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breech - ms obg final exam long answer -with viva questions

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Breech presentation: MS OBG final-exam topic map
  1. Definition, incidence, and types
  2. Predisposing factors and aetiology
  3. Diagnosis: abdominal examination, vaginal examination, ultrasound
  4. Antenatal management and external cephalic version
  5. Selection for vaginal breech delivery versus caesarean delivery
  6. Conduct of assisted vaginal breech delivery
  7. Special manoeuvres for extended arms and after-coming head
  8. Complications and neonatal outcomes
  9. Viva questions with model answers
High-level overview: Breech presentation is a longitudinal lie in which the fetal buttocks or lower limbs present at the pelvic inlet. At term, planned caesarean delivery is commonly preferred for many singleton breech pregnancies, but a carefully selected vaginal breech delivery remains an option when criteria are favourable and an experienced obstetrician, anaesthesia, neonatal resuscitation, and immediate caesarean capability are available. External cephalic version at about 36-37 weeks can reduce the number of persistent breech presentations and caesarean births.
Which section would you like as the detailed long answer first?
  1. Complete exam answer
  2. Vaginal breech delivery and manoeuvres
  3. ECV and antenatal management
  4. Viva questions only

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mkdir -p "/tmp/workspace/breech-quick-reference/src" "/tmp/workspace/breech-quick-reference/output" && python - <<'PY' from reportlab.lib.pagesizes import A4 from reportlab.lib import colors from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle from reportlab.lib.enums import TA_CENTER from reportlab.lib.units import cm from reportlab.platypus import SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle, PageBreak, KeepTogether from reportlab.pdfbase.ttfonts import TTFont from reportlab.pdfbase import pdfmetrics from reportlab.lib.colors import HexColor from reportlab.pdfbase.pdfmetrics import stringWidth from reportlab.pdfgen.canvas import Canvas from reportlab.lib.pagesizes import A4 from reportlab.lib.units import mm from reportlab.pdfbase.pdfmetrics import registerFontFamily out='/tmp/workspace/breech-quick-reference/output/Breech_Presentation_Quick_Reference.pdf' W,H=A4 NAVY=HexColor('#12304A'); TEAL=HexColor('#007C83'); PALE=HexColor('#EAF4F4'); RED=HexColor('#A32638'); GOLD=HexColor('#F2C14E'); GREY=HexColor('#4A5560') styles=getSampleStyleSheet() styles.add(ParagraphStyle(name='TitleX', parent=styles['Title'], fontName='Helvetica-Bold', fontSize=21, leading=25, textColor=NAVY, alignment=TA_CENTER, spaceAfter=4)) styles.add(ParagraphStyle(name='Sub', parent=styles['Normal'], fontSize=9.5, leading=12, alignment=TA_CENTER, textColor=GREY, spaceAfter=10)) styles.add(ParagraphStyle(name='H', parent=styles['Heading2'], fontName='Helvetica-Bold', fontSize=12, leading=14, textColor=NAVY, spaceBefore=8, spaceAfter=5)) styles.add(ParagraphStyle(name='BodyX', parent=styles['BodyText'], fontSize=8.45, leading=11, spaceAfter=3)) styles.add(ParagraphStyle(name='Small', parent=styles['BodyText'], fontSize=7.5, leading=9.2, spaceAfter=2)) styles.add(ParagraphStyle(name='Q', parent=styles['BodyText'], fontSize=8.6, leading=10.8, leftIndent=0, spaceAfter=4)) def P(txt, sty='BodyX'): return Paragraph(txt, styles[sty]) def bullet(items): return [P('• '+x) for x in items] def section(title, content): return [P(title,'H')] + content def box(title, lines, color=TEAL): data=[[P('<b>'+title+'</b>','BodyX')],[P('<br/>'.join('• '+x for x in