VAGINAL BREECH

This tutorial reviews intrapartum care for women with breech presentation. It will focus on the
practical aspects of vaginal breech delivery and on the complications, that might be encountered
during the procedure.
On completion of this tutorial, you will understand the methods used during vaginal breech delivery
to reduce maternal and perinatal morbidity. You will also have knowledge of techniques that will
assist you in your daily practice.
Learning objectives

When you have completed this tutorial you will be able to:
describe the types of breech presentation
recognize the risk factors for breech presentation
describe the techniques of vaginal breech delivery
describe the techniques for managing the complications of vaginal breech delivery
present a balanced argument for ad against vaginal breech delivery
counsel an antenatal patient with breech presentation of the fetus regarding the mode of
delivery
recognise the importance of a skills drill to gain experience of the manoeuvres necessary for
vaginal breech delivery.

OVERVIEW

Breech presentation may be idiopathic but can occur in increasing frequency in association with
some maternal conditions, such as:

multiparity
congenital uterine anomalies
fibroids
cephalopelvic disproportion
previous breech presentation
placenta praevia.

Breech presentation can also occur in some fetal conditions, such as:

preterm delivery
polyhydramnios
oligohydramnios
fetal macrosomia
multiple pregnancy
fetal anomalies anencephaly, hydrocephaly.

The incidence of breech presentation is approximately 20% at 28 weeks of gestation, 16% at 32

weeks of gestation and 34% at term. This is the reason breech presentation is more common in
preterm labour and why the majority of fetuses with breech presentation early in the third trimester
will turn spontaneously and be cephalic at term.
However, spontaneous version rates for nulliparous women with breech presentation at 36 weeks of
gestation are less than 10%.

TYPES OF BREECH PRESENTATION

There are four types of breech presentation. They are determined by the way in which the fetal legs
are flexed or extended, and these have implications for the birth.
See the next pages for more information on each type of presentation:
1.
2.
3.
4.

Frank/extended breech
Complete or flexed breech
Footling breech
Knee presentation

FRANK OR EXTENDED BREECH

This is the most common (65%) type of breech presentation and occurs most
frequently in primigravid women at term.
Extended breech is when the fetal thighs are flexed, but the legs are extended at
the knees and lie alongside the trunk, the feet being near the fetal head.

COMPLETE OR FLEXED BREECH

This is the least common variety of breech presentation (510%), occurring more
commonly in the multiparous woman. Flexed breech is when the fetus sits with
the thighs and knees flexed with the feet close to the buttocks.

FOOTLING BREECH AND KNEE PRESENTATION

Footling breech
This type of breech presentation may occur in 1040% of breech
presentations and is more likely to occur when the fetus is preterm.
Footling breech is when one or both feet present below the fetal
buttocks, with hips and knees extended.
Knee presentation
This is the least common type of breech presentation. This occurs when
one or both knees present below the fetal buttocks, with one or both
hips extended and the knees flexed.

UNFAVOURABLE FACTORS FOR VAGINAL BREECH

Factors regarded as unfavorable for vaginal breech birth include the following:

footling or kneeling breech presentation

large baby (usually defined as larger than 3800 g)
growth-restricted baby (usually defined as smaller than 2000 g)
hyperextended fetal neck in labour (diagnosed with ultrasound) 'star-gazing' fetus
other contraindications to vaginal birth (e.g. placenta praevia, fetal compromise)
clinically inadequate pelvis
lack of presence of a clinician trained in vaginal breech delivery
previous caesarean section.

Women with these clinical features should be counselled regarding the increased risk to themselves
and their babies of attempting vaginal breech birth, and they should be offered delivery by
caesarean section.

