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Hyperrotation and deflexion of the head in breech presentation
HYPERROTATION AND DEFLEXION OF THE HEAD BREECH PRESENTATION*’ With a New and More Descriptive RALPH (From
the
A. REIH,
Department
M.D.,
of
AND
Obstetrics and
EDWIK
Terminology
for Breech Presentation
.J. DFXOSTA,
and Gynecology, Michael Rwse
IN
M.D.,
Northwestern Hospital)
CHICAGO, ILL. Vniversity
Medirnl
Rchool
ARIATIONS in fetal attitude occurring in breech presentation are well known. These include : complete (full) breech, incomplete (frank) breech, footling and knee presentations, all of which arise from varying relationships between the lower extremities and the spine. In addition, there are varying relationships between the fetal head and/or the upper extremities and spine. Fetal attitude in utero can be fully appreciated only by roentgenographic studies. This is especially true with reference t,o the fetal head and spine.
V
Excellent x-ray studies have been made in the past. Warnekrosl in 1919 published a magnificent atlas of roentgenographic plates of fetal presentations, positions, and attitudes. Brakemann” (1936) was concerned specifically with the relationship of the fetal head to the spine. He showed that the head was well flexed in only 22 per cent of patients and hyperextended in 11 per cent,. Stein” (1941) studied deflexion attitudes and called attention to the frequency of frank breech. He advocates careful scrutiny of roent,genographs to determine the extent and degree of deflexion in order to anticipate difficulties which may be encountered. More recently, Wilcox” (1949) has drawn attention to t,he deflexed head and to the frequency and significance of deflexion attitudes. In all these studies there are only two passing references to hyperrotation and deflexion of the head. The first was by Warnekros (Fig. 1) and the second by Stein. Standard textbooks are silent on the subject. Recently we have had two patients whose babies, presenting by the breech, manifested this peculiar attitude of hyperrotation and deflexion of t.he head. The management of the first patient presented a perplexing problem because of our unfamiliarit,y with this fetal attitude. The patient was delivered by elective cesar’ean section in the belief that we were dealing with an unusual pathologic condition which might lead to insurmountable dystocia or to fetal axphvxia during labor. Encountering the same condition in a second patient within fifteen months indicates that such attitudes probably are not rare. Two additional insta.nces of this peculiar attitude have since been brought to our attention. CASE l.-Mrs. A. C., a 22.year-old primigravida, entered Michael Reese Hospital in mild labor on TIec. 5, 1946, seven days before her estimated delivery date. On the day preceding admission, a routine roentgenograph of the abdomen revealed a full-term fetus in left sacrum transverse position. The fetal head was rotated and deflexed so that the face seemed to point toward the fetal back (Fig. 2). Several possibilities were considered in attempting to explain this peculiar fetal attitude. ‘rhe most probable cause seemed to be h’ext in our consideration was the a t,umor of the neck, such as a congenital goiter. possibility of several loops of cord being wrapped around the fetal neck under sufficient *I’rrscnte~l
before
the
Chiraga
Gyncmlopicnl
Society.
637
Dee.
16.
19%
Fig.
I.-Hyperrotation
ant1
deflexion
of
the
heacl.
(Warnekros.)
CASE 2.-Mrs. 8. H., a ::7-year-old gravida ii, para i, was admitted to Michael Reese Ilospital on Jan. 28, 1948, one meek before her estimated delivery date, because of breech presentation and suspected cephalopelvie disproportion. Roentgenograph on .Jan. 30, lY4S, revealed a full-term fetus in left sacrum position with the head deflexed and rotated so that the occiput pointed toward the chest (F’ig. Z). The attitude of this fetus seemed to he identical with that in Case 1. Because of our previous experience, the patient was examined again roentgenographically four days later. At this time the fetus was fount1 to have undergone spontaneous cephalic version, and was presenting as a well-flexed occiput transverse (Fig. 4). One week later labor began spontaneously. After a S-hour, lo-minute first st,age and 27.minute second stage, a 3,100 gram male infant was delivrrrd h,v ontlf~l forceps. The child was normal in all respects.
