As with many other aspects of breech position, induction or augmentation of labor is controversial. Here again, data are limited and mostly retrospective. With labor induction, Burgos and coworkers (2017) reported equivalent vaginal delivery rates compared with spontaneous labor. With induction, however, they reported higher rates of neonatal intensive care unit admission. But, others have found similar perinatal outcome and cesarean delivery rates Qarniat, 2017; Marzouk, 2011). Finally, others described greater cesarean delivery rates with induction but similar neonatal outcomes (Macharey, 2016).
In many studies, successful vaginal delivery is associated with orderly labor progression. hus, some protocols avoid augmentation for the breech-presenting fetus, whereas others recommend it only for hypotonic contractions (Alarab, 2004; Kotaska, 2009). In women with a viable fetus, at Parkland Hospital, we attempt amniotomy induction but prefer cesarean delivery instead of pharmacological labor induction or augmentation.
On arrival to the labor unit, surveillance offetal heart rate and uterine contractions begins, and immediate recruitment of necessary staf includes: (1) a provider skilled in the art of breech extraction, an associate to assist with the delivery, (3) anesthesia personnel who can ensure adequate analgesia or anesthesia when needed, and an individual trained in newborn resuscitation. For the mother, intravenous access is obtained. his allows, if needed, emergency induction of anesthesia or maternal resuscitation following hemorrhage from lacerations or from uterine atony.
At admission, the status of the membranes and progression of labor are assessed. Knowledge regarding cervical dilatation, cervical efacement, and presenting part station is essential for preparation. If labor is too far advanced, pelvimetry may be unsafe if fetal expulsion in the radiology department is a pos sibility. This alone, however, should not force the decision for cesarean delivery. As mentioned, stepwise labor progression itself is a good indicator of pelvic adequacy (Biswas, 1993).
Sonographic assessment, described earlier, is completed. Ulti mately, the choice of abdominal or vaginal delivery is based on factors discussed earlier and listed in Table 28-1.
During labor, one-on-one nursing is ideal because of cord prolapse risks, and physicians must be readily available for such emergencies. Guidelines for monitoring the high-risk fetus are applied (Chap. 24, p. 478). For first-stage labor, while most clini cians prefer continuous electronic monitoring, the fetal heart rate is recorded at a minimum of every 15 minutes. A scalp electrode can be safely aixed to the buttock, but genitalia are avoided. If a nonreassuring fetal heart rate pattern develops, then a decision must be made regarding the necessity of cesarean delivery.
When membranes rupture, either spontaneously or artificially, the cord prolapse risk is appreciable and is increased when the fetus is small or when the breech is not frank. Therefore, vaginal examination is performed immediately following rupture, and special attention is directed to the fetal heart rate for the irst 5 to 10 minutes thereafter.
For women in labor with a breech presentation, continuous epidural analgesia is advocated by some. This may increase the need for labor augmentation and prolong second-stage labor (Chadha, 1992; Confino, 1985). hese potential disadvantages are weighed against the advantages of better pain relief and increased pelvic relaxation should extensive manipulation be required. Analgesia must be suicient for episiotomy, for breech extraction, and for Piper forceps application. Nitrous oxide plus oxygen inhalation can provide further relief from pain. If general anesthesia is required, it must be induced quickly.