PROBLEMS WITH VAGINAL BREECH DELIVERY

Maternal problems

Trauma to the birth canal

Fetal problems

Head entrapment
Fetal neurologic condition (torticollis, palsy, paralysis)
Fetal joint dislocation (neck, shoulder, knee, etc)
Fracture of fetal long bones and soft tissue injury
Cord prolapse
Presentation

Risk of cord prolapse

Cephalic

0.4%

Frank breech

0.5%

Complete breech

5%

Incomplete/footling breeach

15%

KEY POINTS

When a breech presentation is diagnosed, you should keep in mind unusual (congenital
uterine malformation) or potentially serious conditions (placenta praevia)
In cases of preterm labour, you should beware of fetal presentation; it could be breech in
20% of cases
Frank breech is the most common type of breech presentation
Footling breech is the second most common type of breech; this has the highest risk of cord
prolapse
You should counsel the mother carefully regarding mode of delivery, especially if she is keen
for vaginal delivery; document the content of the discussion in the notes.

THE PLACE OF VAGINAL BREECH DELIVERY IN CURRENT OBSTETRIC PRACTICE

The Term Breech Trial (Hannah et al 2000), a multi-center randomised controlled trial across 121
centers in 26 countries, found that planned caesarean deliveries of breech babies were associated
with a reduced risk of perinatal morbidity and mortality compared to planned vaginal breech
deliveries.
The study findings, however, have been heavily criticised and the place of evidence-based medicine
for answering 'complex' phenomena questioned, i.e. those which incorporate complex steps and in
which human heterogeneity in skills is concerned (Kotaska 2004). There were also criticisms
regarding the appropriateness of applying the results to broader populations, appropriateness of
subgroup analyses in understanding this 'complex' phenomenon, lack of generalisability, the
inappropriateness of intention to treat analyses, the impossibility of masking to allocation and
justification of applying the result of one randomised trial in influencing the standard obstetric
practice of breech delivery.
Influenced mainly by the potential medico-legal implications for practitioners not adhering to the
best practices, the Term Breech Trial had an immediate and dramatic impact with rapid changes in
policies and clinical practice in managing breech presentation. Within two months of publication of
the Term Breech Trial, the overall caesarean rate increased from 50% to 80% in the Netherlands
(Rietberg et al 2005). Another follow-up survey of 80 participating centres from 23 countries found
that 92% had changes in clinical practice to plan ceasarean section for all term breech presentations
(Hogle et al 2003).
The rapid change in policies and practices following the trial led to the legitimate concern that there
will be loss of clinical skill in vaginal delivery of breech births, as well as significant public health
implications of unintended increases in adverse outcomes associated with additional caesarean
deliveries.
Nonetheless the technique of vaginal breech deliveries will remain integral component of obstetric
practice as:

caesarean section may be inadvisable or not feasible in many patients

many women will opt for vaginal breech delivery
there are still unresolved issues regarding the best practice of delivering preterm breech and
breech presentation in multiple pregnancies.

In this current situation, the best ways of gaining experience and maintaining skills in vaginal breech
deliveries for the clinicians are regular skills drill and simulation training exercises.

