fetus in transverse lie.

5. What care should be taken in performing rotation at cervical spine?

• Vertebral arteries are susceptible to compromise at this point and excessive rotation (>105°)
may result in torsional injury to the cervical spine.
6. What is Kristellar manoeuvre:

• Pressure on the uterine fundus towards the vagina with the aim of expediting vaginal
delivery is known as Kristellar manoeuvre.

• Not of much help in vaginal breech delivery; therefore, should not be applied.
7. Describe Prague’s manoeuvre:

• It is a technique used to deliver after-coming head in breech when occiput is posterior
(when back of fetus fails to rotate anteriorly).
Technique

• Baby is laid with his back on the operator’s forearm

• Index and middle fingers of one hand should be placed on either side of the fetal neck from
behind, with the other hand grasping the legs above ankles

• Assistant uses 2 fingers over facial bones to maintain an attitude of flexion

• By this, the occiput passes forward over sacral concavity and then over perineum. The fetal
larynx serves as a fulcrum in this type of delivery.
8. Is there any antenatal postural treatment to help spontaneous version?
Antenatal postural treatment to help spontaneous version:

i. Knee chest position (difficult) for 15 minutes every 2 hours of waking for 5 days (Elkin’s
manoeuvre)

ii. Lying on back with woman’s hips elevated well above her shoulders for 20 minutes, 2–3
times/day preferably on an empty stomach at the time of the day when the fetus is active
(Juliet D’Souza treatment).
9. Role of ultrasound in breech
Ultrasound is a must in breech to confirm:

a. Presentation

b. Type of breech


420 Section 1: Long Cases








c.

d.
e.
f.
g.
h.

Maturity
Fetal well-being assessment
Amount of liquor
Placental site
Hyperextension of head
For uterine anamoly/pelvic tumour.

SUGGESTED READING
1. Andrew Kotaska, Yellowknife NT Savas Menticoglou, et al. Vaginal Delivery of Breech Presentation, SOGC
Clinical practice guideline, JOGC. June 2009.
2. Andrew Kotaska. Breech Birth Can Be Safe, But Is it Worth the Effort? J Obstet Gynaecol. Can 2009;
31(6):553-4.
3. André B Lalonde: Vaginal Breech Delivery Guideline: The Time Has Come, J Obstet Gynaecol. Can 2009;
31(6):483-4.
4. Christine L Roberts, Natasha Nassar, Alexandra Barratt, Camille H Raynes-Greenow, et al. Protocol for the
evaluation of a decision aid for women with a breech-presenting baby, BMC Pregnancy and Childbirth.
2004;4:26.
5. Dunn PM. Erich Bracht (1882–1969) of Berlin and his “Breech” Manoeuvre, Arch Dis Child Fetal Neonatal.
Edn 2003;88:F76-F77.
6. External cephalic version and reducing the incidence of breech presentation: RCOG Guideline No. 20a,
2010.
7. Management of breech presentation: SLCOG National guidelines.
8. The management of breech presentation: RCOG Guideline No. 20b. December 2006.

CHAPTER 13

Cardiac Disease in Pregnancy (Part I)
Tania G Singh

HISTORY
Cardinal Symptoms
• Dyspnea on exertion or breathlessness (including paroxysmal nocturnal dyspnea, orthopnea,
platypnea and trepopnea)
• Chest pain
• Cough
• Expectoration
• Hemoptysis
• Palpitations (awareness of heart beat)
• Syncopal attacks
• Dizziness
• Fatigue.

Past History
•
•
•
•
•
•
•
•
•
•

Hypertension
Diabetes milletus
Coronary artery disease
Hyperlipidemia
Obesity
Recurrent lower respiratory tract infections
TB/Syphilis/STDs/HIV
Thyroid/connective tissue disorders
Smoking/alcohol abuse
Drug history:
– Tricyclic antidepressants and β agonists → Tachyarrythmias
– β blockers and Ca2+ channel blockers → bradycardia
– Vasodilators →↓ in BP → syncopal attacks.

