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SECOND EDITION OF THE ALARM INTERNATIONAL PROGRAM SYLLABUS

CHAPTER 8

VAGINAL BREECH DELIVERY

Learning Objectives: List the selection criteria for the vaginal delivery of a term breech Define the appropriate principles in the intrapartum management of the term Explain the safe and appropriate techniques for assisted vaginal delivery of the term

What are the selection criteria for vaginal breech delivery at term?__________________________________________________________________________________________________________________________________________________________________________________________

8.0.1 Definition:

Breech presentation affects three to four percent of all pregnant women reaching term. Breech presentation is associated with an increased frequency of perinatal mortality and morbidity due to prematurity, congenital anomalies (occur in 6% of all breech presentations), and birth trauma/asphyxia.

Studies that showed higher rates of perinatal mortality and morbidity with vaginal birth either failed to emphasize, or ignored, crucial issues. These issues include judicious selection of patients, appropriate intrapartum management, and the skill, experience and judgement of the obstetrical attendant. The only randomized trials that compared elective cesarean section and selective planned vaginal delivery showed no difference in perinatal mortality or low Apgar scores between the two groups. These same studies showed a slight increase in short term morbidity in those that delivered vaginally. These trials lacked the power to show any differences in these outcomes. Nevertheless, it is probable that elective cesarean section is associated with increased maternal morbidity.

8.0.2 Selection Criteria

The following selection criteria for vaginal breech delivery are recommended:

1. Planned vaginal birth should be recommended for either frank or complete breech presentations at 36 weeks or more gestation and/or when the estimated birth weight is 2500 to 4000 grams.

2. Planned vaginal birth should be offered for either frank or complete breech presentations at 31 to 35 weeks gestation and/or when the estimated birth weight is 1500 to 2500 grams.

3. Cesarean section should be offered (there was less certainty about the adequacy of the data) for either frank or complete breech presentation at 30 weeks or less gestation and/or when the estimated birth weight is less than 1500 grams.

4. There was insufficient data on which to base a recommendation for frank or complete breech presentations when the estimated birth weight is more than 4000 grams. The attending physician’s judgement about the most appropriate course of action should determine which delivery method is suggested.

ALARM INTERNATIONAL * Chapter 8 - Vaginal Breech Delivery * 108


Selection CriteriaInformation for the selection criteria that are relevant: Type of breech - Frank or complete breech Attitude of fetal head - not hyperextended EFW 2500-4000g

Several criteria were examine and were felt not to be important in the selection of patient for a trial of labor. These included: parity, maternal age, pelvimetry and medical/obstetrical complications.

8.0.3 Management

Intrapartum Management

The following intrapartum management issues should be considered. Induction of labor Augmentation of labor Duration of labor Intrapartum fetal monitoring Analgesia-anesthesia Amniotomy Delivery technique Intrapartum consultation

Management in Labor

Admission to a maternity unit in early labor or immediately after rupture of membranes Appropriate fetal surveillance Epidural for the usual indications Artificial rupture of membranes for same indications as cephalic Immediate vaginal examination at rupture of membranes to rule out cord prolapse Assess labor progress and expect same progress as in cephalic presentation

Management at Delivery

Experienced newborn resuscitator should be present at the delivery Maternal bladder should be emptied just prior to delivery Ideally, maternity attendant with experience in breech delivery should be involved Forceps, if available, may be helpful

Technique

1. Explain the necessity of effective pushing in the second stage of labor.2. Ensure adequate analgesia.3. Spontaneous descent and expulsion to the umbilicus should occur with maternal pushing ONLY. DO NOT PULL ON THE BREECH!


In addition, ultrasonography also provides the following useful information: Amniotic fluid assessment Cord position Assessment for congenital anomalies Confirms placenta localisation


4. Rotation to the sacrum anterior position is desired and may be facilitated.5. Episiotomy may be considered once the anterior buttock and anus are ‘crowning’.6. Do not extract the legs until the popliteal fossae are visible (Pinard’s manoeuvre).7. Support the baby around the hips and have the patient push until the scapulae are visible. Do not pull on the

breech or compress the abdomen. Maintain flexion of the fetal head by keeping the body below the horizontal.8. Rotate the body to facilitate delivery of the arms using the Loveset manoeuvre.9. Support the baby to maintain the head in a flexed position. Suprapubic pressure may help. Maternal expulsive

efforts should be encouraged.10. The body should be supported in a horizontal position. 11. The Mauriceau-Smellie-Veit manoeuvre can be used to deliver the head in flexion..12. Use forceps if needed.


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