FOLLOWING ON FROM THE TERM BREECH TRIAL

In 2006, in response to the Term Breech Trial (TBT), Goffinet et al published the PREMODA study: a
multicentre descriptive study four-times larger than the TBT. Prospective data were collected from
8105 women in 174 centres in France and Belgium, using the same short-term combined outcome of
perinatal mortality or serious neonatal morbidity as the TBT. Contemporary practice in France and
Belgium involves a cautious, consistent level of care, which was not altered by the investigators. The
PREMODA study was descriptive, and the percentage of women attempting vaginal birth varied
between centres (47.889.0%). Overall, caesarean section was planned in 69% of cases and a trial of
labour (TOL) undertaken in 31% of cases, consistent with non-randomisation. Of 2526 women having
a TOL, 1796 (71%) delivered vaginally for an overall vaginal birth rate of 22.5%. Pre- or early-labour
ultrasound and continuous electronic fetal monitoring in labour were universal. Failure to progress
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for more than 2 hours in the first stage of labour occurred in 3.8% of labours, and an active second
stage longer than 60 minutes occurred in only 0.2% of cases. Only 0.6% of women planning
caesarean section eventually delivered vaginally, and all fetuses were breech at delivery. Although
not strictly comparable, the PREMODA outcomes contrast with those of the TBT. There was no
difference in perinatal mortality (0.08% versus 0.15%) or serious neonatal morbidity (1.6% versus
1.45%) between a TOL and planned caesarean section. The only difference in outcome was a 0.16%
incidence of five-minute Apgar score <4 in the TOL group versus 0.02% in the planned caesarean
section group. Eight-times larger than the low-perinatal-mortality subset of the TBT, the PREMODA
study provides a robust estimate of the risk of a cautious breech TOL in a modern, well-supported
obstetrical unit.
A Cochrane review of planned caesarean section for term breech deliveries reviewed three trials
involving 2396 women and concluded that planned caesarean section compared with planned
vaginal birth reduced perinatal or neonatal death as well as the composite outcome death or serious
neonatal morbidity, at the expense of somewhat increased maternal morbidity. In a subset with 2year follow up, infant medical problems were increased following planned caesarean section and no
difference in long-term neurodevelopmental delay or the outcome "death or neurodevelopmental
delay" was found, though the numbers were too small to exclude the possibility of an important
difference in either direction.

AVOIDING VAGINAL BREECH DELIVERY

One of the effective ways to reduce the incidence of vaginal breech deliveries is to offer wider
service for external cephalic version (ECV), which can reduce the caesarean section rate by almost
50%.
A Cochrane review has suggested that using ECV around 36 weeks of gestation or more increased
the chance that babies were born head-first and reduced the risk of having a caesarean section.
There were no clear differences in other outcomes such as the risk of babies dying.
For more information on ECV, see the StratOG Core Training tutorial on Principles of Antenatal Care.

KEY POINTS

The Term Breech Trial (TBT) had an immediate and dramatic impact, with rapid changes in
policies and clinical practice in managing breech presentation
There has been rapid attrition of the clinical skill in vaginal breech delivery and a rapid rise of
elective caesarean section to deliver breech babies
The findings of the PREMODA (2006) study contrast with the TBT trial; it provides an
estimate of the risk of a cautious breech trial of labour in a modern, well-supported
obstetrical unit; however, a Cochrane systematic review (2015) concluded that planned
caesarean section compared with planned vaginal birth reduced perinatal or neonatal death
as well as the composite outcome death or serious neonatal morbidity, at the expense of
somewhat increased maternal morbidity
It is likely that the current practice of offering elective caesarean section to women with
breech presentation will remain unchanged in the short term
It is extremely important to keep the skill level of medical and midwifery personnel for
breech vaginal delivery updated regularly by simulation practice
External cephalic version should be offered to every eligible woman with breech
presentation to reduce the risk of breech presentation at term.
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MANAGEMENT OF LABOUR AND DELIVERY FOR BREECH PRESENTATION

Intrapartum care for breech presentation is similar regardless of whether or not the breech
presentation has previously been diagnosed.
The finding of an 'undiagnosed breech' during labour is not a contraindication to vaginal breech
delivery; it is the experience and the competency of the attending obstetrician and the wishes of the
couple that usually determines the mode of delivery.
1. What would make you suspect breech presentation in labour?
2. How would you confirm the diagnosis?
3. How would you counsel the woman in labour with undiagnosed breech presentation
regarding the mode of delivery?

CONFIRMING THE DIAGNOSIS

1. In what circumstances can a breech presentation be missed on routine obstetric
examinations?
2. What could be done to confirm the diagnosis?