The sequence of events in Case 1, which resulted in a spontaneous correctiou of t,he fetal a.ttitude, prompted us to be more complacent in the manage-
HYPERROTATTON
AND
DEFLEXION
OF
HEAD
639
ment of Case 2. In the second instance there was not only a restoration of the normally poised head but also a spontaneous cephalic version, which resulted in simple delivery one week later as a left occiput anterior. It has been our privilege to obtain two additional roentgenographs of similar attitudes from Dr. I. F. Stein (see Fig. 5 for one). These patients were delivered vaginally without difficulty and no fetal anomaly was encountered.
Fig.
Z.-Case
1.
Hyperrotation
and
deflexion
of
the
head.
legs
extended.
In the light of these experiences it would seem advisable to manage hyperrotation and deflexion of the fetal head in breech presentation by close continued observation rather than active interference. Such a “hands-off” policy will probably result in spontaneous correction either before or during labor. There would seem to be no additional danger of dystocia or of fetal death when hyperrotation and deflexion of the head are present. There is much to learn concerning the reasons for breech presentation and the various fetal attitudes. Gravitational influence on ultimate presentation is no longer considered important. It is accepted that anything which interferes with the normal feto-uterine accommodation may lead to other than cephalic presentation. Thus, if the uterus is arcuate, septate, bieornuate or distorted by tumors or another fetus, the fetus may accommodate better as a breech. A low-lying placenta or small pelvis may have a similar effect. The
The wurtl +‘ultimatc”
to tlenotr the ~~twcntation and position nt ;IISO lllay Iw al)pliecl to attitude. ‘I\‘e hare tleluouxtra.ted that, I)oth attitude ;Ind ~)rwcntation Illily change whell labor is imminent. I lence iC r~oe~it~e~~o~~~~i~~hs iire to Iw of greatest ynlue they must, be Hoetli gwlographs taken sollle (lays Iwfow taken when the patient is iti Iah~r. the onset oi l;ihor should not lw ;11lowfvl to ovt~riufiueticw the marlagetnent oi’ in l)Werh to I)C SOUrltl the patient. Alost J,ocntKcuo~~aI)liic SLIP vc)x 01’ iIttitLLdf3 in the literature PZII he c~riticiztvl I’rolrl this \.iewpoint. Attitude, PVPII mot’e than presentation, 111aych;tngr, auf1 tlwisiolls reache(l t’rurll the study of rorntgenographs takeu at the thirty-srvellth 01. t hit? y-eight \VCPII of gestation fwqucntly art’ Ilot :tpl)licahle ilt the oIlset of I~~)oY. I)retlis~wsirip I’actw iu hrecch presI’remat~uritg often is referrwl to iis entation, hut it. seems more logical to a~eyt prematurit)as coexistent rather than as responsible for the brewh presentation. The fetus is free to pyratc t,hf’
OllSf?t
Of
IClhfJY.
is
Lmfltl
“~T~tillliltf”’
il
at will during early pregnancy. This also holds near term when the fluid is excessive. Usually, however, as the fetus grows, it hecolnes more confined by the ut,erine walls. This is t)articularly true if the amount of liquor arnnii is scant. Tartan” has shown that the commonly accepted etiological factors could be demonstrated in only ‘i per cent of breech l,l,es~~llt;ltions, if prematurity and mult,iple pregnancy were eliniinatetl. Although it has heeu recognized that.
