Fetal and maternal injuries in case of improper delivery technique
The main danger during the birth of the head is its entrapment between the maternal pubic symphysis and the fetal suboccipital fossa. This occurs with improper management of the second stage of labor, when the natural biomechanism of labor is disrupted. Such an error leads to severe consequences for the newborn:
- Pathological extension of the head.
- Ruptures and strains of the neck muscles.
- Traumatization of the vertebral arteries.
- Damage to the structures of the cervical spine and spinal cord.
Furthermore, surgical interventions and manual obstetric aids significantly increase the risk of trauma to the maternal soft birth canal. For this reason, postpartum infectious and inflammatory diseases in such patients occur more frequently than in classic cephalic presentation. At the same time, the third stage of labor (separation and expulsion of the placenta) proceeds standardly and has no specific differences.
Classic manual aid: arm delivery
If, after the birth of the torso up to the inferior angles of the scapulae, the head is not delivered within 2–3 minutes, a critical threat to the fetus's life arises. In such cases, as well as in case of shoulder dystocia or nuchal arms, the classic manual aid is used.
Basic principles:
- The arms are always freed first, and only then the head.
- The "rule of the homonymous hand" applies: the obstetrician delivers the right arm of the fetus with their right hand, and the left with the left.
- It is forbidden to apply strong pressure on the fetal forearm or humerus due to the high risk of fractures.
Stages of arm extraction:
- Release of the posterior arm. The arm facing the perineum (posterior) is always extracted first. Only there is enough space for the obstetrician's hand insertion. The doctor holds the fetus by the ankles, moves the torso toward the opposite maternal groin, and extracts the arm by the elbow crease using a "swiping motion" (guiding it in front of the baby's face).
- Release of the anterior arm. If it does not drop spontaneously, the fetal torso is grasped with both hands (thumbs on the back) and carefully rotated by 180°. The back should pass under the symphysis during this maneuver. To facilitate rotation, the fetus can be pushed slightly upward into the uterine cavity. After rotation, the anterior arm becomes the posterior one and is extracted in a similar manner.
Delivery of the aftercoming head (Mauriceau–Smellie–Veit maneuver)
During artificial extraction, the head must repeat the natural biomechanism: flexion, internal rotation, and fixation under the pubic bone. Emergence proceeds in a strict sequence: chin, face, scalp.
The Mauriceau–Smellie–Veit method is used for proper grip and traction:
- Position and grip. The baby is "straddled" over the forearm of the obstetrician's left hand. The index and middle fingers of the same hand are placed on the fetal upper jaw (or the index finger is inserted into the mouth, pressing on the lower jaw) to ensure maximum head flexion.
- Position of the second hand. The right hand is placed in a V-shape on the fetal shoulders (index and ring fingers), with the middle finger placed on the occiput for additional flexion.
- Traction vector. Tractive movements are performed strictly along the pelvic axis. If the head is in the wide part of the pelvic cavity, pull obliquely backward, downward, and forward. In the narrow part — downward and forward only.
- Assistant's help. At this time, the assistant applies moderate pressure to the uterine fundus through the anterior abdominal wall, preventing the head from extending.
Indications for emergency caesarean section
Due to the high risk of trauma to the mother and fetus, breech delivery often requires a transition to surgical delivery. The decision on an emergency caesarean section is made when threatening conditions arise.
Main indications during labor:
- Premature rupture of membranes with an unripe cervix.
- Footling presentation or prolapse of the legs in primiparae with incomplete cervical dilation.
- Prolapse or presentation of umbilical cord loops in the first stage.
- Uterine inertia or labor dyscoordination.
- Arrest of pelvic descent.
- Signs of acute hypoxia according to cardiotocography monitoring.
Important nuance: if the fetal pelvis is already in the wide part of the pelvic cavity, this is not a contraindication for performing a caesarean section.
Rule of the homonymous hand: Right arm — Right hand, Left arm — Left hand. The arm on the perineal side (posterior) is always freed first, as there is more free space there.
Class and exam questions
Why is the posterior arm of the fetus delivered first?
There is more free space on the side of the mother's perineum. This allows the obstetrician to freely insert a hand into the birth canal and reach the fetal elbow crease.
How to deliver the anterior arm if it does not emerge on its own?
The fetal torso is carefully rotated 180 degrees. Thus, the anterior arm moves toward the perineum and becomes the posterior one, after which it is extracted with a "swiping motion".
What is the role of the assistant during the delivery of the head?
The assistant exerts moderate pressure on the uterine fundus through the mother's abdomen. This aids the descent of the fetus through the birth canal and prevents dangerous extension of its head.
Is the location of the pelvic end in the wide part of the pelvis a contraindication to caesarean section?
No, such a position of the fetus does not hinder the emergency surgery if indications for it have arisen.
What else to study on this topic
- Types and classification of breech presentations
- Etiology and diagnostic methods for breech presentation
- Biomechanism of labor in breech presentation
- Conditions for safe vaginal delivery
- Principles of pregnancy management in fetal breech presentation
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