[CG] Breech delivery, management of complications

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Applicable unit policies:

Breech extraction is a “dire emergency” procedure carried out when there is severe fetal distress and/or problems with the delivery of a second twin in a transverse or oblique lie after internal podalic version. The technique of internal podalic version is described first.

Panic will not help!

Call for help so that it is on the way.

Internal podalic version

This may be necessary to deliver:

  • a second twin at CS or at a vaginal birth • if there is an immediate need to deliver baby.
  • Tranverse lie caesarean section.

Documentation will inevitably be retrospective and must be clear.

The operator’s hand and forearm may need to be in uterus / lower genital tract.

Method

A fetal foot is identified by recognizing a heel through intact membranes. The foot is grasped and pulled gently and continuously lower into the birth canal (or through uterotomy at CS). The membranes are ruptured as late as possible. The baby is then delivered as an assisted breech or breech extraction with pelvi-femoral traction, Lovset’s manoeuvre to the shoulders if required and a controlled delivery of the head. This procedure is easiest when the transverse lie is with the back superior or posterior. If the back is inferior or if the limbs are not immediately palpable, do not panic, follow the curve of the back and down and round to find the leg. Confirm you have a foot before applying traction. This will minimise the risk of the unwelcome experience of bringing down a fetal hand and arm in the mistaken belief that it is a foot.

If ultrasound is immediately available to an experienced sonographer this may help identify where the limbs are.

A few seconds of calm consideration and accurate assessment will almost certainly result in an effective delivery manoeuvre.

Emergency Breech Extraction

  • Both of your hands are required: one inside, one outside.
  • A hand must be placed into the uterus and if possible BOTH feet grasped but one will do.
  • ENSURE it is a foot that is grasped.
  • If you grasp a hand, replace and locate a foot / feet.
  • Pull down the legs and press the head upwards using the external hand on the woman’s abdomen.
  • Traction must be steady and maintained on the delivered leg(s) until the breech is fixed.
  • Thereafter action takes the place of contractions and the Breech can then be delivered as per the diagrams and instructions for vaginal breech (see vaginal breech guideline).
  • Obtain paired cord pH.
  • Remember to document carefully.

 

Vaginal Breech Delivery - Head Entrapment

Fetal head entrapment during vaginal breech delivery is an obstetric emergency.

It is typically associated with preterm vaginal breech delivery when the fetal buttocks and trunk pass through an incompletely dilated cervix. The uterus subsequently contracts and clamps tightly around the fetal head.

N.B Entrapment can also occur at Caesarean section and although the reasons may be different the obstetrician needs to have a strategy (see Delivery of Breech at LUSCS)

Management of Entrapment at Vaginal Delivery

  • Inform anaesthetist, paediatric staff, senior midwife
  • Re-try Mauriceau-Smellie-Veit(MSV) manœuvre
  • Rotate baby to sacrum transverse
  • McRobert’s manoeuvre
  • Suprapubic pressure
  • Start tocolysis with GTN

1. Emergency cervico-uterine relaxation

Maternal IV cannula requires to be sited prior to administration of GTN (the drug may cause profound drop in BP)

Sublingual GTN via metered pump:

Nitrolingual pump spray should be primed before using it by pressing the nozzle once.

1 – 2 sprays (400-800 micrograms) administered as spray droplets beneath the tongue (do not inhale). Ask woman to close her mouth after spray is administered.

Repeat after 5 minutes if hypertonus is sustained.

Haemodynamic monitoring, a rapidly running I.V. infusion and immediately available ephedrine and phenylephidrine are mandatory prior to the use of Nitroglycerin (Glyceryl Trinitrate)

Cautions:

  • Nitrates may increase intraocular pressure and so should be used with caution to glaucoma.

Contraindications:

  • Uncorrected hypovolaemia
  • Severe anaemia (Hb<60 g/L)
  • Increased intracranial pressure
  • Constrictive pericarditis /pericardial tamponade
  • Hypersensitivity to GTN. Nitrates, coconut oil, ethanol, glycerol, monocarprylocaproate, peppermint oil

General Anaesthesia with a high end tidal concentration of volatile agent will often produce useful relaxation of the cervix

Once the third stage is complete, a Syntocinon infusion should be commenced.

2. Emergency surgical option: Cervical Incisions

Incise cervix - Duhrssen’s incisions @ 2,10 and 6 o’clock (see below)

Pictorial diagram of Duhrssen's incision at 2,10 and 6 o’clock*

*Incisions at 2 + 10 o’clock are usually sufficient. (PROMPT 2nd edition) Take great care to only cut the cervix

3. Emergency Surgical Option: Symphysiotomy Technique

  1. Lithotomy position for patient
  2. Analgesia
  3. Catheterise bladder (indwelling)
  4. Incise skin above the symphysis with a solid scalpel. The top of the symphysis is probed with the tip of the scalpel to identify the non-bony joint.
  5. The urethra is kept displaced from the midline by a finger in the vagina pushing the catheterised urethra laterally.
  6. The scalpel, held at an angle 30 degrees from the horizontal, is advanced vertically towards the vagina until the sharp tip is sensed by the intravaginal finger. Divide the joint by a sawing action.
  7. When the separation of the joint is felt remove the catheter, apply forceps and deliver the fetal head.
  8. An episiotomy and traction towards the sacral aspect of the pelvis relieves pressure on the unsupported urethra.
  9. After a symphysiotomy it is essential to refer to physiotherapy and orthopaedics for follow up as there can be significant morbidity.

4. Caesarean section after replacement similar to Zavanelli for Shoulder Dystocia (see shoulder dystocia guideline)

References

Images from:

www.manbit.com/images/f14-2a.gif www.who.int/reproductive-health/impac/procerdures/breech

Seeds JW. Malpresentations. In: Gabbe SG, Niebyl JR, Simpson JL, editors. Obstetrics: normal and problem pregnancies. 2nd ed. New York: Churchill Livingstone, 1991:5 3 9-72. Baskett TF. Essential management of obstetric emergencies. 2nd ed. Bristol: Clinical Press, 1991:126-3 5.

Last reviewed: 27 April 2015

Next review: 01 April 2021

Author(s): Dr. A.M. Mathers, Consultant Obstetrician, PRM on behalf of Obstetric Governance Group

Version: 3

Approved By: A.M. Mathers, Chief of Medicine