BREECH PRESENTATION INTRODUCTION During pregnancy, a fetus is said to be in a breech presentation when the buttocks of the baby are

presenting first at the bottom of the uterus, and the head is in the upper part, or fundus of the uterus. Breech presentation occurs in 3-4% of all deliveries. The occurrence of breech presentation decreases with advancing gestational age. Breech presentation occurs in 25% of births that occur before 28 weeks' gestation, in 7% of births that occur at 32 weeks, and in 1-3% of births that occur at term. Perinatal mortality is increased 2- to 4-fold with breech presentation, regardless of the mode of delivery. Deaths are most often associated with malformations, prematurity, and intrauterine fetal demise. TYPES OF BREECHES There are a number of variations of the breech

presentation, determined by the position of the baby's body parts, like arms and legs, in relation to his or her head and trunk. In the case of the breech, it is significant whether one or both legs are folded at the knees ("complete" breech), fully extended with the feet near the face ("frank" breech), or a foot or knee (or two) descending first. Types of breech presentations include:

Frank breech (50-70%) - Hips flexed, knees extended (pike position) Complete or full breech (5-10%) - Hips flexed, knees flexed (cannonball position) Footling or incomplete breech (10-30%) - One or both hips extended, foot presenting (one footling or double footling)

Picture 1. Frank breech where the thighs are flexed on the abdomen and both legs are extended at the knee so that the feet are near the head.

Picture 2. Complete breech where the thighs are flexed on the abdomen and both legs are flexed at the knee.

Picture 3. Footling breech where one or both legs are extended below the level of the buttocks.

Picture 4. Knee breech where one or both knees are extended below the level of the buttocks.

BREECH POSITIONS Fetal position in breech presentations is determined by using the sacrum as the fetal point of reference to the maternal pelvis. This si true for frank, complete, and footling breeches. Here are the possible positions in breech presentation.

Picture 5. Breech Positions

ETIOLOGY AND PRESDISPOSING FACTORS Predisposing factors for breech presentation include

prematurity, uterine abnormalities (eg, malformations, fibroids), fetal abnormalities (eg, CNS malformations, neck masses, aneuploidy), multiple gestations, etc. Abnormalities are observed in 17% of preterm deliveries that have breech presentation and in 9% of term gestations with breech presentation.

Predisposing following:
o

factors

for

breech

presentation

include

the

Gestational age of fetus less than term . Prior to onset of labor, the fetus turns into cephalic presentation. If labor occurs abruptly or unexpectedly (eg, following trauma), then the fetus may not have had the chance to shift position.

Increased maternal parity may cause stretch or laxity of the uterus, predisposing the patient to breech deliveries.

Multiple fetuses: As a result of limited space in the uterus, fetuses in cases of multiple births may position themselves head to foot.

Hydramnios, or too much amniotic fluid, may allow the fetus too much movement.

Oligohydramnios, or too little amniotic fluid, may impede final shift of the fetus to cephalic presentation.

Hydrocephalus, or enlarged head in the fetus, makes it more difficult for the fetus to make final shift to cephalic presentation prior to onset of labor.

Previous breech deliveries may increase likelihood of breech presentation, as the uterus may have an anomaly, predisposing it to breech presentations.

Uterine anomalies that predispose to breech presentation include bicornuate uterus and septate uterus.

Pelvic tumors may impede fetal movement and trap the fetus in breech pr esentation position. Contracted pelvis, or borderline pelvis may predispose to breech presentation Placental cornual-fundal implantation also increases risk of breech presentation. Placenta previa, or placental implantation over the cervical os, allows the fetus too much space for movement within the uterus.

DIAGNOSIS The diagnosis of breech presentation can be established by taking history of possible predisposing factors, doing the Leopold manuvers, hearing the fetal heart sounds (taking note of the position where it can be heard loudest), examination, and imaging techniques. Leopolds maneuver During the first maneuver, the hard, round fetal head can be palpated at uterine fundus. The second maneuver indicates the back to be on one side of the abdomen and the small parts on the other. On the third maneuver if engagement has not occurredthe intertrochanteric diameter of the fetal pelvis has not passed through th pelvic inletthe breech is moveable above the pelvic inlet. After engagement, the fourth maneuver shows the firm breech to be beneath the symphisis. doing vaginal

Picture 6. Leopolds Maneuver

Fetal Heart Sounds Fetal heart sounds usually are heard loudest slightly above the umbilicus, whereas with engagement of the fetal head, the heart sounds are loudest below the umbilicus.

