Question

Critically appraise different maneuvers for delivering after coming head of breech.

Hint:

The MSV maneuver is the most commonly used technique for the after-coming head in breech deliveries. However, it requires careful application to avoid injury to the baby.

Answer 1

Step 1: Maneuvers for Delivering the After-coming Head in Breech Presentation.
In breech deliveries, especially after the body of the fetus has been delivered, the delivery of the after-coming head can be challenging. Several maneuvers have been described to assist with the safe delivery of the after-coming head. These maneuvers are critical to reduce the risk of cord prolapse, head entrapment, or asphyxia. Below are the main maneuvers used in clinical practice: (1) Mauriceau-Smellie-Veit (MSV) Maneuver:
- Description: The MSV maneuver is one of the most commonly used techniques for delivering the after-coming head. The baby’s body is delivered, and the obstetrician places one hand on the baby’s face while using the other hand to support the lower back. The head is flexed, and gentle traction is applied to help the head deliver.
- Pros: It is simple and effective when the baby is in a favorable position. It avoids excessive manipulation of the neck and helps in flexion of the head, preventing head entrapment.
- Cons: The maneuver may not be successful in cases of inadequate flexion of the fetal head or when the shoulders are impacted. It also requires experience and skill to prevent injury to the infant's neck.
(2) Piper’s Forceps:
- Description: Piper’s forceps are used to assist with the delivery of the after-coming head in breech presentations. The forceps are applied around the head, and gentle traction is applied to assist delivery.
- Pros: Forceps provide a firm grip on the fetal head, reducing the risk of head entrapment and improving control during delivery.
- Cons: Piper's forceps require skill and can cause injury to the baby, particularly if applied too forcefully. It also can cause trauma to the maternal perineum and cervix in the process.
(3) Breech Extraction (Cunningham's Maneuver):
- Description: This maneuver involves using the hand to flex the fetal head by placing one hand on the occiput (the back of the fetal hea and gently guiding the head out through the birth canal.
- Pros: It can be used in certain breech presentations with poor flexion of the head, as it helps bring the fetal head into a more favorable position for delivery.
- Cons: If the baby is in hyperextension (head is tilted backwar, this maneuver may not be effective. There is also a risk of cervical damage during the process.
(4) Reverse Breech Extraction (Brandt's Maneuver):
- Description: In some cases, especially with a deeply impacted head, Brandt's maneuver involves using gentle fundal pressure to assist the fetal head out of the birth canal.
- Pros: It can be used when the baby is in a very tight breech position and requires help in guiding the head downward.
- Cons: It can increase the risk of injury to both the mother and fetus and is not commonly used in modern practice due to associated risks.