MMED in obstetrics and gynecology

1. BREECH PRESENTATION
Mentor : Dr Okilipa
Presesnter: Dr Fatima Abdallah
Reg No: 2022-08-12641

2. INTRODUCTION
 In breech presentation, the lie is longitudinal and the podalic pole presents at the pelvic brim.
 It is the most common malpresentation.
 Incidence: is about 20% at 28th week and drops to 5% at 34th week and to 3–4% at term.

3. VARIETIES
 There are two varieties of breech presentation .
Complete & Incomplete

4. COMPLETE (FLEXED BREECH):
 The normal attitude of full flexion is maintained.
 Thighs are flexed at hips and legs at knees.
 The presenting part consists of two buttocks,
external genitalia and two feet.
 It is commonly present in multiparae (10%).

5. INCOMPLETE BREECH
 This is due to varying degrees of extension of thighs or legs at the podalic pole.
 Three varieties are possible:

6. A) BREECH WITH EXTENDED LEGS (FRANK BREECH):
 In this condition, thighs are flexed on the trunk
and legs are extended at the knee joints
 The presenting part consists of the two buttocks
and external genitalia only.
 It is commonly present in primigravidae, about
70%.
 The increased prevalence in primigravida is due
to
 a tight abdominal wall,
 good uterine tone and
 early engagement of breech.

7. B) FOOTLING PRESENTATION
 Both thighs and legs are partially extended
bringing the legs to
 Incidence is about (25%)
 Ususally present at brim.

8. C) KNEE PRESENTATION:
 Thighs are extended but the knees are flexed, bringing the knees down to present at the brim.
 The latter two varieties are not common.

9. CLINICAL VARIETIES:
 In an attempt to find out the dangers inherent to
breech, breech presentation is
 clinically classified as:
(1) Uncomplicated—
 It is defined as one where there is no other
associated obstetric complications
 apart from the breech, prematurity being
excluded.
(2) Complicated—
 When the presentation is associated with
conditions which adversely influence the
prognosis such as
 prematurity,
 twins,
 contracted pelvis,
 placenta previa, etc.
 It is called complicated breech.

10. ETIOLOGY OF BREECH PRESENTATION
 There is higher incidence of breech in earlier weeks of pregnancy.
 Smaller size of the fetus and comparatively larger volume of amniotic fluid allow the fetus to undergo
spontaneous version by kicking movements until by 36th week when the position becomes stabilized.

11. FACTORS RESPONSIBLE FOR BREECH PRESENTATION.
 The following are the known In a significant number of cases, the cause remains obscure.
 Prematurity: It is the most common cause of breech presentation.
 Factors preventing spontaneous version:
 (a) Breech with extended legs,
 (b) Twins,
 (c) Oligohydramnios,
 (d) Congenital malformation of the uterus such as septate or bicornuate uterus,
 (e) Short cord, relative or absolute,
 (f ) Intrauterine death of the fetus.

12. Favorable adaptation:
(a) Hydrocephalus—big head can be well accommodated in the wide fundus,
(b) (b) Placenta previa,
(c) (c) Contracted pelvis,
(d) (d) Cornu-fundal attachment of the placenta— minimizes the space of the fundus where the smaller head can be placed
comfortably.
 Undue mobility of the fetus: (a) Hydramnios, (b) Multiparae with lax abdominal wall.
 Fetal abnormality: Trisomies 13, 18, 21, anencephaly and myotonic dystrophy due to alteration
of fetal muscular tone and mobility.
Recurrent breech:
On occasion, the breech presentation recurs in successive pregnancies.
When it recurs in three or more consecutive pregnancies, it is called habitual or recurrent breech.