Picture 7. Fetal Heart Sounds

Vaginal Examination In frank presentations, the ischial tuberosities, sacrum, anus, and/or genitals may be palpated. In addition, meconium staining of the examiner's digit may occur. In complete presentations, the feet of the fetus may be palpated with the buttocks. In incomplete presentations, one or both of the feet/knees may be palpated.

Imaging Techniques X-ray studies will differentiate breech from cephalic

presentations and also help determine the type of breeh by locating the positions of the lower extremities. Because of the risks of radiation exposure to the fetus with this technique, ultrasonography is now often used instead to determine fetal presentation or malformations. Ultrasonographic scanning can be used to know whethere there is any fetal abnormality or non-fetal abnormality that can be a predisposing factors. Ultrasonographic scanning by an experienced examiner will document fetal presentation, attitude, and size. And so it can document multiple gestation, location of the placenta and amniotic fluid volume. Ultrasound will also reveal skeletal and soft tissue malformations of the fetus. MANAGEMENT It has been widely recognised that there is higher perinatal mortality and morbidity with breech presentation, due principally to prematurity, congenital malformations and birth asphyxia or trauma. Breech presentation, whatever the mode of delivery, is a signal for potential fetal handicap and this should inform antenatal, intrapartum and neonatal management. The following are the antepartum management and the management during labor. Antepartum Management Following confirmation of breech presentation, the mother must be closely followed to see if spontaneous version to

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cephalic presentations occurs. If breech presentation persist beyond 36 weeks, external cephalic version should be considered. Current success rates for external cephalic version range from 35-85%, with a mean of 30%. External cephalic version is a procedure used to turn the fetal presenting part from breech to cephalic presentation. Patients with unengage singleton breech presentations of at least 36 weeks gestation are candidates for external cephalic version. Contraindications to external anencephalus, previous uterine cephalic version include (cessarean sectio; multiple fetus, hydramnios, oligohydramnios, hydrocephalus, surgery myomectomy) , uterine anomalies, contracted pelvis, placental anterior implantation, antepartum hemorrhage (placenta previa, solutio placenta), mother with hypertension, fetus with others congenital malformations or abnormalities (including intrauterine growth retardation), presence of nuchal cord, premature rupture of the fetal membranes, engagement of the presenting part in the pelvis, and hyperextension of the fetal head. Complications to external cephalic version are rare, occuring in only 1-2% of all external cephalic version. Examples include placental abruption, uterine rupture, amniotic fluid embolism, preterm labor, fetal distress, and fetal demise. External cephalic version is performed as follows: 1. Obtain informed concent from the patient 2. Perform an ultrasound examination to verify presentation and rule out fetal or uterine abnormality 3. Perform a nonstress test. Result must be reactive 4. If desired, administer a tocolytic to prevent contractions or irritability 5. Administer anesthesia if desired

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6. Perform external cephalic version. Place both hands on the patients abdomen, and perform a forward roll by lifting the breech upward while placing pressure on the head downward toward the pelvis. If this is unsuccessfull,a backward roll may be attempted 7. Fetal well-being should be monitored intermittently with Doppler or real time ultrasound scanning. The procedure should be abondoned for any significant fetal distress, patient discomfort, or if multiple attemps are unsuccessfull. 8. Following the procedure, external fetal heart rate monitoring should be continued for 1 hour to ensure stability. If the patient is Rh (-), administer anti D immune globuline. 9. If stable, the patient may be sent home to await the onset of spontaneous labor if the version is successful. If unsuccessful, the patient may be scheduled for an elective cesarean section, or plan a trial of labor with a breech vaginal delivery, if the mother is a good candidate.

Picture 8. External Cephalic Version

Management During Labor Patient with singleton breech presentations are admitted to the hospital with the onset of labor or when spontaneous rupture

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of the fetal membranes occurs because of the increased risk of umbilical cord complications. Upon admission, a repeat ultrasound is obtained to confirm the type of breech presentation and to ascertain head flexion. A thorough history is taken, and a physical examination is performed to evaluate the status of the mother and fetus. Based on this findings, a decision must be made regarding the route of delivery. The decision regarding route of delivery must be made carefully on an individual basis. There are a breech scoring index (Zatuchni-Andros Score) to predict the feasibility of attempting a breech delivery. It can be a great help to decide whethere the patient can be assisted for vaginal delivery or she should undergo cesarean section. Breech Index Scoring System Points assigned Parity Gestational Age Estimated Fetal Weight Dilation Station Previous Breech 0 Primagravida 39 weeks or more Over 3600 gr 2 cm -3 or upper None 1 Multigravid a 38 weeks 3000-3600 gr 3 cm -2 One 37 weeks < 3000 gr 4 cm or more -1 or lower 2 or more 2

