Vaginal breech delivery and symphysiotomy

By Grover Koelpin No comments

Most babies turn to the cephalic or head-down
presentation by the time they are born. Persistent breech, or bottom-first presentation
places the baby at risk of difficult delivery, and the mother at increased risk of caesarean
section. Systematic review of randomized trials shows
that the chance of breech presentation at birth is reduced by attempting external cephalic
version. For persistent breech presentation the options
for delivery are caesarean section, or vaginal breech delivery. Systematic review shows that planned caesarean
section prevents about 1 perinatal death for every 100 deliveries. In some situations the
risks to the baby of vaginal birth are outweighed by the current and future risks to the mother
of caesarean section, or caesarean section is not feasible. It is thus important for health workers who
care for women in labour to be skilled in breech delivery techniques. Favourable factors
for vaginal breech delivery are shown here. If labour does not progress well or the buttocks
do not deliver easily, it is preferable to opt for caesarean section. The techniques of vaginal breech delivery
shown in this program have evolved from clinical experience, not randomized trials. The delivery position used in the cases which
follow is with the mother sitting propped up at 45 degrees with a backrest, or resting
on the thighs of an assistant kneeling on the bed, and her legs in lithotomy stirrups.
She has an intravenous infusion in place and her bladder has been emptied. An assistant
encourages her to bear down effectively. It is most important that the baby be expelled
by effective bearing down efforts. Any traction from below tends to cause extension of the
arms and head. An episiotomy may be cut as the buttocks distend the perineum. Only after the buttocks have delivered easily
and spontaneously and the decision is taken to continue with the vaginal delivery, commence
an oxytocin infusion to assist uterine contractions. As long as the delivery progresses spontaneously,
resist the temptation to pull the baby down, up to the point that the shoulders have delivered.
Once the baby’s head is engaged in the pelvis and the hairline is visible, control the delivery
of the head with a method such as the Mauriceau-Smellie-Veit method. With the baby straddling your right
forearm, position the right 3rd finger in the baby’s mouth and the second and fourth
fingers on the malar bones. Place the second and fourth fingers of the left hand over the
shoulders, and the third finger against the occiput to maintain flexion while the head
is carefully delivered. The second breech delivery shown here is more
complicated. The extension of one of the baby’s legs is an unfavourable factor. In the case of a frank breech presentation,
splinting of the baby’s body by both legs may prevent progress. In such a case, deliver
the legs by gently flexing at the knees. When the umbilical cord appears, pull down
a small loop to prevent traction on the cord later in the delivery. The baby’s back will
usually rotate anteriorly. If it is tending to rotate posteriorly, hold the baby with
a towel around the pelvis, not shown here, and gently turn the baby so that the back
faces anteriorly. If the shoulders do not deliver spontaneously
despite effective bearing down efforts, their delivery may be assisted by various manouvres. The anterior arm may be delivered by passing
two fingers over the baby’s back, along the humerus to the elbow, and sweeping the
arm around in front of the baby’s face and chest. One or both of the shoulders may be
delivered by the Lövset manouvre. Hold the baby by the pelvis with a towel, not shown
here. Rotate the baby through 180 degrees, back uppermost, so that the posterior shoulder
appears below the symphysis pubis to be swept down over the baby’s face and chest. If the baby cannot be rotated, the posterior
shoulder may be delivered by lifting the baby upward, chest towards the mother’s thigh,
passing two fingers up the baby’s back and sweeping the posterior arm over the baby’s
face and chest. Once the arms have delivered, encourage the
mother to bear down until the baby’s neck and hairline appear, indicating that the head
is engaged in the pelvis. If the head does not engage, the Mauriceau-Smellie Veit method
may be used to push the head up slightly, rotate to the oblique diameter, flex it and
pull it down. Suprapubic pressure may be used to assist flexion and descent of the head. Here, the baby’s head is delivered by the
Mauriceau-Smelli-Veit method as described before. An assistant may support the perineum. The second breech delivery shown, though difficult,
took 4 minutes and the baby was in excellent condition after birth. An alternative method of delivering the head
is the Burns-Marshall method. Once the head is engaged and hairline is visible, hold the
baby by the ankles with your left hand, and swing the baby through an arc up to a vertical
position and then over the mother’s abdomen. Support the perineum with your right hand
as the face delivers. For forceps delivery, hold the baby by the
ankles and swing to the 45 degree or vertical position where they are held by an assistant.
Use long curved forceps or Pipers’ forceps. Fit the forceps handles together with the
pelvic curve uppermost. Hold the left handle vertically with the left hand fingers, as
one would a pen. Insert you lubricated right hand posterolaterally into the vagina. Guide
the forceps blade with the fingers of the internal hand to lie alongside the baby’s
head. Apply the right blade in the same fashion, using your left hand to guide it into position. Confirm the correct positioning by the fact
that the handles lock together easily, and the baby’s face is symmetrically positioned
between the forceps blades. Deliver the head by steady traction on the
handles and downward pressure with the left hand on the shanks of the forceps, so that
the resultant pull follows the curve of the pelvis. If the head cannot be delivered, consider
rapid caesarean section or symphysiotomy. For symphysiotomy, infiltrate the skin and
subcutaneous tissues overlying the symphysis pubis with local anaesthetic. Two assistants
support the mother’s legs to prevent unnecessary separation of the pelvic bones. Pass a firm plastic catheter through the urethra.
Insert the index finger of your left hand into the vagina alongside the urethra, and
move the urethra away from the midline. Make a small vertical scalpel incision above the
lower part of the symphsis pubis. Angle the blade towards the top of the symphysis pubis.
Cut the anterior fibers of the symphysis pubis with a sawing action from the top to the bottom
of the joint, keeping a thin layer of the innermost fibres intact. Deliver the head by the Mauriceau-Smellie-Veit
maneuver or with forceps. The symphysis pubis separates just enough
to allow passage of the baby’s head. It is useful to routinely have local anaesthetic,
a scalpel and a urinary catheter available during breech delivery in case an emergency
symphysiotomy is needed. Reducing perinatal mortality depends on the
presence of a skilled attendant at birth, one who, among other skills, is able to deal
with problems encountered during vaginal breech delivery.

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