What are the pitfalls in managing breech presentations?

Pitfalls in Breech Management

Critical Technical Pitfalls During Delivery

The most dangerous pitfall in breech management is improper execution of disimpaction techniques during cesarean delivery, particularly misplaced digital pressure that causes fetal head hyperextension rather than flexion, compounding impaction and increasing risk of skull fracture and neurological injury. 1

Disimpaction Technique Errors

• Inadequate hand positioning during vaginal "push" technique: Using only 2-3 fingers instead of the full hand to elevate the fetal head is less effective and may increase risk of fetal trauma, including skull fractures. 1

• Causing inadvertent hyperextension: Misplaced pressure during vaginal disimpaction can lead to inadequate flexion or unintended hyperextension of the fetal head, rendering the maneuver ineffective or counterproductive. 1

• Lack of standardized technique: Most studies fail to report specific details of how disimpaction techniques are performed, and most clinicians lack formal training or competence assessment in these procedures. 1

• Premature or excessive traction: During reverse breech extraction, applying fetal traction before spontaneous delivery to the level of the umbilicus increases risk of injury. 2

Selection and Timing Pitfalls

Inappropriate Case Selection for Vaginal Delivery

• Ignoring absolute contraindications: Proceeding with vaginal delivery despite cord presentation, fetal growth restriction, macrosomia, non-frank/non-complete breech presentations, deflexed fetal head, or clinically inadequate pelvis. 2

• Inadequate ultrasound assessment: Failing to perform pre-labor ultrasound to assess breech type, fetal weight, and head attitude—if ultrasound unavailable, cesarean section is recommended. 2

• Weight estimation errors: Attempting vaginal delivery outside the 2500-4000g range significantly increases perinatal risk. 2

Timing and Preparation Failures

• Inadequate preparation: Failure to have appropriate equipment, multidisciplinary team, and operating room immediately available for emergency cesarean section. 3

• Delayed decision-making: Hesitation in cases of true fetal distress with breech presentation results in worse neonatal outcomes. 3

• Failure to rehearse emergency protocols: Not having a practiced plan for trapped after-coming head or irreducible nuchal arms (symphysiotomy or emergency abdominal rescue can be life-saving). 2

Labor Management Pitfalls

Intrapartum Monitoring Failures

• Inadequate fetal monitoring: Not using continuous electronic fetal heart monitoring in first stage, or failing to use mandatory monitoring in second stage. 2

• Missing cord prolapse: Not performing immediate vaginal examination when membranes rupture to rule out prolapsed cord. 2

• Allowing prolonged second stage: Permitting active pushing beyond 60 minutes without imminent delivery, or passive second stage beyond 90 minutes. 2

Labor Augmentation Errors

• Inappropriate induction: Attempting labor induction for breech presentation is not recommended and increases complications. 2

• Failure to recognize inadequate progress: Not proceeding to cesarean section when adequate progress in labor is absent—good progress is the best indicator of adequate fetal-pelvic proportions. 2

Counseling and Consent Pitfalls

Information Gaps

• Not offering external cephalic version (ECV): Approximately one-third of potentially suitable women are not made aware of ECV as an option, missing opportunity to reduce breech presentations and cesarean rates. 4, 5

• Incomplete risk disclosure: Failing to inform women that vaginal breech delivery carries approximately 2 per 1000 perinatal mortality and 2% serious short-term neonatal morbidity with careful case selection. 2

• Ignoring long-term outcomes: Not discussing that long-term neurological infant outcomes do not differ by planned mode of delivery, even in presence of serious short-term neonatal morbidity. 2

Documentation Failures

• Poor communication: Not documenting the consent discussion and chosen plan, or failing to communicate it clearly to labor-room staff. 2

• Absence of written protocols: Hospitals offering trial of labor without written protocols for eligibility and intrapartum management. 2

Provider Competency Pitfalls

Skill Deficits

• Inadequate training: The health care provider must possess requisite skills and experience—an experienced obstetrician comfortable with vaginal breech delivery should supervise trainees. 2

• Attempting total breech extraction: This technique is inappropriate for term singleton breech delivery and increases complications. 2

• Improper delivery technique: Not waiting for spontaneous delivery to umbilicus level before applying any fetal manipulation, or using excessive traction. 2

Emergency Management Gaps

• Inability to manage complications: Not being proficient in Løvset or Bickenbach maneuvers for nuchal arms, or Mauriceau-Smellie-Veit maneuver and Piper forceps for head delivery. 2

• Lack of neonatal resuscitation readiness: Not having a health care professional skilled in neonatal resuscitation present at delivery. 2

Maternal Risk Underestimation

Long-term Maternal Complications

• Underestimating cesarean risks: Chronic wound pain occurs in 15.4% at 3-6 months postpartum; subsequent pregnancies face higher risk of placenta previa, accreta (22 per 10,000 uterine ruptures), venous thromboembolism (2.6 per 1000), and secondary infertility (up to 43%). 3

• Not considering future pregnancies: Pregnancies after cesarean delivery are at higher risk of uterine rupture, placenta accreta spectrum disorders, and hysterectomy. 5

Common Clinical Misconceptions

• Assuming all nulliparous women need cesarean: Nulliparity alone is not a contraindication to planned vaginal delivery with appropriate selection criteria. 5

• Routine pelvimetry requirement: Radiologic pelvimetry is not necessary for safe trial of labor—good progress in labor is the best indicator of adequate fetal-pelvic proportions. 2

• Universal cesarean policy: A universal policy of cesarean delivery for all breech presentations leads to unnecessary maternal complications without benefit to fetus or newborn—approximately 40% could be delivered vaginally safely. 6