1. Zatuchni-Andros breech scoring for breech delivery - If score is <4, caesarean delivery is recommended due to risk of fetal morbidity and prolonged labor. Zatuchni- Andros breech scoring for breech delivery 01 point2 points ParityPrimigraviaMultigravida Gestational age>= 39 weeks38 weeks<37 weeks EFW (kg)>3.53-3.5<3 Previous breech01>=2 Dilatation (cm)<=23>=4 StationAbove and at -3-2Below and at -1

2. Term breech trial (Hannah Trial) -Hannah from university of Toronto, Canada (2000) conducted a randomized controlled multicentre trial called ‘Term breech trial’ to compare planned vaginal birth for breech presentation at term with planned caesarean delivery involving 2088 women in 121 centres from 26 countries (including India). -Trial conducted that for term breech, planned caesarean delivery is more favourable maternal and fetal outcome than for vaginal birth; benefits being greater in countries with low perinatal mortality rates. -Perinatal mortality was 3 per 1000 in planned caesarean group as compared with 13 per 1000 in planned vaginal delivery group. -Serious neonatal morbidity was 1.4% in planned caesarean group while it was 3.8% in planned vaginal delivery group. -Even urinary incontinence was less in elective caesarean delivery group. -However on long-term data, the difference in poor perinatal outcome was much less.

3. COMPLICATED BREECH DELIVERY Can be delay and arrest of breech at all levels of delivery. 1.Delay in descent in breech (arrest) at the outlet Breech must be assisted at the outlet due to -insufficient uterine action -unforeseen disproportion of pelvic outlet -tight perineum -macrosomic fetus MANAGEMENT Cesarean delivery Emergency caesarean delivery should be performed for all cases of arrest of breech at outlet due to pelvic disproportion and macrosomic fetus.

4. -For selected cases of insufficient uterine action or tight perineum without pelvic contraction or large fetus, judicious oxytocin administration is started. -Generous episiotomy and suprapubic pressure may achieve vaginal breech delivery in such cases. Groin traction -Unilateral or bilateral groin traction is performed using forefingers hooked in groin. -Pull should be with uterine contractions obliquely downwards towards trunk rather than towards femur.

5. GROIN TRACTION

6. 2. Arrest of breech in the cavity or above the level of ischial spines Careful assessment of maternal and fetal conditions should be made. Management Cesarean delivery should be performed for all cases of arrest at mid pelvis or high up especially if there is fetopelvic disproportion due to either abnormal pelvis or macrosomic fetus. various maneuvers can be performed for vaginal breech delivery in such case are as follows: 1.Bringing down of legs Done under general anaesthesia for flexed breech in the cavity with fully dilated cervix.

7. Catch on ankle (the nearest) and brings it down followed by the other leg, the delivery is then completed by breech extraction. 2.Pinard’s maneuver for frank breech extraction -Extended breech stuck up high in the pelvic cavity, is not possible to reach the feet to bring them down. -Under general anaesthesia nearly fully dilated cervix, put hand inside passing it along the anterior thigh and presses the fingers into popliteal fossa which abducts the thigh and flexes the leg with foot falling over the back of hand. -Foot is then held and brought down and out and breech extraction is completed.

8. PINARD’S MANUVER

9. Management of extended arms -One or both arms may be extended or lie behind the neck (nuchal displacement) -Usually occurs due to inappropriate traction to breech up to this point in delivery or if fetal trunk got delivered through an uncompletely dilated cervix Management 1. Lovset’s maneuver -Method of choice for delivery of shoulders especially for extended arms and nuchal displacement of the arms and can even be used for assisted breech delivery -Not required general anaesthesia -No intrauterine manipulation

10. Principal based on that the inclination of the pelvis is such that the posterior shoulder enters the pelvic cavity before the anterior shoulder. Hence even when the anterior shoulder is above the pubic symphysis the posterior shoulder is usually below the sacral promontory. Rotating the fetal trunk to anterior with downward traction causes posterior shoulder to reach below the pubic arch. Technique: Only done when the inferior angle of anterior scapula is visible underneath the pubic arch. Baby is wrapped in a warm dry breech towel and held at the buttocks and back using both hands by femoro-pelvis grip Using gentle traction and rotation, the posterior shoulder is rotated through 180 degree so that back faces anterior.

11. LOVESET’S MENUVER

12. Posterior shoulder thus made anterior. Emerges under pubis and delivered by gentle downward traction. Keeping back upper most, fetal body is than rotated back by 180 degree to bring back the other shoulder Anterior shoulder which was made posterior is thus again made anterior and is delivered as it emerges under the pubis. Position of head remains as it was in the beginning. Classical method: Also called direct traction of extended arms and rarely used when lovset’s menuver is failed General anaesthesia given

13. Whole hand is passed along dorsal surface of the body to reaxh nuchal armwhich is grasped in uteroand is drawn out over the chest by flexing it. Nuchal displacement of hands (nuchal arms) -One or both arms are present around the back of fetal head and neck and are impacted at the level of pelvic inlet -My be delivered by lovset’s menuver -If fetus is dead, blunt hook is passed into the uterine cavity under protection of forefingers and the arm is hooked at elbow and brought it out.

14. NUCHAL ARMS

15. ARREST OF AFTER COMING HEAD Pelvic inlet – inlet contraction, hydrocephalus, macrosomia Midcavity - midpelvic contraction and deflaxed head Outlet - Outlet contraction and tight perineum 1.Burns-Marshall technique -Most commonly used -Applicable when both arms have been delivered and patient is in lithotomy position. -Fetus allowed to hang by its own weight completely unsupported. -Assistant gives suprapubic with every contraction in downward and backward direction (Kristeller maneuver) to assist in engagement of fetal head until the delivery of the head.

