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

• Leopold’s 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!
• 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 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