What is the recommended head position during a vaginal breech delivery in a supine position?

Vaginal Breech Delivery Head Management in Supine Position

During a vaginal breech delivery in the supine position, you should maintain the head in a flexed position to facilitate safe delivery of the aftercoming head. 1

Proper Technique for Head Delivery in Vaginal Breech

When managing the delivery of the fetal head during a vaginal breech delivery in the supine position, the following sequential approach is recommended:

1. Maintain head flexion: This is critical to ensure the smallest diameter of the fetal head presents to the maternal pelvis
2. Use suprapubic pressure: An assistant should apply suprapubic pressure to promote head flexion and engagement 2
3. Avoid hyperextension: Do not hyperextend the baby over the maternal abdomen as this can increase risk of trauma

Key Maneuvers for Head Delivery

After the shoulders and arms are delivered:

• Allow the fetus to hang by its own weight briefly to facilitate natural descent
• Apply gentle downward traction until the nape of the neck becomes visible
• Rotate the sacrum to anterior position if not already there
• Use the Mauriceau-Smellie-Veit maneuver to maintain head flexion while applying controlled delivery pressure

Managing the Complete Delivery Process

The vaginal breech delivery should follow this algorithmic approach:

1. Proper patient selection: Ensure estimated fetal weight is between 2500g and 4000g 2
2. Continuous fetal monitoring: Especially mandatory during second stage 2
3. Allow passive descent: Permit up to 90 minutes for passive descent before active pushing 2
4. Limit active pushing: If delivery is not imminent after 60 minutes of active pushing, consider cesarean section 2
5. Proper arm delivery: When shoulders are visible, sweep the arms around to the front if needed using Løvset or Bickenbach maneuvers 2
6. Head delivery: Maintain flexion using suprapubic pressure and appropriate maneuvers 2

Avoiding Common Pitfalls

• Do not apply excessive traction: This increases risk of brachial plexus injury and cervical spine injury
• Avoid fundal pressure: This can worsen impaction and increase maternal and fetal complications
• Do not attempt 180-degree rotation of the fetal head: This can cause cervical spine injury
• Avoid hyperextension of the fetal head: This increases risk of spinal cord injury

Expert Presence and Preparation

• An experienced obstetrician-gynecologist comfortable with vaginal breech delivery should be present 2
• A healthcare professional skilled in neonatal resuscitation should be in attendance 2
• Delivery should take place in or near an operating room with equipment and personnel available for emergency cesarean section 2

Alternative Positions to Consider

Recent evidence suggests that the all-fours maternal position may be comparable to supine position regarding neonatal safety and potentially offers advantages:

• 51.4% of deliveries in all-fours position occurred without obstetric intervention 3
• No significant differences in APGAR scores or NICU transfers between all-fours and supine positions 3
• May be useful for emergency management by less experienced attendants 3

Regardless of chosen position, maintaining head flexion remains the critical principle for safe delivery of the aftercoming head in vaginal breech birth.