6.3 Total breech extraction

Breech extraction of the second twin, in particular when the condition of the foetus requires rapid extraction (foetal distress); may be preceded by internal version for transverse foetal lie.

This technique requires experience in obstetrical manoeuvres. If possible, it should be performed in a CEmONC facility. Prepare for a caesarean section in case the total breech extraction fails.

6.3.1 Relative contra-indication

– Scarred uterus (risk of uterine rupture)

6.3.2 Technique

– Routinely insert an IV line.
– Empty bladder.
– Proceed slowly; it may be necessary to pause periodically to allow the uterus to re-soften.
– Insert a hand into the uterus and bring down one foot.
– Do not rupture the membranes right away (they will rupture on their own when the foot is pulled down, or will be ruptured artificially once the foot is down).
– Delivering the foot:

Complete breech (Figures 6.7a and 6.7c)
• Grasp one or both ankles with one hand, index and middle finger straddling the back of the foot;
• Apply gentle traction to bring the leg to the vulva.

Frank breech (Figures 6.7b and 6.7c)
• Grasp a single foot, and bring it down by bending the knee until the lower leg is against the thigh, then continue bringing it down until the leg is fully extended;
• If a hand is grasped rather than a foot, push it back up and start over (feel for the bend at the ankle).

Figures 6.7 - Total breech extraction

6.7a - Grasping one or both feet in the complete breech

6.7b - Grasping the anterior foot in the frank breech

6.7c - Bringing one foot down

– Delivering the breech (Figures 6.8)
• Apply gentle, continuous, downward traction on the leg to deliver the anterior hip, the foetal back anteriorly.
• Once the anterior hip has been delivered, pull gradually upward to deliver the posterior hip.
• Once the pelvis is out, with thumbs on the loins, take hold of the hips and pelvis with the other fingers. Pull the pelvis downward, keeping the back anterior, until the tips of the shoulder blades are seen.

Figures 6.8 - Delivery of the breech in a total breech extraction

6.8a - Downward traction to deliver the anterior hip

6.8b - Upward traction to deliver the posterior hip

– Deliver the shoulders and head: Lovset and Bracht manoeuvres (Section 6.1.4).
– Explore the uterus to rule out uterine rupture.
– Routine antibiotic prophylaxis after clamping the cord: cefazolin or ampicillin slow IV1 , 2 g single dose.

Ref Notes
1 For patients with a history of immediate hypersensitivity reaction to penicillin (urticaria, respiratory problems or oedema): clindamycin IV 900 mg single dose + gentamicin IV 5 mg/kg single dose.