CONFIRMING THE DIAGNOSIS - MODEL ANSWER

1. In what circumstances, can a breech presentation be missed on routine obstetric
examinations?
Answer: Clinical examination findings may suggest breech presentation. On abdominal palpation, the
firm, round, ballotable fetal head will be detected at the fundus. The breech will be detected in the
lower abdomen and its smooth rounded nature may be mistaken for a vertex presentation. This is
particularly true in case of extended breech.
On vaginal examination, the absence of obvious sutures and fontanelles should alert the examiner to
the possibility of a breech presentation. The breech may be detected or fetal limbs may be felt.
During vaginal examination, face presentation may be confused with breech presentation. In breech
presentation, the anus and ischial tuberosities form a straight line. In face presentation, the mouth
and malar prominences form a triangle.
2. 2. What could be done to confirm the diagnosis?
Answer: An ultrasound scan (USS) is essential to confirm breech presentation. All cases of women
with preterm labour and women with preterm prelabour rupture of membranes (PPROM) should
have an USS to check for fetal presentation; fetal presentation should also be checked on USS in
women in labour at term if there is any doubt about the fetal presentation (especially with intact
membranes where vaginal examination may be difficult).
As part of the routine assessment of the pregnant woman, maternal and/or fetal risk factors for
breech presentation should be assessed. Following the diagnosis of breech presentation, relevant
obstetric or medical complications should be identified. Any issues identified should be taken into
consideration when counselling the woman about the safest and most appropriate method of
delivery.

MANAGEMENT OF THE FIRST STAGE OF LABOUR

1. How would you manage a woman attempting vaginal breech delivery with a suspicious CTG?
2. How would you manage a woman attempting vaginal breech delivery with poor progress in
labour?
Answer: Diagnosis of breech presentation for the first time during labour is not a contraindication
for vaginal breech birth, but individual cases should be assessed carefully before selection for vaginal
breech birth.
Induction of labour may be considered if individual circumstances are favourable and if the womanis
keen to try for vaginal breech delivery. Labour should be allowed to continue as long as there is
evidence of progressive cervical dilatation and descent of the presenting part without any evidence
of maternal or fetal compromise. Augmentation of labour is not generally recommended because
poor progress may be a sign of fetopelvic disproportion. Women should have a choice of analgesia
in labour, including epidural analgesia.
Senior midwifery, obstetric, anaesthetic and paediatric staff should be alerted to the possibility of a
vaginal breech delivery. An experienced obstetrician should be available to supervise labour and
delivery. One-to-one midwifery care should also be available.
If the membranes rupture spontaneously, vaginal examination is required immediately to exclude
umbilical cord prolapse. If the membranes do not rupture spontaneously, then amniotomy should
only be performed for standard obstetric indications.
Continuous electronic fetal monitoring is the mainstay for monitoring the fetus during labour. The
presence of meconium is an unreliable sign of fetal distress in breech presentation. Fetal blood
sampling from the fetal buttock is technically possible but generally not advised.
Generally speaking, vaginal breech delivery is a potentially complicated process demanding highly
skilled obstetricians and midwives and with potential for neonatal complications and medico-legal
implication. In well selected cases, vaginal deliveries can be attempted after proper counselling of
the couple and with appropriate documentation. However, in the presence of suspicious CTG and
poor progress in labour, there should be a low threshold for delivery of the baby by caesarean
section after proper counselling of the couple.

MANAGEMENT OF THE SECOND STAGE OF LABOUR AND VAGINAL BREECH DELIVERY

Basic principles:

avoid handling the breech

ensure adequate uterine activity and good maternal effort
avoid handling the umbilical cord
keep the sacrum anterior
delay active pushing until the breech has descended to the pelvic floor
delay placing the mother in the lithotomy position until the fetal anus is visible over the
posterior fourchette
avoid traction at all times.

Ideally, a senior obstetrician with experience of vaginal breech delivery should be available for the
management of the second stage of labour.
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The maternal bladder should be emptied and need for episiotomy considered. The breech should
descend spontaneously without traction and allowed to rotate spontaneously to a sacroanterior
position.
Active pushing should be delayed until the breech is distending the introitus. At this time, the
woman should be placed in the dorsal lithotomy position.
If there is any failure of descent then delivery by caesarean section should be considered.

