Breech Presentation Nursing Care
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Direct answer
Breech presentation — buttocks or feet presenting at term — affects roughly 3-4 per cent of deliveries at 37 weeks and is managed mainly by offering external cephalic version (ECV) at 36-37 weeks, with planned caesarean section as the standard route if version fails or is declined. Nursing care spans antenatal diagnosis and ECV preparation, the theatre pathway for caesarean birth, and — where a vaginal breech birth is planned or arrives unexpected — the disciplined intrapartum conduct: hands off the breech until the nape and both arms are visible, Lovset's manoeuvre for nuchal arms, and the Mauriceau-Smellie-Veit grip for the aftercoming head, with neonatal resuscitation ready.
What you must remember
- Types and risk: frank (hips flexed, knees extended — most common), complete (hips and knees flexed), incomplete or footling (foot presenting); footling and complete breeches carry the highest cord prolapse risk, so ruptured membranes in an unengaged breech demand immediate vaginal examination.
- ECV essentials: offered around 36-37 completed weeks, with cardiotocograph before and after, tocolysis as prescribed, anti-D for Rh-negative mothers, and theatre availability as a safety net.
- Vaginal breech conduct: no routine intervention until the nape, chin and both arms deliver spontaneously — early traction causes nuchal arms and head entrapment.
- Named manoeuvres: Lovset's — rotate the body by the bony pelvic girdle so each shoulder and arm delivers under the pubic arch in turn; Burns-Marshall — suspension of the body to allow spontaneous head delivery; Mauriceau-Smellie-Veit — head flexed with fingers on the maxilla and the other hand on the shoulders, plus suprapubic pressure by an assistant.
- Aftercoming head emergencies: head entrapment (Duhrssen's incisions by the obstetrician), forceps to the aftercoming head — the nurse prepares, the obstetrician performs.
- Standing readiness: functioning resuscitation trolley, warmer and suction checked before every breech birth, because breech babies are the likeliest to need resuscitation.
- Complications to anticipate: cord prolapse, birth asphyxia, brachial plexus injury and fractures, and trapped aftercoming head.
An unexpected vaginal breech, conducted step by step
A multipara arrives fully dilated at a peripheral facility, breech diagnosed just as membranes rupture — the first nursing action is an immediate vaginal examination to exclude cord prolapse, because a footling breech plus ruptured membranes is that emergency's classic setup. With the cord felt nowhere and the buttocks filling the pelvis, transfer is no longer possible: warmer on, resuscitation trolley checked, suction and oxygen present, second pair of hands called.
The conduct itself is restraint. The buttocks deliver spontaneously and the body hangs with its own weight; the nurse resists every instinct to pull, because traction before the nape appears creates the nuchal arms that Lovset's manoeuvre must then release — the body grasped by the bony pelvis (never the abdomen, to avoid organ injury), rotated to bring the anterior shoulder under the symphysis, delivering that arm, then rotated back for the other. When the nape and chin appear, the Mauriceau-Smellie-Veit grip flexes the head — fingers on the maxilla, the other hand supporting shoulders, an assistant applying suprapubic pressure. The interval from umbilicus to full delivery is kept short, since the cord is compressed once the body is out. The baby goes straight to the warmer, the third stage is actively managed, and the obstetric team is informed. Preparation plus restraint is the entire art.
Where students slip
The classic error in orals is answering "assist delivery by traction" — that phrase fails, because the cardinal principle is hands-off until the nape and arms are visible, with the manoeuvres as rescue, never routine. Cord prolapse vigilance is remembered for transverse lie but forgotten for footling and incomplete breeches with ruptured membranes, so the immediate examination after membrane rupture is examinable. ECV timing is another favourite: before 36 weeks risks spontaneous reversion and preterm labour, past 37 weeks reduces success as engagement fixes the breech — 36-37 weeks is the quotable window. Finally, Lovset belongs to the arms and Mauriceau-Smellie-Veit to the aftercoming head, and mixing them in a viva is noticed.
Frequently asked questions
Which breech type carries the highest risk of cord prolapse?
Incomplete or footling breech, because the presenting foot fails to plug the pelvis, leaving space for the cord once membranes rupture.
When is external cephalic version attempted and what preparation does it need?
Around 36-37 completed weeks, with a cardiotocograph before and after, tocolysis as prescribed, anti-D for Rh-negative mothers, and emergency caesarean capacity available.
What is Lovset's manoeuvre used for?
Delivering the arms in vaginal breech birth — the body is grasped at the bony pelvis and rotated to bring each shoulder under the pubic arch in turn.
Why must traction be avoided during vaginal breech delivery?
Pulling before the nape and arms deliver causes nuchal arms and entrapment of the aftercoming head — the injuries the no-touch discipline exists to prevent.
What is the Mauriceau-Smellie-Veit manoeuvre?
A technique for delivering the aftercoming head, the body supported on the operator's forearm with fingers flexing the maxilla, combined with suprapubic pressure to maintain flexion.