13. DIAGNOSIS OF BREECH PRESENTATION
DIAGNOSIS
Clinical Sonography

14. CLINICAL DIAGNOSIS

15. ULTRASONOGRAPHY
 is most informative.
(1) It confirms the clinical diagnosis—especially in primigravidae with engaged frank breech or with
tense abdominal wall and irritable uterus.
(2) It can detect fetal congenital abnormality and also congenital anomalies of the uterus.
(3) Type of breech eg: (complete or incomplete).
(4) It measures biparietal diameter, gestational age and estimated weight of the fetus.
(5) It also localizes the placenta.
(6) Assessment of liquor volume (important for ECV).
(7) Attitude of the head —flexion or hyperextension (important for decision making at the time of
delivery).

16. POSITIONS: OF THE BREECH PRESENTATION
 Sacrum is the denominator of breech and there are four positions.
 In anterior positions, sacrum is directed toward iliopubic eminences and in posterior positions, sacrum is
directed to sacroiliac joints.
 The positions are:
(1) First Position—Left Sacroanterior (LSA)—being the most common
(2) Second position— right sacroanterior (RSA)
(3) Third position—right sacroposterior (RSP) and
(4) Fourth position—left sacroposterior (LSP).

17. MECHANISM OF LABOR IN BREECH
PRESENTATION
 SACROANTERIOR POSITION:
 In the mechanism of breech delivery,
 the principal movements occur at three places—buttocks, shoulders and the head.
 The first two successive parts to be born are bigger but more compressible while the head because of
non molding due to rapid descent, presents difficulties.
 Each of the three components undergo cardinal movements as those of normal mechanism.

18. 1) BUTTOCKS
1. the diameter of engagement of the buttock is one of the oblique diameters of the inlet.
2. the engaging diameter is bitrochanteric (10 cm or 4") with the sacrum directed toward the iliopubic
eminence.
 When the diameter passes through the pelvic brim, the breech is engaged.
3. Descent of the buttocks occurs until the anterior buttock touches the pelvic ! oor.
4. Internal rotation of the anterior buttock occurs through 1/8th of a circle placing it behind the symphysis
pubis.

19. 5. Further descent with lateral flexion of the trunk occurs until the anterior hip hinges under the symphysis
pubis which is released first followed by the posterior hip.
6. Delivery of the trunk and the lower limbs follow.
7. Restitution occurs so that the buttocks occupy the original position as during engagement in oblique
diameter.

21. II. SHOULDERS
 Bisacromial diameter (12 cm or 4 3/4") engages in the same oblique diameter as that occupied by the
buttocks at the brim soon after the delivery of the breech.
 Descent occurs with internal rotation of the shoulders bringing the shoulders to lie in the anteroposterior
diameter of the pelvic outlet.
the trunk simultaneously rotates externally through 1/8th of a circle.
 Delivery of the posterior shoulder followed by the anterior one is completed by anterior flexion of the
delivered trunk.
 Restitution and external rotation: Untwisting of the trunk occurs putting the anterior shoulder toward
the right thigh in LSA and left thigh in RSA.
 External rotation of the shoulders occurs to the same direction because of internal rotation of the occiput through 1/8th of a
circle anteriorly.
 the fetal trunk is now positioned as dorso anterior.

22. III. HEAD
 Engagement occurs either through the opposite oblique diameter as that occupied by the buttocks or
through the transverse diameter.
 the engaging diameter of the head is suboccipitofrontal (10 cm).
Descent with increasing flexion occurs.
 Internal rotation of the occiput occurs anteriorly, through 1/8th or 2/8th of a circle placing the occiput
behind the symphysis pubis.
 Further descent occurs until the subocciput hinges under the symphysis pubis.
 Head is born by flexion—chin, mouth, nose, forehead, vertex and occiput appearing successively. "
 expulsion of the head from the pelvic cavity depends entirely upon the bearing-down efforts and not at all
on uterine contractions.

23.  Sacroposterior position:
 In sacroposterior position, the mechanism is not substantially modified.
 The head has to rotate through 3/8th of a circle to bring the occiput behind the symphysis pubis.

