Most babies who present by the breech are born spontaneously or with the help of, but not interference from, the attendant. The Kristellar/Bracht maneuver (suprapubic pressure) is all that is needed to deliver the after-coming head. However, progress may cease, and active interference then becomes mandatory. Arrest may take place at the head, neck, shoulders and arms, or buttocks.
Sometimes the body, shoulders, and arms are born, but the bearing-down efforts of the mother and the Kristellar/Bracht maneuver are not successful in delivering the head. When the head is arrested, several measures are available to extract it.
The body of the baby is placed on the arm of the operator with the middle finger of the hand of that arm placed in the baby’s mouth and the index and ring fingers on the malar bones (Fig. 25-13A). The purpose of the finger in the mouth is not for traction but to encourage and maintain flexion. With the other hand, the obstetrician exerts suprapubic pressure on the head through the mother’s abdomen.
Different maneuvers for arrest of the head.
The position is the same as the Wigand-Martin maneuver, with one finger in the baby’s mouth and two on the malar bones. The difference is that the accoucheur places his or her other hand astride the baby’s shoulders and produces traction in this way (Fig. 25-13B). The efficiency of this procedure is increased by an assistant’s applying suprapubic pressure on the fetal head while the operator is performing the Mauriceau maneuver.
Piper Forceps on the After-Coming Head
With the exception of simple suprapubic pressure, the best method of delivering the after-coming head is by the use of the Piper forceps. In contrast to maneuvers in which traction on the head is applied through the neck, the forceps exert traction directly on the head, thereby avoiding damage to structures in the baby’s neck.
Although any type of forceps can be used for this procedure, the Piper forceps, which was designed especially for this operation, is best. The handles are depressed below the arch of the shanks, the pelvic curve is reduced, and the shanks are long and curved. These features make this instrument easier to apply to the after-coming head.
The long axis of the head is in the AP diameter of the pelvis
The occiput is anterior
The face is posterior
Orientation and Desired Application
The cephalic application is biparietal and mento-occipital, with the front of the forceps (concave edges) toward the occiput and the convex edges toward the face
The pelvic application is good, with the diameter of the forceps in the transverse diameter of the pelvis, the concave edges pointing toward the pubis, and the convex edges toward the sacrum. The sides of the blades are next to the side walls of the pelvis
The baby’s feet are grasped by an assistant, and the body is raised (Fig. 25-13C). Care must be taken not to elevate the body too much for fear of damage to the sternomastoid muscles. The lower and upper limbs and the umbilical cord are kept out of the way. A good way to keep the arms out of the way is to use a folded towel as described by Savage
The handle of the left blade is grasped in the left hand
The right hand is introduced between the head and the left posterolateral wall of the vagina
The left blade is then inserted between the head and the fingers into a mento-occipital application
The fingers are removed from the vagina, and the handle is steadied by an assistant
The handle of the right blade is grasped with the right hand
The left hand is introduced between the head and the right posterolateral wall of the vagina
The right blade is introduced between the head and the fingers into a mento-occipital application
The fingers are removed from the vagina
The forceps are locked (Fig. 25-14), and vaginal examination is made to be certain that the application is correct
Piper forceps for delivery of an after-coming head.
Traction is outward and posterior until the nape of the neck is in the subpubic angle
The direction is then changed to outward and anterior, and the face and forehead are born over the perineum in flexion
An episiotomy should be used
When there is delay in delivery of the head and one is waiting for help or instruments, an ordinary vaginal retractor can be used temporarily to clear an airway in the vagina to the baby’s mouth (Fig. 25-15). The retractor is placed in the vagina and pressure exerted posteriorly. The vaginal contents are sponged out so that air can get to the baby if he or she breathes.
Vaginal retractor providing airway to the baby’s mouth and nose.
Anterior rotation of the chin is rare and occurs usually as part of posterior rotation of the back. The preferred management is as follows: (1) institute deep anesthesia, (2) cease all traction, (3) dislodge the chin from behind the pubis, (4) rotate the face posteriorly and the back anteriorly, (5) flex the chin, (6) effect engagement by suprapubic pressure, and (7) deliver the head with Piper forceps.