Family History
•
•
•
•

Hypertension
DM
CAD
Hyperlipidemia

422 Section 1: Long Cases

• Congenital heart disease
• Cardiomyopathies (single family history of sudden death is the single most important indicator
of risk).

General Physical Examination
•
•
•
•
•
•
•
•




•

Build and nutrition
Nails and conjunctiva (for pallor/icterus) → anemia exacerbate angina and failure
Clubbing
Cyanosis
Lymphadenopathy/thyroid swelling
Pyrexia
Edema
Skin
– Petechiae


– Osler nodes
 Infective endocarditis
– Janeway lesions 
– Subcutaneous nodules → rheumatic fever
CVS examination.

INSPECTION
CentralPeripheral
•  Precordium
JVP
•  Apex impulse
PR
•  Pulsations
BP
•  Dilated veins over chest wall
Peripheral signs of wide pulse pressure

Central
Precordium
Anterior aspect of chest which overlies the heart.
BulgingFlattened
• Enlarged heart
Fibrosis of lung
• Pericardial effusion
Congenital deformity
• Pleural effusion

Apex Impulse
•

•
•





Lower most and outermost part of cardiac impulse seen
Normally in 5th left intercostal space just inside mid clavicular line
Invisible:
– If lying behind rib → turn patient to left lateral position and see in anterior axillary line
– Emphysema
– Pericardial effusion
– Dextrocardia.

Pulsations
• Juxta apical → ventricular aneurysm
• Left parasternal:


Chapter 13: Cardiac Disease in Pregnancy (Part I) 423




•
•
•

•
•
•

– Right ventricular enlargement
– Left ventricular enlargement
– Aneurysm (localized abnormal dilatation of blood vessel) of aorta
Epigastric → right ventricular hypertrophy
In 2nd left intercoastal space
Suprasternal:
– Aortic regurgitation
– Aneurysm of aorta
– Coarctation of aorta (COA)
At back → COA
In neck → Aortic regurgitation (AR)
On right side of chest → dextrocardia.

Dilated Veins
• SVC and IVC obstruction
• Right sided heart failure.
Scars
• Previous heart surgery.

Peripheral
JVP
Normal
• Fluctuations in right atrial pressure during cardiac cycle generate a pulse which is transmitted
backwards into jugular veins
• Best examination: When patient reclines at 45°

• Normal JVP → 5-8 cm from right atrium
• 5 cm → vertically above sternal angle (≈ 8 cm from right atrium)
• We measure JVP for 2 purposes:
– For inspection of wave forms
– Estimation of central venous pressure (CVP)
‘a’ wave—atrial systole (most prominent deflection)
‘x’ descent interrupted by small ‘c’ wave, marking tricuspid valve closure
‘v’ wave—atrial pressure then rises again as atrium fills passively during ventricular systole
‘y’ descent—decline in atrial pressure as tricuspid valve opens.


424 Section 1: Long Cases

Abnormal
•
•


•
•

Absent ‘a’ wave → atrial fibrillation
Large ‘a’ wave → tricuspid stenosis; pulmonic stenosis
– Cannon ‘a’ wave → atrial systole against closed tricuspid valve (in complete heart block)
– Giant ‘a’ wave → atrial contraction against stenosed tricuspid valve
Giant ‘v’ wave → tricuspid regurgitation
Prominent ‘x’ and ‘y’ descents → constrictive pericarditis.

Pulse Rate
• Waveform felt by finger and produced by cardiac systole

• Normal 60-100/min
Tachycardia
Bradycardia
– Emotion


Athlete
– Exertion


Sleep
– Hypovolemia


Hypothermia
– Anemia


Myxedema
– Thyrotoxicosis


Obstructive jaundice

Features of Pulse
Rhythm
• Radial artery
• Regularly irregular:
– Ventricular bigemini; trigemini
– Atrial tachyarrythias

• Irregularly irregular:
– Atrial fibrillation
– Ectopics
Volume
• Carotid artery
• Pulse pressure (N 30-60 mm Hg) determines pulse volume.
Character
Carotid artery
• Hypokinetic (low volume):
– Hypovolemia
– Mitral stenosis
– Left ventricular failure
• Hyperkinetic (high amplitude with rapid rise):
– Anemia
– Mitral regurgitation
– Aortic regurgitation
– Ventricular septal defect.

