Breech presentation

If a baby presents by his breech, he is about 4 times more likely to die than if he presents by his vertex. This is so, even if you exclude the excess mortality due to the higher rate of prematurity and fetal abnormality that is associated with breech deliveries. This increased mortality is due to: (1) The rapid compression and decompression of his unmoulded head. (2) Asphyxia due to the delayed delivery of his head, if there is any CPD, or if his mother has an incompletely dilated cervix. (3) The aspiration of meconium, if he tries to breathe while his head is still in her pelvis. (4) The increased risk of his cord prolapsing.

[f11]

External cephalic version (ECV, M 19.1). [f09]If you can reduce the number of breeches you deliver, you can reduce the perinatal mortality associated with them. Turning a breech presentation in the third trimester will do this, but it is of little value before 34 weeks in a primip, or 36 weeks in a multip, because many breech presentations spontaneously correct themselves before this. After 36 weeks a baby gradually becomes less mobile, which makes version more difficult. On the other hand, if version does succeed, it is more likely to be permanent.

[f11]The knee-chest position (M 19.1) [f09]is an alternative to ECV which often works. It is also safer, but has never been objectively evaluated; this is being done as we go to press. Ask a mother to spend 10 minutes three times a day in the knee-chest position. This may allow her baby's breech to disimpact in her pelvis, so that he can turn spontaneously.

[f11]If external version or the knee-chest position fail, [f09]you can deliver a breech: (1) Vaginally, by assisted breech delivery (M 19.1). (2) Vaginally, by breech extraction. Or, (3) abdominally, by Caesarean section. In breech extraction you, rather than his mother, provide the power for pulling the baby down. You exert traction on his legs, groins and pelvis, so it is potentially more dangerous than an assisted breech delivery, which is the usual way of delivering a breech. Breech extraction is described here, but not in [f10]Primary Mother Care, [f09]and is only indicated on the rather unusual indications given below.

[f11]What should your policy be towards Caesarean section in breech deliveries? [f09]Liberal use of it will reduce your perinatal mortality, but you will have to weigh this against the increased maternal morbidity and mortality that will follow from it (18.1). In the developed world the risks of breech delivery have fallen so much, that it is hardly more dangerous than delivery by the vertex. This is the result of: (1) Safer Caesarean section. (2) Quicker section if the cord prolapses, or there is unexpected delay in the second stage. (3) Greater emphasis on controlled delivery of the head, often assisted by forceps and epidural anaesthesia. (4) Less CPD owing to better maternal nutrition. (5) An increased readiness to section mothers with borderline pelvises, very small breech babies, and footlings (a breech with one foot down and one up). These factors have combined to make Caesarean section so popular in some centres in the developed world, that their section rate for breeches is now over 50%.

The increased safety of breech delivery in the developed world has made obstetricians there look closely at the small risks of ECV, which include: (1) Knotting of the cord. (2) Placental abruption. And, (3) uterine rupture. In the developed world, the risks of ECV, small though they are, are commonly held to be more than those of breech delivery, so that ECV is increasingly out of favour. However, in the developing world, the risks of breech delivery and section are much greater, and grand multiparity is much commoner, so that ECV still has an important place here. It is therefore described in [f10]Primary Mother Care. [f09]Unfortunately, ECV is not done by doctors as often as it should be, or by experienced midwives (it should not be done by inexperienced ones). If your excess perinatal mortality with breech deliveries is more than 20/1000, after correcting for prematurity and fetal abnormality (see below), the risks of ECV are worth taking. Don't attempt it under general anaesthesia.

[f11]If there is any question of CPD [f09]before the second stage of labour, section the mother. In communities where contracted pelves are common, the risks of a breech delivery are great, so that if you want these babies to survive, you may have to section 25% of your breeches. A mother with a true conjugate of less than 9 cm should not be allowed to deliver a full term breech baby vaginally.

[f11]A baby with IUGR or prematurity [f09]presenting by his breech is a problem. Much depends on his age: (1) Under 28 weeks' gestation ([lt]1000 g) his chances of life are small, the lower segment is poorly formed, and it is questionable if section will be any less traumatic than vaginal delivery. (2) From 28 to 32 weeks (1000[nd]1500 g) he may have a better chance with Caesarean section, especially if he is a footling presentation. However, about 20% of these babies have severe abnormalities, and if you don't have ventilators, even the normal ones have a poor chance of surviving. So, in an area of high parity and high perinatal mortality, you should rarely section a premature baby presenting by his breech.

