Vaginal Breech Delivery

International

Vaginal Breech Delivery

 Vaginal Breech Delivery
International
Objectives
Incidence and Significance
Selection
Management
- Intrapartum
- Delivery
 Vaginal Breech Delivery
International
Definition
longitudinal lie
breech or lower extremity presenting
cephalic pole in the uterine fundus

Types
1. frank - flexed hips, extended knees
2. complete - flexed hips, flexed knees
3. footling - extended hip(s)
 Vaginal Breech Delivery
International

Types of Breech

Complete Footling Frank

 Vaginal Breech Delivery
International

Incidence
3 to 4% of all pregnancies
increases with decreasing gestational age
7 to 10% at 32 weeks
25 to 35% at < 28 weeks
 Vaginal Breech Delivery
International

Etiology of Breech Presentation

idiopathic
prematurity (head to trunk size)
uterine or pelvic structural abnormality
uterine fibroid
fetal anomaly or abnormality
polyhydramnios
multiple gestation
 Vaginal Breech Delivery
International

Diagnosis

maternal perception of movement

Leopolds maneuvers
FH auscultated above umbilicus
vaginal exam
ultrasound
X-ray
 Vaginal Breech Delivery
International

Recommendations for Breech Delivery

recommend trial of labour at 36 weeks or when
estimated weight is 2500 to 4000 grams
offer trial of labour at 31 to 35 weeks gestation or
when estimated weight is 1500 to 2500 grams
offer caesasean section at 30 weeks gestation or
when estimated weight is < 1500 grams*
no recommendation for when estimated weight is >
4000 grams*

* acknowledged lack of evidence for recommendation

 Vaginal Breech Delivery
International

Selection Criteria for Trial of Labour

frank or complete breech
fetal head not hyperextended
estimated fetal weight 2500 to 4000g
 Vaginal Breech Delivery
International

Ultrasound Assessment
confirm lie and type of breech
assess head position
obtain estimate of fetal weight
assess for IUGR and congenital anomalies
assess amniotic fluid volume
confirm placental localization
 Vaginal Breech Delivery
International

Contraindications to Trial of Labour

fetal or maternal contraindication to labour
footling breech
hyperextension of the fetal head
absence of informed consent
absence of experienced maternity health
care giver
 Vaginal Breech Delivery
International

Management in Labour
planned delivery in hospital
admission in early labour or with ROM
appropriate fetal surveillance
epidural and ARM for usual indications
immediate vaginal exam at ROM to rule out cord
prolapse
good progress in labour ( 0.5 cm/h after 3 cm)
induction and augmentation permissible
 Vaginal Breech Delivery
International

Management at Delivery
experienced newborn resuscitator
present
empty maternal bladder
maternity attendant with experience in
breech delivery
forceps if available, may be helpful
 Vaginal Breech Delivery
International

Entering the Pelvis

Obstetrics - Normal and Problem Pregnancies, 2nd Edition

Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)
 Vaginal Breech Delivery
International

Descent of the Breech

Obstetrics - Normal and Problem Pregnancies, 2nd Edition

Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)
 Vaginal Breech Delivery
International
Spontaneous Expulsion
spontaneous expulsion to
the umbilicus
the sacrum should be
gently guided anteriorly
singleton breech extraction
is contraindicated
C/S is indicated for failure
of descent or expulsion

Obstetrics - Normal and Problem Pregnancies, 2nd Edition

Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)
 Vaginal Breech Delivery
International
Hurry up & Wait!
DONT PULL!
traction deflexes
the fetal head
may cause
nuchal arm

Obstetrics - Normal and Problem Pregnancies, 2nd Edition

Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)
 Vaginal Breech Delivery
International

Deliver Legs by lateral rotation of thighs and

flexion of knees - keep sacrum anterior

Obstetrics - Normal and Problem Pregnancies, 2nd Edition

Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)
 Vaginal Breech Delivery
International
Delivery of Arms
good maternal pushing
deliver when winging
of scapulae seen
rotate arm to anterior
sweep humerus across
the chest and deliver
rotate other arm
anterior and repeat to
deliver

Obstetrics - Normal and Problem Pregnancies, 2nd Edition

Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)
 Vaginal Breech Delivery
International

Avoid Over-extension

Obstetrics - Normal and Problem Pregnancies,2nd Edition

Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)
 Vaginal Breech Delivery
International
Delivery of the head

Mauriceau - Smellie - Veit

manoeuvre to deliver the head in
flexion
The body should be supported in
a horizontal position
 Vaginal Breech Delivery
International
Delivery of the head

Obstetrics - Normal and Problem Pregnancies, 2nd Edition

Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)
 Vaginal Breech Delivery
International
Delivery of the head

Forceps
assistant
elevating babe
direct application

Obstetrics - Normal and Problem Pregnancies, 2nd Edition

Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)
 Vaginal Breech Delivery
International
 Vaginal Breech Delivery
International

Prevention of Breech
consider external cephalic version at
36 weeks gestation for eligible
candidates
success rate 30 - 70% depending on
experience
results in lower cesarean section rate