Vaginal Breech Delivery Manoeuvres
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Direct answer
Vaginal breech delivery manoeuvres are the hand techniques used to deliver the breech after the buttocks, body and arms, and then the aftercoming head. The key manoeuvres are Lovset for the arms, Mauriceau-Smellie-Veit for flexing the aftercoming head and Burns-Marshall for bringing a held-up head down. Safe delivery depends on a skilled operator, a fully dilated cervix, an adequate pelvis and a term singleton fetus.
What you must remember
- Types of breech: frank (hips flexed, knees extended), complete (hips and knees flexed) and footling (one or both feet presenting).
- Conditions: a term singleton of normal size, an adequate pelvis, a flexed head, a reassuring trace and an experienced operator.
- Lovset manoeuvre: rotation of the fetal body through half a turn to bring each posterior arm down in turn.
- Mauriceau-Smellie-Veit manoeuvre: flexion of the aftercoming head with two fingers on the maxilla while the body rests on the operator's forearm.
- Burns-Marshall manoeuvre: the body hangs until the nape shows, then the feet are swung upward in an arc to deliver the head.
- Piper forceps: an option for the aftercoming head when the head remains arrested and other manoeuvres fail.
- Timing: the aftercoming head should be delivered within a few minutes of the body, because the fetus is at risk of hypoxia during head entrapment.
A sequence for the breech birth
A breech birth is a set of controlled movements that the operator must keep in order, and the aftercoming head is the step that most often goes wrong. The steps below show the order in which the manoeuvres are used once the trunk has descended.
- Assess the breech and pelvis. Confirm the type of breech, that the cervix is fully dilated and that the fetal heart is reassuring before any manoeuvre.
- Deliver the body. Let the body descend under its own power, support it with the operator's hand and avoid traction on the trunk alone.
- Deliver the arms. The Lovset manoeuvre rotates the body to bring each posterior arm down in turn, with the arm swept across the chest.
- Control the aftercoming head. The Mauriceau-Smellie-Veit manoeuvre flexes the head with two fingers over the maxilla while the body lies along the forearm.
- Add suprapubic pressure. An assistant applies suprapubic pressure to keep the head flexed as the operator guides it down.
- Use Burns-Marshall or forceps if stuck. The Burns-Marshall manoeuvre lets the body hang until the nape is visible, then swings the feet upward in an arc to deliver the head, and Piper forceps are used when the head is persistently arrested.
Where the exam tries to catch you
Breech questions test the correct manoeuvre for each part and the safety limits of traction on the fetal body.
- Trap: pulling on the legs to speed the head Correct: traction on the body can injure the spine and does not deliver the head, so flexion and suprapubic pressure are used instead.
- Trap: allowing the aftercoming head to remain in the pelvis for a long time Correct: the head must follow the body promptly, since the cord may be compressed and the fetus is at risk of asphyxia.
- Trap: attempting a vaginal breech in a footling presentation without expertise Correct: a footling or unfavourable breech needs an experienced operator, and caesarean section is the default in many settings.
Frequently asked questions
What is the Lovset manoeuvre used for?
The Lovset manoeuvre is used to deliver the arms in a vaginal breech birth. It rotates the fetal body through half a turn so that each posterior arm can be brought down in turn. It is applied gently with the trunk supported.
What is the Mauriceau-Smellie-Veit manoeuvre?
The Mauriceau-Smellie-Veit manoeuvre is a technique for delivering the aftercoming head in a breech birth. Two fingers rest on the maxilla to flex the head while the body lies along the operator's forearm. Suprapubic pressure from an assistant helps keep the head flexed.
Which manoeuvre helps deliver an arrested aftercoming head?
The Burns-Marshall manoeuvre helps deliver an arrested aftercoming head by letting the body hang until the nape is visible and then swinging the feet upward in an arc over the mother's abdomen to deliver the head. Piper forceps are an alternative when this is not enough. The choice depends on the operator's skill and the situation.
Why must the aftercoming head be delivered quickly?
The aftercoming head must be delivered quickly because the umbilical cord can be compressed once the trunk is out, so the fetus is at risk of hypoxia. Prolonged head entrapment is a serious emergency. The operator therefore moves promptly through the manoeuvres to limit the delay.
What conditions make a vaginal breech delivery safer?
Safer vaginal breech delivery needs a term singleton fetus of normal size, a fully dilated cervix, an adequate pelvis and a skilled operator. A reassuring fetal heart trace and a flexed head are also required. A footling presentation is treated with more caution than a frank or complete breech.