Obstetrics Simplified - Diaa
Complex (Compound) Presentation
It is the presence of a limb alongside the presenting part usually
the arm presents with the head.
About 1:800 labours.
Interference of adaptation of the presenting part to the pelvic brim
which may be:
- Foetal causes:
- Multiple pregnancy.
- Maternal causes:
- Contracted pelvis.
- Pelvis tumours.
Vaginal examination reveals limb beside the head.
- contracted pelvis and
- cord prolapse.
Nothing is done as in most cases the arm will be displaced
spontaneously away from the head.
- Forceps extraction with or without reposition of the arm:
reposition of the arm is tried first, if difficult apply forceps
without reposition but do not include the arm in the blades. This is
done if the head is engaged.
- Caesarean section: is indicated in
- Nonengagement of the head.
- Contracted pelvis.
- Other indications for caesarean section.
- Craniotomy: if the foetus is dead and labour is
It is a longitudinal lie in which the buttocks is the presenting part
with or without the lower limbs.
3.5% of term singleton deliveries and about 25% of cases before 30
weeks of gestation as most cases undergo spontaneous cephalic version up
In general, the foetus is adapted to the pyriform shape of the uterus
with the larger buttock in the fundus and smaller head in the lower
Any factor that interferes with this adaptation, allows free mobility
or prevents spontaneous version, can be considered a cause for breech
- Prematurity: due to
- relatively small foetal size,
- relatively excess amniotic fluid, and
- more globular shape of the uterus.
- Multiple pregnancy: one or both will present by the breech to
adapt with the relatively small room.
- Poly-and oligohydramnios.
- Intrauterine foetal death.
- Bicornuate and septate uterus.
- Uterine and pelvic tumours.
- Placenta praevia.
- Complete breech:
- The feet present beside the buttocks as both knees and hips
- More common in multipara.
- Incomplete breech:
- Frank breech:
- It is breech with extended legs where the knees
are extended while the hips are flexed.
- More common in primigravida.
- Footling presentation:
- The hip and knee joints are extended on one or
- More common in preterm singleton breeches.
- Knee presentation:
- The hip is partially extended and the knee is flexed on
one or both sides.
- Left sacro-anterior.
- Right sacro-anterior.
- Right sacro-posterior.
- Left sacro-posterior.
- Left and right sacro- transverse (lateral).
- Direct sacro-anterior and posterior.
Sacro-anterior positions are more common than sacro-posterior as in
the first the concavity of the foetal front fits into the convexity of
the maternal spines.
- A transverse groove may be seen above the umbilicus in
sacro-anterior corresponds to the neck.
- If the patient is thin, the head may be seen as a localised
bulge in one hypochondrium.
- Fundal grip: the head is felt as a smooth, hard, round
ballottable mass which is often tender.
- Umbilical grip: the back is identified and a depression
corresponds to the neck may be felt.
- First pelvic grip: the breech is felt as a smooth, soft mass
continuous with the back. Trial to do ballottement to the breech
shows that the movement is transmitted to the whole trunk.
- FHS is heard above the level of the umbilicus. However in
frank breech it may be heard at or below the level of the
- It is used for the following:
- To confirm the diagnosis.
- To detect the type of breech.
- To detect gestational age and foetal weight:
measures can be taken to determine the foetal weight as the
biparietal diameter with chest or abdominal circumference
using a special equation.
- To exclude hyperextension of the head.
- To exclude congenital anomalies.
- Diagnosis of unsuspected twins.
In addition to the previous findings, vaginal examination reveals;
- The 3 bony landmarks of breech namely 2 ischial tuberosities and
tip of the sacrum.
- The feet are felt beside the buttocks in complete breech.
- Fresh meconium may be found on the examining fingers.
- Male genitalia may be felt.
Mechanism of Labour
Delivery of the buttocks
- The engagement diameter is the bitrochanteric diameter 10 cm
which enters the pelvis in one of the oblique diameters.
- The anterior buttock meets the pelvic floor first so it rotates
1/8 circle anteriorly.
- The anterior buttock hinges below the symphysis and the
posterior buttock is delivered first by lateral flexion of the
spines followed by the anterior buttock.
