Chapter 134. Breech Delivery

The breech presentation exists when the cephalic pole of the fetus is positioned in a longitudinal lie and the buttocks or feet of the fetus enter the maternal pelvis before the head.1 Management of the breech presentation in labor is an area of much trepidation and controversy, even among seasoned clinicians. A breech delivery is considered a high-risk obstetric complication that is best handled by an Obstetrician.

There are, however, unavoidable situations when a pregnant woman will present to the Emergency Department in active labor with a fetus in the breech position. A vaginal breech delivery may be the best delivery option in situations such as advanced labor, the absence of surgical assistance, the presence of an acute situation, fetal distress, or umbilical cord prolapse. Knowledge and preparedness facilitate comfort and promote success in approaching any emergent procedure. The breech delivery is no exception to this rule.

The breech presentation may be associated with a variety of maternal and fetal conditions.1,2 Maternal abnormalities that increase the risk of a breech presentation include a small pelvis and uterine anomalies. Fetal conditions associated with a breech presentation include low birth weight, prematurity, abnormal amniotic fluid volume, fetal malformations (e.g., hydrocephalus, cystic hygroma, and anencephaly), neurologic disorders, and genetic abnormalities.

Prematurity is a risk factor for a breech presentation. The incidence of breech presentations is inversely related to the fetal gestational age.1,2 At 28 weeks of gestation, 24% of fetuses are in the breech presentation. The fetus usually turns spontaneously to a cephalic presentation so that at term, only 3% to 4% are in the breech presentation.1,2

There are three main types of breech presentation (Figure 134-1). The most common is the frank breech, accounting for 50% to 73% of breech presentations. The fetus is flexed at the hips and extended at the knees (Figure 134-1A). The fetus is in the “pike” position. The complete breech is the least common type and accounts for approximately 5% to 11% of breech presentations. The fetus is flexed at both the hips and the knees (Figure 134-1B). The footling or incomplete breech accounts for approximately 12% to 38% of breech presentations. The fetus is incompletely deflexed at one or both knees or hips (Figure 134-1C). This results in one or both feet presenting before the buttocks. The risks of umbilical cord prolapse and prematurity associated with the breech presentation are listed in Table 134-1.

A breech presentation may be suspected upon clinical examination. The abdominal examination may reveal the hardness of the fetal head palpable in the fundus rather than above the pelvic inlet. A vaginal examination can confirm this suspicion. When a breech presentation in labor is suspected, an ultrasound examination is recommended to confirm presentation and exclude a fetal abnormality.1

Breech delivery is divided into three categories. These include unassisted or spontaneous expulsion, partial breech extraction, and total breech extraction.3 Unassisted or spontaneous expulsion of the fetus occurs when there is no assistance from the provider in the delivery of the infant. This generally occurs only with very premature infants or in precipitous deliveries where the baby delivers so rapidly as not to allow the provider to arrive.

Partial breech extraction is defined as spontaneous delivery of the infant to the level of the umbilicus followed by assistance from the provider. This is the usual manner of breech delivery. Allowing the fetus to descend naturally into the pelvis avoids an increased incidence of head entrapment, deflexion of the fetal head, nuchal arms, and umbilical cord prolapse. This is the preferred method of delivery for the Emergency Physician confronted with an actively laboring breech presentation and little hope of obtaining an Obstetrician before delivery.

