BREECH PRESENTATION
CORRECTING A BREECH PRESENTATION
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.
Figure 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 tid like
this.
Contraindications
(1) Multipara. (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 detected fetal
abnormality. (6) A Rhesus-negative mother and no anti-Rh imunoglobulin to treat her
with.
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 2mins, 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 both 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 1wk later to make sure the presentation is still cephalic.
If you cannot turn her by 37 weeks, manage her as a breech delivery.
INDICATIONS FOR CAESAREAN SECTION IN A BREECH DELIVERY
If she has a normal 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 >11 cm (true conjugate >9cm), she probably has a large enough pelvis. If
you can touch her sacral promontory easily, and her diagonal conjugate is <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 <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. (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 >3.7 kg (fundal height >40 cm),
regardless of the size of her pelvis, do a Caesarean section. (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 >42 weeks. (8) Perhaps a baby with IUGR, or prematurity, weighing
1000–1500 g, especially if he is a footling.
INDICATIONS 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 multipara 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. (4) Cord presentation or prolapse. (5) Fetal distress. (6)
Prolonged rupture of the membranes.
ASSISTED BREECH DELIVERY
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.
Figure 19.3: THE BURNS–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.
THE FIRST STAGE. If her cervix dilates at < 1cm/hr in the active phase, or there are
any other signs of delay, do a Caesarean section. 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, do a Caesarean section.
THE SECOND STAGE. A common fault is to try to deliver a breech through an
incompletely dilated cervix, which may force his arms to extend 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 the next 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 the
mother’s 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 (23-3A). 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–MARSHALL manoeuvre. Wait until you can see the hairs on the nape of
his neck (23-3A). Stand with your back to her left leg, take his legs in your right hand
(23-3B), 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 (23-3C). Then, carefully deliver the rest of his head (23-3D).
If you cannot get at least his mouth and nose into fresh air with the Burns–
Marshall method: (1) use the MAURICEAU–SMELLIE–VEIT manoeuvre, or (2)
apply forceps to his aftercoming 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. 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–Smellie–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–Smellie–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.
EARLY DIFFICULTIES DELIVERING A BREECH
CAUTION! (1) Do an episiotomy (except in a grand multipara 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.
Figure 19.4: TWO METHODS FOR DELIVERING THE HEAD IN A BREECH
PRESENTATION. A, applying forceps to the aftercoming head. B, the Mauriceau–
Smellie–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.
If his breech is DELAYED AT THE BRIM, or in midcavity, this is probably a
warning sign of CPD; do a Caesarean section. Don’t try to deliver her with oxytocin.
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, do a
Caesarean section. If all is otherwise well, do gentle groin traction, as for breech
extraction.
Figure 19.5: LØVSET’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 the pelvic brim, his arms are probably extended (23-5A). Normally
you can put a finger up her posterior vaginal wall and easily bring them down. If you
cannot, they are probably forced into extension. Try LØVSET’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 promontory, (2) her pubis. The principle of this method is that, by pulling him
tightly down on to both, and by turning him through 180
, 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 (23-5A), start by turning him through
90
, so that his back faces to her left. His left shoulder will then be above her
symphysis, and his right shoulder above her sacrum (23-5B). With your first 180
turn (23-5B–C), bring his left shoulder under her sacrum. With your second second
turn (23-5C–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 (23-5D–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
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 23-5A with both arms extended, so you have to begin with a 90
turn,
followed by three 180
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 LØVSET’S MANOEUVRE FAILS TO DELIVER HIS SHOULDERS, 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, and is
better than letting him die.
LATER DIFFICULTIES DELIVERING A BREECH
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–Smellie–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–
SMELLIE–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 50mg 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. 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) (22.9). Ask
an assistant to pull down 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
foramen magnum. Or perforate his occiput. He should now deliver quite easily by the
Mauriceau–Smellie–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 HYDROCEPHALUS, see 23.6.
If she is brought in with HIS DEAD BODY PROTRUDING FROM HER
VULVA, 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. If it is not fully
dilated, hang a weight of 1 kg on his trunk. His head will usually mould and deliver
within 1hr. If this fails, do a craniotomy.
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—do a Caesarean section, 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 GA. 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 Løvset’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. Løvset’s manoeuvre and the Mauriceau–
Smellie–Veit manoeuvre should solve these problems.
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 (19-2). 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 <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 >20/1000, do external
version. In many district hospitals it is 50/1000.