Breech / compound presentation: (Imminent birth)
 
Assess

• Stage of Labour and birth imminent
• Buttocks or both feet presenting first
• One foot or hand/arm presenting first
   
Stop

• Do not attempt delivery of one foot or hand/arm presentation
• Only proceed with delivery if birth is imminent
           
Non imminent birth
General maternal care
Transport to booked obstetric unit with notification
 
   
One foot, hand or arm presenting
Do not attempt to deliver
Transport urgently to an obstetric unit with notification
Consult with PERS for advice
       
Imminent breech birth - buttocks or both feet presenting

Manage as per Normal Birth except for:
  - Request urgent assistance
  - Allow the birth to occur spontaneousl
  - Position mother with buttocks to bed edge and legs supported to allow gravity to assist
  - Do not touch baby as it emerges 
  - Hands off the breech
  - The birth of buttocks/feet will occur slowly
   
Buttocks first presentation – delivery of body/legs

• This is the most common presentation
• Do not attempt to pull the baby out
• Encourage mother to push hard with contractions
• Feet and legs should spring free
• Await further descent
• Keep body warm by wrapping in a towel or bubble wrap if needed
• The body will further descend to the clavicles and arms should swing free
• Let baby hang until the nape of neck is visible Assist birth of the head using modified Mauriceau Smellie Veit Manoeuvre
   
Buttocks first presentation - delivery of head
Modified Mauriceau Smellie Veit Manoeuvre

• Place the index and ring finger of non dominant hand on the baby's shoulders and middle finger on the occiput to assist with flexion of the head
• Place dominant hand under the baby to support the body, with ring and index fingers on the baby's cheekbones
• Slowly lift the baby straight up in a circle onto the mother's abdomen, allowing the head to birth slowly
• An assistant can aid flexion of head by applying direct pressure behind the pubic bone (shown right)

  
   
Buttocks first presentation - back not uppermost

• The baby's back needs to remain uppermost
• If legs delivered and back is not uppermost
  - Gently hold the baby by placing thumbs on bony sacrum with fingers around thighs
  - Do not squeeze the abdomen
  - Rotate/turn baby uppermost between contractions taking care of baby's spine
  - Take great care to never pull the baby
   
Buttocks first presentation - legs don't birth spontaneously

• If extended legs (frank breech)
  - slip one hand along the leg of the baby lying anteriorly
  - place a finger behind the baby's knee and deliver it by flexion and abduction
   
Buttocks first presentation - arms don't birth spontaneously
Lovsett's Manoeuvre

• Hold baby by the sacrum
• Turn baby 90 degrees so that one shoulder is in the antero-posterior diameter
• Insert a finger into the brachial plexus and sweep the arm down over the baby's chest
• Turn baby 180 degrees so that the opposite shoulder is in the antero-posterior diameter
• Repeat the finger manoeuvre
• Turn the baby 90 degrees again so that the back is uppermos
• Await further descent
• Do not pull or apply traction

  
 
Contact PERS on 1300 137 650 for advice (via clinician)
 
Special Notes

Types of Breech Presentation

A: Breech with extended legs (frank) - buttocks present first with flexed hips and legs extended on the abdomen.
     Most common = 1⁄2 of all breech presentations

B: Breech with flexed legs (complete) - buttocks present first with flexed hips and flexed knees

C: Footling – one or both feet present as neither hips nor knees are fully flexed. Feet are palpated lower than the buttocks

• It is normal for meconium to be passed as the baby's buttocks are squeezed
• Cord prolapse is more common with breech presentation
• If a known breech and birth is not imminent, transport to a booked obstetric unit with capacity for surgical intervention. Provide early hospital notification
 
General Care
During all breech labour

• Keep mother informed of progress. Encourage mother to push hard with contractions
• Position mother with buttocks to bed edge with legs supported (lithotomy position) if on a stretcher or bed. Standing or squatting may be preferred by the mother and is more anatomically and physiologically sound though not suited to transport or imminent birth.
• Hands off approach encourages the baby to maintain a position of flexion during birth which simplifies birth
• Only touch to gently support – if too much stimulus the baby will extend flexed head
• Main force of birth is maternal effort. Do not attempt to pull baby out. The key is to allow the birth to occur spontaneously with minimal handling of the newborn.
• Most additional manoeuvres are only required in the event of delay
• Prevent hypothermia by maintaining a warm environmental temperature if possible and/or using towel/bubble wrap if the body is exposed for a prolonged period. Cool air may stimulate breathing efforts with head still unborn.