- External rotation occurs so that the sacrum comes anteriorly.
Delivery of the shoulders
- The shoulders enter the same oblique diameter with the
biacromial diameter 12 cm (between the acromial processes of the
- The anterior shoulder meets the pelvic floor first, rotates 1/8
circle anteriorly, hinges under the symphysis, then the posterior
shoulder is delivered first followed by the anterior shoulder.
Delivery of the after-coming head
- The head enters the pelvis in the opposite oblique diameter.
- The occiput rotates 1/8 circle anteriorly, in case of sacro-
anterior position and 3/8 circle anteriorly in case of sacro-
- Rarely, the occiput rotates posteriorly and this should be
prevented by the obstetrician.
The head is delivered by movement of flexion in:
- Direct occipito-posterior (face to pubis).
- Face mento-anterior.
- The after coming head in breech presentation.
The head is delivered by extension in normal labour only i.e.
occipito - anterior positions.
Management of Breech Presentation
External Cephalic Version
It regains its importance after increased rate of caesarean sections
Timing: After the 32nd weeks up to the 37th week and some authors
extend it to the early labour as long as the membranes are intact and
there is no contraindications.
Version is not done earlier because:
- Spontaneous version is liable to occur.
- Return to breech presentation is liable to occur.
- If labour occurs the foetus will have a lesser chance for
Version is difficult after 37th weeks due to:
- Larger foetal size.
- Relatively less liquor.
- More irritability of the uterus.
- To detect cephalo-pelvic disproportion.
- Cephalic delivery is safer for the mother and foetus.
Success rate: 50-70%.
Causes of failure:
- Large sized foetus.
- Oligo- or polyhydramnios.
- Short umbilical cord.
- Uterine anomalies as bicornuate or septate uterus.
- Irritable uterus. Tocolytic drugs may be started 15
minutes before the procedure to overcome this.
- Rigid abdominal wall.
- Frank breech because the legs act as a splint.
- Contracted pelvis.
- Multiple pregnancy.
- Antepartum haemorrhage.
- Uterine scar.
- Hypertension as the placenta is more susceptible to
- Elderly primigravida.
- Ruptured membranes.
- Anaesthesia during version is contraindicated as pain is a
safeguard against rough manipulations.
- Accidental haemorrhage due to separation of the placenta.
- Rupture of membranes .
- Preterm labour.
- Foetal distress.
- Cord presentation or prolapse.
- Entangling of the cord around the foetus.
- Isoimmunisation in Rh-negative mothers due to
- Large foetus i.e. > 3.75 kg estimated by ultrasound.
- Preterm foetus but estimated weight is still more than 1.25 kg.
- Footling or complete breech: as the presenting irregular part is
not well fitting with the lower uterine segment leading to;
- Less reflex stimulation of uterine contractions.
- Susceptibility to cord prolapse.
- Early bearing down as the foot passes through
partially dilated cervix and reaches the perineum.
- Hyperextended head: diagnosed by ultrasound or X-ray.
- Contracted pelvis: of any degree.
- Uterine dysfunction.
- Complicated pregnancy with:
- Diabetes mellitus.
- Placenta praevia.
- Pre - labour rupture of membranes for ≥
- Intrauterine growth retardation.
- Placental insufficiency.
- Primigravidas: breech in primigravida equals caesarean section
in opinion of most obstetricians as the maternal passages were not
tested for delivery before.
- Frank breech.
- Estimated foetal weight not more than 3.75 kg.
- Gestational age: 36-42 weeks.
- Flexed head.
- Adequate pelvis.
- Normal progress of labour by using the partogram.
- Uncomplicated pregnancy.
- An experienced obstetrician.
- In case of intrauterine foetal death.
During vaginal delivery, prematures are more susceptible to:
- trauma, and
- retained after-coming head as the partially dilated cervix
allows the passage of the body but the less compressible relatively
larger head will be retained.
However, caesarean section should only be done if the premature
foetus has a reasonable chance of post - natal survival.
Management of Vaginal Breech Delivery
First stage: as other malpresentations.
