BREECH DELIVERY MANEUVERS: HANDS OFF, ROJAS, MAURICEAU... BASIC RULES. - Gynecology and Obstetrics -

BASIC MANEUVERS IN VAGINAL BREECH DELIVERY
With decreasing rates of vaginal breech birth, simulation training and other teaching aids such as illustrations and videos, can be useful to improve outcomes.

In this video we review exclusively the basic aspects and maneuvers to assist breech vaginal delivery in singleton fetus.

ESSENTIAL ASPECTS:
Ask for presence of a gyne.
Not to pull the baby.
Not to touch the baby until you see scapula bone.

DELIVERY OF BUTTOCKS, TRUNK AND LOWER LIMBS:
Encourage the mother to push. Maternal expulsive efforts should be adequate to deliver the buttocks, lower trunk and lower limbs, if not extended. Mother should bear down until the trunk is visible to the level of the scapulae. Meconium passage is common.
If lower limbs are extended, when trunk has delivered to the level of the umbilicus, the operator may use his/her fingers to expert to help he extraction of the foot and legs (never pulling them).
After legs have delivered, cord is checked for pulse and small loop is pulled down to prevent traction on the cord.

DELIVERY OF ARMS:
Mother is asked to push again and shoulders should present in the anterior-posterior plane and deliver spontaneously, along with the arms, usually crossed in front of the chest.
Never pull the baby, as this can cause the arms to drag behind, or extended, causing shoulder dystocia.
When you see the scapula bone, wrap legs/pelvis in a towel, keep the back upwards, and hold the baby by hips bones (never by the abdomen because injury to kidneys/ adrenals is possible). The trunk is supported by the operator in a plane at or below the horizontal plane of birth canal.
Rotate fetus through 180 degrees to deliver first shoulder and arm and then in the opposite direction so the other shoulder and arm deliver under symphysis pubis. The second rotation may be assisted by a gentle traction on the delivered arm in the direction of rotation.
When delivery of arms is not happening spontaneously, then this is managed by sliding an index finger along fetal scapula, over the shoulder to find elbow and forearm. Then forearm is swept in front of the face and downward to the chest, to be delivered. This can be repeated for the other side. This has to be done kindly and without applying force, nor to dislocate the shoulder or lead to fracture.

DELIVERY OF THE HEAD:
The head is delivered by neck flexion.
For routine delivery of the head use both hands: let the fetal trunk lies along your right forearm with legs straddling the forearm. The middle finger of the right hand can be placed in the mouth of the baby, or can be placed on the maxilla and second and fourth fingers on malar eminences. Do not make any traction on the jaw, as this can injure temporomandibular joint.
Left hand will be holding the occiput with the middle finger, to apply counterpressure at the same time we are promoting the flexion with right fingers. The pressure is carefully given into the shoulders by left hand toward down, and when you see the occiput, then movement is towards up.
The traction is made by left hand, VERY KINDLY, as an excess weight on cervical spine from downward traction can dislocate fetus’s neck with ominous prognosis.
If hairline is not visible, Mc Roberts and suprapubic pressure towards the occiput is applied by assistant to flex neck/ head and push it down into the pelvis.
The trunk should be no more than 45 degrees above horizontal to avoid traction on cervical spine during delivery of the head. This could cause serious damages, even the death of the baby.
The combination of encouraging maternal expulsive effort, avoiding operator traction on the fetus and applying suprapubic pressure to prevent prolonged expulsion phase, has been reported to reduce perinatal mortality.

IF HEAD ENTRAPMENT:
More risk in preterm babies or with big babies, if mother starts to push before full cervical dilation occurs.
IF after trying this maneuvers HEAD IS STUCK, DO NOT PULL THE BABY OR MAKE ANY MOVEMENTS, JUST ASK FOR HELP and do not stimulate the baby.
Administration of Salbutamol, Solinithrine by anesthetist can be useful to help head delivery in case of head’s stuck and also head extraction by forceps.
In case of forceps, the gyne will ask the assistant to hold the baby from the legs up with back up to apply the forceps.

Remember breech delivery is HANDS OFF procedure, never pull the baby, hold from hipbones and routinely deliver head with both hands.

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