GENERAL KNOWLEDGE

MANAGING BREECH BIRTH SAFELY AND EFFECTIVELY

Introduction

Breech vaginal delivery refers to the delivery of a baby in a position other than the typical head-first position. In a normal vaginal delivery, the baby’s head is the presenting part that enters the birth canal first. However, in a breech presentation, the baby’s buttocks or feet are positioned to come out first.

 

Types of Breech Vaginal Delivery

There are several types of breech vaginal deliveries, each with its own set of considerations and techniques. These include:

1. Frank Breech: This is the most common type of breech presentation, accounting for about 65-70% of all breech cases. In a frank breech, the baby’s buttocks are presenting first, with the hips flexed and the knees extended. The feet are positioned near the baby’s head. During delivery, the baby’s legs are usually brought up towards their abdomen, allowing the buttocks and body to be delivered first.

2. Complete Breech: In a complete breech presentation, both the baby’s hips and knees are flexed. The buttocks and feet are presenting first, with the knees bent and the feet near the buttocks. During delivery, the baby’s legs remain folded against their body as they are delivered.

3. Footling Breech: In this type of breech presentation, one or both of the baby’s feet are positioned to be delivered first instead of the buttocks. Footling breeches occur in around 10-15% of all breech cases. There are two subtypes of footling breech: single footling (one foot presenting) and double footling (both feet presenting). Delivering a footling breech requires special attention to avoid cord prolapse or other complications.

4. Incomplete Breech: Although not commonly discussed as a separate type, incomplete breech presentation refers to a situation where the baby’s buttocks are presenting first, but one or both of their feet are extended towards the cervix. This can make vaginal delivery more challenging and may require additional maneuvers or interventions to safely deliver the baby.

When considering a vaginal delivery for a breech presentation, several factors need to be taken into account, including the mother’s medical history, the baby’s size and position, and the experience and expertise of the healthcare provider. It is crucial to have a thorough assessment of the risks and benefits before making a decision.

In recent years, there has been a shift towards recommending planned cesarean section for most breech presentations due to concerns about potential complications during vaginal delivery. However, there are still situations where vaginal delivery can be considered a safe option. The decision should be made on an individual basis, taking into account factors such as gestational age, fetal size, maternal pelvis shape, and the presence of any additional risk factors.

During a vaginal breech delivery, certain techniques can be employed to optimize safety and reduce the risk of complications. These include:

  • Hands-off technique: This approach involves minimal intervention by the healthcare provider during delivery. The baby is allowed to descend through the birth canal without excessive manipulation.
  • Maternal positioning: Different positions can be used to facilitate delivery, such as kneeling or squatting positions. These positions can help widen the pelvic outlet and provide more space for the baby’s passage.
  • Manual assistance: In some cases, gentle maneuvers may be necessary to guide the baby’s progress through the birth canal. This can involve applying pressure on specific areas of the baby’s body or using hands to guide their movements.
  • Episiotomy: In certain situations, an episiotomy (a surgical cut made in the perineum) may be performed to enlarge the vaginal opening and facilitate delivery.

It is important to note that breech vaginal delivery requires a skilled and experienced healthcare provider who is knowledgeable about the techniques and potential complications associated with this type of delivery. Continuous fetal monitoring and close observation of both the mother and baby are essential to ensure their well-being throughout the process.

In conclusion, breech vaginal delivery encompasses various types, including frank breech, complete breech, footling breech, and occasionally incomplete breech. Each type requires specific considerations and techniques to optimize safety and minimize complications. The decision to pursue vaginal delivery for a breech presentation should be made on an individual basis, taking into account various factors and involving an experienced healthcare provider. Proper management, careful monitoring, and adherence to established protocols are crucial for ensuring the best possible outcomes for both the mother and baby.

 

Complications of Breech Delivery

The complications of breech delivery can affect both the mother and the baby. In this comprehensive discussion, we will explore the various complications that can arise during a breech delivery.

A) Complications for the Baby:

1. Head Entrapment: One of the most significant complications during a breech delivery is head entrapment. Unlike in a cephalic presentation, where the head acts as a natural wedge to dilate the cervix, in a breech presentation, the largest part of the baby’s body (the head) is delivered last. This can result in difficulties in delivering the head, leading to prolonged labor and potential compression of the umbilical cord.

2. Cord Prolapse: Breech presentations are associated with an increased risk of cord prolapse, where the umbilical cord slips through the cervix and becomes compressed between the baby’s body and the birth canal. Cord prolapse can lead to fetal distress due to compromised blood flow and oxygen supply.

