(English Case)

BREECH PRESENTATION

Presented By:
dr. Ari Fuad Fajri
Resident Of Obstetrics dan Ginecology

Guidance:
DR. dr. H. Defrin, SpOG (K)

OBSTETRICS AND GYNAECOLOGY DEPARTMENT

MEDICAL FACULTY OF ANDALAS UNIVERSITY /
DR. M. DJAMIL CENTRAL GENERAL HOSPITAL, PADANG
2018
 PROGRAM PENDIDIKAN DOKTER SPESIALIS (PPDS)
OBSTETRI DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS ANDALAS
RSUD RSUP M. DJAMIL PADANG

LEMBAR PENGESAHAN

Nama : dr. Ari Fuad Fajri

Semester : II (dua) / Patologi I

Telah menyelesaikan English Case dengan judul:

BREECH PRESENTATION

Padang, Desember 2018

Mengetahui / menyetujui Peserta PPDS
Pembimbing Obstetri & Ginekologi

DR. dr. H. Defrin, SpOG (K) dr. Ari Fuad Fajri

Mengetahui :
KPS PPDS OBGIN
FK UNAND RS. Dr. M. DJAMIL PADANG

dr. H. Syahredi SA, Sp.OG (K)

 PROGRAM PENDIDIKAN DOKTER SPESIALIS (PPDS)
OBSTETRI DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS ANDALAS
RSUD RSUP M. DJAMIL PADANG

LAPORAN HASIL PENILAIAN

Nama : dr. Ari Fuad Fajri

Semester : II (dua) / Patologi I

Telah menyelesaikan English Case dangan judul BREECH PRESENTATION

Hasil Penilaian
NO KRITERIA PENILAIAN NILAI KETERANGAN
1 Pengetahuan

2 Keterampilan

3 Attitude

Padang, Desember 2018

Mengetahui/Menyetujui
Pembimbing

(DR. dr. H. Defrin, SpOG (K))

2
 TABLE OF CONTENTS

TABLE OF CONTENTS..........................................................................................i
LIST OF TABEL....................................................................................................iii
LIST OF PICTURE................................................................................................iv
CHAPTER 1............................................................................................................1
1.1 Background...............................................................................................1
CHAPTER 2............................................................................................................3
2.1 IDENTITY...............................................................................................3
2.2 HISTORY TAKING...............................................................................3
2.3 PHYSICAL EXAMINATIONS...............................................................5
2.4 DIAGNOSE..............................................................................................8
2.5 MANAGEMENT.....................................................................................9
2.6 DIAGNOSE..............................................................................................9
CHAPTER 3..........................................................................................................11
3.1 Definition................................................................................................11
3.2 Types of breech presentation..................................................................11
3.3 Incidence.................................................................................................12
3.4 Etiology..................................................................................................12
3.5 Diagnose.................................................................................................13
3.6 Pathophysiology.....................................................................................14
3.7 Management...........................................................................................15
3.8 Planning the mode of delivery................................................................15
3.8.1 Vaginal Breech Delivery..............................................................18
3.8.2 Type of vaginal breech delivery...................................................19
3.8.3 Manual aid Procedure (partial breech extraction)........................22
3.8.4 Delivery of The Aftercoming Head..............................................28
3.8.5 Cesarean Delivery........................................................................37
3.9 External Cephalic Version (ECV)..........................................................37

i
 3.9.1 Prerequisites.................................................................................39
3.9.2 Contraindications..........................................................................39
3.9.3 Risks.............................................................................................40
CHAPTER 4..........................................................................................................41
4.1 DISCUSSION.........................................................................................41
CHAPTER 5..........................................................................................................45
REFERENCES......................................................................................................46

ii
 LIST OF TABEL

Table 1 Zatuchni-Andros Breech Scoring in this patient.........................................6

Table 2 Zatuchni-Andros Breech Scoring.............................................................16

iii
 LIST OF PICTURE

Figure 1 CTG of patient..........................................................................................7

Figure 2 Patient USG..............................................................................................8
Figure 3 picture of the baby..................................................................................10
Figure 4 There are different kinds of breech presentations..................................12
Figure 5 table indication for caesarean delivery...................................................17
Figure 6 MR Pelvimetry for Breech Presentation.................................................19
Figure 7 Lovset Manuever....................................................................................25
Figure 8 Louwen maneuvers Technique...............................................................26
Figure 9 nuchal arm..............................................................................................28
Figure 10 Delivery of the aftercoming head using the Mauriceau maneuver.......29
Figure 11 Naujoks Technique...............................................................................30
Figure 12 Piper forcep for delivery of the aftercoming head................................31
Figure 13 Procedure of ECV.................................................................................40

iv
 CHAPTER 1

1.1 Background

Breech presentation, the most common obstetric malpresentation,

complicates approximately 4% of deliveries.1 Breech presentation refers to the
fetus in the longitudinal lie with the buttocks or lower extremity entering the
pelvis first. Three types are recognized: frank breech presentation (about 60% to
65% of breech presentations), incomplete breech presentation (about 25% to 35%
of breech presentations and is more common among premature fetuses), Complete
breech presentation (about 5% of breech presentations).2
The incidence of breech presentation is closely associated with birth
weight. Breech presentation accounts for 4% of births overall but occurs in 15%
of deliveries of low at birth-weight (<2,500 g) infants. Furthermore, the smaller
the infant, the higher the incidence of breech presentation, rising to 30% among
infants weighing 1,000 to 1,499 g and to 40% among those weighing <1,000 g.
Viewed from another perspective, the association between breech presentation and
low birth weight is even more striking. Only 70% of infants who present as
breeches weigh >2,500 g; 30% weigh <2,500 g (compared with 5% to 6% of
infants who are in vertex presentation), and 12% are of very low birth weight,
weighing <1,500 g.
In a breech birth, the baby’s head is the last part of its body to emerge
making it more difficult to ease it through the birth canal. Sometimes forceps are
used to guide the baby’s head out of the birth canal. Another potential problem is
cord prolapse.4 In this situation the umbilical cord is squeezed as the baby moves
toward the birth canal, thus slowing the baby’s supply of oxygen and blood. In a
vaginal breech delivery, electronic fetal monitoring will be used to monitor the
baby’s heartbeat throughout the course of labor. A cesarean delivery may be an

1
option if signs develop that the baby may be in distress.5

For several decades, research on breech birth has centered on whether

cesarean or vaginal delivery produce better neonatal/maternal outcomes, with
minimal focus on how to improve vaginal breech birth. Since 2000, large registry
studies have found increased neonatal mortality and/or morbidity in vaginal
versus cesarean breech deliveries, but most cohort studies in high-resource
countries using targeted screening and skilled practitioners report little difference
in neonatal mortality. Antepartal MR pelvimetry is used to assess the viability of
vaginal breech delivery
The management of the breech presentation continues to be controversial.
Studies show that the standard of care for breech delivery is a cesarean section
when available. In 2000, the Term Breech Trial was published. 8 This trial was a
multicentre RCT. Women, who were recruited from developed and developing
countries with breech singleton pregnancies at term, were randomized to either a
planned cesarean section or a planned vaginal birth. The trial was stopped early
after the review of an interim analysis that showed a large reduction in risk of
perinatal or neonatal mortality or serious neonatal morbidity with planned
cesarean section. The final results (developed and developing countries) showed
the rate of perinatal or neonatal mortality or serious neonatal morbidity to be 1.6%
in the planned cesarean group and 5.0% in the planned vaginal birth group.
Perinatal death was also reduced in the planned cesarean group (0.3% vs. 1.3%,
RR 0.23, 95% CI: 0.07–0.81). A Cochrane review of planned cesarean section for
term breech delivery includes the findings from the Term Breech Trial and two
prior much smaller trials, and confirms these findings. In the total sample
(worldwide), perinatal or neonatal death (excluding fatal anomalies) was reduced
overall (RR 0.29, 95% CI 0.10–0.86) with a policy of planned cesarean section.9
In all countries, but particularly in developing countries, and for reasons
including patient choice, unsafe cesarean section conditions, advanced labour, or
error in diagnosis, it is important that the skills of vaginal breech delivery be
taught to and retained by all health care providers(in alarm),for that reason, this
paper discuss a case with vaginal breech delivery with manual aid to refresh and
review this topic.10

