Obstetrics and Gynecology - A.M. Hromova 2000

Operative Obstetrics
Delivery Operations
Breech Extraction

Breech extraction is a surgical Procedure performed during labor in cases of breech presentation when there are maternal or fetal indications for prompt delivery. This procedure must be distinguished from manual assistance in breech presentations. Manual assistance is used when a fetus in a breech presentation delivers spontaneously.

Breech extraction is defined as the active removal of the fetus when the majority of its body is already in the birth canal.

Indications for the procedure:

1. Fetal indications:

— grade II–III Fetal Hypoxia.

2. Maternal indications:

— uterine inertia;

— severe forms of gestosis;

— infectious diseases accompanied by fever;

— intrapartum endometritis;

— decompensated extragenital disorders;

— severe neuropsychiatric disorders;

— intoxication or poisoning;

— following a classic podalic version.

Conditions required for breech extraction:

— full cervical dilation;

— rupture of the amniotic membranes;

— adequate proportion between the fetal HEAD dimensions and the maternal pelvis;

— a living fetus.

To perform breech extraction, the parturient woman must be placed in the lithotomy position on the operating table.

Anesthesia: general anesthesia or perineal Muscle relaxation (atropine, novocaine with lidase, no-shpa).

No instruments are required for breech extraction. The Use of the Smellie blunt hook is permitted only in the delivery of a dead fetus.

Depending on the presentation, breech extraction may involve extraction by one FOOT, both feet, or the groin.

Extraction by one foot is indicated in cases of incomplete footling presentation.

Surgical technique. The fetal foot is grasped with the entire hand such that the thumb lies along the calf Muscles and the fingertip rests in the popliteal fossa. The thumb must be positioned strictly parallel to the axis of the fetal leg without crossing it. The remaining fingers grasp the front of the fetal leg. By applying traction downward and slightly toward oneself, the entire leg is delivered in such a way that its anterior surface faces backward. As the leg emerges, it is grasped closer to the vulva with both hands. The fetus is extracted by the leg until the groin crease appears beneath the lower margin of the Pubic Symphysis. After the anterior groin crease and iliac bone emerge from beneath the symphysis, the fetal thigh must be elevated upward (anteriorly). As a result, the lower buttock is delivered over the Perineum. Once the buttocks are born, the hands are placed on them such that the thumbs lie adjacent and parallel along the sacrum, while the other four fingers grasp the fetal iliac bones and thighs. Using traction toward oneself and backward (downward), the obstetrician facilitates the delivery of the pelvis in the oblique diameter with the fetal back facing the symphysis. Thus, the fetal trunk is delivered up to the umbilicus, and subsequent traction achieves extraction up to the lower angle of the anterior scapula. At this point, the fetal head enters the pelvic inlet, and the umbilical cord may become compressed against the pelvic walls. Therefore, the clinician's actions must be prompt and precise.

As soon as the lower angle of the anterior pubic bone appears from beneath the symphysis, delivery of the arms is initiated. First, the posterior arm is delivered, as is done in classical manual assistance. Then, by rotating the fetus 180°, the other arm is delivered in the same manner. Finally, the head is delivered using the Mauriceau-Smellie-Veit maneuver.

Total breech extraction by the foot (extraction by a single foot)

In complete footling presentation, extraction of the fetus begins by grasping both feet. Each foot is encircled by the corresponding hand in such a way that the thumbs lie along the length of the calf muscles, and their tips reach the popliteal fossae. As traction is applied, the physician's hands move first to the thighs, and then to the fetal pelvis, as in single-foot extraction. Subsequently, delivery of the shoulder girdle and the aftercoming head of the fetus is performed.

Extraction of the fetus by the groin (inguinal crease)

This procedure is performed in frank (pure breech) presentation, if the buttocks are fixed, impacted in the pelvis, or located on the pelvic floor. Extraction of the fetus must be carried out in accordance with The Mechanism of physiological breech delivery. During the first stage of labor, the fetus is delivered up to the navel level.

The index finger of the corresponding hand (the left hand for the first fetal position, the right for the second) is inserted into the corresponding inguinal crease of the fetus, and the thumb is placed on the sacrum. Traction is performed backward (downward) using the index finger. The traction force must be directed toward the fetal pelvis rather than the thigh to prevent its fracture. Since the finger performing traction tires quickly, it is advisable to grasp the forearm with the hand of the second hand to increase pulling power. An assistant presses on the uterine fundus to prevent extension of the fetal head. After the anterior buttock crowns, it should be lifted upward; from the side of the fetal back, the index finger of the second hand is inserted behind the inguinal crease of the posterior leg, and by downward traction, the fetal buttock is brought down. By pulling toward oneself using both inguinal creases, the fetal pelvis is delivered.

Next, the Second Stage of the operation is commenced. The pelvic end of the fetus is grasped with both hands so that the thumbs lie along the sacrum, and the remaining four fingers embrace the iliac bones and the thighs of the fetus no higher than the inguinal fold, and by pulling toward oneself and downward, the trunk is delivered to the level of the navel.

Then, the second stage of labor is performed — delivery of the fetal trunk to the lower angle of the scapula. Only after this can one proceed to the extraction of the arms and the fetal head (third and fourth stages), which is carried out using the same Methods as in classical manual assistance.

Instrumental extraction of the fetus by the inguinal crease is performed using a special blunt hook, which is inserted into the anterior crease of the anterior buttock. Traction with the hook and stepwise extraction of the fetus are performed in the same manner as with digital extraction. Since There is a high risk of fetal injury, extraction with a hook is permitted only in cases of fetal demise.

Complications in the mother and fetus during breech extraction:

- lacerations of the soft Tissues of the birth canal (cervix, perineum);

- injuries to the pubic and sacroiliac joints;

- fetal injuries (damage to the lower and upper extremities of the fetus, up to and including fractures);

- intracranial trauma, fractures of the fetal clavicles.

Control questions

1. Define the operation of breech extraction of the fetus.

2. Indications for the procedure.

3. Conditions required for breech extraction.

4. Types of the operation.

5. Technique of single-foot fetal extraction.

6. Technique of double-foot fetal extraction.

7. Technique of extraction by the inguinal crease.

8. Complications for the mother and fetus.