Total breech extraction occurs when the provider reaches into the uterus and literally pulls or extracts the fetal feet into the vagina and through the vulva, followed by the assisted delivery of the remainder of the infant. Total breech extraction is indicated when expedient delivery is preferred in the absence of an experienced Obstetrician to perform a cesarean section and if performed for the breech presentation of a second twin, acute and profound fetal distress, and/or umbilical cord prolapse.2

Regardless of the mode of delivery, the breech presentation has been associated with an increased risk of cerebral palsy and perinatal mortality. Thus, failure to adopt the cephalic presentation may in some cases be a marker for some type of preexisting fetal impairment.4 The cesarean section has been suggested as the way to reduce perinatal problems associated with the breech presentation.5 Cesarean section has become the normal mode of breech delivery in many European countries and in North America. The rate of cesarean section for the breech presentation in the United States has increased from 12% in 1970 to 87% in 2002.6 However, prospective and retrospective studies over the last two decades are now beginning to refute this practice.7–10

No consensus exists concerning the absolute preferred method of breech delivery due to the conflicting data.11 Currently, the American College of Obstetricians and Gynecologists recommends that the decision regarding the mode of delivery should be based on the experience of the healthcare provider. It is recognized that cesarean delivery will be the preferred mode of delivery for most Physicians. Maternal morbidity and mortality are higher if an emergency cesarean delivery is performed when compared to an elective cesarean delivery. There are circumstances such as patient preference, an obstetric indication, or a precipitous delivery in which a vaginal breech delivery will be preferable.12

Obstetricians will often perform external cephalic version prior to the delivery date if a breech presentation is identified during prenatal visits.1,2,10 This technique is reserved for the experienced Obstetrician as it can be associated with significant complications. External cephalic version cannot be performed if the mother is in active labor and the fetus is engaged in the maternal pelvis.

Vaginal breech delivery by the Emergency Physician is indicated when the mother is in active labor and an Obstetrician is not available to perform the delivery or a cesarean section.

There are no agreed upon absolute contraindications to a vaginal breech delivery. Recommendations have been made based upon factors that increase morbidity and mortality in vaginal and cesarean breech deliveries.1–3,8 Maternal risk factors for increased morbidity and mortality with a vaginal breech delivery include a small pelvis, pelvic anomalies, uterine masses, uterine malformations, and arrest of labor. Fetal risk factors for increased morbidity and mortality with a vaginal breech delivery include extremes of fetal weight, fetal head extension, prematurity, nonfrank breech, and a nonreassuring fetal heart rate pattern.

There are factors regarded as unfavorable for a vaginal breech birth.13–15 Contraindications include placenta previa, a compromised fetal condition, a clinically inadequate maternal pelvis, and the arrest of active labor. Large infants (larger than 4000 g) and low birth weight infants (smaller than 2500 g) should not be vaginally delivered if in the breech position. The footling breech presentation can result in more complications than other breech presentations when delivered vaginally. A hyperextended fetal neck makes delivery more complicated and risks injury to the fetus. A Physician not experienced in the technique should not vaginally deliver a breech fetus.

Unfortunately, many of these conditions are not known in an emergent breech presentation. The Emergency Physician may not have the time or experience to assess these conditions. Emergent cesarean delivery is indicated if any of the conditions listed above are known and the setting permits it.

The normal progress of labor with breech presentation has not been extensively evaluated. Poor progress in the active phase of labor may be a sign of fetopelvic disproportion. Failure of the breech to descend once the cervix is completely dilated should be managed with a cesarean section.13–15

• Povidone iodine or chlorhexidine solution
• Electronic fetal monitor
• Delivery instrument pack (see Chapter 131)
• Piper forceps
• Towels
• Clock or timer watch
• Sterile gowns and gloves
• Chromic or Vicryl suture, 2-0 or 3-0
• Richardson or right-angle retractors
• Ring forceps
• Straight Mayo scissors
• 8 inch needle driver
• Sterile drapes

Personnel

• Two medical practitioners if available
• Nursing personnel
• Timekeeper
• Anesthesiologist or Anesthetist if available
• Pediatric or neonatal team if available

Perform an abdominal examination and cervical examination to assess the fetal position. Apply a fetal monitor and tocodynamometer to the maternal abdomen. Perform ultrasonography if available to confirm the fetal position, to estimate fetal weight, and to evaluate for any gross fetal anomaly.

