Singleton Breech Delivery & Operative Vaginal Delivery PDF

# 2024 Singleton Breech delivery ## Breech - **Definition:** fetal buttocks or legs enter the pelvis before the head, the presentation is breech - **Incidence:** 2 to 5% ### Categories 1. **Frank:** lower extremities are flexed at the hips and extended at the knees, and thus the feet lie close to...

# 2024 Singleton Breech delivery ## Breech - **Definition:** fetal buttocks or legs enter the pelvis before the head, the presentation is breech - **Incidence:** 2 to 5% ### Categories 1. **Frank:** lower extremities are flexed at the hips and extended at the knees, and thus the feet lie close to the head. 2. **Complete:** both hips are flexed, and one or both knees are also flexed. 3. **Incomplete:** one or both hips are extended. As a result, one or both feet or knees lie below the breech, and thus a foot or knee is lowermost in the birth canal. 4. **Footling breech:** an incomplete breech with one or both feet below the breech. 5. **Stargazing fetus:** neck is extremely hyperextended (5%) in transverse lie, due to fetal or uterine anomalies. ## Risk Factors - remote from term - Multifetal gestation - extremes of amniotic fluid volume - fetal anomalies - structural uterine abnormalities - placenta previa - nulliparity - increased maternal age - female fetal gender - prior breech delivery (recurrence 10%) - size that is small for gestational age ## Diagnosis 1. **Leopold maneuvers:** * LM1: hard, round mass occupies the fundus * LM2: hard, broad back to be on one side of the abdomen and the knobby small parts on the other * LM3: softer mass is movable above the pelvic inlet * LM4: breech to be beneath the symphysis 2. **Internal Examination:** fetal ischial tuberosities, sacrum, and anus; further fetal descent; and the external genitalia. 3. **Ultrasound** * fetal sacrum is palpated to establish position: * left sacrum anterior (LSA): fetus's back is up and its sacrum occupies the left upper (ventral) quadrant of the mother's pelvis * right sacrum anterior (RSA) * right or left sacrum posterior (RSP or LSP) * right or left sacrum transverse (RST or LST) ## Delivery Route - factors: maternal parity and pelvic dimensions; coexistent pregnancy complications; provider experience; patient preference; hospital capabilities; and fetal size, anatomy, and gestational age. ### >CS in the following features: #### Clinical characteristics - Lack of operator experience - Patient request for cesarean delivery - Prior perinatal death or neonatal birth trauma #### Sonographic fetal characteristics - Large fetus: >3800 to 4000 g - Severe fetal-growth restriction; term weight <2500 to 2800 g - Oligohydramnios - Fetal anomaly incompatible with vaginal delivery - Incomplete breech presentation - Hyperextended neck - Apparently healthy, viable preterm fetus either with active labor or with indicated delivery #### Maternal characteristics - Pelvic contraction or unfavorable pelvic shape determined clinically or with pelvimetry - Prior cesarean delivery ### Delivery Route 1. **Term Breech Fetus: Vaginal:** * Favors: * EFW: between >2500 to 2800 g and <3800 to 4000 g, prior vaginal birth, spontaneous labor and normal labor curves * Contraindications: Fetal-growth restriction and oligohydramnios, prior hysterotomy/CS: arrested or CPD 2. **Preterm Breech Fetus: Vaginal** * Favors: fetuses with a poor prognosis ### > Note - **Individualized decision-making:** for whom resuscitation is planned, for resuscitation is not planned. - ** Vaginal delivery ** - **Preterm(24 and 32 weeks) breech fetuses:** planned cesarean delivery confers a survival advantage compared with planned vaginal delivery. - **23 to 28 weeks:** CS to avoid fetal injury from vaginal birth that may include anoxia, trauma, and head entrapment. - **Periviable fetuses( 20 to 256/7 weeks):** data do not consistently support routine cesarean delivery to improve perinatal mortality or neurological outcomes - **Classical uterine incision:** early preterm group due to a poorly developed lower uterine segment. BUT poses a risk of greater blood loss, higher infection rate, and increased risk of uterine rupture in future pregnancies - **Provider skill, gestational age, parity, labor curve, and facility capability.