Tuesday, September 14, 2021

Vaginal Breech Delivery Case File

Posted By: Medical Group - 9/14/2021 Post Author : Medical Group Post Date : Tuesday, September 14, 2021 Post Time : 9/14/2021
Vaginal Breech Delivery Case File
Eugene C. Toy, MD, Konrad P. Harms, MD, Keith O. Reeves, MD, Cristo Papasakelariou, MD, FACOG

Case 4
A 36-year-old G3P2002 at 38 weeks’ gestation presents to labor and delivery (L&D) with uterine contractions, and is found to be in active labor with the fetus in breech presentation. She has had an uncomplicated antepartum course with good prenatal care including a normal anatomy scan in the second trimester. Her prior infants, each weighing approximately 3000 g, were delivered vaginally without complications. Ultrasound evaluation upon presentation to L&D confirms that the infant is in frank breech presentation and the head is flexed; the estimated fetal weight (EFW) is 3200 g. Clinical assessment of the maternal pelvis is determined to be adequate for a fetus of this estimated weight. The cervix is 5 cm dilated, 100% effaced and the fetal sacrum is at zero station, frank breech, left sacrum transverse. After being counseled on delivery options, the patient states that she would like to avoid a cesarean section if at all possible.

➤ What are the prerequisites for offering women at term with breech presentation an attempt at vaginal breech delivery?
➤ With careful selection criteria, how do the perinatal outcomes of vaginal breech delivery compare to those of infants delivered via cesarean?
➤ What technical principles are important to optimize perinatal outcome?


ANSWERS TO CASE 4:
Vaginal Breech Delivery

Summary: A multiparous woman with a frank breech presentation at term, with a clinically adequate pelvis, desires to avoid cesarean delivery. Following the steps outlined in the subsequent discussion will assist caregivers in achieving satisfactory results.

➤ Prerequisites: Frank or complete breech presentation, estimated fetal weight between 2500 and 4000 g, flexed fetal head, adequate maternal pelvis, patient counseling and consent, and an experienced operator present at delivery are all important prerequisites.

➤ Perinatal outcomes comparing vaginal delivery to cesarean: The largest randomized trial conducted by Hannah and colleagues found an increased neonatal morbidity and mortality for infants delivered vaginally compared to those delivered by cesarean.1 A follow-up report of surviving infants from that trial at 2 years of life revealed no significant differences between groups.2 Since the publication of that large trial, several smaller nonrandomized reports have documented better outcomes than those obtained in the large trial.3

➤ Important technical principles: These include conscientious labor management, delivery in a setting with immediate cesarean capability, avoidance of early operator interference, adequate episiotomy if indicated, gentle manipulation of the infant, and the use of forceps for the aftercoming head.


ANALYSIS
Objectives
  1. Identify an appropriate candidate for vaginal breech delivery.
  2. Effectively counsel a woman regarding risks, benefits, and alternatives related to vaginal breech delivery.
  3. Become familiar with the technical principles involved in achieving satisfactory neonatal outcomes.

Considerations
Ideally, the fetus in breech presentation should be diagnosed between 36 and 39 weeks gestation in the prenatal clinic where the option of external cephalic version can be discussed. Many women who present at term in labor with a fetus in breech presentation are not candidates for vaginal breech delivery.

The first step in management is therefore to identify appropriate cases for attempted vaginal breech delivery4,5 and delivery by cesarean for the women who do not meet strict selection criteria. The next section will outline in detail these selection criteria. The second step is to counsel potential candidates
regarding risks, benefits, and alternatives to vaginal breech delivery. This counseling step is critically important and should reflect institutional and individual operator experience in the context of the available evidence, and should take into account their local results. A variable portion of women who satisfy the first two steps will require cesarean delivery in labor, for either abnormal progress or nonreassuring fetal status. At most institutions less than 50%, and at some centers only 10%, of carefully selected women will achieve successful vaginal breech delivery. To optimize outcomes for those who do, the final step in management consists of proper technique in the performance of the delivery itself.


APPROACH TO
Vaginal Breech Delivery

DEFINITIONS

TYPES OF BREECH: A frank breech has hips flexed and knees extended. A complete breech has both hips and knees flexed. An incomplete breech has one or both hips extended, such that part of a lower extremity is palpable in the birth canal below the buttocks. Planned vaginal breech delivery should only apply to fetuses in frank or complete breech presentation.

CLINICAL PELVIMETRY: Some authors prefer to call this clinical pelvic assessment rather than measuring (-metry) the pelvis, but the end result is the same. The aftercoming head of the fetus will not have time to mold as it passes through the birth canal. Thus, the operator must determine that the pelvis is sufficiently large to accommodate the unmolded head using only physical examination skills and not radiographic pelvimetry.

