LETTERS
Letters to the Editor
MANAGEMENT OF
B m C H PRESENTATION
Sir.
We read with great interest Green-top Guideline 20: The
management of breech presentation (enclosed with The
Ohstet?-ician G G''vzaeco1ogist Vol 1, No I), especially
section 3.3 ('l'raining - skill, experience and judgement of
the intrapartum attendant 1. This is significant and relevant
to the future practice of vaginal breech deliveries. Breech
vaginal births have become a rare event in many
institutions. The opportunities for obstetric residents to
learn the techriicpes of breech delivery have thus heen
greatly reduced.
In 1955, Harold Henderson stated: 'It is not the number
of breech deliveries that a resident handles but how a7ell
he is iinbued with the correct technique of handling
them." Residents need to he well versed in the
mcchanism o f labour and delivery of the breech fetus.
Instructions and demonstrations using an obstetric
mannikin should be provided.2 The art of breech delivery
needs to be stressed, as it may not have k e n seen in
practice.
Experience can be gained by observing breech
deliveries performed by experienced staff members. The
same techniques employed to safely deliver the vaginally
horn breech fetus should be used during caesarean
section. A second twin. prescnting as breech, is often
delivered easily and presents an opportunity for learning
vaginal tireech delivery when there is adequate
supervision. Finally, women f u l f i h g protocol criteria for
trial of labour may be delivered by residents, when
assisted by ;in experienced and skilful obstetric attendant.
The following mnemonic (IIANDS OFF) may assist in
performing a systematic and safe vaginal breech delivery.
At all stages, maternal effort needs to be encouraged.
hands off the breech end.
H Hands off: keep y o ~ u
A Allow breech to deliver to the umbilicus with
maternal effort.
Mow legs to deliver with maternal effort.
Abduct: you may need LO abduct the legs with
pressure on the popliteal fossae to assist delivery.
Anterior: always keep the back anterior.
N Kneel down on one knee to deliver the breech so
that the fetal body is at 45 degrees t o the horizontal.
D Do not dig into t h e ahdomen. This is to avoid injury
to the internal organs. Hold the bony pelvis with pour
thumbs on the sacro-iliac joints.
s See the umbilicus: when you can sec the umbilicus,
pull a loop of cord down.
The Obstetriciarz G C;ynaecologist October 2000 Vol. 2 No. 4
Scapula: allow delivery with maternal effort until the
lower part o f the scapula can be seen.
0 Oblique: when the lower edge of the scapula can he
seen, turn the fetal body into the oblique positions, one
after the other, to facilitate delivery of the arms by
sweeping them across the chest (the Lsvset's
manoeuvre).
F Flexion of the head is critical and needs to he
maintained by an assistant applying modest suprapubic
pressure with the heel of their dominant hand as the
head descends.
Flexion of the head vaginally using the Mauriceau-
Smellie-Veit manoeuvre: the middle finger of one hand
applies pressure on the occiput with the index and ring
fingers applying modest traction on the shoulders. The
fetd tiody rests on the other liand with the index and
ring fingers applying rnodcst pressure on the maxillae.
The aim is to deliver the head by flexion and the baby
on to the maternal abdomen.
F Flexion o f the maternal hips to perform McRoberts'
manoeuvre (as in shoulder dystocia) has heen reported
to release an after-coming head when all other
procedures fail.3
Forceps: Piper forceps could be applied to deliver the
after-coming head by an experienced attendant.
Fetal mouth needs suction to clear any debris present.
This mnemonic is easy to remember when faced with a
planned or especially an unexpected vaginal breech delivery.
Sunit M Rane hfRCOG, Specialist Registmr. Department of
Obstetrics and Gynaecology, St Mary's Hospital, Milton
Road, Portsmouth PO3 GAD, UK (corresponding author)
Vicky M Osgood MKCOG, Comultnnt i)bstetricinn and
Gymecologist, Sr Mary's IHospital, Portsmouth, UK
References
I Goethals TR. Cesarean section as the method o f choice in
management of breech delivery. A m J Ohstet Gviiecol 1956;71:536
2 Recommendations of the F I G 0 Conitnittee o n I'erindtal Health.
Guidelines for the rrlanagenient of breech delivery, Srpteinber 1993.
Rome, Italy. Chairman: Professor Dr W Kunzel, Giesl, Germany. Ii7t
.J G)VZt?COl Ohstet 199)4;44:297-30(1
3 Sliuslyan A, Yoiounis J. McRoberts' maneuver for thc- management of
the aftcrcoming head in breech delivery. Gynecol Oi7sfet f??zx~.st
lOW;34:1X&9
GROUNDS FOB LUIGATION tN
RE~TOTUBALsfWfLlsATKlN
Sir,
Part two of Marcus Filshie's comprehensive review on
sterilisation in the first issue' dealt with medico-legal
aspects. During 197%1998 I furnished reports on 1 2 8