2
 CHAPTER 2
CASE REPORT

2.1 IDENTITY

 Name : Mrs. Y
 Age : 32 years old
 MR : 62 95 92
 Address : Baso
 Date : September 15th 2018

2.2 HISTORY TAKING

Chief Complain :

A 32 years old patient was admitted to the Obstetric Emergency Room of Dr.
Achmad Muchtar General Hospital Bukittinggi on Sept 15st, 2018 at 03.15 am,
referred from Primary Health Care of Baso with diagnosed G4P3A0L3 38-39
weeks of term parturient of Latent phase of first stage + breech presentation.

Present Illness History:

 Feeling of pain from waist region which referred to the groin since 6 hours
ago.
 Bloody show from the vagina was felt since 6 hours ago
 Fluid leakage from the vagina since 1 hours ago, clear fluid, and fishy odor.
 No massive vaginal bleeding.
 Amenorrhea since 9 months ago.
 First date of last menstrual period was forgotten
 Estimation date of delivery was difficult to examinate

3
 Fetal movement was felt since 5 months ago.
 No complain of nausea, vomiting and vaginal bleeding neither during early
pregnancy nor late pregnancy.
 Prenatal care with midwife in Primary Health Care of Baso once in a month
since 4th month of gestational age, there was no complain about her pregnancy
during control, she got vitamin everytime she was control.
 Menstruation history : menarche at 12 years old, irregular menstrual cycle in 3
month before pregnancy its about once in 25-35 days, which last for 4-7 days
each cycle with the amount of 2-3 times pad change/day without menstrual
pain.

Previous Illness History:

There was not previous history of heart, liver, kidney, DM and hypertension.
There is no history of allergy

Family Illness History :

There was not history of hereditary disease, contagious and psychological

illness in the family.

Occupation, Socioeconomics, Psychiatry, and Habitual History:

 Marriage history : once in 2008
 History of pregnancy/abortion/delivery : 4/0/3

1. 2009, male, 3600 gram, term, spontaneous, midwifes, alive

2. 2012, male, 3200 gram, term, spontaneous, midwives, alive
3. 2015, male, 3300 gram, term, spontaneous, midwives, alive
4. Present

 History of family planning : was absent

4
 History of immunization : was absent
 History of education : Junior high school
 Occupation : House wife
 History of habit : Smoking (-), Alcohol (-), Drug abuse (-)

2.3 PHYSICAL EXAMINATIONS :

General Record:

General appearrance :Moderate

Conciousness : Composmentis cooperative
Body Height : 163 cm
Body Weight : 70 kg
(before pregnant : 60 kg, BMI : 22,6kg/m2)
Nutrisional status : Good
Blood pressure : 120/80 mmHg
Heart rate : 80 x/m
Respiratory rate : 20 x/m
Body Temperature : 37⁰ C
Eyes : Conjunctiva anemic (-), sclera icteric (-)
Neck : JVP 5-2 cmH2O, thyroid gland no enlarge
Chest : H/L normal
Abdoment : OR
Genitalia : OR
Extremity : Oedem -/-, Physiological Reflex +/+,Pathological Reflex -/-

Obstetric Record:

Abdomen :
Inspection : Enlargement in accordance with term pregnancy, median line
hyperpigmentation, striae gravidarum (+), cicatrix (-)
Palpation :

5
L1 : Uterine fundal was palpable 3 fingers below proc. Xhypoideus
A hard round mass was palpable and bounce
L2 : A hard resistance was felt on the left side
Numerous small, irregular were felt on the right side
L3 : A soft, large nodular mass palpable, fixated
L4 : Divergent
Uterine Fundal Height : 31 cm
Estimated fetal body weight : 3100 grams
Uterine contraction : 3-4x/20-30”/moderate
Au : Peristaltic sound normal Fetal Heart Sound : 130-135 bpm
Genitalia :
Inspection : V/U normal , vaginal bleeding (-)
Vaginal Toucher : Ø 6-7 cm
Amnionic sac (-) clear residue

Buttock palpated left transversed sacrum bone at HII-III

Pelvic inlet and pelvic outlet:

Impression : adequate pelvic

Zatuchni-Andros Breech Scoring

Add 0 Points Add 1 Points Add 2 Points
Parity 0 1 2
Gestational Age (wk) 39 + 38 < 37
EFW (gr) 3630 gr 3629 – 3179 gr < 3176 gr
Previous breech 0 1 2
Dilatation 2 3 4
Station -3 -2 -1
Table 1 Zatuchni-Andros Breech Scoring in this patient

Zatuchni-Andros Breech Scoring in this patient : 9 and recommended for vaginal

delivery.

6
Laboratory Finding:

Result Normal Limit 3rd Trimester

Routine Blood Count
Hemoglobine 10,7 gr/dl 9,5-15,0
Leucocyte 17.720/mm3 5.9–16.9
Hematocrit 31 % 28.0–40.0
Trombocyte 415.000/mm3 146–429
HbsAG Non-reactive Non-reactive
Anti-HIV Non-reactive Non-reactive
Tabel Laboratory Result

Cardiotocograph :

Figure 1 CTG of patient

Interpretation :

Baseline : 130 bpm

Variability : 5-10 bpm
Acceleration : (+)
Deceleration : (-)

7
Contraction : (+)
Impression : Category 1

Ultrasonograph :

Figure 2 Patient USG

Interpretation :
• Fetal Alive singleton intra uterin breach presentation
• Fetus movement was good
• Biometric :
– BPD : 83 mm
– AC : 317 mm
– FL : 76 mm
• EFW : 3071 gr
• SDP : 65 mm
• Plasenta Implanted at posterior corpus with maturation gr III
• Impresion :
• 37-38 weeks of pregnancy , fetal alive breach presentation

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2.4 DIAGNOSE :
G4P3A0L3 term parturient of Active phase of first stage
Fetal alive, singleton, intra uterine, breech presentation left transversed sacrum
bone at HIII-IV

2.5 MANAGEMENT :
• Control of GA, VS, Uterine Contraction, FHR
• Routine blood test
• Informed Consent
• Consult to Perinatologist
• IVFD RL gtt 20/mnt
• Follow the Labor progress

PLAN :
1. Vaginal Delivery with Spontaneuos breech delivery

At 04.45 am

The mother felt like pushing harder and more often. Ø 10 cm. mother led to push
while contraction to come. Episiotomy is performed.

At 04.51 am

Feet, Hip until umbilical of the baby was born. After 2 minutes, The spontaneous
breech was failed. shoulder and upper arm cannot be born spontaneously
The helper decides to do manual aid: lovset maneuver & mauriceau maneuver.

