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Department of Reproductive Health and Research (RHR), World Health Organization

Managing Complications in Pregnancy and Childbirth

A guide for midwives and doctors 

 


Section 3 - Procedures


Breach delivery

 

COMPLETE OR FRANK BREECH

Figure P-13

 Breech presentation 

              

DELIVERY OF THE BUTTOCKS AND LEGS

  • Once the buttocks have entered the vagina and the cervix is fully dilated, tell the woman she can bear down with the contractions.

  • If the perineum is very tight, perform an episiotomy.

  • Let the buttocks deliver until the lower back and then the shoulder blades are seen.

  • Gently hold the buttocks in one hand, but do not pull.

  • If the legs do not deliver spontaneously, deliver one leg at a time:

- Push behind the knee to bend the leg;

- Grasp the ankle and deliver the foot and leg;

- Repeat for the other leg.

Do not pull the baby while the legs are being delivered. 

  • Hold the baby by the hips, as shown in Fig P-14. Do not hold the baby by the flanks or abdomen as this may cause kidney or liver damage.

Figure P-14

 Hold the baby at the hips, but do not pull 

 

DELIVERY OF THE ARMS

ARMS ARE FELT ON CHEST

ARMS ARE STRETCHED ABOVE THE HEAD OR FOLDED AROUND THE NECK

Use the Lovset’s manoeuvre (Fig P-15):

  • Hold the baby by the hips and turn half a circle, keeping the back uppermost and applying downward traction at the same time, so that the arm that was posterior becomes anterior and can be delivered under the pubic arch.

  • Assist delivery of the arm by placing one or two fingers on the upper part of the arm. Draw the arm down over the chest as the elbow is flexed, with the hand sweeping over the face.

  • To deliver the second arm, turn the baby back half a circle, keeping the back uppermost and applying downward traction, and deliver the second arm in the same way under the pubic arch.

Figure P-15

Lovset’s manoeuvre 

 

BABY’S BODY CANNOT BE TURNED

If the baby’s body cannot be turned to deliver the arm that is anterior first, deliver the shoulder that is posterior (Fig P-16): 

  • Hold and lift the baby up by the ankles.

  • Move the baby’s chest towards the woman’s inner leg. The shoulder that is posterior should deliver.

  • Deliver the arm and hand.

  • Lay the baby back down by the ankles. The shoulder that is anterior should now deliver.

  • Deliver the arm and hand. 

Figure P-16

 Delivery of the shoulder that is posterior 


 

DELIVERY OF THE HEAD

Deliver the head by the Mauriceau Smellie Veit manoeuvre (Fig P-17) as follows:

  • Lay the baby face down with the length of its body over your hand and arm.

  • Place the first and third fingers of this hand on the baby’s cheekbones and place the second finger in the baby’s mouth to pull the jaw down and flex the head.

  • Use the other hand to grasp the baby’s shoulders.

  • With two fingers of this hand, gently flex the baby’s head towards the chest, while applying downward pressure on the jaw to bring the baby’s head down until the hairline is visible.

  • Pull gently to deliver the head.

Note: Ask an assistant to push above the mother’s pubic bone as the head delivers. This helps to keep the baby’s head flexed.

  • Raise the baby, still astride the arm, until the mouth and nose are free.

Figure P-17

 The Mauriceau Smellie Veit manoeuvre 

 

ENTRAPPED (STUCK) HEAD

  • Catheterize the bladder.

  • Have an assistant available to hold the baby while applying Piper or long forceps.

  • Be sure the cervix is fully dilated.

  • Wrap the baby’s body in a cloth or towel and hold the baby up.

  • Place the left blade of the forceps.

  • Place the right blade and lock handles.

  • Use the forceps to flex the baby’s head and deliver the head.

  • If unable to use forceps, apply firm pressure above the mother’s pubic bone to flex the baby’s head and push it through the pelvis.

FOOTLING BREECH

A footling breech baby (Fig P-18) should usually be delivered by caesarean section.

 

Figure P-18

 Single footling breech presentation, with one leg extended at hip and knee 

 

  • Limit vaginal delivery of a footling breech baby to:

- advanced labour with fully dilated cervix;

- preterm baby that is not likely to survive after delivery;

- delivery of additional baby(s).

  • To deliver the baby vaginally:

- Grasp the baby’s ankles with one hand;

- If only one foot presents, insert a hand (wearing high-level disinfected gloves) into the vagina and gently pull the other foot down;

- Gently pull the baby downwards by the ankles;

- Deliver the baby until the buttocks are seen;

- Proceed with delivery of the arms.

BREECH EXTRACTION

- ampicillin 2 g IV PLUS metronidazole 500 mg IV;

- OR cefazolin 1 g IV PLUS metronidazole 500 mg IV.

POST-DELIVERY CARE

Top of page

Clinical principles

Rapid initial assessment

Talking with women and their families

Emotional and psychological support

Emergencies

General care principles

Clinical use of blood, blood products and replacement fluids

Antibiotic therapy

Anaesthesia and analgesia

Operative care principles

Normal Labour and childbirth

Newborn care principles

Provider and community linkages

Symptoms

Shock

Vaginal bleeding in early pregnancy

Vaginal bleeding in later pregnancy and labour

Vaginal bleeding after childbirth

Headache, blurred vision, convulsions or loss of consciousness, elevated blood pressure

Unsatisfactory progress of Labour

Malpositions and malpresentations

Shoulder dystocia

Labour with an overdistended uterus

Labour with a scarred uterus

Fetal distress in Labour

Prolapsed cord

Fever during pregnancy and labour

Fever after childbirth

Abdominal pain in early pregnancy

Abdominal pain in later pregnancy and after childbirth

Difficulty in breathing

Loss of fetal movements

Prelabour rupture of membranes

Immediate newborn conditions or problems

Procedures

Paracervical block

Pudendal block

Local anaesthesia for caesaran section

Spinal (subarachnoid) anaesthesia

Ketamine

External version

Induction and augmentation of labour

Vacuum extraction

Forceps delivery

Caesarean section

Symphysontomy

Craniotomy and craniocentesis

Dilatation and curettage

Manual vacuum aspiration

Culdocentesis and colpotomy

Episiotomy

Manual removal of placenta

Repair of cervical tears

Repair of vaginal and perinetal tears

Correcting uterine inversion

Repair of ruptured uterus

Uterine and utero-ovarian artery ligation

Postpartum hysterectomy

Salpingectomy for ectopic pregnancuy

Appendix

 

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