Second stage: The foetus may be delivered by one of the following
- Spontaneous breech delivery:
- This is rarely occurs in multipara with adequate pelvis,
strong uterine contractions and small sized baby. The baby is
delivered spontaneously without any assistance but perineal
lacerations may occur.
- Assisted breech delivery:
- This is the method of delivery in far majority of cases.
- The assistance is indicated for delivery of the shoulders
and after-coming head and the infant is allowed to be delivered
up to the umbilicus spontaneously.
- Delivery of the buttocks:
- The golden rule is to "Keep your hands off".
- The patient is asked to bear down during uterine
contractions and relax in between until the perineum is
distended by the buttocks.
- An episiotomy is done especially in primigravida to
avoid much lateral flexion of the spines, perineal
lacerations and intracranial haemorrhage due to sudden
compression and decompression of the after - coming
- The legs are hooked out but without traction.
- When the umbilicus appears, a loop of the cord is
hooked to prevent traction or compression of the cord
and detect its pulsation.
- The foetus is covered with warm towel to prevent
premature stimulation of respiration.
- Delivery of the shoulders:
- Gentle steady downward traction is applied to the
foetal pelvic girdle during uterine contractions with
gradual rotation of the foetus to bring the shoulders in
the antero-posterior diameter of the pelvis.
- When the anterior scapula appears below the
symphysis, both arms are delivered by hooking the index
finger at the elbow and sweep the forearm across the
chest of the foetus
- The back is rotated anteriorly.
- Kristeller manoeuvre: gentle fundal pressure is done
during uterine contractions to guide the head into the
pelvis and maintain its flexion.
- Delivery of the after-coming head:
- It is delivered by one of the following methods:
- Jaw flexion- shoulder traction (Mauriceau-Smellie-Veit) method:
- Two fingers of the left hand, (as originally
described) or better on the malar eminencies
(the maxillae) to avoid dislocation of the jaw.
- The index and ring finger of the right hand
are placed on each shoulder while the middle
finger is pressing against the occiput to
promote flexion and act as a splint for the neck, preventing hyperextension and hence cervical
- Traction is commenced downwards and
backwards till the nape of the foetus appears,
the body is lifted towards the mother’s abdomen.
- Burns - Marshall’s method:
- The foetus is left hanging so that its
weight exerts gentle downwards and backwards
traction. When the nape appears, grasp the feet
and left the body towards the mother’s abdomen.
- Piper’s forceps is more suitable than the
ordinary forceps as it has a perineal but not
pelvic curve and has longer shanks. It is
applied from the ventral aspect of the foetus.
- Traction is applied downwards and backwards
till the nape appears, then downwards and
forwards to deliver the head by flexion.
- Forceps delivery has the following
- It promotes flexion of the head.
- Traction is applied on the head and not
on the neck.
- It prevents sudden compression and
decompression of the head.
- It protects the head from compression by
pelvic bones or rigid perineum.
- Breech extraction:
- Maternal or foetal distress.
- Prolonged second stage.
- To shorten the second stage in maternal respiratory and
- Prolapsed pulsating cord with fully dilated cervix.
- Like assisted breech delivery except that:-
- It is done under general anaesthesia.
- Both legs are bringing down.
- Traction on the legs is done helped by fundal
pressure to deliver the breech and the trunk.
- The after - coming head is delivered by jaw
flexion - shoulder traction or forceps.
Complicated Breech Delivery
Arrest of the buttocks at the pelvic brim
|Inefficient uterine contractions
||Oxytocin drip, if
contraindicated do caesarean section
Breech extraction - if cervix is fully dilated
|Large - sized baby
Arrest of the buttocks at the pelvic outlet
| Inefficient uterine contractions
|Extended legs (frank breech)
||Breech deeply impacted: Groin traction
- Living foetus:
- traction is done by the index or the index and middle
fingers put in the anterior groin in a downward and backward
- The traction is done towards the trunk to avoid dislocation
of the femur.
- Traction is done during uterine contractions and aided by
- When the posterior buttock appears traction is done by the 2
index fingers in both groins in a downward and forward
- Dead foetus:
Groin traction is done by breech hook.
