What are the step-by-step maneuvers for a partial breech delivery in a patient with a high-risk pregnancy?

Step-by-Step Partial Breech Delivery with Maneuvers

For partial breech delivery (body delivered, head entrapped), immediately perform the Mauriceau-Smiley-Veit maneuver as the primary technique, with Piper forceps as backup if head delivery fails within 3-5 minutes. 1

Initial Assessment and Positioning

• Position the mother in lithotomy with adequate hip flexion to maximize pelvic outlet dimensions 1
• Ensure the fetal body is supported at all times to prevent hyperextension of the cervical spine 2
• Call for immediate assistance including anesthesia, pediatrics, and additional obstetric personnel 1
• Administer tocolysis (terbutaline 0.25 mg subcutaneous or nitroglycerin 50-100 mcg IV) to relax the uterus if the head is tightly entrapped 1

Delivery of the Arms (If Not Yet Delivered)

• Allow the body to hang by its own weight for 30-60 seconds to promote flexion of the fetal head 2
• Rotate the fetus so the back is anterior to facilitate arm delivery 2
• Sweep each arm across the chest using two fingers along the humerus, delivering the posterior arm first 2
• If arms are nuchal (extended behind the head), rotate the body 180 degrees to bring each arm down sequentially using Lovset's maneuver 1

Mauriceau-Smiley-Veit Maneuver for Head Delivery

• Place the fetal body astride your forearm with the fetal chest resting on your palm 1
• Insert your index and middle fingers into the fetal mouth or over the maxilla (NOT into the mouth if possible to avoid jaw injury) 2
• Apply gentle downward traction to flex the fetal head while an assistant applies suprapubic pressure to maintain flexion 1
• Your other hand grasps the fetal shoulders from above, with fingers on the occiput to maintain flexion 2
• Apply steady, coordinated downward and outward traction until the subocciput appears under the pubic symphysis 1
• Once the subocciput is visible, elevate the body upward in an arc to deliver the face over the perineum 2

Critical Technical Points

• Never apply traction without simultaneous flexion of the fetal head, as this causes hyperextension and increases entrapment 2
• Limit total time from body delivery to head delivery to under 5 minutes to minimize hypoxic injury 1
• Avoid excessive force on the fetal neck, which can cause brachial plexus injury or cervical spine damage 2
• Do not insert fingers deeply into the fetal mouth, as this can fracture the mandible 2

Piper Forceps Application (If Mauriceau Maneuver Fails)

• Have an assistant support the fetal body horizontally or slightly elevated 1
• Apply Piper forceps from below while kneeling, with the handles pointing downward initially 2
• Ensure proper application over the malar eminences and parietal bones before applying traction 1
• Apply gentle downward traction until the subocciput delivers, then elevate to complete delivery 2

Emergency Maneuvers for Entrapped Aftercoming Head

• If the cervix is incompletely dilated and entrapping the head, perform Dührssen's cervical incisions at 2,6, and 10 o'clock positions 1
• Consider symphysiotomy only in extreme circumstances where all other methods fail and cesarean is impossible 2
• Prepare for immediate neonatal resuscitation given the high risk of hypoxia with prolonged head entrapment 1

Common Pitfalls to Avoid

• Never pull on the fetal body without controlling the head position, as this worsens hyperextension and entrapment 2
• Do not attempt delivery during active uterine contractions without tocolysis, which significantly increases entrapment risk 1
• Avoid applying pressure to the fetal abdomen, which can cause liver or spleen injury 2
• Never use vacuum extraction for breech delivery, as this causes severe intracranial hemorrhage and subgaleal bleeding 3
• Do not delay calling for help or proceeding to emergency cesarean if vaginal delivery is not progressing 1

Post-Delivery Management

• Examine the neonate immediately for birth trauma including brachial plexus injury, clavicular fracture, and intracranial hemorrhage 4
• Administer slow IV oxytocin infusion (<2 U/min) after placental delivery to prevent hemorrhage while avoiding hypotension 1
• Monitor the mother for at least 24 hours for postpartum hemorrhage and other complications 1
• Document the exact maneuvers used, timing of delivery stages, and any complications encountered 2