Obstetrics 12: Malpresentations and Malpositions: Breech, Occiput

Posterior Portal
Breech presentation may be classified into:

Frank (45% to 50%)hips flexed and legs extended over anterior body surface
Complete (10% to 15%)hips and legs flexed
Footling (35% to 45%)foot or knee presenting

Incidence and Etiology: Breech presentation is more common in preterm fetuses. As term approaches,
the incidence drops to 3% to 4% of singleton deliveries.

Factors, other than gestational age, that appear to predispose to breech presentation include
multiparity and uterine relaxation, hydramnios, hydrocephaly, previous breech, tumors in the pelvis,
multiple gestation, oligohydramnios, anencephaly, and uterine anomalies.

Diagnosis: Abdominal palpation and vaginal exam usually reveals the diagnosis. Confirmation is by
imaging. Immediate confirmation is unnecessary if a breech is detected in the second trimester, but if
breech presentation persists into the third trimester, obtain ultrasound confirmation.

Antenatal Version: Conversion of breech to vertex presentation has been undertaken to lower the
incidence of breech presentations in labor. Version is usually attempted about the 36th week and is
performed where there are emergency Cesarean section facilities. Tocolytic agents are used to aid in
relaxation, the FHR is continuously monitored, and the procedure is performed with ultrasound
guidance. If the mother is Rh-negative, administer RhoGAM prophylaxis following the procedure.

The success rate of external cephalic version varies greatly, dependent on many fetal and maternal
factors as well as on the skill of the operator. However, when performed after 36 weeks, the gain in
vertex presentations at delivery is about 30%. Complications include fetal bradycardia, fetomaternal
bleed, unexplained fetal mortality, and possible maternal mortality due to amniotic fluid embolism.

Delivery Route: Due to the greater risk of cord prolapse and head entrapment, manage footling
breeches with Cesarean delivery. Frank and most complete breeches are managed on a case-by-case
basis. The final choice of birth route depends upon the physician's delivery room experience.

Guidelines for consideration of vaginal delivery of the frank or complete breech:

Facilities: Capability of emergency cesarean delivery

Physician: Experience in vaginal breech delivery
Anesthesia: Personnel present for delivery
Fetal Size: Optimal estimates weight < 4000 g but > 1500 g
Head Position and Size: Exclusion of hyperextension and macrocephaly
Pelvimetry: Radiation exposure may be reduced by using CT pelvimetry, which may provide useful
information on the type of breech, presentation, presence or absence of a flexed fetal head, and
accurate pelvis measurements. All measurements should be average or above. Note the shape.
Platypelloid (A-P narrowing) and android (heart-shaped) pelvises are much less favorable for vaginal
delivery.

Mechanisms of Labor and Delivery: There are fundamental differences between labor and delivery in
cephalic and breech presentations. With a breech, successively larger and much less compressible parts
of the fetus are born after the smaller and compressible legs and pelvis.

Labor is allowed to continue as long as there is progressive dilation, effacement, and descent. Allow
labor to evolve spontaneously, even if slow, as long as FHR patterns are normal, until the umbilicus
appears at the introitus. Rapid delivery or traction on the fetal body prior to the delivery of the
umbilicus may increase the risk of developing nuchal arms or extension of the head. The insertion of an
episiotomy is usually recommended for delivery.

The breech will usually deliver with the axis of the fetal hips in the AP plane with the sacrum either on
the maternal right or left. The anterior hip descends to the introitus and then, with lateral flexion of the

fetal body, the posterior hip delivers over the perineum. External rotation follows delivery of the breech,
allowing the infants back to turn anteriorly.

Allow the delivery to proceed spontaneously until the umbilicus appears at the introitus. Gently pull
down several inches of cord to prevent tension as the body delivers and to monitor the pulse by
palpation. In the case where the delivery is a breech presentation (flexed hips and extended knees),
deliver the legs by Pinard maneuver. This consists of rotating the breech in the oblique diameter and
inserting two fingers up along the posterior thigh of the fetus to the knee. This will cause the knee to
flex and allow the leg to be grasped and withdrawn. Rotating the breech in the opposite direction
facilitates delivery of the other leg.