[f11]Symphysiotomy [f09]needs skill (see below), and is best kept only for unbooked patients, who are admitted in the second stage of labour, whose pelves you cannot assess, and when there is no time for section. You can do a symphysiotomy to help deliver a baby's shoulders, or you can keep it until unsuspected CPD has delayed the delivery of his head[md]but you will have to be quick, and have a solid-bladed scalpel and a catheter ready!

[f11]Epidural anaesthesia [f09](A 7.2) will prevent a mother bearing down before she is fully dilated, and it will make any manipulations that you have to do in the second stage of a vaginal delivery, much easier. Alas, it is seldom practical under the conditions in which you work. If the difficulties of vaginal breech delivery worry you, and you are tempted to section all breeches, remember the dangers of Caesarean section from anaesthesia, bleeding, and sepsis. An occasional ''stuck breech', and a dead baby, are more acceptable than a maternal death. As your skill and experience and that of your staff improve, so will your successful vaginal deliveries.

Armon PJ, ''The management of singleton breech presentations'. Tropical Doctor 1984;167[nd]169.[-3] Lovset J, ''Shoulder delivery by breech presentation'. Journal of Obstetrics and Gynaecology of the British Empire 1937;44:696.[-3] Thornton JG, ''External cephalic version. Tropical Doctor 1985;173[nd]174.[jl] Fig. 19-2 CORRECTING A BREECH PRESENTATION. A, to C, external cephalic version. Flex him between his hands so that you make him do a forward somersault. D, the knee-chest position. Ask his mother to spend 10 minutes 3 times a day like this.

BREECH PRESENTATION CORRECTING A BREECH PRESENTATION THE KNEE-CHEST POSITION. Ask her to spend 10 minutes in the knee-chest position 3 times a day. If this fails try external cephalic version.

EXTERNAL CEPHALIC VERSION can be done at any time after 34 weeks, until labour starts. It is not necessary before 34 weeks. You may not succeed after 36 weeks, but it is still worth trying.

Contraindications. Take a history from her and examine her to exclude: (1) Multiple pregnancy. (2) Antepartum bleeding in this pregnancy. (3) A previous Caesarean section. (4) The need to do a Caesarean section in this pregnancy for some other reason. (5) A diastolic blood pressure greater than 100 mm. (5) A fetal abnormality, if you can detect it. (6) A Rhesus- negative mother and no anti-Rh imunoglobulin to give her.

Method. Explain carefully what you are going to do. Ask her to empty her bladder and lie on her back tilted a little to one side. Make sure your hands are warm and she is comfortable. You may find it helpful to lubricate your hands and her abdomen with glove powder.

Find which side the baby's back is. Count his heart rate. Place one hand below his breech, and your other hand above his head. Flex him between your hands, so that you make him do a forward somersault (turn head over heels). Listen to his heart.

If his heart rate slowed to less than 100, turn her on her side and wait until it is more than 100. If his heart rate has not started to recover within 2 minutes, turn him into his original position. His umbilical cord may be tight round his neck.

If a forward somersault fails, try turning him in a backward somersault.

If you fail, rest her with the foot of her bed raised. If she is anxious give her diazepam 5 mg by month. Try again in an hour. If you fail again, try again at the next visit.

If you succeed, see her again one week later to make sure the presentation is still cephalic.

If you cannot turn her by 37 weeks, manage her as a breech delivery.

THE INDICATIONS [s7]FOR CAESAREAN SECTION IN A BREECH DELIVERY If she has a normal or or large pelvis, and he is a normal- sized baby, she will probably deliver vaginally. If you cannot touch her sacral promontory easily, and her diagonal conjugate is [mt]11 cm (true conjugate [mt]9cm), she probably has a large enough pelvis. If you can touch her sacral promontory easily, and her diagonal conjugate is less than 11 cm, she has a small pelvis.