This assessment is designed to be made at the onset of labor. A score of less than 3 would indicate the need for a cesarean section. A score of 4-5 would indicate that a careful

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review be made and would suggest that one should proceed with caution. A score of five or better would indicate a reasonable chance for a successful vaginal delivery. There are of course some moderating factors. If a multipara has had two nine pound babies vaginally, and this baby is of similar size, she should do fine as long as the baby does not go post dates. One point should be subtracted for footling breeches, as they are somewhat difficult to manage. In general, this is a very reliable system for predicting outcome. If the mother is a good candidate for a breech vaginal delivery, then we can assist a breech vaginal delivery. Vaginal breech deliveries were previously the norm until 1959 when Wright proposed that all breech presentations delivered follows: Spontaneous breech (rare): No manipulation of the infant is necessary, other than supporting the infant. Partial breech extraction/ Assisted breech delivery/ Manual aid: Fetus descends spontaneously to where umbilicus is at the vaginal introitus, and then maneuvers are initiated to assist in the delivery of the remainder of the body, arms, and head. This is the most common type of vaginal breech delivery. Total breech extraction/ Complete breech extraction: The entire body is extracted. This is indicated only if there is evidence of fetal distress unresponsive to routine abdominally to reduce perinatal should be and morbidity

mortality. There are three types of vaginal breech delivery, as

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maneuvers and a cesarean delivery is not possible. It is imperative that the cervix be fully dilated and effaced before the infant is delivered past its umbilicus. The presence of the feet at the vulva is not an indication to the physician to proceed with active extraction.

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1. Spontaneous Vaginal Delivery During spontaneous delivery of an infant in the frank breech position, delivery occurs without assistance, and no obstetrics manuevers are applied to the body.

Picture 9. Mechanism of labor in breech delivery

The Bracht maneuver is a variant approach to the assisted vaginal breech delivery. With this procedure, first described in 1938, simulation of the cardinal movements observed in a spontaneous vaginal breech delivery is attempted. The breech is

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allowed to spontaneously deliver to the level of the umbilicus. After spontaneous rotation of the infant to a spine-anterior position, the operator gently holds the body and legs upward against the maternal symphysis. With the force of uterine contractions and moderate suprapubic pressure by an assistant, the fetal arms are delivered without traction, and the head, which has been hyperextended at the neck, follows shortly thereafter. While the Bracht maneuver was initially evaluated in Europe, it was never popularized in the United States, and it is predominantly mentioned for historical interest. 2. Partial Breech Extraction Partial breech extraction is employed when the operator discerns that spontaneous delivery will not occur or that expeditious delivery is indicated for fetal or maternal reasons. The body is allowed to deliver spontaneously up to the level of the umbilicus. The operator then assist in delivery of the legs, shoulders, arms, and head. There are so many maneuver that can be implemented, including Deventer, Mueller, Lovset, Bickenbachs, Pinard, Mauriceau, Najouks, Modified Prague, and Forceps Piper. As the umbilicus appears at the maternal perineum, the operator places a finger medial to one thigh and then the other, pressing laterally as the fetal pelvis is rotated away from that side by an assistant. Thus, the thigh is externally rotated at the hip and result in flexion of the knee and delivery of one, then the other leg. The fetal trunk is then wrapped in a towel to support the body. When both scapulas are visible, the body is rotated counterclockwise. The operator locates the right humerus and

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laterally sweep the arms across the chest and out the perineum. In a similar fashion, the body is rotated clockwise to deliver the left arm. The head then spontaneously delivers by gently lifting the body upward and applying fundal pressure to maintain flexion of the fetal head.

