Assessment of fetal condition and labor activity
To timely detect labor abnormalities, tocography is used and a partogram is maintained. The physician's crucial task is monitoring the fetal heart rate, as signs of hypoxia change depending on the stage of labor.
- In the first stage: initial manifestations include tachycardia (175–190 bpm) or bradycardia (up to 100 bpm), short-term arrhythmia, and rhythm monotonicity. As severity increases, the heart rate goes beyond 80–200 bpm, and prolonged late decelerations appear.
- In the second stage: initial hypoxia is indicated by a drop in baseline heart rate to 80 bpm combined with arrhythmia and monotonicity. Pronounced hypoxia presents as persistent arrhythmia, tachycardia over 200 bpm, or bradycardia under 80 bpm.
Tactics in the second stage and critical moments
Until the crowning of the buttocks under normal labor activity, one should not interfere with the process. Cardiorate monitoring and drug prevention are mandatory: oxytocin infusion is started at the end of the first stage, and atropine (to prevent cervical spasm) and episiotomy are performed upon crowning of the buttocks.
There are 4 stages of fetal birth after the crowning of the buttocks:
- Up to the navel.
- From the navel to the lower angle of the scapulae.
- Shoulder girdle and arms.
- Head.
The critical moment occurs after the birth of the torso up to the navel. The head that has entered the pelvis compresses the umbilical cord, so delivery must be completed strictly within 3–5 minutes. A delay of more than 5–6 minutes threatens antenatal death. Furthermore, a sharp decrease in uterine volume at this stage creates a high risk of premature placental abruption. If umbilical cord tension hinders progress, it is immediately clamped and cut.
Tsovyanov's manual maneuver for frank breech presentation
The goal of the maneuver is to keep the fetus in a cone-shaped form expanding upward. The extended legs press the crossed arms against the chest, preventing them from extending backward. The volume of the shoulder girdle together with the legs reaches 42 cm, which is larger than the volume of the subsequent head (32–34 cm), allowing it to be born without obstruction.
Execution Technique:
- The maneuver is initiated when the buttocks move into the oblique diameter of the pelvic outlet.
- The thumbs grasp the fetal thighs from behind, while the remaining four fingers rest on the sacrum.
- As the baby is born, the physician's hands move along the torso, constantly remaining on the parturient woman's perineum.
- To deliver the head, the buttocks are directed toward oneself and anteriorly. A fixation point is formed between the suboccipital fossa and the lower edge of the pubic symphysis. The assistant gently pushes on the head through the abdomen while maintaining its flexion.
Important: It is strictly forbidden to pull the fetus by the torso—this will inevitably lead to arm entrapment and head extension.
Specifics in footling and complete breech presentations
Footling presentation is dangerous because the small volume of the born feet is unable to adequately dilate the birth canal. This leads to arm entrapment and head entrapment in a incompletely dilated cervix.
To avoid this, the physician covers the appearing heels with a sterile cloth and uses the palm of their hand to resist their prolapse. The buttocks descend into the vagina, and the presentation converts into a mixed one. Opposition is ceased only at full cervical dilatation (gaping of the anus, marked perineal bulging, crowning of the feet against palm resistance).
In incomplete/mixed breech presentation, management is strictly expectant until the birth of the lower angles of the scapulae. The fetus is supported without compression, deflecting it toward the symphysis. Then the same techniques as in frank breech presentation are applied. If the process is delayed, one immediately proceeds to the classical manual maneuver.
Briefly: answers to topical questions
What is the technique for performing the classical manual maneuver in breech presentation?
The technique of the classical manual maneuver consists of the sequential delivery of the arms and the subsequent fetal head in the second stage of labor. The manipulation is initiated after the birth of the torso up to the lower angle of the scapula.
Main steps:
- Release of the posterior arm — the arm facing the perineum is always delivered first. The "rule of the homonymous hand" applies: the right arm is delivered by the obstetrician's right hand, the left arm by the left hand. The hand is inserted up to the elbow crease, and the arm is extracted with a "washing motion".