** ## Delivery Complications ### Mother genital tract laceration, extend hysterotomy incisions, uterine atony, and postpartum hemorrhage ### Fetus - umbilical cord prolapse: 0.5% frank breech presentation, 5% complete breech, 15% footling presentation - humeral or clavicular fracture, brachial plexus injury, and sternocleidomastoid muscle trauma - spinal cord & genital injury ## Imaging - to confirm presentation, anomalies, fetal size, breech type, and degree of neck flexion, nuchal arm, and cord - **Biparietal diameter (BPD):** >90 to 100 mm is often considered exclusionary for vaginal delivery ## Pelvimetry - one-view computed tomography (CT), magnetic resonance (MR) imaging, or plain film radiography - **SVD:** inlet anteroposterior diameter ≥10.5 cm; inlet transverse diameter ≥12.0 cm; and midpelvic interspinous distance ≥10.0 cm ## Biometry Correlation - maternal-fetal biometry correlation: sum of the inlet obstetrical conjugate minus the fetal BPD is ≥15 mm; the inlet transverse diameter minus the BPD is ≥25 mm; and the midpelvis interspinous distance minus the BPD is ≥0 mm ## MRI - SVD: interspinous distance was >11 cm and true obstetrical conjugate was >12 cm ## Preparations and Procedures for Vaginal Breech Delivery: GETHIPPOS Mnemonic | Letter | Description | |---|---| | **G** | Growth assessment: rule out IUGR | | **E** | EFM recommended | | **T** | Type of breech (frank or complete) | | **H** | Help needed (from department of anaesthesia, OR staff, pediatrics, second MD) | | **I** | IV in place, CBC & group and screen | | **P** | Progress in labour adequate? (maximum 60-minute active second stage) | | **P** | Power from above after crowning (Bracht manoeuvre & oxytocin) safer than pulling from below | | **O** | Oxytocin ready and hanging to ensure strong contractions at delivery | | **S** | Smellie-Veit manoeuvre for after coming head if needed | ## Labor and Delivery ### Labor Unit 1. a provider skilled in the art of breech extraction 2. an associate to assist with the delivery 3. anesthesia personnel who can ensure adequate analgesia or anesthesia when needed 4. an individual trained in newborn resuscitation ### First Stage - Continuous electronic monitoring ### Second Stage - <30 min to >60 min - **Passive phase**: Cesarean if the breech is not visible after 1 1/2 to 2 hours. - **Once the breech is visible:** active pushing is encouraged, hands-off approach in which hands are poised merely to support delivering parts is preferred to allow spontaneous delivery. - **Cesarean:** if completed or imminent delivery is not accomplished after 60 min of pushing. ## Labor Induction or Augmentation (controversial) ### Vaginal Delivery Methods 1. **Spontaneous breech delivery:** fetus is expelled entirely without any traction or manipulation other than support of the newborn. 2. **Partial breech extraction:** the fetus is delivered spontaneously as far as the umbilicus, but the remainder of the body is delivered by provider traction and assisted maneuvers, with or without maternal expulsive efforts. 3. **Total breech extraction:** the entire fetal body is extracted by the provider. ### Sequential Cardinal Movements - engagement and descent, internal rotation, descent continues, lateral flexion of the fetal body. - After the birth of the breech, there is slight external rotation, with the back turning anteriorly; shoulders then descend rapidly and undergo internal rotation; head is then born in flexion. ## Summary Criteria for Breech Vaginal Delivery vs Contraindication | Criteria | Contraindication | |---|---| | Clinical pelvic examination must be adequate | Cord presentation | | Continuous electronic fetal heart monitoring | Footling breech presentation| | Membranes should be kept intact as long as possible | Hyperextended fetal head| | Operating room with equipment and personnel available to perform a timely Caesarean section if necessary | Clinically inadequate maternal pelvis | | A health care professional skilled in neonatal resuscitation should be in attendance at the time of delivery | Fetal anomaly incompatible with vaginal delivery | | | Fetal macrosomia (>4000g) | | | Fetal growth restriction (EFW <2500g) | ## Zatuccini & Andros Score (3) | Category | 0 Point | 1 Point | 2 Points | |---|---|---|---| | Parity | Primi | Multip | | | AOG | > 39 wks | 38 wks | < 37 wks | | EFW | > 3630 gm | 3176-3630 | < 3176 | | Prev Breech > 