extension of the legs is a t)rimary fetal attitude in breech presentation. Vartan (1940) apparently was the first to call attention to the possibility that such extension can interfere with spontaneous cephalic version. Extension of the legs was noted in 7.3 per cent, of the cases studies. Stein!” Henderson,” and others have found such extension in over’ 50 per cent. Tompkins7 considers extension of the legs, an inactive chiltl, and itrrpniretl motor Inechanism as important etiological factors in breech prcsent~ation. On the other hand, Tartan also has shown that leakextension does ilot ncccssarily t)reTent spontaneous version nor t)reclude external version-although the latter is known to he more difficult when the legs are extended. Thus it appears that ultimate breech presentation results from interference with the free motion of the fetus in the majority of instances. Extension of the legs on the thighs eliminates the downward thrust, that might lead to spontaneous
642 cephalic version. How do the legs l~ccome cxtontled >~hcql flexion provi(lcs ;I more compact ovoid ‘! This is probably due to chance. Normal fetal movements in complete breech presentation mily permit the legs to flay orlt towartl the iliac fossa and be deflected ~~pwar~l by the ulcrine wall. Onc~eextension has occurred, the ut,erine walls xvi11 tent1 to maintain this attitude, and prevent spontaneous cephalic version. Deflexion of the spine and head likewise seems a matter of chance. 11 could be produced by transient fetal movement. Tt the forehead impinges OII the fundus or placenta during such movement, the head may be cxarrirtl gratlually to full extension. By the same process chance movement alone (aan 1~ Wsponsible for the hyperrotation of the head ljresented here. That such an attitude may be transient is proved by our observations. Further it can bc demonstrated that the head of the newborn child can rotate through an arc of more t,han 90 degrees from the midline on slight, pressure without harm to the baby. Some authors believe that muscle spasn-even though transitory-may IN responsible for malpresentations and attitudes. Gihberd’s’ original suggestion has been applied by Knowlton” and ru’agyfy’” to explain hyperextension in transverse presentation. There is no need to theorize a,bout muscle spasm-chance active fetal movement will account for occasional bizarre attitudes. The terminology of attitude in breech presentation should be revised. The expressions “complete” or full and “incomplete” or frank breech arc not sufficiently descriptive. It, would seem more descriptive to refer to a breech presentation, a breech-footling presentation, a footling presentation, or a knee presentation. To complete the description of attitude, it seems atlvisablc to add : legs flexed, legs extended. arms flexed, arms extended: spine flexetl. spine extended, head flexed, head extended, or head rotated. Such infornlatioll As now tmployed. estcrision of is rarely obtained without a roentgenograph. the legs may or may not connote deflesion at,titude ot’ the spine or head. III the past some authors have nscd the expression “deflexion” or “extension” very loosely to refer to deflexion or extension of the legs. or the spine, or the here suggested seems preferarms, or the head, or all four. The terminology able because of its specificity.
Flexed “cgsmExtended
Breech Rreech-Footling-Doub,e
Footling-
Single
Single noub,e
with
Spine-Flexed Extended Hen&-
Flexed Extended Rotated
Summary Two instances
presentation
of hyperrotation
have been described.
and deflexion
of the fetal head in breech
III I)oth instances, spontaneous flexion and corrective counterrotatjion oc*c~rl174 before delivery. lioentgenographs taken prior to the onset of labor should not be allowed 1o overinfluence the management of the patient. The diagnosis of hyperrotation and deflexion of the fetal head in breech l)rtbsentation does not seem to warrant active interference. Such att,itudes probably are the result of chance movements and require IIO corrective maneuvers. The terms “ultimate presentation,” “ultimate position,” and “ult,imate attitude” are suggest,ed to denote the presentation, position, and attitude at the onset, of labor. The nomenclature of attitude in breech presentation has been discussed and a more specific terminology is suggested.
References 1. 2. 3 4: 5. 6. 7. 8. 9. 1 I).