9
At 04.55 am
A female baby was born by vaginal delivery with manual aid (lovset maneuver
and mauriceau maneuver), 3000 grams in weight, 48 cm in lenght, and Apgar
Score 7/8
Placental was born spontaneously, complete, size was 17x16x3 cm, weight
approximately 580 gr.
Umbilical cord was approximately 50 cm in length with paracentral insertion
Episiotomy wound was sutured and treated

2.6 DIAGNOSE :
P4A0L4 post vaginal delivery with manual aid
mother and child were in good condition

Management :
Observe fourth stage

10
Figure 3 picture of the baby

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 CHAPTER 3

BREECH PRESENTATION

3.1 Definition

Breech presentation is the most common malpresentation. When the

buttocks of the fetus enter the pelvis before the head, the presentation is breech.
The incidence of breech presentation is higher in early pregnancy: 40% at 20
weeks, 25% at 32 weeks, and only 3-4% by term. It is normal in pregnancy for the
buttocks and feet to come to lie in the fundus, perhaps because the fundus has
more space and the heavier head gravitates to the lower pole.1
Conditions predisposing towards breech presentation include contracted
pelvis, uterine anomaly, fibroid uterus, placenta previa, multiple pregnancies,
polyhydramnios, oligohydramnios, fetal spina bifida (baby cannot kick well), fetal
goiter (baby cannot flex its head), or a hydrocephalic baby (the ‘lower segment’ is
too small). Ultrasound may show the cause and influence the management,
although in the vast majority of cases no cause can be identified.

3.2 Types of breech presentation

The breech may present in one of three ways :

 Extended (or frank) breech presentation is the most common (50-70%) , i.e.
flexed at the hips but extended at the knees, with the buttocks presenting to the
pelvic inlet.
 Flexed (or complete) breech presentation (5-10%) where the fetus sits with
hips and knees both flexed so that the presenting part is a mixture of buttocks,
external genitalia, and feet.
 Footling breeches are the least common. One thigh is flexed and one is
extended so that the foot or knee would descend first through the cervical os

12
 into the vagina. This type has the greatest risk of cord prolapse (10-30%).

Figure 4 There are different kinds of breech presentations (Source: Cunningham FG, Leveno
KJ, Williams JW, Bloom SL, Spong CY. Williams obstetrics. 25rd ed. New York: McGraw-Hill
Medical; 2015. xv, 1509)

The position of the fetus is described by using the sacrum as the

denominator (the occiput is the denominator for a vertex presentation).

3.3 Incidence

Breech presentation occurs in 3% to 4% of all term pregnancies. A

higher percentage of breech presentations occurs with less advanced gestational
age. At 32 weeks, 7% of fetuses are breech, and 28 weeks or less, 25% are breech.
Specifically, following one breech delivery, the recurrence rate for the second
pregnancy was nearly 10%, and for a subsequent third pregnancy, it was 27%.
Prior cesarean delivery has also been described by some to increase the incidence
of breech presentation two-fold.

3.4 Etiology

Clinical conditions associated with breech presentation include those that

may increase or decrease fetal motility, or affect the vertical polarity of the uterine
cavity. Prematurity, multiple gestations, aneuploidies, congenital anomalies,
Mullerian anomalies, uterine leiomyoma, and placental polarity as in
placenta previa are most commonly associated with a breech presentation.  Also,
a previous history of breech presentation at term increases the risk of repeat

13
breech presentation at term in subsequent pregnancies.2

Factors Predisposing to Breech Presentation

 Fetal anomalies

Headanomalies
Anencephaly
Hydrocephalus
Chromosomalanomalies
Autosomaltrisomies
Multiple anomaly syndromes
 Uterine anomalies

Septate
Bicornuate
Unicornuate
 Uterine overdistension

Polyhydramnios
Multiple gestation
 High parity with lax abdominal and uterine musculature

3.5 Diagnose
Diagnosis should be made antenatally. The mother may complain of pain
under the ribs. On palpation, the lie is longitudinal, a broad pole is felt in the
pelvis, and there is a smooth, round mass (the head) that can be palpated and
balloted in the fundal area. The fetal heart is best heard at the level of the
umbilicus or above. If the diagnosis is uncertain in late pregnancy, vaginal
examination may resolve it, but, if doubt still remains, an ultrasound examination
should be performed.1
On abdominal examination, Leopold's first maneuver will identify the fetal
head in the fundus. The third maneuver reveals the softer breech over the pelvic
inlet. It is useful to remember that the head narrows down to the neck before
attaching to the body, whereas there is no such tapering between the buttocks and

14
body. Auscultation of fetal heart tones usually reveals them to be most easily
detected in the upper quadrants of the uterus when the fetus is in breech
presentation.,
The diagnosis often is made by vaginal examination. In frank or complete
breech presentation, the anal orifice may be identified, with the bony prominences
of the ischial tuberosities directly lateral to it. Face presentation may be difficult
to distinguish from frank breech presentation on digital examination, with the fetal
mouth being mistaken for the anus. It is helpful to remember that the mouth is
surrounded by bone, whereas the anus is not. In incomplete breech presentations,
palpation of the feet on vaginal examination is diagnostic. During labor, any
presentation that is not clearly vertex by vaginal examination should be confirmed
by an intrapartum ultrasound.14

3.6 Pathophysiology

The most common clinical conditions or disease processes that result in the
breech presentation are those that affect fetal motility or the vertical polarity of the
uterine cavity. Conditions that change the vertical polarity or the uterine cavity,
or affect the ease or ability of the fetus to turn into the vertex presentation in the
third trimester include:

 Mullerian anomalies: Septate uterus, bicornuate uterus, and didelphys

uterus 
 Placentation: Placenta previa as the placenta is occupying the inferior
portion of the uterine cavity. Therefore, the presenting part cannot engage
 Uterine leiomyoma: Mainly larger myomas located in the lower uterine
segment, often intramural or submucosal, that prevent engagement of the
presenting part.
 Prematurity
 Aneuploidies and fetal neuromuscular disorders commonly cause
hypotonia of the fetus, inability to move effectively
 Congenital anomalies:  Fetal sacrococcygeal teratoma, fetal thyroid goiter
 Polyhydramnios: Fetus is often in unstable lie, unable to engage

15
  Oligohydramnios: Fetus is unable to turn to vertex due to lack of fluid
 Laxity of the maternal abdominal wall: Uterus falls forward, the fetus is
unable to engage in the pelvis.

The risk of cord prolapse varies depending on the type of breech. Incomplete or
footling breech carries the highest risk of cord prolapse at 15% to 18%, while
complete breech is lower at 4% to 6%, and frank breech is uncommon at 0.5%.2

3.7 Management

Breech presentation is associated with an increased risk of perinatal

mortality and morbidity caused principally by prematurity, congenital
malformations, and birth asphyxia from cord compression or trauma. Recent
evidence supports a policy of elective cesarean delivery prior to labor or rupture
of membranes for all singleton breech fetuses as a way of reducing the associated
neonatal problems. Despite the large Canadian trial recommending elective
cesarean delivery as safest for the baby, some mothers may elect to have a vaginal
breech delivery. Breech presentation, whatever the mode of delivery, is a signal
for potential fetal handicap, and this should influence antenatal, intrapartum, and
neonatal management.

