Techniques for Breech Delivery

Chapter 21 Techniques for Breech Delivery


June 14. 1999

1st year resident, Sang Yun Oh M.D.

Breech Presentations






I. Vaginal Delivery of Breech


- Three general methods of breech delivery through the vagina

? Spontaneous breech delivery - The infant is expelled entirely spontaneously
without any traction or manipulation other than support of the infant.

? Partial breech extraction - The infant is delivered spontaneously as far as
the umbilicus but the remainder of the body is extracted.

? Total breech extraction - The entire body of the infant is extracted by the obstetrician.

1. Management of Labor


- A rapid assessment - status of the fetal membranes, labor, and condition of the fetus

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with fetal heart rate, uterine contractions

1) Stage of Labor

- Assessment of cervical dilatation and effacement and the station of the presenting part??? --> planning the route of delivery

2) Fetal Condition

- Evaluation : If vaginal delivery is planned, the fetal head should be well flexed

? sonography

? X-ray

? CT

3) Intravenous infusion and Laboratory Values

- For anesthesia, for hemorrhage from lacerations or from uterine atony,

? for administration of medicines or fluids or blood

4) Fetal Monitoring

- Continuous electronic monitoring of fetal heart rate and uterine contractions

- Vaginal examination for umbilical prolapse, when membrane ruptured

5) Recruitment of Nursing and Medical Personnel

6) Route of Delivery

- should be determined before admission or as soon as possible after admission

- based upon the type of breech, flexion of the head, fetal size, quality
of uterine contraction, size of the maternal pelvis


2. Timing of Delivery


- When the buttocks or feet appear at the vulva

- Composition of delivery team :

? 1) an obstetrician skilled in the art of breech extraction

? 2) an associate to assist with the delivery

? 3) an anesthesiologist who can assure adequate anesthesia when needed

? 4) an individual trained to resuscitate the infant, including tracheal intubation

- Delivery is easier, perinatal morbidity and mortality are probably
lower, when the breech of the fetus is allowed to deliver spontaneously to the
umbilicus. If a nonreassuring fetal heart rate pattern develops before this
time, a decision must be made whether to perform manual breech extraction or to default to cesarean delivery.


3. Assisted Delivery of Frank Breech


- Unless there is considerable relaxation of the perineum, an episiotomy should be made.

- As the breech progressively distends the perineum, the posterior hip will deliver, and often with sufficient pressure to evoke passage? of thick
meconium at this point (F21-1)


- The anterior hip then delivers followed by external rotation to the sacrum anterior position (F21-2)


CAUTION : the cord is compressed with resultant fetal bradycardia

- Delivery of the legs by splinting the medial thighs of the fetus with the fingers positioned parallel to the femur and exertion of pressure laterally so as to sweep the legs away from the midline (F21-3)

?


- Fetal bony pelvis is grasped with both hands. The fingers should rest on the anterior superior iliac crest and the thumbs on the sacrum

? Gentle downward traction until the scapulars are clearly visible (F21-4)



4. Extraction of Frank Breech


- The Moderate traction exerted by a finger in each groin and facilitated
by a generous episiotomy (F21-5)


- If moderate traction does not effect --> the Breech decomposition

5. Extraction of the Complete or Incomplete Breech


- Both feet are grasped and pulled through the vulva simultaneously. (F21-6)


- Successively higher portions are grasped, first the calves and then the thighs (F21-7)


- As the buttocks emerge, the back of the infant usually rotates to the anterior

? Gentle downward traction is continued until the scapulars become visible (F21-4)

- As the scapulars become visible, the back of the infant tends to turn spontaneously toward the side of the mother to which it was originally directed (F21-8)

?


- The appearance of one axilla indicates that the time has arrived for delivery of the shoulders

** Two methods for delivery of the shoulders

1) ( F21-8 )

- With the scapulars visible, the trunk is rotated in such a way that the anterior shoulder and arm appear at the vulva. The body of the fetus is then rotated in the reverse direction to deliver the other shoulder and arm

2) If trunk rotation was unsuccessful, the posterior shoulder must be delivered first

( F21-9 ) ( F21-10 )


- Delivery of? the head : The head may be extracted with forceps or by the Mauriceau maneuver

?

** Mauriceau Maneuver ( F21-11 )


** modified Prague Maneuver

- If the back still remains posteriorly, extraction may be accomplished using the Mauriceau maneuver and delivering the fetus back down. If this is impossible, the fetus still may be delivered using the modified Prague maneuver ( F21-12 )


- Two fingers of one hand grasping the shoulders of the back-down fetus, from below, while the other hand draws the feet up over the abdomen of the mother

** Bracht Maneuver

- In the Bracht maneuver, the breech is allowed to deliver spontaneously
to the umbilicus.

