Vaginal Breech Delivery: Contraindications, Manoeuvres & Head Entrapment

Assisted vaginal breech delivery step by step: who shouldn't have one, what to do at each fetal landmark, and what to do if the head gets stuck. Based on the OLSS (Obstetric Life Saving Skills) lecture on vaginal breech delivery at Hospital Sultan Haji Ahmad Shah (HOSHAS), Temerloh.

Contraindications

• Compromised fetus, e.g. IUGR.
• Fetopelvic disproportion, including hydrocephalus.
• Hyperextended fetal neck.
• Suspected macrosomia (>4.0 kg).
• Footling breech.
• A limited setting: no skilled professional or paediatric support.

Remark: IUGR = intrauterine growth restriction.

Manoeuvres by fetal landmark

Buttocks

Hands off: allow the buttocks and trunk to deliver spontaneously. Consider an episiotomy.

Hips

• Make sure the sacrum is facing anteriorly.
• Pinard manoeuvre for an extended breech: abduct and flex the knee, then flex the hip, to deliver each leg.
• Wrap the baby's body in a towel to keep it warm, and hold the baby gently at the pelvis (not the abdomen).

Umbilicus

Avoid excessive handling of the cord. If the cord is under undue tension, pull down a loop to loosen it.

Scapula: delivering the arms

• Flexed arms: hook a finger at the elbow and sweep the arm across the chest.
• Extended arms: Lovset manoeuvre. Holding the baby at the pelvis, gently rotate it 180 degrees until the posterior shoulder comes to lie anteriorly, below the pubic symphysis. Flex the elbow at the cubital fossa and sweep the arm across the chest to deliver it.
• Nuchal arm (arm extended and lying above or behind the head): gently rotate the fetus 90 degrees (clockwise to free the right arm), then flex the arm at the cubital fossa and complete its delivery.

Nape of the neck: delivering the after-coming head

• Mauriceau-Smellie-Veit manoeuvre: place the index and ring fingers on the zygomatic arches and the middle finger on the chin, with a finger on the occipital region, to flex the fetal head as it delivers.
• Forceps to the after-coming head.
• The Burns-Marshall manoeuvre is not recommended, because of the risk of hyperextending the fetal neck.

Head entrapment

The options listed in the lecture:

• Put the mother in McRoberts position and apply suprapubic pressure.
• Dührssen incisions of the cervix at 2, 6 and 10 o'clock (avoid 3 and 9 o'clock).
• Rotate the baby laterally, then back to the sacro-anterior position, and try again.
• If the above fails, prepare for a category 1 caesarean section and consider tocolysis.
• Symphysiotomy can be performed.

Complications

1. Birth asphyxia from cord compression and head entrapment.
2. Intracranial haemorrhage from sudden decompression of the fetal head.
3. Nerve injury: brachial and cervical plexus.
4. Intra-abdominal injury: liver and spleen.
5. Dislocations and fractures: humerus, clavicle and femur.
6. Cervical spine and basal skull fractures.

Sources

• Obstetric Life Saving Skills (OLSS) lecture: Vaginal Breech Delivery. Hospital Sultan Haji Ahmad Shah (HOSHAS), Temerloh, 2026.