2500 gm | None | 1 | 2 or more | | Cx Dilatation | 2cm or less | 3 cm | 4 cm or more | | Station | -3 | -2 | -1 or lower | ## Criteria For Trial Of Labor: Partial Breech Extraction - Frank breech - 36-42 weeks AOG - EFW: 2500-3800 gm - BPD < 9.5cm - Flexed fetal head - Adequate maternal pelvis - No maternal or fetal indication for CS - Breech score of 4 or more ## Be Careful OR Bee CCCAAARREEFUL - Bladder empty & IV - Educate patient and your assistant(s), and prepare your Equipment (delivery pack, & Piper forceps) - Cervical dilation, presentation (U/S prn), rule out Cord prolapse, and Call for help (including notifying surgical and neonatal teams) - Await umbilicus and the popliteal area of the knees, Assisting leg delivery (Pinard maneuver) as needed once popliteal fossae visible, loosen umbilical cord, then wrap in blanket/towel and supporting the hips/pelvis ensure sacrum Anterior - Rotate and Remove arms (Loveset's maneuvers) as needed once tips of scapulae visible - Enter x 2 for Mauriceau-Smellie-Veit (MSV) maneuvers (occiput and cheeks) as needed once nape of neck visible, and Episiotomy as needed - Flex head as part of MSV maneuver (back) Up (sacrum anterior) - Lift baby onto mother ## Vaginal Breech Delivery ### Consent - Secure consent ### Anesthesia - Request for anesthesia ### Episiotomy - Do episiotomy ### Spontaneous Delivery - Mentions Partial Breech Extraction (PBE) - Wait! Don't Pull! * Demonstrates correctly * Holds baby when umbilicus is outfit ### Delivery of Legs - Mentions Pinard's: * Lateral rotation of thighs * Flexion of knees * Keep sacrum anterior ### Delivery of Arms - Delivery starts when wing of scapula is seen - Rotate arm to anterior - Mentions Loveset Maneuver * Sweep humerus across the chest and deliver - Rotate other arm to anterior and repeat the Loveset maneuver to deliver ### Nape of Neck - Mentions and demonstrates correct positioning of fetus on the arm/opposite hand - Mentions: * Apply suprapubic pressure * Avoid over-extension ### Delivery of Aftercoming Head - Mentions Mauriceau-Smellie-Veit Maneuver * Demonstrates correctly * 2nd & 3rd fingers over the malar prominence * 2nd & 3rd fingers over the nape of the baby - Mentions use of Piper's forceps ### Inspection - Inspect the baby for any fracture / injuries - Inspect the birth canal for any lacerations ### Documentation - Document ## Delivery Technique in Breech Delivery | Technique | Description | |---|---| | Pinard maneuver | decomposition of frank into a footling breech by applying pressure in the popliteal fossa to prompt spontaneous knee flexion | | Bickenbach or Løvset's maneuvers | Nuchal arm delivery or reduction | | Bracht maneuver | Aftercoming fetal head delivered spontaneously, with the assistance of suprapubic pressure | | Mauriceau maneuver| Delivery of the Aftercoming Head, the index and middle finger of one hand are applied over the maxilla, to flex the head, while the fetal body rests on the palm of the same hand and forearm. | | Piper forceps or Laufe-Piper forceps | specialized forceps Delivery of the Aftercoming Head | | Prague mane | back of the fetus fails to rotate to the symphysis, two fingers of one hand grasp the shoulders of the back-down fetus from below while the other hand draws the feet up and over the maternal abdomen| | Zavanelli maneuver | w/ halogenated agents, replacement of the fetus higher into the vagina and uterus, followed by cesarean delivery, can rescue an entrapped breech fetus or to relieve intractable shoulder dystocia | | Dührssen incisions | To release entrapped head, cut at 2 o'clock, 10 o'clock, & at 6 o'clock | | Symphysiotomy | Intentionally fracturing the symphysis pubis | | Total breech extraction | hand is introduced through the vagina, and both fetal feet are grasped to deliver | | **For the delivery of the second of twin vaginally** | | | **Delivery in CS** | ## External Cephalic Version - **Definition:** fetal presentation is altered by physically substituting one pole of a longitudinal presentation for the other, or converting an oblique or transverse lie into a longitudinal presentation done abdominally that yield a cephalic presentation. - **Vs internal podalic Version:** Manipulations accomplished inside the uterine cavity that yield a breech presentation for delivery of a second twin - **Prognosis:** 50-60%, spontaneous