Breech Presentation

Breech presentations occur in 3 to 4 percent of term pregnancies and are associated with a morbidity rate three to four times greater than that of cephalad presentations. Breech presentations most frequently occur in premature infants, since final rotation in the pelvis may not have occurred. The major concern in breech deliveries is head entrapment. In a normal cephalic delivery, the larger head dilates the cervical canal, thus ensuring that the rest of the infant follows. With breech deliveries, however, the head emerges last and then may become trapped by an incompletely dilated cervix ( Fig, 1.0.3.-2).

FIG. 103-2. Management of the vaginal breech delivery. A. The Pinard maneuver. The operator's hand is placed behind the fetal thigh, putting gentle pressure at the knee and allowing delivery of the leg. B. A similar maneuver of the opposite leg. C. The feet are grasped with the thumb and third finger over the lateral malleolus and the second finger is placed between the two ankles. D. With maternal expulsive efforts, the breech is delivered to the level of the umbilicus. The sacrum should be kept anterior. E. Again, with maternal expulsive efforts, the infant is delivered to the level of the clavicles, keeping the sacrum anterior. Excessive outward traction by the operator will frequently result in the nuchal arms. F. The fetus is rotated 90° allowing visualization of the now anterior right arm. G. The arm is well visualized and a single digit is used to deliver it. Delivery of the opposite arm is accomplished by rotating the fetus 180° in a clockwise direction and repeating the maneuver. H. Delivery of the fetal vertex is accomplished by placing the operator's fingers over the maxillary processes of the fetus, keeping the body parallel to the floor. The body should never be lifted above parallel to prevent hyperextension of the neck. An assistant applies suprapubic pressure, aiding flexion of the fetal head and accomplishing delivery.

Breech presentation is associated with a greater incidence of fetal distress and umbilical cord prolapse. Breech presentations may be classified as frank, complete, incomplete, or footling. The frank breech and the complete breech presentation serve as a dilating wedge nearly as well as the fetal head, and delivery may proceed in an uncomplicated fashion. Footling and incomplete breech positions are not safe for vaginal delivery. The main point in a frank or complete breech presentation is to allow the delivery to progress spontaneously. This lets the presenting portion of the fetus dilate the cervix maximally prior to the presentation of the fetal head. It is recommended that the examiner refrain from touching the fetus until the scapulae are visualized. Then the infant may be gently supported by wrapping a towel around its lower half. The infant is then gently rotated until one arm emerges and then rotated the opposite way to allow delivery of the other arm. Do not pull on the fetus, as this may put pressure on the head within the pelvis or entrap the extended fetal arm.

Footling and incomplete breech positions are not considered safe for vaginal delivery because of the possibility of cord prolapse or incomplete dilatation of the cervix.

In any breech delivery, immediate obstetric consultation should be requested.

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