Intrapartum management

Careful selection of patients for assisted vaginal delivery is essential to achieve optimal outcome. Frank and complete breech with fetal weights <4000 g are favoured while those with footling should be advised regarding increased chance of cord prolapse. Pelvic adequacy should not be in doubt and clinical estimation appears adequate with no evidence to suggest that CT or X-ray pelvimetry increases the chance of success. Spontaneous onset of labour is preferred. Induction of labour with breech should be only in highly selected cases as CS may be a better option than induction.

Mothers are advised to attend the delivery unit when membranes rupture or with onset of painful contractions. Cord presentation or prolapse should be excluded on admission. The labour is conducted as for vertex presentation. Rate of cervical dilatation and descent of the breech and the FHR pattern are the key arbitrators to guide conduct of labour. If progress of labour was poor, adequacy of uterine contractions should be evaluated. Limited period of oxytocin augmentation could be of value and safe in selected cases. If the progress is poor in the first few hours of augmentation, it is better to opt for CS. The second stage needs full cooperation from the mother and assistance; hence epidural anaesthesia is recommended for pain relief and for management of the second stage.

In most cases of breech presentation there is a tendency for mothers to have early bearing down sensation and hence cervical dilatation should be checked and the mother encouraged to bear down only when the breech has reached the perineal phase of the second stage. It is important not to intervene early and to have the mother in lithotomy only after the anterior buttock and anus of the baby come into view over the mother's perineum with no retraction in between contractions. An episiotomy may not be essential in multipara with a distensible perineum but may be an advantage in a primigravida. This is done with the regional block or with pudendal block and local infiltration of the perineum.

Usually the fetus emerges in the sacro-lateral position. The mother should be encouraged to bear down with uterine contractions to deliver the fetus unassisted up to the level of the umbilicus. Assistance for the breech should be in the form of lateral manipulation with traction only for delivery of the head. In cases with extended knees (frank

Breech Delivery Shoulder AssistanceDelivery Breech PrimigravidaBreech Delivery Shoulder Assistance
Fig. 24.5 Delivery of the arm by rotation of the body so that the posterior shoulder, which was below the sacral promontory, becomes anterior and below the pubic symphysis.

breech) the legs are delivered by slight abduction at the hip followed by flexion of the knees (Fig. 24.4). The body of the fetus is ideally kept with the dorsum facing upwards.

When the scapulae become visible, if the arms are flexed the forearms are delivered by sweeping it in front of the fetal chest. If the arms are extended adduction and flexion of the shoulder followed by extension at the elbow helps to bring down the forearm and hand. In case this was not possible, 'Lovset manoeuvre' is resorted to where the posterior shoulder, which is below the level of the sacral promontory, is brought anterior below the sym-physis pubis by rotating the fetus clockwise by holding the baby with the thumbs on the sacrum and index fingers on the anterior superior iliac spines (Fig. 24.5). After delivery of the shoulder which has come anterior the fetus is turned in the anticlockwise direction to enable descent of the opposite shoulder. After delivery of the shoulder the dorsum of the fetus should face anterior and on vaginal examination the chin should be facing the sacrum.

The descent of the head in the pelvis is assisted by the weight of the fetus which is gently supported till the nape of the neck is seen under the symphysis pubis. This signals that the head is low in the pelvis and could be delivered by one of three methods (1) Swinging the trunk towards the maternal abdomen till the mouth and the nose of the fetus become visible; (2) Mauriceau-Smellie Veit manoeuvre can be employed where two fingers are pressed over the maxilla to flex the head and delivery is accomplished by shoulder traction (Fig. 24.6); (3) A Piper or Neville Barnes Forceps can be applied from below while an assistant holds the baby just below the horizontal and traction applied. Following any of the three methods delivery of the fetal head is completed after suctioning the oro-pharynx followed by nasopharynx and by ironing the perineum beyond the forehead.

Mauriceau Smellie Veit

Fig. 24.6 Delivery of the head by jaw flexion and shoulder traction.

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Getting Back Into Shape After The Pregnancy

Getting Back Into Shape After The Pregnancy

Once your pregnancy is over and done with, your baby is happily in your arms, and youre headed back home from the hospital, youll begin to realize that things have only just begun. Over the next few days, weeks, and months, youre going to increasingly notice that your entire life has changed in more ways than you could ever imagine.

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