Vaginal breech delivery and symphysiotomy

Uploaded by WHOrhl on 03.04.2012

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
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