• Delivery of the posterior arm. If the previous endeavours have been unsuccessful the last of the ‘enter’ manoeuvres is when an attempt to deliver the posterior arm is made. The midwife enters in front of the baby’s body and locates the lower arm.
Pressure is exerted on the elbow to try to make the lower arm raise, this is then grasped and gently pulled across the baby’s face in a ‘cat lick’ motion thereby delivering the posterior shoulder
If the above manoeuvres are unsuccessful the whole round of pro- cedures should be performed again. It is recommended that this is undertaken by another midwife or obstetrician.
Documentation
Every obstetric emergency must be carefully documented after the event. This can be aided by using the mnemonic and writing the time each manoeuvre is performed and by whom. This will enable good debriefi ng of the parents when they are ready to talk about the event.
Risk management
With the advent of clinical governance, professionals are more accountable to the mothers and are encouraged to learn from events.
Reporting forms for all obstetric risk events are available in all units across the country. They allow for accurate audit of events and aid the planning of training programmes designed to keep professionals up to date with current practices in maternity care.
• Oligohydramnious (reduced amount of amniotic fl uid) – restricting movement
• Polyhydramnious (increased amount of amniotic fl uid) – providing plenty of space for movement
• Multiple pregnancy
• Contracted pelvis
• Primigravid woman (expecting her fi rst baby) with fi rm uterine and abdominal muscles
• Grand multiparous woman (expecting her fi fth or subsequent baby) with lax uterine and abdominal muscles
Or for fetal reasons such as:
• Anomalies, such as anencephaly (partially formed brain)
• Short umbilical cord
• Prematurity
• Lack of tone such as fetal death in utero
A breech is defi ned when the fetus is lying in a longitudinal position with the buttocks presenting. It may described as:
• Flexed or complete breech. The legs are bent at the hips and knees so the baby is sitting cross-legged. This is more common in a multiparous woman or when there is polyhydramnious
• Extended or frank breech. The hips are fl exed and the knees extended so that the feet are near the head. This is more common in primigravid women with fi rm uterine and abdominal tone. It is also the most diffi cult to diagnose as the buttocks may be deeply engaged on abdominal palpation
• Footling breech. The foot or feet present before the buttocks. This is rare, but more common in premature gestations
• Kneeling breech. This is very uncommon, but occurs when the baby is in a kneeling position
A breech is identifi ed by:
• Abdominal palpation. The presenting part will be fi rm, but not hard and smooth, although this might be diffi cult to identify if it is deeply engaged. The head may be ballotable (moveable) in the fundus, and the fetal heart may be auscultated above the level of the umbilicus, but again, this may be lower if the breech is deeply engaged
• Vaginal examination. The presenting part if breech may be higher in the pelvis prior to labour than when cephalic (head down). If the legs are in the extended position, the breech may be mistaken for the head, especially while the cervix is partially closed
• Ultrasound scan. This is conclusive and should screen for anoma- lies in the fetus and mother at the same time
If a baby is known to be presenting by the breech prior to labour, there are a variety of methods to try to turn the baby, including visualisation techniques, breech tilt exercises, massage, homeopa- thy, hypnosis, acupuncture, acupressure, moxibustion, chiropractic adjustments and external cephalic version (Banks 1998). However, discussion concerning these are beyond the scope of this chapter.
It is important to remember that if labour proceeds spontaneously and easily, the breech presenting baby should be born without problem. The baby should be born by propulsion, not traction. If labour is not progressing, a caesarean section may be advised.
However, it is important to understand that the use of oxytocic drugs to augment labour, or forceful traction by the birth attendant, leads to an increase in poor outcomes such as brain and spinal inju- ries, particularly if the baby is preterm (Banks 1998; Cronk 1998).
It is commonly thought that the baby’s bottom is smaller than the diameter of the head and may pass through a cervix that is not fully dilated. The concern is that the larger head may become trapped behind the cervix. However, this is more likely with preterm infants.
For a term infant presenting in a frank breech position, the bottom will be the same size as the head (Banks 1998).
If a woman presents in established labour and a breech presenta- tion is diagnosed, the following procedures will help to promote a safe outcome:
• If ultrasound facilities are available, they should be used to confi rm the presentation of the baby and to identify if any obstruction is present such as placenta praevia or a fi broid
• The woman should be enabled to assume whatever position she is comfortable to labour in. Lying prone or semi-recumbent works against the normal physiology of birth. Hands and knees is a good posture to adopt (Cronk 1998). There is a concern that if an upright position is used in the second stage, the placenta may separate from the uterus too quickly because of traction on the cord/placenta just after the birth due to gravity and in the absence of a contraction (Cronk 1998)
• If the woman is semi-recumbent, her legs should be in a lithot- omy position and an episiotomy is generally recommended when the buttocks distend the perineum, especially if it is the woman’s fi rst birth. If she is upright, this should not be necessary
• Hands should be kept off the breech that is birthing spontane- ously. Excessive handling may cause the baby to extend its arm above its head and lead to more complications
• The fetal back needs to rotate anteriorly to the woman. If it is necessary to assist this process, the baby should be supported by the hips. It is not advised to hold the abdomen as damage can occur to the kidneys and adrenal glands
• If required, a fi nger may be used to fl ex the knee and abduct the thigh to deliver the legs. They should not be pulled out
• The umbilical cord should not be handled as it may go into spasm
• If necessary, once the tip of the scapulae is visible, the attendant can splint the baby’s upper arm between the index and middle fi nger, then fl ex it and bring it down over its face, like a cat washing its face. If the arms are extended or nuchal (around the nape of the neck), it may help to undertake a modifi ed Lovsett’s manoeuvre. For this, the baby is fi rst rotated by holding the hips and using downward traction, so the posterior arm is brought into an anterior position and then released as described above.
If necessary the procedure can be repeated for the second arm by rotating the baby back through a semicircle, ensuring the back remains anterior. This manoeuvre is more likely to be required if the woman is lying on her back. It is rarely needed when an upright position is adopted (Banks 1998)
• Once the nape of the neck is visible, the woman should lean forward if she has been upright. A modifi ed Mauriceau- Smellie-Veit grip may be used to assist the birth of the head, which should be born slowly (see Figure 6.4). The procedure is as follows:
– Rest the baby with its face and body over your hand and arm with legs either side
Figure 6.4 Breech presentation
– Place the fi rst and third fi ngers of this hand on the baby’s cheekbones to encourage fl exion of the head. Current advice is to avoid placing a fi nger in the baby’s mouth as this can damage the jaw. An assistant could be asked to push above the mother’s pubic bone as the head delivers, to keep the head fl exed
– Use the other hand to grasp the baby’s shoulders and fl ex the baby’s head towards its chest, while applying downward pressure to gently deliver the head (WHO 2003)
• Some breech babies will be slow to breathe spontaneously at birth, usually due to shock. It is important to have resuscitation equipment available and ready, and that the parents are aware that this may be required (Cronk 1998)
• As with any event, good communication with the parents is important as well as the maintenance of contemporaneous records