Head Birth and Hand Maneuvers for Occiput Anterior Birth (PDF)

Birth of the Fetal Head  Birth of the Fetal Head The ideal time for birth of the fetal head is between contractions. The combination of the uterine contraction and the maternal pushing effort exerts a double force on the perineum at the moment of birth, which makes birth of...

Birth of the Fetal Head  Birth of the Fetal Head The ideal time for birth of the fetal head is between contractions. The combination of the uterine contraction and the maternal pushing effort exerts a double force on the perineum at the moment of birth, which makes birth of the head more rapid and the release of restraining pressure more abrupt. Close communication between the midwife and the woman facilitates a team approach to help the woman gently give birth while making every effort to protect perineal integrity.  Ritgen Maneuver The Ritgen maneuver, is an old technique in which the clinician applies pressure on the fetal chin with one hand and pressure on the occiput with the other hand to control the birth of the head. The fetal chin is palpated behind the woman’s rectum and pulled forward while the other hand maintains flexion of the occiput. The result is that the fetal head is pulled forward while maintaining flexion. The maneuver is performed between uterine contractions. The original rationale for using this procedure was to control extension of the fetal head and prevent perineal lacerations. This maneuver is rarely used today, as vacuum or forceps are chosen for indicated operative vaginal birth.  Ritgen Maneuver The original Ritgen maneuver, which was first introduced in 1855 in Germany, recommended placing fingers in the woman’s rectum. The modified Ritgen maneuver places the fingers between the rectum and the coccyx. The Ritgen maneuver is not associated with a decrease in perineal lacerations. Although rarely needed, the Ritgen maneuver may expedite birth by a short period if needed and other resources are not available. https://www.youtube.com/shorts/fjk6v-JCM8U https://www.youtube.com/watch?v=dkoOB1MEaBI  Head-to-Body Interval and Two-Step Birth Once the head is born, the midwife can move immediately to assist restitution and birth of the body (one step), or wait for the next contraction to effect spontaneous restitution and birth of the shoulders before guiding the infant’s body out of the vagina (two step). The assumption is that the one-step approach decreases the expulsive phase duration, thereby preventing neonatal acidemia. The two-step approach is a physiologic phenomenon. The mean head-to-body interval using the two-step process is approximately 88 seconds, whereas that for the one-step process is approximately 24 seconds.  Head-to-Body Interval and Two-Step Birth Although umbilical artery pH values have been shown to decline with longer head-to-body intervals, this decline was not statistically or clinically significant after controlling for the duration of the second stage. The choice of performing a one-step or two-step method for facilitating birth is based on the individual circumstance. the one-step procedure may be better if the FHR pattern indicates possible developing acidemia or at increased risk for acidemia the two-step physiologic method is safe when the fetus is not developing acidemia and is not at increased risk for acidemia.  Hand Maneuvers for Birth The first hand placement used during birth is directed toward preserving perineal integrity as the fetus emerges. Once the head emerges, the next hand placement is critical as it will allow the midwife to hold the newborn securely throughout the birth process and immediately after the birth. Jj Newborns are slippery, and sometimes the combination of maternal pushing and uterine contractions results in a rapid forceful birth. Controlling extension of the fetal head with one hand is the technique that has the most evidence with regard to decreasing the incidence of perineal lacerations.  Hand Maneuvers for Birth Other techniques include: perineal massage application of warm compresses “hands off,” wherein the midwife does not touch the fetal head or perineal area until the biparietal diameter is born “hands on,” which is variously described as flexion of the fetal head to control extension and manual support of the perineum. In practice, the hands-on technique refers to placement of one hand on the fetal head to control extension. The thumb and forefinger of the other hand are placed on either side of the perineum near so that a slight amount of pressure is directed inward to counter the transverse stretching of the perineum caused by pressure from the fetal head.  