Breech Extraction of a Second Twin

Breech extraction has been performed for a long time with different results among the operators. It is usually used to describe the delivery of the second twin with vertex-breech presentations. Breech extraction is preferred over passive delivery of a breech second twin. It is reasonable to avoid the procedure when the weight of the second twin is either <1500 or >4000 g, and when the second twin is much larger than the first twin. Of course, the experience of the operator is paramount to its success. Following the delivery of the first twin, the following steps are used for the breech delivery of the second twin:

• With ultrasound assess (a) the heart rate and (b) the presentation of the second twin

• Inform the patient on the steps for the delivery of the twin

• Do not rupture the membranes yet

• Place a hand in vagina and grasp the feet as in Fig 12.1 (it is important to differentiate between hands and feet)

  

• Pull the feet through the vagina and vulva. There will be fetal resistance that is proportional to fetal weight ( Fig. 12.2 )

  

• Continue with gentle extraction and deliver legs, thighs, and buttocks ( Fig. 12.3 )

  

• Continue with the delivery as reported in Figure 11.6 , Figure 11.7

It is preferable that the membranes are ruptured following the delivery of the lower extremities. However, if they rupture earlier, that is not a problem.

Usually, the back of the fetus rotates anteriorly.

If the back rotates posteriorly, following delivery of the upper extremities, the fetus is elevated toward the maternal abdomen with one hand; two fingers of the other hand are placed around the neck and above the shoulders (Prague maneuver) and the fetus is delivered, as is detailed in Fig. 12.4 .

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If the baby is delivered with the spine facing down, the baby is elevated toward the mother's abdomen with the provider's right hand. The left hand is used to aid flexion of the head (Prague manuever).

What Can Go Wrong That Ought to Be Corrected?

Nuchal Arm

One or both arms may be found around the back of the neck .

Simulation Checklist

		Time	Comments
Initial response	Ultrasound performed for fetal heart rate and presentation
	Breech presentation identified
Management	Feet identified and grasped
	Feet drawn through the vagina
	Freed loop of cord to reduce cord tension
	Rotated fetus to sacrum anterior position
	Complete the extraction if possible
	Delivered arms with Løvset’s maneuver, as necessary
	Delivered head with Mauriceau–Smellie–Veit maneuver or Piper forceps, as necessary
Documentation	Timing of events
	Persons present
Communication	Kept patient and partner informed
	Directed communication
	Closed-loop communication

In case of only one nuchal arm, the following maneuvers are usually applied (Figs. 12.5-12.7) :

• Rotate the back of the fetus toward the same side of the nuchal arm

• Introduce three fingers in the vagina. Place the thumb at the axilla level and the other two fingers anteriorly to the arm and draw the arm anteriorly across the body .

  Breech Extraction Simulation

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