The planned vaginal delivery of a term baby in a breech presentation is associated with an increased risk of neonatal mortality and morbidity when compared with a term baby delivered from a cephalic presentation. In some cases, women will decline the offer of cesarean delivery, or one is not possible, and vaginal delivery must be safely performed. This chapter is written to help clinicians doing a planned breech delivery and does not necessarily reflect a personal and/or institutional recommendation for this. In fact, in most institutions worldwide where safe cesarean delivery is available, that is the preferred method of delivery.
Breech presentation occurs when the presenting part of the fetus is the buttocks and/or feet. There are three different types of breech presentation (see Figure 4.2.1):
Complete breech: The hips are flexed and the knees are flexed. The legs are crossed over the front of the fetal trunk.
Frank breech: The hips are fully flexed with the knees extended and the feet close to the head.
Footling breech: There is one extended limb presenting, and the other limb is flexed.
On abdominal palpation: The head can be palpated in the fundus of the uterus. The presenting part does not feel as round and firm as a fetal head.
On vaginal examination during the late first stage and second stage, the type of breech determines what part of the baby will be palpated:
With a frank breech, the buttocks will be palpated.
Occasionally, a face presentation may be confused with a breech presentation. The easiest way to distinguish the two is with ultrasound. If this is not available, the examiner should try to identify the palpable boney prominences (ischial spines in a breech, cheekbones in a face presentation) and soft tissue opening (anus in a breech and mouth in a face presentation): In a breech presentation, the ischial spines and anus form a relatively straight line. In a face presentation, the cheekbones and the mouth form a triangle. In addition, a mouth is generally larger, and the tongue and lips may be palpated. Care should be taken not to palpate a suspected face presentation vigorously because of the risk of ocular trauma.
With a complete breech, the feet will be felt under the buttocks. The heel of the foot usually forms a 90-degree angle with the leg.
With a footling breech, a single foot will be felt in the vagina.
With ultrasound, the head will be confirmed in the fundus of the uterus.
Prematurity
Fetal anomalies—May be associated with 2× to 3× increased risk
Placenta previa
Uterine anomalies
Polyhydramnios
Previous breech delivery
Multiple pregnancies
Short umbilical cord
Any obstetrical indication for cesarean delivery
Rupture of the membranes
Severe oligohydramnios
Fetal anomaly
Nonreassuring fetal heart rate monitoring
Uterine anomaly
Multiple gestations
Controlled maternal hypertension
Maternal obesity
Fetal growth restriction
Previous cesarean delivery (except for a classical scar), but this contraindication remains controversial.
Fetal heart rate abnormalities during the procedure
HIV infection
Under most circumstances, the procedure is best performed after 36 weeks’ gestation in a suite where immediate cesarean delivery can be performed and all necessary people and equipment are available.
Obtain informed consent.
Perform ultrasound to exclude any contraindications and confirm the lie, presentation and position, and absence of major anomalies.
Consider the administration of a tocolytic, such as terbutaline, and analgesia which may include conscious sedation and/or regional anesthesia. The use of the combination of pain relief and tocolytics has been found to double the rate of success of ECV but does not alter the long-term outcomes of the rate of cesarean delivery or cephalic presentation at birth.
Elevate the breech out of the pelvis using gentle abdominal manipulation. This may be aided by Trendelenburg positioning and even a gentle elevation of the breech by an assistant using a vaginal hand.
Either a forward roll or a backward flip can be used to effect the version.
Using both hands, move the fetal head from the fundus and the breech out of the pelvis.
Manipulate the fetus through a transverse position into a cephalic presentation.
Check the fetal heart regularly during the procedure.
Check the mother for development of abdominal pain.
Administer 300 micrograms (1500IU) of Anti-D Rhogam if she is Rh-negative.
Perform a nonstress test (NST) and monitor the fetus postprocedure for at least 2 hours.
Consider performing a Kleihauer-Betke test to rule out a significant abruption if the procedure was complicated or if the patient is experiencing pain and/or contractions postprocedure.
Inform the mother of the potential for increased fetal and neonatal mortality and morbidity as compared with cesarean delivery.
Cesarean delivery as an alternative to labor and vaginal delivery should be discussed, and the patient’s decision should be documented.