24. PROGNOSIS OF VAGINAL BREECH DELIVERY
MATERNAL:
 Labor is usually not prolonged.
 But because of increased frequency of operative delivery including cesarean section, the morbidity is increased.
The risks include
 trauma to the genital tract,
 operative vaginal delivery (episiotomy, forceps),
 cesarean section,
 sepsis and
 anesthetic complications.
 As a consequence, maternal morbidity is slightly raised.
 Frank breech acts as an effective cervical dilator.
 Flexed breech, although, theoretically might cause delay in first stage, but rarely so because of its prevalence among
multiparae.

25.  FETAL:!The fetal risk in terms of perinatal mortality is considerable in vaginal breech delivery.
 It is difficult to assess the magnitude of the real risk because the complicating factors, such as
prematurity,
 birth trauma, congenital malformation of the fetus that contribute significantly to the fetal hazards.
 The corrected (excluding fetal abnormality) perinatal mortality ranges from 5 to 35 per 1,000 births.
 The overall perinatal mortality in breech still remains 9–25% compared with 1–2% for nonbreech
deliveries.
 Perinatal death (excluding congenital abnormalities) is 3 to 5 times higher than the nonbreech
presentations.

26. THE FACTORS WHICH SIGNIFICANTLY INFLUENCE THE FETAL RISK ARE—
 (a) skill of the obstetrician,
 (b) weight of the baby,
 (c) position of the legs and
 (d) type of pelvis.
 The fetal mortality is least in frank breech and maximum in footling presentation, where the chance of
cord prolapse is also more.
 Gynecoid and anthropoid pelvis are favorable for the aftercoming head.
 The fetal risk in multipara is no less than that of primigravida.
 This is because of increased chance of cord prolapse associated with flexed breech.

27. THE DANGERS TO THE BABY
(1) Intrapartum fetal death specially with preterm babies
(2) Injury to brain and skull —
(a) Intracranial hemorrhage: Compression followed by decom pression during delivery of the
unmolded after-coming head results in tear of the tentorium cerebelli and hemorrhage in the
subarachnoid space. The risk is more with preterm babies,
(b) Minute hemorrhages,
(c) Fracture of the skull.

28. (3) Birth asphyxia: It is due to—
(1) Cord compression soon after the buttocks are delivered and also when the head enters into the pelvis.
A period of more than 10 minutes will produce asphyxia of varying degrees.
(2) Retraction of the placental site,
(3) Premature attempt at respiration (amniotic fluid, vaginal fluid) while the head is still inside,
(4) Delayed delivery of the head,
(5) Cord prolapse and
(6) Prolonged labor.

29. (4) Birth Injuries (7%): The following injuries are inflicted during manipulative deliveries.
It is 13 times more than the vertex presentation.
Hematoma—over the sternomastoid or over the thighs.
Fractures—The common sites are femur, humerus, clavicle and odontoid process. there may be dislocation
of the hip joint, mandible or 5th and 6th cervical vertebrae and epiphyseal separation.
Visceral injuries include rupture of the liver, kidneys, suprarenal glands, lungs and hemorrhage in the
testicles.
Nerve—Medullary coning, spinal cord injury, stretching of the cervical and brachial plexus to cause either
Erb’s or Klumpke’s palsy .
Long-term neurological damage.

30. ANTENATAL MANAGEMENT
 Antenatal management in breech presentation consists of:
 Identification of the complicating factors related with breech presentation.
 External cephalic version, if not contraindicated.
 Formulation of the line of management, if the version fails or is contraindicated.
 Identification of complicating factor: It can be detected by clinical examination, supplemented
by sonography.
Sonography is particularly useful to detect congenital malformations of the fetus, the precise location of
the placental site and congenital anomalies of the uterus.