DELIVERY OF THE LOWER LIMBS AND TRUNK

Maternal effort should expel the breech to the level of the umbilicus. The back will arch towards the
maternal symphysis pubis.
Care should be taken to avoid handling the umbilical cord as this might result in vasospasm. The
operator's hands should remain away from the breech unless the fetus is rotating away from a
sacroanterior position.
If the fetal legs are flexed, they will deliver spontaneously with further descent of the baby. If the
fetal legs are extended, the legs may be delivered by applying pressure with two fingers in the
popliteal fossa to flex the legs at the knee joint.
If the fetal legs are flexed, they will deliver spontaneously with further descent of the baby. If the
fetal legs are extended, the legs may be flexed one after another by applying gentle pressure
with two fingers in the popliteal fossa. The foot is then grasped to deliver the leg. Extreme care is
needed at this stage to avoid any injury to the fetus.

DELIVERY OF THE SHOULDERS AND ARMS

As the fetal trunk descends with maternal effort, the tip of the scapula of the anterior shoulder will
become visible. If the fetal arms are flexed, then they will deliver spontaneously.
The anterior arm should be delivered by splinting the humerus between two fingers. The other
shoulder should rotate spontaneously to allow similar delivery of the other arm.

If the fetal arms are extended or a nuchal arm is diagnosed, Lovset's manoeuvre should be used. A
nuchal arm is when one or both arms extend upwards behind the fetal neck and is usually the
consequence of inappropriate handling of the fetus during vaginal breech delivery.
Lovset's manoeuvre is not a routine part of a vaginal breech delivery. Gentle traction should be
applied using a femoralpelvic grip with the operator's thumbs resting on the lower fetal back,
parallel to the fetal spine.
While applying gentle downward traction, the fetus should be rotated towards the maternal
symphysis pubis through 180 allowing the posterior arm to be delivered by flexion at the elbow
joint. The grip should be maintained and the fetus should be rotated through 180 in the opposite
direction to deliver the other arm.
While applying gentle downward traction, the fetus should be rotated towards the maternal
symphysis pubis through 180 allowing the posterior shoulder to come anterior under the symphysis
pubis. The arm is then delivered by flexion at the elbow joint. The grip should be maintained and the
fetus should be rotated through 180 in the opposite direction to bring the other shoulder anterior
under the symphysis pubis to deliver the other arm.
The images below show Lovset's manoeuvre. Top: lateral flexion is exaggerated to facilitate descent
of the posterior shoulder beneath the promontory; with the back uppermost, the body is rotated
180 degrees. Bottom: the posterior shoulder has now been rotated anteriorly beneath the symphis
and can be hooked down; the body is then rotated 180 degrees and the other arm delivered the
same way.

Lovset's manoeuvre.

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If trunk rotation is unsuccessful ...

DELIVERY OF THE AFTERCOMING HEAD

After the delivery of the shoulders and arms, the baby should be allowed to descend further until
the nape of the neck is visible. Manoeuvres should now be attempted to deliver the aftercoming
head.
Gentle suprapubic pressure at this stage will promote entry of an well-flexed head in the pelvis. Any
attempt to deliver the head before the nape of the neck is visible will result in extension of the head;
this should be avoided.
The aftercoming head is delivered by Burns-Marshall technique or Mauriceau-Smellie-Viet (MSV)
manoeuvre. If none of these manouevres are successful, obstetric forceps should be used to deliver
the aftercoming head.

THE MAURICEAU-SMELLIE-VIET MANOEUVRE

The Mauriceau-Smellie-Viet (MSV) manoeuvre encourages flexion of the fetal head.
The fetus is placed in a horse-riding position on the inner aspect of the non-dominant forearm. Two
fingers of that hand should be placed over the malar prominences. Fingers should not be placed
inside the fetal mouth as this may be associated with jaw traction and subsequent dislocation or
even fracture.
The dominant hand should be placed over the fetal back with middle finger on the fetal occiput to
promote flexion and the index and ring fingers on each of the fetal shoulders to promote traction.
11

Both hands are used to promote flexion of the head. The fetal body is raised upward in an arc
completing delivery.
An assistant may apply suprapubic pressure to further promote flexion. The whole of the fetus is
delivered in a controlled manner with maternal contraction.