? The suspension of the fetus in this position, coupled with the effects of uterine contractions and moderate suprapubic pressure by an assistant, often results in a spontaneous delivery

** Pinard Maneuver ( F21-13 )


- Two fingers are carried up along one extremity to the knee to push it away from the midline. Spontaneous flexion usually follows, and the foot of the fetus is felt to impinge upon the back of the hand. The fetal foot then may be grasped and brought down

6. Forceps to Aftercoming Head


- Piper forceps may be applied electively or whin the Mauriceau maneuver cannot be

? accomplished easily. (F21-14)



7. Analgesia and Anesthesia for Labor and Delivery.


1) Continuous epidural analgesia

? - 371 singleton breech fetuses delivered vaginally. About 25% of these women had given continuous epidural analgesia ( Confino and colleagues 1985 )

?

? # Oxytocin augmentation was necessary to effect delivery in half of them

? # First-stage labor was not longer than in a control group, the second stage
was prolonged significantly in women whose fetuses weighed more than 2500 g and was doubled if the fetus weighed more than 3500 g

? # Increased incidence of cesarean delivery

- Anesthesia sufficient to induce appreciable uterine relaxation may cause uterine atony and, in turn, postpartum hemorrhage

8. Prognosis


1) Maternal risks

? maternal infection

? rupture of the uterus

? lacerations of the cervix

? extensions of the episiotomy and deep perineal tears

? uterine atony -> postpartum hemorrhage

- The general prognosis with breech extraction? -> somewhat better than with cesarean delivery

2) Fetal risks

? outlook is less favorable

? trauma with incomplete breech presentations

? cord prolapse

- Adverse outcomes for properly selected and managed vaginally delivered breeches are uncommon.

- Vaginally born infants were not at increased risk for adverse outcomes related to head trauma, neonatal seizures, cerebral palsy, mental retardation,
spasticity ( Croughan-Minihane 1990 )

- No differences in Apgar scores, hospital stay, neonatal complications, and cord blood gases between vaginally delivered frank breeches and those delivered
by cesarean section ( Christian 1990 )

- Breeches delivered vaginally had lower cord blood pH and higher Pco2 compared with cephallic-presenting infants delivered vaginally ( Christian and Brady 1991 )

- A three- to fourfold significantly higher perinatal mortality rate and neonatal morbidity due to trauma in planned vaginally delivered infants, compared with those undergoing planned cesarean section ( Cheng and Hannah 1993 )

- The risk of any fetal injury, or any injury and death was tenfold increased after a trial of labor ( Gifford 1995 )

** Fetal injuries

? Fracture of the humerus and clavicle

? Fracture of the femur

? Neonatal perineal tears

? Hematomas of the sternocleidomastoid muscles ( disappear spontaneously )

? Separation of the epiphyses of the scapular, humerus, or femur

? Paralysis of the arm

? Spoon-shaped depressions or actual fractures of the skull

? Neck fracture

? Testicular injury

? Sevenfold increased incidence of sudden infant death syndrome

II. Version


- Procedure in which the presentation of the fetus is altered artificially

- Methods

??? * external version : performed exclusively through the abdominal wall

??? * internal version : the entire hand is introduced into the uterine cavity

1. External Cephallic Version


- If version is not performed, approximately 80 percent of nonmetallic presentations

? diagnosed in the late third trimester will persist at delivery.

? This is compared only with 30 percent of those who underwent a successful version.

- Cesarean delivery rates in untreated women are more than twice the rate in those women in whom a version was performed (32 versus 15 percent)

- The success rate of external version was approximately 65 percent, with a range of 50 to 80 percent.

- Once version succeeded almost all fetuses remained in the vertex position until birth


1) Risks

? maternal mortality

? placental abruption

? uterine rupture

? fetomaternal hemorrhage

? isoimmunization

? preterm labour

? fetal distress

? fetal demise

2) Indications

- In the last weeks, Breech or Shoulder presentation ( transverse lie ) -> should be no marked disproportion between the size of the fetus and the pelvis and no placenta previa

- Using tocolysis ( Fortunato 1988 ) is more likely to be successful if :

? * the presenting part has not descended into the pelvis

? * there is a normal amount of amnionic fluid

? * the fetal back is not positioned posteriorly

? * the woman is not obese

- More successful in a parous woman, unengaged fetus, and a normal amount of

? amnionic fluid ( Hellstrom 1990 )

3) Technique

- Uterine relaxation with a tocolytic agent ( Terbutalline 0.25 gm SC )

?? ->? Ritodrine, Salbutamol did not improve their success rate

- Presentation and position should be checked by sonography

- Each hand then grasps one of the fetal poles (F21-16)


- This procedure should always be performed with frequent fetal heart rate monitoring before, during, and after the procedure

- Version probably is best attempted in a labor and delivery unit or close by, so that rapid cesarean delivery can be accomplished if necessary.

? The risk of such an event is less than 1 percent.

2. Internal Podalic Version


- By inserting a hand into the uterine cavity, seizing one or both feet,
and drawing them through the cervix while pushing transabdominnally the
upper portion of the fetal body in the opposite direction.

- Indication - delivery of a second twin