NAVIGATING BREECH VAGINAL DELIVERY: WHAT EXPECTING MOTHERS NEED TO KNOW
A breech vaginal delivery occurs when a baby is delivered through the birth canal in a breech position, meaning the baby’s buttocks or feet are positioned to come out first instead of the head. This type of delivery can be more complicated and risky than a head-first (vertex) delivery due to the potential for complications such as cord prolapse, head entrapment, and trauma to the baby.
Types of Breech vaginal delivery
There are three main types of breech vaginal deliveries:
- Spontaneous Breech Delivery: In this type, no traction or manipulation is used. The baby delivers on its own up to the umbilicus, and then maneuvers may be initiated if necessary. This usually occurs in very preterm deliveries.
- Assisted Breech Delivery: This is the most common type of breech vaginal delivery. The baby is allowed to deliver spontaneously up to the umbilicus, after which specific maneuvers are performed to assist in delivering the rest of the body, arms, and head.
- Total Breech Extraction: In this method, the fetal feet are grasped, and the entire fetus is extracted from the birth canal. This technique should only be used for a noncephalic second twin and not for a singleton fetus because it carries high risks such as incomplete cervical dilation leading to head entrapment.
Complications of Breech delivery
Breech deliveries can lead to several complications:
- Perinatal Mortality: Increased 2-4 times compared to vertex deliveries.
- Birth Injuries: Higher risk of trauma including fractures and nerve injuries.
- Cord Prolapse: The umbilical cord may slip into the birth canal ahead of the baby.
- Head Entrapment: The baby’s head may get stuck if the cervix isn’t fully dilated.
- Neonatal Depression: Higher prevalence due to potential complications during delivery.
- Fetal Malformations: More common in breech presentations.
Management of Breech delivery
Managing a breech delivery involves several steps:
- Pre-delivery Assessment: Determining fetal position through physical examination or ultrasound.
- Intrapartum Monitoring: Continuous monitoring of fetal heart rate during labor.
- Delivery Planning:
- For term pregnancies with persistent breech presentation, a planned Cesarean section is often recommended.
- If attempting vaginal delivery, ensure availability of experienced clinicians and necessary facilities like anesthesia and neonatal care.
- Delivery Techniques:
- Avoid premature rupture of membranes to prevent cord prolapse.
- Use maneuvers like Pinard maneuver for leg extraction in frank breeches.
- Perform episiotomy if needed to prevent soft tissue dystocia.
- Post-delivery Care: Immediate assessment by pediatricians due to higher risk for neonatal depression and anomalies.
Term breech
A term breech refers to a fetus that remains in a breech position at full-term (37 weeks or later). At this stage, options for safe delivery need careful consideration due to increased risks associated with vaginal breech births.
Management of Caesarean for Breech delivery
When managing a Cesarean section for a breech presentation:
- Preoperative Preparation:
- Confirm fetal position via ultrasound.
- Discuss risks and benefits with parents.
- Surgical Procedure:
- Perform standard C-section with possible modifications based on fetal position.
- Ensure readiness for potential complications like uterine atony or excessive bleeding.
- Postoperative Care:
- Monitor mother and baby closely post-surgery for any complications.
- Provide appropriate pain management and support breastfeeding initiation.
External cephalic version
External cephalic version (ECV) is a procedure used to turn a fetus from a breech position into a head-down (vertex) position before labor begins:
- Procedure Steps:
- Performed around 36-37 weeks gestation under ultrasound guidance.
- Tocolytics may be administered to relax uterine muscles.
- Gentle pressure applied externally on maternal abdomen to rotate fetus.
- Success Rates & Risks:
- Success rates range from 50% to 60%.
- Risks include transient changes in fetal heart rate, placental abruption, or preterm labor.
- Post-procedure Monitoring:
- Continuous monitoring of fetal heart rate post-procedure.
- Follow-up ultrasound may be needed to confirm successful repositioning.