Schwangerschaft und Geburt in RSntgenbilde, Warnekros, Kurt: J. F. Bergmann, Tafel “7. Brakemann, 0.: Ztschr. f. Geburtsh. II. Gyniik. 112: 154, 1936. Stein, I. F.: J. A. M. A. 117: 1430, 1941. Wilcox. H. I,.: AM. J. OBST. & GYNEC. 58: 478. 1949. Vartani C. K.: Lancet 1: 595,194O. Henderson, H. : J. A. M. A. 117: 1435, 1941. Tompkins, P. : AIV~. J. OBST. & GYNEC. 51: 595,1946. Gibberd, G. F.: J. Obst. & Gynaec. Brit. Emp. 42: 596, 1935. Knowlton, R. W.: J. Obst. & Gynaec. Brit. Emp. 45: 834, 1938. West. J. Surg. 57: 165, 1949. Nagyfy, S. F.:
Wiesbaden,
1918,
Discussion DR. H. CLOSE HESSELTINE.-Dr. Reis and Dr. DeCosta offer essentially two main ljoints in their presentation. The first point about breech as the presenting part is an emphasis on the need for exact knowledge at the onset of labor; the second point concerns itself with a plea for a common terminology on breech classifiration. With all the attention and discussion which have been presented on breech delivery, the fetal mortality and injury of tllose who survive still exrretl that of vertex presentation. It is recognized generally that when the fare is the presenting part, it is abnormal. \-et this occurs only one-sixth as often as does breech. I believe that, in every instance, breech should be looked upon as an abnormal situation if not as a pathologic situation. inch universal teachings and warnings might offer hett,er safeguards to both the mother and the baby. In the year 1925-1926, while I was at the University Hospital in Iowa City, a good s-rn.v picture of “breech” was desired for teaching purposes. A patient was found who had the breech as the presenting part. When the patient was sent to the roentgenological department the picture revealed a vertex. The following week the patient was again seen and again was thought to have a breech and this was confirmed by two other staff memI)ers. The patient was again taken to the x-ray department in a wheel chair and again it was a T-ertex. 9 few days later the same observations were noted but this time the patient was taken on a cart for the picture. This time a (‘breech” was found over the inlet. Afterward the patient was put in the erect position and walked a short distance. This amplifies and Yubsequentlp a picture showed that the pole had changed to a vertex. emphasizes the point that Drs. Reis and DeCosta stress, that the fetal attitude is subject to change, sometimes in a short period and possibly without an obviously particular provoking factor. No doubt many obstetricians recognize but may not heed the point that the essayists emphasize: (I) that roentgenographs prior to the onset of labor must not unduly influence
n~anagement of tlrc pat irut ; XIII] (2 i t ha1 vari:tl)lr arlrl peculiar positiorts w11Vn tll*a breech is the presenling part C:LII a\vait thth I~rlst~t of l:tl,or 11r11rss t11rre arc OthPr ol,stf.trir~ indications for interference. The proposals of Keis anal De(‘osta have real virtues, hu! I llelieve they 11:1\-t> t*arriwl it to a romplicated degree I,>- introtluczing factors of the arms, spine, and heat]. In conrlusion, every t*ontril)ution that t*an he udvancaetl to reduce fetal in,juries and lower the fetal mortality and, at the same time, redut~t: irl,jury to the mother in the iw stance when the breech is presenting is rtlost t~or~nnrr~~lal~lr. t,he
DR. FREDERI~‘T< H. F’AT,IJH.-A similar deflexion attitude with I~ac~kward I)ominp of the spine was descril)ed 1)~ me in 191.5, and hecause no similar intrauterine fetal positiorl had been previously descritw~l \V:IS given tilt> namt of 6 ’ opisthotonos fetus. ’ * In this t’ilw, which presented trarrsT.ersely, after rupture of the n~rml~ranes the heart tones sutldenl> disappeared. A I)reec~h extraction after- \-ersion failetl to recover u live l)al)y. Our explanation was that the decompression of the uterus aftrr rupture of the mernlmmes ~esultotl in cord compression due to its uril~rotrctrd position l)ecanse of the deflexion al;titudr of the fetus. After deli\ cry thert~ was no reason fountl, on careful physical c:samirrntion of the baby intdlutling autopsy, to rsplain the opistliotonos position. JVrl,stcY. I)cl,w, :LIIlI Williams said they hat1 not seen an x-ra>- demonstration of a similar case. Since that time nw-t) l)reec*l1 and ottll,rs 1 have seen several examples of this twrlition, norne of whicli (‘esareart section may I)e indicated in such cases if cephalic or transverse presentations. spontaneous correction does not occur lwfore or during lalmr. DR. DE COSTA (Closing).--T am well nrquainted with the findiugs of opistho;onos There are many reports in the literature including those of Gibherd, Nagyfy. fetalis. Knowlton, Kobnk and others. However, we are not tliscussing opisthotonos fetalis. Opistwcountrretl in transvrrw prtwnt:r~ thotonos is an extension of the spirit B ant1 head, most often tions. In the condition we are tlistwssing, the spine is well flexed iLIlt1 the heat1 is hylwrrotatetl and moderately extended. The two conditions are not the same.
