Counseling Sheet

Agatha M. Thrash, M.D.
Preventive Medicine‍

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Breech Delivery‍

1. Position mother at the edge of the bed so the baby can be manipulated downward to give traction. Always examine the mother immediately when the membranes rupture in a breech delivery to determine if the cord is prolapsed, a serious complication of breech delivery.

2. Do not use traction until the buttocks and thighs are born as traction is more likely than the mother's pushing efforts to cause extension upward of the arms beside the ears, and extension of the head, as it enters the brim of the pelvis. An extended head presents a wider diameter to transverse the pelvis.

3. Have the bladder empty so that pressure from above can be given for the after coming head at the suprapubic position. A full bladder can seriously interfere.

4. "Hands off the breech." Exhort the mother to push. The baby is born to the umbilicus with one contraction. A loop of cord is pulled down at this stage to avoid traction on the umbilicus and spasm of the cord vessels.

5. Feel if the elbows are on the chest; usually they are. Wait for the next contraction, but bear always in mind the likelihood of hypoxia from much delay. Have a timekeeper. Begin timing when the cord is in view.

6. The weight of the breach brings the shoulders down to the pelvic floor. Pull downward with both hands, grasping the sacrum only (not the chest or abdomen). After the birth of the anterior shoulder, lift the legs straight up toward ceiling to deliver the posterior shoulder. The back must not be turned uppermost, until the shoulders have been born, in order that the head will descend through the transverse diameter of the pelvis.

7. As soon as the shoulders are born, the infant is again allowed to hang by its own weight, which brings the head down on the pelvic floor. The occiput rotates anterior. If rotation does not occur, put the fingers in mouth and rotate occiput anterior. The back is now uppermost. Allow the baby to hang one or two minutes. The neck elongates, and the hairline appears.

8. Grasp baby by feet when hairline appears and put on the stretch. Then rotate the feet 180 degrees upward for the second time (first was for the shoulder), and get the mouth and nose free. Suction mucous and the baby can breathe before the occiput is born. Timekeeper notes when first breath is taken and length between birth of cord and birth of shoulder and between shoulders and birth of the mouth and first breath taken.

9. Two to three minutes should be allowed for the birth of the occiput. It is best accomplished by deep, regular breaths by the mother called "breathing the head out." Suprapubic pressure may be needed.

10. If the legs of the baby are extended, upward by chest, she will need some assistance, rather than "hands off the breech" when the popliteal fossae are visible at the vulva. Press on the fossae of the most accessible leg, abduct the thigh, and flex the knee, and sweep the foot over the baby's abdomen.

11. Extended arms. Pull on the sacrum to get the axillae in view. Use only downward traction. Rotate anticlockwise to the position of back uppermost. The arm that was posterior is now anterior, and ready for delivery. Remember to maintain downward traction or the maneuver will not succeed. The arm, now anterior (was posterior) is delivered under the pubic arch. Splint the humerus between two fingers to prevent breaking, and draw the elbow downward. Now rotate the posterior shoulder so that it is anterior, by going in the clockwise direction still using downward traction.‍

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Postpartum Hemorrhage Causes

• Most often postpartum hemorrhage is due to mismanagement of the third stage.
• Full bladder interferes with proper placental separation.
• Kneading, squeezing, massaging, pushing, and overstimulation of the uterus may cause hemorrhage. Must use controlled traction on the cord.
• Too much massage will prevent clot formation at the placental site.
• Rapid expulsion of large baby, twins, polyhydraminos, prolonged labor, and uterine fibroids.

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Treatment

• Massage the uterus to make it contract, and to remove bulky blood clots and the placenta.
• Manually remove the placenta, if necessary. Move quickly, but very gently, as any rough handling can result in pain and shock for the mother because of pain.
• Hold the cord taut (by an assistant).
• Insert the right hand along the cord to the placenta. Insinuate the fingers between the deciduas and the placenta and thumb folded into palm. Use a sideways, slicing movement, advancing edge being fifth finger, gently displace.
• The right hand steadies the uterus abdominally, cupped over the fundus.
• Use bimanual compression
• Place fist into vagina, pressure against the anterior lip of the closed cervix and the lower uterine segment, pushing cervix backward.
• Use cupped hand over fundus, pulling fundus forward against fist in vagina.
• Check around the urethra and clitoris for an external source of bleeding. Apply direct pressure.