Breech birth care: Number 1 – 2024

Abstract

It is essential to resume teaching external cephalic version and obstetric maneuvers in vaginal breech birth, both in lithotomy and in the vertical position.• The adoption of strict protocols for planned vaginal breech birth correlates with a success rate of approximately 70% and adverse outcome rates of less than 7%. Fetal and neonatal morbidity and mortality are similar to those of a planned cesarean section. • Pregnant women eligible for vaginal breech birth must agree to the mode of delivery, be at low risk of complications and have assistance of professionals with experience in vaginal birth of abnormal presentations and in obstetric maneuvers. • Previous cesarean section and prematurity between 32 and 36 weeks are not absolute contraindications to vaginal breech birth and must be individually evaluated when deciding on the route of delivery. • Neonatologists must be present at the birth of breech fetuses, and a complete neonatal examination must be performed. • Posterior rotation of the fetal back, prolapse of the umbilical cord, deflection of the arms and/or cephalic pole and retention of the after-coming head are the main dystocias related to vaginal breech birth assistance. Every professional assisting vaginal breech births must be trained to adequately resolve these events. • In vaginal breech birth in lithotomy, the main maneuvers to help in the delivery of the fetal pelvis are bidigital inferior traction on the inguinal region and the Pinard maneuver; for the release of the fetal trunk, those of Rojas, Deventer-Miler and Pajot; and for the release of the after-coming head, those of Mauriceau, Bracht, Champetier de Ribes and Prague and operative vaginal delivery with Piper's forceps. • Non-lithotomic positions in vaginal breech birth are associated with reduced dilation and expulsion periods, need for maneuvers for fetal extraction, as well as reduced rates of cesarean sections and neonatal injuries. • In vaginal breech birth assisted in the all fours position, the aspects to be observed during delivery of the fetal body include the fetal muscle tone of lower limbs, the correct rotation of the fetal trunk (fetal abdomen facing the maternal back), vascular engorgement of the umbilical cord, the presence of elbows and folds of the fetal chest and maternal anal dilatation. • In vaginal breech births assisted in the all fours position, more than half of fetuses are delivered without the need for any maneuver. Usually, only two maneuvers may be necessary: one to help release the shoulders (180°-90° rotation) and another to release the fetal head (Frank's nudge). Recommendatios• In order to prevent cesarean sections and dystocia associated with vaginal breech birth, the external cephalic version, when available, should be offered to pregnant women who reach term with their fetuses in breech presentation. • The mode of delivery in breech presentation must be an informed choice, defined according to the values and preferences of the parturient woman, the experience, values and preferences of the care team, ade...