Vaginal Breech Birth Updated 2023
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Incidence • 3–4% of pregnancies at term • Associated with higher perinatal morbidity and mortality: – Birth asphyxia – Birth trauma – Prematurity – Congenital malformations
Risk factors Factors associated with breech presentation Previous breech birth Uterine anomalies Premature labour Maternal pelvic tumour or fibroids High parity Placenta praevia Multiple pregnancy Hydrocephaly/anencephaly Polyhydramnios Fetal neuromuscular disorders Oligohydramnios Fetal head and neck tumours
Types of Breech Extended (65%) Flexed (10%) Footling (25%)
‘Term Breech’ Trial • Randomised Controlled Trial • Planned vaginal birth vs Planned Caesarean Section (CS) • 75% reduction in perinatal mortality in planned CS group • However 2 year follow-up data did not demonstrate any statistically significant differences in neuro development between infants born by CS or vaginally • Therefore unclear if long-term benefits of child being born by planned CS outweigh the maternal risks of additional caesareans
RCOG Green-top Guideline for vaginal breech birth (2017) • When planning vaginal breech birth, women should be informed of risks of perinatal mortality: – Approximately 0.5/1000 with CS after 39 weeks, 2.0/1000 with panned vaginal birth • Planned vaginal breech birth increases risk of low Apgar scores and serious short-term complications, but has not been shown to increase the risk of longterm morbidity
RCOG Green-top Guideline for vaginal breech birth (2017) • Planned CS leads to a small reduction in perinatal mortality compared with planned vaginal breech birth • Any decision to perform CS needs to be balanced against the potential adverse consequences that may result • The presence of a skilled birth attendant is essential for safe vaginal breech births
Types of vaginal breech birth • Spontaneous • Assisted (with recognised manoeuvres) • Total breech extraction – high rate of birth injury (25%) – mortality (10%) with singletons
Planned vaginal breech birth • Essential components for planned vaginal breech birth: – appropriate case selection –management according to a strict protocol – availability of skilled attendants – birth in hospital with facilities for immediate caesarean section as labour complications are more common – birth in water is not recommended
Unplanned vaginal breech birth • Breech presentation at term is not diagnosed until labour in about 25% of women • For some women labour may progress rapidly and a quick vaginal breech birth is inevitable • Unplanned vaginal breech birth is associated with increased risks • At NBT an US Scan for presentation should be conducted on all IOL’s prior to commencing induction
First stage of labour The health care provider for a planned vaginal breech delivery needs to possess the requisite skills and experience. A senior obstetrician who is comfortable in the performance of vaginal breech delivery should be present at the delivery to supervise and support the junior trainees and midwives if needed. • An operating room must be available for emergency Caesarean section within 30- minutes of the decision to proceed to caesarean delivery. • If a trial of vaginal delivery is the decision, labour should be allowed to commence spontaneously. Induction of labour is not recommended. • Continuous electronic fetal heart monitoring should be offered to women in labour. • Fetal blood sampling from the buttock’s during labour is not advisable. • Choice of analgesia in labour is similar to those with cephalic presentation. • Oxytocin augmentation is not recommended, in the absence of adequate progress in labour, Caesarean section is advised. • When membranes rupture, immediate vaginal examination is recommended to rule out cord prolapse
Second stage of labour • Senior Obstetrician (senior registrar or consultant) should be present in the room. • Consider episiotomy. • The on-call anaesthetist should be on labour ward during the second stage • A passive second stage without active pushing may last up to 90 minutes, allowing the breech to descend well into the pelvis. • Effective maternal pushing efforts are essential to safe delivery and should be encouraged. Once active pushing commences, if delivery is not imminent after 60 minutes, Caesarean section is recommended. • Once the breech begins to be delivered, keep the baby’s back uppermost during birth by rotation of the baby’s pelvis, not the abdomen (to prevent trauma to abdominal organs, particularly the liver) delivery to the level of the umbilicus. Avoid traction as this promotes head extension and nuchal placement of arms. • If the legs do not deliver within 10 or 15 seconds spontaneously, they can be ‘flicked out’ by gently inserting a finger behind each knee in turn, and encouraging it to flex and abduct i.e. to bring the legs into the position that they would be in if the baby was crouching). The foot will then usually easily flick out. • Do not touch the cord as this may cause spasm must be avoided until delivery of the breech commences.
Second stage of labour • Allow the trunk to deliver spontaneously up to the neck over the next 20 to 30 seconds, but if it does not, then nuchal arms may be removed by the Lovset manoeuvre. Gently holding the pelvic girdle, rotate the baby so that the plane of the back is vertical and the shoulder and scapula move anteriorly. Hook the arm downwards. Rotate the baby through 180o to deliver the opposite arm. • In delivery of the head, ideally there should be about up to one minute of head flexion, followed by a smooth delivery of the head over the next 30 seconds – neither too fast nor too slow, and without stress or strain. Because situations vary greatly, the practitioner must now decide whether to accelerate the process or slow it down. • If it is going fast, then use a hand across the perineum to slow the process down and allow gentle delivery without compression/decompression strains.
Second stage of labour If the head is not delivering spontaneously, then initially wait before delivery of head until head flexion is secured. This might take up to a minute. During this time, secure head flexion by: Suprapubic pressure. An assistant may need to apply gentle suprapubic pressure to favour flexion and engagement of the fetal head. Mauriceau-Smellie-Veit manoeuvre: • Place your dominant hand above the baby’s head with the middle finger on occiput and the others on shoulders • Put your other hand underneath and place a finger on each cheekbone. • Do not put a finger in the mouth as may dislocate jaw or cause soft tissue injury • Keep body in neutral position to prevent premature extension of the head • Allow the mouth and nose to appear over the perineum If the head has not delivered within a minute or so, consider forceps delivery. The practitioner should have rehearsed a plan of action and should be prepared to act promptly in the rare circumstance of a trapped after-coming head or irreducible nuchal arms.
Signs that birth requires assistance • Signs that the vaginal breech birth should be assisted include: – Evidence of poor infant condition with lack of tone and/or colour observed in infant’s body – Delay commonly due to extended arms or an extended neck – Delay of more than 5 minutes from birth of the baby’s buttocks to birth of the head – Delay of more than 3 minutes from visualisation of baby’s umbilicus to birth of the baby’s head
• 5% of breech births • Turn the fetal trunk towards symphysis pubis Complications – Nuchal Arms
Encourage flexion of head
Supra-pubic pressure to encourage flexion of fetal head
Forceps for after-coming head
Entrapment of after-coming head • More common in preterm infants • Check for cervix: – if present, consider incising cervix at ‘10 and 2 o ’clock’to avoid cervical neurovascular bundles that run laterally in the cervix, the bladder anteriorly and rectum posteriorly
• Intrapartum death • Intracranial haemorrhage • Brachial plexus injury • Rupture of the liver, kidney or spleen • Dislocation of the neck, shoulder or hip • Fractured clavicle, humerus or femur • Cord prolapse Complications