Consent for episiotomy and regional anesthesia (combined spinal-epidural or epidural) should be obtained. Regional anesthesia is very important to enable a controlled delivery.
Parity: The patient should understand that primiparity is not a contraindication but does reduce the chances of successful vaginal delivery.
Table 4.2.1 Maternal and Fetal Complications of ECV
Maternal
Fetal
High rate of cesarean delivery
Abruptio placenta
Alloimmunization
Non reassuring fetal heart rate
Potential risk of uterine rupture
Rupture of membranes
Cord prolapse
Reversion back to breech
Fetomaternal hemorrhage
Fetal death—rare
Pitocin: Although Pitocin is an option under some circumstances in experienced hands, the patient should understand that this is unusual and that few data support this option.
Care should be taken that labor progresses at least at a normal rate. Do not attempt to speed up a protracted first stage with Pitocin—labor arrest or protraction is a sign of high risk for complications.
Previous cesarean delivery: Additional information should be part of the consent before attempting trial of labor after cesarean (TOLAC) and breech delivery. This is an unresolved issue in the literature.
If not in labor and no contraindications exist, the patient should be offered the option of an ECV and her decision documented.
Pertinent fetal factors include the following:
Table 4.2.2 shows contraindications for vaginal breech delivery, and Table 4.2.3 shows prerequisites for safe vaginal breech delivery.
Fetal weight <2,000 g and >4,000 g (although some authors recommend a lower limit of 1,500 g and an upper limit of 3,500 g)
Babies that are too small are at risk of having cervical head entrapment.
Babies that are too big are at risk for intrapartum dystocia but do not usually suffer cervical head entrapment. Both clinical (Leopold maneuvers) and sonographic estimates are recommended, with careful consideration of the source if the discrepancy is large. In addition, we recommend taking note of the mother’s opinion on whether her current baby weighs more or less than her previous baby/ies.
Table 4.2.2 Summary of Fetal and Maternal Contraindications to Vaginal Breech Deliveries
Fetal
Maternal
Fetal weight <2,000 g or <32 weeks and >4,000 g
Distorted pelvic cavity (prior fracture or rickets)
Stargazing attitude—hyperextended neck
Narrow retropubic arch
Anomalies, e.g., hydrocephalus/neck masses
Narrow subpubic arch
Sacral posterior position
Maternal obesity
Cord presentation
Pelvic shape—android pelvis
Footling breech
Amniotic fluid anomalies
Table 4.2.3 Prerequisites for Planned Vaginal Breech Delivery
No Contraindication to Vaginal Birth
No Hyperextension of Fetal Head
Absence of fetal anomaly
Frank or complete breech
EFW 2,000-4,000 g
Normal progress of labor
EGA 36 weeks or more
Continuous fetal heart rate monitoring
Flexed fetal head
Skilled staff
Facilities for safe emergency Cesarean delivery
EFW, estimate of fetal weight; EGA, estimated gestational age.
The sonographic biometrics should also be checked for disproportion (i.e., head circumference vs. abdominal circumference [HC/AC] or femur length vs. biparietal diameter [FL/BPD], particularly at the extremes of weight estimates). If there is a large discrepancy between these measurements, there is an increased risk of head entrapment.
Flexion of the cervical spine, and the specifics of the breech presentation.
A fetus with a hyperextended cervical spine is labeled “stargazing” and indicates a maximally extended neck. A stargazing fetus is ineligible for a vaginal breech delivery based on the increased risk of cervical spinal cord injury reported in that circumstance. If a stargazing fetus is encountered, the cause of the fetal head and neck extension should be sought—often found to be associated with a neck swelling (thyroid/branchial arch cyst) or tumor, hydrocephalus, or a spinal malformation.
Position of the sacrum: A posterior sacrum is a concern because if the baby descends and delivers in that position, the head will be much more difficult to deliver. This is because head descent and flexion are opposed by the sacral curve, leading to greater presenting head diameters.
The location of the umbilical cord: Cord prolapse is more common in complex breech presentations. In a frank breech presentation, the rate of cord prolapse is similar to that in cephalic presentation. However, cord prolapse in a complete breech presentation is two to four times more common than in a cephalic presentation and up to 10-fold increased in a footling or incomplete breech presentation.