lines),'BodyX')]] t=Table(data, colWidths=[17.3*cm]) t.setStyle(TableStyle([('BACKGROUND',(0,0),(-1,0),color),('TEXTCOLOR',(0,0),(-1,0),colors.white),('BACKGROUND',(0,1),(-1,-1),PALE),('BOX',(0,0),(-1,-1),0.6,color),('LEFTPADDING',(0,0),(-1,-1),7),('RIGHTPADDING',(0,0),(-1,-1),7),('TOPPADDING',(0,0),(-1,-1),5),('BOTTOMPADDING',(0,0),(-1,-1),5)])) return t def footer(canvas, doc): canvas.saveState(); canvas.setStrokeColor(TEAL); canvas.setLineWidth(.5); canvas.line(18*mm,15*mm,W-18*mm,15*mm) canvas.setFont('Helvetica',7.5); canvas.setFillColor(GREY) canvas.drawString(18*mm,10.5*mm,'Breech presentation quick-reference | Educational use: follow local protocol and senior supervision') canvas.drawRightString(W-18*mm,10.5*mm,f'Page {doc.page}') canvas.restoreState() doc=SimpleDocTemplate(out,pagesize=A4,rightMargin=18*mm,leftMargin=18*mm,topMargin=14*mm,bottomMargin=20*mm,title='Breech Presentation Quick Reference') story=[] story += [P('BREECH PRESENTATION','TitleX'), P('MS Obstetrics & Gynaecology final exam | Quick-reference for theory, labour ward, and viva','Sub')] story.append(box('EXAM ONE-LINER',["Breech presentation is a longitudinal lie in which the fetal buttocks or lower limbs present at the pelvic inlet.","At term it occurs in about 3-4% of pregnancies. Confirm by ultrasound, offer ECV when appropriate, then individualise planned caesarean versus planned vaginal birth."])) story += section('1. Classification', bullet([ '<b>Frank breech:</b> hips flexed, knees extended; buttocks present.', '<b>Complete breech:</b> hips and knees flexed; buttocks and feet present.', '<b>Footling / incomplete breech:</b> one or both feet present below buttocks. High cord-prolapse risk.', '<b>Kneeling breech:</b> rare.' ])) story += section('2. Why breech occurs', bullet([ 'Prematurity; uterine anomaly or fibroids; placenta praevia/fundal placentation; polyhydramnios or oligohydramnios.', 'Multiple pregnancy; fetal anomaly or neuromuscular disorder; previous breech presentation. In many cases no cause is found.' ])) story += section('3. Diagnosis', bullet([ '<b>Abdominal examination:</b> hard, ballotable head in fundus; soft irregular breech in lower pole; fetal heart often heard above umbilicus.', '<b>Vaginal examination:</b> sacrum, ischial tuberosities, anus, genitalia or feet. Do not confuse a foot with a hand: heel and non-opposable toes help identify a foot.', '<b>Ultrasound:</b> confirm lie/type, placental site, estimated fetal weight, liquor, fetal anatomy and head attitude (flexion versus hyperextension).' ])) story.append(box('CORE RISKS', ['Cord prolapse, especially footling breech or after membrane rupture.','Fetal hypoxia due to cord compression.','Entrapment of the after-coming head, especially preterm birth or incomplete cervical dilatation.','Birth trauma, including arm injury, cervical spine injury and intracranial haemorrhage.'], RED)) story += section('4. Antenatal plan at term', bullet([ 'If breech persists at about <b>36-37 weeks</b>, confirm with ultrasound; discuss options, informed consent and local expertise.', '<b>Offer external cephalic version (ECV)</b> if no contraindication to vaginal birth. Perform where ultrasound, fetal monitoring, anti-D for eligible RhD-negative patients, and immediate caesarean capability are available.', 'If ECV is declined, contraindicated or unsuccessful: counsel on planned caesarean birth versus a planned vaginal breech birth in a suitably selected patient and experienced unit.', 'Planned caesarean is usually recommended for contraindications to vaginal birth, footling presentation, fetal compromise/anomaly, hyperextended head, suspected fetopelvic disproportion, or absent skilled team.' ])) story.append(PageBreak()) story += [P('VAGINAL BREECH DELIVERY: SAFE SYSTEM','TitleX'),P('Only in a selected patient, after