The MSV manoeuvre.

Note that the method of applying suprapubic pressure with a breech delivery is different to the
method used for shoulder dystocia. In the image above, note the difference in the position of the
hand that is aiming to flex the fetal head.

THE BURNS-MARSHALL METHOD

The baby should be allowed to hang until the nape of the

neck is visible so that its weight exerts gentle downwards
and backwards traction to promote flexion of the fetal
head.
The fetal trunk is then swept in a wide arc over the
maternal abdomen by grasping both the feet and
maintaining gentle traction; the aftercoming head is slowly
born in this process.

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APPLICATION OF FORCEPS

In up to 20% of vaginal breech deliveries,

obstetric forceps may be required to deliver the
fetal head. The head is generally in a direct
occipitoanterior position or no more than 15
left or right of the occipitoanterior position.
Forceps are indicated for the management of
vaginal breech delivery if the MSV manoeuvre
is unsuccessful. In general, forceps should be
considered if the head has not delivered within
23 minutes of attempting the MSV
manoeuvre.
An assistant should gently lift and support the
baby without undue traction. The baby can be
wrapped in a towel to keep it warm.
If available, Piper obstetric forceps should be
used. Piper obstetric forceps are specifically
designed for vaginal breech delivery. These are
long forceps and have an axis traction curve. If
these are not available then Kielland's forceps
should be the instrument of choice.
Alternatively, any other type of midcavity
obstetric forceps can be used. Wrigley's
obstetric forceps should not be used for vaginal
breech delivery.
The forceps should be applied in the same
manner as is used for cephalic presentation.
Delivery of the fetal head should be controlled
and slow; gentle downward traction should be
applied and upward traction should commence
when the fetal chin reaches the perineum. The need for an episiotomy should be considered if not
already performed.
Adapted from O'Grady JP, Gimovsky ML,
McIlhargie CJ. Operative Obstetrics.
Williams and Wilkins; 1995.

The main difficulty encountered in the use forceps during vaginal breech delivery is the application
of the blades. There may be insufficient room to place a hand inside the vagina in order to ensure
correct application of the instrument. However, if the forceps can be applied then delivery can
almost always be accomplished.

MANAGEMENT OF THE THIRD STAGE OF LABOUR AND VAGINAL BREECH DELIVERY

The third stage should be managed in the usual manner and the perineum should be assessed for
trauma. For all vaginal breech deliveries, a comprehensive note of the delivery and the manoeuvres
used to complete the delivery should be recorded.
Following vaginal breech delivery, the paediatric team should always assess the baby.
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INTERNAL PODALIC VERSION AND BREECH EXTRACTION

Breech extraction describes the emergency procedure that is undertaken in order to expedite
delivery with a breech presentation.
Rarely, it may be required when there is severe fetal distress during the second stage of labour with
a breech presentation.
It is occasionally required during delivery of multiple pregnancy when there are problems with the
delivery of a second twin because of fetal distress or an abnormal fetal lie. In these circumstances,
internal podalic version will be required prior to breech extraction. However, as the operator's hand
must be introduced within the uterine cavity, there are greater risks of maternal and fetal injury; it
can also result in sudden severe maternal shock if not performed under adequate analgesia or
anaesthesia.

TECHNIQUE

The operator's hand is placed into the uterus and a fetal foot should be identified through intact
membranes by recognising the heel. The fetal foot should then be grasped and pulled gently and
continuously into the birth canal. If possible both fetal feet should be identified and grasped.
Internal podalic version is easiest when there is a transverse lie with the fetal back superior or
posterior. If the fetal back is inferior or if the limbs are not immediately palpable, then ultrasound
may be used to locate the fetal limbs.
As it is an emergency manoeuvre, the rest of the breech delivery is undertaken with a combination
of the techniques described earlier to deliver the lower limbs and trunks, shoulder and arms and the
aftercoming head. There is a high risk of injury to the mother and fetus and a contemporaneous
documentation and de-briefing of the couple is essential.

