Vaginal Breech

International Delivery

Vaginal Breech
Delivery
 Vaginal Breech
International Delivery

Objectives
• Incidence and Significance
• Selection
• Management
– Intrapartum
– Delivery
 Vaginal Breech
International Delivery

Definition
• longitudinal lie
• breech or lower extremity presenting
• cephalic pole in the uterine fundus

Types
• frank - flexed hips, extended knees
• complete - flexed hips, flexed knees
• footling - extended hip(s)
 Vaginal Breech
International Delivery

Types of Breech

Complete Footling Frank

 Vaginal Breech
International Delivery

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
International Delivery

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
International Delivery

Diagnosis
• maternal perception of movement
• Leopold’s maneuvers
• FH auscultated above umbilicus
• vaginal exam
• ultrasound
• X-ray
 Vaginal Breech
International Delivery

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
International Delivery

Selection Criteria for Trial of Labour

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

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
International Delivery

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
International Delivery

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
International Delivery

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
International Delivery

Entering the Pelvis

Obstetrics - Normal and Problem Pregnancies, 2nd Edition

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

Descent of the Breech

Obstetrics - Normal and Problem Pregnancies, 2nd Edition

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

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
International Delivery

Hurry up & Wait!

• DON’T 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
International Delivery

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
International Delivery

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
International Delivery

Avoid Over-extension

Obstetrics - Normal and Problem Pregnancies,2nd Edition

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

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
International Delivery

Delivery of the head

Obstetrics - Normal and Problem Pregnancies, 2nd Edition

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

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
International Delivery

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
 Vaginal Breech
International Delivery

Conclusions
• proper selection of patients
• thorough explanation and informed consent
• good progress in labour ( 0.5 cm/h after 3 cm)
• induction and augmentation permissible
• experienced attendants
• standard fetal monitoring
• assisted delivery - DON’T PULL - stay cool!