counselling, with continuous intrapartum assessment and an immediately available skilled team. Criteria vary by guideline and institution.','Sub')] story += section('5. Reasonable selection features for planned vaginal breech birth', bullet([ 'Term singleton, frank or complete breech; clinically adequate pelvis; spontaneous labour with normal progress.', 'Estimated fetal weight commonly within a moderate range, often roughly <b>2.0-3.8 kg</b> in classic selection protocols. Use local policy rather than a single universal cut-off.', 'Flexed fetal head, no major fetal anomaly likely to impede vaginal birth, reassuring fetal status.', 'Experienced obstetrician present or immediately available; anaesthesia, neonatal team, theatre and caesarean capability ready.' ])) story += section('6. Intrapartum checklist', bullet([ 'Inform senior obstetrician, anaesthetist and neonatal team. Secure IV access, group-and-save/crossmatch as indicated; prepare warm neonatal resuscitaire and instruments including Piper forceps if used locally.', 'Continuous electronic fetal monitoring. Avoid unnecessary amniotomy: retain membranes until established labour where feasible to reduce cord prolapse risk.', 'Confirm full cervical dilatation before active traction. Avoid routine induction/augmentation unless a senior obstetric decision under local protocol.', 'Mother in lithotomy or all-fours according to clinical situation and team expertise. Episiotomy only if required for delivery or manoeuvres.' ])) story.append(box('PRINCIPLE: “HANDS OFF THE BREECH”',["Allow spontaneous descent to the umbilicus/scapulae. Premature traction can cause arm extension, head deflexion and entrapment.","When assistance is required, hold the bony pelvis, not the abdomen or soft tissues."],TEAL)) story += section('7. Mechanism and assisted delivery sequence', bullet([ '<b>Buttocks to umbilicus:</b> spontaneous delivery. If legs extended, gently flex at knee and sweep each leg down only when needed (Pinard manoeuvre).', '<b>Umbilicus to scapulae:</b> maintain the fetus with sacrum anterior; a loop of cord may be gently drawn down only enough to prevent traction.', '<b>Arms:</b> normally deliver by sweeping the humerus across the chest and out. If nuchal arms, use <b>Lovset manoeuvre</b>: rotate trunk 180° to bring posterior shoulder anterior, deliver arm; rotate opposite way and deliver other arm.', '<b>After-coming head:</b> keep head flexed. Options include <b>modified Mauriceau-Smellie-Veit manoeuvre</b>, <b>Burns-Marshall manoeuvre</b>, or <b>Piper forceps</b> by an experienced operator. Apply suprapubic pressure to aid flexion and descent.' ])) story += section('8. Emergency problems', bullet([ '<b>Cord prolapse:</b> call for help, elevate presenting part, avoid handling cord, maternal knee-chest/left lateral head-down position as appropriate, expedite birth, usually emergency caesarean if vaginal birth is not imminent.', '<b>Arms extended/nuchal:</b> Lovset manoeuvre. Do not pull on the fetus or arm.', '<b>After-coming head delayed:</b> ensure full dilatation, assistant gives suprapubic pressure, use a skilled head-delivery manoeuvre or Piper forceps. If cervix traps head, senior obstetric emergency management is required.', '<b>Fetal compromise or poor progress:</b> do not persist with a difficult vaginal breech birth. Expedite delivery according to station and circumstances.' ])) story.append(PageBreak()) story += [P('VIVA: HIGH-YIELD QUESTIONS','TitleX'),P('Give a definition first, then a safe, structured answer.','Sub')] qas=[ ('1. Define breech presentation.','A longitudinal lie in which the fetal buttocks or lower limbs present at the pelvic inlet.'), ('2. Name the types.','Frank, complete, footling/incomplete, and