Breech birth

Emergency

• Footling
• Buttocks or feet 

Non emergency - Variation on normal

• Extended
• Flexed

Spontaneous breech birth

• less common, delivered without assistance or manipulation 

Assisted breech birth 

• Accoucher hands off until required. More common 

·      Practitioners managing breech birth should be informed and competent 

·      ensure there is continuous electronic fetal monitoring during labour and birth 

·      Full cervical dilatation must be confirmed before commencing pushing 

·      Visualisation of breech at perineum before commencing pushing

·      Avoid traction and adopt hand off approach as much as possible 

·      Understand manoeuvres

awareness of risks/ alternatives 

location 

experience of practitioners 

fetal size, gestation 

• Communication can be impaired under stress. (PROMPT, 2017) advises the SBAR format is succinct and effective, especially in emergencies when prompt decision making and action is required (Siassokos et al, 2010). 
• The message should be 
• formulated
• addressed to specific individuals
• delivered
• acknowledged
• acted upon 

Communication should utilise non-verbal communication, accurate terminology and respect, being clear concise and calm. 

Women and birth partners should also be communicated with. If possible, a staff member should be allocated to convey messages to them; the cause, the condition of the baby, and immediate and ultimate aims of treatment. (Bristowe et al, 2012). 

• Inform senior midwife, senior obstetrician, anaesthetist, theatre staff and enonataologist of mothers admission. Skilled members of staff should be available
• Discuss mode of birth again, and ensure choice remains.
• Discuss analgaesia, no evidence for routine epidural anaesthesia, but can increase risk of intervention (RCOG, 2017) range should be offered and pudendal block considered 
• Explanation of birth techniques and needs for neonatalogists. 
• Establish IV access - FBC and G&S
• Prepare room and neonatal resuscitation equipment. Ensure prerequisites for assisted vaginal breech birth pack - operative vaginal birth pack, warm towels, forecps, lithotomy supports. 
• EFM should be recommended to improve outcomes (RCOG, 2017) If CTG pathological C/S recommended unles buttocks visible 
• Augmentation not recommended
• Upright materal positioning offers physiological advantages, and increased maternal choice. (Evans, 2012) (Thies Lagregern, 2013)

Need for review by consultant midwife/ neonatologist after birth and consultant neonatal review if concerns 

• Resuscitation if necessary
• APGARs
• Cord gases 
• If well; feeding support and skin to skin etc

• Risk of intrapartum death
• intracranial haemorrhage
• HIE 
• rupture of liver, kidney or spleen
• dislocation of neck, shoulder or hip
• cord prolapse
• occipital diastasis and cerebellar injury
• Humeral, femural and clavicular fracture 

All procedures involved would maintain asespsis in line with infection control and Aseptic Non Touch Technique to prevent infection and contamination. 

This would include appropriate PPE, including sterile gloves and thorough hand hygiene. 

(WHO, 2009) (Sax et al, 2007)

Risks 

• Risk of intrapartum death
• intracranial haemorrhage
• HIE 
• rupture of liver, kidney or spleen
• dislocation of neck, shoulder or hip
• cord prolapse
• occipital diastasis and cerebellar injury
• Humeral, femural and clavicular fracture 

Complications 

• Head entrapment; preterm - 14% of vaginal breech births- RCOG recommends cervical incision 
• Nuchal arms extended and trapped behind head - caused by early traction on breech. High morbidity association - 25% risk of neonatal trauma. Can be released with rotation using Lovsetts manouevre to flex arm. 
• Cord Prolapse More commonwith breech especiallly footling. Should be prevented by amniotomy undertaken with caution and filling presenting part. 

Documentation

of difficult and potentially traumatic birth essential. It should include a clear explanation of manouevres used, such as they are reproducable by another. Pro formas can be used. This must include: 

time of birth breech, cord, manouevres performed, timing and sequence, time of birth of body, head, staff in attendance and time they arrived, condition of baby, umbilical cord blood acid-base measurements (cord pH or lactate), position of baby at birth; type of breech

Debriefing

Frightening and potenitally traumatic experience. Parents should be informed about what is happening and what is being done to help, and give clear instructions during emergency. contemperaneous communication if possible increases patients feeling of safety. (Sissakos et al, 2011). 

Communication and explanation essential - Birth afterthoughts and datix 

Lovsett's manouvre 

• Gently hold baby over bony prominences of hips and sacrum rotate baby one arm uppermost, index finger placed over shoulder followed to antecubital fossa, flex for delivery.  Rotate 180 degrees and repeat with second arm. 

Mariceau-Smellie-Veit manouevre 

• Assist's birth of head. Body supported on flexor surface of accoucheur's forearm . 1st and 3rd fingers should be placed on cheekbones (not in mouth due to injury - historically used)
• With other hand, apply pressure to occiput with middle finger and place other fingers on fetal shoulders to promote flexion of head and reduce diameter 

Burns-Marshall 

No longer used due to concerns of overextension of baby's neck. Not advised. 

(RCOG, 2017)

Shoulder dystocia is an unpredictable, acutely life-threatening obstetric emergency, with significant risk of harm to the infant if managed inappropriately. 

Effective and sustainable multi- professional training is crucial in reducing these risks and improving maternity care and safety. 

The PROMPT programme has resulted in significant improvements in reducing preventable harm

• 50% reduction in hypoxic brain injury [HIE] 
• 34% reduction in maternal deaths 
• 91% reduction in litigation costs (North Bristol Trust)

 (NHSLA 2012)

Term breech trial – reduction in skills and expertise; all the more important professionals are experienced; as there are always some which are not recognised until late gestation, and due to maternal choice.

(Hannah et al, 2000)

2 year follow up data showed no differences in neurodevelopment between babies born vaginally or c/s – therefore it is unclear if the benefits for the child outweigh maternal risk of c/s

(Whyte et al, 2004)

• Call for help - midwife coordinator, experienced obstetrician, neonatal team 
• Ensure continous electronic fetal monioring
• maternal position - semi recumbant/ forward facing/all 4's - preference and experience
• Hands off as much as possible at all stages, risk of nuchal arms, awareness of when to intervene - poor infant tone or colour - more than 3 minutes from birth of cord, 5 minutes from birth of buttocks- start clock 
• Avoid handling of cord - risk of vasospasm
• Avoid touching anything but pelvic girdle reduce risk of soft tissue injury 
• await visualisation of breech at perinuem before encouraging pushing 
• if assistance required - gentle popliteal pressure to deliver legs
• if arms require assstance perform Lovsett's manouevre - only hold baby over hip bones  - pelvic girdle. Turn baby left and right keeping back uppermost "1 tum 1 bum" 
• Encourage spontaneous birth with maternal effort until visible scapulae
• if assistance required for birth of head, when nape is visible flex head placing 1 hand on babies shoulders and back of head, 1st and 3rd fingers on cheeck bones to aid flexion of head. "mariceau smellie veit manouvre"
• suprapubic presssure can alsobe done to aid babies head delivery. (RCOG, 2019) (PROMPT, 2017)