What are the guidelines for managing a breech delivery?

Guidelines for Managing Breech Delivery

External cephalic version (ECV) should be attempted for all women with breech presentation at term to reduce the need for cesarean section, followed by planned cesarean delivery if ECV is unsuccessful or contraindicated. 1, 2

Diagnosis and Initial Assessment

• Breech presentation occurs in 3-6% of pregnancies at term 3
• Confirm breech presentation via ultrasound to determine:
  • Type of breech (frank, complete, or footling)
  • Estimated fetal weight
  • Amniotic fluid volume
  • Placental location
  • Fetal anomalies

Management Algorithm

1. External Cephalic Version (ECV)

• Timing: Should be performed from 36 weeks gestation 2
• Success factors:
  • Higher success rates in multiparous women 2
  • Lower success rates in obese women 2
  • Average success rate >45% 3

ECV Procedure:

• Perform cardiotocography before the procedure 2
• Use parenteral tocolysis (β-mimetics or atosiban) to increase success rate 2
• Most institutions perform 1-3 attempts 3
• Monitor fetal heart rate during and for 30 minutes after the procedure 2
• Administer Rh immunoglobulin for Rh-negative women 2

Contraindications to ECV:

• Oligohydramnios (most consistently cited contraindication) 4
• Need for immediate delivery
• Abnormal fetal heart rate pattern
• Multiple gestation
• Uterine anomalies

2. If ECV Fails or is Contraindicated:

Option A: Planned Cesarean Section

• Currently the most common approach in many countries
• Reduces risks associated with breech vaginal delivery
• Schedule at 39 weeks for uncomplicated pregnancies

Option B: Vaginal Breech Delivery (Selected Cases)

• Requires specific expertise and experience
• Strict selection criteria needed

Criteria for Considering Vaginal Breech Delivery:

• Frank or complete breech (not footling)
• Estimated fetal weight 2500-3800g
• Flexed fetal head
• Adequate maternal pelvis confirmed by clinical examination
• No fetal anomalies
• Experienced provider available

Techniques for Managing Impacted Fetal Head During Cesarean:

If encountering an impacted fetal head during cesarean delivery:

1. Consider uterine relaxation (tocolysis) 5
2. Manual vaginal disimpaction (vaginal push method) 5
3. Reverse breech extraction - grasping one or both feet and applying traction toward the woman's feet to deliver legs and abdomen 5
4. Patwardhan method - a modification of reverse breech extraction where arms are delivered first 5

Complications and Risks

ECV Complications:

• Transient fetal heart rate abnormalities (most common) 2
• Emergency cesarean section (rare)
• Placental abruption (rare)
• Fetomaternal hemorrhage (rare, <0.1%) 2

Vaginal Breech Delivery Complications:

• Head entrapment
• Birth trauma
• Cord prolapse
• Asphyxia

Key Points for Delivery Management

• Maintain head flexion during vaginal breech delivery to ensure the smallest diameter of the fetal head presents to the maternal pelvis 6
• Continuous fetal monitoring during labor is essential
• Avoid forceful manipulation of the fetus
• Be prepared for emergency cesarean delivery if complications arise
• Ensure neonatal resuscitation team is present at delivery

Alternative Methods

• Acupuncture, moxibustion, and postural methods are not effective in reducing breech presentation at birth and are not recommended 2

Institutional Preparedness

• Hospitals managing breech deliveries should have protocols in place
• Regular simulation training for managing breech deliveries and complications
• Immediate access to operating room for emergency cesarean section 2