What should be excluded in managing labor with vaginal breech: allowing passive second stage up to 90 minutes, early Artificial Rupture of Membranes (ARM), spontaneous delivery, or Cesarean Section (CS) if active second stage >60 minutes?

Management of Vaginal Breech Delivery

In the management of labour with a vaginal breech, allowing passive second stage up to 90 minutes should be excluded as it contradicts current evidence-based practice guidelines for safe breech delivery.

Appropriate Management Strategies for Vaginal Breech Delivery

Consideration of Early ARM

• Early artificial rupture of membranes (ARM) is an appropriate consideration in vaginal breech management
• While there is no objective proof that ARM is useful for treating protraction or arrest of dilatation in general labor 1, it may be necessary in breech presentations for specific reasons:
  • To apply fetal monitoring scalp electrodes
  • To insert an intrauterine pressure transducer if needed
  • To facilitate controlled descent of the breech

Allowing Spontaneous Delivery

• Allowing the breech to deliver spontaneously is a key principle in modern breech management
• Spontaneous or assisted breech delivery is acceptable, but fetal traction should be avoided 2
• Fetal manipulation should only be applied after spontaneous delivery to the level of the umbilicus 2
• This approach minimizes trauma to the fetus and reduces the risk of complications such as trapped head or nuchal arms

Considering Cesarean Section for Prolonged Active Second Stage

• Consider cesarean section if active second stage exceeds 60 minutes and delivery is not imminent 2
• This recommendation is evidence-based and helps prevent fetal compromise
• Prolonged active second stage is associated with increased risk of:
  • Fetal acidemia
  • Birth trauma
  • Neonatal morbidity

Why Passive Second Stage Up to 90 Minutes Should Be Excluded

The recommendation to allow a passive second stage up to 90 minutes in breech deliveries contradicts best practices for several reasons:

1. Prolonged second stage increases the risk of cephalopelvic disproportion (CPD), which is particularly dangerous in breech presentations 1

2. The frequency of CPD is considerably greater with a prolonged deceleration phase, making thorough cephalopelvimetric assessment imperative 1

3. A prolonged deceleration phase is a harbinger of second stage labor abnormalities and is frequently accompanied by failure of descent 1

4. If vaginal delivery occurs after prolonged second stage, it may result in complications such as shoulder dystocia and brachial plexus injury 1

5. The combination of a prolonged deceleration phase with any disorder of fetal descent makes safe vaginal delivery very unlikely 1

Algorithm for Safe Vaginal Breech Delivery

1. Pre-labor assessment:

   • Confirm type of breech presentation (frank or complete)
   • Estimate fetal weight (should be between 2500g and 4000g)
   • Assess fetal head attitude (should be flexed or neutral)
   • Evaluate maternal pelvis adequacy

2. First stage management:

   • Continuous electronic fetal heart monitoring
   • Consider early ARM if indicated
   • Avoid induction of labor (contraindicated in breech)
   • Oxytocin augmentation acceptable only for uterine dystocia

3. Second stage management:

   • Active pushing should commence only when breech has descended well into pelvis
   • If delivery not imminent after 60 minutes of active pushing, proceed to cesarean section
   • Ensure delivery takes place near an operating room with equipment and personnel available for emergency cesarean

4. Delivery technique:

   • Allow spontaneous delivery when possible
   • Avoid fetal traction
   • Apply fetal manipulation only after spontaneous delivery to umbilicus
   • Have experienced provider skilled in breech delivery present

Common Pitfalls to Avoid

• Allowing prolonged passive second stage increases risk of CPD and fetal compromise
• Total breech extraction is inappropriate for term singleton breech delivery 2
• Induction of labor is not recommended for breech presentation 2
• Failing to have an experienced provider present during delivery
• Not having immediate access to cesarean section capabilities
• Applying traction to the fetus during delivery

By following these evidence-based guidelines, providers can optimize outcomes for both mother and baby during vaginal breech deliveries while minimizing the risks associated with this challenging presentation.