3.8 Planning the mode of delivery

Internationally rates of vaginal breech delivery have decreased

dramatically since the early 1990’s and, as a result, planned vaginal breeches at
term are now unusual (Vidaeff AC, 2006). Rates of vaginal breech delivery in the
Irish obstetric population similarly showed a decrease during the 1990s and this
trend was cemented by the publication of the Term Breech Trial in 2000.8
Following this landmark publication, the American College of Obstetricians and
Gynecologists (ACOG) and the Royal College of Obstetricians and
Gynaecologists (RCOG, UK) 2001 guidelines recommended elective caesarean
delivery for all term breech-presenting babies (ACOG Committee Opinion No.
265, RCOG Green Top No 20). In 2006, however, both ACOG and RCOG opted

16
to recommend that a trial of labour is justified in certain circumstances (ACOG
Committee Opinion No. 340, RCOG Guideline no 20b).
A vaginal breech delivery should be conducted by a senior obstetrician.
All obstetricians and midwives involved in intrapartum care should be trained as
to how to conduct a vaginal breech delivery using, if necessary, simulators
because all pregnancies where there is a breech presentation may be complicated
by a precipitous labour and delivery ( Royal College of Physicians of Ireland,
2017)5
In a twin pregnancy where the first baby is delivered vaginally, the second
baby with a breech presentation can be delivered in the absence of intrapartum
complications as a vaginal delivery by an experienced obstetrician. 5
The Zatuchni-Andros score was applied to assessment of deliveries from
breech presentation as describes, as follow:1

Add 0 Points Add 1 Points Add 2Points

Parity 0 1 2
Gestational Age (wk) 39 + 38 < 37
EFW (gr) 3630 gr 3629 – 3179 gr < 3176 gr
Previous breech 0 1 2
Dilatation 2 3 4
Station -3 -2 -1
Table 2 Zatuchni-Andros Breech Scoring

If the score is 0-4, cesarean delivery is recommended. If the operator is not

experienced or comfortable with vaginal breech deliveries, cesarean delivery may
be the best choice.

Below table of indication for caesarian delivery1

17
Figure 5 table indication for caesarean delivery (source: Cunningham FG, Leveno KJ, Williams
JW, Bloom SL, Spong CY. Williams obstetrics. 25rd ed. New York: McGraw-Hill Medical; 2015. xv,
1509 p. p.)

There is some of the criteria used by the handle that breech location in
Sarwono (2010) must be used are:13
1. Old Primigravidas
2. High social value
3. Poor labor history
4. Large fetus, more than 3.5-4 kg
5. Suspected pelvic tightness
6. Prematurity

BJOG 2017, recommended for caesarian delivery if estimated fetal weight > 3.8
gram.17 When breech presentation is first recognised in labour, the obstetrician
should discuss the options of emergency caesarean section or proceeding with

18
attempted vaginal breech birth with the woman, explaining the respective risks
and benefits of each option according to her individual circumstances.10

3.8.1 Vaginal Breech Delivery

Approximately 50% of those with breech presentation are candidates for

vaginal delivery. Of these candidates, 60-82% successfully deliver vaginally.
Gestational age younger than 26 weeks, note mode of delivery, is the greatest risk
factor for the neonate. Vaginal delivery can be considered, but open and honest
discussion of risk from prematurity and lack of data regarding the ideal mode of
delivery should be reviewed with the parents.
If gestational age is 26-32 weeks, consider caesarean delivery based on
retrospective reports. After 32 weeks gestational age, consider vaginal breech
delivery after a discussion of risks and benefits with the parents. If estimated fetal
weight (EFW) is 4000-4500 gram, some recommend cesarean delivery because of
concern for entrapment of the unmolded head in the maternal pelvis, although
limited data exist to support this approach.
A frank breech presentation is preferred for trial of vaginal delivery.
Complete breeches and footling breeches still are candidates as long as the breech
infant is well applied to the cervix. The infant should show no hyperextension of
the neck on ultrasound evaluation. Flexed or military position is acceptable.1 How
about vaginal breech delivery between primigravida and multiparous? It
commonly is believed that primigravidas should be delivered by cesarean
delivery, although no data (prospective or retrospective) exist to support this view.
The only documented risk related to parity is cord prolapse, which is 2-fold higher
in parous women than in primigravidas.
Historically, pelvimetry was believed to be useful to quantitatively assess
the inlet and midpelvis. Recommended criteria include that the inlet has a
transverse diameter larger than 11,5 cm and an anteroposterior diameter larger
than 10,5 cm and that the midpelvis has a transverse diameter (between ischial

19
spines) larger than 10 cm and an anteroposterior diameter larger than 11,5 cm.18

Antepartal MR pelvimetry is used to assess the viability of vaginal breech

delivery. We evaluated the reliability of MR pelvimetric measurements as well as
incidental findings noted by different clinicians and assessed potential reference
values. calculated proportions between fetal breech and maternal pelvic diameters,
which were significantly less favorable in women with failure to progress in labor
than in women who delivered vaginally.7

Figure 6 MR Pelvimetry for Breech Presentation (source: von Bismarck A, Ertl-Wagner B,

Stocklein S, Schoppe F, Hubener C, Hertlein L, et al. MR Pelvimetry for Breech Presentation at
Term- Interobserver Reliability, Incidental Findings and Reference Values. Rofo. 2018.)

Measurement conjugate vera and diameter transversalis with MR

pelvimetry can helped Obstetrian make a choice type of delvery. A randomized
controlled study found a significantly higher VD rate in women with previous MR
pelvimetry compared to women with only manual pelvic assessment (76 % and 59
%, respectively).7

20
3.8.2 Type of vaginal breech delivery

There are three types of vaginal breech deliveries as describes, as follows: 1

2. Spontaneous breech delivery

No traction or manipulation of the infant is employed. This occurs

predominantly in very preterm deliveries.

3. Assisted breech delivery.

This is the most common types of vaginal breech delivery. The infant is
allowed to spontaneously deliver up to the umbilicus, and then maneuvers are
initiated to assist in the delivery of the remainder of the body, arms and head.

4. Total breech extraction

The fetal feet are grasped, and the entire fetus is extracted. It should be
used only for the noncephalic second twin. It should not be used for singleton
fetuses because the cervix may not be adequately dilated to allow passage of
the fetal head. If the feet prolapse through the vagina, expectantly manage as
long as the fetal heart rate is stable to allow the cervix to completely dilate
around the breech. Total breech extraction for the singleton breech is
associated with a 25 % rate of birth injuries and a mortality rate of
approximately 10 %. Total breech extraction are sometimes performed by less
experienced accoucheurs when a foot unexpectedly prolapses through the
vagina. As long as the fetal hearth rate is stable in this situation, it is
permissible to manage expectantly to allow the cervix to completely dilate
around the breech.

21
Delivery procedures the breech presentation spontaneously:

1. Slow stage : start from birth of buttocks until the umbilical is phase ones
that are not harmful .
2. Fast stage: of the birth of the umbilical until the mouth , in this phase it the
head of a fetus in the pelvic inlet , thus the probability of the umbilical
cord wedged .
3. Slow stage : the birth of the mouth that part of the head , the head out of a
room that is pressurized high ( the uterus ) to the world beyond lower
pressure is going to be so the head need to be born slowly to avoid the
intracranial bleeding (tentorium cerebellum)13

Mechanism of Labour
1. preparation of mother, fetus, and properti such as piper cunam
2. patient on lithotomy position, the helper stands in front of a of the vulva at
the time of the rump of a start opening up of the vulva , is injected 2-5 a
unit of oksitosin intramuskulus .doing episiotomi 
3. As soon as the buttocks born , the buttocks grip by means of bracht, that is
the two the thumb of his right savior one to rescue and parallel the long
axis of the thigh , while another finger to another holding the pelvis
4. When the umbilical cord born and looking stretched thin, the umbilical
cord slacky first.
5. The helper do hiperlordosis the fetus to cover the rotation anterior ,
namely the fetus nearest back onto the mother abdoment, this movement
adapted to the weight fetus .Along with hiperlordosis , an assistant do
kristeller expression .The aim is to have energy straining stronger so quick
to be completed phase .Keeping the head of the fetus fixed in position
flexion , and avoid vacant space between fundus the uterus and the head of
the fetus , so there is no arms toggles 

