Encyclopedia of breech maneuvers

Question 1

What are the 10 steps of physiologic breech birth?

Answer 1

1. Baby rumps sacrum transverse
2. Body rotates to sacrum anterior (as baby comes down)
3. Legs spontaneously release
4. Chest cleavage
5. Tummy crunches
6. Arms spontaneously release
7. Full perineum - indicates heads flexed
8. Head spontaneoulsy released
9. Baby is passed to mom
10. Cord remains intact

Question 2

What is a good indication that the baby’s arms are extended, behind the head or otherwise obstructed?

Answer 2

Baby is stuck sacrum transverse (ie. not rotating sacrum anterior) – even with good descent – can descend to the nipples or shoulders but if stays transverse theres likely a problem!

Question 3

If you have a stuck arm, which one is it usually?

Answer 3

Anterior arm stuck on the pubic bone

Question 4

What are the two main solutions for stuck arms/shoulders and what kind of maneuvers are they?

Answer 4

1) Side-to-side maneuver
2) Front-to-back maneuver

They are both rotational maneuvers that involve dis-impaction and rotation

Question 5

What are the basic steps of the side-to-side maneuver?

Answer 5

1) disimpact
2) Rotates baby 180 degrees - all the way through sacrum anterior to the other side
3) Rotate back 90 degrees (to sacrum anterior)

Question 6

What are the basic steps of the front-to-back maneuver?

Answer 6

Insert flat hands (as high as you can go with thumbs tucked) – and one on baby’s chest the other on the back. Disimpact. Rotate to sacrum posterior. Release the anterior arm. Disimpact. Rotate 180 to sacrum anterior. Other arm will likely release. Let go.

Question 7

What is the result of the side-to-side maneuver

Answer 7

Release the stuck arm from the pubic bone and sweep the arms in a forward position by the baby’s face

Question 8

What might you need to do after returning baby to SA to finish out the side to side maneuver?

Answer 8

Sweep the arms down if they do not release spontaneously or if you are worried about the baby’s condition

Question 9

What manuever is good as a first line defense in helping a deflexed/extended head in the pelvic outlet?

Answer 9

Shoulder press - involves grasping the shoulders and pushing straight back towards the pubic bone

Question 10

Whats a variation of the shoulder press that you can try if the basic maneuver is not doing the trick?

Answer 10

Rock and Roll - doing the shoulder press in short bursts

Question 11

What is the crowning touch maneuver? Who was it developed by?

Answer 11

• Take two fingers and place them in the mother along the babys cheekbone. Once hit the ear angle downward. Insert until your Middle finger is behind the neck and your first finger is on the occiput. Other two fingers under the chin on the chest. Then rotate hand forward.
• Betty Anne Daviss - she developed this after seeing forceps used to flex an aftercoming head

Question 12

What is the ritgen maneuver and when would you use it?

Answer 12

Going into the rectum to flex a head.

Question 13

When would it be advantageous to use the ritgen?

Answer 13

When there is a soft tissue dystocia and you want a different access point

Question 14

How could you modify the ritgen if mom is in a supine position?

Answer 14

Have another person hold the legs up and out of the way

Question 15

How do you do an upright modified MSV?

Answer 15

Finger in the mouth or two fingers on the cheekbones or a combination of the two. Other hand behind the occiput. Simultaneously push up on the occiput and down on the mouth as you bring baby around the sacral curve.

Question 16

Why is an MSV a last resort maneuver?

Answer 16

Its difficult to accomplish/ more invasive

Question 17

Problem: Baby stuck in a side facing position with no progress.

Solution?

Answer 17

Solution: Release arms and shoulders between ctx with Side to Side or Front to back Maneuver

Question 18

Problem: Extended head in the pelvic outlet

Solution?

Answer 18

Flex/disimpact the head between or during ctx with the shoulder press, modified shoulder press (rock and roll), crowning touch, ritgen or modified MSV

Question 19

Problems: maternal exhaustion, poor ctx pattern, poor fetal condition, diagnosing an obstruction

Solution?