Picture 10. Lovset Maneuver

The operator may elect to manually assist in delivery of the head by performing the Mauriceau-Smellie-Veit Maneuver. In this procedure, the index and middle fingers of one of the operators hands are applied over the maxilla as the body rests on the palm and forearm of the operator. Two fingers of the operators other hand are applied on either side on the neck with gentle downward traction. At the same time, the body is

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elevated toward the pubic symphysis, allowing for control delivery of the mouth, nose and brow over the perineum. Likewise, Piper forceps may be used electively or when the Mauriceau-Smellie-Veit Maneuver fails to deliver the aftercoming head. If, after delivery of the body , the spine remains in the posterior position and rotation is unsuccessful, extraction of the head in a persistant occiput posterior position may be accomplished by the modified Prague maneuver. One hand of the operator supports the shoulder from below, while the other hand gently elevates the body upward toward the maternal abdomen. This flexes the head within the birth canal and results in delivery of the occiput over the perineum.

Picture 11. Mauriceau-Smellie-Veit Maneuver

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Picture 12. Forceps Piper

3. Complete Breech Extraction For complete or footling presentation, total breech extraction is accomplished by initially grasping both feet and applying gentle downward pressure until the buttocks are delivered. A generous midline or mediolateral episiotomy is then performed. The operator gently grasp the fetal pelvis, with both thumbs placed directly on either side of the sacrum. The spine is rotated, if necessary, until it rests under the pubic symphisis. Gentle, firm downward pressure is applied to the body until both scapulas are visible. The shoulders, arms, and head are delivered as in partial breech extraction.

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Picture 13 . Complete Breech Extraction

Picture 14. Complete Breech Extraction

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Picture 15. Complete Breech Extraction

COMPLICATIONS Breech delivery may follow by such complications: a. Birth Anoxia Umbilical cord compression and prolapse may be associated with breech delivery, particularly in complete (5%) and footling (15%). This is due to inability of the presenting part to fill the maternal pelvis, either due to prematurity or poor application of the presenting part to the cervix, so that the umbilical cord is allowed to prolapse below the level of the breech. Frank breech presentation offers a contoured presenting part, which is better accommodated to the maternal pelvis and is usually well applied to the cervix. The incidence of cord prolapse in frank breech is only 0.5% (the same as cephalic presentations).

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Picture 16. Cord Prolapse

Compression of the prolapsed cord may occur during uterine contractions, causing moderate to severe variable decelerations in the fetal heart rate, leading to fetal anoxia or death. Continous electronic monitoring is thus mandatory during labor in these cases to detect omnious decelerations. If they occur, immediate cesarean delivery must be performed. b. Birth Injury The incidence of birth trauma during vaginal breech delivery is 6.7%, 13 times that of cephalic presentations (0.51%). Only high forceps and internal version and extraction procedures have higher rates of birth injury than vaginal breech deliveries. The types of perinatal injuries reported in breech delivery include tears in the tentorium cerebellum, cephalohematomas, disruption of the spinal cord, brachial palsy, fracture of long bones, and rupture of the sternocleidomastoid muscle. Vaginal breech delivery is also the main cause of injuries to the fetal adrenal glands, liver, anus, genitalia, spine, hip joint, sciatic nerve, and musculature of the arms, legs, and back. Factors contributing to difficult vaginal breech delivery include a partially dilated cervix, unilateral or bilateral nuchal arms, and deflexion of the head. The type of procedure used may also affect the neonatal outcome.

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BIBLIOGRAPHY

1. Bratakoesoema, Dinan S.

2005.

Distosia in Obstetri

Patologi. Jakarta: EGC: 132-145 2. Cunningham, F. G., MacDonald, P. C., et. al. 2005. Williams Obstetrics. 22th ed. New York: Mc Grw Hill: 565-583 3. De Charney Alan H,M.D. Hill: 369-385 4. Fischer, Richard. 2005. Breech Presentation. In eMedicine. In www.emedicine.com, online on December, 26th, 2005 5. Gillstrap III, Larry C, et al. 2000. Operative Obstetric. 2nd Ed. New York: McGraw-Hill: 145-162 6. Gimovsky, ML, et al. 1995. Operative Obstetric. 10th ed. 2003. Current Obstetric dan

Gynaecology Diagnosis and Treatment. New York: McGraw-

Baltimore: Williams&Wilkins: 209-236 7. Jenis, Andrew. eMedicine. 26th, 2005 8. Kimsey, Bobbi. eMedicine. 26th, 2005 2003. Baby in Breech Presentation. In 2003. Pregnancy, Breech Delivery. In

In www.emedicine.com, online on December,

In www.emedicine.com, online on December,

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9. Linden, Ann. eMedicine. 26th, 2005

2005.

Baby in Breech Presentation.