31. EXTERNAL CEPHALIC VERSION (ECV):
 There are protagonists and antagonists to external version.
 . The success rate of version is about 65%
 Successful version reduces the risk of cesarean section significantly.
 Prior sonography should be a routine.
 Cardiotocography (CTG) should ideally be done before and after the procedure

32. TIME OF VERSION:
 ECV has been considered from 36 weeks onward.
 While version in the early weeks is easy but chance of reversion is more.
 Late version may be difficult because of increasing size of the fetus and diminishing volume of liquor
amnii.
 the use of uterine relaxant (tocolysis) has made the version at later weeks less difficult.
 It minimizes chance of reversion and should fetal complications develop, it can be effectively tackled by
cesarean section.

33. BENEFITS OF ECV
 (i) Reduction in the incidence of breech presentation at term,
 ii) Reduction in the incidence of breech delivery (Vaginal or cesarean) and the associated complications
 (iii) Reduction in the incidence of cesarean delivery by 5%.

34.  Successful version is likely in cases of:
(i) Complete breech,
(ii) Nonengaged breech,
(iii) Sacroanterior position (fetal back anteriorly),
(iv) Adequate liquor,
(v) Nonobese patient.

35. DANGERS OF VERSION:
The dangers of version are—
 (1) premature onset of labor,
 (2) premature rupture of the membranes,
 (3) placental abruption and bleeding,
 (4) entanglement of the cord round the fetal part or formation of a true knot leading to impairment of fetal
circulation and fetal death and
 (5) increased chance of fetomaternal bleed.
 (6) Amniotic fluid embolism.
 Immunoprophylaxis with anti-D gammaglobulin is to be administered in nonimmunized Rh-negative mother .
 The perinatal mortality should not exceed beyond 1%. A reactive cardiotocographic trace should be obtained
after the procedure (see p. 693).

36. DELIVERY PLAN
 Two methods of delivery can be planned.
1. To perform an elective cesarean section.
2. To allow spontaneous labor to start and vaginal breech delivery to occur.

37. ELECTIVE CESAREAN SECTION:
Because of the complications involved in vaginal breech delivery, there is a tendency to liberalize the use
of cesarean section in breech.
The indications of CS in breech are:
 Big baby (estimated fetal weight >3.5 kg),
 small baby (<1.5 kg), estimated fetal weight <1.5 or >3.5 kg,
 hyperextension of the head (stargazing fetus), footling presentation (risk of cord prolapse),
 suspected pelvic contraction or severe IUGR.
 Anyassociated complications (obstetric or medical) is often considered for CS in breech.

38.  The overall incidence of cesarean section in breech ranges from 15% to 50%, out of which about 80% is
elective.
 Delivery of preterm breech (weight <1,500 g) by cesarean section is commonly done but it should be
reserved in selected centers, equipped with intensive neonatal care unit.

39.  MANAGEMENT OF VAGINAL BREECH DELIVERY

40. CRITERIA TO BE FULFILLED ARE—

41. THE SCORE USED PARITY, GESTATIONAL AGE, ESTIMATED WEIGHT, PRIOR
SUCCESSFUL BREECH VAGINAL DELIVERY, DILATION, AND STATION TO
ASCERTAIN LIKELIHOOD OF SUCCESSFUL VAGINAL DELIVERY

42.  A Zatuchni-Andros score of less than 4 accurately predicted poor outcomes in patients with infants
presenting as a breech.

43. FIRST STAGE:
 The management protocol is similar to that mentioned in normal labor.
 The following are the important considerations.
 Spontaneous onset of labor increases the chance of successful vaginal delivery.
 Vaginal examination is indicated—
(a) at the onset of labor for pelvic assessment,
(b) soon after rupture of the membranes to exclude cord prolapse.
 An intravenous line is sited with Ringer’s solution, oral intake is avoided, blood is sent for group and cross
matching (considering the chance of CS).
 Adequate analgesia is given, epidural is preferred.
 Fetal status and progress of labor are monitored.
 Oxytocin infusion may be used for augmentation of labor

44.  Indications of Cesarean Section (CS):
(a) Cases seen for the first time in labor with presence of complications;
(b) Arrest in the progress of labor;
(c) Non reassuring FHR pattern (Fetal distress);
(d) Cord presentation or prolapse.