22
 6. With hyperlordosis movement, successive consecutive born the umbilical,
abdoment , the shoulder , arms , the chin , the mouth and eventually the
whole head
7. A newborn laid on mother abdomen

Advantage
 The hand of helper did not enter the birth canal to reduce infection
 Approaching physiological labor, thereby reducing trauma to the fetus.
Weakness
 5-10% failure occurs if the pelvis is narrow, the fetus is large, the birth
canal of the foot, for example the primigravida arm is tilted or pointed. 13
3.8.3 Manual aid Procedure (partial breech extraction) :13
Indication : if labor with Bracht fails, for example congestion occurs when giving
birth to the shoulder or head.
Procedure :
1. The birth of the buttocks to the navel is born with the mother's own
energy.
2. The birth of shoulders and arms that use helper power in the classical
technique (Deventer), Mueller, Louvset, & Bickenbach.
3. The Birth of heads with Mauriceau (Veit Smellie), Wajouk, Wid and
Martin Winctel, Prague inverted, Cunan Piper.

Stage of labour
1. First step: start from birth of buttocks until the umbilical is phase ones that
are not harmful .
2. Second stage: of the birth of the umbilical until the mouth with helper
power with:
a. Classic / Deventer
b. Mueller
c. Lovset
d. Bickenbach
e. louwen

23
 3. Slow stage : the birth of the head with technique:
a. Mauriceau
b. Najouks
c. Wigand Martin-winckel
d. Prague maneuver
e. Cunam piper

Classic technique :13

1. The principles of giving birth to the forearm first because the back arm is
in a larger room (sacrum), then giving birth to the forearm under the
simpisis but if the forearm is difficult to birth then the front arm is rotated
into the back arm, namely by turning the shoulder strap towards back and
then the back arm is born.
2. Both fetal legs are born and the right hand helps the ankle and is elevated
to or as far as possible so that the fetus' abdomen approaches the mother's
abdomen.
3. At the same time the helper's left hand is inserted into the birth canal and
with the middle and index fingers tracing the fetal shoulder until the fossa
cubiti then the forearm is born with movement as if the forearm is rubbing
the fetus's face.
4. To give birth to the forearm, the handle on the fetal ankle is replaced with
the helper's right hand and is pulled steeply down so that the fetus's back
approaches the mother's back.
5. With the same way the front arm is born.
6. If the forearm is difficult to birth, it must be rotated into the back arm.
Born wrists and arms are gripped with the helper's hands in such a way
that the helper's thumbs are located on the back and parallel to the fetus's
body axis while the other fingers grip the chest. The round is directed to

24
 the abdomen and chest of the fetus so that the forearm is located behind
and the arms are born in the same way.

Advantage: That it can generally be done on all breech deliveries.

Disadvantage: The fetal arm is still relatively high in the pelvis, so that the
helper's finger must enter the birth canal which can cause infection.

Mueller Technique13
1. Principle : give birth to the front shoulder and arm with extraction, then
give birth to the shoulder and back arm.
2. The fetal butt with femuro-pelviks, ie the two helper thumbs are placed
parallel to the sacralis spina media and the index finger on the crista illiaca
and the other fingers grip the front thigh. The body of the fetus is pulled
steeply down as far as possible until the front shoulder appears under the
sympathy, and the front arm is born with the arm under it.
3. After the front shoulder and forearm are born, the fetal body that is still
held femuro-pelviks is pulled up until the back shoulder is born. If the
back of the shoulder is not born by itself, then the back arm is born by
hooking the forearm with the two helper fingers.

Advantage :
Helper hands do not enter deep into the birth canal so that the danger of
infection is minimal.

Louvset Technique :13

1. The principle: turning the fetal body in a semicircle back and forth while
carried out laying down traction so that the shoulder that was previously
behind was finally born under the simpisis.

25
2. The fetal body is held femuro-pelviks and while steep traction is carried
down, the fetal body is rotated half circle, so that the back shoulder
becomes the front shoulder. Then while traction is carried out, the fetal
body is rotated again in the opposite direction of the semicircle. And so on
back and forth so that the back shoulder appears under the sympathy and
the arm can be born.

26
Figure 7 Lovset Manuever

Advantage
 A simple technique and rare to fail.
 can be done on all breech locations regardless of the position of the arm
 Helper hands do not enter the birth canal, so that the infection is minimal

27
  this method is recommended in leading the breech delivery in
circumstances where it is expected that difficulties will occur, such as a
primigravida, large fetus, & relatively narrow pelvis.

Bickenbach Technique
the principle of bickenbach delivery is a combination of the mueler method in the
classical way. this technique is almost the same as the classic method

Louwen Manuever

Figure 8 Louwen maneuvers Technique

(Source: Louwen F, Daviss BA, Johnson KC, Reitter A. Does breech delivery in an upright
position instead of on the back improve outcomes and avoid cesareans? Int J Gynaecol Obstet.
2017;136(2):151-61.)

28
Maneuvers created by Dr. Frank Louwen to assist during vaginal breech delivery
with mother in an upright position (on knees, all fours, or standing). The top left
image shows what should be seen during a normal vaginal breech delivery,
whereas the top right image shows a sign of shoulder dystocia. The middle three
images show the “180 degree torque” maneuver. When shoulder dystocia occurs,
the practitioner grasps the shoulders and turns the fixed shoulder away from the
maternal symphysis (the opposite direction to the Loveset), and back 90°. The
bottom two diagrams show “the Frank Nudge” maneuver, in which the
practitioner pushes the neonate’s shoulders up against the pubic bone to flex the
head to enable it to emerge.6

Nuchal Arm
During delivery, one or both fetal arms occasionally may lie across the back of the
neck and become impacted at the pelvic inlet. With such a nuchal arm, delivery is
more difficult and can be aided by rotating the fetus through a half circle in such a
direction that the friction exerted by the birth canal will draw the elbow toward
the face. With a right nuchal arm, the body should be rotated counterclockwise,
which rotates the fetal back toward the maternal right. With a left nuchal arm, the
rotation is clockwise. If rotation fails to free the nuchal arm, it may be necessary
to push the fetus upward to a roomier part of the pelvis. If the rotation is still
unsuccessful, the nuchal arm often is extracted by hooking a finger(s) over it and
forcing the arm over the shoulder, and down the ventral surface for delivery of the
arm. In this event, fracture of the humerus or clavicle is common.1

29
Figure 9 Reduction of a right nuchal arm is accomplished by rotating the fetal body 180 degrees
counterclockwise, which directs the fetal back to the maternal right. Friction exerted by the birth
canal will draw the elbow toward the face. (Source : Williams obstetrics. 25rd ed. New York:
McGraw-Hill Medical; 2015. xv, 1509 p. p.)

3.8.4 Delivery of The Aftercoming Head

Mauriceau Technique (Veit-Smellie) :
1. Helper hands that correspond to the fetal face are inserted into the birth
canal. The middle finger is inserted into the mouth and the index finger
and 4th finger grip the canine fossa, while the other finger grips the neck.
The child's body is placed above the helper's forearm, as if the fetus is
riding a horse. The index finger and fingers of the other 3 helpers grabbed
the neck of the fetus from the back.
2.  Helper hands pulled the steep fetal head down while an assistant
performed an expressikristeller. The pulling force is mainly carried out by
the helper's hand which grips the fetal neck from the back. If the
suboxyput appears under the symptom, the fetal head is exhaled upward

30
 with suboxyput as a hypomoclion so that the chin, mouth, nose, eyes,
forehead, crown, and finally the entire fetal head is born.