Most additional factors, which compromise the wellbeing of a baby, are indications for section. Only a healthy normal-sized mother with a baby less than 3.7 kg (as indicated by a fundal height of [lt]40 cm), who progresses normally in both stages of labour, should be allowed a vaginal delivery. In more detail the indications for section are these:

ANTENATAL INDICATIONS FOR ELECTIVE CAESAREAN SECTION. (1) CPD or suspected CPD. (2) A large baby; feel the size of his head. If he feels as if he is big, that is [mt]3.7 kg (fundal height [mt]40 cm), regardless of the size of her pelvis, section her. (3) The scar from a previous section. (4) Other obstetric hazards, such as placenta praevia, diabetes, gestational hypertension, or APH. (5) An elderly primigravida, or a long history of infertility. (6) A previous stillbirth, especially if it was associated with a breech. (7) Postmaturity [mt]42 weeks. (8) Perhaps a baby with IUGR, or prematurity, weighing 1000[nd]1500 g, especially if he is a footling.

INDICATIONS FOR CAESAREAN SECTION DURING LABOUR. (1) A prolonged active phase. (2) Arrest at the brim, or delay in the descent of the breech during the second stage. (3) A footling presentation. A multip is likely to develop an irresistible desire to push before full dilatation, as her baby's feet enter her vagina. This can result in his head being caught behind her undilated cervix. Other obstetric indications such as: (4) Cord presentation or prolapse. (5) Fetal distress. (6) Prolonged rupture of the membranes.

Fig. 19-3 THE BURNS[nd]MARSHALL MANOEUVRE for delivering the head in a breech delivery, if it does not deliver spontaneously. A, allow his body to hang, until you can see the hair at the back of his neck. B, hold his feet. C, swing his feet upwards over his mother's abdomen. Free his mouth and pause while you clean it. D, finish delivery by swinging him over her abdomen.

ASSISTED BREECH DELIVERY [em]CAUTION ! For breech delivery you need a quiet atmosphere and good communication with the patient. A crowd of supporters crying ''Push, push' is not what you want. Quiet them and explain what is happening. You will need an assistant

THE FIRST STAGE. If her cervix dilates at less than 1 cm per hour in the active phase, or there are any other signs of delay, section her. Until his buttocks are delivered, you can turn back and do a Caesarean section. Only when his buttocks have been delivered have you reached the point of no return. If there is any delay before the delivery of his buttocks, section her.

THE SECOND STAGE. A common fault is to try to deliver a breech through an incompletely dilated cervix, which may extend his arms and make his head difficult to deliver. Full dilatation may not be easy to diagnose in a breech, so don't consider that the second stage has started until his anterior buttock is easily visible. Put her into the lithotomy position (essential if ]]you do the Burns Marshall manoeuvre or apply forceps to his aftercoming head) when his posterior buttock is distending her perineum. As soon as she wants to bear down, do a vaginal examination to make sure that her cervix is fully dilated.

His breech should advance with every contraction. Infiltrate her perineum, and do an episiotomy, when his buttocks are distending it, and you can see a boy's scrotum (or a girl's labia). Protect his scrotum (you don't want the episiotomy to castrate him!). His buttocks and legs will then deliver.

When his umbilicus delivers there is often a temporary halt in descent. Look at the clock. He should be delivered in 5 minutes.

Wait for progress to resume with the next contraction. His shoulders and arms should deliver with a twisting movement, and his head should follow immediately. Don't touch him, or try to disentangle his legs, until you see his umbilicus. Touching him promotes breathing movements and the aspiration of meconium. Put your hand on her fundus, observe each contraction, and keep a steady gentle pressure on his head.

When his umbilicus appears, disengage his extended legs and pull down a loop of his cord, which may be stretched.

CAUTION ! Encourage him to turn so that his back is uppermost. Never allow his ventral surface to face upwards.

When his anterior scapula appears (and not before), search for his arms in front of his chest. If, as is usual, his arms are not extended, they will both be in front of his chest. You should be able to deliver one or both of them. If you have difficulty, feel up to his shoulder and from there feel down his arm, first one then other.

Allow his body to hang, as in A, Fig. 19-3. His own weight will make his head descend through her birth canal. It will have been entering her pelvis, and will be compressing his cord. Assist its descent with gentle suprapubic pressure. He must be able to breathe in the next 5 minutes.

