Vaginal Breech Delivery

Presentation of the infant buttocks or feet before the head

Considered a high-risk delivery even among seasoned obstetricians

PRESENTATION TYPES

Frank breech—fetus with bilateral hip flexion and knees extended with feet opposite the head

Footling (incomplete) breech—one or both hips or knees extended and presenting before buttocks

Complete breech—bilateral hip and knee flexion with feet opposite the trunk (FIGURE 42.1)

INDICATIONS

Imminent vaginal delivery without obstetrical backup and buttocks or feet of the fetus appear at the vulva

CONTRAINDICATIONS

Placenta previa

Spontaneous arrest of labor

Immediate availability of obstetric services

CONSENT

Obtain informed consent if possible and time permits

RISKS

Peripartum fetal and maternal morbidity or mortality

Maternal bleeding and pain

Breech position may result from underlying fetal or uterine abnormalities

General Basic Steps

Examine for presenting part

Place the mother in lithotomy position

Allow natural delivery of baby as much as possible; assist without excessive traction

Flex baby’s head to assist with delivery

FIGURE 42.1 Fetal attitude in frank, incomplete, and complete breech presentations. (From Cruikshank DP. Breech, other malpresentations, and umbilical cord complications. In: Scott JR, Gibbs RS, Karlan BY, et al, eds. Danforth’s Obstetrics and Gynecology. 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2003:382, with permission.)

TECHNIQUES

Examine the vagina to determine the presenting part

Use ultrasonography or Leopold maneuver to determine fetal lie

Consult obstetrics emergently

Prepare for possible cesarean section

Place the mother in the lithotomy position with a wedge under her buttocks

Consider episiotomy once the fetal anus has appeared at the vulva

Allow maternal effort to spontaneously deliver the fetal buttocks, flexed knees, and lower limbs

Avoid excessive premature traction of the fetus, which can cause undesirable positioning of the head, resulting in head and nuchal arm entrapment

If knees are extended, the physician may flex each knee (Pinard maneuver—see FIGURE 42.2) to facilitate delivery

Grasp the infant’s bony pelvis during vaginal delivery

Rotate the fetus in the anteroposterior plane to deliver each shoulder

Shoulder delivery may be expedited by flexing the fetal elbow or adducting the extended elbow by placing a finger in the antecubital fossa

When delivering the head, attempt to flex the neck by holding the chin and applying suprapubic pressure (FIGURE 42.3) or use the Mauriceau maneuver

The index and middle fingers are placed over the infant’s maxillary bones (not in the infant’s mouth) to help keep the head flexed. This should allow the mother to expel the fetus.