Obtain an informed consent for the delivery if possible and time permits. Epidural anesthesia or a spinal block by an Anesthesiologist is recommended if available and time permits. A pudendal nerve block with local perineal infiltration may be used as an alternative. Refer to Chapter 131 for the details regarding the pudendal nerve block. Place the mother in the lithotomy position. Scrub the perineum with povidone iodine solution, chlorhexidine solution, or antibacterial soap. The Emergency Physician should apply a mask with eye protection or goggles, a sterile gown, and sterile gloves. Apply sterile drapes to isolate the patient's perineum (Figure 131-10).

This method is appropriate for all breech presentations. The fetus enters the maternal pelvis with the bitrochanteric diameter in an oblique position (Figure 134-2A). The sacrum is the point of designation for these presentations. The fetus rotates with labor and descent, so that the bitrochanteric diameter is in the anteroposterior axis and the sacrum is in the transverse axis (Figure 134-2B).

Encourage maternal “pushing” to expel the fetal buttocks (Figure 134-3A). Support the fetal buttocks with a toweled hand. Do not assist with the delivery of the buttocks as they emerge (Figure 134-3B). Allow the fetus to deliver spontaneously to the level of the umbilicus with only maternal uterine propulsive efforts. Early extraction of the buttocks increases the risk of head entrapment in a partially dilated cervix, results in deflexion of the fetal head, and increases the risk of nuchal arm entrapment. Perform a midline episiotomy when the buttocks crown. Do not perform the episiotomy too early, as this may lead to excessive maternal blood loss. Refer to Chapter 132 for complete details regarding an episiotomy.

Proceed with the delivery of the fetal legs when the umbilicus emerges (Figure 134-4). The legs will likely have delivered themselves by this time if the fetus is in the complete or incomplete breech position. Insert the fingers of the dominant hand along the long axis of the medial fetal thigh (Figure 134-4A). Apply laterally directed pressure on the fetal thigh to flex the knee and externally rotate the leg out and down through the vulva (Figure 134-4A). Simultaneously apply opposite rotation on the fetal hip and pelvis. Deliver the other leg in a similar manner (Figure 134-4B). Rotation of the hip in a direction opposite the direction of knee flexion facilitates the delivery of the distal extremities. Therefore, rotate the left leg clockwise and the right leg counterclockwise.

Prepare to deliver the fetal arms (Figure 134-5). Place a sterile towel around the legs and trunk of the fetus for support (Figure 134-5A). Continue to support the fetal body and encourage maternal pushing efforts. Do not actively assist in the delivery until the fetal scapulae are visible. Aggressive extraction of the fetus following the delivery of the legs may cause deflexion of the vertex or nuchal entrapment of the arms.

Proceed with active delivery of the shoulders and arms as the scapulae emerge from the vagina (Figure 134-5). Rotate the fetal trunk to present the anterior arm and shoulder (Figure 134-5A). Insert the fingers of the dominant hand longitudinally along the humerus of the presenting arm (Figure 134-5A). Apply traction to the humerus to flex the elbow. Sweep the arm across the chest and deliver it through the mother's vulva (Figure 134-5B). Rotate the fetus in a manner to bring the alternate shoulder into the anterior position (Figure 134-5C). Gently rotate the fetus clockwise to deliver the left arm and counterclockwise to deliver the right arm. This direction of motion prevents the arm from becoming entrapped on the neck. Repeat the procedure to deliver the second arm.

The fetal shoulders and arms may not easily deliver utilizing the above technique. Perform this alternate technique if the arms and shoulders do not deliver. Place the thumbs of both hands over the fetal posterior iliac spines and sacroiliac area. Place the palms and fingers over the fetal hips. Apply pressure only over the iliac spines. Never grasp the fetal abdomen. The adrenal glands, kidney, liver, and spleen may be injured with excessive pressure during the delivery process. Elevate the fetal body to deliver the posterior shoulder over the more pliable posterior perineum. Deliver the posterior arm as described above. Lower the fetal trunk. Deliver the anterior shoulder from under the maternal pubic symphysis as described above.

