1. Breech delivery
Lecture, Medical Students 2D, NTNU 2009, Pepe Salvesen

2. Breech presentation Prevalence: 2-3% at term
More frequent in preterm deliveries 30% at 30 weeks - 15% at 34 weeks
Breech presentation is associated with increased morbidity/mortality ( i.e. Cerebral Palsy) - independent of mode of delivery

3. Breech presentation - terminology
Extended breech
“Frank” breech
Flexed breech
Complete breech
Footling

4. Risk factors Preterm delivery Multiparity Uterus- and fetal anomalies
Myoma, pelvic tumors
Poly- and oligohydramnios
Previous breech

5. Breech Exercises Not scientifically proven! Knee Chest Position
Deep Trendelenburg
Not scientifically proven!

6. External cephalic version (ECV) Success factors
Multiparity
Frank breech
Normal amount of amniotic fluid
Relaxed uterus
Gestational length < 37 weeks
Tocolysis

7. Lift the breech out of the pelvic inlet

8. Fetal forward somersault
(or backwards)
No use of force Attempted version

9. Fetus in transverse lie
Check with ultrasound

10. Succesful version
- in about 50%

11. Contraindications for ECV
Multiple pregnancy
Placenta previa
Previous CS or myomectomy
History of antepartum bleeding
Pathologic CTG
Uterus anomalies

12. Complications are rare
Placental abruption
Cord accident
PROM, bleeding
Transplacental haemorrhage
Fetal bradycardia (CTG)
IUFD
Amniotic fluid embolism?

13. The most favourable head diameter is similar
Head and breech delivery
The most favourable head diameter is similar
Symphysis
Symphysis
Sacrum
Sacrum
Breech delivery
Cephalic delivery

14. Practical routines breech delivery
Avoid amniotomy, but examine when the water breaks (umbilical cord)
CTG monitoring
Avoid pushing too early (epidural)
Do not pull ! Never!
Spontaneous delivery of lower part of the body down to apex of the anterior scapula
Active delivery of shoulders (Løvset’s method)
Head delivery by Mauriceau – Veits – Smellie method or forceps

15. Vaginal breech delivery
Remember to get the back anterior

16. Leg delivery

17. Be active when the cord insertion is delivered

18. Shoulder delivery Løvset’s method

19. MSV maneuver + suprapubic pressure

20. Cervical cut if the head is stuck

21. Contraindications - breech delivery
Cephalopelvic disproportion (X ray pelvimetry)
Macrosomia (> 4000 g)
Preterm delivery (< 34 weeks)
IUGR – placental failure
Footling breech
Extended neck or nuchal arm
Inexperienced birth attendants

22. Pelvimetry - vaginal breech delivery
Pelvic inlet - Conjugata vera > 11,5 cm
Sum pelvic outlet > 32,5 cm
Interspina diameter + intertubar diameter + sagital outlet
The clinical value of X ray (or CT) pelvimetry is debatable

23. Information to pregnant women with breech presentaion
Don’t wait home, but come to the labour ward immediately when the contractions start
Epidural – pro and cons
Baby is delivered by an obstetrician

24. Breech delivery outside hospitals
Should be avoided!
Advice:
Get help (midwife)
No active pushing (panting breath with open mouth – no Valsalva)
Do not pull !!
Let the baby hang from the head
Mother lies across the bed

25. Hannah-study: Term breech trial Lancet 2000; 356: 1375-83
RCT countries and 121 OB dept.
N = 2088 women with breech presentation randomised to CS or vaginal delivery
Mortality 0,3 % / 1,3 %
Morbidity 1,4 % / 3,8 %
Study heavily critized
Results probably not applicable in Norway