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 !" of all breech presentations#, and birth trauma$asphyxia.
%tudies that showed higher rates of perinatal mortality and morbidity with vaginal birth either failed to emphasi&e,
or ignored, crucial issues. 'hese issues include (udicious selection of patients, appropriate intrapartum management,
and the s)ill, experience and (udgement of the obstetrical attendant. 'he only randomi&ed trials that compared
elective cesarean section and selective planned vaginal delivery showed no difference in perinatal mortality or low
*pgar scores between the two groups. 'hese same studies showed a slight increase in short term morbidity in those
that delivered vaginally. 'hese trials lac)ed the power to show any differences in these outcomes. +evertheless, it is
probable that elective cesarean section is associated with increased maternal morbidity.
8.0.2 Selection Criteria
'he following selection criteria for vaginal breech delivery are recommended,
-. .lanned vaginal birth should be recommended for either fran) or complete breech presentations at /!
wee)s or more gestation and$or when the estimated birth weight is 0122 to 3222 grams.
0. .lanned vaginal birth should be offered for either fran) or complete breech presentations at /- to /1 wee)s
gestation and$or when the estimated birth weight is -122 to 0122 grams.
/. 4esarean section should be offered there was less certainty about the adequacy of the data# for either fran)
or complete breech presentation at /2 wee)s or less gestation and$or when the estimated birth weight is less
than -122 grams.
3. 'here was insufficient data on which to base a recommendation for fran) or complete breech presentations
when the estimated birth weight is more than 3222 grams. 'he attending physician5s (udgement about the
most appropriate course of action should determine which delivery method is suggested.
ALARM INTERNATIONAL 6 Chapter 8 - Vaginal Breech Delivery 6 108
SECOND EDITION OF THE ALARM INTERNATIONAL PROGRAM SYLLABUS
Selection Criteria
7nformation for the selection criteria that are relevant,
'ype of breech 8 9ran) or complete breech
*ttitude of fetal head 8 not hyperextended
E9: 012283222g
%everal criteria were examine and were felt not to be important in the selection of patient for a trial of labor. 'hese
included, parity, maternal age, pelvimetry and medical$obstetrical complications.
8.0.3 Management
Intraart!m Management
'he following intrapartum management issues should be considered.
7nduction of labor
*ugmentation of labor
Duration of labor
7ntrapartum fetal monitoring
*nalgesia8anesthesia
*mniotomy
Delivery technique
7ntrapartum consultation
Management in Labor
*dmission to a maternity unit in early labor or immediately after rupture of membranes
*ppropriate fetal surveillance
Epidural for the usual indications
*rtificial rupture of membranes for same indications as cephalic
7mmediate vaginal examination at rupture of membranes to rule out cord prolapse
*ssess labor progress and expect same progress as in cephalic presentation
Management at Deliver"
Experienced newborn resuscitator should be present at the delivery
;aternal bladder should be emptied (ust prior to delivery
7deally, maternity attendant with experience in breech delivery should be involved
9orceps, if available, may be helpful
#ec$ni%!e
-. Explain the necessity of effective pushing in the second stage of labor.
ALARM INTERNATIONAL 6 Chapter 8 - Vaginal Breech Delivery 6 109
In a&&ition' !ltrasonogra$" also rovi&es t$e follo(ing !sef!l information:
)mniotic fl!i& assessment
Cor& osition
)ssessment for congenital anomalies
Confirms lacenta localisation
SECOND EDITION OF THE ALARM INTERNATIONAL PROGRAM SYLLABUS
0. Ensure adequate analgesia.
/. %pontaneous descent and expulsion to the umbilicus should occur with maternal pushing O*L+.
DO *O# ,-LL O* #./ 01//C.<
3. =otation to the sacrum anterior position is desired and may be facilitated.
1. Episiotomy may be considered once the anterior buttoc) and anus are >crowning5.
!. Do not extract the legs until the popliteal fossae are visible .inard5s manoeuvre#.
?. %upport 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. ;aintain flexion of the fetal head by )eeping the body below the hori&ontal.
@. =otate the body to facilitate delivery of the arms using the Loveset manoeuvre.
A. %upport the baby to maintain the head in a flexed position. %uprapubic pressure may help. ;aternal expulsive
efforts should be encouraged.
-2. 'he body should be supported in a hori&ontal position.
--. 'he ;auriceau8%mellie8Beit manoeuvre can be used to deliver the head in flexion..
-0. Cse forceps if needed.
ALARM INTERNATIONAL 6 Chapter 8 - Vaginal Breech Delivery 6 110