The fetal vertex will generally rotate into the anteroposterior orientation after delivery of the arms and shoulders. The fetal vertex will lie against the maternal pubic symphysis. The fetal chin will lie in the posterior aspect of the vagina and/or lower uterine segment. Wrap the fetal arms and trunk in a towel. Encourage maternal pushing efforts. The fetal head may deliver spontaneously. Note when the fetal chin and mouth appear at the posterior perineum. Instruct the mother to stop pushing. Suction the fetal mouth. Gently lift the infant upward to deliver the head in a controlled manner (Figure 134-6). Avoid hyperextending the fetal back.

Complete the delivery of the infant. Clamp and cut the umbilical cord. Place the infant in the warmer for examination and resuscitation. The Apgar scores for infants delivered from a breech position are generally slightly lower than from a vertex delivery. The infant may show some initial signs of short-term and generally clinically insignificant hypoxia.

Cervical entrapment (inadequate cervical dilation) is a more common occurrence in the delivery of a fetus in the breech presentation. It is most frequently observed when rapid labor results in the fetal trunk being delivered through a partially dilated cervix or during the delivery of a premature breech when the fetal head is relatively larger than the fetal trunk.

The fetal head often delivers spontaneously with maternal pushing efforts, but it may occasionally fail to do so. Several options exist to aid in the delivery of the fetal head. These include manual extraction, manual extraction with the McRoberts maneuver or the Mauriceau–Smellie–Viet maneuver, forceps-assisted delivery, and Dührssen's incisions.

Adequate anesthesia is vital to the extraction of the fetal head. A pudendal block and peroneal infiltration should have been performed previously. If not, consider the administration of parenteral sedation and analgesia (Chapter 129) and local infiltration. Inhaled halogenated agents, intravenous beta-mimetics (i.e., terbutaline or ritodrine), or intravenous nitroglycerin are all useful for uterine relaxation in the event of entrapment of the after-coming head or if intrauterine manipulation is necessary. Utilize assistants as needed to offer adequate visualization. Gently place Richardson or Pratt retractors in the vagina to maximize the view.

McRoberts Maneuver

Apply the McRoberts maneuver if the fetal head does not deliver. The McRoberts maneuver is easy to perform (Figure 133-6). Place an assistant on each side of the patient. Hyperflex the mother's thighs onto her abdomen (Figure 133-6A). Instruct the assistants to maintain support of the hyperflexion while applying suprapubic pressure (Figure 133-6B). This results in flattening of the lumbosacral curve with rotation of the pubic symphysis cephalad (Figure 133-6C). Perform the manual extraction.

Mauriceau–Smellie–Viet Maneuver

Perform the Mauriceau–Smellie–Viet maneuver if the McRoberts maneuver is unsuccessful in the spontaneous delivery of the head (Figure 134-7). Rest the body of the infant on the dominant arm. Place the index and middle finger of the dominant hand on the fetal maxilla. Apply pressure to the maxilla to maintain the fetal head in flexion. Do not place the fingers on the fetal mandible or in the fetal mouth. Place the nondominant hand on the posterior aspect of the fetal neck and shoulders. Slightly elevate the fetal body from the horizontal plane.

Exert continued and gentle downward traction with both hands until the occiput moves under the mother's pubic symphysis. Never hyperextend the fetal trunk to avoid spinal cord injuries. Never apply pressure to the mandible or the fetal mouth during this maneuver. The force applied to the mandible or mouth can dislocate the mandible. Instruct an assistant to apply firm and gentle suprapubic pressure in conjunction with gentle downward traction by the operator. Continue this process until the head delivers.

