Breech Extraction Delivery - Indications and Complications

Introduction:

Delivery of a breech baby vaginally can be risky. Normally, with the cephalic presentation (head-first presentation), the largest part of the baby gradually stretches to open the ligaments and soft tissues of the birth canal through labor. Even the fetal skull slowly changes shape to fit into the mother's pelvis (molding). With a breech presentation, the largest part, which is the head, comes out at last, and the baby's head has not had a chance to adjust to the pelvis by the time of delivery. If the delivery of a baby's head takes too long to be born after the body is out, the baby might have some complications from lack of oxygen. For this reason, if the baby is delivered vaginally, the proper mode of delivery should be followed like breech extraction for the safe birth of the baby. To avoid complications, most breech births (90 percent) are given birth by cesarean.

What Is Breech Extraction Delivery?

Breech extraction is a procedure in which the doctor grasps the feet of the fetus so that the fetus is delivered (extracted) from the uterus through the vagina. This procedure is commonly performed for the delivery of the second twin in a head-down, breech presentation, or a baby lying obliquely in the mother's uterus. This technique is not advisable for the delivery of a single fetus. In most cases of twin delivery, after the delivery of the first twin, the next twin often changes its position breech presentation. If the second twin is in a normal head-down presentation, the baby is allowed to gradually come out through the pelvis. But if the baby is not in a normal position, then breech extraction is preferred. The procedure is performed under epidural anesthesia with adequate pain control.

What Are the Types of Vaginal Breech Delivery?

Three types of vaginal breech deliveries are described as follows:

• Spontaneous Breech Delivery - In this type, no manipulation or traction of the infant is used. Spontaneous breech delivery happens predominantly in pre-term deliveries.

• Assisted Breech Delivery - This is the common type of vaginal-assisted breech delivery. The baby is allowed to deliver up to the umbilicus spontaneously, and then steps are taken to assist in the delivery of the remaining parts like the head, body, and arms.

• Total Breech Extraction - In this type, the entire fetus is taken out by grabbing the feet of the fetus. Total breech extraction is followed only for a non-cephalic second twin (in a twin pregnancy, the first twin is in the head-first position, and the second twin does not come in the head-down position).

What Are the Indications for Breech Extraction Delivery?

Safe vaginal delivery of the breech presentations can be performed with the following precautions:

• The baby should be near full-term and in a frank breech position. Any other position of the baby will not dilate the birth canal sufficiently.

• The head of the baby should be flexed, with the chin on the chest.

• The mother should have delivered a child previously. The delivered baby should be bigger than the breech fetus's estimated weight.

• The doctors, midwives, or nurses who carry out the delivery should be experienced in performing breech births.

• Normally and spontaneously progressing labor.

• A healthy mother and fetus.

What Is the Procedure of Breech Extraction Delivery?

The following are the steps of breech extraction delivery:

• After the delivery of the first baby, the second twin's heart rate is monitored.

• There should be no delay in the second twin delivery because the cervix may clamp down.

• Using the ultrasonographic, the second twin’s presentation is checked, and the twin’s feet are located.

• A uterine relaxing agent is administered to the mother.

• Then a doctor inserts one hand into the uterus to grasp the feet of the baby.

• The feet of the baby are palpated and grasped. Then gentle and continuous traction toward the birth canal is done.

• The other hand is placed over the mother's belly to guide the fetal head upward.

• The mother is encouraged to push.

• Once the feet have reached the birth canal, it is delivered out of the birth canal.

• Following the delivery of the legs, a moist towel is placed around the baby for a better grasp then the downward traction is continued until the hips emerge.

• When the fetal hips have been delivered, the thumb of the doctor is placed over the sacrum and fingers over the anterior iliac crests. Then gentle traction is applied with slight rotation until the shoulder is visible.

• The anterior arm is delivered by rotating the baby to 90 degrees and placing one to two fingers parallel to the arm until the elbow is reached.

• Both arms are swept gently by applying pressure downward.

• Once both arms have been delivered, rotate the baby 90 degrees so that the spine is located anteriorly.

• The fetal head is delivered by the Mauriceau-Smellie-Veit maneuver (one person applies pressure on the mother's uterus, other person inserts one finger into the vagina and gives gentle pressure on the baby's head) or by applying Piper forceps.

What Are the Complications of Breech Extraction Delivery?

The success of the breech extraction procedure mostly depends upon an experienced and well-trained doctor. Many studies have proved that breech extraction gives a good outcome. However, there are some complications that can occur. These include

• Injuries to the baby.

• Injury to the mother.

• The baby’s thigh bone and hip socket may get separated during childbirth.

• Problems with the umbilical cord, such as flattening or compression of the umbilical during delivery, can cause brain and nerve damage in the baby due to oxygen deficiency.

• The second twin's head may get entrapped if the cervix if it is not fully dilated or if the second baby is larger than the first baby.

• When the placenta separates from the uterus before delivery, it is referred to as abruptio placenta, which can lead to excessive bleeding.

• Postpartum hemorrhage (excessive bleeding after the delivery) occurs most commonly due to the inability of the uterus to contract after delivery.

Conclusion:

Breech extraction surgery is a complicated vaginal delivery mostly carried out in twin delivery when the second twin baby goes to breech presentation. It is a safe method of delivery when the delivery comes under the criteria for breech extraction, and the health care professionals are well experienced in handling it.