kneeling breech.'), ('3. What is the commonest type?','Frank breech.'), ('4. What is the incidence at term?','Approximately 3-4%; frequency falls as gestation advances.'), ('5. What causes breech presentation?','Prematurity, uterine/placental factors, abnormal liquor volume, multiple pregnancy, fetal anomaly or reduced fetal mobility, and prior breech. Often idiopathic.'), ('6. How do you confirm the diagnosis?','Abdominal examination plus ultrasound. Ultrasound determines type, head attitude, growth, liquor, placenta and anomalies.'), ('7. When do you offer ECV?','Usually at 36-37 weeks in a suitable singleton breech pregnancy, in a setting able to monitor the fetus and undertake urgent caesarean if required.'), ('8. What are broad contraindications to ECV?','Any contraindication to vaginal birth, such as placenta praevia or major antepartum bleeding, and situations where fetal or maternal safety makes manipulation unsuitable. Use local protocol.'), ('9. What is the greatest risk in footling breech?','Umbilical cord prolapse.'), ('10. Which factors favour planned vaginal breech birth?','Term singleton, frank/complete breech, flexed head, appropriate estimated fetal size, adequate pelvis, reassuring fetal status, spontaneous progressive labour, informed patient, and expert team.'), ('11. State the cardinal rule of assisted breech delivery.','Hands off until the breech delivers spontaneously to the umbilicus/scapulae, unless intervention is indicated.'), ('12. How are extended legs delivered?','Pinard manoeuvre: flex the knee by pressure in the popliteal fossa and sweep the foot down.'), ('13. How are nuchal arms delivered?','Lovset manoeuvre, with controlled rotation of the trunk to deliver each arm.'), ('14. How do you deliver the after-coming head?','Maintain flexion, use suprapubic pressure and a skilled manoeuvre such as modified Mauriceau-Smellie-Veit, Burns-Marshall, or Piper forceps where appropriate.'), ('15. What are the key fetal complications?','Cord prolapse/compression, asphyxia, head entrapment and birth trauma.'), ('16. Why should early traction be avoided?','It may extend the arms or deflex the head, making delivery difficult and traumatic.'), ('17. What must be available for planned vaginal breech birth?','Experienced obstetrician, continuous fetal monitoring, anaesthesia, neonatal resuscitation, theatre and immediate caesarean capability.'), ] for q,a in qas: story.append(P('<b>'+q+'</b><br/><font color="#4A5560">'+a+'</font>','Q')) story += section('Remember for the examiner', [P('<b>“Breech vaginal birth is not a routine delivery. It is a planned, team-based procedure requiring correct case selection, informed consent, continuous fetal assessment, skilled manoeuvres and readiness for immediate caesarean delivery.”</b>','BodyX')]) story += section('Sources and update note', [P('Core factual content: <i>Creasy & Resnik’s Maternal-Fetal Medicine: Principles and Practice</i>, Breech Presentation and Breech Vaginal Delivery, pp. 953-955. Current context: RCOG Green-top Guideline 20a (ECV) and 20b (Management of Breech Presentation), 2017. A 2024 systematic review (PMID 39154352) reports variation and ongoing controversy in national contraindications for vaginal breech delivery. This sheet supports revision, not bedside substitution for current local policy.','Small')]) doc.build(story,onFirstPage=footer,onLaterPages=footer) print(out) PY python - <<'PY' from pypdf import PdfReader p='/tmp/workspace/breech-quick-reference/output/Breech_Presentation_Quick_Reference.pdf' r=PdfReader(p) print('pages',len(r.pages),'bytes',__import__('os').path.getsize(p)) for i,page in enumerate(r.pages): text=page.extract_text() or '' print(i+1, len(text), text[:55].replace('\n',' | ')) PY