In

In www.emedicine.com, online on December,

10.Wijayanegara, Hidayat, et al. 1997. Pedoman Diagnosis dan Terapi Obstetri dan Ginekologi RSUP Dr. Hasan Sadikin. Bandung: Bagian/SMF Obstetri & Ginekologi FKUP/RSUP Dr. Hasan Sadikin: 3-4; 28; 90-92

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The following conditions make vaginal delivery in case of frank breech less risky:
o

Favorable pelvis - Gynecoid (ie, round) or anthropoid (ie, elliptical)

Fetus weighing less than 3600 g - The larger the fetus, the larger the head is, as well as other noncompressible body parts, leading to increased fetal hypoxia and birth trauma

Complete dilation and effacement of the cervix Provides the head a better chance to pass through the pelvis.

Availability of skilled obstetrician, neonatal resuscitation equipment, and anesthesia

The following conditions are unfavorable for delivery:

o o

Fetus weight more than 3600 g Unfavorable pelvis - Breech delivery does not allow sufficient time for molding of the fetal head; thus, a platypelloid (ie, anteroposterior flat) or android (ie, heart-shaped) pelvis decreases ability of the head of the fetus to navigate maternal pelvis

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Hyperextension of the head - Increases risk of cervical spine injury

Footlings - Incidence of umbilical cord prolapse increases with coiling of the umbilical cord around the legs of the fetus

Complications:

E pTraumatic mortality to the fetus is 12 times more likely. Intracranial fetal hemorrhage is the most common injury in breech delivery.

The spinal cord, liver, adrenals, and spleen also are injured, in decreasing order of frequency. Complications
o o

Premature Rupture of Membranes Cord prolapse

Vaginal breech deliveries were previously the norm until 1959 when Wright proposed that all breech presentations should be

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delivered abdominally to reduce perinatal morbidity and mortality. Vaginal breech delivery Three types of vaginal breech deliveries are described, as follows:

Spontaneous breech delivery: No traction or manipulation of the infant is used. This occurs predominantly in very preterm deliveries.

Assisted breech delivery: This is the most common type of vaginal breech delivery. The infant is allowed to spontaneously deliver up to the umbilicus, and then maneuvers are initiated to assist in the delivery of the remainder of the body, arms, and head.

Total breech extraction: The fetal feet are grasped, and the entire fetus is extracted. Total breech extraction should be used only for a noncephalic second twin; it should not be used for singleton fetuses because the cervix may not be adequately dilated to allow passage of the fetal head. If the feet prolapse through the vagina, treat expectantly as long as the fetal heart rate is stable to allow the cervix to completely dilate around the breech (see Image 1). Total breech extraction for the singleton breech is associated with a birth injury rate of 25% and a mortality rate of approximately 10%.

Picture 1. Footling breech presentation. Once the feet have delivered, one may be tempted to pull on the feet. However, a singleton gestation should not be pulled by the feet because this action may precipitate head entrapment

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in an incompletely dilated cervix or may precipitate nuchal arms. As long as the fetal heart rate is stable and no physical evidence of a prolapsed cord is evident, management may be expectant while awaiting full cervical dilation.

Picture 1. Footling breech presentation. Once the feet have delivered, one may be tempted to pull on the feet. However, a singleton gestation should not be pulled by the feet because this action may precipitate head entrapment in an incompletely dilated cervix or may precipitate nuchal arms. As long as the fetal heart rate is stable and no physical evidence of a prolapsed cord is evident, management may be expectant while awaiting full cervical dilation.

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Technique and tips for assisted vaginal breech delivery Leaving the fetal membranes intact as long as possible to act as a dilating wedge and to prevent overt cord prolapse is advisable. Oxytocin induction and augmentation are controversial. In many studies, oxytocin is used for induction and augmentation for dysfunctional labor, especially for hypotonic uterine dysfunction. Results from other studies indicate that nonphysiologic forceful contractions could result in an incompletely dilated cervix and an entrapped head. An anesthesiologist and pediatrician should be present for all vaginal breech deliveries. A pediatrician is needed because of the higher prevalence of neonatal depression and the increased risk for unrecognized fetal anomalies. An anesthesiologist may be needed if intrapartum complications develop and the patient requires general anesthesia. Perform an episiotomy when crowning is evident. This is advocated by many authors for all breech deliveries, even in multiparas, to prevent soft tissue dystocia (see Images 2-3).