LOVSET MANEUVER: There are many eponyms associated with the various maneuvers used in vaginal breech delivery. Lovset of Norway is credited with describing rotational movement of the fetal trunk once the lower third of the scapula has become visible to allow for delivery of the anterior fetal arm and shoulder first, followed by a 180 degree rotation to deliver the remaining shoulder anteriorly as well. In difficult cases the posterior shoulder of the fetus may need to be delivered first and this maneuver is not associated with Lovset.

CLINICAL APPROACH
Unfortunately, selection criteria for candidates for planned vaginal breech delivery vary throughout the literature. For this chapter four important requirements are recommended: frank or complete breech presentation, adequate maternal pelvis, estimated fetal weight 2500 to 4000 g, and a flexed fetal head.6 Ultrasound is an important tool for assessing each criterion except pelvic adequacy, which depends on physical examination by an experienced clinician, supplemented at some centers by radiographic pelvimetry. Confirmation of fetal head flexion is difficult using only clinical examination; the use of either ultrasound or a flat-plate radiograph is recommended. Hyperextension of the fetal head is associated with an unacceptable risk of cervical spine injury and possible head entrapment. Restricting planned vaginal breech delivery to frank or complete breech presentation is designed to reduce the risk of umbilical cord prolapse associated with incomplete breech presentation. The lower estimated-weight limit of 2500 g should eliminate both premature and growth restricted fetuses. The upper limit of 4000 g should reduce the possibility of attempting to deliver a macrosomic infant vaginally.

Counseling a well-selected candidate for vaginal breech delivery may be the key to her decision regarding the options of planned vaginal versus planned cesarean delivery (assuming that the option of external cephalic version has been previously addressed). If the counselor begins the session with a statement like “the baby’s head may get trapped and that could cause brain damage or even death,” the woman will most likely choose cesarean delivery. In contrast, a statement like “our careful selection process has minimized many of the risks of vaginal breech delivery and we have a proven track record of good outcomes” may persuade more women to carefully weigh the risks to themselves of cesarean delivery. If an obstetrician experienced in vaginal breech delivery is not available, cesarean delivery is a safer option.

If residents in training are not taught the technical skills of vaginal breech delivery, they will be unable to offer this option to their patients. Simulation training7 and vaginal breech delivery of second twins can help to enhance the resident’s understanding of many of the technical aspects of breech delivery. The same techniques that facilitate safe vaginal breech delivery are also applicable to cesarean breech delivery.

In order to arrive at the moment where vaginal delivery techniques can be employed, one must first manage the woman’s labor adroitly (Figures 4–1 to 4–4). Careful attention to fetal heart rate monitoring and judicious, infrequent use of oxytocin are recommended. Delivery should occur in a


Vaginal Breech Delivery

Figure 4–1. Delivery of the body. The hands are applied, but not above the pelvic girdle. Gentle downward rotational traction is accomplished until the scapulas are clearly visible. (Reproduced, with permission, from Cunningham FG, Leveno KJ, Bloom SL, et al. Williams Obstetrics. 23rd ed.New York,NY: McGraw-Hill; 2010.)


fully equipped operating room with the capability of proceeding immediately with cesarean delivery if necessary. The operator should grasp the fetal pelvis over bony prominences (sacrum and iliac crests) and should apply pressure parallel to, and not transverse to, long bones. Either Piper or Laufe- Piper forceps should be used routinely to deliver the aftercoming head (Figure 4–5). Laufe-Piper forceps can be easily applied to the aftercoming head at cesarean delivery, whereas Piper forceps are a bit unwieldy when used at cesarean section. In certain circumstances, an assistant may apply suprapubic pressure to facilitate engagement and flexion of the fetal head, but frequently this step is not necessary.

The patient presented in the case scenario is an ideal candidate for vaginal breech delivery. Astute labor management coupled with the presence of an experienced obstetrician at delivery should produce excellent maternal and perinatal outcomes.


Vaginal Breech Delivery Case

Figure 4–2. Delivery of body is accomplished using clockwise rotation of the fetal pelvis to bring the sacrum to left sacrum transverse, which gentle downward traction, and gently splinting the arm against the body delivers the arm. (Reproduced, with permission, from Cunningham FG, Leveno KJ, Bloom SL, et al. Williams Obstetrics. 23rd ed.New York,NY: McGraw-Hill; 2010.)


Vaginal Breech Delivery

Figure 4–2.


Vaginal Breech Delivery Case

Figure 4–3. Counterclockwise rotation from sacrum anterior to right sacrum transverse along with gentle traction downward effects delivery of the right scapula. (Reproduced,with permission,from Cunningham FG,Leveno KJ,Bloom SL,et al. Williams Obstetrics. 23rd ed.New York,NY: McGraw-Hill; 2010.)