Hand Maneuvers for Birth When the Fetus Is in an Occiput Anterior Position and the Woman Is in a Semi-Sitting, Lateral, or Dorsal Position 1. Ensure both access to the perineum and visibility of the vulvar–perineal area. a. The midwife stands or sits in a position that allows for a clear visual field and comfortable access to the woman’s perineum. b. A sterile drape is placed on a surface within easy reach, on which instruments and a bowl for the placenta are placed.  ↳ Hand Maneuvers for Birth When the Fetus Is in an Occiput Anterior Position and the Woman Is in a Semi-Sitting, Lateral, or Dorsal Position 2. extension of fetal vertex. The primary goal is to prevent sudden extension of the fetal head, which increases the likelihood of perineal laceration. a. To control extension of the fetal head during crowning, the midwife places the palmar side of one hand, with fingers held straight, on the occiput of the fetal vertex visible at the vaginal introitus. This should be done as the vulva begins to stretch around the presenting part. Control of extension is maintained best when the fingers are kept in a straight plane with the hand. When just the fingertips are placed on the head, the midwife does not have as much control. b. If the midwife choses to use a second hand to support the perineum (“hands on” approach): Using the hand that is not controlling the pace of extension of the fetal head, a thumb and one finger is placed on the perineum below the fourchette, so that the midline area of the perineum, which is likely to tear, is between the thumb and the finger. Applying pressure with the thumb and fingers inward toward each other and the middle of the perineum (perineal body) reduces the transverse pressure created as the fetal head extends.  Hand Maneuvers for Birth When the Fetus Is in an Occiput Anterior Position and the Woman Is in a Semi-Sitting, Lateral, or Dorsal Position 3. Check for a nuchal cord: As soon as the head has emerged, the fingertips of one hand palpate the infant’s neck, sweeping the fingers along the neck in both directions, to determine if the umbilical cord is looped around the neck. If a nuchal cord is present, slip fingertips between the cord and neck to ascertain how tight the cord is. There are four options for proceeding with the birth if a nuchal cord is present: a. Cord reduction: If the cord is loose, slip it forward over the head before delivery of the shoulders. 39 b. Birth through the cord: If the cord is too tight to reduce but still has some mobility, slip it back over the shoulders as the infant is born, allowing the infant to be born through the cord. - c. Somersault maneuver: If the cord is too tight to slip over the shoulders but loose enough to permit some movement, use one hand to keep the head close to the maternal thigh throughout the birth of the body and the other hand to “somersault” the body over the perineum, which will limit the traction placed on the cord. d. Clamp and cut: If the cord is too tight to accomplish the other preferred steps, double-clamp and cut the cord between the clamps at the neck before the infant’s body is born.  nuchal cord Somersault maneuver Clamp and cut  Hand Maneuvers for Birth When the Fetus Is in an Occiput Anterior Position and the Woman Is in a Semi-Sitting, Lateral, or Dorsal Position 4. If planning a two-step process (assuming the cord has not been clamped and cut): While waiting for restitution, external rotation, and the next contraction, the midwife or assistant may wipe fluid from the neonate’s face, nose, and mouth with a soft, absorbent cloth but it is not necessary to stimulate the infant at this moment. Suctioning with a bulb syringe of the fetal nasal and oral passages is not necessary. a. Wait for the next contraction and for restitution and external rotation to occur, which will be evident when the occiput rotates 90°. b. If there is a need to expedite the birth (e.g., the cord has been clamped and cut), rotation of the shoulders into the anterior–posterior position to facilitate restitution and external rotation can be facilitated by using a modified Rubin’s maneuver if needed.  Rubin’s maneuver Insert and place two fingers over the scapula of the anterior shoulder, and two fingers against the clavicle of the posterior shoulder. Firmly move the infant’s head into the oblique diameter of the outlet.  Hand Maneuvers for Birth When the Fetus Is in an Occiput Anterior Position and the Woman Is in a Semi-Sitting, Lateral, or Dorsal Position 5. Facilitate birth of the shoulders. a. Place one hand on each side of the head over the parietal and cheek bones so that the midwife’s fingers point toward the fetal face and nose, as the midwife’s little fingers are closest to the woman’s perineum and the thumb is farthest away from the perineum. This step result in maintaining a secure hold on the newborn. Remember, “Pinkies to the perineum.” b. Assist the woman to give birth to the anterior shoulder. Avoid gripping the fetus’s neck by keeping the fingers straight so the hands are flat on the sides of the head. During the next contraction, while the woman pushes, exert gentle, downward pressure on the head until the top of the anterior shoulder and axilla can be seen beneath the symphysis pubis. Maintain parallel alignment between the head and the fetal spine during this process. Pulling down on the head alone laterally flexes the fetal head toward the posterior shoulder. This widens the angle between the neck and anterior shoulder, which can cause undue stretch and injure the infant’s brachial plexus.  