version rate of 7% (2%among nulliparas, 13% among multiparas) - **Indications:** non cephalic presentation, transverse lie - **AOG:** 37 weeks - **Contraindications:** if vaginal delivery is not an option, placenta previa, early labor, oligohydramnios or ruptured membranes, known nuchal cord, structural uterine abnormalities, fetal-growth restriction, multifetal gestation, and prior abruption or its risk factors, previous uterine surgery. - **Success:** multiparity, unengaged presenting part, nonanterior placenta, nonobese patient, and abundant amniotic fluid - **Complications:** placental abruption, preterm labor, and fetal compromise. Bradycardia, Uterine rupture, fetomaternal hemorrhage, alloimmunization, amnionic fluid embolism, and maternal or fetal deaths. - **Preparation:** ready OR access, IVF, NPO for 6 hours, UTZ, Anti-D immune globulin is given to Rh D-negative women. Tocolysis and regional analgesia. - **Technique:** forward roll of the fetus, backward flip. -**Stop:** excessive discomfort, for persistently abnormal fetal heart rate, or after multiple failed attempts. - **Post procedure:** Repeat NST, transient abnormal fetal heart rate tracing in 6 to 9%, Resuscitate: intravenous fluids, oxygen, and lateral tilt. Or else immediate cesarean delivery 0.2 to 0.4%. 39 weeks: immediate labor induction. - **Tocolysis:** betamimetics terbutaline and ritodrine, salbutamol, calcium-channel blockers: nifedipine, nitric oxide donors:nitroglycerin, oxytocin-receptor antagonist: atosiban ## Moxibustion - traditional Chinese medicine technique that burns a cigarette-shaped stick of ground Artemisia vulgaris-which is also known as mugwort or in Japanese as moxa - BL 67 acupuncture point, the stick is directly placed against the skin or indirectly heats an acupuncture needle at the site to increase fetal movement and promote spontaneous breech version - 33 and 36 weeks' gestation to permit a trial of ECV if not successful. ## 2024 Operative Vaginal Delivery ## Operative Vaginal Delivery (OVD) - **Definition:** birth accomplished with assistance from forceps or a vacuum-cup device - **Incidence:** 3.1%, vacuum-to-forceps delivery ratio approximates 4:1 - **Prognosis:** FAILURE: 0.4%: forceps, 0.8%: vacuum extraction - **Indication:** termination of second-stage labor: any condition that threatens the mother or fetus and that is likely to be relieved by delivery. * **Maternal indications:** exhaustion and prolonged second-stage labor, preexisting or intrapartum conditions that limit effective pushing or warrant expedited delivery: Severe or acute pulmonary compromise, decompensation from intrapartum infection, neurological disease, and serious cardiac disorders * **Fetal indications:** nonreassuring fetal heart rate and premature placental separation. ## 2 Discriminators 1. **Station:** number of centimeters, either above or below, an anatomical zero station, which is a line drawn between the ischial spines. Stations range from -5 to 0 to +5. (outlet, low, midpelvic) 2. **Rotation:** rotation to OA position performed before traction (45 degree) ## **Operative Vaginal Delivery Prerequisites and Classification According to Station and Rotation** | Procedure | Criteria | Prerequisites | |---|---|---| | Outlet forceps | Scalp is visible at the introitus without separating the labia, Fetal skull has reached pelvic floor, Fetal head is at or on perineum, Head is OA or OP or, Head is right or left OA or OP position but rotation ≤45 degrees | Engaged head, Vertex presentation, Known fetal head position, CPD not suspected, Fetal weight estimated | | Low forceps (2 types) | Fetal station is ≥+2 cm but not on the pelvic floor, and: (a) Rotation ≤45 degrees is required or,(b) Rotation >45 degrees is required | Experienced operator, Ruptured membranes, Completely dilated cervix, Adequate anesthesia, Emptied maternal bladder | | Midforceps | Fetal station is between 0 and +2 cm | | | | | No fetal coagulopathy, No fetal demineralization disorder, Informed consent completed, Willingness to abandon OVD | ## Operative Vaginal Delivery (OVD) - **Complications:** higher station and greater degrees of rotation raise procedure difficulty and the chance of injury. - **Morbidity:** Same as CS - **Lacerations:** higher rates of third- and fourth-degree perineal lacerations (obstetrical