3. Birth Trauma: Breech deliveries have a higher likelihood of birth trauma compared to cephalic deliveries. The vulnerable areas include the head, neck, shoulders, and arms. The risk of injury increases when excessive force is applied during extraction or if there are difficulties in delivering the aftercoming head.

4. Hypoxic-Ischemic Encephalopathy (HIE): HIE refers to brain damage caused by oxygen deprivation before, during, or after birth. Breech deliveries have an increased risk of HIE due to potential cord compression, prolonged labor, or difficulties in delivering the baby’s head. HIE can lead to long-term neurological disabilities.

5. Intrauterine Infection: Prolonged labor during a breech delivery can increase the risk of intrauterine infection. This can occur due to prolonged rupture of membranes or contamination of the birth canal during the extended delivery process.

6. Meconium Aspiration Syndrome (MAS): Meconium is the first stool passed by a newborn. In some cases of breech delivery, the baby may pass meconium before birth, and if it is aspirated into the lungs, it can cause respiratory distress and lead to MAS.

7. Fractures and Dislocations: Breech deliveries carry a higher risk of fractures and dislocations, particularly in the baby’s arms and collarbone area. These injuries can occur due to difficulties in delivering the aftercoming head or excessive force applied during extraction.

 

B) Complications for the Mother:

1. Perineal Tears: Breech deliveries are associated with an increased risk of perineal tears compared to cephalic deliveries. The perineum (the area between the vagina and anus) may experience significant stretching or tearing during the delivery process.

2. Uterine Rupture: Although rare, uterine rupture is a severe complication that can occur during a breech delivery. It involves a tear in the uterine wall, which can result in severe bleeding and endanger both the mother and baby’s lives.

3. Postpartum Hemorrhage: Breech deliveries have a higher risk of postpartum hemorrhage compared to cephalic deliveries. This can be due to factors such as uterine atony (inability of the uterus to contract effectively), retained placenta, or trauma to the birth canal.

4. Infection: Prolonged labor during a breech delivery can increase the risk of infection in the mother’s reproductive tract. This can occur due to prolonged rupture of membranes or contamination of the birth canal during the extended delivery process.

5. Pelvic Floor Dysfunction: Breech deliveries may contribute to pelvic floor dysfunction, including urinary and fecal incontinence, pelvic organ prolapse, and sexual dysfunction. These complications can arise due to trauma to the pelvic floor muscles and nerves during delivery.

6. Psychological Impact: Breech deliveries can have a psychological impact on the mother, especially if complications arise during the process. The stress and anxiety associated with a difficult delivery can affect the mother’s emotional well-being and postpartum recovery.

It is important to note that not all breech deliveries result in complications, and many factors influence the outcome, including the experience and skill of the healthcare provider, the baby’s size and position, and the overall health of both the mother and baby.

 

Management of Breech Delivery

The management of breech delivery depends on various factors, including the type of breech presentation, gestational age, and the mother’s overall health. Options for managing breech delivery include:

1. Vaginal Breech Delivery: In certain cases, a vaginal breech delivery may be attempted if specific criteria are met. This includes having an experienced healthcare provider who is skilled in performing vaginal breech deliveries and ensuring that the baby is in a favorable position for a safe delivery.

2. Caesarean Section: A caesarean section (C-section) is often recommended for breech presentations due to the increased risks associated with vaginal breech delivery. It provides a safer option for both the mother and the baby.

3. External Cephalic Version (ECV): ECV is a procedure performed during pregnancy to manually turn a breech baby into a head-down position. It involves applying pressure on the mother’s abdomen to rotate the baby. ECV is typically attempted between 36-38 weeks of gestation and is successful in about 50% of cases.

 

Term Breech

Term breech refers to a breech presentation that occurs at or near full term, usually after 37 weeks of gestation.

 

Management of Caesarean for Breech Delivery

A caesarean section (C-section) is a surgical delivery procedure that is sometimes necessary when a baby is in a breech position, meaning the feet or buttocks are positioned to come out first instead of the head. The management of C-section for breech delivery is a complex and delicate process that requires careful planning and execution. In this answer, we will discuss the management of C-section for breech delivery, including the indications, preparation, and procedure.

A) Indications for C-Section for Breech Delivery

A C-section may be recommended for breech delivery in the following situations:

1) Fetal Distress

If the baby is in distress or showing signs of fetal compromise, such as a slow heart rate or decreased movement, a C-section may be necessary to ensure the baby’s safety.