the
A. REIH,
Department
M.D.,
of
AND
Obstetrics and
EDWIK
Terminology
for Breech Presentation
.J. DFXOSTA,
and Gynecology, Michael Rwse
IN
M.D.,
Northwestern Hospital)
CHICAGO, ILL. Vniversity
Medirnl
Rchool
ARIATIONS in fetal attitude occurring in breech presentation are well known. These include : complete (full) breech, incomplete (frank) breech, footling and knee presentations, all of which arise from varying relationships between the lower extremities and the spine. In addition, there are varying relationships between the fetal head and/or the upper extremities and spine. Fetal attitude in utero can be fully appreciated only by roentgenographic studies. This is especially true with reference t,o the fetal head and spine.
V
Excellent x-ray studies have been made in the past. Warnekrosl in 1919 published a magnificent atlas of roentgenographic plates of fetal presentations, positions, and attitudes. Brakemann” (1936) was concerned specifically with the relationship of the fetal head to the spine. He showed that the head was well flexed in only 22 per cent of patients and hyperextended in 11 per cent,. Stein” (1941) studied deflexion attitudes and called attention to the frequency of frank breech. He advocates careful scrutiny of roent,genographs to determine the extent and degree of deflexion in order to anticipate difficulties which may be encountered. More recently, Wilcox” (1949) has drawn attention to t,he deflexed head and to the frequency and significance of deflexion attitudes. In all these studies there are only two passing references to hyperrotation and deflexion of the head. The first was by Warnekros (Fig. 1) and the second by Stein. Standard textbooks are silent on the subject. Recently we have had two patients whose babies, presenting by the breech, manifested this peculiar attitude of hyperrotation and deflexion of t.he head. The management of the first patient presented a perplexing problem because of our unfamiliarit,y with this fetal attitude. The patient was delivered by elective cesar’ean section in the belief that we were dealing with an unusual pathologic condition which might lead to insurmountable dystocia or to fetal axphvxia during labor. Encountering the same condition in a second patient within fifteen months indicates that such attitudes probably are not rare. Two additional insta.nces of this peculiar attitude have since been brought to our attention. CASE l.-Mrs. A. C., a 22.year-old primigravida, entered Michael Reese Hospital in mild labor on TIec. 5, 1946, seven days before her estimated delivery date. On the day preceding admission, a routine roentgenograph of the abdomen revealed a full-term fetus in left sacrum transverse position. The fetal head was rotated and deflexed so that the face seemed to point toward the fetal back (Fig. 2). Several possibilities were considered in attempting to explain this peculiar fetal attitude. ‘rhe most probable cause seemed to be h’ext in our consideration was the a t,umor of the neck, such as a congenital goiter. possibility of several loops of cord being wrapped around the fetal neck under sufficient *I’rrscnte~l
before
the
Chiraga
Gyncmlopicnl
Society.
637
Dee.
16.
19%
Fig.
I.-Hyperrotation
ant1
deflexion
of
the
heacl.
(Warnekros.)
CASE 2.-Mrs. 8. H., a ::7-year-old gravida ii, para i, was admitted to Michael Reese Ilospital on Jan. 28, 1948, one meek before her estimated delivery date, because of breech presentation and suspected cephalopelvie disproportion. Roentgenograph on .Jan. 30, lY4S, revealed a full-term fetus in left sacrum position with the head deflexed and rotated so that the occiput pointed toward the chest (F’ig. Z). The attitude of this fetus seemed to he identical with that in Case 1. Because of our previous experience, the patient was examined again roentgenographically four days later. At this time the fetus was fount1 to have undergone spontaneous cephalic version, and was presenting as a well-flexed occiput transverse (Fig. 4). One week later labor began spontaneously. After a S-hour, lo-minute first st,age and 27.minute second stage, a 3,100 gram male infant was delivrrrd h,v ontlf~l forceps. The child was normal in all respects.
