Breech Delivery Treatment & Management

If a vaginal delivery is planned, or the fetus has an underlying concern leading to a breech presentation transport the mother to the nearest facility with neonatal intensive care. If the mother is in the second-stage of labor or if amniotic membranes have ruptured, take the mother to the nearest hospital or urgent care center for emergency delivery.

Administer supportive oxygen and IV fluids. Transport the mother in a comfortable position or in the left lateral decubitus position.

Inform the hospital of an impending arrival and of the clinical situation.

See the list below:

• Provide supportive care, including IV, oxygen, monitor, complete blood count (CBC), and blood type and screen.

• Consult an obstetrician and neonatologist.

• Alert labor & delivery.

• Three types of vaginal breech delivery exist:

  • Spontaneous breech (rare): No manipulation of the infant is necessary, other than supporting the infant.

  • Partial breech extraction (most common): Fetus descends spontaneously to the point where the umbilicus is at the vaginal introitus; then, the fetus is further extracted.

  • Total breech extraction: The entire body is extracted. This is typically only done for a second twin delivery, and with a singleton is indicated only if there is evidence of fetal distress unresponsive to routine maneuvers and a cesarean delivery is not possible. As mentioned earlier, it is imperative that the cervix be fully dilated and effaced before the infant is delivered past its umbilicus. Note: The presence of the feet at the vulva is not an indication to the physician to proceed with active extraction.

• Technique for footling extraction (see image below)

  Footling breech presentation. Once the feet have delivered, one may be tempted to pull on the feet. However, a singleton gestation should not be pulled by the feet because this action may precipitate head entrapment in an incompletely dilated cervix or may precipitate nuchal arms. As long as the fetal heart rate is stable and no physical evidence of a prolapsed cord is evident, management may be expectant while awaiting full cervical dilation.

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  • Advance the hand into the vagina and grasp the feet. How do you know the extremity is a foot? Feel for the heel. Place a finger between the legs and apply gentle traction (see image below).

    Assisted vaginal breech delivery. Thick meconium passage is common as the breech is squeezed through the birth canal. This is usually not associated with meconium aspiration because the meconium passes out of the vagina and does not mix with the amniotic fluid.

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  • After the feet are pulled through the vulva, an episiotomy can be made, if necessary (see image below).

    Assisted vaginal breech delivery. The Ritgen maneuver is applied to take pressure off the perineum during vaginal delivery. Episiotomies are often performed for assisted vaginal breech deliveries, even in multiparous women, to prevent soft tissue dystocia.

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  • Wrap the legs with a towel to aid in grasping the fetus (see image below).

    Assisted vaginal breech delivery. With a towel wrapped around the fetal hips, gentle downward and outward traction is applied in conjunction with maternal expulsive efforts until the scapula is reached. An assistant should be applying gentle fundal pressure to keep the fetal head flexed.

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  • Perform gentle downward traction to deliver the hips, and, then, the buttocks. At this point, the fetus's back should rotate anteriorly.

  • Adjust grip so that the thumbs overlay the sacrum. With the fingers over the hips, continue gentle downward traction with a left and right rotation (to reduce any nuchal arms).

  • As the scapulae are delivered, the fetus's back rotates laterally. If this does not occur spontaneously, gently rotate the fetus.

  • Once the lower halves of the scapula have passed the vulva and the axillae are identified, deliver the shoulders by 1 of 2 maneuvers:

    • In the first method, rotate the trunk posteriorly until the anterior arm and shoulder are delivered; then, rotate the body in the reverse direction to deliver the other shoulder and arm beneath the symphysis pubis (see images below).

      Assisted vaginal breech delivery. After the scapula is reached, the fetus should be rotated 90° in order to deliver the anterior arm.

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      Assisted vaginal breech delivery. The anterior arm is followed to the elbow, and the arm is swept out of the vagina.

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      Assisted vaginal breech delivery. The fetus is rotated 180°, and the contralateral arm is delivered in a similar manner as the first. The infant is then rotated 90° to the backup position in preparation for delivery of the head.

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    • If the rotation and counter-rotation method is unsuccessful, deliver the posterior shoulder first. Grasp the feet of the fetus in one hand and, with upward traction, pull the fetus over the mother's groin. The posterior shoulder and extremity slide out above the perineum. Afterward, deliver the anterior shoulder and upper extremity with downward traction.

    • If the arm does not pass with the shoulder, deliver the upper extremity manually. Slide two fingers along the humerus until the elbow is reached. Use fingers to splint the humerus, and sweep the forearm of the fetus across the chest and out of the vagina.

  • The last part to pass is the head. Typically, the fetal chin is posterior. The head is extracted using the Mauriceau maneuver, as follows (see image below):

    Assisted vaginal breech delivery. The fetal head is maintained in a flexed position by using the Mauriceau maneuver, which is performed by placing the index and middle fingers over the maxillary prominence on either side of the nose. The fetal body is supported in a neutral position, with care to not overextend the neck.

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    • With the fetus resting on your hand and forearm, insert index and middle fingers into the vagina to rest upon the fetal maxilla.

    • This maneuver accomplishes flexion of the head. Use caution to avoid placing fingers into the mouth or pushing hard on the neck, as tears may occur.

    • Hook 2 fingers from the other hand on either side of the fetus's neck. Grasp the shoulders and apply downward traction until the fetal subocciput appears beneath the symphysis pubis.

    • The fetus subsequently is elevated toward the maternal abdomen with delivery of the mouth, nose, brow, and occiput beyond the perineum.

    • An assistant may apply suprapubic pressure during the Mauriceau maneuver to aid in delivery of the head.

    • As an alternative, Piper forceps may be used to deliver the aftercoming head. These forceps are designed to prevent hyperextension of the fetal neck with delivery.

• Technique for frank delivery

• After episiotomy, allow breech birth to proceed spontaneously as far as possible. Then, apply posterior traction with a finger from each hand placed around the hips of the fetus and into each inguinal region.

• Once the knees appear, flex the legs gently to assist in delivery.

Inform an obstetrician skilled in breech delivery of its possibility. Their presence at the bedside is imperative.

As most infants delivered breech are premature, notify a neonatologist or a pediatric intensivist.

Premature infants do not have great pulmonary reserve. Thus, airway support and intubation may be necessary. ^[11]