Breech Presentation Quick Reference

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Includes classification, diagnosis, ECV, vaginal breech selection and manoeuvres, complications, and 17 high-yield viva questions with answers.

Complete exam answer

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RCOG breech presentation guideline ECV vaginal breech delivery selection 2025

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diagram of vaginal breech delivery mechanisms and assisted maneuvers

Breech Presentation

Definition

Breech presentation is a longitudinal lie in which the fetal buttocks, feet, or both present at the pelvic inlet, with the fetal head occupying the uterine fundus.
It occurs in approximately 3-4% of term pregnancies and is more frequent earlier in pregnancy because many fetuses turn spontaneously to cephalic presentation with advancing gestation. Creasy & Resnik’s Maternal-Fetal Medicine, pp. 953-954.

Classification

TypeDescriptionFrequency / importance
Frank breechHips flexed, knees extended; buttocks present firstCommonest type
Complete breechHips and knees flexed; buttocks and feet presentLess common
Incomplete breech / footlingOne or both hips not flexed; one or both feet present below buttocksHigh risk of cord prolapse
Kneeling breechHips extended, knees flexedRare

Denominator and position

  • Denominator: Sacrum.
  • Positions: Left sacro-anterior (LSA), right sacro-anterior (RSA), left sacro-transverse (LST), right sacro-transverse (RST), left sacro-posterior (LSP), right sacro-posterior (RSP).
  • The commonest position is left sacro-anterior.

Incidence

  • Approximately 3-4% at term.
  • Frequency decreases with gestational age.
  • It is common in preterm labour.
  • It is more frequent in nulliparous women. The RCOG breech guideline notes its association with uterine and congenital abnormalities and recurrence in future pregnancies.

Aetiology and Predisposing Factors

Maternal factors

  • Uterine malformations, such as bicornuate or septate uterus
  • Fibroids, especially lower-segment fibroids
  • Placenta praevia or fundal/cornual placentation
  • Multiparity with lax uterine and abdominal musculature
  • Pelvic tumour
  • Previous breech pregnancy

Fetal factors

  • Prematurity
  • Multiple pregnancy
  • Fetal growth restriction
  • Congenital anomalies:
    • Hydrocephalus
    • Anencephaly
    • Neuromuscular disorders
    • Fetal neck masses
  • Short umbilical cord

Liquor abnormalities

  • Polyhydramnios
  • Oligohydramnios
A breech fetus may reflect an underlying limitation in fetal movement or intrauterine space rather than simply an abnormal fetal position. Creasy & Resnik’s Maternal-Fetal Medicine, p. 953.

Diagnosis

1. History

The mother may report:
  • Fetal kicks felt in the lower abdomen
  • A hard mass felt in the fundus
  • Discomfort under the ribs due to the fetal head

2. Abdominal examination

Inspection

  • Longitudinal lie
  • Fundal height may be greater than expected because the hard head occupies the fundus

Palpation

  • Fundus: hard, smooth, round, ballotable fetal head
  • Lower pole: soft, broad, irregular, less ballotable breech
  • Lateral grips: fetal back on one side, small parts on the other
  • Pelvic grip: breech may be felt above the pelvic brim

Auscultation

  • Fetal heart sound is usually heard above the umbilicus.

3. Vaginal examination

Done during labour or if necessary after excluding placenta praevia.
Findings:
  • Soft irregular mass
  • Sacrum, ischial tuberosities, anus, and genitalia may be identified
  • In footling breech, one or both feet may be palpable
Differentiating foot from hand:
FootHand
Heel is palpableNo heel
Toes are in one planeThumb is opposable
Ankle movement is limitedFingers are long and mobile

4. Ultrasonography

Ultrasound is essential to:
  • Confirm breech presentation and type
  • Identify placental location
  • Estimate fetal weight
  • Assess amniotic fluid
  • Exclude gross congenital malformations
  • Assess fetal head attitude, particularly hyperextension
  • Assess cord position where relevant

