Breech birth mostly safe, according to updated guidelines

Learning several simple skills can make a breech birth safer for both mother and baby. A presentation at the 2018 Annual ACOG Meeting in Austin highlighted several techniques to enhance safety for both a planned or unplanned vaginal breech birth.

“Upright vaginal breech is actually an easier way to deliver the baby’s breech,” said Annette Fineberg, MD, an ob/gyn at Sutter Medical Group in Davis, Calif. “Gravity, combined with 1 to 2 cm of extra space, results in rarely needing forceps or complicated maneuvers.”

Dr. Fineberg told Contemporary OB/GYN that when the baby is in the upright position, gravity helps the baby be born. “The baby is able to rotate and flex on its own,” she said. “By knowing what is supposed to happen, you then know when to intervene. A lot of times, the birth will happen on its own. In essence, hands off the breech, unless there is a danger sign.”

Many of the tips Dr. Fineberg shared originate from Frank Louwen, MD, an ob/gyn in Frankfurt, Germany, and his colleagues.

In the case of a surprise breech, when the mother is starting to deliver, “it is best for the mother to get on her hands and knees,” said Dr. Fineberg. “The baby will then perform specific maneuvers to get itself out. If the baby does not rotate properly, you know there is a problem.”

Likewise, if there is no crease in the baby’s chest, “you may need to do a Loveset’s maneuver to retrieve a nuchal arm,” said Dr. Fineberg.

“The baby has a limited time to get out. With a reassuring fetal heart rate and a vigorous infant, you have about 5 minutes,” said Dr. Fineberg.

Conversely, ob/gyns need to know when to abandon a breech birth and deliver by cesarean instead. “If the baby is not following the expected rotation and descent, you are probably better off pushing the baby up,” said Dr. Fineberg.

Dr. Fineberg has heard numerous stories of mothers being placed at risk, when in reality the baby was simply trying to come out on its own. “For example, a mother having her fifth baby at 36 weeks is put under a general anesthesia, after a full meal,” she said. “If the mother had been able to push instead, the baby probably would have been born in 5 minutes.”

Good candidates for vaginal breech delivery are mothers who are at least 36 to 37 weeks pregnant, frank or complete breech, spontaneous labor progressing, normal descent, adequate pelvis and an estimated fetal weight between 2,500 and 4,000 g. 

“MRI pelvimetry is not absolutely needed, but it can decrease the odds of needing an intrapartum cesarean,” said Dr. Fineberg.

A growth-restricted or preterm baby is actually more dangerous for breech delivery than a large baby because the body can be small and the head bigger in proportion.

For an unplanned breech birth, the two signs of an adequate pelvis are rapidly progressing cervical dilation and rapid descent of the baby. “You should also check the fetal head position with ultrasound,” said Dr. Fineberg.

One newer technique to increase safety during breech delivery is a shoulder press. “You apply pressure at the midclavicular line, which causes a reflexive tuck of the chin,” said Dr Fineberg.

Most obstetricians learn to perform a routine episiotomy for breech, especially with a first-time birth. “But an intact perineum can often help the baby flex its own head,” she said.

A 2000 breech trial in The Lancet found that for breech pregnancies in general, planned cesarean delivery was safer than vaginal births for babies. “Since the publication of that study, there has been a dramatic decrease in the incidence of planned vaginal breech, not only in the United States where it had already been slowly decreasing, but in the rest of the world as well,” Dr. Fineberg said.

However, many studies since 2000 are much more encouraging about the risk of a vaginal breech. “There is no question that vaginal breech babies have lower Apgar scores than C-section babies, but the incidence of serious long-term complications is not significantly different between the two techniques,” said Dr. Fineberg.

Based on more recent optimistic clinical studies, the British, Canadian and ACOG guidelines now reflect more positive breech guidelines. “The main problem, though, is that most obstetricians have not learned how to deliver babies breech,” said Dr. Fineberg.

For an informed patient using shared decision-making, breech delivery “is a reasonable decision and the professional guidelines support it,” said Dr. Fineberg. “However, most women are not given a choice.”

For an unplanned breach or an emergency situation, “I want the ob to feel more safe and comfortable performing a vaginal breech,” said Dr. Fineberg said. “I would also like to see referral centers, so mothers have an option.”

Disclosures:

Dr. Fineberg reports no relevant financial disclosures.

References:

Hannah ME, Hannah WJ, Hewson SA, et al. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group. Lancet. 2000 Oct 21;356(9239):1375-83.