If his head does not immediately deliver spontaneously when his arms are out, try the BURNS[nd]MARSHALL manoeuvre. Wait until you can see the the hairs on the nape of his neck (A, Fig. 19-3). Stand with your back to her left leg, take his legs in your right hand (B), pull him outwards a little and draw him outwards over her pubis. Guard her perineum with your left hand and prevent his head from emerging too quickly. As soon as his mouth and nose appear, pause, and ask your assistant to clear his airways and allow him to breathe (C). Then, carefully deliver the rest of his head (D).

If you cannot get at least his mouth and nose into fresh air with the Burns[nd]Marshall method: (1) use the MAURICEAU [nd] SMELLIE [nd] VEIT manoeuvre, or (2) apply forceps to his aftercoming head (see under ''Difficulties' below). Rest his belly and chest on your right forearm; put your right middle finger in his mouth, and your index and ring fingers on his malar bones. Put your left hand over his back; put your middle finger on his occiput and your index and ring fingers over his shoulders. This will give you some control over the flexion and rotation of his head. Grip his skull and guide it through her birth canal. Ask her to stop pushing. Ask your assistant to put his fist on the baby's head, which is still palpable above her pubis, and to press obliquely downwards in the direction of her coccyx. You will feel a ''plop' indicating that his head has gone into her pelvis, and further delivery by the Mauriceau[nd]Smellie[nd]Veit manoeuvre should then be easy.

CAUTION ! This is a method for getting a grip directly on his head. NEVER pull on his shoulders, you can too easily distract his cervical vertebrae and damage his cord.

NOTE: Although Mauriceau[nd]Smellie[nd]Veit is a cumbersome eponym, it is preferred to the alternative which is ''jaw shoulder traction' since this suggests, although it does not intend, traction on the neck, which is very dangerous.

Fig. 19-4 TWO METHODS FOR DELIVERING THE HEAD IN A BREECH PRESENTATION. A, applying forceps to the aftercoming head. B, the Mauriceau[nd]Smellie[nd]Veit manoeuvre is a method for getting a grip directly on a baby's head. Rest his belly and chest on your right forearm; put your right middle finger in his mouth, and your index and ring fingers on his malar bones. Put your left hand over his back; put your middle finger on his occiput and your index and ring fingers over his shoulders. This will give you some control over the flexion and rotation of his head. Guide his head through his mother's birth canal and don't pull on his shoulders. The finger in his mouth is for convenience only.

EARLY DIFFICULTIES [s7]DELIVERING A BREECH [em]CAUTION ! (1) Do an episiotomy (except in a grand multip with a very lax outlet) before you do any manipulations, because there is a high risk of a perineal tear. (2) Don't squeeze his abdomen! (3) If his head fails to descend, don't pull on his neck. (4) If his head becomes impacted and he dies, don't sever his neck, or be tempted to open her uterus from above.

If his breech is DELAYED AT THE BRIM, or in midcavity, this is probably a warning sign of CPD; section her. Don't try to deliver her with oxytocin. If section is impossible, consider reaching for his anterior groin with a finger and bringing down his leg. This was once the traditional method, and will probably injure him seriously.

If his breech is DELAYED AT THE OUTLET, make sure that the episiotomy is adequate. There may be CPD. If her pelvis feels contracted, or he is large, section her. If all is otherwise well, do gentle groin traction, as for breech extraction (see below).

Fig. 19-5 LOVSET'S MANOEUVRE for the delivery of the shoulders in a breech presentation. The bottom row of drawings show a view from the patient's perineum. The top row shows the same stage viewed from her left. Remember ''If you don't know which way to turn him, keep his back anterior, so that it passes under her clitoris''. Many obstetricians merely wiggle him one way then the other, pull, and try to find an arm: but this is the detailed manoeuvre. Practise it on a model.

If you have delivered his legs but BOTH HIS SHOULDERS HAVE NOW STUCK above his mother's pelvic brim, his arms are probably extended (A, Fig. 19-5). Normally you can put a finger up her posterior vaginal wall and easily bring them down. If you cannot, they are probably extended. Try LOVSET'S manoeuvre. It is a breech extraction for obstruction late in delivery, and should rarely be necessary. The delivery of his shoulders is prevented by two obstructions at different levels; (1) her sacral promontary is higher than (2) her pubis. The principle of this method is that, by pulling him tightly down on to both, and by turning him through 180[de], the shoulder which was held up above her pubis will turn to pass into the hollow of her sacrum, and the shoulder which was above her sacrum will now be above her pubis. Two further ''unscrewing' half-turns like this, each bringing his shoulders progressively below these obstructions will deliver him.