The sequence of events in Case 1, which resulted in a spontaneous correctiou of t,he fetal a.ttitude, prompted us to be more complacent in the manage-
HYPERROTATTON
AND
DEFLEXION
OF
HEAD
639
ment of Case 2. In the second instance there was not only a restoration of the normally poised head but also a spontaneous cephalic version, which resulted in simple delivery one week later as a left occiput anterior. It has been our privilege to obtain two additional roentgenographs of similar attitudes from Dr. I. F. Stein (see Fig. 5 for one). These patients were delivered vaginally without difficulty and no fetal anomaly was encountered.
Fig.
Z.-Case
1.
Hyperrotation
and
deflexion
of
the
head.
legs
extended.
In the light of these experiences it would seem advisable to manage hyperrotation and deflexion of the fetal head in breech presentation by close continued observation rather than active interference. Such a “hands-off” policy will probably result in spontaneous correction either before or during labor. There would seem to be no additional danger of dystocia or of fetal death when hyperrotation and deflexion of the head are present. There is much to learn concerning the reasons for breech presentation and the various fetal attitudes. Gravitational influence on ultimate presentation is no longer considered important. It is accepted that anything which interferes with the normal feto-uterine accommodation may lead to other than cephalic presentation. Thus, if the uterus is arcuate, septate, bieornuate or distorted by tumors or another fetus, the fetus may accommodate better as a breech. A low-lying placenta or small pelvis may have a similar effect. The
The wurtl +‘ultimatc”
to tlenotr the ~~twcntation and position nt ;IISO lllay Iw al)pliecl to attitude. ‘I\‘e hare tleluouxtra.ted that, I)oth attitude ;Ind ~)rwcntation Illily change whell labor is imminent. I lence iC r~oe~it~e~~o~~~~i~~hs iire to Iw of greatest ynlue they must, be Hoetli gwlographs taken sollle (lays Iwfow taken when the patient is iti Iah~r. the onset oi l;ihor should not lw ;11lowfvl to ovt~riufiueticw the marlagetnent oi’ in l)Werh to I)C SOUrltl the patient. Alost J,ocntKcuo~~aI)liic SLIP vc)x 01’ iIttitLLdf3 in the literature PZII he c~riticiztvl I’rolrl this \.iewpoint. Attitude, PVPII mot’e than presentation, 111aych;tngr, auf1 tlwisiolls reache(l t’rurll the study of rorntgenographs takeu at the thirty-srvellth 01. t hit? y-eight \VCPII of gestation fwqucntly art’ Ilot :tpl)licahle ilt the oIlset of I~~)oY. I)retlis~wsirip I’actw iu hrecch presI’remat~uritg often is referrwl to iis entation, hut it. seems more logical to a~eyt prematurit)as coexistent rather than as responsible for the brewh presentation. The fetus is free to pyratc t,hf’
OllSf?t
Of
IClhfJY.
is
Lmfltl
“~T~tillliltf”’
il
at will during early pregnancy. This also holds near term when the fluid is excessive. Usually, however, as the fetus grows, it hecolnes more confined by the ut,erine walls. This is t)articularly true if the amount of liquor arnnii is scant. Tartan” has shown that the commonly accepted etiological factors could be demonstrated in only ‘i per cent of breech l,l,es~~llt;ltions, if prematurity and mult,iple pregnancy were eliniinatetl. Although it has heeu recognized that.