Answer 19

Fundal pressue ONLY if the buttocks are on the perineum

Question 20

Problem: Hyperextended head in the pelvic inlet (rare)

Solution?

Answer 20

Solution: Flex, Flop, Drop

Question 21

Why is a supine MSV awkward?

Answer 21

You have to lift baby up and around the sacral curve as you flex the head

Question 22

What other maneuvers besides the MSV could you try if a woman is in a supine position?

Answer 22

Bracht,

Question 23

Explain how to do the bracht maneuver

Answer 23

When umbilicus or legs are out, grasp the babys femurs and splint the body as close to the maternal abdomen as you can

Question 24

Explain the Burns-Marshall maneuver

Answer 24

• hands off until the arms deliver
• when you see the nape of the neck you take the feet and sweep baby up in a wide arch

Question 25

When would you do a Loveset maneuver?

Answer 25

When the baby is stuck and remains in a sacrum transverse position and the arms are not delivering

Question 26

Explain how to do a loveset maneuver

Answer 26

1) Grasp the pelvic girdle - anterior grasp if the mother is upright and posterior grasp if the mother is supine 2) Flex laterally to bring posterior shoulder lower into the sacrum 3) With traction towards you, rotate 180 degrees, lowering at the end to give the now anterior shoulder space to deliver under the pubic arch 4) REPEAT steps 2 & 3 to deliver the other arm 5) Orient baby to sacrum anterior (if resistance -- disimpact and try again)

Question 27

What are three signs that there is a hyperextended head in the inlet?

Answer 27

1) baby rumps and descends directly SA 2) will likely have low or no tone 3) baby remains high, not descending past the umbilicus or perhaps not even quite to it

Question 28

How do you confirm a diagnosis of a hyperextended head in the pelvic inlet?

Answer 28

Palpate the pubic bone and right above it -- should feel the baby

Question 29

What are the initial few steps once you confirm the dx of a hyperextended head in the pelvic inlet?

Answer 29

- call for assistant/resus team - mentally prepare for a difficult birth and/or long resus - tell your assistant the dx - ask assistant to cup hands and find baby's head + put counter pressure + hold hands steady *Kristin -- we should practice this!

Question 30

After you instruct your assistant on their role in the delivery of a baby with a diagnosed hyperextended head in the pelvic inlet -- what do you do as the primary birth attendant? What is the result of this manuever?

Answer 30

- grasp baby's femur's - disimpact/elevate significantly against your assistants hands (the baby's head hitting the counterpressure will force flexion of the head) result: the head will then flop to either side of the sacral promontory

Question 31

In the case of a baby with a hyperextended head in the pelvis -- what is it that the assistant should communicate to you after you disimpact and elevate the baby against their cupped hands? when they do this what should you then do?

Answer 31

the assistant should communicate to you that they've felt a change in the orientation of the baby's head (when it flops to either side of the sacral promontory) - at that point you LET GO

Question 32

In the case of a baby with a hyperextended head in the pelvis -- what does the assistant do once you've let go of the baby in response of its head flopping to the left or right of the sacral promontory? how far of a descent are you hoping for?

Answer 32

guide the baby's head down with cupped hands you are hoping that baby comes down to its armpits/nipples

Question 33

In the case of a baby with a hyperextended head in the pelvis -- once baby has been dislodged from the sacral promontory and has descended enough, what can the primary midwife do to complete the birth?

Answer 33

Extraction if necessary (eg. the arms are not then born spontaneously) -- usually a Loveset maneuver;

Question 34

What is the flex, flop and drop and why is it so named?

Answer 34

The name of the maneuver designed to aid a baby who has a diagnosed hyperextended head in the pelvis? The head is flexed against the counterpressure of the assistants cupped hands, the head drops into one of the obliques of the pelvis (right or left), the head is dropped further into the pelvis with fundal pressure