Obstetrics Simplified - Diaa M. EI-Mowafi

Complex (Compound) Presentation
Breech Presentation

Definition

It is the presence of a limb alongside the presenting part usually the arm presents with the head.

Incidence

About 1:800 labours.

Aetiology

Interference of adaptation of the presenting part to the pelvic brim which may be:

• Foetal causes:
  • Malpresentations. 
  • Prematurity.  
  • Multiple pregnancy.
  • Polyhydramnios.
• Maternal causes:
  • Contracted pelvis.
  • Pelvis tumours.

Diagnosis

Vaginal examination reveals limb beside the head.

Management

Exclude:

• contracted pelvis and
• cord prolapse.

First stage

Nothing is done as in most cases the arm will be displaced spontaneously away from the head.

Second stage

• 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 obstructed.

BREECH PRESENTATION

Definition

It is a longitudinal lie in which the buttocks is the presenting part with or without the lower limbs.

Incidence

3.5% of term singleton deliveries and about 25% of cases before 30 weeks of gestation as most cases undergo spontaneous cephalic version up to term.

Aetiology

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 uterine segment.

Any factor that interferes with this adaptation, allows free mobility or prevents spontaneous version, can be considered a cause for breech presentation as:

• 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.
• Hydrocephalus.
• Intrauterine foetal death.
• Bicornuate and septate uterus.
• Uterine and pelvic tumours.
• Placenta praevia.

Types

• Complete breech:
  • The feet present beside the buttocks as both knees and hips are flexed.
  • 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 both sides.
    • More common in preterm singleton breeches.
  • Knee presentation:
    • The hip is partially extended and the knee is flexed on one or both sides.

Positions

• 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.

Diagnosis

During pregnancy

• Inspection:
  • 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.
• Palpation:
  • 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.
• Auscultation:
  • FHS is heard above the level of the umbilicus. However in frank breech it may be heard at or below the level of the umbilicus.
• Ultrasonography:
  • It is used for the following:
    • To confirm the diagnosis.
    • To detect the type of breech.
    • To detect gestational age and foetal weight:  Different 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.

During Labour

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 scapulae).
• 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- posterior position.
• Rarely, the occiput rotates posteriorly and this should be prevented by the obstetrician.

N.B.

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 nowadays.

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 survival.

Version is difficult after 37th weeks due to:

• Larger foetal size.
• Relatively less liquor.
• More irritability of the uterus.

The aim:

• 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.
• Obesity.
• Rigid abdominal wall.  
• Frank breech because the legs act as a splint.

Contraindications:

• Contracted pelvis.
• Multiple pregnancy.    
• Hydrocephalus.
• Antepartum haemorrhage.   
• Uterine scar.
• Hypertension as the placenta is more susceptible to separation.
• Elderly primigravida.
• Ruptured membranes.
• Anaesthesia during version is contraindicated as pain is a safeguard against rough manipulations.

Complications:

• 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 foeto-maternal transfusion.

Caesarean Section

Indications:

• 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:
  • Hypertension.
  • Diabetes mellitus.       
  • Placenta praevia.
  • Pre - labour rupture of membranes for ≥ 12 hours.
  • Post-term.
  • 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.

Vaginal Delivery

Prerequisites:

• 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.
• Multiparas.
• An experienced obstetrician.
• In case of intrauterine foetal death.

N.B.

During vaginal delivery, prematures are more susceptible to:

• hypoxia,
• 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 methods:

• 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 head.
      • 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 spine injury.
          • 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.
        • Forceps:
          • 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 advantages:
            • 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:
  • Indications:
    • Maternal or foetal distress.
    • Prolonged second stage.
    • To shorten the second stage in maternal respiratory and heart diseases.
    • Prolapsed pulsating cord with fully dilated cervix.
  • Technique:
    • 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

Arrest of the buttocks at the pelvic outlet

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 direction.
  • The traction is done towards the trunk to avoid dislocation of the femur.
  • Traction is done during uterine contractions and aided by fundal pressure.
  • When the posterior buttock appears traction is done by the 2 index fingers in both groins in a downward and forward direction.
• 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 pubis.
  • 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 hand:

• Presence of the heel.
• Absence of the mobile thumb.
• The toes are shorter than the fingers.

Arrest of the shoulders

Classical method:

• 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.

Lövset method:

• 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

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Edited by Aldo Campana,