When this technique fails, the Prague maneuver (Fig. 25-16) may be used. Here, the fingers are placed over the shoulders, and outward and upward traction is made. The legs are grasped with the other hand, and the body is swung over the mother’s abdomen. With this procedure, the occiput is born over the perineum. Because this method carries with it the danger of overstretching or breaking the infant’s neck, it is used rarely.
When delivery of the head is not accomplished within a reasonable time, the baby may die. If he or she does perish, the mother’s welfare alone should be considered. To save her from needless injury, reduction of the size of the fetal head by perforation of the skull is preferable to extraction by brute force.
Occasionally, the cervix, which has opened sufficiently to allow the trunk and shoulders to be born, clamps down around the baby’s neck, trapping the head in the uterus. The possibility of this happening is greater with premature delivery, when the body has not yet developed its adipose tissue and is a poor dilating wedge. This dangerous situation calls for rapid action to break the spasm of the previously dilated cervix. This is accomplished by a single bold incision of the cervix with the scissors. The resultant relaxation of the spasm permits the head to be born.
Arrest of the Shoulders and Arms
The arms are simply extended over the baby’s head (Fig. 25-17A).
Extended and nuchal arms.
There is extension at the shoulder and flexion at the elbow so that the forearm is trapped behind the fetal head (Fig. 25-17B). One or both arms may be affected.
One method of reducing the incidence of this complication is to resist the temptation of pulling on the baby’s legs to speed delivery, especially when the uterus is in a relaxed state.
When this problem occurs, an attempt should be made first to deliver the arms by sweeping them over the chest in the usual way. This succeeds in most cases of simple extension and in some instances of nuchal arms when the upper limb is not jammed tightly behind the head.
If extraction fails in the case of a nuchal arm, the baby’s body is rotated in the direction to which the hand is pointing (Fig. 25-17C). This dislodges the arm from behind the head, and its delivery is then usually possible as described above (Fig. 25-17D). If both arms are nuchal, the body is rotated in one direction to free the first arm, which is then extracted, and then in the opposite direction to free the other arm.
In the rare instance when rotation fails, the humerus or clavicle must be fractured. This can be done directly, or it can be ensued by simply pulling on the arm until it breaks. Once this occurs, delivery can be accomplished. Because the fracture usually heals rapidly and well and because the choice may be between a dead baby and a broken arm, extreme measures are justified.
Failure of Descent of the Breech
In any situation, the size of the passenger, the capacity of the pelvis, the dilatability of the maternal soft tissues, and the character of the uterine contractions all play a part in determining whether spontaneous delivery takes place. In frank breech presentation, there is an added factor—the splinting effect of the baby’s legs across its abdomen can reduce the maneuverability of the fetus to such an extent that progress is arrested.
In the presence of good uterine contractions, nondescent of the breech is an indication not for hasty interference but for the most careful reassessment. Keeping in mind the fact that one of the causes of breech presentation is a large head that cannot engage easily, the accoucheur must be assured not of the general capacity of the pelvis but of its adequacy with respect to that particular baby. When a breech fails to descend, despite good contractions, disproportion is present, and cesarean section should be performed.
If cesarean section cannot be performed, progress and descent can be expedited by reducing the bulk of the breech, an operation known as decomposition. This is done by bringing down the legs, both whenever possible. When there is flexion at the hips and the knees, the feet can be reached easily. The hand is placed in the uterus, the membranes are ruptured, and a foot is grasped and brought down (Fig. 25-18A). Be sure it is not a hand. The same is done with the other foot. The position has been changed to a footling breech, and labor proceeds.
Frank Breech: Pinard Maneuver
If the breech is frank (flexion at the hips and extension at the knees), it may be impossible to reach the feet because they are high in the uterus near the baby’s face. In such a situation and when cesarean section cannot be carried out, the Pinard maneuver is performed under anesthesia (Figs. 25-18B and C). With a hand in the uterus, pressure is made by the fingers against the popliteal fossa in a backward and outward direction. This brings about sufficient flexion of the knee so that the foot can be grasped and delivered. When possible, both feet should be brought down. Unless there are urgent indications for immediate extraction of the infant, labor is allowed to carry on as for a footling breech.