Complications of Breech Presentation

Fetal and neonatal complications

  • Cord prolapse, especially in footling breech
  • Cord compression and fetal hypoxia
  • Birth asphyxia
  • Entrapment of the after-coming head
  • Extended arms or nuchal arms
  • Birth trauma:
    • Fracture humerus or clavicle
    • Brachial plexus injury
    • Cervical spine injury
    • Intracranial haemorrhage
    • Genital injury
  • Prematurity-related complications
The major specific dangers are cord prolapse, head entrapment due to an incompletely dilated cervix, and trauma caused by arm extension or head deflexion. Creasy & Resnik’s Maternal-Fetal Medicine, p. 953.

Maternal complications

  • Perineal tears and cervical tears
  • Postpartum haemorrhage
  • Operative delivery complications
  • Risks associated with caesarean birth, including future placenta accreta spectrum and uterine scar complications

Management

Management depends on gestational age, type of breech, fetal size, fetal wellbeing, parity, pelvic adequacy, labour progress, and availability of a skilled obstetric team.

A. Antenatal Management

Before 36 weeks

  • Explain that spontaneous version is common before term.
  • Evaluate for associated maternal, placental, liquor, or fetal conditions.
  • Perform ultrasound if presentation is uncertain or persists.

At 36-37 weeks

If breech persists:
  1. Confirm by ultrasound.
  2. Counsel regarding:
    • External cephalic version
    • Planned caesarean delivery
    • Planned vaginal breech birth in appropriately selected cases
  3. Document informed consent and the woman's preference.
  4. Plan delivery in a unit with obstetric, anaesthetic, neonatal, and emergency theatre facilities.

B. External Cephalic Version

Definition

External cephalic version (ECV) is manual conversion of a breech fetus to cephalic presentation by abdominal manipulation.

Timing

  • Usually offered at 36-37 weeks in a suitable singleton pregnancy.
  • It should be done in hospital, with ultrasound and fetal monitoring, where emergency caesarean delivery can be performed.
The RCOG ECV guideline supports ECV to reduce persistent term breech presentation and related caesarean birth.

Prerequisites

  • Confirmed breech presentation
  • Live singleton fetus
  • Intact membranes
  • Reassuring fetal heart rate
  • Ultrasound assessment of placenta, liquor, fetal anatomy, head position, and estimated fetal weight
  • Informed consent
  • Facilities for immediate caesarean birth
  • Anti-D prophylaxis as appropriate for an unsensitised RhD-negative patient

Contraindications

Contraindications vary across guidelines and should follow local protocol. Important situations where ECV is generally avoided include:
  • Contraindication to vaginal birth, such as placenta praevia
  • Antepartum haemorrhage
  • Ruptured membranes or established labour in many cases
  • Multiple pregnancy, except selected specialist situations
  • Major uterine anomaly
  • Significant oligohydramnios
  • Fetal compromise or uteroplacental insufficiency
  • Major fetal anomaly
  • Suspected cephalopelvic disproportion

Technique

  1. Obtain baseline CTG/non-stress test.
  2. Perform ultrasound assessment.
  3. Give tocolysis if indicated by local protocol.
  4. Elevate the breech from the pelvis.
  5. Guide the breech laterally and upwards while rotating the head in the opposite direction.
  6. Attempt a forward roll first; a backward roll may be attempted if unsuccessful.
  7. Reassess fetal heart rate during and after the procedure.
  8. Continue post-procedure fetal monitoring.

Success and complications

  • Success is higher in multiparity, adequate liquor, non-engaged breech, posterior placenta, and smaller fetus.
  • The textbook reports about 65% success at 36 weeks and a reduction in caesarean birth after successful ECV, though exact rates vary by setting. Creasy & Resnik’s Maternal-Fetal Medicine, pp. 955-956.
  • Transient fetal bradycardia can occur.
  • Rare serious complications include placental abruption, persistent fetal bradycardia, fetomaternal haemorrhage, cord complications, and emergency caesarean delivery.