2) Abnormal Fetal Presentation

If the baby is in an abnormal position, such as a footling or shoulder presentation, a C-section may be necessary to avoid complications during delivery.

3) Maternal Medical Conditions

If the mother has a medical condition that makes vaginal delivery risky, such as high blood pressure or a history of previous uterine surgery, a C-section may be recommended.

3) Fetal Macrosomia

If the baby is larger than average, a C-section may be necessary to avoid complications during delivery, such as a large tear in the mother’s vagina or perineum.

 

B) Preparation for C-Section for Breech Delivery

Preparing for a C-section for breech delivery is similar to preparing for a traditional C-section. The mother will need to:

1) Meet with the Anesthesiologist

The mother will meet with the anesthesiologist to discuss the type of anesthesia that will be used during the procedure.

2) Prepare the Operating Room
The operating room will be prepared with the necessary equipment and personnel for the C-section.

3) Administer Antibiotics
The mother will be given antibiotics to reduce the risk of infection.

4) Place an Indwelling Catheter
An indwelling catheter will be placed in the mother’s bladder to collect urine during the procedure.

5) Prepare the Baby

The baby will be monitored and prepared for delivery.

 

C) Procedure for C-Section for Breech Delivery

The procedure for a C-section for breech delivery is similar to a traditional C-section, with a few modifications to accommodate the breech presentation. The steps include:

1) Make an Incision

The surgeon will make an incision in the mother’s abdomen and uterus.

2) Deliver the Baby

The baby will be delivered through the incision, and the surgeon will carefully extract the baby from the uterus.

3) Remove the Placenta
The placenta will be removed from the uterus.

4) Close the Incision
The incision will be closed with sutures or staples.

5) Recovery

The mother will recover from the anesthesia and be monitored for any complications.

 

External Cephalic Version explained 

External cephalic version (ECV) is a procedure performed during pregnancy to manually turn a breech baby into a head-down position. It is typically attempted between 36-38 weeks of gestation and can be done in a hospital setting under close monitoring. ECV is considered a safe procedure when performed by experienced healthcare providers. It carries certain risks, such as temporary changes in fetal heart rate, premature rupture of membranes, or placental abruption, but serious complications are rare.

The ECV procedure involves applying pressure on the mother’s abdomen to manipulate the position of the fetus. It is usually carried out by an obstetrician or a healthcare provider with expertise in performing ECVs. The aim of this procedure is to encourage the baby to rotate into a head-down position, allowing for a vaginal delivery.

Before performing an ECV, various factors are taken into consideration to ensure that it is safe and appropriate for both the mother and the baby. These factors include gestational age, fetal size, amniotic fluid levels, placental location, and maternal health conditions such as high blood pressure or placenta previa. Additionally, an ultrasound examination may be conducted prior to the procedure to assess the exact position of the fetus and determine if it is suitable for an ECV.

During the ECV procedure, the mother lies on her back while her abdomen is gently manipulated by the healthcare provider. The provider applies pressure on specific areas of the abdomen to encourage the baby’s movement. Ultrasound guidance may be used during the procedure to monitor fetal well-being and ensure that there are no complications arising from the manipulation.

The success rate of ECV varies depending on several factors, including gestational age, parity (number of previous pregnancies), and fetal size. On average, studies have reported success rates ranging from 40% to 60%. However, success rates can be higher in certain cases, such as when performed by experienced healthcare providers or when combined with other techniques like tocolysis (administration of medications to relax the uterus).

ECV is generally considered a safe procedure when performed by skilled healthcare providers in appropriate settings. However, as with any medical intervention, there are potential risks and complications associated with ECV. These can include fetal distress, premature rupture of membranes, placental abruption, and umbilical cord complications. To minimize these risks, ECV is typically performed in a hospital or a healthcare facility equipped to handle any potential emergencies.

It is important to note that ECV is not recommended in certain situations. These may include cases where the mother has certain medical conditions or obstetric complications that make the procedure unsafe, such as placenta previa, multiple pregnancies, or a history of uterine surgery. Additionally, if the baby’s head is engaged in the pelvis or if there are concerns about the baby’s well-being, an ECV may not be attempted.

In conclusion, external cephalic version (ECV) is a medical procedure used to manually turn a fetus from a breech position to a head-down position in preparation for vaginal delivery. It involves applying pressure on the mother’s abdomen to manipulate the position of the baby. ECV is generally safe and effective when performed by experienced healthcare providers in appropriate settings. However, it is not suitable for all pregnancies and carries potential risks and complications.