45. SECOND STAGE:
 There are three methods of vaginal breech delivery:
 Spontaneous (10%): Expulsion of the fetus occurs with very little assistance.
 Assisted breech: the delivery of the fetus is by assistance from the beginning to the end.
this method should be employed in all cases.
 Breech extraction (partial or total): When part or the entire body of the fetus is extracted by the obstetrician. It
is rarely done these days as it produces trauma to the fetus and the mother.
Indications are:
(a) Delivery of the second twin after IPV
(b) Cord prolapse,
(c) Extended legs arrested at the cavity or at the outlet.

46. ASSISTED BREECH DELIVERY
 Breech delivery should be conducted by a skilled obstetrician.
 The following are to be kept ready beforehand, in addition to those required for conduction of normal
labor:
(1)Anesthetist—to administer anesthesia as and when required.
(2) An assistant—to push down the fundus during contraction.
(3)Instruments and suture materials for episiotomy.
(4) A pair of obstetric forceps for the aftercoming head, if required.
(5) Appliances for resuscitation of the baby, if asphyxiated.
(6) Neonatologist.

47. PRINCIPLES IN CONDUCTION:
 (1) Never to rush,
 (2) Never pull from below but push from above
 (3) Always keep the fetus with the back
anteriorly.
 It is expected that good uterine contractions and
maternal expulsive forces will maintain the
flexion of the fetal head and result in descent
and safe delivery.

48. STEPS:
 patient is brought to the table when the anterior buttock and fetal anus are visible.
 She is placed in lithotomy position when the posterior buttock distends the perineum.
 To avoid aortocaval compression, the woman is tilted laterally (15°) using a wedge under the back.
 Antiseptic cleaning is done, bladder is emptied with an “in and out” catheter.
 Pudendal block is done along with perineal infiltration if not epidural has been used earlier.
 Episiotomy: It should be made in all cases of primigravidae and selected multiparae.
 Its advantages are—
(a) to straighten the birth canal which especially facilitates the delivery of breech with extended legs where lateral flexion is
inadequate;
(b) to facilitate intravaginal manipulation and for forceps delivery,
(c) to minimize compression of the aftercoming head.

49. the best time for episiotomy is when the perineum is distended and thinned by the breech as it is
“climbing” the perineum.
The patient is encouraged to bear down as the expulsive forces from above ensure flexion of the fetal head
and safe descent.
the “no touch to the fetus” policy is adopted until the buttocks are delivered along with the legs in flexed
breech and the trunk slips up to the umbilicus.
Soon after the trunk up to the umbilicus is born. the following are to be done:

50.  the e extended legs (in frank breech) are to be decomposed by pressure on the knees (popliteal fossa) in
a manner of abduction and flexion of the thighs.

51.  If the umbilical cord is to be pulled down and
to be mobilized to one side of the sacral bay to
minimize compression.
 there may be transient abnormality in cord
pulsation at this stage which has got no
prognostic significance.
 An attempt of hasty delivery for this reason
alone should be avoided.
(c) If the back remains posteriorly, rotate the trunk
to bring the back anteriorly (SACROANTERIOR).
(d) the baby is wrapped with a sterile towel to
prevent slipping when held by the hands and to
facilitate manipulation, if required.

52. DELIVERY OF THE ARMS:
 The assistant is to place a hand over the fundus and keep a steady pressure during uterine contractions
to prevent extension of the arms.
 Soon, the anterior scapula is visible. The position of the arm should be noted.
 When the arms are flexed, the vertebral border of the scapula remains parallel to the vertebral
column and when extended there is winging of the scapula (parallelism is lost).
 The arms are delivered one after the other only when one axilla is visible, by simply hooking down each
elbow with a finger.
 It is immaterial as to which arm is to be delivered first.
 The baby should be held by the feet over the sterile towel while the arms are delivered

