Vaginal Breech Birth

Breech presentation is where the presenting part of the fetus is the buttocks or feet; the breech can be extended, flexed or footling.

In the UK 3-4%, although higher earlier in pregnancy (20% at 28 weeks).

Breech presentation is associated with a higher perinatal morbidity and mortality than cephalic presentation, particularly with vaginal birth.

Factors that predispose to a breech presentation:

• Previous breech birth
• Premature labour
• High parity
• Multiple pregnancy
• Polyhydramnious
• Oligohydramnious 
• Uterine abnormalities
• Maternal pelvic tumour or fibroids
• Placenta praevia
• Hydrocephaly (abnormal buildup of cerebrospinal fluid (CSF) in the ventricles of fetal brain)
• Anencephaly (absence of a major portion of the brain, skull, and scalp that occurs during embryonic development)
• Fetal neuromuscular disorders
• Fetal head and neck tumours

There has been a large reduction in the incidence of vaginal breech birth since the publication of the Term Breech Trial. 

The Term Breech Trial compared outcomes after planned vaginal and planned caesarean births for breech presentation, and demonstrated a significant reduction in perinatal morbidity and mortality in the planned c-section group (reduction in mortality by 75%). 

There was no significant increase in maternal morbidity or mortality with planned caesarean birth.

However the 2-year follow-up did not demonstrate any statistically significant differences in neurodevelopment between infants born by c-section and those born vaginally. Therefore, it is unclear whether the long-term benifits for a child being born by c-section for breech presentation, outweigh the maternal risk of the additional c-sections.

RCOG states that the selection of appropriate pregnancies , together with skilled intrapartum care, may allow planned vaginal breech to be nearly as safe as planned vaginal cephalic birth.

• Spontaneous breech birth: The fetus is allowed to descend and deliver without assistance or manipulation. This accounts for a small proportion, most of which are preterm
• Assissted breech birth: The most common method of vaginal breech birth. The fetus is allowed to descend with the carer employing a 'hands off' approach. However, recognised manoeuvres are used to assist birth when required.
• Breech extraction: Mainly for assisting the birth of the non-cephalic second twin. Involves grasping one or both of the fetal feet from within the uterine cavity and bringing them down through the vagina, before continuing with the manoeuvres used in an assisted breech birth.

• RCOG recommend that when a woman presents with an unplanned vaginal breech labour, management should depend on gestation, stage of labour, whether factors associated with increased complications are found, the avalibilty of appropriate clinical expertise and informed consent from the mother.
• Also recommends that birth should take place in a hospital with facilities for emergency caesarean section, but not routinely necessary to transfer to operating theatre for vaginal birth

• Inform senior midwife, senior obstetrican, anaesthetist, theatre staff and neonatologist of the mothers admission
• Ensure that key members of staff are avalible who are skilled in managing vaginal breech birth
• Discuss mode of birth again with woman and ensure she wishes to opt for vaginal birth
• Discuss analgesia early in the process. There is no evidence to support routine epidural, but it may increase the risk of intervention if used. Consider a pudendal block if epidural is not used (local anesthetic, such as lidocaine or chloroprocaine, is injected into the pudendal canal where the pudendal nerve is located. This allows quick pain relief to the perineum, *****, and vagina)
• Explain all birth techniques and that a paediatrician will attend the delivery
• Get intravenous access and take blood for full blood count and group and save
• Prepare labour roomand neonatal resuscitation equipment. Ensure equipment for an assisted vaginal breech birth are present: Operative vaginal birth pack, warm towels, obstetric forceps, lithotomy supports

• Continuous electronic fetal monitoring (EFM) should be recommended to all women with a breech presentation during labour and birth, as is likely to improve neonatal outcomes
• Vital that EFM continues right up until birth, including when decision is made for c-section during labour
• When CTG is considered to be pathological before active second stage, a caesarean birth is recommended, unless buttocks are visable or progress is rapid.
• Fetal blood sampling is not recommended

• Labour augmentation with oxytocin is not recommended, however recent Green-top Guidelines suggest that it may be considered if there is an epidual in situ and contracions less that 4:10
• Once spontaneous rupture of membranes occurs, VE to exclude a cord prolapse

• Recommended that women presenting in labour in the near or active second stage with a breech presentation should not be routinely offered a caesarean section
• However, if there is a delay in the descent of the breech at any point in the second stage- caesarean section should be considered, as this may be a sign of fetopelvic disproportion (too large for the pelvic opening)
• Women undergoing vaginal breech should be looked after by professionals with adequate experience and skills to conduct and assist the birth
• Attendants should include, senior midwife, obstetrican and neonatologist. Anaesthetist should be present on labour ward and theatre staff should be on standby
• Some experienced obstetricians and midwives have suggested that upright maternal positioning (mother kneeling on all fours, sitting on birthing stool or standing upright) may have some physiological advantages, as well as offering maternal choice about positioning
• Upright positioning may lead to greater maternal satisfaction in childbirth
• Studies have shown that upright and active psoitioning create greater space in the pelvis, but there is limited other study to compare 
• RCOG recommend that women should be advised to be either in a semi-recumbent position or foward-facing squatting position or all-fours position, but psoitioning should depend on maternal preference and the expeirence of the attendant