C. Choice of Mode of Delivery at Term

1. Planned caesarean delivery

Planned caesarean delivery is commonly advised if:
  • ECV is contraindicated, declined, or unsuccessful
  • Footling breech
  • Hyperextended fetal head
  • Suspected fetal macrosomia or very small fetus, depending on local criteria
  • Fetal growth restriction with compromise
  • Major fetal anomaly
  • Placenta praevia
  • Previous difficult breech delivery or suspected contracted pelvis
  • Lack of an experienced breech-delivery team
  • Non-reassuring fetal status
  • Poor labour progress
A large randomized trial reported higher short-term perinatal morbidity and mortality with planned vaginal breech birth than planned caesarean birth, which greatly changed practice. Creasy & Resnik’s Maternal-Fetal Medicine, pp. 953-954.

2. Planned vaginal breech delivery

A planned vaginal breech birth may be considered only after informed counselling, strict selection, and the presence of a skilled obstetrician with immediate access to caesarean delivery.

Favourable criteria

  • Term singleton pregnancy
  • Frank or complete breech
  • Estimated fetal weight in an acceptable range, commonly about 2.0-3.8 kg in traditional protocols
  • Flexed fetal head
  • Clinically adequate pelvis
  • No fetal anomaly likely to obstruct vaginal birth
  • Spontaneous labour with satisfactory progress
  • Reassuring fetal monitoring
  • Skilled obstetrician, anaesthetist, neonatal team, and theatre immediately available
Creasy & Resnik’s Maternal-Fetal Medicine, p. 954.
Exam point: Planned vaginal breech birth is not routine. It is a specialised, team-based delivery requiring careful case selection and documented informed consent.
A 2024 systematic review found that national guidelines differ in their contraindications for vaginal breech birth, underlining the need to follow local institutional policy and clinician expertise (PMID 39154352).

Conduct of Assisted Vaginal Breech Delivery

Preparation

  • Inform senior obstetrician, anaesthetist, paediatrician/neonatologist, and theatre team.
  • Ensure IV access, blood availability as appropriate, neonatal resuscitation equipment, and access to Piper forceps if used locally.
  • Continuous electronic fetal monitoring.
  • Avoid early amniotomy where possible because intact membranes lessen cord-prolapse risk.
  • Encourage bladder emptying.
  • Lithotomy position is commonly used. All-fours may be used in selected settings with trained personnel.
  • Adequate analgesia or anaesthesia as required.
  • Episiotomy only if necessary.

Cardinal principle

“Hands off the breech”

Allow spontaneous descent and delivery until the fetus reaches the umbilicus or scapulae.
Premature traction may:
  • Extend the arms
  • Deflex the head
  • Cause head entrapment
  • Produce fetal trauma

Mechanism of Breech Delivery

  1. Engagement of bitrochanteric diameter in an oblique diameter of the pelvis.
  2. Descent with internal rotation of the sacrum anteriorly.
  3. Delivery of buttocks and trunk by lateral flexion.
  4. Delivery of legs, if not already delivered.
  5. Delivery of shoulders with bisacromial diameter entering the pelvis.
  6. Internal rotation of shoulders into anteroposterior diameter.
  7. Delivery of arms.
  8. Delivery of after-coming head by flexion.

Steps of Assisted Breech Delivery

1. Delivery of buttocks and trunk

  • Allow spontaneous delivery to the umbilicus.
  • Hold the fetus by the bony pelvis, not by the abdomen or soft tissues.
  • Keep the fetal back uppermost, with sacrum anterior where possible.

2. Delivery of extended legs: Pinard manoeuvre

Indication: legs remain extended alongside the fetal trunk.
Method:
  • Insert fingers along the thigh to the popliteal fossa.
  • Apply pressure behind the knee to flex it.
  • Sweep the lower leg and foot downward over the fetal abdomen.
  • Repeat on the other side if required.

