BREECH EXTRACTIONS

A breech extraction may be done without the aid of instruments. And as for its antiquity, I venture to guess that, if Mrs. Noah had two breech children, the second was delivered by extraction. Probably the first was allowed to deliver unaided; part of the child was born spontaneously, then further progress was temporarily arrested, and by the time that birth completed itself the child was lost For the second breech—if Mrs. Noah had two—Mr. Noah stood by and tugged on the child at the proper moment In some such way the operation began. Since then science has evolved certain technical maneuvers which have increased the efficiency of breech extractions.

It is quite usual for the child to present as a breech (the buttocks over the pelvis, head up toward the ribs) until the last four to six weeks of pregnancy, when most of them turn spontaneously to a head presentation. However, 3.5 to 4 per cent persist as breeches, remaining so during labor. No cause is to be found for the majority of breech presentations. Even if there is no apparent cause for the breech, the likelihood for it to recur in subsequent pregnancies is increased; although even in these women the chances probably remain less than one in four.

A breech birth, except for a slight lengthening of labor in an average case, is no more difficult for the mother, nor has she increased likelihood to complications postpartum. On the other hand, a breech birth carries a somewhat greater risk for the baby than a cephalic (Greek: ‘head’) delivery. However, the hazard today is materially less than it was years ago. The improvement is due to several causes. It has now become current practice to visualize and measure by X-ray the mother’s pelvis when the diagnosis of a breech presentation is made near term, unless the adequacy of her pelvis has already been proved by the previous vaginal de- livery of a large baby. In the case of a breech presentation, a good-sized baby, and an unfavorable pelvis, risk to the baby is obviated by a Cesarean section before labor begins. Improved anesthesia has also paid its dividend in the reduction of breech mortality. Then, too, certain technical operative steps—notably the proper method of bringing down the baby’s arms when they rest straight upward above the head, extended like a cheerleader’s, and the application of forceps to the after-coming head for its delivery—have contributed their part.

The labor of the patient delivering a breech is followed with unusual care, and the patient is taken to the delivery room as soon as the cervix is fully dilated. At this stage the fetal heart is listened to frequently, for one of the fatal accidents that may occur to the breech child is compression of the navel cord between the infant’s body and the pelvis in the course of its descent If at any time after the cervix becomes fully dilated the fetal heart becomes significantly slow or irregular, the operation of extraction is begun at once. If not, the patient is allowed to give birth to the breech, as far as its hipbones, through her own unaided expulsive efforts. The child descends through the vagina on its side, and when the hipbones come into view, the mother is completely anesthetized and prepared and draped as for a forceps delivery. If it is a frank breech (the legs completely bent at the hips so that the feet rest against the chest), the operator hooks a finger in each groin and pulls downward in the axis of the vagina. The legs soon drop out, and then he grasps and pulls on the child’s thighs, trunk, and chest in turn, climbing up the body with his hands. Now the front axilla (armpit) comes into view, and the doctor inserts a finger in the vagina, with which he hooks the upper arm, and the whole extremity is flipped out. The rear arm is similarly delivered. When the baby is a footling breech—legs extended straight down, not flexed upward at the hips—delivery is simpler. As soon as the cervix is fully dilated and the feet appear outside of the vagina, extraction can be begun.

The head of the baby remains to be delivered. This can be done manually; the operator allows the chest and belly of the child to rest on his forearm and hand, two fingers of which he inserts in the vagina to make pressure on the upper Up and jaw of the infant. This keeps its head flexed, which aids in the delivery. The fingers of the other hand encircle the nape of the neck, which by this time is born and presents at the entrance to the vagina, and make down- ward and outward traction. By this maneuver the head is slowly bora. The alternative operation is to apply forceps to the sides of the head after the shoulders are delivered and to do a forceps extraction of the after-coming head. We prefer the latter technique, particularly in a primipara.

Since cephalic (head first) deliveries are safer for the baby, during late pregnancy or even during the early hours of labor the doctor frequently attempts to convert a breech presentation to a head presentation. This is performed by grasping the fetus through its mother’s abdominal wall, and turning it through 180 degrees by gradually pushing the breech to one side with one hand, and the head and shoulders to the opposite side with the other hand. When successful, this rotates the child to a cephalic presentation. Not infrequently the infant thumbs its embryonic nose in utero and reverts back to a breech presentation.

Version

Just the reverse of cephalic version, podalic (Greek: ‘foot’) version consists in turning the child from a vertex to a breech and extracting it at once as a breech. The procedure is technically termed an internal podalic version because the operator inserts his whole hand inside the uterus, reaches up and grasps the child by the feet, turning it completely upside down. The cumbersome name, internal podalic version, is usually referred to by the abbreviated term, version.

Version was the earliest obstetrical operation, except for breech extraction. It was used in antiquity, lost in the intervening centuries, and reintroduced in 1550. At this time the forceps had not been thought of, and Cesarean section, if used at all, was still a freak spectacle. Naturally, therefore, version became very popular in difficult cases. With the introduction of the forceps and the free and safe use of Cesarean section, version is used infrequently today.

Podalic version is indicated in two groups of cases: in transverse presentations, when the long axis of the child lies across the mother’s pelvis; and in all head presentations in which it is believed that delivery can be more safely and rapidly accomplished by means of it Of course it can never be done unless the cervix is completely out of the way by being fully dilated. The necessity for version in transverse presentations is obvious, since birth is mechanically impossible until the fetus is converted into a longitudinal presentation. In head presentations version may rarely be indicated if the head is very high or if the head is engaged and attempts at forceps fail. Today the more usual solution for such problems is Cesarean section. In cases of prolapse of the cord (slipping down of the navel cord into the vagina ahead of the child), with the cervix fully dilated, version may offer the ideal method of delivery, for it can usually be accomplished more rapidly than any other method.

Version is not attempted if there is disproportion between the size of the fetus and the pelvis, nor when the membranes have ruptured sometime before and much of the amniotic fluid has drained away. For then the uterus fits so snugly about the child that there is danger of rupturing it in the process of turning the child.

The technique of version calls for the same anesthetization, draping, and preparation of the patient as are demanded by forceps and breech deliveries. In addition, some operators pour sterile liquid soap into the lower birth canal to make it slippery. The operator wears a special long rubber gauntlet, which encases his arm to the elbow. When the patient is deeply anesthetized, the whole hand is inserted into the vagina and the fetal head gently displaced. The obstetrician ruptures the membranes, passes his hand beyond the head, up into the uterus. He folds the baby’s arms over its chest in a sort of Napoleonic gesture. This aids in preventing the arms from passing through the pelvis at the same time as the head; for the excessive diameter of both arms plus the head blocks the pelvic inlet. The operator then grasps both feet of the child and pulls gently on them, while at the same time he manipulates the head with his external hand through the thickness of the sterile coverings and the abdominal wall. He pushes the head up as he pulls the feet down. This rotates the child so that its feet are over the pelvis and its head high up in the uterus under the ribs. The obstetrician then pulls the feet through the vagina, and the rest of the delivery becomes an ordinary breech extraction.

The outlook for the mother is good if the contraindications to the operation are borne in mind; the main accident to be feared is rupture of the uterus. This is uncommon; it can be largely avoided by having the patient completely relaxed by deep anesthesia and by gentleness in the process of the actual turning. The outlook for the child is approximately the same as in the breech extraction.