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Management of the Breech Presenting at the Introitus

5/4/2016 - Joseph E. Peterson, MD

Mentor: Julie DeCesare, MD

Editor:  Ronald T. Burkman, MD

Breech presentation at term occurs in 3-4 % of pregnancies. Frank breech accounts for over 50% of breech presentations. Factors predisposing to persistent breech presentation at term include anything that can distort the normal relationship of the fetal lie to the longitudinal axis of the uterus, including congenital or acquired uterine anomalies, fetal anomalies, abnormalities of amniotic fluid volume, and abnormalities of placentation. The majority of term breech presentations are managed with Cesarean delivery. However, if the fetal breech is at the introitus, it is unlikely that an abdominal delivery can be accomplished, particularly if the patient is in very active labor and the presentation is either a frank or a complete breech.

The patient and fetus must meet criteria for safe breech vaginal delivery. These criteria include:

  • Lack of uterine or fetal anomalies
  • Estimated fetal weight between 2500-4000g
  • Frank or complete (not footling) presentation
  • Obstetrician with appropriate training and experience

Patience is important as maternal expulsive efforts alone should accomplish the delivery of the fetal umbilicus to the perineum. Only at this point should the obstetrician assist the delivery. The Pinard maneuver, (pressure in the popliteal space of the knee, which results in external rotation of the thigh and flexion of the knee) accomplishes delivery of the legs. Once both legs are delivered, the fetus should be supported in the prone position. A dry towel wrapped around the fetal pelvis by the obstetrician or a skilled assistant can facilitate this. During the delivery, the obstetrician’s fingers should be on bony parts such as the pelvic bones or spine as opposed to soft tissues.

Once both scapulae have passed through the introitus, one arm at a time is delivered using the Lovset maneuver (splinting the humerus and sweeping the arm downward across the fetal thorax which should be rotated so the shoulder of the arm being delivered is anterior). The fetus is then rotated 180 degrees to accomplish delivery of the other arm in a similar fashion.

Spontaneous delivery of the fetal head may occur, but efforts should be made to insure that flexion is maintained throughout. This may be accomplished by a single obstetrician using the Mauriceau-Smellie-Veit maneuver (fetus supported on the forearm with the middle and index fingers on the fetal maxillae and the other hand applying pressure to the fetal occiput) or with an assistant applying suprapubic pressure.

Several important things must be in place to manage potential head entrapment. Anesthesia personnel should be present to provide maternal analgesia or anesthesia and uterine relaxation. Piper Forceps should be available. The obstetrician should be familiar with the technique of performing Duhrssen’s incisions (incisions through the cervix to relieve soft tissue entrapment).

Replacement of a footling breech into the uterine cavity can be considered to complete a cesarean delivery, particularly if the estimated fetal weight is less than 1500 g and the trunk has not traversed the cervix and is still in the uterine cavity.

Further reading:

Mode of term singleton breech delivery. ACOG Committee Opinion No. 340. American College of Obstetricians and Gynecologists. Obstet Gynecol 2006;108:235–7.

Cunningham, F. Gary, et al. "Breech Delivery." Williams Obstetrics, Twenty-Fourth Edition. Eds. F. Gary Cunningham, et al. New York, NY: McGraw-Hill, 2013.

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