Breech presentation in primiparae

BREECH PRESENTATION ALEXANDER

E.

DUNBAR,

BROOKLYN,

0

75 60 72 45 12

6 82 53

85

IO 25 13

2 114 15 6 * Submitted

Y.

85 50

The breech extraction varied from a simpIe puIIing down of a foot which presented itseIf at the vulvar orifice to the most diffIcuIt procedure of puIIing down one or both feet from the interior of the uterus. In two instances, extraction was performed by appIying forceps directIy to the breech.

Over 50 per cent of the cases which had membranes intact, ruptured very shortIy after admission to the hospita1. The shortest period of rupture before deIivery I 5 minutes. The Iongest period of rupture before deIivery 8 days. The duration of Iabor varied from two hours to eight days, the average being twenty-four hours. Types of Pelvis: Normal................................ GeneraIIy contracted.. Funnel..................................... Fiat......................... GeneraIIy contracted funnel.. Types of Breech: Frankbreech............................... FootIing................................... DoubIe footling.

N.

M.D.

Procedures: Delivery (~)Spontaneous.......................... (2) Breech extraction.

of the most important and potentiaIIy formidabIe situations which confronts the obstetrician is the breech presentation in the primiparous woman. The accoucheur must reaIize that there are certain weII-defined reasons for carefu1 and thoughtfu1 management of this situation : (I) proIonged Iabor due to premature rupture of the membranes, thus making the breech a poor diIating wedge; (2) inteIIigent management of the cprd and the arms; (3) Iast but not Ieast, is the management of the after-coming head. Let us review the resuIt of five years’ work at the Methodist EpiscopaI HospitaI, rg24-1928 incIusive. In this series there are 135 cases of breech in primiparous women. NE

Private Cases. WardCases................................... Positions: Left sacrum anterior.. Rightsacrumanterior........................ Left sacrum posterior.. Right sacrum posterior.. Condition of the membranes on admission: Intact................... Ruptured...................................

IN PRIMIPARAE *

CompIications: Nuchalhitch................................ Cord between Iegs. Prolapsedcord............................... Other Maneuvers: Manual dilation of the cervix.. . Diihrssen’s incisions of the cervix. Separation of a vagina1 septum.. The Perineum: NoIaceration................................ First degree laceration.. Second degree Iaceration. Third degree Iaceration.. Extension from IateraI episiotomy . Extension from median episiotomy. Right Iateral episiotomy.. Left IateraI episiotomy Median episiotomy.

2 I

5

.

I I 3 8

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2 6 82 12

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In 81.5 per cent of the cases, some type of episiotomy was used. Forceps: The Piper type of forceps was used in the majority of the cases requiring such in the deIivery of the after-coming head. In 32 cases or 23.7 per cent, forceps were required. Craniotomy was done twice in macerated feti. In I case of this series abdominal cesarean section was empIoyed as the procedure of eIection rather than of necessity. Morbidity: There were 15 cases in this series which showed morbidity. It might be here stated that the majority of these cases were dehvered before the vaginal antiseptic, mercurochrome, came reaIIy into its own. The morbidity percentage

for pubIication December

62

4

IO, 1930.

NEW SERIES VOL. XIII,

was I 1.1 foIIows :

I

Dunbar-Breech

No. I

per cent and can be detaiIed

Sapremia...................................... Lochiametra.. Parametritis. Pyelitis........................................ Infected perineum.. Subinvolution. Causes unknown..

MortaIity : MaternaI: mothers case.

died

as a resuIt

Presentation

as

I

7 I I

I I 3

None of these of this type of

Fetal: 17 or 12.6 per cent StiII-births.. Intracranial hemorrhage.. PIacentaI separation.. Macerated fetus............................ Died after delivery.. IntracraniaI hemorrhage. GastrointestinaI.. Monstrosities.. Spina b&da.. Evisceration.. . Osteogenesis imperfecta..

g 6

* 2

3 4 I 3

I I 1

The corrected mortaIity for this series is 9.78 per cent. Six of the babies that Iived showed definite signs of cerebra1 irritation but recovered, apparentIy, without any definite damage. On investigating the reports of other clinics, we find that we are doing as we11 as any of them and better than most of them. Why is the breech presentation in the primiparous woman a great probIem to the obstetrician? The breech is a soft mass which does not diIate the cervix we11 due to its consistency and its Iack of weight. The breech predisposes to a premature or an earIy rupture of the membranes, thus taking away the natura1 hydrostatic diIator. Labor is most commonIy proIonged because of these facts. WhiIe the pains may be present in frequency, they do not have sufficient power to drive the baby through the pelvis as we11 as the vertex. Draining off of the Iiquor amnii is usuaIIy greater, thereby aIIowing the uterus to wrap itseIf around the baby and thus inhibiting the progress of Iabor. The breech does not engage we11