16. - Hold infant’s legs in the right hand, placing the middle finger between the two ankles and lift the infant towards the mother’s abdomen by swinging in an arc. -Head extracted by traction on the infant’s feet, causes flexion of the head helping in its delivery. -Left hand gives perineal support and prevents too rapid emergence of the fetal head. -Once mouth and nose of the infant are delivered, they should be cleared by removing debries with suction. -Rest of the head is then delivered slowly and carefully.

17. BURNS-MARSHALL MANUVER

18. 2.Bracht maneuver Baby is not allowed to hang down by gravity but extended at once

19. 3. Mauriceau- smellie-Veit maneuver - Mauriceau and smellie used to p ut index finger in the fetal mouth for jaw flexion. -Veit modified by putting fingers on the malar bones for flexion to avoid mandibular fracture. -Can be used for fast delivery of the head and when no assistant is available or there is no time for application of forceps. -Left supinated forearm is placed under the fetal body with fetal limbs on either sides. -The index and middle finger pushing up the occiput to promote flexion while the other fingers grasping shoulders. -Downward traction is applied till the suboccipital region appears under the pubic symphysis. -The fetal body is then raised towards the maternal abdomen and the mouth, nose, brow and ultimately the occiput are delivered successively over the perineum.

20. Mauriceau- smellie-Veit maneuver

21. 4.Wigand- martin maneuver -Body of fetus is placed on the arm. -The middle finger of the hand of that arm is placed in the baby’s mouth to maintain flexion of head while the index and ring fingers of the same hand are placed on the malar bones to exert traction. -A continuous suprapubic pressure is exerted by the other hand on the occipital region so as to force the head down through the pelvis -The advantage is that all the traction is applied directly to the head.

22. Wigand- martin maneuver

23. 5.Modified prague maneuver - Used for modified occipito-posterior position(chin to pubis rotation) -Fingers are placed over the shoulders from behind and outward and upward traction is made -Other hand grasp the legs and the bod is swung over the mother’s abdomen -Thus the occiput is born over perineum -The risk of stretching of the neck and fracture of spine. -A better method is to use general anaesthesia to dislodge the chin and rotate the face posteriorly and the back anteriorly -Chin is flexed and the head is delivered with forceps.

24. Modified prague maneuver

25. 6. Forceps application on the after coming head Provides protection from compression and sudden decompression forces thus reducing incidence of fetal intracranial hemorrahge. Traction is on head is rather tan on neck, gentle traction promotes flexion of head reducing the diameter and aiding descent. The obstetrician kneels while an assistant holds and lifts infant’s body with breech towel at or just above the horizontal plane. This prevents hyperextension of fetal neck which can cause dislocation of cervical spine, haemorrhage in the venous plexus around the cervical spinal cord and even quadriplegia. Left blade of forcep in left hand and passed over the right hand placed in the vagna to the left side of the maternal pelvis over the right side of the fetal head.

26. -The right blade is inserted on the opposite side and blades locks so that they set along the occipito-mental diameter, one over each ear. -During initial traction, direction of forces is downwards, then forwards and finally upwards along the curve of carus. -When chin and mouth are visible over the perineum, then forceps, body and legs of fetus are raised together to complete the delivery of head slowly and gradually to avoid fetal intracranial haemorrhage from compression-decompression forces. -Ordinary mid cavity forceps with usual length of shank as Das’s forceps or Neville barne’s forceps are quite effective. -Piper forceps were practically designed for the after-coming head of breech.

27. Forceps application on the after coming head

28. 7. Duhrssen’s incision - Cutting the cervix at 2,6 and 10 o’clock position up to depth of 3-4 cm was used in the past to deliver a trapped after-coming head of breech as preterm delivery - Rarely used in modern days for fear of major haemorrhage

29. 8. Carniotomy If the fetus is dead, perforation of head or hard palate can be used to deliver the baby even without full cervical dilatation.

30. Insufficiently dilated cervix Sometimes patient bears down prematurely leading onto delivery of the trunk through insufficiently dilated cervix especially in the small preterm fetus or in footling presentation with entrapment of fetal head. MANAGEMENT Cervix can be pushed up above the fetal head gently using fingers in the ‘shoe horn method’ for a premature fetus and the reaching the chin of the fetus for further delivery by Mauriceau- smellie-veit maneuver Alternatilvely, twe Duhrseen’s incisions can be made at 2 and 10 o’clock position

31. Impacted breech -Inspite of good contraction and complete dilatation of cervix, the breech fails to descent -Occurs only in extended breech and is usually due to disproportion -Impaction can occur at the inlet, cavity or outlet -If within 30 minutes of full cervical dilatation, breech does not descent and descent of preterm, caesarean delivery is done regardless of the level of impaction.

32. Hyperextension of fetal head Most commonly seen in face presentation bu can be seen in transverse lie and breech presentation ETIOLOGY 1.Spasm of congenital shortening of extensor muscles of the neck 2.Umbilical cord around neck 3.Congenital tumors of fetal neck 4.Fetal malformations 5.Uterine anomalies 6.Placental tumors

33. DIAGNOSIS 1.x-ray appearance is classically called ‘ star gazing fetus’ 2.Ultrasound is done for the measurement of the craniospinal angle FETAL DANGERS -Damage to lower cervical spinal cord of the fetus during vaginal delivery due to excessive longitudinal stretching of the spinal cord, extreme flexion of the neck during delivery and marked torsion -Occasional tears in the dura and epidural haemorrhage -Dislocation or fracture of cervical vertebrae is rare.

34. MATERNAL RISKS sudden flexion of the fetal head may result in vaginal lacerations. MANAGEMENT Best managed by elective caesarean delivery.