Vaginal Delivery of the Term or Near-Term Breech Fetus
Until recently, vaginal delivery of a breech fetus at or near term was considered reasonable in skilled hands. In 2001, the of Obstetricians and Gynecologists released a statement essentially mandating that all women with a breech fetus who are not close to delivery should undergo a cesarean delivery. Vaginal breech deliveries may be considered if the mother is very close to delivery by the time she presents to the hospital.
The following points traditionally were weighed if vaginal delivery was being considered for the term or near-term breech baby:
- The baby must be in a frank breech presentation, with the buttocks presenting first and the legs extended up in front of the body-babies in an incomplete breech presentation should be delivered by cesarean section.
- The estimated weight of the baby must not exceed 8.3 pounds.
- The mother's bony pelvis must be large enough for the delivery-x-ray or computed tomography (CT) may be used to measure the diameter of the pelvis.
- The mother must not have had a prior cesarean section or other major operation on the uterus.
- The baby's head must be in a normal position and of normal size.
- The course of labor must be normal-oxytocin (Pitocin) should not be used to stimulate labor.
The method of delivery in selected cases of term or near-term breech fetuses, typically weighing between 4.5 and 8.3 pounds, has been the subject of several, well-designed, though small studies. These studies showed that vaginal breech delivery was relatively safe for the baby in carefully selected cases. More recent data to the contrary from a large international randomized trial found:
- The rate of neurologic injury to breech babies delivered vaginally is higher. The risk of any birth injury is approximately 3.8% in breech babies undergoing labor compared to 1.4% in breech babies delivered by elective cesarean section. The risk of death or any birth injury is approximately 1.3% in breech babies undergoing labor compared to 0.3% in breech babies delivered by elective cesarean section.
- Up to 40% of women electing to attempt vaginal delivery end up having a cesarean section for one reason or the other.
- The chances of the mother having complications after delivery are similar, if she delivers vaginally or has a cesarean section.
Epidural anesthesia is an excellent method to use in attempted vaginal breech delivery, but it should not be so dense or heavy that the mother cannot aid in pushing the fetus out when needed. Two obstetricians should be present for the delivery, and at least one of them should be trained and experienced in breech delivery. Once the baby's legs, trunk, and arms are delivered, Piper forceps are often used to facilitate delivery of the head. The use of Piper forceps should not be confused with other forceps procedures.