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KEY POINTS
First stage of labour:

Breech presentation is associated with higher rates of perinatal morbidity and mortality
An experienced obstetrician should be available to supervise labour and delivery
Epidural anaesthesia should be offered but it is not essential for vaginal breech delivery
In general, augmentation of labour with oxytocin is not recommended for women with a
breech presentation
Continuous electronic fetal monitoring should be used to monitor the fetus during labour.

Second stage of labour:

The breech should descend spontaneously without traction and active pushing should be
delayed until the breech is distending the introitus
Lovset's manoeuvre is not a routine part of a vaginal breech delivery
In up to 20% of vaginal breech deliveries, obstetric forceps may be required to deliver the
fetal head
A nuchal arm is usually the consequence of inappropriate handling of the fetus during
vaginal breech delivery
Fetal head entrapment during vaginal breech delivery is an obstetric emergency that
requires prompt action using some of the manoeuvres that are used during the
management of shoulder dystocia.
Top of Form

COMPLICATIONS OF VAGINAL BREECH DELIVERY

The following section discusses complications of vaginal breech delivery:

fetal head entrapment

incising the cervix (Duhrssen's incisions)
symphysiotomy
caesarean section.

FETAL HEAD ENTRAPMENT

Fetal head entrapment during vaginal breech delivery is an obstetric emergency.
It is typically associated with preterm vaginal breech delivery when the fetal buttocks and trunk pass
through an incompletely dilated cervix. The uterus subsequently contracts and clamps tightly around
the fetal head.
Fetal head entrapment during vaginal breech delivery may also be associated with undiagnosed
hydrocephalus. In this rare situation, decompression of the fetal ventricles or cephalocentesis may
be required.
Management of fetal head entrapment:

Call for help inform anaesthetist, paediatric staff, senior midwife and maternity operating
theatre staff
Perform McRobert's manoeuvre as per shoulder dystocia
Apply suprapubic pressure as per shoulder dystocia
15

MSV manoeuvre should be reattempted in conjunction with suprapubic pressure

Rotate baby to sacrotransverse position
Administer tocolysis; consider 100 micrograms intravenous glyceryl trinitrate (GTN)
Attempt forceps delivery
Surgical management.

Emergency surgical management of fetal head entrapment includes:

cervical incisions
symphysiotomy
caesarean section.

INCISING THE CERVIX - DUHRSSEN'S INCISIONS

If the head fails to deliver despite additional
manoeuvres, then consideration should be
made for performing cervical incisions. These
are known as Duhrssen's incisions.
Cervical incisions should be made at 2 o'clock
and 10 o'clock to avoid lateral extension of the
incision involving the descending cervical
vessels. An additional incision at 6 oclock
position is rarely needed.
The main difficulties when performing cervical
incisions for head entrapment at breech
delivery are achieving adequate analgesia and
exposure. There is a significant risk of
haemorrhage; the cervical incision may extend
upwards within the broad ligament causing
broad ligament haematoma.

SYMPHYSIOTOMY
Symphysiotomy is a rarely performed procedure which may be worth considering in managing fetal
head entrapment as a desparate measure.
However, there is little place for this in modern obstetric practice as the experience is limited and
subsequent discomfort and complications of the mother from the procedure are significant.

CAESAREAN SECTION
If the baby is still alive, an alternative to cervical incision and symphysiotmy is delivery by caesarean
section.
The baby will need to be supported and pushed up from below.

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KEY POINTS

An essential pre-requisite for vaginal breech delivery is the presence of medical/midwifery

personnel competent in vaginal breech delivery and managing its complications
Teamwork within the medical, midwifery, anaesthetic and neonatal team is of utmost
importance
Leadership and clear communication is essential to manage the complications that might
arise in vaginal breech delivery
Documentation must be contemporaneous and detailed
Senior medical personnel need to be involved in vaginal breech delivery.

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