54. DELIVERY OF THE AFTERCOMING HEAD:
 This is the most crucial stage of the delivery.
 The time between the delivery of umbilicus to delivery of mouth
should preferably be 5–10 minutes.
 There are various methods of delivery for the aftercoming head.
 Each one is quite safe and effective in the hands of an expert,
conversant with that particular technique

55. THE FOLLOWING ARE THE COMMON METHODS EMPLOYED:
(a) Burns-Marshall method
(b) Forceps delivery:
(c) Malar flexion and shoulder traction (modified Mauriceau-
Smellie-Veit technique):

56. (A) BURNS-MARSHALL METHOD
 The baby is allowed to hang by its own weight.
 The assistant is asked to give suprapubic pressure with the flat of hand in a downward and backward
direction, the pressure is to be exerted more toward the sinciput.
 The aim is to promote flexion of the head so that favorable diameter is presented to the pelvic cavity.
 Not more than 1–2 minutes are required to achieve the objective.
 When the nape of the neck is visible under the pubic arch, the baby is grasped by the ankles with a
finger in between the two.
 Maintaining a steady traction and forming a wide arc of a circle, the trunk is swung in upward and
forward direction (Fig. 26.18).
 Meanwhile, with the left hand to guard the perineum, slipping the perineum off successively the face and
brow.
 When the mouth is cleared off the vulva, there should be no hurry. Mucus of the mouth and pharynx is
cleared by mucus sucker.
 The trunk is depressed to deliver rest of the head.

58. (B) FORCEPS DELIVERY:
 Forceps can be used as a routine.
 The head must be in the cavity.
 The advantages of foreps delvery: —
(a) delivery can be controlled by giving pull directly on the head and the force is not transmitted through
the neck,
(b) flexion is better maintained and
(c) mucus can be sucked out from the mouth more effectively.
The head should be brought as low down as possible by allowing the baby to hang by its own weight aided
by suprapubic pressure.

59.  When the occiput lies against the back of the symphysis pubis, an assistant raises the legs of the child as
much to facilitate introduction of the blades from below.
 Too much elevation of the trunk may cause extension of the head.
 The forceps pull maintains an arc, which follows the axis of the birth canal (Fig. 26.19).
 Piper forceps is especially designed (absent pelvic curve) for use in this condition.
 The head should be delivered slowly (over 1 minute) to reduce compression-decompression forces
that may cause intracranial bleeding.

61. (C) MALAR FLEXION AND SHOULDER TRACTION (MODIFIED
MAURICEAU-SMELLIE-VEIT TECHNIQUE):
 The technique is named after the three great obstetricians who described the use of the grip
independently.
 The baby is placed on the supinated left forearm (preferred) with the limbs hanging on either sides.
 The middle and the index fingers of the left hand are placed over the malar bones on either sides
(modification of the original method, where the index finger was introduced inside the mouth).
 This maintains flexion of the head.
 The ring and little fingers of the pronated right hand are placed on the child’s right shoulder, the index
finger is placed on the left shoulder and the middle finger is placed on the suboccipital region.
 Traction is now given in downward and backward direction till the nape of the neck is visible under the
pubic arch.

63.  The assistant gives suprapubic pressure during the period to maintain flexion.
 Thereafter, the fetus is carried in upward and forward direction toward the mother’s abdomen releasing
the face, brow and lastly, the trunk is depressed to release the occiput and vertex.
 Resuscitation of the baby: The baby may be asphyxiated and need to be resuscitated.

64. THIRD STAGE:
 The third stage is usually uneventful.
 The placenta is usually expelled out soon after delivery of the head.
 If prophylactic ergometrine is to be given, it should be administered intravenously with the crowning of
the head.

