In cases with cephalopelvic disproportion and arrest of aftercoming head, the Zavanelli maneuver or symphysiotomy are options (Sunday-Adeoye, 2004; Wery, 2013). Using local analgesia, symphysiotomy surgically divides the intervening symphyseal cartilage and much of its ligamentous support to widen the symphysis pubis up to 2.5 cm (Basak, 2011). Lack of provider training and potentially serious maternal pelvic or urinary tract injury explain its rare use in the United States. That said, if cesarean delivery is not possible, symphysiotomy may be lifesaving for both mother and baby (Hofmeyr, 2012).
At times, total extraction of a complete or incomplete breech may be required. A hand is introduced through the vagina, and both fetal feet are grasped. he ankles are held with the middle finger lying between them. With gentle traction, the feet are brought through the introitus (Fig. 28-14). As the legs begin to emerge through the vulva, downward gentle traction is continued. As the legs emerge, successively higher portions are grasped, first the calves and then the thighs. When the breech appears at the vaginal outlet, gentle traction is applied until the hips are delivered. The thumbs are then placed over the sacrum and the fingers over the iliac crests. Breech extraction is then completed, as described for partial breech extraction (p. 544).
FIGURE 28-14 Complete breech extraction begins with traction on the feet and ankles.
If only one foot can be grasped, it can be brought down into the vagina and held with the appropriate hand, right hand for right foot and left hand for left foot (Yeomans, 2017). With the irst foot secure, the opposite hand is introduced, passed upward along the leg, and guided to locate the other foot. If the remaining hip is extended, the second foot is usually easily grasped and brought down. If the hip is lexed and knee extended, a finger is hooked into that groin, and traction will bring the lower half of the fetus down until the leg can be reached. For cesarean delivery, these total breech extraction maneuvers can be used to deliver a complete, incomplete, or footling breech through the hysterotomy incision.
During complete extraction of a frank breech, moderate traction is exerted by a finger in each groin and aided by a generous episiotomy. Once the breech is pulled through the introitus, the steps described for partial breech extraction are then completed (p. 544). These maneuvers are also used during cesarean delivery of a frank breech through a hysterotomy incision.
Rarely during vaginal delivery, a frank breech will require decomposition inside the uterine cavity. Attributed to Pinard (1889), this procedure converts a frank breech into a footling breech. It is accomplished more readily if the membranes have ruptured only recently. It becomes extremely diicult if amnionic luid is scant and the uterus is tightly contracted around the fetus. Pharmacological relaxation by general anesthesia or intravenous magnesium sulfate, nitroglycerin, or a betamimetic agent may be required. To begin, two ingers are carried up along one leg to externally rotate the hip by pressing on the medial side of the thigh parallel to the femur. Simultaneously, pressure in the popliteal fossa should prompt spontaneous knee flexion, which brings the corresponding foot into contact with the back of the provider's hand. he fetal foot then may be grasped and brought down.