in breech baby presentation tell me the Manoeuvres used, Hands Off and on approach and foetal and maternal Complications
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Breech Presentation: Manoeuvres, Hands-Off vs. Hands-On, and Complications
Types of Breech (Quick Orientation)
| Type | Features | Cord Prolapse Risk |
|---|---|---|
| Frank breech | Hips flexed, knees extended - 60-65% of breeches | ~0.5% |
| Complete breech | Hips and knees flexed - ~5% of breeches | ~5-6% |
| Incomplete (footling) | Incomplete hip flexion, single/double footling - 25-35% | 15-18% |
Mechanism of Labour in Breech
The widest engaging diameter is the bitrochanteric diameter, which enters in an oblique diameter of the inlet. As descent occurs, the anterior hip descends faster, internal rotation brings the bitrochanteric diameter into the AP position, and lateral flexion delivers the posterior hip first. The shoulders then engage obliquely and follow the same sequence. The head engages in the same diameter as the shoulders, then undergoes flexion, descent, and rotation to bring the posterior neck under the symphysis - and is born in flexion.
Manoeuvres in Breech Delivery
1. Delivery of the Legs
Pinard's Manoeuvre - Used in frank breech to deliver 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
For complete/footling breech: legs may deliver spontaneously. Splint the medial thigh with fingers parallel to the femur and sweep laterally to assist.
2. Delivery of the Trunk/Shoulders
Lovset's Manoeuvre - For delivery of the arms (especially nuchal/extended arms):
- 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
Standard Shoulder Delivery (without nuchal arms):
Once scapulae are visible, rotate the trunk to bring the anterior shoulder/arm to the vulva and sweep the arm across the chest. Then rotate in reverse to deliver the second arm.
Important grip during trunk delivery: Both hands grasp the bony pelvis with fingers on the iliac crests and thumbs on the sacrum. Wrapping the body in a towel helps grip. Apply gentle downward traction with maternal expulsive efforts - never pull on the abdomen or umbilical cord.
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
This is a foundational principle in breech delivery:
Hands-Off (Passive / Spontaneous Delivery)
The clinician supports but does not pull or extract the fetus. Maternal expulsive efforts do the work.
| Principle | Detail |
|---|---|
| Allow spontaneous expulsion to the umbilicus before intervening | Ensures full cervical dilatation and adequate pelvic space |
| Support - do not traction - the presenting part | Premature traction can trap the after-coming head |
| In frank breech: allow descent to the umbilicus before any manipulation | "The mere appearance of feet through the vulva is NOT an indication to proceed" |
| Grip the bony pelvis, not the abdomen | Abdominal pressure can cause liver/splenic injury |
The Roberts & Hedges text states explicitly: "Avoid fetal traction and apply fetal manipulation only after spontaneous delivery to the level of the umbilicus."
When to Use Hands-On (Active/Assisted Delivery)
Hands are applied only at specific, defined steps:
- After delivery to the umbilicus - sweep out the legs (Pinard)
- Grasp bony pelvis for trunk rotation with downward traction
- Lovset's manoeuvre for nuchal arms
- Mauriceau manoeuvre for the after-coming head
- Piper forceps if Mauriceau fails
Premature or aggressive assistance/traction is one of the most common causes of fetal morbidity in breech delivery.
Summary Table
| Hands-Off Scenarios | Hands-On Scenarios |
|---|---|
| Spontaneous descent of buttocks | After umbilicus delivers - assist legs |
| Allow legs to deliver spontaneously | Lovset's for nuchal/extended arms |
| Maternal effort delivering trunk | Grasp bony pelvis for body rotation |
| Waiting for full cervical dilatation | Mauriceau for after-coming head |
| Do NOT rupture membranes prematurely | Piper forceps for failed Mauriceau |
Complications
Fetal / Neonatal Complications
| Complication | Mechanism / Notes |
|---|---|
| Umbilical cord prolapse | Most common in footling breech (15-18%); presenting part does not occlude the os - cord can slip past |
| Entrapment of the after-coming head | Especially in preterm infants (<1500 g) and with CPD; cervix closes around the neck after body delivers |
| Intracranial haemorrhage / tentorial tears | Rapid, uncontrolled delivery of the head; also from inadequate pelvic capacity |
| Brachial plexus injury | Excessive lateral traction during shoulder delivery |
| Nuchal arm entrapment | Arm extends behind the neck, greatly increases dystocia of the head |
| Spinal cord injury | If neck is hyperextended; vaginal delivery with hyperextended neck is associated with a high incidence of cord injuries |
| Birth asphyxia | From cord compression, head entrapment, or traumatic delivery |
| Liver / splenic rupture | Abdominal grip (instead of bony pelvis grip) during extraction |
| Hip dislocation / femur fracture | Inappropriate traction on legs |
| Perinatal death | Overall, one-third of breech fetal deaths are considered preventable; primarily from asphyxia (cord prolapse or head entrapment) |
Neurological outcome is also influenced by why the fetus is in breech - infants with neuromuscular disorders have higher breech rates, and studies show these children score lower on motor skills regardless of delivery method.
Maternal Complications
| Complication | Notes |
|---|---|
| Perineal lacerations (3rd/4th degree) | Larger presenting part, need for episiotomy, especially with delivery of after-coming head |
| Cervical and vaginal lacerations | From rapid forceful delivery or instrumentation |
| Postpartum haemorrhage | Higher operative delivery rates; uterine atony following prolonged/traumatic labour |
| Uterine rupture | From obstructed labour, especially with footling or transverse lie |
| Increased caesarean section rate | Primary planned CS is now standard for most term breeches; failed trial of labour leads to emergency CS with higher morbidity |
| Complications of general/regional anaesthesia | More operative deliveries |
| Psychological trauma | Emergency unplanned breech delivery in an obstetric/ED setting |
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
Sources: Creasy & Resnik's Maternal-Fetal Medicine, 9e; Roberts and Hedges' Clinical Procedures in Emergency Medicine, 7e; Rosen's Emergency Medicine, 9e
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