extension of the legs is a t)rimary fetal attitude in breech presentation. Vartan (1940) apparently was the first to call attention to the possibility that such extension can interfere with spontaneous cephalic version. Extension of the legs was noted in 7.3 per cent, of the cases studies. Stein!” Henderson,” and others have found such extension in over’ 50 per cent. Tompkins7 considers extension of the legs, an inactive chiltl, and itrrpniretl motor Inechanism as important etiological factors in breech prcsent~ation. On the other hand, Tartan also has shown that leakextension does ilot ncccssarily t)reTent spontaneous version nor t)reclude external version-although the latter is known to he more difficult when the legs are extended. Thus it appears that ultimate breech presentation results from interference with the free motion of the fetus in the majority of instances. Extension of the legs on the thighs eliminates the downward thrust, that might lead to spontaneous
642 cephalic version. How do the legs l~ccome cxtontled >~hcql flexion provi(lcs ;I more compact ovoid ‘! This is probably due to chance. Normal fetal movements in complete breech presentation mily permit the legs to flay orlt towartl the iliac fossa and be deflected ~~pwar~l by the ulcrine wall. Onc~eextension has occurred, the ut,erine walls xvi11 tent1 to maintain this attitude, and prevent spontaneous cephalic version. Deflexion of the spine and head likewise seems a matter of chance. 11 could be produced by transient fetal movement. Tt the forehead impinges OII the fundus or placenta during such movement, the head may be cxarrirtl gratlually to full extension. By the same process chance movement alone (aan 1~ Wsponsible for the hyperrotation of the head ljresented here. That such an attitude may be transient is proved by our observations. Further it can bc demonstrated that the head of the newborn child can rotate through an arc of more t,han 90 degrees from the midline on slight, pressure without harm to the baby. Some authors believe that muscle spasn-even though transitory-may IN responsible for malpresentations and attitudes. Gihberd’s’ original suggestion has been applied by Knowlton” and ru’agyfy’” to explain hyperextension in transverse presentation. There is no need to theorize a,bout muscle spasm-chance active fetal movement will account for occasional bizarre attitudes. The terminology of attitude in breech presentation should be revised. The expressions “complete” or full and “incomplete” or frank breech arc not sufficiently descriptive. It, would seem more descriptive to refer to a breech presentation, a breech-footling presentation, a footling presentation, or a knee presentation. To complete the description of attitude, it seems atlvisablc to add : legs flexed, legs extended. arms flexed, arms extended: spine flexetl. spine extended, head flexed, head extended, or head rotated. Such infornlatioll As now tmployed. estcrision of is rarely obtained without a roentgenograph. the legs may or may not connote deflesion at,titude ot’ the spine or head. III the past some authors have nscd the expression “deflexion” or “extension” very loosely to refer to deflexion or extension of the legs. or the spine, or the here suggested seems preferarms, or the head, or all four. The terminology able because of its specificity.
Flexed “cgsmExtended
Breech Rreech-Footling-Doub,e
Footling-
Single
Single noub,e
with
Spine-Flexed Extended Hen&-
Flexed Extended Rotated
Summary Two instances
presentation
of hyperrotation
have been described.
and deflexion
of the fetal head in breech
III I)oth instances, spontaneous flexion and corrective counterrotatjion oc*c~rl174 before delivery. lioentgenographs taken prior to the onset of labor should not be allowed 1o overinfluence the management of the patient. The diagnosis of hyperrotation and deflexion of the fetal head in breech l)rtbsentation does not seem to warrant active interference. Such att,itudes probably are the result of chance movements and require IIO corrective maneuvers. The terms “ultimate presentation,” “ultimate position,” and “ult,imate attitude” are suggest,ed to denote the presentation, position, and attitude at the onset, of labor. The nomenclature of attitude in breech presentation has been discussed and a more specific terminology is suggested.
References 1. 2. 3 4: 5. 6. 7. 8. 9. 1 I).
