Learning objectives
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Identify the types of vaginal breech deliveries.
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Describe the complications associated with vaginal breech delivery.
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Be able to safely perform vaginal breech delivery.
Breech presentation occurs when the presenting part of the fetus is the buttocks or feet. There are three main types of breech presentation Fig. 11.1 .
Types of Vaginal Breech Delivery
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Spontaneous breech delivery → fetus delivers without assistance or manipulation; usually occurs when fetus is preterm
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Assisted breech delivery → fetus descends with a “hands-off” approach. Recognized maneuvers are used to assist when required
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Breech extraction → one or both fetal feet are grasped from the uterine cavity and brought down through the vagina; usually reserved for delivery of a second twin
Management
Optimal Patient Selection
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No contraindication to vaginal birth
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No prior cesarean deliveries
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Gestational age >36 weeks
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Spontaneous labor
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Facility equipped for safe emergency cesarean delivery
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Staff skilled in breech delivery
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Ultrasound examination showing:
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Frank or complete breech presentation
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No hyperextension of the fetal head
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Absence of any fetal anomaly that may cause dystocia
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Estimated fetal weight between 2000 and 3500 g
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Incomplete breech presentation is a contraindication to vaginal delivery (high risk of cord prolapse)
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Labor Management
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Avoid induction of labor
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Determine the type of breech (ultrasound and/or physical examination)
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Avoid artificial rupture of membranes. Perform vaginal exam after spontaneous rupture of membranes to exclude cord prolapse
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Continuous electronic fetal monitoring—if necessary, place fetal scalp electrode on buttocks
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Consider regional anesthesia
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In case of poor labor progress in the active phase, cesarean delivery should be considered. Data suggests better outcomes if the second stage is less than 40 minutes
Delivery Technique
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Dorsal lithotomy or any other “upright” maternal positions are acceptable options
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Empty the bladder and remove any indwelling catheter
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Perform episiotomy only if necessary and not until the presenting part is at the level of the vulva
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Once the breech is visible at the perineum, encourage active pushing
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The mother bears down until feet, legs, and trunk to the scapula are visible. Spontaneous delivery of the limbs and trunk is preferable—do not pull! ( Fig. 11.2 )
Fig. 11.2
Encourage active pushing keeping the hands off.
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If the legs are extended after the umbilicus has delivered, legs may be delivered by Pinard maneuver, which employs a constant pressure on the back of the knee ( Fig. 11.3 )
Fig. 11.3
Pinard maneuver. Pressure is exerted on the back of the knee. This assists delivery of extended legs.
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Check cord pulsation and pull a small loop of cord down to prevent traction on the cord
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If the arms do not deliver spontaneously, support the fetus by placing your hands at the levels of the bony prominences of the iliac crests ( Fig. 11.4 )
Fig. 11.4
The practitioner’s hands are placed on the bony prominences of the iliac crests.
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Rotate the fetus 180° to deliver the first shoulder and arm. Then, repeat in the opposite direction. This is called Løvset’s maneuver ( Fig. 11.5 )