American Journd

of Surgery

63

and we find many arrests of the breech high in the pelvis, thus necessitating deIivery from that point. ParticuIarIy is this true in the cases of abnorma1 peIvis. We see from our study that 40 per cent of the cases require interference. The resistance of the undiIated peIvic floor adds stiI1 another factor in sIowing up the advance of the breech. When the breech has been born to the umbiIicus, the cord begins to pIay an important part. Compression of the cord may do serious damage to the baby at this time. It is now puIIed down a short way to reIieve this pressure. The arms may present further diffIcuIty. It is hoped that these have maintained their norma reIation. VaIuabIe time may be Iost if one or both arms are extended or if there is a true nucha1 hitch. The after-cpming head usuaIIy presents the greatest amount of diffIcuIty. We have here a head which has not been moIded by the process of Iabor. It may therefore engage in the peIvis in fauIty fIexion, and give rise to dificuIt deIivery. Technique: Our poIicy of procedure has been one of “Hands off.” Our worst enemy is the undiIated cervix. When a case is progressing in a norma way and the breech presents itseIf, crowning, the obstetrician may assist its progress by IightIy anesthetizing the patient. The perineum is thoroughIy ironed out as Irving W. Potter of BuffaIo, teaches. Also, if extra room is to be required, an episiotomy, preferabIy a IateraI one, is done. The patient is aIIowed to recover from the analgesia and proceeds in Iabor until the breech is borne up to the umbilicus. The cord is then puIIed down. The baby is now rotated so that the back Iies under the subpubic angIe. GentIe traction is made down toward the floor unti1 the scapuIae can be seen. In rotating the back under the subpubic angIe, the shouIders are released, preventing the extension of the arms, or if they have not been reIeased, they can be more readiIy freed from this position. Either arm may now be deIivered ante-

64

American

Journal

of Surgery

Dunbar-Breech

riorIy. If the left arm is to be dehvered, the baby is rotated to the mother’s Ieft 90’. The arm wiI1 be seen to drop down under the subpubic angIe. GentIe pressure in the elbow wiI1 bring down the entire arm. To deIiver the other arm, the baby is rotated 180~ in the opposite direction and the arm is deIivered by gentIe traction in the elbow. This brings us to the deIivery of the head. It is at this point that the inteIIigent use of suprapubic pressure may be of vaIue. With this aid, the finger is inserted into the baby’s mouth, merely to maintain flexion and not to be used as a tractor. The body is heId up with the other hand whiIe the arms are heId above it by an assistant. The body shouId not be extended over on to the abdomen, for fear of rupturing the faIx cerebri or the tentorium cerebeIIi. GraduaIIy the head is being born. By using a perinea1 retractor, the mouth is exposed a IittIe sooner, and mucus can be sucked out of the mouth. This aids the chiId iti getting air earIier and deIivery does not have to be rushed. Where the case is arrested Piper and Bachman, in a recent paper, fee1 that the breech shouId not be aIlowed to go aIong undeIivered, fuIIy reaIizing the diffIcuIties of an incompIeteIy diIated cervix. If the cervix is not compIeteIy paraIyzed, it may cIamp down around the neck. In order to offset this diffIcuIty, the patient is compIeteIy anesthetized to the degree of deep surgica1 anesthesia. The hand is then passed up into the uterus, care being taken to keep away from the pIacenta and the cord. The breech is then decomposed by bringing both feet down, treating it then as a doubIe footIing. Traction is made so that when the buttocks reach the peIvic Aoor they are practicaIIy sitting in the hoIIow of the sacrum. From this point the fetus is rotated anteriorIy so that the back Iies up under the subpubic angIe before any further traction is made. The

Presentation

JULY.

,931

remainder of the procedure is as before described. In 3 of the 32 cases in which the Piper forceps were used we found that the babies died, one as a stiII-birth and two died within a few days after deIivery, as a resuIt of an intracrania1 hemorrhage. In 2 other cases we found two babies that presented signs of cerebral edema. Piper and Bachman fee1 that their speciaIIy devised instrument shouId be routineIy used, fuIIy reaIizing that the said forceps are of IittIe or no vaIue if the after-coming head is arrested above the peIvic brim. I do not beIieve that any type of forceps shouId be used routineIy in the treatment of the after-coming head. In our clinic we have feIt that the poIicy of “Let nature take its course” is the wisest one. We have not used hydrostatic bags, bougies or other means to hasten the Iabor in women who have a breech presentation and are having a proIonged Iabor. Our greatest fear is undiIated cervix. By “keeping hands off” we fee1 that our results compare favorabIy with those of other cIinics. In prophyIaxis of this situation we have feIt as J. 0. PoIak says, “it wouId have been a head if it couId have We therefore have not been a head.” adopted externa1 version as a prophyIactic measure. Conclusion: (I) Hands off the breech. (2) Our worst enemy is the cervix. Give it time to diIate. (3) Cases of markedIy abnorma1 peIvis with oversized babies, and eIderIy primiparae shouId be treated by cesarean section. (4) Where there has been an arrest after fuII diIation patients should be surgicaIIy anesthetized, the soft tissues thoroughly diIated, pIus episiotomy and a carefu1 extraction shouId be done. (5) Breech cases should at a11 times be in the hands of the trained obstetrician.