TOG - internal podalic version

Question 1

What is internal podalic version

Answer 1

A series of manoeuvres performed prior to breech extraction to deliver a fetus with persistent transverse or oblique lie in 2nd stage of labour

Question 2

In which scenario is it most commonly performed?

Answer 2

For the delivery of the 2nd twin after vaginal birth of the first. Can expedite delivery in the case of profound bradycardia.

Question 3

What are the potential fetal complications of internal podalic version and breech extraction?

Answer 3

Cord prolapse
Shoulder presentation with a prolapsed arm
Skeletal injury
Visceral injury
Neural injury
Hypoxic brain injury
Death

Question 4

What are the potential maternal complications of internal podalic version?

Answer 4

Failure of procedure
Uterine rupture
Vaginal and perineal trauma
Placental abruption
PPH
Ascending infection
Anaesthetic risks

Question 5

What can be considered contraindications to internal podalic version with breech extraction

Answer 5

Lack of maternal consent
Cervix not fully dilated
Inadequate analgesia
Inexperienced accoucheur
First twin
EFW >4kg
Short maternal stature
Singleton pregnancy

Question 6

Describe how you would prepare for IPV

Answer 6

Consent
Ensure adequate regional anaesthesia
Palpate the abdomen ? position
Lithotomy position
Clean
Drape
Empty bladder
Take a seated position with your the vulva at the height of your own upper abdomen.

Question 7

IPV - Describe step 1 (after prep)

Answer 7

• Pass your dominant hand through the vagina, cervix and into the cavity
• Find one heel (ensure it isnt a wrist).
• grasp the heel between thumb, index and middle fingers.
• Where possible with membranes still intact
• If preterm traction may be better if both heels are grasped

Question 8

Describe step 2 of IPV

Answer 8

• Apply traction to bring the foot or feet through the pelvis
• This will cause the fetus to rotate and membranes will usually rupture.
• The head will extend and both arms may come to lie behind the head
• anticipate bilateral nuchal arms
• Continue longitudinal traction until the fetal pelvis comes into view externally
• Anticipate a high chance that the cord will prolapse esp if both feet grasped.

Question 9

Describe step 3 of IPV
- from fetal pelvis in view externally

Answer 9

• Consider episiotomy.
• Grip the pelvis - thumbs on PSIS and fingers in acetabular fossae
• If the fetus has descended sacroposterior rotate to sacroanterior.
• Continue longitudinal traction until the scapulae are seen.

Question 10

Describe step 4 of IPV
- from scapulae visible externally

Answer 10

• Perform Lovset’s manoeuvre to deliver the arms.
• Rotate the fetus in one direction, then deliver the anterior arm by sweeping the forearm across the chest
• Repeat for the other side then bring the pelvis back to the midline

Question 11

Describe step 5 of IPV
- from delivery of the arms and shoulders

Answer 11

• Place your left forearm under the fetal body, with arms and legs either side,
• allow the body to dangle vertically while supported so the head flexes
• Once the occiput is in view deliver the head with forceps or Mauriceau-Smellie-Veit manoeuvre.
  -get the woman to bear down, sweep the fetal face across the perineum by pulling gently with your left hand and pushing with the right,
• simultaneously rise from the sitting position to encourage flexion of the head.