Vaginal Breech Delivery

Objectives Incidence and Significance Selection Management Intrapartum Delivery

Definition Types 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)

Types of Breech Complete Footling Frank

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

Etiology of Breech Presentation idiopathic prematurity (head to trunk size) uterine or pelvic structural abnormality uterine fibroid fetal anomaly or abnormality polyhydramnios multiple gestation

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

* acknowledged lack of evidence for recommendation 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

Selection Criteria for Trial of Labour frank or complete breech fetal head not hyperextended estimated fetal weight 2500 to 4000g

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

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

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

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

Entering the Pelvis Obstetrics - Normal and Problem Pregnancies, 2nd Edition Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

Descent of the Breech Obstetrics - Normal and Problem Pregnancies, 2nd Edition Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

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)

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)

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)

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)

Avoid Over-extension Obstetrics - Normal and Problem Pregnancies,2nd Edition Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

Mauriceau - Smellie - Veit manoeuvre to deliver the head in flexion Delivery of the head Mauriceau - Smellie - Veit manoeuvre to deliver the head in flexion The body should be supported in a horizontal position

Delivery of the head Obstetrics - Normal and Problem Pregnancies, 2nd Edition Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991)

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)

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

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!