How do you deliver a breech baby?

Delivery of Breech Baby

For term breech presentation, planned cesarean section is the recommended delivery method, as it significantly reduces perinatal mortality and serious neonatal morbidity compared to planned vaginal delivery. 1, 2

Primary Recommendation

Cesarean delivery should be the standard approach for breech presentation at term because:

• Perinatal mortality is reduced by approximately 70% (RR 0.29,95% CI 0.10-0.86) with planned cesarean section compared to planned vaginal delivery 2
• Serious neonatal morbidity is reduced by 67% (RR 0.33,95% CI 0.19-0.56) with planned cesarean section 2
• Birth trauma risk is 4 times higher with vaginal delivery (RR 4.12,95% CI 2.46-6.89) 3
• Low Apgar scores (<7 at 5 minutes) are 3 times more common with vaginal delivery (RR 3.33,95% CI 1.95-5.67) 3

When Vaginal Breech Delivery May Be Considered

Vaginal delivery can only be considered when ALL of the following strict criteria are met 4:

• Frank breech presentation only (not footling or complete breech) 4
• Estimated fetal weight between 2500-3500 grams 4
• Adequate pelvimetry with no hyperextended fetal head 4
• Maternal weight under 90 kg 4
• Provider has appropriate expertise in vaginal breech delivery 5
• Continuous fetal monitoring capability available 4
• Immediate access to emergency cesarean section 5
• Normal progression of labor with no evidence of fetal hypoxia 4

Important caveat: Even when attempting planned vaginal delivery, the conversion rate to emergency cesarean section ranges from 16-51% (median 41.8%), meaning nearly half of planned vaginal deliveries will require emergency cesarean anyway 6

Breech Extraction Technique During Cesarean Delivery

When performing cesarean delivery for breech or encountering an impacted fetal head, use the Reverse Breech Extraction (Pull Technique) 1:

1. Grasp one or both fetal feet 1
2. Apply traction toward the woman's feet to deliver the legs and abdomen 1
3. Rotate the body in the midline to deliver each arm in turn 1
4. Apply traction toward the woman's head to deliver the baby's head 1

Alternative: Patwardhan Method

The Patwardhan Method is a modification where an assistant introduces their whole hand into the vagina to cup the baby's head with the woman's legs in semilithotomy position, but this requires specialist training that many obstetricians lack 1, 7

Critical Safety Warnings

Never use these dangerous techniques 7, 1:

• Single forceps blade as a lever - considered dangerous and can cause maternal visceral injury 7, 1
• Vacuum extraction abdominally - potential for significant fetal injury including intracranial and subgaleal hemorrhage 7
• Digital pressure with only 2-3 fingers - less effective and may increase risk of skull fractures 7

Maternal Considerations

While cesarean section increases short-term maternal morbidity modestly (RR 1.29,95% CI 1.03-1.61), this must be weighed against the substantial reduction in perinatal mortality and morbidity 2. At 3 months postpartum, women who had cesarean delivery report less urinary incontinence (RR 0.62) and less perineal pain (RR 0.32), though more abdominal pain (RR 1.89) 2

Training Requirements

Proper technique is crucial as errors in performing breech extractions may increase the risk of femoral and humeral fractures 1. High-fidelity simulation training with multiprofessional teams is recommended, as many obstetricians lack adequate training in these techniques 7, 1