Breech presentation and transverse position

Rather than having the head ready to be born first, about 3 per cent of babies present themselves bottom-down with their heads high in the stomach; this is called a The feet only very rarely come first- usually the baby is squatting like a tiny gnome with knees and hips bent up in front of him.

A baby’s soft buttocks don’t fit the (neck of the uterus) as well as his head would, so labour is often slower. The baby starts to descend down the vagina once the cervix has dilated fully, helped by controlled pushing on the part of the mother. The buttocks and body usually come fairly easily, but the shoulders might get held up in the pelvis. Then the head, the largest and hardest part of fthc baby to deliver, comes last.

F the breech baby is expected to weigh between and pounds, and the mother’s condition is normal, then a breech deliver)- – with the aid of an experienced obstetrician – usually presents problems. But if the baby is very small or very large, a Caesarean section may be advised to avoid any hazards. Since complications may arise, the labour should always take place in a fully equipped maternity unit.

On extremely rare occasions a baby may He across the uterus so that the head and body are in a horizontal line across the mother’s body. A baby in this transverse position is impossible to deliver via the normal vaginal route, so the obstetrician usually performs a Caesarean section.

To get round the problems of foetal distress, maternal distress or malpresentation of the baby, several courses of action are open.

Forceps delivery

If the cervix is fully open, forceps can be used to aid deliver}’. Forceps have been around in Britain for 300 years. They are shaped like large serving spoons with a part of the bowl cut out. The’spoons’ fit together around the baby’s head and guard it against pressure while the baby is being gently removed. The baby is then led from the pelvis through the vagina to the outside world.

From the mother’s viewpoint, forceps tend to look rather big and clumsy, but most of the instrument stays outside the body. Only the slim blades are inserted to guard the baby’s head and guide it out.

A local anaesthetic at the base of the vagina is nearly always given with a forceps delivery. (However, if the woman is already anaesthetized with an epidural this won’t be necessary). The forceps are then cupped around the baby’s head and ihe doctor skilfully draws the baby down the birth canal. Once the head is born the forceps are removed and the rest of the delivery can proceed normally.

Vacuum extraction

If the cervix is partlv, but not fully, dilated then it’s not safe to use forceps to help out a stressed baby. A special vacuum cap can be used instead to bring the baby’s head quickly down against the cervix to stimulate full dilation, allowing the baby to be delivered more rapidly. The method has been in use for 250 years.

A vacuum extractor is usually used in the last part of the first stage of labour. A small flat cap is passed through the vagina and partly dilated cervix to lie against the baby’s head. The air is extracted from the inside of the cap through a tube so that the soft, loose skin on the baby’s head is gently sucked against the cap. When the vacuum is just right, the doctor gently pulls down and brings the head into contact with the cervix. This makes the cervix dilate and within a few minutes the head is usually in the vagina. A few more gentle pulls combined with the mother’s pushing, deliver the babv.

Caesarean section

When it is dangerous to speed up delivery via the vagina, an abdominal delivery of the baby may become necessary. This is called a Caesarean section.

An Caesarean section is one which is decided on and performed in the last weeks of pregnancy before labour even starts. This might happen if the n other’s blood pressure had risen loo suddenly or if the baby’s head and mother’s pelvis are known to be a tight lit.

Sometimes a Caesarean section in labour is decided upon because prolonged labour may be dangerous to the child or the mother. The most common reason for this is foetal distress, when the baby might die ifleft in the uterus.

Some form of anaesthesia is alwavs needed. A general anaesthetic is the most common type, but sometimes an anaesthetic, which numbs only the lower part of the body, is used so that the woman can stay completely conscious. Occasionally a local anaesthetic is given in the stomach wall.

The most common incision is a low one close to the pubic mound. This results in a small scar which is hidden by the pubic hair, when it regrows. The baby is taken out through the incision and handed over to a paediatrician who ensures that the baby starts to breathe properlv. The umbilical cord is cut and the placenta can then be removed from the uterus. The uterus then contracts and the surgical wound in its wall closes up. The stomach wall is closed in layers using sutures (stitches) which dissolve after a few days. The whole procedure takes about 45 minutes.

Induction

Sometimes, late in pregnancy, the obstetrician thinks it unwise for the baby to stav in the uterus any longer, and may induce labour, because, for example, toxaemia has occurred.

Induction methods vary according to the hospital in which they are done, but first the cervix is checked to see if it is ripe and ready for labour. Then the membrane around the baby is punctured (it’s not painful) so that some fluid escapes and the baby’s head comes down into contact with the cervix.

A labour-stimulating hormone may be given as well. An hormone may be given as an intravenous drip put into one of the veins on the back of the wrist. Alternatively, may be given in the form of a pessary or paste inserted into the upper vagina. Both methods cause the uterus to start contracting within a few hours, and so labour commences.

Acceleration of labour

This is the same as inducing or starling off labour even though similar methods are used. Sometimes, when labour has already started quite spontaneously, the obstetrician may feel that the baby is not progressing well, and decide to speed up its arrival. Either labour-stimulating hormones are used to hurry things along, or the membrane is snagged via the cervix once dilation has started. For most women, labour is a safe event and a happy one, too. As long as the woman is thoroughly prepared, and provided adequate care is available for the lew who may run into trouble, then labour can be kept safe and pleasant.