1. Recognising abnormal breech birth
…. Interventions

2. abnormalities
Hypoxia
Mechanical
Both
……BUT STAY CALM

3. 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

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

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

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

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

10. 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

11. Decision making
Key skill
Do not force the situation

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

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

14. 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

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

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

17. Examine
Best done in hands and knees
Go along the abdomen

18. Hands next to FACE
Examine
Sweep arms down
Baby will birth

19. 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

20. Baby in a good position for Lovset

23. 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

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

25. 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

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

27. Start
Stay Calm
Flex the head

28. 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

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

30. Rotate baby’s head 45 degrees
Then Modified Mauriceau

31. “Praying hand forceps”
Demonstrate

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

33. 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.

34. 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

35. 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

36. 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.