Chapter 48: Breech Delivery Techniques
Dr. Ernesto S. Uichanco
Classification of Breech Presentation
Vaginal Delivery Versus Cesarean Section
Management of Labor and Delivery
Spontaneous Breech Delivery
Assisted Breech Delivery
Delivery of the Shoulder and Arms
Delivery of the Head
Piper’s Forceps Application
Complete Breech Extraction
Difficulties in Vaginal Breech Delivery
Cervical Entrapment of the Head
Malposition of the Head
External Cephalic Version
The management of breech presentation represents an excellent example of a group of difficult and uncertain therapeutic choices facing the obstetrician in current practice. For many decades, the vaginal delivery of a breech presenting fetus was regarded as an obstetric art. The skill of an obstetrician could be judged by the elegance and efficiency in the conduct of such deliveries. During the last 100 years the management of breech presentation has been undergoing dramatic changes, and will probably continue to remain so in the next half century.
Classification of Breech Presentation
Breech presentation occurs in 3.5 to 4.0% of all singletons in labor. When multiple pregnancies are included, the incidence of breech presentation rises to 4.4 to 5.2%. The earlier in gestation, the higher is its incidence. The great majority though, converting to cephalic presentation by the 34th week.
The risk of recurrent breech presentation is more than threefold, resulting in a 10 to 12% incidence in term pregnancies after prior breech delivery.
There are three major types of breech presentation:
1. Frank breech: Hips are flexed on the abdomen and knees are extended. 2. Complete breech: Hips and knees are flexed and the buttocks and knees are at the same level. 3. Incomplete breech: One or both hips are extended so that one or both feet and/or knees are below the level of the buttocks. Footling breech is included here.
Complete Breech Incomplete Breech Frank Breech
Figure 1: Types of Breech presentations
The most common type is the frank breech, although the footling breech is seen relatively more frequently in multiparas and in association with premature labor.
In the majority of breech presentations, no etiologic factors are identified. The following are factors reportedly associated with this malpresentation:
2. Uterine anomalies
3. Abnormal amniotic fluid volume
4. Multiple gestation
5. Placenta previa
6. Contracted pelvis
7. Pelvic tumors
8. Fetal abnormalities
Vaginal Delivery VS Cesarean Section
Prior to the 1950’s, most breech fetuses were delivered by the vaginal route. Maternal safety was the main concern because at that time modern antibiotic, blood banking and safe anesthesia were not readily available. By the mid-1950’s, abdominal delivery became more popular with the proclaimed purpose of minimizing perinatal mortality and morbidity. This attitude became so widespread that some practitioners indiscriminately advocated cesarean sections for all breech presentations, regardless of the circumstances. As a result, many young obstetricians were not trained to do vaginal breech deliveries and did not feel competent to manage them, especially in emergencies. Although the perinatal mortality rate associated with breech presentation has decreased since the widespread application of abdominal delivery, there are concomitant concerns about the maternal risks of cesarean section like infectious morbidities and the danger or uterine rupture in subsequent pregnancies.
One alternative to abdominal delivery is selective trial of labor for breech fetuses. Recent controlled studies have shown that for the appropriately selected patient with a breech presentation, whose delivery is performed by a...
References: Hellston C, Lindqvist P, Olofsson P. Vaginal breech delivery: is it still an option?. Eu J Obstet Gynecol Rep Biol. 111 (2003):122-128.
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