- Bringing down a leg (Pinard’s method):
- Under general anaesthesia.
- Press by 2 fingers in the popliteal fossa of the anterior
leg to flex it then grasp the ankle and bring it down. This will
prevent the anterior buttock from over-riding the symphysis
- If the posterior leg was brought down first it must be
rotated anteriorly with the trunk then bring the other leg which
is now becomes posterior.
N.B. The foot has the following features differentiating it from the
- Presence of the heel.
- Absence of the mobile thumb.
- The toes are shorter than the fingers.
Arrest of the shoulders
|Extension of the arms: due to
traction on the breech before full dilatation of the cervix.
||The shoulders are delivered by:
Classical method or
|Nuchal position of the arm: The
forearm is displaced behind the neck due to rotation of the trunk in a wrong direction.
||Rotation of the foetal trunk in the
direction of the finger tips of the displaced arm.
- Under epidural or general anaesthesia.
- As there is more space posteriorly, bring down the posterior arm
first by using 2 fingers pressing against the cubital fossa and
sweep the arm in front of the foetal body to avoid fracture humerus.
- The anterior arm is then brought down by the same manoeuvre. If
this is difficult rotate the body180o to make the anterior arm
posterior and bring it down.
- Under epidural or general anaesthesia.
- Gentle downward and backward traction is applied to the foetus
by grasping its pelvis till the inferior angle of the anterior
scapula appears, the foetal trunk is rotated 180o to bring the
posterior shoulder anteriorly emerging beneath the symphysis pubis.
So the arm can be brought down.
- The trunk is again rotated 180o in the opposite direction to
bring the other shoulder anteriorly emerging beneath the symphysis
so the second arm can be brought down.
- The back should be kept always anterior during rotation.
Arrest of the after - coming head
(A) Faults in the head
1- Large head
Dead foetus: Craniotomy
|3- Extended head
||Jaw flexion - shoulder
|4- Posterior rotation of the occiput
||Jaw flexion - shoulder
traction till the sinciput hinges below the symphysis then deliver the head
by flexion. If the head is extended do Prague manoeuvre
(B) Faults in passages
1- Contracted pelvis
Dead foetus: Craniotomy
|2- Rigid perineum
||Episiotomy + forceps
|3- Incompletely dilated cervix
incisions especially if the foetus is living: 2 incisions of 1-2 cm are
made with scissors at 2 and 10 o’clock then sutured after delivery. A third
incision at 6 o’clock may be needed
- When the occiput rotates posteriorly and the head extends, the
chin hangs above the symphysis pubis.
- Foetus is grasped from its feet and flexed towards the mother’s
abdomen, while the other hand is doing simultaneous traction on the
shoulders to deliver the head by flexion.
Complications of Breech Delivery
- Prolonged labour with maternal distress.
- Obstructed labour with its sequelae may occur as in impacted
breech with extended legs.
- Laceration especially perineal.
- Postpartum haemorrhage due to prolonged labour and
- Puerperal sepsis.
- Foetal mortality:
- Is about 4% in multipara and 8% in primigravida which
may be due to:
- Intracranial haemorrhage: is the commonest cause of
death due to sudden compression and decompression of the
head as there is no gradual moulding of the head.
- This can be avoided by:
- Forceps delivery of the after -coming head.
- Slow delivery of the head.
- Vitamin K to the mother early in
- Fracture dislocation of the cervical spines
prevented by avoiding lifting the body towards the
mother’s abdomen until the nape appears below the
- Asphyxia due to:
- Cord prolapse or compression by the head.
- Premature stimulation of respiration
leading to inhalation of mucus, liquor or blood.
This can be avoided by covering the body of the
foetus with warm towels during delivery.
- Rupture of an abdominal organ: from rough
manipulations avoided by grasping the foetus from its
- Non-fatal injuries:
- Fracture femur, humerus or clavicle.
- Dislocation of joints or lower jaw.
- Injury to the external genitalia.
- Brachial plexus injury.
- Lacerations to the sternomastoid muscles.
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Edited by Aldo Campana,