The management of breech presentation

We have reported 473 primary breech deliveries which occurred in 11,745 private patients delivered by three physicians since 1928, an incidence of 4.02 per cent for breech presentations in patients 28 weeks or more pregnant and infants weighing 1,814 grams (4 pounds) or more. We recognize that external version of breech presentations should reduce the fetal and infant mortality associated with this complication, but we do not recommend the routine use of this procedure. There was no maternal mortality. Eliminating infants who died before labor and those with congenital anomalies incompatible with survival, our corrected fetal and infant mortality rate for babies weighing 1,814 grams (4 pounds) or more or pregnancies of 28 weeks' or more duration was 2.11 per cent, and the uncorrected rate for all fetal and infant deaths was 5.7 per cent. This rate of fetal and infant mortality is low by comparison with rates reported in the literature for infants of the same weight. Breech presentation necessitates a careful evaluation of the maternal pelvis and the fetal size and position before the onset of labor whenever possible. X-ray studies frequently give valuable information in this type of presentation. The total duration of labor in the vaginal deliveries was short as compared with that in other published reports. The average duration of labor for our primiparas was 10 hours and 57 minutes and for the multiparas the average was 8 hours and 48 minutes. The baby was completely extracted in 15 per cent of the cases and some assistance, less than complete extraction, was given in 52 per cent of the cases. We advise conservative treatment of patients with breech presentations whenever this plan can be followed. Labor should rarely be induced and it should not be hurried. A second stage of one or two hours will make extraction of the breech easier if it becomes necessary. In the presence of maternal or fetal distress, this plan cannot be followed. Wide episiotomy should be used in most vaginal breech deliveries. No third-degree laceration occurred in any of our patients. We believe a wide episiotomy reduces trauma to both the mother and the baby. We have found Potter's method of breech extraction most useful in our vaginal deliveries and we use it almost routinely. In some cases, the Wigand-Martin maneuver for flexing and extracting the fetal head has been used most successfully. This maneuver is particularly useful when the fetal head is high in the pelvis and forceps should not be applied. Piper forceps should be used whenever the fetal head is engaged in the pelvis and cannot be delivered easily by the Wigand-Martin manuever. Finally, a breech extraction should never be hurried and overextension of the fetal head must be carefully avoided.