What do you suspect may have happened in this scenario?
1 Sylvia is having a breech delivery.
What factors led you to this conclusion?
Due to her parity, she could have breech presentation, she’s at 37 weeks’ gestation which is when it is more likely to present with a breech presentation, she’s had a SROM, and there is thick meconium draining which could be due to pressure on the fetal abdomen in the breech position. She’s also been diagnosed antenatally as having a breech presentation.
Demonstrate and discuss how you would manage this situation - Help
3 I would introduce myself to Sylvia. ‘Hi, my name is Ayesha, and I am a student midwife. I will be taking care of you today. Is it okay if I look under the covers?’
After checking under covers, say ‘Sylvia, your baby is coming bottom first, so I am going to press the buzzer and get some help. This is not an emergency, babies can be born in this position, but we just want some extra staff in case baby needs some assistance. It will get busy in here but just know you are in safe hands.’ I would ensure the safety and dignity of Sylvia, and communicate with her and her partner. I am going to put out a double 2 double 2 call. I am going to ask for urgent medical assistance because it is not an emergency, we just need urgent medical assistance for a breech delivery. So, I would ask for an obstetrician, an anaesthetist on standby, paediatricians, a senior midwife, and any other available staff. I would also want theatre to be aware in case of transfer. I’m getting my emergency trolley and a pair of gloves.
SBAR
I’m going to give an sbar to the staff.
SBA - This is sylvia, she is having a breech vaginal birth at 37 weeks’ gestation. She is a 28-year-old para 2+2 and has had 2 previous SVBs and 2 previous early miscarriages. Her BMI is 30 and she is a smoker. The fetal sacrum is not yet visible at the vulva but there is thick meconium draining per vagina. She has presented at triage with 4 strong contractions in 10, and the fetal heart rate is 150bpm.
R – I want to prepare the room for a breech vaginal birth, so making sure we have a warm environment. My recommendations are that I am going to cannulate, obtain bloods, an in and out catheter, I’m going to get her legs up into lithotomy, remove the end of the bed and deliver the baby safely using a hands-off approach and the appropriate manoeuvres.
IV access
Sylvia, I’m going to remove some of these pillows and is it okay if I put two cannulas in your arms? I’m going to cannulate using 2 large bore grey cannulas and an aseptic non touch technique. The reason for this is if we have to give fluids, obtain any bloods or administer any drugs. Once my cannula is in situ I’m going to cover it with a sterile dressing. I’m going to date and time it, and have it flushed by a trained professional.I’m then going to take my bloods, so a group and save in case we need to crossmatch any blood if there was a big blood loss. I’m going to take a full blood count to ensure we have her haemoglobin levels and her platelet levels.
Catheterise
I’m going to catheterise with consent, using an aseptic technique to empty the bladder. This will increase the diameter in the pelvic cavity for descent of the fetal head, if Sylvia hasn’t already been mobile and emptying her bladder. No specimen is required so it will be an in and out catheter.
Lithotomy
We want Sylvia to be in the lithotomy position at the end of the bed. The reason for this is so that the baby can negotiate with the pelvis for delivery. Is that okay Sylvia? I’m going to put the stirrups on the edge of the bed. We will then lift her legs at the same time and put them onto the stirrups. We are then going to remove the end of the bed.
You’re doing really well Sylvia.
pain relief
I’m going to offer Entonox to Sylvia for pain relief assuming she does not already have an epidural.
sacrum
When the buttocks have distended the perineum, I could infiltrate the perineum if an episiotomy was required. I’m going to encourage sylvia to push with her contractions.
The sacrum is now visible at the vulva. We are going to allow for descent and encourage sylvia to push. The next landmark has appeared, however the legs are flexed and not delivering.
legs and body
I’m then going to apply popliteal pressure. Pressure applied with my fingers to the popliteal fossa. I’m going to flex the knee toward the fetal chest. The leg is then swept down by the side of the abdomen, abducting at the hip. The leg is then delivered.
This is then replicated for the other leg.
Once the legs and body are birthed, the cord will become visible. The cord is not to be touched as that can cause spasm which can decrease blood flow and cause fetal distress.
I’m going to encourage sylvia to push and with further descent the scapula become visible. If the arms are flexed, then they will slip underneath the suprapubic arch and they will be birthed.
extended arms
However, both the arms are extended so I am going to use the love set manoeuvre.
I’m going to grasp the thighs of the baby with my thumbs over the sacrum. I’m going to avoid applying pressure on the baby’s abdomen above the pelvic girdle and I’m going to avoid touching the cord. I’m going to try to facilitate the delivery of the lower arm first. The aim is to deliver the fetal shoulders when the arms are extended by rotating the fetus a half circle (180˚) whilst keeping the back uppermost. I’m bringing the posterior arm into the anterior. This arm should then slip under the suprapubic arch, flex and be delivered.
I’ll then rotate the baby back 180 degrees so that the current posterior shoulder then becomes anterior. It will then also slip under the suprapubic arch, flex and then be delivered. The love set manoeuvre is not a routine part of vaginal breech. It’s a manoeuvre for assistance which we had to use because the arms were extended.
engagement
I’m now going to allow time for the head to engage into the pelvis and allow for the fetal head to navigate. The fetal cavity. I’m going to let the body hang by the neck so that the weight of the limbs and the trunk encourages engagement of the head in the pelvic outlet.
At this point I can cover the baby with a towel to minimise heat loss.
I’m going to wait until the hairline Is visible at the nape of the neck. This is going to tell me that the occipital region of the head has passed under the suprapubic arch. Allowing this to happen prevents pivoting of the head, fracture of the vertebrae and damage to the fetal spinal cord when the delivery occurs.
When the full body has been delivered, the idea timing of the birth of the head is within 3 minutes.
if hairline is not visible at nape of neck.
. If the hairline is not visible at the nape of the neck, then the delivery of the fetal head requires assistance and there is one recommended manoeuvre for this. That manoeuvre is called Mauriceau-Smellie-Veit
It encourages flexion of the head, allowing for delivery. I’m going to lie the body of the baby along one arm and 2 fingers are going to be placed on the maxilla of the fetus to assist flexion. The other hand will go over the fetal shoulders and 2 fingers are going to apply pressure to the occiput to flex the head. I’m going to use controlled traction to assist delivery and when the suboccipital region appears I’m going to lift the baby to allow the head to come under the suprapubic arch.
Delivery of the head must be slow to avoid sudden expansion of the head which can cause intracranial trauma.
unrecommended manoeuvre
Another manoeuvre called burns marshall is not recommended for delivery of the fetal head. This can cause fracture of the baby’s neck and damage the baby’s spine. The baby would be looked over by the paediatrician.
documentation
Once mum and baby are united I’m going to document the date and time called for help, the names of staff who came to help, the times of the landmarks, manoeuvres used and what their outcomes were, date and time of birth, fetal outcomes, blood gases and APGARS. Additionally a debrief for mum and family to make sure they understood what happened