Schwangerschaft und Geburt in RSntgenbilde, Warnekros, Kurt: J. F. Bergmann, Tafel “7. Brakemann, 0.: Ztschr. f. Geburtsh. II. Gyniik. 112: 154, 1936. Stein, I. F.: J. A. M. A. 117: 1430, 1941. Wilcox. H. I,.: AM. J. OBST. & GYNEC. 58: 478. 1949. Vartani C. K.: Lancet 1: 595,194O. Henderson, H. : J. A. M. A. 117: 1435, 1941. Tompkins, P. : AIV~. J. OBST. & GYNEC. 51: 595,1946. Gibberd, G. F.: J. Obst. & Gynaec. Brit. Emp. 42: 596, 1935. Knowlton, R. W.: J. Obst. & Gynaec. Brit. Emp. 45: 834, 1938. West. J. Surg. 57: 165, 1949. Nagyfy, S. F.:
Wiesbaden,
1918,
Discussion DR. H. CLOSE HESSELTINE.-Dr. Reis and Dr. DeCosta offer essentially two main ljoints in their presentation. The first point about breech as the presenting part is an emphasis on the need for exact knowledge at the onset of labor; the second point concerns itself with a plea for a common terminology on breech classifiration. With all the attention and discussion which have been presented on breech delivery, the fetal mortality and injury of tllose who survive still exrretl that of vertex presentation. It is recognized generally that when the fare is the presenting part, it is abnormal. \-et this occurs only one-sixth as often as does breech. I believe that, in every instance, breech should be looked upon as an abnormal situation if not as a pathologic situation. inch universal teachings and warnings might offer hett,er safeguards to both the mother and the baby. In the year 1925-1926, while I was at the University Hospital in Iowa City, a good s-rn.v picture of “breech” was desired for teaching purposes. A patient was found who had the breech as the presenting part. When the patient was sent to the roentgenological department the picture revealed a vertex. The following week the patient was again seen and again was thought to have a breech and this was confirmed by two other staff memI)ers. The patient was again taken to the x-ray department in a wheel chair and again it was a T-ertex. 9 few days later the same observations were noted but this time the patient was taken on a cart for the picture. This time a (‘breech” was found over the inlet. Afterward the patient was put in the erect position and walked a short distance. This amplifies and Yubsequentlp a picture showed that the pole had changed to a vertex. emphasizes the point that Drs. Reis and DeCosta stress, that the fetal attitude is subject to change, sometimes in a short period and possibly without an obviously particular provoking factor. No doubt many obstetricians recognize but may not heed the point that the essayists emphasize: (I) that roentgenographs prior to the onset of labor must not unduly influence
n~anagement of tlrc pat irut ; XIII] (2 i t ha1 vari:tl)lr arlrl peculiar positiorts w11Vn tll*a breech is the presenling part C:LII a\vait thth I~rlst~t of l:tl,or 11r11rss t11rre arc OthPr ol,stf.trir~ indications for interference. The proposals of Keis anal De(‘osta have real virtues, hu! I llelieve they 11:1\-t> t*arriwl it to a romplicated degree I,>- introtluczing factors of the arms, spine, and heat]. In conrlusion, every t*ontril)ution that t*an he udvancaetl to reduce fetal in,juries and lower the fetal mortality and, at the same time, redut~t: irl,jury to the mother in the iw stance when the breech is presenting is rtlost t~or~nnrr~~lal~lr. t,he
DR. FREDERI~‘T< H. F’AT,IJH.-A similar deflexion attitude with I~ac~kward I)ominp of the spine was descril)ed 1)~ me in 191.5, and hecause no similar intrauterine fetal positiorl had been previously descritw~l \V:IS given tilt> namt of 6 ’ opisthotonos fetus. ’ * In this t’ilw, which presented trarrsT.ersely, after rupture of the n~rml~ranes the heart tones sutldenl> disappeared. A I)reec~h extraction after- \-ersion failetl to recover u live l)al)y. Our explanation was that the decompression of the uterus aftrr rupture of the mernlmmes ~esultotl in cord compression due to its uril~rotrctrd position l)ecanse of the deflexion al;titudr of the fetus. After deli\ cry thert~ was no reason fountl, on careful physical c:samirrntion of the baby intdlutling autopsy, to rsplain the opistliotonos position. JVrl,stcY. I)cl,w, :LIIlI Williams said they hat1 not seen an x-ra>- demonstration of a similar case. Since that time nw-t) l)reec*l1 and ottll,rs 1 have seen several examples of this twrlition, norne of whicli (‘esareart section may I)e indicated in such cases if cephalic or transverse presentations. spontaneous correction does not occur lwfore or during lalmr. DR. DE COSTA (Closing).--T am well nrquainted with the findiugs of opistho;onos There are many reports in the literature including those of Gibherd, Nagyfy. fetalis. Knowlton, Kobnk and others. However, we are not tliscussing opisthotonos fetalis. Opistwcountrretl in transvrrw prtwnt:r~ thotonos is an extension of the spirit B ant1 head, most often tions. In the condition we are tlistwssing, the spine is well flexed iLIlt1 the heat1 is hylwrrotatetl and moderately extended. The two conditions are not the same.