What are the prerequisites for a planned vaginal breech delivery?

Prerequisites for a Planned Vaginal Breech Delivery

For a planned vaginal breech delivery to be considered safe, the fetus must be in a frank or complete breech presentation with a flexed or neutral head attitude (not extended/star gazing), have an estimated fetal weight between 2500g and 4000g, and the mother should have an adequate pelvis. 1

Essential Prerequisites

Fetal Factors

• Type of breech presentation:

  • ✅ Frank or complete breech only
  • ❌ Footling breech is contraindicated 1
  • ❌ Any presentation other than frank or complete breech is contraindicated 1

• Fetal head position:

  • ✅ Flexed or neutral head attitude required
  • ❌ Hyperextended head (star gazing) is contraindicated 1, 2
  • Maintaining head flexion is critical to ensure the smallest diameter of the fetal head presents to the maternal pelvis 3

• Estimated fetal weight:

  • ✅ Between 2500g and 4000g 1
  • ❌ <2500g or >4000g are contraindicated 1, 2

Maternal Factors

• ✅ Clinically adequate maternal pelvis 1
• ✅ No contraindication to vaginal delivery 1

Additional Contraindications to Vaginal Breech Delivery

• ❌ Cord presentation 1
• ❌ Fetal growth restriction 1
• ❌ Fetal anomaly incompatible with vaginal delivery 1

Important Considerations for Management

Pre-delivery Assessment

• Pre-labor ultrasound should be performed to:
  • Confirm type of breech presentation
  • Assess fetal growth and estimated weight
  • Evaluate fetal head attitude 1

Labor Management

• Clinical pelvic examination should be performed to rule out pathological pelvic contraction 1
• Continuous electronic fetal heart monitoring is preferable in first stage and mandatory in second stage 1
• Induction of labor is not recommended for breech presentation 1

Delivery Setting

• Delivery should take place in or near an operating room with equipment and personnel available for emergency cesarean section 1
• An experienced obstetrician-gynecologist comfortable with vaginal breech delivery should be present 1
• A healthcare professional skilled in neonatal resuscitation should be in attendance 1

Common Pitfalls to Avoid

• Attempting vaginal delivery with a footling breech presentation increases risk of cord prolapse and fetal trauma
• Failure to identify hyperextended fetal head before labor can lead to significant complications
• Inadequate assessment of fetal weight (both underestimation and overestimation) can lead to poor outcomes
• Proceeding with vaginal delivery without appropriate facilities for emergency cesarean section

While some older literature suggests that approximately 40% of breech presentations could be delivered vaginally without endangering neonatal outcome 4, careful selection of appropriate candidates based on the prerequisites above is essential to minimize risks of perinatal morbidity and mortality.