Breech Presentation: Manoeuvres, Hands-Off vs. Hands-On, and Complications

Types of Breech (Quick Orientation)

Mechanism of Labour in Breech

Manoeuvres in Breech Delivery

1. Delivery of the Legs

• Place two fingers along the fetal femur toward the popliteal fossa
• Abduct and flex the knee to bring the foot down into the vagina
• This converts a frank breech into a footling presentation for delivery

2. Delivery of the Trunk/Shoulders

• Grasp the fetal bony pelvis (thumbs on sacrum, fingers on anterior superior iliac crests) - never grip the abdomen or soft tissues
• Rotate the trunk 180° while maintaining downward traction, bringing the posterior shoulder (which was above the symphysis) to the anterior position
• Sweep the arm down across the chest and deliver it
• Reverse the rotation 180° to deliver the other arm by the same method
• This works because the posterior arm is always below the pelvic brim and can be swept out

3. Delivery of the After-Coming Head

Mauriceau-Smellie-Veit Manoeuvre (most commonly used)

• Rest the fetal body on the clinician's palm and forearm
• Place the index and middle fingers of one hand over the maxilla (not the mandible) to maintain head flexion and draw the chin in
• Hook two fingers of the other hand over the fetal neck, grasping the shoulders
• Apply downward traction until the suboccipital region appears under the symphysis
• Then elevate the body toward the mother's abdomen - this delivers the mouth, nose, brow, and occiput over the perineum
• An assistant can apply suprapubic pressure to help flex and deliver the head
• Avoid excessive elevation (hyperextension of the neck)

Burns-Marshall Method (alternative for after-coming head)

• Allow the baby to hang by its own weight for up to 1-2 minutes to encourage flexion and descent of the head
• Then hold the feet and swing the body in a wide arc upward over the mother's abdomen
• This delivers the chin, mouth, nose, and forehead in sequence over the perineum
• (Note: not favoured as much as Mauriceau because it relies on the neck as a lever)

Piper Forceps

• Applied to the after-coming head when the Mauriceau manoeuvre fails or there is difficulty
• Requires an assistant to hold the body elevated while forceps are applied from below
• Milner's data showed that application of forceps to the after-coming head was associated with reduced neonatal mortality from breech delivery
• Piper forceps should be available even at caesarean section - they can be applied through the uterine incision if there is difficulty extracting the after-coming head

The "Hands-Off" vs "Hands-On" Approach

Hands-Off (Passive / Spontaneous Delivery)

When to Use Hands-On (Active/Assisted Delivery)

1. After delivery to the umbilicus - sweep out the legs (Pinard)
2. Grasp bony pelvis for trunk rotation with downward traction
3. Lovset's manoeuvre for nuchal arms
4. Mauriceau manoeuvre for the after-coming head
5. Piper forceps if Mauriceau fails

Summary Table

Complications

Fetal / Neonatal Complications

Maternal Complications

Key Clinical Pearls

• ECV (External Cephalic Version) at 36 weeks has ~65% success and reduces CS rate by 50% - it is the preferred first step if the fetus is breech at term with intact membranes
• Vaginal breech delivery requires: frank or complete breech, fetal weight 2000-3800 g, normal gynecoid pelvis, and a flexed fetal head
• A hyperextended fetal neck on ultrasound = contraindication to vaginal delivery (high spinal injury risk)
• Oxytocin in breech labour must be used with extraordinary caution - a disproportionate number of perinatal deaths in the Term Breech Trial occurred with oxytocin-augmented labours
• Pull a 10-15 cm loop of cord after the umbilicus clears the perineum to allow working room and prevent cord traction

Breech Manoeuvres - Picture Guide

Breech Types (from Rosen's Emergency Medicine)

Manoeuvre 1 - PINARD'S MANOEUVRE

Used for: Frank breech - converting to footling to deliver legs

Steps: Two fingers along femur → reach popliteal fossa → abduct and flex the knee → foot swept down into vagina. Do this for each leg.

Manoeuvre 2 - LOVSET'S MANOEUVRE

Used for: Nuchal / extended arms - prevents arm entrapment

Steps: Grip bony pelvis (thumbs on sacrum, fingers on iliac crests) → rotate trunk 180° with downward traction → posterior arm becomes anterior → sweep arm across chest → reverse 180° for the other arm.

Manoeuvre 3 - TRUNK GRIP & SHOULDER DELIVERY

Used for: Delivering trunk and shoulders safely

Key rule: ALWAYS grip the bony pelvis - thumbs on sacrum, fingers on ASIS. NEVER grip the abdomen (causes liver/spleen rupture). Wrap body in a towel for grip.

Manoeuvre 4 - MAURICEAU-SMELLIE-VEIT MANOEUVRE

Used for: Delivering the after-coming head (first-line)

Steps: Body rests on forearm → index + middle fingers on maxilla (not mandible!) to flex head → other hand hooks two fingers over back of neck → downward traction until subocciput under symphysis → elevate body toward abdomen → mouth, nose, brow, occiput deliver. Assistant can apply suprapubic pressure.

Manoeuvre 5 - BURNS-MARSHALL METHOD

Used for: Delivering the after-coming head (alternative)

Steps: Allow baby to hang by own weight 1-2 minutes (gravity assists head descent and flexion) → grasp both ankles → swing body in a wide arc upward over mother's abdomen → chin, mouth, nose, forehead deliver over perineum sequentially.

Manoeuvre 6 - PIPER FORCEPS

Used for: After-coming head when Mauriceau fails

Steps: Assistant holds baby body elevated upward → clinician applies Piper forceps blades to sides of the head from below → traction downward first, then arc upward to deliver head. Also used through uterine incision at caesarean if head delivery is difficult.

Summary Sequence

LEGS born → PINARD'S (frank breech)
     ↓
TRUNK descends → LOVSET'S (if arms nuchal/extended)
     ↓
SHOULDER DELIVERY → correct bony pelvis grip + rotation
     ↓
AFTER-COMING HEAD → MAURICEAU-SMELLIE-VEIT (first line)
                  → BURNS-MARSHALL (alternative)
                  → PIPER FORCEPS (if above fail)