Hand Maneuvers for Birth When the Fetus Is in an Occiput Anterior Position and the Woman Is in a Semi-Sitting, Lateral, or Dorsal Position 5. Facilitate birth of the shoulders. c. Once the anterior shoulder and axilla is visible, apply gentle upward pressure on the fetal head with both hands. Avoid laterally flexing the infant’s neck during this maneuver as well. Some midwives suggest that the perineum can be protected during the birth of the posterior shoulder by sliding the bottom hand over the shoulder and keeping the infant’s arms and hands close to the body during the birth. d. As the posterior shoulder is emerging, pivot the bottom hand under the fetal head, forming a C-shape cup with that hand facing the fetus so that the palmar side of the hand is facing the woman’s perineum. Loosely grasp the infant’s chest and back between the thumb and fingers. The head will be supported by the midwife’s forearm in this position. This is the first secure grip that will be maintained. e. Slide the hand that was on the top of the fetal head down the infant’s back; grasp one or both thighs, using this hand. This is the second secure grip that will be maintained.  Hand Maneuvers for Birth When the Fetus Is in an Occiput Anterior Position and the Woman Is in a Semi-Sitting, Lateral, or Dorsal Position 6. Complete the final phase of birth. As the body of the infant emerges, the newborn can be placed immediately onto the woman’s abdomen, pivoted to rest on the midwife’s forearm facing the midwife, or handed to another clinician for assessment. a. To place the infant immediately on the woman’s abdomen: Using the bottom hand that is supporting the head by cupping the chest and scapula. Position the infant laterally on the woman’s abdomen with the head and face slightly lower than the body to facilitate drainage of oral and nasal fluids. i. While moving the infant onto the woman’s abdomen, confirm that there is no tension on the umbilical cord. ii. Maintain both secure grips on the newborn until the woman is safely holding her infant. b. To hand the newborn to another clinician: Pivot the hand cupping the infant’s chest and scapula in one of two ways: i. Keeping the thumb and fingers around the newborn’s shoulders, extend a finger to support the occiput and stabilize the neck. The newborn’s shoulders are in the palm of the hand, and the thumb and remaining fingers are resting—not pressing —against the sides of the neck. The top hand continues its grasp around legs. ii. Alternatively, the bottom hand can slide up toward the head and grasp the two parietal bones between the thumb and fingers, with the occiput resting in the palm of the hand. Wi iii. The newborn’s hips and legs are then tucked securely between the midwife’s bottom arm and body at waist level. The newborn’s back is supported on the midwife’s lower arm. The newborn’s head is held firmly, in a slightly dependent and lateral position to encourage postural drainage. This is the third secure grip that can be maintained regardless of the woman’s position. An initial assessment should be conducted at this time.  Hand Skills for Birth of a Fetus in the Occiput Posterior Position The same hand maneuvers used to facilitate birth for the woman whose fetus is in the occiput anterior (OA) position are applicable for the fetus in the occiput posterior (OP) position, with one exception: The direction of pressure exerted to maintain flexion of the head is maintained by upward pressure instead of downward pressure because the occiput is closer to the rectum than it is to the symphysis. Once the biparietal diameters are visible, releasing the upward pressure on the occiput, in a controlled manner, controls extension. This technique is also used for the fetus in a face presentation: In a face presentation, the mentum (chin) will be under the symphysis and the rest of the head will be born by flexion of the neck. A face presentation that rotates so the mentum is posterior will not deliver vaginally because the neck is too short. Once the head is out, the remaining hand maneuvers are the same as described previously.  Immediately Following the Birth Placing the Newborn in Skin-to-Skin Contact Clamping and Cutting the Umbilical Cord (Delayed Cord-Clamping)? Umbilical Cord Blood Banking? Inspection of the Perineum and Laceration Repair Apgar Score