LABOR AND DELIVERY MANAGEMENTe. . . . . . . . . . . . . 543
PARTIAL BREECH EXTRACTION ................... 544
TOTAL BREECH EXTRACTIONe. . . . . . . . . . . . . . . . . . . . . 548 EXTERNAL CEPHALIC VERSION. . . . . . . . . . . . . . . . . . . . 549 extremities and buttocks. With a frank breech, lower extremities are flexed at the hips and extended at the knees, and thus the feet lie close to the head
With a complete breech, both hips are lexed, and one or both knees are also lexed (Fig. 28-2). With an incomplete breech, one or both hips are extended. As a result, one or both feet or knees lie below the breech, such that a foot or knee is lowermost in the birth canal (Fig. 28-3). A footling breech is an incomplete breech with one or both feet below the breech.
FIGURE 28-1 Frank breech presentation.
The essential prerequisite or the successful peormance of breech extraction lies in the complete dilatation of the cervix and the absence of any serious mechanical obstacle. It is true that in a certain number of cases extraction through an impeecty dilated cervix is possible, but this is usualy fected ony at the cost of deep cervical tears.
-J. Whitridge Williams (1903)
Near term, the fetus typically has spontaneously assumed a cephalic presentation. Conversely, if the fetal buttocks or legs enter the pelvis before the head, the presentation is breech. This fetal lie is more common remote from term, as earlier in pregnancy each fetal pole has similar bulk. At term, breech presentation persists in approximately 3 to 5 percent of singleton deliveries (Cammu, 2014; Lyons, 2015; Macharey, 2017).
he categories of frank, complete, and incomplete breech presentations difer in their varying relations between the lower
FIGURE 28-2 Complete breech presentation.
FIGURE 28-3 Incomplete breech presentation.
Of term breech fetuses, the neck may be extremely hyperextended in perhaps 5 percent, and the term stargazing etus is used (Cimmino, 1975). With these, fetal or uterine anomalies may be more prevalent and are sought if not previously identified (Phelan, 1983). With this hyperextension, vaginal delivery can result in injury to the cervical spinal cord. hus, if identified at term, this is an indication for cesarean delivery (Westgren, 1981). hat said, flexion itself may be implicated, s cses of spinal cord injury have been reported following uneventul cesarean delivery of such fetuses (Hernandez-Marti, 1984). With transverse lie and similar hyperextension of the fetal neck, the term iyingetus is applied.
Understanding the clinical settings that predispose to breech presentation can aid early recognition. Other than early gestational age, risk factors include extremes of amnionic fluid volume, multifetal gestation, hydrocephaly, anencephaly, structural uterine abnormalities, placenta previa, pelvic tumors, and prior breech delivery. One study found that following one breech delivery, the recurrence rate for a second breech presentation was 10 percent, and for a subsequent third breech it was 28 percent (Ford, 2010).
Leopold maneuvers to ascertain fetal presentation are discussed in Chapter 22 (p. 424). With the irst maneuver, the hard, round fetal head occupies the fundus. he second maneuver identifies the back to be on one side of the abdomen and the small parts on the other. With the third maneuver, if not engaged, the softer breech is movable above the pelvic inlet.