Grasp his thighs and pelvis with both hands (if he is slippery use a gauze swab or small towel), your thumbs along his sacrum, your forefingers on his symphysis, and your remaining fingers round his thighs.

If, in the extreme case, he obstructs transversely (A), start by turning him through 90[de] (A to B), so that his back faces to her left. His left shoulder will then be above her symphysis, and his right shoulder above her sacrum (B). With your first 180[de] turn (B to C), bring his left shoulder under her sacrum. With your second second turn (C to D) bring his right shoulder under her sacrum. His left arm will now be low enough for you to gently sweep it down. With your third turn turn (D to E) bring his right shoulder under her pubis; it will now be low enough for you to bring his right arm down.

CAUTION ! (1) These three 180[de] turns are in opposite directions, so that his back always passes under her clitoris, and the arm which started posterior always drags across his face. His belly should never pass under her clitoris. (2) In the worst case you start in A with both arms extended, so you have to begin with a 90[de] turn, followed by three 180[de] turns. If he arrests at a later stage, with only one arm extended, you may only need two turns, or perhaps only one. (3) The first two turns release the shoulder which was arrested above her symphysis when you started it. The third enables you to bring down his right arm. (5) Don't squeeze his belly, or back, or you may rupture his liver, kidneys, spleen, or adrenals (huge in the newborn). If you hold his chest, take care not to compress his abdomen. (6) Remember that the upper part of the birth canal, in which he has stuck, is directed backwards, so start by pulling him backwards.

If LOVSET'S MANOEUVRE FAILS TO DELIVER HIS SHOULDERS (uncommon), it is usually a failure of technique. You may have to be a little firmer, or reach up a little higher to get his arm down. A broken arm will soon heal, so it is no disaster (71.17), and is better than letting him die.

DIFFICULTY [s7]DELIVERING HIS HEAD CPD is the most important cause.

IF HIS HEAD IS STUCK ABOVE THE BRIM, you are in trouble. You may be able to draw it into her pelvis with the Mauriceau[nd]Smellie[nd]Veit manoeuvre. If this fails, he will probably be dead, and the best treatment will be craniotomy (see below).

If HIS HEAD HAS ENTERED THE PELVIS and the MAURICEAU[nd]SMELLIE[nd]VEIT manoeuvre fails to deliver it, rotating his head in her pelvis may help. Stop struggling and think. What is the cause? If it is CPD, and you are an experienced symphysiotomist with an equally experienced obstetric team, a quick symphysiotomy may save him. On the other hand, an unskilful symphysiotomy may cause pelvic trauma and laceration of her urinary tract, so only attempt this if you and your team are expert.

If CPD IS THE CAUSE or SHE IS NOT FULLY DILATED, and you cannot deliver him, let him die and avoid harming her. While she is still in the lithotomy position, sedate her with pethidine 50 mg and let him hang for a while. His head will usually mould, or her cervix will dilate, so that he is delivered in less than an hour.

Alternatively, if his head has stuck in her incompletely dilated cervix (uncommon) either: (1) Apply standard obstetric forceps, such as those of Neville Barnes, inside it. While you apply gentle traction, try to slip her cervix over his head. Or, (2) if this fails, cut her cervix boldly with scissors at 4 and 8 o'clock, and repair your incisions afterwards (M 24.2). Some contributors consider this a relatively safe and successful method, one considers it bloody and dangerous. This complication usually happens to premature breech deliveries, who may not be worth the risk involved.

If the ABOVE MEASURES FAIL and CPD is severe, you may have to do a CRANIOTOMY through his foramen magnum (unpleasant but effective). See Section 18.5 for the general principles of destructive operations. A craniotomy is best done in the theatre under general anaesthesia; but you can do it in the labour ward.

Ask an assistant to pull down his his body. Retract her anterior vaginal wall with a Sims' speculum and expose the back of his neck. Pick up a fold of of the skin over his cervical spine with toothed forceps, and incise it transversely. Use curved Mayo's scissors to cut a tunnel under his skin up to his occipital bone, and push scissors into his head. Open the scissors a few times to break up his brain compartments. Pull gently on his neck while his brain gradually escapes. Or, make a transverse incision over his highest cervical spine and push a straight metal catheter through it on into his his foramen magnum. Or perforate his occiput. He should now deliver quite easily by the Mauriceau[nd]Smellie[nd]Veit manoeuvre.

