International

Vaginal Breech
Delivery

Vaginal Breech
Delivery

International

Vaginal Breech
Delivery

Objectives
Incidence and Significance
Selection
Management
Intrapartum
Delivery

International

Vaginal Breech
Delivery

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

Types
frank
complete
footling

- flexed hips, extended knees

- flexed hips, flexed knees
- extended hip(s)

International

Vaginal Breech
Delivery

Types of Breech

Complete

Footling

Frank

International

Vaginal Breech
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
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

International

Vaginal Breech
Delivery

Diagnosis
maternal perception of movement
Leopolds maneuvers
FH auscultated above umbilicus
vaginal exam
ultrasound
X-ray

International

Vaginal Breech
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

International

Vaginal Breech
Delivery

Selection Criteria for Trial of Labour

frank or complete breech
fetal head not hyperextended
estimated fetal weight 2500 to 4000g

International

Vaginal Breech
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

International

Vaginal Breech
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
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

International

Vaginal Breech
Delivery

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

International

Vaginal Breech
Delivery

Entering the Pelvis

Obstetrics - Normal and Problem Pregnancies, 2nd Edition

Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

International

Vaginal Breech
Delivery

Descent of the Breech

Obstetrics - Normal and Problem Pregnancies, 2nd Edition

Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

International

Vaginal Breech
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)

International

Vaginal Breech
Delivery

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)

International

Vaginal Breech
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)

International

Vaginal Breech
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)

International

Vaginal Breech
Delivery

Avoid Over-extension

Obstetrics - Normal and Problem Pregnancies,2nd Edition

Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

International

Vaginal Breech
Delivery

Delivery of the head

Mauriceau - Smellie - Veit manoeuvre to

deliver the head in flexion
The body should be supported in a horizontal
position

International

Vaginal Breech
Delivery

Delivery of the head

Obstetrics - Normal and Problem Pregnancies, 2nd Edition

Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

International

Vaginal Breech
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)

International

Vaginal Breech
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
Delivery

International

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 - DONT PULL - stay cool!