Category: BREECH

BREECH

Posted on by The Rebel Surgeon in BREECH

Safer to deliver by C/S in primipara

C/S in Breech

SPONTANEOUS BREECH DELIVERY

Be prepared for a retained caput!

  • Catheterize the bladder.
  • Leave the catheter indwelling
  • Place the patient with legs in stirrups
  • Buttocks hanging free of the table
  • Infiltrate the pubic area with local anesthesia
  • Have the following items at hand:
    • Large vaginal speculum
    • Delivery Forceps  
    • Scalpel
    • Heavy scissors
  • Check fetal heart rate continuously
  • Do not intervene before the lower part of the body has been delivered unless the heartbeat slows down critically
  • As soon as the lower part of the body has been delivered palpate the umbilical cord for pulsations.
  • If feeble or absent proceed urgently with EXTRACTION OF BREECH
  • Let body be delivered spontaneously
  • Let arms be delivered spontaneously
  • Leave body hanging by the head for a short moment (Burn-Marshall maneuver)
  • Grasp both feet from the front with a forked finger grip
  • Lift the body vertically by both feet
  • Let the head be delivered spontanesously (Bratt’s procedure)

ASSISTED BREECH DELIVERY

Be prepared for a retained caput!

  • Catheterize the bladder.
  • Leave the catheter indwelling
  • Place the patient with legs in stirrups
  • Buttocks hanging free of the table
  • Infiltrate the pubic area with local anesthesia
  • Have the following items at hand:
    • Large vaginal speculum
    • Delivery Forceps  
    • Scalpel
    • Heavy scissors
  • Check fetal heart rate continuously
  • Do not intervene before the lower part of the body has been delivered
    • Unless fetal heartbeats slow down critically
  • As soon as the lower part of the body has been delivered palpate the umbilical cord for pulsations.
  • If feeble or absent proceed urgently with EXTRACTION OF BREECH
  • Release the posteriorly positioned arm first
  • Use left hand when the back is turned to the (mother’s) right
    • And vice versa
  • Place left thumb on the frontal aspect of the truncus
    • Left index and middle fingers on the back
  • Slide hand inwards
    • Along the truncus
    • Until the thumb reaches the axilla
  • With a sweeping movement
    • Across the head
    • Bring the arm down
    • With index and middle fingers
  • Change hands
  • Release the anteriorly positioned arm
    • Using same technique
  • Check fetal heartbeats
  • Check puls in umbillical cord
  • Posterior arm release
  • Anterior arm release
  • In case the anteriorly positioned arm is difficult to release, rotate the truncus 180 ° bringing the arm to a posterior position and release /as described above
  • Leave the body hanging free for a short moment to facilitate the descent of the head in the birth canal. (Burn-Marshall maneuver)
Burn-Marshall maneuver
  • Deliver the head by Mauriceau-Levret’s maneuver:
    • Introduce index finger in the mouth
    • Flex the head with the index in the mouth
    • Apply traction with a forked finger grip posteriorly to the neck with the other hand
    • Apply fundal pressure by assistant
  • Fundal pressure
  • Forked fingergrip
  • Index in mouth
Assisted Breech Delivery

EXTRACTION OF BREECH

In case of fetal distress do a fast extraction:

  • Grasp one foot / both feets
  • Use forked finger grip with heel(s) in the palm of the hand
  • Grasp knee(s) with other hand
  • Apply strong traction
  • Combine with exaggerated pumping movements
  • Release arms
  • Perform Burn-Marshall’s procedure
  • Deliver head by Mauriceau-Levret’s maneuver
Extraction of Breech

RETAINED HEAD / FETUS ALIVE

Be prepared!    

  • Make a generous episiotomy. That might solve the problem by itself.
  • If needed to buy time:
    • Have an assistant lift the body vertically by the feet
    • Place large speculum posteriorly in the vagina.
    • Apply downward traction on the speculum
    • This will keep the airway free and accessible for suction.
  • Make a symphysiotomy:
    • Push the catheterized urethra to the side with two fingers in the vagina
    • Cut through the symphysis strictly in the midline with a scalpel
    • Cut until the pubic bones separate and you can feel the gap
  • Deliver the head with Mauriceau-Levret’s maneuver
Symfysiotomy in Breech

RETAINED HEAD DUE TO HYDROCEPHALUS

If not detected by previous palpation and/or ultrasound, the diagnosis will come into light when a myelomeningocele becomes visible as the lower part of the body is being delivered.

  • Puncture the hydrocephalic head suprapubically with a large bore needle
  • Drain the cerebrospinal fluid
  • Deliver the collapsed head by Mauriceau-Levret’s maneuver
  • Puncture and drainage of the head does not harm the child
Suprapubic Puncture and Drainage of Hydrocephalic Head

RETAINED HEAD / FETUS DEAD

Craniotomy

  • Apply firm traction on the neck
  • Perforate the back of the skull in the occipital area.
  • Be sure to perforate the skull. Not the upper part of the cervical spine.
  • Open the shanks of the perforating instrument
  • Destruct all intracranial septa.
  • Perform Mauriceau-Levret’s maneuver as follows:
    • Introduce index finger in the mouth
    • Flex the head with the index finger
    • Apply traction to the neck with a forked finger grip to the back of then neck
    • Extract the head by traction on the neck
  • Proceed slowly
  • Allow time for the head to collapse
Craniotomy in Breech

Occasionally attempts to extract the head by forceful traction to the neck have been attempted. The result may be a fractured spine with an elongated neck. When applying further traction to the neck the head will inevitably separate from the trunk.

Separation of head and trunk also occurs if you by mistake perforate the upper part of the spine instead of the skull. 

In case of such a scenario:

  • Remove the body
  • Extract the head from uterus with a finger in the mouth and the fractured spine in the palm of your hand
  • Apply fundal pressure with other hand
Retained Head in Breech. Separation from neck