Cradle to College
Vol. 19 No 3 | Spring 2017
Letters
Hands off the breech
Max W Jotkowitz
MBBS, FRCOG, FRANZCOG, FICS


This article is 5 years old and may no longer reflect current clinical practice.

Having had a long-time interest in vaginal breech delivery – an obstetric art rapidly falling into disrepute due to the modern trend of delivering the breech presentation by caesarean section.1 – I noted the recent article, ‘Hands off the Breech’ (O&G Magazine Vol. 19 No. 2 Winter 2017 p33–5). This once again disappointingly details the whole gamut of the standard manual manipulations taught as the old-style technique of ‘Liverpool’ vaginal breech delivery, falling into the usual trap of not keeping their hands off and ‘doing something’ such as pressure in the fetal popliteal fossa, fetal body at 45 degrees to the horizontal, the Lovset manoeuvre and so on.

Whether vaginal term birth, rather than caesarean birth, is a breach of best practice.2 I suggest that there may still be a place in present-day obstetrics for a planned vaginal breech birth.3 It becomes indicated in, say, an emergency situation or in a well progressing undiagnosed breech in a multi-labour with a full understanding of the pros and cons. Overlooked completely, however, is the significantly less traumatic technique of the Bracht method of breech delivery. This technique is a great deal more than the described supra-pubic pressure or what Bracht himself called the ‘handgriff’ to release the after-coming head. I respectfully draw attention to my paper4 describing and illustrating this spontaneous, non-interference delivery of the fetus presenting breech, in which the obstetrician is an educated observer supervising a natural process, rather than an active participant with a compulsion to ‘do something’. This technique was first described by the Berlin obstetrician, Erich Bracht (1882–1969) at a meeting in 1935, but discussed little in the English obstetric literature.

Nowadays there are registrars and even younger consultants who have never delivered a vaginal breech; therefore, allow me to remind the readership again of the Bracht manoeuvre in which the breech is allowed to deliver spontaneously to the umbilicus. If the mother is supine, the baby and its extended legs are held upwards by the operator, gently maintaining the spontaneous upward and anterior rotation of the body continuing this position, only counteracting gravity with uterine contractions together with the occasional supra-pubic pressure by an assistant (the handgriff previously mentioned). The delivery then completes by the feet passing over the perineum, releasing spontaneously, followed by elbows, hands, arms and shoulders. As extreme extension continues to be produced, the after-coming head delivers either spontaneously or by the old Mauriceau-Smellie-Veit finger in the mouth technique, (or, occasionally, requires protective lift-out Wrigley’s forceps delivery). This upward sweeping spontaneous delivery (in lithotomy) is well demonstrated in the illustrations accompanying the paper of years ago on this subject.5 Having watched competent obstetricians struggling to ‘pull out’ a baby by the breech at caesarean section, the same technique may also be readily employed at abdominal delivery.

In these days of more freedom in the delivery suite, I would suggest that this procedure could best be undertaken with the mother in the genu-pectoral position, allowing the fetus to deliver spontaneously in the correct direction. Interestingly, this delivery method mimics the delivery of a spontaneous miscarriage, which usually arches upwards or imitates quadruped mammals such as horses delivering standing-up or South African Bantu tribeswomen squatting, leaning forward and delivering by arching and lifting the fetus up towards themselves, or Polynesians lying prone across a delivery pole to deliver.

Permit me to reiterate that the Bracht manoeuvre is suggested for student, resident, registrar, consultant and/or midwife teaching6 if vaginal delivery becomes indicated; a no-interference method of breech confinement, rather than using the older style multiple manipulations of yesteryear postulated in this recent paper.

References

  1. Hannah ME, Hannah WJ, Hewson SA, et al, Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group. Lancet. 2000;356(9239):1375-83.
  2. Seeho SKM, Nippita TA. Term Breech Delivery: Is recommending vaginal birth a breach of best practice. ANZJOG. 2017;57(3):375-77.
  3. Bisits A. There is a place in current obstetric practice for planned vaginal breech birth. ANZJOG. 2017;57(3):372-3.
  4. Jotkowitz MW, Picton T. Appraisal of an Anatomically and Physiologically Correct Method of Breech Delivery: the Bracht Manoeuvre. ANZJOG. 1970;10(3):151.
  5. Jotkowitz MW, Picton T. Appraisal of an Anatomically and Physiologically Correct Method of Breech Delivery: the Bracht Manoeuvre. ANZJOG. 1970;10(3):151.
  6. MackayEV, Beischer NA, Pepperell RJ, et al. Illustrated Textbook of Gynaecology, 2nd Edition. 1992. Saunders Australia.

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