Pulses Parvus et Tardus
• Aortic stenosis (severe).


Chapter 13: Cardiac Disease in Pregnancy (Part I) 425

Bisferiens Pulse
•

Brachial or radial artery:
– Aortic regurgitation
– Aortic regurgitation with aortic stenosis
– Hypertrophic obstructive cardiomyopathy (HOCM).

Dicrotic Pulse
• Dilated cardiomyopathy.

Pulse Alternans
• Severe left ventricular dysfunction
• Paroxysmal tachycardia

Pulse Bigeminus
• Pericardial tamponade.

Pulse Paradox
• Pericardial tamponade.

Water Hammer Pulse/Collapsing Pulse/Corrigans Pulse
• Aortic regurgitation
• Patent ductus arteriosus.

Blood Pressure
• Both supine and erect measurements
• Cuff width ≈ 40% the arm circumference
• Auscultation of brachial artery.

Korotkoff Sounds
•
•

•
•

Phase 1: first appearance of sounds → systolic pressure
Phase 2 and 3: increasing loud sounds
Phase 4: muffling of sounds
Phase 5: disappearance of sounds

Diastolic BP—Korotkoff 5 is the best. But in conditions where sound remains audible, Korotkoff 4
is taken, as in:
• Aortic regurgitation
• Arterio venous fistula
• Pregnancy.


426 Section 1: Long Cases

PALPATION
Apex Beat
Same as apex impulse:
• Heaving apex—left hypertrophy
• Well sustained heave—aortic stenosis
• Ill sustained heave—aortic or mitral regurgitation
• Tapping apex—mitral stenosis (because of loud S1 and right ventricular enlargement).

Parasternal Heave
• Systolic impulse in left parasternal region commonly seen in right ventricular enlargement is
called para sternal heave.

Diastolic Shock (Palpable S2)

• Loud P2 (pulmonary component)—pulmonary hypertension
• Loud A2—systemic hypertension.

Thrill
•
•
•
•
•









Sensation like ‘purring’ of a cat, that is felt by hand when murmur is palpable
Its presence → definite evidence of organic heart disease
Present in systolic lesions
Absent in regurgitant lesions
Types:
Systolic thrill
– Aortic stenosis
– Pulmonary stenosis
– Ventricular septal defect
Presystolic thrill
– Mitral stenosis
Continuous thrill

– Patent ductus arteriosus.

PERCUSSION
• To determine boundaries of heart
• Right, left and upper borders are percussed
• Lower border cannot be percussed because it can’t be distinguished from liver dullness.

Left Border
• Percussion in 4th and 5th intercostal space in mid axillary region and then medially towards left
border of heart
• Resonant note of lung becomes dull
• Normally left border is along apex beat
• Outside apex beat in → pericardial effusion.


Chapter 13: Cardiac Disease in Pregnancy (Part I) 427

Upper Border
• Percussion in 2nd and 3rd left intercostal spaces in parasternal line (line between midclavicular
and lateral sternal line)
• Normally there is resonant note in 2nd space and dull note in 3rd
• Dull note in 2nd space:
– Pericardial effusion
– Pulmonary hypertension
– Aneurysm of aorta.

Right Border
•
•
•

•





Percussion anteriorly in midclavicular line on right side until liver dullness is percussed
Then percussion is done one space higher from midclavicular line medially to sternal border
Normally, right border of heart is retrosternal
Dullness in parasternal region:
– Pericardial effusion
– Aneurysm of aorta
– Right atrial enlargement
– Dextrocardia.

AUSCULATION
Heart sounds auscultated in all 4 areas of chest:

Mitral Area
• 5th left intercostal space just inside mid clavicular line.

Tricuspid Area
• Lower end of sternum near ensiform cartilage.

Pulmonary Area
• 2nd left intercostal area.

Aortic Area
• 2nd right intercostal area.

Erb’s Area
• 3rd left intercostal area.

Heart Sounds
S1
• Best heard in mitral area
• Single because tricuspid and mitral components occur simultaneously