After the umbilicus appears, gentle downward traction at a 45-degree angle may be used to draw the
infant further into the pelvis. While performing this traction, the operators fingers should grasp the
fetal pelvis rather than the abdomen to reduce the risk of injury to the fetus abdominal organs. Delivery
of the arms is accomplished by rotating the infants body to the oblique and inserting one finger over
the shoulder and following the arm to the elbow. Apply pressure to the arm to flex the elbow across the
infants chest and withdraw the forearm. Rotation in the opposite direction allows delivery of the
opposite arm. If nuchal arm exists, the infants feet may be pulled upward and laterally over the
mothers groin in the direction of the infants ventral surface. This motion draws the posterior shoulder
over the perineum and permits delivery of the posterior arm. The anterior arm may then be delivered by
depressing the body of the fetus.

After the shoulders emerge, delivery of the head is facilitated with the help of one or more assistants.
The head should be in the OA position. A common technique is the modified Mauriceau Smellie Veit
(MSV) maneuver, designed to maintain the fetal head in a flexed position throughout the delivery. Place
one hand on top of the fetus, with one finger inserted into the vagina to apply firm pressure on the
babys occiput. Place another finger of the same hand on each fetal shoulder. The providers other hand
is placed beneath the baby, and upward pressure is applied to the fetal maxilla. (The classic Mauriceau
maneuver, which describes placing a finger in the fetal mouth to apply pressure on the maxilla, is no
longer recommended due to the risk that the provider will apply traction on the mandible and dislocate
the jaw.) During the MSV maneuver, supra-pubic downward pressure on the occiput of the fetal head by
an assistant helps to maintain the flexion of the head and facilitate delivery. Another assistant may
wrap the fetal trunk with a sling and raise the body of the baby through a large arc as the head is being
delivered, ensuring that the body stays in a neutral position relative to the head (avoiding
hyperextension of the neck).

As the head emerges (or immediately after complete delivery), an assistant can suction the mouth and
nose. The delivery of the head is completed by further flexion with the fetus at this point in an almost
vertical position. The fetus can be flipped over unto the mothers abdomen at this point and the delivery
finished. In the case of difficulty with the delivery, Piper forceps may be applied to facilitate delivery of
the fetal head.

Occiput Posterior (OP): The OP labor and delivery is not remarkably different from that of the occiput
anterior (OA). Check the progress of labor by following the rate of cervical dilatation and the descent of
the fetal head through the birth canal.

Presented with the situation of the fetal head well down into the pelvis and a persistent occiput
posterior (OP) position, the possibilities for vaginal delivery are:

Spontaneous delivery in the OP position

Forceps delivery in the OP position
Manual rotation to the OA position and delivery
Forceps rotation to the OA position and delivery

Spontaneous Delivery: If the pelvic outlet is roomy and the vaginal outlet and perineum are somewhat
relaxed from previous vaginal delivery, rapid spontaneous delivery often occurs. The OP position places
more strain on the perineum. The head is driven against the perineum with more force than in the OA
position. The second stage of labor may be prolonged. A generous episiotomy is usually needed.

Forceps Delivery in Occiput Posterior: Usual indications for applications of forceps apply. Mere presence
of an OP position does not, in itself, indicate the use of forceps. The operator must carefully ascertain
position and station of the head and assure good perineal anesthesia. If the biparietal diameter is
engaged, forceps are applied in the usual manner. An episiotomy is usually necessary.

The mechanisms of labor are somewhat different with an OP position: extension will not occur, and
further flexion of the head is limited. Therefore, apply horizontal traction to the forceps until the top of
the nose comes beneath the symphysis. Slow, upward motion then exposes the occiput. Follow by

downward pressure to deliver the face. The vacuum extractor may not work as well, due to inability to
apply adequate traction and a tendency to deflex the head.

Manual Rotation: The cervix must be fully dilated, the head must be low in the pelvis, and the pelvis
must be adequate to allow this maneuver. The operators hand, with palmar surface upward next to the
fetal head, is inserted into the vagina. Place the thumb and fingers about the level of the ears. The fetal
head may be dislodged upward slightly. During a contraction, exert rotational pressure on the occipital
suture line clockwise with the left hand or counter-clockwise with the right. If the rotation is successful,
spontaneous delivery may occur or forceps may be needed.

Forceps Rotation: Only skilled and experienced operators should consider this approach; generally,
cesarean section is the preferable alternative to forceps rotation.

Compared to the OA position, labor with OP position is prolonged on the average by 1 hour in parous
women and 2 hours in nulliparous women. The perinatal mortality rate does not differ significantly from
the OA position, and there is no significant difference in APGAR scores. Extensions of the episiotomy,
however, may be increased. In those cases in which the vertex in the OP position fails to descend (with
adequate contractions), true CPD probably exists, and cesarean section is indicated.
Reference

Advanced Life Support in Obstetrics, 3rd ed. American Academy of Family Physicians, 1996.