Forceps-Assisted Delivery of the Head

The utilization of forceps may be warranted if none of these maneuvers is successful.14,17 The Piper forceps have a minimal pelvic curve, allowing direct application to the fetal head. They are used solely for the delivery of an after-coming head in the breech delivery. Forceps-assisted delivery can result in significant injury to the fetus and the mother. The use of the Piper forceps is not recommended unless the Emergency Physician has training and experience in their proper use.

Apply the Piper forceps. Instruct an assistant to elevate the fetal trunk slightly above the horizontal plane (Figure 134-8A). Kneel below the fetus. Insert the forceps directly into the vagina and along the fetal head. Apply the right forceps blade. Grasp the blade in the left hand. Place the right hand along the left fetal parietal bone, between the fetal head and the right maternal pelvic side wall. Insert and apply the forceps blade. Instruct the assistant to hold the blade in this position. Apply the left forceps blade. Grasp the blade in the right hand. Place the left hand along the right fetal parietal bone, between the fetal head and the left maternal pelvic side wall. Insert and apply the forceps blade. Gently join the forceps handles while avoiding excessive pressure.

Apply gentle downward and outward traction to the forceps blades to deliver the fetal head (Figure 134-8B). Slowly elevate the plane of the fetal trunk toward the maternal abdomen as the fetal face delivers. Do not hyperextend the fetal neck. Stop the extraction as the mouth appears. Gently suction the fetal mouth. Deliver the head.

Dührssen's Incisions

Perform Dührssen's incisions if the fetal head is entrapped, if other methods of extraction have failed, and if you are unfamiliar with the use of forceps. Dührssen's incisions consist of two to four incisions placed circumferentially around the cervix (Figure 134-9). The two required incisions are at the 10 and 2 o'clock positions. Additional incisions can be made at the 5, 6, and/or 7 o'clock positions. The cervix must be more than 70% effaced and dilated more than 6 cm for the procedure to be successful and to prevent significant hemorrhage.

Grasp two pairs of ring forceps. Grasp the cervix around the point of the incision. For example, place ring forceps at the 9 and 11 o'clock positions to make the 10 o'clock incision (Figure 134-9A). Make the incisions 2 to 3 cm in length with a straight Mayo scissors. Deliver the fetal head.

Persistent Fetal Head Entrapment

The fetal head may fail deliver despite the maneuvers described above. True cephalopelvic disproportion must be differentiated from cervical entrapment (inadequate cervical dilation). The options are limited in the rare case of a true cephalopelvic disproportion. The Emergency Physician can perform a symphysiotomy (Chapter 137), the fetal body can be pushed back into the uterus and a cesarean section performed, or an experienced Obstetrician may perform a destructive procedure if the fetus is nonviable.

Breech extraction is to be performed only in the rare instances of a second twin presenting in a breech position, extreme fetal distress without the capability of performing a cesarean section, and/or umbilical cord prolapse that does not allow time for setup or performance of a cesarean section.2,17–19

If available, utilize ultrasound to identify the fetal legs and feet. This will ensure you grasp the appropriate extremity. Reach into the lower uterine segment with the dominant hand and firmly grasp the fetal feet. Place the fingers around the fetus's ankles, with the index finger between the two ankles (Figure 134-10A). Apply continuous and firm traction in a downward and outward direction. Deliver the fetal feet and legs through the vaginal opening (Figure 134-10A). Continue to apply traction to deliver the fetus to the level of the buttocks (Figure 134-10B). Instruct an assistant to support the fetus. Perform a midline episiotomy if necessary. Deliver the fetus to the level of the umbilicus. Grasp the bony sacrum and pelvis. The remainder of the technique is as described above.

Complete and incomplete breech deliveries may occur in the same fashion as the frank vaginal breech delivery. The one exception is that one or both feet may already be extended and not require attention.2 There is an increased risk of umbilical cord prolapse, umbilical cord entanglement, and entrapment of the after-coming head.2,7,10 This is the basis for the recommendation for cesarean delivery in these cases.2,7,10 However, one randomized trial reported nonfrank vaginal breech delivery to be relatively safe as well.2,10

The two patients must now be assessed and treated. If available, a second Physician or neonatal team can evaluate and resuscitate the infant. Determine the infant's Apgar score. Examine the infant for birth trauma and signs of prematurity (e.g., fusing of eyelids), as both correlate with perinatal morbidity and mortality.

