Vaginal Breech Delivery – Long journey of gyn&obs

Question

What are the contraindications for vaginal birth in breech presentation?
Demonstrate how you would teach a first year registrar to conduct a breech delivery.

Dummy and pelvis

(5 marks for any 5)

Inquire whether he/she has seen a breech delivery (2 marks)

Preliminaries (mention) 8 marks 1 for each point

Inform him/her regarding preliminaries:

The suitability for vaginal delivery should be assessed.
The delivery should be carried out by a senior experienced member of the medical staff.
The paediatrician should be present. Facilities should be arranged for advanced neonatal resuscitation.
Patient should be informed regarding the procedure and what is expected from her.
Check whether all equipment equipment including forceps and the equipment required for neonatal resuscitation are available. An assistant should be present.
Confirm full dilatation of the cervix and assess the station of the breech by performing a vaginal examination.
Allow the breech to descend and prevent the patient from pushing during the passive phase of the second stage.
Once the breech has descended and the woman gets bearing down sensation place her in the lithotomy position at the edge of the bed. Clean and drape the patient. Empty the bladder if necessary.

Delivery of the buttocks

Explain and demonstrate- 10 marks, 2 for each

The patient is advised to push with the contractions.
The principle of ‘masterly inactivity ‘is followed. The entire effort is by the mother and the operator will only assist.
When the breech is distending the introitus and the anterior buttock and the anus are seen, a wide medio-lateral episiotomy is given.
This should be done at the height of a contraction taking care not to damage the fetal genitalia.
Legs will deliver spontaneously if they are flexed.

Explain and Demonstrate

Delivery of extended legs and the body 20 marks

If extended Pinard’s manoeuvre is done. Three fingers are placed on the thigh of the antero-lateral leg, above the knee to slightly abduct and flex the hip followed by flexion of the knee. The procedure is repeated on the other side. (8 marks)
Buttocks should always be anterior. Otherwise gentle rotation is carried out. (4 marks)
The baby is wrapped in a sterile towel and gently held by the pelvis, but traction should not be applied. (4 marks)
A loop of the cord is pulled down to ensure that it is not too short and to prevent cord compression. (4 marks)

Delivery of the arms 20 marks

Explain and Demonstrate

Delivery of the arms is commenced when the inferior angle of the scapula is seen. (4 marks)
If the arms are flexed they can be eased out. (4 marks)
Loveset‘s manoeuvre is used to deliver extended arms. (8 marks)
The trunk is held by the pelvis and is gently drawn down and the body is lifted to cause upward and lateral flexion.
The baby is held by the pelvis and rotated by 180 degrees in one direction to deliver the posterior arm. Ease out the arm when it is visible by sweeping the humerus across the fetal chest.
Rotate by 180 degrees in the opposite direction to deliver the anterior Ease out the arm when it is visible.
- The baby is allowed to hang down from the edge of the bed and the mother is encouraged to push. (4 marks)

Delivery of the head 30 marks

Explain and Demonstrate

Delivery of the head is commenced when the hairline is seen.
- The head is preferably delivered with forceps. (15 marks , 3 for each)

Although Piper forceps were designed for this purpose Simpson’s forceps or Kielland’s forceps can be used.
The operator should ideally kneel to see under the trunk.
An assistant should hold the infant’s body in a horizontal plane.
The forceps are assembled and applied in the normal way.
During the initial descent the body of the fetus should be in the horizontal plane.Once the mouth and chin are visible the operator should stand and the body of the fetus and the forceps are rotated upwards.

Explain and Demonstrate

Mauriceau-Smellie-Veit manoeuvre is used to deliver the head if the delivery is occurring rapidly and there is no time to apply forceps or in the absence of an assistant to apply forceps. (15 marks, 3 for each)

The operators forearm is placed under the baby with a foot placed on either side.
The forefinger and the middle finger are placed on the maxilla beside the nose and the head is gently flexed. Flexion may be attempted at the lower jaw if the maxilla is out of reach, but care must be taken as dislocation can occur.
The other hand is placed on the fetal back with the middle finger pushing up the occiput to cause flexion. The other fingers are placed on the fetal shoulders on either side. This manoeuvre will splint and protect the cervical spine while promoting flexion.
Gentle traction is applied in a downward and backward direction to complete the delivery.
This manoeuvre is used to control and slow down the delivery. If traction is required it is safer to use forceps.

Post-delivery (mention) 5 marks

A paediatrician should be present and all arrangements should be made to resuscitate the baby. The baby should be examined for neural, skeletal and internal injuries.
The third stage is managed actively.
5 units of oxytocin is given after the delivery of the baby.
Controlled cord traction is applied to deliver the placenta.
The genital tract should be inspected for tears.
The episiotomy should be sutured.