Vaginal Breech Delivery

Figure 4–4. Delivery of the fetal head using the Mauriceau maneuver, and flexion of the fetal head by the assistant maintaining suprapubic pressure (A). Pressure on the maxilla as careful outward traction is used (B). (Reproduced,with permission, from Cunningham FG, Leveno KJ, Bloom SL, et al. Williams Obstetrics. 23rd ed. New York, NY: McGraw-Hill; 2010.)


Vaginal Breech Delivery

Figure 4–5. Piper forceps are used for the delivery of the aftercoming head. The fetal body is elevated using a warm towel and the left blade of the forceps is applied to the aftercoming head (A). The right blade is applied with the body still elevated (B). Forceps delivery of the aftercoming head, with the movement of the forceps is shown by the arrow (C). (Reproduced, with permission, from Cunningham FG, Leveno KJ, Bloom SL, et al. Williams Obstetrics. 23rd ed.New York,NY: McGraw-Hill; 2010.)


Vaginal Breech Delivery

Figure 4–5.


Comprehension Questions

4.1 Which of the following ultrasound findings would be a contraindication to planned vaginal delivery of a term breech?
A. EFW of 3600 g
B. Fetal pyelectasis
C. Extension (> 90 degrees) of the fetal head
D. Complete breech presentation

4.2 Which of the following named maneuvers are used to deliver the fetal arms during vaginal breech delivery?
A. Pinard maneuver
B. Lovset maneuver
C. Mauriceau-Smellie-Veit maneuver
D. Prague maneuver

4.3 Which of the following types of obstetrical forceps has been shown to be useful for delivery of the aftercoming head at either abdominal or vaginal delivery?
A. Simpson
B. Kielland
C. Laufe-Piper
D. Piper


ANSWERS

4.1 C. Extension of the fetal head increases the risk of C-spine injury. The weight of 3600 g is within the suggested weight range of 2500 to 4000 g. Fetal pyelectasis (dilation of the fetal renal pelvis of > 7 mm at term) is a relative common ultrasound finding which has no bearing on route of delivery. Vaginal delivery is reasonable for either frank or complete breech presentation.

4.2 B. Lovset was a Norwegian obstetrician who advocated rotation of the fetal trunk to facilitate freeing the anterior fetal arm. Pinard was a French obstetrician whose maneuver is used to deliver one or both fetal legs. Mauriceau (French), Smellie (English), and Veit (German) have their names attached to a manual method of delivering the aftercoming head (although forceps are preferable). Finally, the Prague maneuver should be used when the fetus, whose body is delivered, cannot be rotated to dorsum anterior.

4.3 C. Laufe modified the Piper forceps by considerably shortening the length and changing the lock from English to pivot. The short length of the Laufe-Piper facilitates their use at abdominal breech delivery. Simpson forceps have a pelvic curve which is a disadvantage. Kielland forceps are seldom used for either abdominal or vaginal breech delivery. Piper forceps are useful for vaginal breech delivery, but unwieldy for use at cesarean delivery.


Clinical Pearls

See US Preventive Services Task Force Study Quality levels of evidence in Case 1
➤ In order for a practitioner to feel confident in deciding that a pelvis is adequate for attempted vaginal breech delivery, pelvic assessment should be a routine element for all laboring women (Level II-3).
➤ Long bone fractures complicate both vaginal and abdominal breech deliveries. In their handling of fetal extremities, operators should ensure that pressure is applied parallel to, and not perpendicular to long bones (Level II-3).
➤ Strong consideration should be given to conducting vaginal breech delivery in an operating room with personnel and equipment to proceed with immediate cesarean delivery should that be necessary (Level III).
➤ An experienced operator should be present for all breech deliveries, vaginal or abdominal (Level III).
➤ A woman’s choice of delivery mode once she has been appropriately counseled should be respected (Level III).

REFERENCES

1. Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomized multicentre trial. Lancet. 2000;356:1375-1383. 

2. Whyte H, Hannah ME, Saigal S, et al. Outcomes of children at 2 years after planned cesarean birth versus planned vaginal birth for breech presentation at term: the International Randomized Term Breech Trial. Am J Obstet Gynecol. 2004;191:864-871. 

3. American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 340, Mode of term singleton breech delivery. Obstet Gynecol. 2006;108:235-237. 

4. Alarab M, Regan C, O’Connel MP, Keane DP, Herlihy C, Foley ME. Singleton vaginal breech delivery at term: still a safe option. Obstet Gynecol. 2004;103:407-412. 

5. Albrechtsen S, Rasmussen S, Reigstad H, Markestad T, Irgens LM, Dalaker K. Evaluation of a protocol for selecting fetuses in breech presentation for vaginal delivery or cesarean section. Am J Obstet Gynecol. 1997;177:586-592. 

6. SOGC Clinical Practice Guideline: Vaginal delivery of breech presentation, Guideline no. 226. JOGC. June 2009. 

7. Yamamura Y, Ramin KD, Ramin, SM. Trial of vaginal breech delivery: current role. Clin Obstet Gynecol. 2007;50:526-536.

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