- Release of the anterior arm — the fetal torso is rotated by 180° to bring the second arm toward the perineum, after which it is extracted in a similar manner.
- Extraction of the head — performed after releasing the arms, strictly along the axis of the birth canal.
What are the indications for elective cesarean section in fetal breech presentation?
Indications for cesarean section during pregnancy in breech presentation include the following conditions.
In multiparous women, the following indications are distinguished:
- Estimated fetal weight of 3800 g or more.
- Degree III head extension.
- Adverse perinatal outcome of previous pregnancies/deliveries.
- Hypoxia, grade III FGR, or their combination.
- Pregnancy after IVF.
- Unprepared birth canal in post-term pregnancy.
- Uterine scar.
- Pelvic contraction.
- Severe hemolytic disease of the fetus.
- Extragenital diseases requiring the exclusion of pushing efforts.
Additional indications for CS include:
- Impaired blood flow in the maternal-placental-fetal system according to Doppler ultrasound.
- Hemolytic disease of the fetus.
- Breech presentation of the first twin in multiple pregnancy.
- Insistent patient request.
What types of fetal breech presentations exist according to the obstetric classification?
According to the obstetric classification, there are three main variants of fetal breech presentations.
- Frank breech presentation (incomplete) — only the buttocks present to the pelvic inlet, legs are extended along the torso (flexed at the hips and extended at the knees).
- Complete breech presentation (mixed) — buttocks present together with the feet, legs are flexed at the hips and knees.
- Footling presentation — occurs only during labor. It can be complete (both feet present) and incomplete (one foot presents, the other is flexed at the hip).
- Knee presentation — legs flexed at the knees present (extremely rare).
How is the Mauriceau-Levret-Lachapelle maneuver performed for the delivery of the subsequent fetal head?
The Mauriceau-Levret-Lachapelle maneuver is used to grasp and deliver the subsequent fetal head.
Technique:
- The fetal torso is positioned on the forearm of the obstetrician's left hand.
- The II and III fingers of the left hand are placed on the fetal upper jaw, which promotes flexion of the head. Alternatively, the II finger can be inserted into the mouth and pressure applied to the lower jaw to flex the head.
- The II and IV fingers of the right hand are placed on the fetal shoulders, and the III finger on the occiput, which assists in head flexion.
- Traction is performed in the direction of the pelvic axis, following the rotation of the head.
- If the head is in the wide part of the pelvic cavity, traction is directed obliquely backward, downward, and forward.
- If the head is in the narrow part of the pelvic cavity, traction is directed downward and forward.
- During extraction, the assistant supports the uterine fundus, preventing extension of the fetal head.
Rule of the 4 stages of expulsion: Umbilicus — Scapulae — Arms — Head. Remember that after the "Umbilicus", a 3–5 minute timer starts due to umbilical cord compression.
Class and exam questions
Is the passage of meconium in the second stage a sign of hypoxia?
No, in breech presentation this is a physiological process. Meconium is mechanically squeezed out of the fetal intestine as it passes through the birth canal.
Why is it forbidden to pull the fetus by the torso when performing manual assistance?
Pulling disrupts the normal attitude of the fetus. This leads to severe complications: nuchal arm entrapment and head extension, making its unobstructed birth impossible.
When should one stop holding the feet in footling presentation?
Counterpressure is stopped strictly upon complete dilation of the uterine os. Clinically, this is manifested by marked perineal bulging, gaping of the anus, and the feet beginning to protrude from beneath the obstetrician's palm.
What else to study on this topic
- Moriceau-Smellie-Veit maneuver for delivery of the after-coming head
- Technique of classical manual assistance in breech presentation
- Features of pain management and the use of epidural anesthesia in labor
- Biomechanism of labor in various types of breech presentation
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