Breech Presentation

Lucy Pettit

Aims and Objectives

At the end of the session, we should be able to: - Diagnose a breech presentation Carry out a breech delivery Be familiar with the manoeuvres if

assistance is required

Incidence

  3-4% of fetus present by breech at term 7% at 32 weeks 25% at 28 weeks

20% diagnosed initially in labour

Causes / Risk Factors

Primigravida Uterine anomalies Uterine fibroids Pelvic anatomy Fetal anomalies Multiple pregnancy Preterm labour Oligohydraminos / polyhydramnios Grand multiparity Fetal death

External Cephalic Version

Best evidence states that E C V should be offered late in pregnancy

Success rate increased with: multiparity adequate liquor station of breech above the pelvic brim

Diagnosing a Breech

Palpation: The fetal head can be palpated at uterine

fundus

Auscultation: The fetal heart sounds may be heard above

umbilicus

Types of Breech

Frank Complete Footling

Vaginal Examination

extended (frank) presentation: The ischial tuberosities, sacrum anus and/or

genitals may be palpated. In addition, there may be meconium staining of the examiner’s fingers

complete presentation: The feet of the fetus may be palpated with the

buttocks

Emergency Care

Call for help – midwifery colleagues/8000 Support & explanations for parents Take blood for group/hold, FBC Monitor fetal heart Monitor maternal vital signs Prepare IV Normal Saline – cannulation 16g Transfer to theatre – if not Prepare for vaginal delivery

Vaginal Breech Birth in Hospital Explain procedure to patient Legs in lithotomy Empty bladder Confirm full dilatation/presentation/station Infiltrate perineum with 10mls Lignocaine1% Consider episiotomy when presenting part is

on the perineum Perform necessary manoeuvres for the

delivery of breech Record times of procedures / manoeuvres,

designate a scribe

Breech Delivery

The essence of the vaginal breech delivery is allowing as much spontaneous delivery by uterine action and

maternal effort as possible

Operator intervention should be limited to the manoeuvres.

Nuchal arms are present in 0-5% of vaginal breech deliveries and in 9% of breech extractions.

Breech Delivery

The cervix should be fully dilated and the fetal anus visible on the perineum for active second stage.

Breech Delivery

The woman should be in lithotomy position.

Breech Delivery

Delivery of the breech should be ‘hands off’

Legs and abdomen are born spontaneously.

Breech Delivery

Ensure that the fetal back rotates uppermost by carefully grasping the fetal pelvis with fingers & thumbs

Breech Delivery

The fetus should be allowed to hang once the legs and abdomen have emerged until the wings of the scapula are seen.

Lovset’s Manoeuvre

Grasp the fetus around the bony pelvis with the thumbs across the sacrum.

The fetal back should then be turned through 180 degrees until the posterior arm comes to lie anteriorly…….

Lovset’s Manoeuvre

The elbow will appear below the symphysis pubis and the arm is delivered by sweeping it across the fetal body.

The manoeuvre is repeated in reverse to deliver the other arm.

Breech Delivery

Allow the fetus to hang from the vulva until the nape of the neck is visible.

Then carry out Mauriceau-Smellie-Veit manoeuvre

Emergency ChecklistEmergency Checklist Vaginal Breech Delivery

Bradma

Procedure Date________________

Emergency Bell

8000 obstetric emergency call made/ Paediatrician called

Notify theatre of potential emergency LSCS

Delivery trolley with Wrigley/NB forceps

Commence CTG tracing

IV cannula inserted

Mother in left lateral or lithotomy

Maternal pushing when fully

Descent of fetus ‘hands off’

Evaluate for episiotomy when fetal anus at fourchette

Deliver legs if extended by flexing the fetal knees

Rotate to keep back anterior

Any contact with fetus only with hands on fetal pelvis (avoid soft abdomen)

When scapulae visible spontaneous delivery of arms

Lovset’s manoeuvre (if necessary)

Support trunk (fetus along dorsal aspect practitioner arm)

Burns-Marshall or Mauriceau-Smellie-Veit manoeuvre to

deliver head slowly

Delivery time

Cord blood sample for Ph/lactate

Third stage by active management

Documentation Photocopy this checklist and place in patient’s notes with patient label on top of page. Use as reference for more detailed clinical notes. Remember to sign the copy for the clinical notes. Please wipe clean checklist once copied and return to delivery room

Times …………….

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Names of practitioners

present