If he still does not deliver, pass a crotchet up the tunnel and hook it on to the base of his skull.

If he has HYDROCEPHALY, see Section 19.7.

If she is brought in with HIS DEAD BODY PROTRUDING FROM HER VULVA (not uncommon), examine to feel if her cervix is fully dilated or not.

If it is fully dilated, proceed directly to decompress his head with a craniotomy (see above).

If it is not fully dilated, hang a weight of 1 kg on his trunk. His head will usually mould and deliver within an hour. If this fails, do a craniotomy as above.

CAUTION ! Don't try to pull his head forcefully through her undilated cervix. You may cause tears which extend into her lower segment.

If his NECK HAS BEEN SEVERED, and his head has gone back into her uterus, it will be difficult to find and remove. Use craniotomy equipment.

If his CORD PROLAPSES, manage her as you would with a cephalic presentation[md]section her, unless her cervix is fully dilated, and she is about to deliver. Cord prolapse is more common with breech deliveries, especially with a footling.

OTHER METHODS FOR BREECH DELIVERY BREECH EXTRACTION uses your pulling forces, rather than her pushing forces. It is a quick way of delivering a small breech baby, usually a second twin. It may be indicated for: (1) Delay with the second twin. (2) Fetal distress with the second twin. (3) Cord prolapse at full dilatation with a breech. (4) A transverse lie in a second twin, following internal version. (5) A dead baby.

Method. She must be in the lithotomy position. Proceed as for an assisted breech delivery. You will need good anaesthesia: a subarachnoid (spinal) anaesthetic, an epidural or a pudendal block. Avoid general anaesthesia. An episiotomy is vital.

Hook the index fingers of each hand into his groins and pull, preferably during a contraction.

When his umbilicus appears, hook out his legs by flexing his knees. Do this by applying lateral and dorsal pressure in his popliteal fossae, and by sweeping each leg laterally and downwards. Pull on his pelvis, keeping his back anterior. Pull posteriorly. A common error is to pull him towards you, which is not in the axis of her birth canal. When you see his scapulae, hook out his arms. If his arms are not across his chest do Lovset's manoeuvre.

Push his head into his mother's pelvis from above. Then, if necessary, consider applying forceps to his aftercoming head.

The main difficulty is that his arms are more likely to be extended above his head, and his head is more likely to become deflexed. Lovset's manoeuvre and the Mauriceau[nd]Smellie[nd]Veit manoeuvre should solve these problems (see above).

Alternatively, if he is dead: (1) Pull on his leg(s), if you can reach them, or (2) use a combined breech hook and crotchet (Section 15.1a, and Figure 15-2). Pass the blunt hook end of this instrument over an extended leg into his groin, and pull on that. If he is macerated his leg may be pulled off. If it is pulled off, turn the instrument round and hook the sharp crotchet end over his iliac crest.

FORCEPS FOR THE AFTERCOMING HEAD. Standard obstetric forceps, such as those of Neville Barnes: (1) Are not easy to use on the aftercoming head. (2) Are liable to misuse if they are in the labour ward at all. (3) Create the impression for midwifery students that a breech delivery is something that only doctors can do. They must see methods used that they can use themselves at home or in a clinic. Outlet forceps (Wrigley's) are not long enough when you really need them. If they will reach his head they are hardly necessary in a breech delivery.

If you are going to use them, wait until you see his hair line. Ask your asistant to lift him by his ankles, then apply the left blade, followed by the right one. Slowly and gradually deliver his head with them.

THE CORRECTED PERINATAL MORTALITY FOR BREECH DELIVERIES (see above). This should be fairly easy to calculate from your labour ward record books, which should routinely record presentation, birth weight, obvious abnormalities, and live and still births. (1) Work out your perinatal mortality for all babies, excluding breeches, babies [lt]2.5 kg, twins, and babies with obvious malformations. The perinatal period lasts from the 28th week to the end of the first week of life. (2) Do the same for breech deliveries only. Subtract (1) from (2). If the difference is [mt]20/1000, do external version. In many district hospitals it is 50/1000.