Management of the Breech Presenting at the Introitus
Breech presentation occurs in 3-4 % of pregnancies at term. 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 patient presents in late active labor and the fetal breech is presenting at the introitus, it is unlikely that an abdominal delivery can be accomplished. In this circumstance, the surgical risk of cesarean delivery may cause equal or greater trauma than a vaginal delivery.
Maternal expulsive efforts alone should accomplish the delivery of the fetal umbilicus to the perineum. No traction should be applied, and 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) assists delivery of the legs. Once both legs are delivered, the fetus should be supported in the prone position with a dry towel wrapped around the fetal pelvis by the obstetrician or a skilled assistant. 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 ensure 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.
Preparations for potential head entrapment include calling anesthesia personnel 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 of the cervix, which are performed at the 2 and 10 o’clock location, with occasionally needing a third incision at the 6 o’clock position. The location of the incisions is important in order to decrease the risk of injury to the cervical blood vessels.
Breech vaginal delivery can be considered for a patient in advanced labor, even if there might be time to do a safe cesarean if the patient and fetus 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
Cunningham F, Leveno KJ, Bloom SL, et. Al; Breech Delivery. Williams Obstetrics, 25e New York, NY: McGraw-Hill; 2018.
Initial Approval May 2016; Reaffirmed September 2017; Revised March 2019. Reaffirmed September 2020
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