anal sphincter injuries (OASIS)), vaginal wall lacerations, and less often cervical tears. * Prevent OASI: indicated episiotomy, mediolateral episiotomy, early forceps disarticulation and removal, cessation of maternal pushing during disarticulation or as the head begins to crown, dedicated assistant to bolster the perineum, manual or forceps rotation to an occiput anterior (OA) position (modified Ritgen maneuver). - **Pelvic Floor Disorders:** urinary incontinence, anal incontinence, and pelvic organ prolapse (POP), structural compromise or pelvic floor denervation - **Infection:** Lesser puerperal infection: 11% with single intravenous dose of amoxicillin plus clavulanic acid (third- and fourth-degree perineal laceration) - **Acute Perinatal Injury:** - **vacuum extraction:** cephalohematoma, subgaleal hemorrhage, retinal hemorrhage, neonatal jaundice, clavicular fracture, and scalp lacerations - **Forceps delivery:** facial nerve injury, brachial plexus injury, depressed skull fracture, and corneal abrasion ## Trial of Operative Vaginal Delivery - **Definition:** If an attempt to perform OVD is expected to be difficult BUT attempted only if the clinical assessment suggests a successful outcome. - **STOP/NO:** * **Forceps:** if forceps cannot be satisfactorily applied, mentum posterior presentation. * **Vacuum:** if the fetus does not descend with traction, 3 pop offs. - **Prognosis:** Cesarean delivery after an OVD attempt was not associated with adverse neonatal outcomes if the fetal heart rate was concurrently reassuring. * Sequential instrumentation most often involves an attempt at vacuum assisted OVD followed by one with forceps. (ACOG against sequential use of instruments unless there is a "compelling and justifiable reason.") - **OVD Failure:** persistent OP positions, birthweight >4000 g - **Guide:** Bill axis traction device: an arrow and indicator line when it points directly to the line, traction is along the path of least resistance. ## Forceps Delivery: https://youtu.be/4s-fdy7Ye9E?si=d2NnmS3JY7PP_Az6 | Category | Description | |---|---| | Types | * **Luikart forceps:** greater asynclitism * **Kielland forceps:** rotation from OP to OA position * **Simpson Forceps:** to deliver fetus with a molded head (Nulliparous women) * **Tucker-McLane:** used in fetus with a rounded head (Multiparas) * **Piper forceps or Laufe-Piper:** aftercoming head in breech | | Locks | * **At the end of the shank nearest to the handles:** (English lock) * **At the ends of the handles:** (pivot lock) * **Along the shank:** (sliding lock) | | Blades | * **Lies over the lateral face:** equidistant from the sagittal suture. * **A left OA (LOA) or right OA (ROA) position:** then the lower of the two blades is typically placed first. * **Digital rotation:** can correct OT or OP positioning. * **Manual rotation:** an open hand is inserted into the vagina, destationing of the fetal head moves the head to a level in the maternal pelvis with sufficient room to complete the rotation * **Barth:** place the other hand externally on the corresponding side of the maternal abdomen to pull the back of the fetus up and toward the midline in synchrony with internal head rotation | ## Forceps Mnemonic | Letter | Description | |---|---| | **A** | ANAESTHESIA: adequate pain relief, ASSISTANCE: neonatal support | | **B** | BLADDER: bladder empty | | **C** | CERVIX: fully dilated, membranes ruptured | | **D** | DETERMINE: position, station and pelvic adequacy, think possible shoulder dyctocia | | **E** | EQUIPMENT: inspect vacuum cup, pump, tubing and check pressure | | **F** | FORCEPS: * **Left blade:** left hand, maternal left side, pencil grip and vertical insertion, with rigth thumb directing blade. * **Right blade:** right hand, maternal right side, pencil grip and vertical insertion with left thumb directing blade. * **Lock blade and support:** check application. * **Posterior fontanelle:** 1 cm above plane of shanks. * **Fenestration:** no > fingerbreadth between it and scalp. * **Sagittal suture:** perpendicular to plane or shanks with occipital sutures 1 cm above respective blades | | **G** | GENTLE TRANCTION: applied with contraction/expulsive effort | | **H** | HANDLE ELEVATED: traction in axis of birth canal, do not elevate handle too early | | **I** | INCISION: consider episiotomy| | **J** | JAW: remove forceps when jaw is reachable or delivery assured | ## Pathologic Obstetrics: Operative Vaginal Delivery ### Design of Forceps - **Two crossing branches** - **Four components:** * **Blade:** enclose the head may be fenesrated or solid. * **Shank:** connects the handle and blade. * **Lock:** holds the forceps together. * **Handle:** to grip the forceps. - **Two curves:** * **Cephalic curve:** conforms the shape of the fetal head. * **Pelvic curve:** conforms more or less to the axis of the birth canal. →some varieities are fenestrated or pseudofenestrated to permit a firmer hold on the fetal head ### Types of Forceps | Type | Description | |---|---| | Simpson | most common forceps with cephalic and pelvic curve. - parallel, fenestrated blade and the wide shank in front of the English-style lock. -The English lock has a socket located on the shank at the junction with the handle, into which first a socket similarly located on the opposite shank. -used to deliver the fetus with molded head from nulliparous women | | Tucker-McLane | -blade is solid and the shank is narrow, -method of articulation is English lock, -used to deliver fetus with rounded head of multiparous women | | Kielland | -sliding lock, -minimal pelvic curvature and light weight, -used for deep transverse arrest in rotating the head | | Piper | - similar to simpson, -shank is longer ("imagine the PIPE is loooong), -double pelic curve - to facilitate application to the aftercoming head in breech position | | Barton | - good forceps rotation of head in transverse arrest | ## Vacuum Extraction : AKA vacuum extractor, ventouse - **Definition:** suction via cup placed on the fetal scalp so that traction on the cup aids fetal birth ### Vacuum Pressure - increments of 0.2 kg/cm2 every 2 minutes until a total negative pressure of 0.8 kg/cm2 (600) ### Advantage over Forceps - simpler requirements for precise positioning on the fetal head - avoidance of space-occupying blades within the vagina to help mitigate maternal trauma. ### Disadvantage - higher scalp laceration ### Criteria - not younger than 34 weeks (cranial hemorrhage) - fetal scalp blood sampling should not have been recently performed. - ascertaining correct head position ### Anesthesia - low or midpelvic: Regional analgesia - Pudendal blockade: outlet ### Application - flexion point/pivot point: found along the sagittal suture, approximately 3 cm from the posterior fontanel's center and approximately 6 cm from the anterior fontanel's center. - maximizes traction, minimizes cup detachment, flexes the neck, and delivers the smallest head diameter through the pelvic outlet. ## Vacuum Mnemonic | Letter | Description | |---|---| | **A** | ANAESTHESIA: adequate pain relief, ASSISTANCE: neonatal support | | **B** | BLADDER: bladder empty | | **C** | CERVIX: fully dilated, membranes ruptured | | **D** | DETERMINE: position, station and pelvic adequacy, think possible shoulder dyctocia | | **E** | EQUIPMENT: inspect vacuum cup, pump, tubing and check pressure | | **F** | FONTANELLE: * Position the cup over the posterior fontanelle. * Sweep finger around cup to clear maternal tissue. * 100 mm Hg initially and between contractions. * Pull with contractions only. | | **G** | GENTLE TRANCTION: * As contraction begins: * increase pressure to 600 mm Hg * prompt mother for good explusive effort * tranctions in axis of birth canal. | | **H** | HALT: * No progress with three traction aided contractions. * Vacuum pops-off three times. * No significant progress after 30 minutes of assisted vaginal delivery. | | **I** | INCISION: consider episiotomy if laceration imminent | | **J** | JAW: remove vacuum when jaw is reachable or delivery assured | ## Trial Vacuum Extraction - Without early and clear evidence of descent toward delivery - Traction without progress - Multiple disengagements occur following correct cup application and appropriate traction. ## Differences: OFE vs Vacuum | Category | OFE | Vacuum | |---|---|---| | Traction | INTERMITTENT | steady without jerking or rocking.| | Rotation | YES: 45 DEGREES | NO | | Application | SIDES OF THE FACE | FLEXION POINT | ## Training - Residency training - Readily available skilled operators to teach these procedures by simulation as well as through actual cases. ## Quiz - https://forms.gle/4VYU79SKeWw9xxd47