• If a front facing all-fours position is used, then the woman should be advised that going into the semi-recumbrant position may be required if manoeuvres are required, as it may be a better position for the professional
• Women undergoing a vaginal breech birth should be attended by practitioners with adequate experience and skills to conduct and assist the birth 

• All obstetricans and midwives should be familiar with the techniques that can be used to assist vaginal breech birth. 
• The choice of manoeuvres used, if they are required, should depend on the individual experience/preference 
• When the breech is visable at the perinium, active pushing should be encouraged
• Once the buttocks have passed the perineum, significant cord compression is common.
• Signs that birth should be assisted include lack of fetal tone or colour, or delay commonly due to extended arms or an extended neck
• In general, intervention to expedite birth is required if there is evidence of poor fetal condition or there is a delay of 5 minutes between birth of the buttocks and birth of the fetal head (or more than 3 minutes from the umbilicus to the head)
• Aim for a 'hands off' approach to vaginal breech birth. Keep interventions to a minimum and avoid traction. However, if progress is not made once the umbilicus is visable, or if there is poor tone, extended arms or an extended neck, then timely and appropriate intervention is necessary 

• Episiotomy should be used selectively to facilitate birth
• Spontaneous birth of the limbs and trunk is preferable, but the legs may need to be released by applying pressure to the popliteal fossae
• When handling the baby, it is important to ensure that support is only provided over the bony prominences of the pelvic girdle, to redcue the risk of soft tissue internal injury
• Ensure the buttocks remain sacroanterior (sacrum of the baby is anterior)
• Controlled rotation may be required if the trunk appears to be rotating to a sacroposterior position, but handling of the baby should again only be over the bony prominences
• Avoid handling the umbilical cord, as this increases vasospasm
• Encourage spontaneous birth with maternal pushing until the scapulae (shoulder blades) are visable
• Traction on the infant's trunk can cause nuchal arms and should therefore be avoided
• If the arms are not released spontaneously, use the Lovsett's manouvre 
• Lovsett's Manouvre: Gently hold the baby over the bony prominences of the hips and sacrum and rotate the baby so that one arm is uppermost (anterior). To release the uppermost arm, an index finger should be placed over the baby's shoulder and follow the infant's arm to the antecubital fossa. Following the release of the first arm, roate the baby 180 degrees, keeping the back uppermost, so that the second arm is now uppermost and repeat as with first arm.

• After release of the arms, support that baby until the nape of the neck becomes visable, using the weight of the baby to encourage flexion.
• If spontaneous birth of the head does not follow, an assistant may apply suprapubic pressure to assist flexion of the head

• This manoeuvre may be required to assist birth of the after-coming head. 
• When using this manoeuvre, the baby's body should be supported on the flexor surface of the persons forearm
• The first and third finger of the persons hand should be placed on the cheekbones (note that the middle finger is no longer placed in the fetal mouth, as fetal injury had been reported) 
• With the other hand, apply pressure to the occiput with the middle finger and place the other fingers simultaneously on the fetal shoulders to promote flexion of the fetal head (i.e.keep the chin on the chest) to reduce the fetal head diameter

• Not advised as there have been concerns expressed about the risk as it may lead to overextension of the baby's neck

• Alternatively, the birth of the fetal head can be assisted with forceps
• An assistant should hold the baby's body and the forceps should be applied from underneath the fetal body
• The axis of traction should aim to flex the head
• There is debate of which type of forceps should be used for this procedure.
• Kielland's, Rhodes', Piper's and Wrigley's forceps have all been reported

There is no evidence to indicate which of the above techniques is preferable for assisting the birth of the head and previous experience is a very important factor in the decision as to which method is chosen.

Head entrapment during a preterm breech birth

• The major cause of head entrapment is the passage of the preterm fetal trunk through an incompletely dilated cervix.
• This occurs in approximately 14% of vaginal breech births
• In this situation, the cervix can be incised to release the head
• RCOG recommends that the incisions should be made in the cervix at the 2, 6 and 10 o'clock positions, to avoid the cervical neurovascular bundles that run in the cervix laterally, the bladder anteriorly and the rectum posteriorly 
• Care should be taken, as extension into the lower segment of the uterus can occur
• For head entrapment at caeserean birth, it may be necessary to extend the uterine incision to a J shape or inverted T

• This is when one of both of the arms become extended and trapped behind the fetal head
• Nuchal arms complicate up to 5% of breech births and mau be caused by early traction on a breech
• This is high morbidity associated with nuchal arms (25% risk of neonatal trauma, e.g. brachial plexus injuries) and therefore any early traction on a breech should be avoided 
• Nuchal arms can be released with rotation using the Lovsett's manoeuvre and running your fingers along the fetal arm and to the antecubital fossa, where pressure can be applied to flex the arm and achieve birth 

• Cord prolapse is more common with breech presentations, especially footling breech presentations (10-25%)
• The most important factor with cord prolapse is preventiion
• Amniotomy (ARM) should be undertaken with caution and with a presenting part filling the pelvis
• Management of cord prolapse as normal

• Intrapartum death
• Intracranial haemorrhage
• Hypoxis-ischaemic encephalopathy
• Brachial plexus injury
• Rupture of liver, kidney or spleen
• Dislocation of neck, shoulder or hip
• Fractured clavicle, humerus or femur
• Cord prolapse
• Occipital diastasis and cerebellar injury