3. Delivery of arms

Normally, the arms deliver spontaneously as the trunk rotates.
If an arm is retained:
  • Sweep the arm across the fetal chest and face, then out over the perineum.

4. Nuchal arms: Lovset manoeuvre

Indication: one or both arms are extended above or behind the fetal head.
Method:
  1. Hold the fetus by the bony pelvis.
  2. Rotate the trunk through 180 degrees so the posterior shoulder becomes anterior under the symphysis pubis.
  3. Sweep out the anterior arm.
  4. Rotate in the opposite direction.
  5. Deliver the other arm.
Do not pull directly on the arm.

5. Delivery of the after-coming head

Modified Mauriceau-Smellie-Veit manoeuvre

  1. Lay the fetal body over the operator's forearm.
  2. Place one or two fingers on the maxilla or cheekbones to maintain flexion. Avoid pressure on the soft floor of the mouth.
  3. The other hand supports the shoulders.
  4. An assistant applies suprapubic pressure to maintain head flexion and aid descent.
  5. Deliver the head by downward traction until the nape of neck is visible under the symphysis, then lift the body in an arc toward the maternal abdomen.

Burns-Marshall manoeuvre

  • Allow the fetal body to hang briefly until the nape of the neck is visible.
  • Grasp the ankles and elevate the body in a wide arc over the maternal abdomen to deliver the head.
  • Use only in an appropriate situation and by a trained operator.

Piper forceps

  • Used by an experienced obstetrician for the after-coming head.
  • The fetal body is supported while the forceps are applied to the head.
  • Particularly useful when rapid controlled delivery of the after-coming head is necessary.
Forceps are especially useful for the after-coming head in breech delivery, but their use requires substantial expertise. Creasy & Resnik’s Maternal-Fetal Medicine, p. 955.

Management of Complications

1. Cord prolapse

More common in footling breech.

Management

  • Call for help.
  • Avoid handling the cord unnecessarily.
  • Elevate the presenting part digitally to relieve cord compression.
  • Position mother in knee-chest or left lateral head-down position as appropriate.
  • Give oxygen only if clinically indicated for maternal hypoxaemia, not routinely.
  • Expedite delivery:
    • Emergency caesarean if vaginal birth is not imminent
    • Immediate vaginal delivery only if fully dilated and birth can be safely completed rapidly

2. Nuchal arms

  • Perform Lovset manoeuvre.
  • Avoid forceful downward traction.

3. Entrapment of after-coming head

Risk factors:
  • Prematurity
  • Incomplete cervical dilatation
  • Deflexed head
  • Cephalopelvic disproportion

Management

  • Call senior obstetrician and anaesthetist urgently.
  • Ensure suprapubic pressure to maintain flexion.
  • Use Mauriceau-Smellie-Veit manoeuvre or Piper forceps where skilled.
  • If the cervix is trapping the head, urgent specialist management is required. Do not attempt uncontrolled traction.

4. Fetal distress or poor progress

  • Reassess immediately.
  • Do not continue a difficult breech vaginal birth without clear progress.
  • Proceed to emergency caesarean delivery if birth is not imminent and safe vaginal completion is not possible.

Conclusion

Breech presentation is an important malpresentation associated with increased fetal risk, especially cord prolapse, hypoxia, birth trauma, and entrapment of the after-coming head. At 36-37 weeks, a suitable patient should be offered ECV. If breech persists, planned caesarean birth is commonly selected, while vaginal breech birth remains an option only in carefully selected term pregnancies managed by a skilled multidisciplinary team with immediate access to emergency caesarean delivery.
Final exam line:
The safety of vaginal breech delivery depends not only on fetal and maternal selection criteria, but also on the presence of an experienced obstetrician and immediate operative and neonatal support.
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