Figure 10 A. Delivery of the aftercoming head using the Mauriceau maneuver. Note that as the
fetal head is being delivered, flexion of the head is maintained by suprapubic pressure provided by
an assistant. B. Pressure on the maxilla is applied simultaneously by the operator as upward and
outward traction is exerted

Najouks Technique
this technique is done if the head is still high, so that the helper's finger cannot be
inserted into the fetus's mouth. Helper hands gripping the fetal neck from the front
and back. the helper's hands pull the steep shoulders down and together an
assistant pushes the fetus's head down. this method is not recommended anymore
because it can cause severe trauma to the fetal spinal cord.13

31
Figure 11 Naujoks Technique (Source: Sarwono: Ilmu Bedah Kebidanan 2010)

Cunam Piper Technique :13

Installation of cunam in the aftercoming head technique is the same as the

installation of the arm at the back of the head. Only in this case, cunam is inserted
in the lower direction, which is parallel to the fold of the hamstrings. Only in this
case is the cunam inserted from the bottom, which is parallel to the fold of the
hamstrings. After suboxyput appears under the simpisis, cunam is elevated
upward and with suboccipi as hypomoclion successively the chin, mouth, face,
forehead and finally the entire head are born.

32
Figure 12 Piper forcep for delivery of the aftercoming head (Source: Cunningham FG, Leveno
KJ, Williams JW, Bloom SL, Spong CY. Williams obstetrics. 25rd ed. New York: McGraw-Hill Medical;
2015. xv, 1509 p. p)

Technique
 The fetal body is elevated using a warm towel and the left blade of the
forceps is applied to the aftercoming head.
 The right blade is applied with the body still elevated.
 Forceps delivery of the aftercoming head is completed. Note the direction
of movement shown by the arrows.

Head entrapment
Entrapment of the after coming head in a breech presentation is a very
rare complication. It may occur with greater frequency with a preterm baby.

33
Delivery may be accomplished by symphysiotomy or by rapid cesarean section
when attempts to deliver the after coming head are unsuccessful.
During preterm breech delivery, the trunk of the preterm baby may deliver
through an incompletely dilated cervix. In this situation, lateral cervical incisions
have been used to release the after coming head. Similar rates of head entrapment
in the preterm fetus have been described for vaginal and abdominal delivery.

According to ALARM 2016, recommendation for breech delivery:16

1. Pre – or early labour ultrasound should be performed to assess type of

breech presentation, fetal growth and estimated weight, and attitude of
fetal head. If ultrasound is not available, Caesarean section is
recommended.
2. There’s no Contraindications to labour include:
 Cord presentation
 Macrosomia
 Any presentation other than a frank or complete breech with a flexed
or neutral head attitude
 Clinically inadequate maternal pelvis
 Fetal anomaly incompatible with vaginal delivery
 Fetal growth restriction
 Fetal metabolic acidosis in labour due to placental factors puts the
fetus at elevated risk of asphyxia if delay occurs during delivery. It is
very important, therefore, to rule out significant fetal growth
restriction prior to delivery. Significant cord compression (with
variable FHR decelerations) leading up to delivery can also cause
metabolic acidosis and predisposes the fetus to compromise if there is
delay during delivery.
3. The estimated fetal weight is between 2500 g and 4000 g.

34
4. Clinical pelvic examination should be performed to rule out significant
pelvic contraction. Radiologic pelvimetry is not necessary for a safe trial
of labour; good progress in labour is the best indicator of adequate fetal-
pelvic proportions.

Technique and tips for assisted vaginal breech delivery

The fetal membranes should be left intact as long as possible to act as

dilating wedge and to prevent overt cord prolapse. Oxytocin induction and
augmentation are controversial. In many previous study, oxytocin was used for
induction and augmentation, especially for hypotonic uterine dysfunction,
However, others are concerned that nonphysiologic forceful contractions could
result in an incompletely dilated cervix and an entrapped head.1
An anesthesiologist and pediatrician should be immediately available for
all vaginal breech deliveries. A pediatrician is needed because of the higher
prevalence of neonatal depression and the increased risk for unrecognized fetal
anomalies. An anesthesiologist may be needed in intrapartum complication
develop and patient requires general anesthesia.1
Some clinicians perform an episiotomy when the breech delivery is
imminent, even in multiparas. It has been advocated to prevent soft tissue
dystocia. The Pinard maneuver may be needed with a frank breech to facilitate
delivery of the legs but only after the fetal umbilicus has been reached. Pressure is
exerted in the popliteal space of the knee. Flexion of the knee follows, and the
lower leg is swept medially and out of the vagina. No traction should be exerted
on the infant until the fetal umbilicus is past the perineum, after which time
maternal expulsive efforts should be used along with gentle downward and
outward traction of the infant until the scapula and axilla are visible. Use a dry
towel to wrap around the hips (not the abdomen) to help with gentle traction of
the infant. An assistant should exert transfundal pressure from above to keep the
fetal head flexed. Once the scapula is visible, rotate the infant 900 and gently
sweep the anterior arm aout of the vagina by pressing on the inner aspect of the

35
arm or elbow. Rotate the infant 1800 in the reverse direction, and sweep the other
arm out of the vagina. Once the arms are delivered, rotate the infant back 900 so
that the chin is posterior. The head should be maintained in a flexed position
during delivery to allow passage of the smallest diameter of the fetal head. The
flexed position can be accomplished by using Mauriceau-Smellie-Veit maneuver
(finger placed over maxilla) or with Piper foreceps while the assistant applies
suprapubic pressure. During the Mauriceau-Smellie-Veit maneuver, the operator
applies pressure over the fetal maxillary prominences. Piper forceps are
specialized forceps with pelvic, not cephalic, application, which maintains the
head in a flexed position. The forcep are applied while the assistant supports the
fetal body in a horizontal plane. Many early studies recommended routine use of
the Piper forceps to protect the head and to minimize traction of the fetal neck.
During delivery of the head, avoid elevation of the body, which might result in
hyperextension of the cervical spine and potential neurologic injury.1
The Bracht maneuver is a variant approach to the assisted vaginal breech
delivery. This procedure, first described in 1938, attempts to stimulate the cardinal
movements observed in spontaneous vaginal breech delivery. The breech is
allowed to spontaneously deliver to the level of the umbilicus. After spontaneous
rotation of the infant to a spine-anterior position, the operator gently holds the
body and legs upward against the maternal symphysis. With the force of the
uterine contractions and moderate suprapubic pressure by an assistant, the fetal
arms are delivered without traction, and the head, which has been hyperextended
at the neck, follows shortly thereafter. While the Bracht maneuver initially was
evaluated in Europe, it was never popularized in the United States, and it is
mentioned predominantly for historical interest.RCOG,2001
In situations where ECV was contraindicated, was declined, or failed, the
policy for term singleton breech pregnancy management should be based on
available evidence and the choice of the woman. If assisted vaginal delivery is
preferred, there should be a careful selection of patients and extensive ante partum
counseling. A trial of singleton vaginal breech delivery is more likely to be
successful if both mother and baby are of normal proportions. The size of the
fetus should be estimated to be between 2000 and 3500 g and gestational age

