Vaginal breech delivery in all-fours position-Hands off instead of intervention: A prospective observational study

Vaginal delivery in cases of breech presentation is considered potentially stressful for the newborn. The maternal upright position may represent a more physiological approach to facilitating birth. We compare the safety and efficacy of two maternal positions in vaginal breech delivery.

A prospective, single-center, observational cohort study from October 2006 to January 2021 in a high-level obstetric center, in Salzburg, Austria. Vaginal breech deliveries in maternal all-fours position (n = 140) were compared with those in assisted supine position (n = 92). The primary outcome measures for neonatal morbidity included Apgar scores, pH levels, and the rate of transfer to the Neonatal Intensive Care Unit (NICU) postdelivery.

In the all-fours position, 51.4% (n = 72) of deliveries occurred without obstetric intervention. The second stage of labor was significantly shorter in the supine position (39.5 min [95% CI 28-47] versus all fours position 52 min [95% CI 42-63], p = 0.042). Umbilical artery pH levels did not differ significantly (7.21 [95% CI 7.19-7.23] versus 7.19 [95% CI 7.17-7.21] vs. p = 0.06). Nor did the APGAR scores at 5 and 10 min below eight (p = 0.697; p = 0.760). Maternal and neonatal morbidity also did not significantly differ. Transfer of neonates to NICU n = 12 (13%) versus n = 11 (7.9%), p = 0.097, transfer birth-related n = 6 (6.5%) versus n = 8 (5.7%), p = 0.803. The number of postpartum umbilical artery pH < 7.10 were n = 9 (9.8%) versus n = 28 (20%), p = 0.065. There was one reported neonatal death due to intracerebral hemorrhage in the supine position group.

Our results indicate that vaginal breech delivery in the all-fours position seems to be comparable to supine position regarding neonatal safety. Additionally, the all-fours position shows potential for emergency management for unplanned breech deliveries by inexperienced attendants.