Recognising abnormal breech birth …. Interventions

abnormalities Hypoxia Mechanical Both ……BUT STAY CALM

Hypoxia Similar to other higher risk births CTG/ STAN advised Buttock lactate/ Ph- lactate>5 , ph <7.15 Monitoring difficulties second stage Is there a higher incidence of cord compression? Is there a higher incidence of hypoxia? Valuable learning resource Camilla’s videos birth progress and CTGs

Hypoxia Evidence Incidence similar to other high risk situations Norway STAN Incidence similar to other high risk situations Inductions Forceps Limitations

Mechanical problems Thorough understanding of Normal Breech Recite Imagine Demonstrate Practice … Choreography/Dance

The Times 5 mins – Bi trochanteric to birth of head 3mins – umbilicus to birth of head 1 mins – arms to head .

Abnormalities = Delay Birth of breech ( bi trochanteric diameter) Birth of trunk = body and arms Birth of head KEY Skill – Recognising Delay , stay calm

Delay in Bi trochanteric One hour of active pushing No descent / or birth not about to happen Advise caesarean No place for forceps/vacuum ? Syntocinon ? Fundal pressure and groin traction Position changes

Decision making Key skill Do not force the situation

Birth of bi trochanteric/ Delay in body descent Baby will birth – confident 5 mins till birth of head.

Initial steps Recognition Change positions Upright / birthstool Birthstool/upright Lift leg

No progress/ Baby not rotating Arms are in the wrong place Not in front of the chest Hands next to head Arms extended Arms nuchal

Steps Recognise Examine – where are the arms. Sweep Rotate from pelvic girdle Rotate from shoulder girdle, after disimpaction

Recognise Calm awareness of time Keep everyone aware Body not descending … and/or Baby not rotating

Examine Best done in hands and knees Go along the abdomen

Hands next to FACE Examine Sweep arms down Baby will birth

Extended aRMS-suspect if baby sacrum anterior but no descent Examine Sweep Successful Birth Unsuccessful Scapula close – Do Lovset Manoeuvre- birth Scapula not close – fundal pressure Lovset Lovset SAFETY Rule – do not do too early / stop if any major resistance / emphasis on rotation rather than traction If still no descent then do Rotation from Shoulder girdle

Baby in a good position for Lovset

Suspect if poor descent and back not sacrum anterior Nuchal arms Suspect if poor descent and back not sacrum anterior Unilateral Bilateral- minimal descent , most difficult

Nuchal Arms - action Examine Attempt to sweep Attempt Lovset – pelvic girdle rotation Stop if resistance Attempt shoulder girdle rotation

Delays in birth of head Recognise – no descent of head within one minute of birth of the arms and shoulders Problem Head not flexed Occiput transverse Occiput posterior

Delay in birth of head - Actions Stay calm Change positions Modified Mauriceau Rotate head to diagonal Fundal / Suprapubic pressure Praying hand “forceps” Forceps

Start Stay Calm Flex the head

2. Change positions Lithotomy – Hands and Knees Hands and Knees- Lithotomy McRoberts Lithotomy > Birth Stool Hands and Knees > Birth stool Birth Stool > Hands and Knees Lift one leg

Modified Mauriceau Manoeuvre Malar eminence Counter pressure on occiput Suprapubic pressure – industrial grade! Persist

Rotate baby’s head 45 degrees Then Modified Mauriceau

“Praying hand forceps” Demonstrate

Forceps Demonstrate Kjelland , Piper , Nagele, Neville Barnes Same principle as any forceps

Occiput posterior Rare !! Severe if head deflected and chin caught on symphisis Mostly avoidable Prevent baby from rotating to sacrum posterior Caution with breech extraction of second twin.

Occiput posterior - management Prague manoeuvre – will work if head engaged in pelvis Grasp shoulder and head together with “praying hands” Disimpact head Rotate 90 degrees Flex head with modified mauriceau manoeuvre

Summary Know the normal mechanism and normal times Stay calm If the bi trochanteric diameter births then the head will birth Do not pull on the baby. Be aware of possible hypoxia Delays can occur Bitrochanteric Body – due to arms Head – not flexed or not anterior

summary Know and rehearse the manoeuvres while you are waiting for a breech birth Practice the manoeuvres ever three months on a model. Each caesarean for breech should be an opportunity to rehearse normal breech mechanism. Learn from each birth.