FIGURE 28-6 To deliver the body, thumbs are placed over the sacrum, and each index finger wraps over the top of the corresponding fetal iliac crest. Gentle downward traction is applied until the scapulas are clearly visible. (Reproduced with permission from Yeomans ER: Vaginal breech delivery. In Yeomans ER, Hofman BL, Gilstrap LC III, et al (eds): Cunningham and Gilstrap's Operative Obstetrics, 3rd ed. New York, McGraw-Hili Education, 2017.)
FIGURE 28-7 A. After delivery of the first arm, 180-degree rotation of the fetal body brings the sacrum to a right sacrum transverse (RST) position. B. Fingers of the provider's hand extended over the right shoulder and parallel to the humerus. These sweep the arm downward across the chest and out. (Reproduced with permission from Yeomans ER: Vaginal breech delivery. In Yeomans ER, Hoffman BL, Gilstrap LC III, et al (eds): Cunningham and Gilstrap's Operative Obstetrics, 3rd ed. New York, McGraw-Hili Education, 201o7.) sphincter lacerations. Ideally, the breech is allowed to deliver spontaneously to the umbilicus. Delivery of the breech draws the umbilicus and attached cord into the pelvis. Therefore, once the breech has passed beyond the vaginal introitus, the abdomen, thorax, arms, and head must be delivered promptly either spontaneously or assisted.
The posterior hip will deliver, usually from the 6 o'clock position, and oten with suicient pressure to evoke passage of thick meconium (see Fig. 28-4). he anterior hip then delivers, followed by external rotation to a sacrum anterior position. The mother is encouraged to continue to push as the fetus descends until the legs are accessible. The legs are sequentially delivered by splinting the femur with the operator's fingers positioned parallel to the long axis of the femur, and by exerting pressure upward and laterally to sweep each leg away from the midline (Fig. 28-5).
Following delivery of the legs, the fetal bony pelvis is grasped with both hands. The fingers should rest on the anterior superior iliac crests and the thumbs on the sacrum. his minimizes the chance of fetal abdominal soft-tissue injury (Fig. 28-6). Maternal expulsive eforts are again used in conjunction with downward traction to afect delivery.
A cardinal rule in successul breech extraction is to employ steady, gentle, downward traction until the lower halves of the scapulas are delivered, making no attempt at delivery of the shoulders and arms until one axilla becomes visible. It makes little difference which shoulder is delivered irst, and two methods are suitable for their delivery. In the first method, with the scapulas visible, the trunk is rotated either clockwise or counterclocwise to bring the anterior shoulder and arm into view (Fig. 28-7). During delivery of the arm, fingers and hand are aligned parallel to the humerus and act to splint and prevent humeral fracture. he body of the fetus is then rotated 180 degrees in the reverse direction to bring the other shoulder and arm into position for delivery.
he second method is employed if trunk rotation is unsuccessful. With this maneuver, the posterior shoulder is delivered first. For this, the feet are grasped in one hand and drawn upward over the inner thigh of the mother (Fig. 28-8). The