Regional Anaesthesia for Breech Presentation
Leonie Watterson
Breech presentation is defined as the entrance of the fetal lower extremities or pelvis into the maternal pelvic inlet. Three types are described:

Frank breech where the hips are flexed and the knees extended (Figure 14.1). Complete breech, where the hips and knees are both flexed. Footling breech, where one or both hips are not flexed and one or both feet are below the buttocks.

Breech presentation complicates 3% - 4% of pregnancies (1). The anaesthetic management will vary with the mode of delivery which is planned. The increased perinatal mortality which is observed with vaginal delivery has led to an increase in elective caesarean section in this group (2). The hazards associated with vaginal delivery are well recognized (3). There is a higher incidence of dysfunctional labour - both first and second stages may be prolonged (1). Arrest of the after-coming head either due to dystocia or containment by an incompletely dilated cervix is well described, particularly within the context of premature pushing or small infants in premature labour (4, 5). The head can be also be arrested by a contracting lower uterine segment. Fetal asphyxia may then occur due to the resulting compression of the umbilical cord within the pelvis. This risk increases with the duration of the second stage. There is an increased risk of cord prolapse (1). The obstetrician is faced with a high possibility of needing to perform an emergency operative or assisted vaginal delivery (2). As with vertex presentations, forceps delivery is associated with an increased incidence of intracranial hemorrhage(6, 7). This is a particular problem for premature breech infants. Other risks include injury to the spinal cord, peripheral nerves and intra-abdominal organs (1).

Analgesia for vaginal delivery:
The goals of anaesthetic management for vaginal delivery can be summarized as:
1. Adequate pain relief for the mother during first and second stage.
2. Perineal analgesia to facilitate regular examinations.
3. Prevention of a premature bearing-down reflex before full cervical dilatation.
4. A slow, controlled delivery over a relaxed perineum.
5. The ability to rapidly create conditions for delivery by caesarean section or forceps.
6. The ability to relax the uterus if required.
7. Consideration of the special requirements of a premature or acutely distressed fetus.

Epidural analgesia for breech delivery:
The use of epidurals for breech deliveries has been the subject of controversy in the past. Early reports which examined the effect of epidural analgesia on the progress of labour in cephalic presentations suggested a prolongation of the second stage and inhibition of the normal rotation of the presenting part during second stage. Both of these effects increased the incidence of forceps deliveries (8, 9) (Figure 14.2). This observation led to a widespread belief that epidural analgesia in breech vaginal delivery would increase the incidence of fetal asphyxia and total breech extraction (4, 5). The latter involves complete extraction of the fetus with forceps. It carries a high mortality for the fetus and a risk of uterine rupture or cervical trauma for the mother (5). Studies specifically addressing this group have demonstrated that epidural analgesia can be safely employed. The second stage of labour may be prolonged, however there is no increase in the incidence of breech extraction, and the condition of the fetus is either improved or unchanged (10, 11, 12). The sparing effect on perineal muscle tone which has been achieved in cephalic presentations with very low concentration local anaesthetic (eg 0.065% bupivacaine) and epidural opioids is associated with an increased incidence of inadequate perineal analgesia (13, 14, 15). It may also be associated with less reliable suppression of the bearing-down reflex. In contrast, experience with 0.125% bupivacaine has demonstrated that titration of the dose to achieve adequate perineal analgesia is also associated with reliable suppression of the bearing-down reflex (16). Available data suggests that the goals outlined above can be achieved with 0.125% bupivacaine with or without opioid (1, 16).

Spinal anaesthesia for breech delivery:
Spinal anaesthesia may provide excellent analgesia and perineal relaxation for breech delivery (5) (Chapter 63). It is of particular benefit when these conditions are required rapidly and epidural analgesia has not been established. The extent of sensory and motor blockade can be controlled by exploiting concentration and baricity (Chapter 30) (Figure 30.1). As with epidural analgesia, dense motor blockade can be avoided by employing low concentration solutions (17). A major limitation is that the conditions obtained are limited to the duration which is achieved from a single dose unless a subarachnoid catheter is placed or the block is repeated. The former approach has been associated with neurological complications (18).

The requirement for emergency intervention is higher in breech deliveries. Acute cord prolapse and fetal distress (Table 3.1) will require emergency caesarean section in the operating theatre. Assisted delivery of the after-coming head following spontaneous delivery of the breech and total breech extraction are examples of situations which may be managed in either the operating theatre or the delivery room. The constraints of the chosen area, whether it be the operating theatre or the labour room, should be clearly understood by obstetric, nursing and anaesthetic staff. If delivery is planned in the labour room the requirements for general anaesthesia in the labour ward should be met. The patient should be fasted and acid aspiration prophylaxis be given, if an emergency delivery appears likely (Chapter 109). Finally, staff and facilities for resuscitation of the neonate should be prepared.

