Intrapartum management of Breech presentation

Dr. (Mrs.) Vandana BAGRI BUCKTOWARMinistry of Health and Quality of Life

MAURITIUS

The place of vaginal breech delivery in current obstetric practice-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;

The place of vaginal breech delivery in current obstetric practice-KEY POINTS contd.

• 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.

The technique of vaginal breech deliveries will remain integral component of obstetric practice as:caesarean section may be inadvisable or not feasible in many patientsmany women will opt for vaginal breech deliverythere are still unresolved issues regarding the best practice of

delivering preterm breech and breech presentation in multiple pregnancies.

MANAGEMENT

CONFIRMATION

• 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. 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 woman is 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 feto–pelvic 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.

ANSWER CONTD.• 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 (NA in our setup) 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.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 sacro–anterior 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 sacro–anterior 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.

• 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-Lovset's manoeuvre.

• 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 femoral–pelvic 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.

• The images 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.

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.

• 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.

• 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.

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.

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.

Internal podalic version and breech extraction-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.

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.

Key points

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.

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•MSV manoeuvre should be reattempted in conjunction with suprapubic pressure•Rotate baby to sacro–transverse position•Administer tocolysis; consider 100 micrograms intravenous glyceryl trinitrate (GTN)•Attempt forceps delivery•Surgical management.

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.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 o’clock 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.

•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.

Key points

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