65. MANAGEMENT OF COMPLICATED BREECH DELIVERY
 DELAY IN DESCENT OF THE BREECH:
 The breech may be arrested: •
 At the outlet • at the cavity • At the brim
• Arrested at the outlet:
The causes are—
(a) big size baby with extended legs (the most common),
(b) (b) weak uterine contractions,
(c) (c) rigid perineum and
(d) (d) outlet contraction.
Management: If the outlet is contracted and/or the baby is big, cesarean section even at this stage, is the method
of choice

66. In the absence of outlet contraction and feto-pelvic
disproportion:
 Liberal episiotomy and fundal pressure with or
without groin traction (either single groin or
both the groins) usually become effective (Fig.
26.21).
 The index finger(s) is placed in the groin fold and
traction (along with uterine contraction) is
exerted more toward the trunk than toward the
femur (risk of fracture femur).

67. FRANK BREECH EXTRACTION
 (Pinard’s maneuver)— is done by intrauterine
manipulation (for breech decomposition) to
convert a frank breech to a footling breech.
 This is possible when the membranes have
ruptured recently.
 In Pinard’s maneuver, the middle and the index
fingers are carried up to the popliteal fossa.
 It is then pressed and abducted so that the fetal
leg is flexed.
 The fetal foot is then grasped at the ankle and
breech extraction is accomplished.

68.  LOVSET’S MANEUVER: The maneuver should start
only when the inferior angle of the anterior scapula
is visible underneath the pubic arch.
 It is widely practiced in preference to the classical
method of bringing down an arm.
 The following are the advantages:
 (1) Wider applicability—It can be applied even
when the classical method becomes difficult.
 (2) Intrauterine manipulation is nil.
 (3) A single manipulation is effective to all types of
displacement of the arms.
 (4) General anesthesia is usually not needed.

69. Step—1: The baby is lifted slightly to cause lateral
flexion. The trunk is rotated through 180° keeping
the back anterior and maintaining a downward
traction.
 This will bring the posterior arm to emerge
under the pubic arch which is then hooked out.
Step—2: The trunk is then rotated in the reverse
direction keeping the back anterior to deliver the
erstwhile anterior shoulder under the symphysis
pubis.
 Nuchal displacement of arm is where the arm is
flexed at the elbow and extended at the
shoulder and lies behind the fetal head.
 After grasping the baby at the pelvic girdle with
thumbs along the sacrum, the trunk is rotated
180° toward the fingertips of the trapped arm.
 This may draw the elbow forward and render it
amenable to Lovsett’s maneuver.
 If this fails, the arm is forcibly extracted by
hooking. In that case fracture almost always
follows.

70. ARREST OF THE AFTERCOMING HEAD
• At the brim:
 The causes of arrest are—
 (1) deflexed head
 (2) contracted pelvis and
 (3) hydrocephalus.
 Management:
 (1) If the arrest is due to a deflexed head, the
delivery is to be completed by malar flexion and
shoulder traction along with suprapubic pressure
by the assistant.
 The head is to be negotiated through the brim in
the transverse diameter and rotated in the cavity.
Forceps should not be applied in high head.
 (2) If the arrest of the head is due to contracted
pelvis or hydrocephalus, perforation of head is
to be don

71.  In the cavity:
 The causes of arrest of the head in the cavity
are—(1) deflexed head and (2) contracted pelvis.
The best management
 is delivery of the head by forceps which is
effective in both the circumstances.
 Malar flexion and shoulder traction may be
effective only in deflexed head.

72.  • At the outlet:
 The causes of arrest are—
 (1) rigid perineum and
 (2) deflexed head.
 Episiotomy followed by forceps application or
malar flexion and shoulder traction is quite
effective.

73. DELIVERY OF THE HEAD THROUGH AN INCOMPLETELY DILATED
CERVIX:
 The common causes are—
 (1) premature baby,
 (2) macerated baby,
 (3) footling presentation and
 (4) hasty delivery of breech before the cervix is fully dilated.
Management:
 If the baby is living, the cervix is to be pushed up while traction of the fetal trunk is made by malar flexion and
shoulder traction (shoe-horn method).
 If necessary, Duhrssen’s incision can be made at 2 and 10 O’ clock position on the cervix.
 If the baby is dead, perforation of the head is better than watchful expectancy, hoping for full dilatation of the
cervix.