The shape of the maternal pelvis/pelvic capacity: In only ˜40% of cases are all of the qualitatively assessed pelvic diameters of average or better length. The only clinical measure that can be made is of the diagonal conjugate (DC), and it should exceed 11.5 cm (to correlate with an obstetrical conjugate of 10 cm).
Android pelvis: A classic android pelvis that funnels and constricts toward the outlet from a heart-shaped inlet is a contradiction to a planned breech delivery. An assessment of the DC, sacral hollow, shape of the pelvic sidewalls, the prominence of the ischial spines, the retropubic angle, the subpubic angle and arch, and the intertuberosity diameter should all be assessed and compared with those of a classic gynecoid pelvis of ample dimensions.
Narrow subpubic arch: A common disqualifier of planned breech delivery is a significantly narrow subpubic arch. The ability to have two fingers straddle the urethra is consistent with a “Norman” (rounded) rather than a “Gothic” (pointed) arch, and the latter can be an indicator of a narrow subpubic angle.
Retropubic arch: Placement of two fingers along the posterior surface of the inferior pubic rami extending from the symphysis pubis can also be helpful to gain an impression of the angle (90 degrees or more is adequate/gynecoid), and this assessment is of particular importance in predicting the potential for atraumatic reduction of the fetal limbs. An angle of <70 degrees has been associated with dystocia.
Maternal obesity is associated with fetopelvic dystocia, and pre- or retroperitoneal fat may compromise the adequacy of pelvic soft tissue volume. If the pelvic sidewalls, sacrum, and superior pubic rami are difficult to palpate, this may represent increased subcutaneous/retroperitoneal fat. Despite maternal obesity, if the pelvis feels ample in dimension, planned vaginal breech delivery may still be appropriate.
Table 4.2.4 summarizes the steps and maneuvers for a breech delivery. Table 4.2.5 summarizes the management of possible complications with a breech delivery.
The most important piece of advice these authors can give in the management of a vaginal breech delivery is to be patient! As long as the baby is stable and not compromised, the mother should be kept pain-free and calm.
Table 4.2.4 Steps and Maneuvers for a Breech Delivery
Steps
Maneuvers
First stage
Pain control is important. Regional anesthesia preferred to prevent involuntary pushing
Consent for episiotomy
Regional anesthesia
Epidural or spinal for delivery
Second stage
Patience! Allow descent spontaneously to the perineum.
Allow breech to distend perineum.
Do not pull on the breech.
Deliver the legs.
Spontaneously: Allow breech to deliver and if complete gently help feet out.
Pinard maneuver: For extended legs: Once thighs are visible, slide fingers of one hand up the thigh to the extended knee and push it away from the midline. This causes flexion of the knee and brings the foot down to the hand. The foot can then be grasped, the leg adducted and flexed across the belly, and delivered by traction on the foot.
Allow the body to hang down.
This helps maintain head flexion. An assistant can follow the head with an ultrasound probe to keep the head flexed or a hand to do the same.
Exteriorize a small length of cord
This allows palpation of the heart rate and ensures that the cord is not too short or encircling a body part.
Delivery of the arms (flexed)
Once the elbows appear at the perineum, slide your fingers of one hand over the baby’s shoulder and down to the elbow, gently pull the elbow to further flex it, and bring the hand down across the face into your fingers. Deliver the hand. Repeat on the other side.
If there are nuchal arms (extended)
Lovset maneuver: Hold baby with thumbs on the sacrum and fingers on the iliac crests, gently rotate the body through 90 degrees to move one shoulder anteriorly, the rotation will flex the elbow and bring the arm down, then splint the arm, slide the fingers to the elbow, bring the hand across the face and out, deliver the arm, then rotate the baby through 180-degree rotation and deliver the other arm.
Allow baby to hang down briefly.
Allow the baby to hang down until the nape of the neck is seen. Keeps the head flexed.
Delivery of the head
Mauriceau-Smellie-Veit: Place the index and ring fingers of one hand on the baby’s maxilla/cheekbones (not in the mouth), and the index and ring fingers of the other hand on the baby’s shoulders with the middle finger on the occiput. Position the baby’s body on the forearm of the hand on the maxilla, elevate the body slowly and gently, pivot the occiput around the symphysis to gently deliver the head.
Piper and Kielland forceps—see text for technique
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