Breech Presentation & Transverse Lie
The guidelines recommend management of common obstetric conditions at primary and referral level, based on local experience and evidence-based practice. They are not intended as strict protocols nor as standard operating procedures, but rather as a guide to safe effective management of common obstetric problems. The guidelines should be most useful to interns, medical officers and registrars.
Local clinics may refer women with suspected breech presentation & trans-verse lie to hospital for confirmation & further management. Ultrasound scan must be done to confirm the presentation, assess liquor volume, & to exclude multiple pregnancy, placenta praevia, uterine abnormality & fetal abnormality.
EXTERNAL CEPHALIC VERSION
External cephalic version (ECV) should be attempted on all women with singleton breech presentations from 36 weeks gestation, with the following precautions:
- Exclude possible contraindications – hypertension, scarred uterus, oligo-hydramnios, antepartum haemorrhage, ruptured membranes, HIV infection, uterine abnormalities
- Give anti-D 100 mcg IM to Rhesus-negative women with no antibodies
- Do not anaesthetise or sedate the woman
- Use salbutamol 250 mcg IV to relax the uterus
- Never use excessive force
- Do a CTG tracing before & after ECV, whether successful or not
- Observe the woman for a few hours for complications – labour, rupture of membranes, antepartum haemorrhage, fetal distress
LABOUR AND DELIVERY
Elective caesarean section is the safest method of delivery for a baby with breech presentation. Women with breech presentation at 38 weeks should be admitted to hospital for elective caesarean section. Re-examine the woman carefully before surgery to confirm that the presentation is still breech.
Admission of a woman with breech presentation in labour
- Exclude fetal abnormality or multiple pregnancy, by ultrasound if necessary
- Attempt ECV if there are no contraindications
- Estimate fetal weight, maternal height & pelvic adequacy
- Determine cervical dilatation and station of presenting part
- Perform caesarean section unless suitable for vaginal delivery (below)
Vaginal breech delivery
Some women may prefer vaginal breech delivery, & some may arrive at hospital in advanced labour. Vaginal breech delivery can be planned for these women provided that all circumstances are favourable. Primigravidas should be strongly advised to have elective caesarean section. Vaginal breech delivery must be personally supervised by the most senior clinician available in the labour ward.
Breech presentation suitable for vaginal delivery
- The pregnant woman understands and accepts vaginal delivery
- Clinician experienced and confident with vaginal breech delivery
- No signs of pelvic contraction
- Maternal height >1.5 m
- Estimated fetal weight 1.5-3.5 kg
- Ultrasound excludes head extension (‘stargazing breech’)
- Frank or complete breech
- At 6 cm dilatation or more, the fetal buttocks should be at least at the level of the ischial spines, & at full dilatation, should be at the perineum
- Labour progress >1 cm per hour
- Epidural anaesthesia is strongly advised
A dead or grossly abnormal fetus, or with estimated weight <800 g should be delivered vaginally
Vaginal breech delivery technique
- Get help and put the woman in lithotomy position. Call a paediatric doctor.
- Cut an episiotomy after infiltration of the perineum with lidocaine 1%
- Allow the breech to deliver itself & only assist in keeping the fetal back facing upwards. Do not at any stage pull the baby down.
- If extended knees prevent easy delivery, assist by flexing at the knees & gently delivering each leg (Pinard manoeuvre)
- After delivery of the trunk, allow the breech to hang, pull the cord down & cover the delivered parts with a cloth
- As the scapulae appear, be ready to assist with delivery of the arms
- Deliver the arms if necessary (anterior or posterior), by running the fingers from the fetal back over the shoulder & sweeping the arms down in front of the chest, & then out
- With difficult in delivering the arms, the posterior arm can be brought anterior by rotating the baby, holding it by the hips & sacrum (Lovset manoeuvre)
- Allow the baby to hang, & wait for the hairline to appear
- Deliver the head by lying the baby over the right forearm (if right-handed) & inserting the right middle finger into the baby’s mouth, with the index & ring fingers supporting the cheek (Mauriceau-Smellie-Veit manoeuvre)
- The left hand exerts suprapubic pressure downwards to flex the head
- If the head does not deliver, keep the above manoeuvre & push the head up a little and rotate laterally about 30 degrees, then attempt delivery as before with an assistant providing firm suprapubic pressure
- Consider symphysiotomy if the head still does not deliver, if possible
- Should the fetal back face downwards after delivery of the arms, the head may be trapped. Hold the feet & try to swing the baby anteriorly over the maternal abdomen to flex the head, while grasping the shoulders with two fingers of the other hand (modified Prague manoeuvre)
TRANSVERSE LIE
External version may be attempted from 37 weeks’ gestation. Caesarean section is required if version fails to achieve a stable longitudinal lie. Any woman presenting in labour with a transverse lie (alive or dead, expected weight ≥1 kg) needs delivery by caesarean section. Consider classical or low vertical uterine incision, especially with dorso-anterior and dorso-inferior transverse lie.