It is important to stress, that if time permits, all of these situations can be managed using a regional technique. The superior safety afforded is well described in the literature (19). This lends support for the early placement of epidural catheters in this group. If breech extraction or assisted breech delivery are required perineal relaxation can be achieved with higher concentrations of local anaesthetic agent.

Uterine relaxation may be required (Chapter 24). This can be achieved in a number of ways. Inhalational anaesthetic agents cause dose dependent uterine relaxation which remains responsive to oxytocics in normal anaesthetic concentrations. This effect may be lost at higher concentrations (20). This technique carries with it the risks associated with general anaesthesia. Moreover, the long duration of action of inhalational agents creates a risk of uterine atony and post-partum hemorrhage. Large bore intravenous cannula should be established and blood bank services readily available.

A technique of uterine relaxation which is compatible with regional anaesthesia is the use of glyceryl trinitrate. When administered in intravenous boluses of 50 micrograms it gives effective relaxation which is well tolerated by the mother. Prolonged uterine atony is avoided because of its short half life (21). It has recently become available as an intra-nasal preparation (22) (Chapter 52).

Anaesthesia for Caesarean Section:
Either an epidural or spinal technique may be employed. Extraction of the breech through the lower uterine segment may be difficult and may require uterine relaxation.

References:,br> 1. James FM. Anesthetic Considerations for Breech or Twin Delivery Clinics in Perinatology 1982; 9:1 77-94.

2. Lyons ER, Papsin FR. Cesarean section in the management of breech presentation Am. J. Obstet. Gynecol. 1978;130:558-561.

3. De Crespigny LJC, Pepperell RJ. Perinatal mortality and morbidity in breech presentation Obstet Gynecol 1979; 53:2 141-145.

4. Donnai ADG: Epidural analgesia, fetal monitoring and the condition of the baby at birth with breech presentation Br. J. Obstet Gynecol 1975; 82: 360-365.

5. Moir D Obstetric Anaesthesia and Analgsia 2nd ed Balliere Tindall London, 1980; pp252-277.

6. O'Driscoll K, Meagher D: Traumatic intracranial haemorrhage in firstborn infants and delivery with obstetric forceps Br. J. Obstet Gynecol 1987; 88:6 577-579

7. Chiswick ML, James DK: Kiellands forceps: association with neonatal morbidity and mortality British Medical Journal, 6th Jan,1979; 7-9

8. Hoult IJ, MacLennan AH, Carrie LES: Lumbar epidural analgesia in labour: relation to foetal malposition and instrumental delivery. Br. Med J. 1977; 1: 14-16.

9. Kaminiski HM, Stafl A, Aiman J: The effect of epidural analgesia on the frequency of instrumental obstetric delivery . Obstet Gynecol May 1987; 69:5 770-773

10. Confino E, Ismajovich B, Rudick V, David MP: Extradural analgesia in the management of singleton breech delivery. Br. J. Anaesth 1985; 57: 892-895.

11. Breeson AJ, Kovacs GT, Pickles BG, Hill JG: Extradural analgesia- the preferred method of analgesia for vaginal breech delivery. Br. J. Anaesth. 1978; 50:1227-1230.

12. Bowen-Simpkins P, Fergusson IL: Lumbar epidural block and the breech presentation. Br. J. Anaesth. 1974; 46: 420-424.

13. Chestnut DH, et al: Continuous epidural infusion of 0.0625% bupivacaine - 0.002% fentanyl during the second stage of labor. Anesthesiology 1990; 72: 613-618.

14. Chestnut DH, et al: Continuous infusion epidural analgesia with lidocaine: efficacy and influence during the second stage of labor. Obstet Gynecol 1987; 69: 3 part 1 323-327.

15. Reynolds F, O'Sullivan G: Epidural fentanyl and perineal pain in labour. Anaesth. Apr 89; 44:4: 341-344.

16. Van Zundert A, Vaes L, Soetens M, De Vel M, et al: Are breech deliveries an indication for lumbar epidural analgesia? Anesth Analg 1991; 72: 399-403.

17. Russell IF: Spinal anesthesia for cesarean delivery with dilute solutions of plain bupivacaine: the relationship between infused volume and spread Reg Anesth 1991 16:3 130-136

18. Glosten B: Obstetric anesthesia risk: a review of recent literature. International Journal of Obstetric Anesthesia 1994; 3: 7-12.

19. Report on Confidential Enquires into Maternal Deaths in the United Kingdom 1988- 1990. London: HMSO, 1994.

20. Schnider SM, Levinson G: Anesthesia for Obstetrics 3rd ed Williams and Wilkins, Sydney 1993. p53-56.

21. Mayer DC, Weeks S: Antepartum uterine relaxation with nitroglycerin at caesarean delivery . Can. J. Anaesth. 1992; 39:2, 166-169.

22. Redick LF, Livingston E: A new preparation of nitroglycerin for uterine relaxation International Journal of Obstetric Anaesthesia 1995; 4:1 7-14