36
greater than 32 weeks. The presentation should be either frank (hips flexed, knees
extended) or complete (hips flexed, knees flexed, but feet not below the fetal
buttocks). Ultrasound examination after 36 weeks is useful in confirming the
above. There should be no evidence of feto-pelvic disproportion with a ‘clinically
adequate’ pelvis on pelvimetry (although there is little evidence that objective
measurement of pelvic size correlates with the chance of vaginal delivery). If
imaging pelvimetry is required,(CT) scanning may be preferable to X-ray
becausse the radiation dose is less

Management at delivery (ALARM 2016)16

1. Continuous electronic fetal heart monitoring is recommended in the first stage

and mandatory in the second stage of labour.
2. When membranes rupture, immediate vaginal examination is recommended to
rule out prolapsed cord.
3. In the absence of adequate progress in labour, Caesarean section is advised.
4. Induction of labour is not recommended for breech presentation. Oxytocin
augmentation is acceptable in the presence of uterine dystocia during the first
and second stage of labour. In the PREMODA study oxytocin was routinely
administered during the second stage of labour to ensure good uterine activity.
5. A passive second stage without active pushing may last up to 90 minutes,
allowing the breech to descend well into the pelvis. Once active pushing
commences, if delivery is not imminent after 60 minutes, Caesarean section is
recommended.
6. The active second stage of labour should take place in or near an operating
room with equipment and personnel available to perform a timely Caesarean
section if necessary.
7. A health care professional skilled in neonatal resuscitation should be in
attendance at the time of delivery.

Technique for vaginal breech delivery

1. Total breech extraction should not be performed to deliver a singleton
breech.

37
2. Explain the necessity of effective pushing in the second stage of labour.
3. Ensure adequate analgesia; however, dense epidural analgesia will hamper
maternal pushing efforts.
4. Spontaneous descent and expulsion to the umbilicus should occur with
maternal pushing only – DO NOT PULL ON THE BREECH!
5. Rotation to the sacrum anterior position usually occurs spontaneously and
is desired. If the fetus appears to be rotating to a sacrum posterior position,
grasp the fetal pelvis and gently rotate to sacrum anterior.
6. Episiotomy may be considered once the anterior buttock and anus are
‘crowning’.
7. Spontaneous delivery of the entire breech fetus is desirable and is common
with adequate maternal pushing efforts and fundal pressure, if needed.
However, assisted breech delivery is acceptable, and the manoeuvres
employed may be required if there is expulsive delay.
8. Pinard manoeuvre to deliver the fetal legs may be considered once the
popliteal fossae are visible.
9. Løvset manoeuvre for nuchal arms.
10. Support the baby to maintain the head in a flexed position. Suprapubic
pressure may help. Maternal expulsive efforts should be encouraged.
11. The body should be supported in a horizontal position.
12. The Mauriceau-Smellie-Veit manoeuvre can be used to deliver the head in
flexion.
13. Use forceps, if needed. (Piper’s forceps were specifically designed for this
purpose.)

Follow-Up

Care After Breech Delivery

 Active third stage management

 Cord blood gas analysis
 Examination for maternal trauma

38
 o Examination for neonatal trauma examine the hips with care;
repeat the examination prior to discharge
 Review birth with the family
 Documentation

Documentation – Breech Delivery

A complete review of risks and benefits for vaginal delivery and consent must be
clearly and completely documented in all cases. A contemporaneous written note
and a dictated operative record are recommended. It must be documented whether
the vaginal delivery is an incidental emergency vaginal birth or a planned and
consensual event. 16

3.8.5 Cesarean Delivery

The rate of cesarean delivery for breech presentation in the united States
was 14 % in 1970 and 86 % in 1986. It currently is 90-95 %. Breeches account for
10-15 % of all cesarean deliveries. Maneuvers for delivery are similar for vaginal
breech delivery (eg Pinard maneuver, ie wraping the hips with a towel for traction,
head flexion during traction, rotation and sweeping out of arms : Mauriceau-
Smellie-Veit maneuver.1
An entrapped head still can occur during cesarean delivery if the uterus
contracts down after delivery of the body, even with an adequate-appearing lower
uterine segment. Entrapped heads occur more commonly with preterm breeches,
especially with a low transverse uterine incisions. Low vertical incisions usually
require extension in to the corpus, resulting in cesarean delivery with all future
deliveries.1

3.9 External Cephalic Version (ECV)

External Cephalic Version (ECV) is a safe procedure, which can decrease

39
the incidence of breech presentation at term. Obstetric trainees should be capable
of counseling about and performing an ECV. ECV can decrease the incidence of
breech presentation at term and rates of caesarean delivery among those who have
an ECV are lower than those who do not attempt the procedure (Mahomed K,
1991). Both the RCOG and ACOG endorse the use of ECV as an option to
decrease the caesarean delivery rate associated with breech presentation17
ECV is safe and is rarely associated with complications (Grootscholten K,
2008). Case reports, however, do exist of complications such as placental
abruption, uterine rupture and feto-maternal haemorrhage. Randomised controlled
trials have reported no evidence of an increase in neonatal morbidity and mortality
but are underpowered for these rare outcomes (Hutton EK, 2015). Systematic
reviews report a very low complication rate, but are subject to the limitations of
reporting bias. Large consecutive series suggest a 0.5% immediate emergency
caesarean section rate & no excess perinatal morbidity and perinatal mortality.
ECV success rates have been shown to be dependent of the obstetrician’s
skill level (Bogner G, 2012). Published rates of practice in Ireland have been low
(Higgins M, 2006). Hospitals should encourage the use of ECV. Obstetric trainees
should receive teaching and practical experience in order to become capable of
performing of the procedure.
The best available evidence suggests that the ideal time to carry out ECV
is after 37 weeks gestation. 8 Under certain circumstances, it can be offered in
labour. Studies are currently underway to determine if early ECV (i.e. at 34 to 35
weeks gestation) may offer further benefit without additional risk to the woman or
her fetus (Hutton EK et al, 2003). Currently it is recommended that ECV should
be performed at more than 36 weeks because:
1. Spontaneous cephalic version often occurs before 36 weeks.
2. Spontaneous podalic version after the procedure is rare after 36 weeks.
3. Fetus will usually be mature if complications of ECV necessitate
immediate delivery.
A meta-analysis of five randomized control trials (RCTs) comparing ECV at term
to no attempt at ECV showed a significant reduction in non-cephalic births (RR
0.38, 95% CI 0.18–0.80) and cesarean section (RR 0.55, 95% CI 0.33–0.91).

40
There was no significant effect on perinatal mortality (RR 0.51, 95% CI 0.05–
5.54) or other measures of perinatal outcome (Hofmeyr et al, 2006). In certain
situations, ECV may be offered in early labour. This may be considered if the
membranes are intact, and the breech is unengaged.

3.9.1 Prerequisites
1. Singleton pregnancy
2. Gestational age ≥ 37 weeks
3. No contraindication to labour
4. Fetal well-being established prior to procedure
5. Assessment of amniotic fluid volume
6. Position of fetus known prior to procedure
7. Facilities for immediate delivery

3.9.2 Contraindications

ECV should be avoided in a woman who is HIV positive. If the woman’s

status is unknown or she has a very low viral load, ECV may be considered based
on available local resources. The health care provider needs to weigh the potential
risks of mother-to-child transmission vs. vaginal breech delivery in the absence of
cesarean section capability.5

Absolute contraindications
1. Any contraindications to labour, e.g. placenta previa, non-reassuring fetal heart
rate (FHR), or intrauterine growth restriction
2. Congenital abnormality (i.e. hydrocephalus)

Relative contraindications
1. Severe oligohydramnios
2. Hyperextension of the fetal head

41
3. Two or more previous cesarean sections
4. Morbid obesity
5. Active labour

There is no evidence to suggest that ECV is unsafe after one low transverse
uterine incision or cesarean section.