The maternal assessment should occur simultaneously with that of the neonate. Offering reassurance to the mother while delivering the placenta and evaluating for postpartum hemorrhage is of the utmost importance.

The Apgar scores for infants delivered from a breech position are generally slightly lower than from a vertex delivery. The infant may show some initial signs of short-term and generally clinically insignificant hypoxia.

Postpartum recovery for the mother is generally uneventful. She should be observed for evidence of infection or symptomatic anemia. If regional anesthesia is used or if there is significant perineal trauma, urinary output should be monitored for the presence of urinary retention.

Deliver the placenta and repair the cervix if there are any lacerations or Dührssen's incisions. An episiotomy, perineal laceration, and/or vaginal laceration must be repaired (Chapters 132 and 135). Initiate uterine massage. Administer pitocin intramuscularly following delivery of the placenta.

It is vital that postpartum hemorrhage be managed to prevent maternal morbidity and mortality. Refer to Chapter 135 regarding the details of postpartum hemorrhage management. Grasp the base of each cervical incision or laceration to decrease the bleeding. If the distal angle is difficult to visualize, do not waste time attempting to locate it. Apply traction to the proximal edges of the incision or laceration with ring forceps. Alternatively, place 2-0 chromic, Dexon, or Vicryl sutures along the edges of the cervical incision or laceration that can be visualized. Place progressively proximal interrupted sutures until the base is completely visualized (Figure 134-9B). Apply traction to the sutures to better visualize the cervical incision or laceration.

Maternal complications associated with the performance of a vaginal breech delivery include lacerations (e.g., cervical, vaginal, and/or perineal), episiotomy extension, infection, postpartum hemorrhage, and hematomas (e.g., vaginal or pelvic).

Neonatal complications include hypoxia, anoxia (i.e., perinatal asphyxia), umbilical cord prolapse, fractures (e.g., cranial, femoral, and clavicular), cerebral hemorrhage, cephalohematomas, lacerations, brachial nerve palsy, cerebral palsy, spinal cord injuries from head hyperextension, arrest of the after-coming head, and death1,2,7,8,10,20–25 Recent studies suggest that the occurrence of these complications may be greatly influenced by the urgency of the delivery rather than solely the method of delivery.2 Thus, an adequately prepared Emergency Physician may not be able to prevent these complications but will less likely contribute to them.

There are complications that are unique to the breech presentation. Head entrapment is a potentially serious complication of breech delivery. The head is often the largest part of the fetus. There is no time for molding of the aftercoming breech head. If the fetal head does not deliver easily after delivery of the torso, umbilical cord compressions can contribute to fetal hypoxia, acidosis, and death. Attempts to expedite delivery can result in maternal and fetal trauma. The risk of head entrapment is especially high in the preterm infant before 30 weeks as the head is large in relation to the body.16

Nonfrank breech presentation has an increased incidence of umbilical cord prolapse as the presenting part may not completely occlude the cervix. The risks of umbilical cord prolapse and prematurity associated with the breech presentation are listed in Table 134-1.

Perinatal survival is similar for the delivery of a breech infant vaginally or by cesarean section, although controversy still exists. Increased morbidity and mortality may be seen with estimated fetal weights of less than 1500 g or greater than 4000 g, single or double footling presentation, a diminished maternal pelvis, cephalic hyperextension, or in the hands of an inexperienced provider. Cesarean section is preferable in these instances if available. The Emergency Physician managing an imminent breech delivery should be well aware of not only the potential complications but also the relative indications for cesarean delivery and the techniques and tools for vaginal delivery in order to lessen the inherent risks to both patients.