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Picture 2. Assisted vaginal breech delivery. Thick meconium passage is common as the breech is squeezed through the birth canal. This is usually not associated with meconium aspiration because the meconium passes out of the vagina and does not mix with the amniotic fluid.

Picture 3. Assisted vaginal breech delivery. The Ritgen maneuver is applied to take pressure off the perineum during vaginal delivery. Episiotomies are often performed for assisted vaginal breech deliveries, even in multiparous women, to prevent soft tissue dystocia

The Pinard maneuver may be needed with a frank breech to facilitate delivery of the legs, only after the fetal umbilicus has been reached. Pressure is exerted against the inner aspect of the knee. Flexion of the knee follows, and the lower leg is swept medially and out of the vagina. No traction should be exerted on

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the infant until the fetal umbilicus is past the perineum, after which time maternal expulsive efforts should be used along with gentle downward and outward traction of the infant until the scapula and axilla are visible (see Image 4).

Picture 4. Assisted vaginal breech delivery. No downward or outward traction is applied to the fetus until the umbilicus has been reached

Use a dry towel to wrap around the hips, not the abdomen, to help with gentle traction of the infant (see Image 5). An assistant should exert transfundal pressure from above to keep the head flexed.

Picture 5. Assisted vaginal breech delivery. With a towel wrapped around the fetal hips, gentle downward and outward traction is applied in conjunction with maternal expulsive efforts

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until the scapula is reached. An assistant should be applying gentle fundal pressure to keep the fetal head flexed.

Once the scapula is visible, rotate the infant 90 and gently sweep the anterior arm out of the vagina by pressing on the inner aspect of the elbow (see Images 6-7). Rotate the infant 180 in the reverse direction, and sweep the other arm out of the vagina. Once the arms are delivered, rotate the infant back 90 so that the chin is posterior (see Image 8).

Picture 6. Assisted vaginal breech delivery. After the scapula is reached, the fetus should be rotated 90 in order to deliver the anterior arm.

Picture 7. Assisted vaginal breech delivery. The anterior arm is followed to the elbow, and the arm is swept out of the vagina.

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Picture 8. Assisted vaginal breech delivery. The fetus is rotated 180, and the contralateral arm is delivered in a similar manner as the first. The infant is then rotated 90 to the backup position in preparation for delivery of the head.

The fetal head should be maintained in a flexed position during delivery to allow passage of the smallest diameter of the head. The flexed position can be accomplished by using the Mauriceau maneuver (ie, fingers placed over maxilla, see Image 9) or with Piper forceps while the assistant applies suprapubic pressure. During the Mauriceau maneuver, the operator applies pressure over the fetal maxillary prominences. Piper forceps are specialized forceps with pelvic, not cephalic, application, which maintains the head in a flexed position (see Image 10).

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Picture 9. Assisted vaginal breech delivery. The fetal head is maintained in a flexed position by using the Mauriceau maneuver, which is performed by placing the index and middle fingers over the maxillary prominence on either side of the nose. The fetal body is supported in a neutral position, with care to not overextend the neck.

Picture 10. Piper forceps application. Piper forceps are specialized forceps used only for the after-coming head of a breech presentation. They are used to keep the fetal head flexed during extraction of the head. An assistant is needed to hold the infant while the operator gets on one knee to apply the forceps from below.

The forceps are applied while the assistant supports the fetal body in a horizontal plane. In many early studies, routine use of Piper forceps was recommended to protect the head and to minimize traction on the fetal neck.

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During delivery of the head, avoid extreme elevation of the body, which may result in hyperextension of the cervical spine and potential neurologic injury (see Images 12-13).

Picture 12. Assisted vaginal breech delivery. The neonate after birth

Picture 13. Ultrasound demonstrating a fetus in breech presentation with a hyperextended head (ie, "star gazing").

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The Bracht maneuver is a variant approach to the assisted vaginal breech delivery. With this procedure, first described in 1938, simulation of the cardinal movements observed in a spontaneous vaginal breech delivery is attempted. The breech is allowed to spontaneously deliver to the level of the umbilicus. After spontaneous rotation of the infant to a spine-anterior position, the operator gently holds the body and legs upward against the maternal symphysis. With the force of uterine contractions and moderate suprapubic pressure by an assistant, the fetal arms are delivered without traction, and the head, which has been hyperextended at the neck, follows shortly thereafter. While the Bracht maneuver was initially evaluated in Europe, it was never popularized in the United States, and it is predominantly mentioned for historical interest.

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