3.9.3 Risks
1. Intrauterine death is rare but may occur secondary to cord accident, maternal-
fetal hemorrhage, or may be unexplained
2. Placental Abruption
3. Rupture of the membranes
4. Stimulation of (pre-term) Labour
5. Fetal bradycardia
6. Isoimmunization

External cephalic version procedure

Obtain the woman’s fully informed consent. This discussion should include the
following information:
 A policy of offering ECV after 36 weeks will reduce the need for cesarean
section surgery.
 Success is approximately 30% to 50%, and is dependent on the experience
of the health care provider, as well as parity of the woman.
 The procedure may be safely repeated until the buttocks are deeply
engaged in the pelvis, or rupture of membranes has occurred.
 Sedation and tocolysis may be used.

42
Figure 13 Procedure of ECV (Source: Cunningham FG, Leveno KJ, Williams JW, Bloom SL, Spong
CY. Williams obstetrics. 25rd ed. New York: McGraw-Hill Medical; 2015. xv, 1509 p. p.)

CHAPTER 4

4.1 DISCUSSION

This case report discusses a 32 years old patient was admitted to the
Emergency Room of Dr. Achmad Mukhtar General Hospital on Sept 15th, 2018 at
03.15 am, referred from Primary Health Care with diagnosed G4P3A0L3 term
parturient of Active phase of first stage, Fetal alive, singleton, intra uterine, breech
presentation left transversed sacrum bone at HII-III. As a guide to the discussion on
target academically comprehensive scientific then we will discusss some of the
reference questions are as follows :

1. Whether the diagnose of this patient was right ?

2. Whether the management of this patient was appropriate ?
3. What is the cause of breech presentation in this patient ?

1. Whether the diagnose of this patient was right ?

43
 Discussion based on the questions are :
Known by anamnese this patient was a multiparous, haven't had menstrual
since 9 months ago but forgot the first day of last menstrual period. On physical
examination, abdomen was enlarge equal to term pregnancy, fundus uterine was
felt 3 fingers below processus xyphoideus, uterine fundal height was 31 cm. From
the ultrasound examination, confirmed by biometry, placental grading that this
patient have reached term pregnancy.
From the anamnese, we found that she came to the hospital with feeling of
pain from waist region which referred to the groin and bloody show from the
vagina since 6 hours ago. On physical examination, found that uterine contraction
was adequate which last 3-4x/30”/Moderate, then from vaginal toucher we have
got that cervical dilatation is 6-7 cm. This mean that the patient occured in
progression of labor, which is the first stage of active phase.

In additional, we should asked whether this patient had ever felt

discomfort and pain at the right hypochondrium during pregnancy, especially at
3rd trimester of gestasional age. Through physical examination on abdomen, part
of rounded, hard mass which describe as head was founded in Leopold I, while
on Leopold II the baby's back was founded on the right, and on Leopold III
founded that large soft noduler mass which describe as breech. Then, from
auscultation found that locates the fetal heart at a higher level than the level of the
umbilical. From vaginal toucher, the buttocks (no cephalic suture lines) were felt
at hodge II-III. It was also confirmed by Ultrasound scanning impressed that the
fetal was in a breech position. As a conclusion, this patient was having a singleton
pregnancy with malpresentation, a breech presentation.
Prediction of baby weight measured by the height of fundus uterine was
3100 gram. While onassisted examination using USG, baby weight's predicted
based on biometry was 3000 gram. In this pregnancy, the fetal weight as big as
than previous one. No Fetopelvic disproportion enforced by physical examination,
specifically from Leopold III founded that large soft noduler mass which describe
as breech was fixated, it means that disproportion between the lowest part of the
fetus and the pelvic size wasn’t existed. From the vaginal toucher, found that with

44
cervical dilatation 6-7 cm, the lowest part of the baby was inside the pelvic cavity
(hodge II-III fixated).
Based on anamnese, physical and assisted examination, the diagnose of
this patient was correct, a G4P3A0L3 term parturient of Active phase of first stage,
Fetal alive, singleton, intra uterine, breech presentation left transversed sacrum
bone at HII-III.

2. Whether the management of this patient was appropriate ?

This patient pregnancy was planned to be terminated by Vaginal Delivery with

Spontaneous Breech. Based on recommedation 7 and 8 at RANZCOG 2016 , on
recomendations for delivery in breech presentation must take place in a facility
where appropriate experience and infrastructure are available:
 Continuous fetal heart monitoring in labour.
 Immediate availability of caesarean facilities.
 Availability of a suitably experienced obstetrician to manage the delivery
On this patient, delivery with spontaneous breech is planned to be carried
out at the Achmad Mukhtar hospital which has this all category.
When breech presentation is first recognised in labour, the obstetrician
should discuss the options of emergency caesarean section or proceeding with
attempted vaginal breech birth with the woman, explaining the respective risks
and benefits of each option according to her individual circumstances. On this
patient, the helper don’t performed that recommendation, but still explaining the
respective risks and benefits of vaginal breech birth & patient was accepted.

Based on ALARM 2016 & Sarwono 2010, Recommended cesarean

delivery is commonly but not exclusively, used in the following circumstances : a
large fetus > 3800gram, any degree of contraction or unfavorable shape of the
pelvis determined clinically or with CT pelvimetry, a hyperextended head, high
social value fetus, incomplete or footling breech presentation, an apparently
healthy and viable preterm fetus with the mother in either active labor or in whom
delivery is indicated, severe fetal-growth restriction, previous perinatal death or

45
children suffering from birth trauma, a request for sterilization, lack of an
experienced operator, and prior caesarian delivery.
Zatuchni-Andros point less or equal to 4. This patient's Zatuchni andros
point is 9 (nine) : multiparous, baby, 38 weeks gestasional age’s prediction,no
history of previous breech delivery, weight's prediction <3176 gram, decreasing of
station -1, cervical opening 6-7 cm.
The diagnosis of active phase of first stage was right, we must do the trial
of labor by evaluating the progression of labor. Patient was a muliparous woman,
with history of deliver baby weight as big as this one, vaginal delivery with
Spontaneous breech was the best choice for this patient.

3. What is the cause of breech presentationin this patient ?

According to Cunningham 2014 & RCOG As term approaches, the uterine

cavity usually accommodates the fetus in a longitudinal lie with the vertex
presenting. Factors other than gestational age that predispose to breech
presentation include hydramnios, high parity with uterine relaxation, multiple
fetuses, small fetus/preterm, large fetus, oligohydramnios, hydrocephaly,
anencephaly, previous breech delivery, uterine anomalies, placenta previa, fundal
placental implantation, and pelvic tumors. The factor in this patient was maybe
multiparous. And based on hydroamnion cannot be assessed because it is already
in a ruptured of membranes.

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 CHAPTER 5
SUMMARY

1. the diagnose of this patient was correct, a G4P3A0L3 term parturient of Active
phase of first stage, Fetal alive, singleton, intra uterine, breech presentation
left transversed sacrum bone at HII-III .
2. The management on this case was correct by doing the vaginal delivery
planning with Spontaneous Breech and changed into manual aid was the best
choice for this patient.
3. The cause of breech presentation in this patient was multiparous

47
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