OT notes · Obstetrics

Assisted breech delivery / breech extraction (incl. second twin, internal podalic version)

Usual anaesthesia
Epidural analgesia if running (preferred for twin delivery), or no regional block with local infiltration for the episiotomy; anaesthetist present in the second stage so that general anaesthesia can be given quickly for extended arms, head entrapment or internal version
Position
Mother in any comfortable position until the posterior buttock distends the perineum, then lithotomy at the edge of the bed
Setting
emergency

Operative note template for vaginal breech delivery, from assisted breech delivery to total breech extraction and internal podalic version of a second twin, with a filled example for an assisted breech delivery of a frank breech in a multipara who came in advanced labour.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • emergency caesarean section if labour does not progress or the baby shows distress
  • cord prolapse
  • difficulty delivering the arms or the aftercoming head, with lack of oxygen to the baby
  • injury to the baby: fracture of the arm or collar bone, nerve injury to the arm, hip or leg injury
  • need for forceps to the aftercoming head
  • episiotomy and tears of the perineum, vagina or cervix
  • bleeding after delivery
  • for a second twin: internal version, and caesarean for the second twin if vaginal delivery fails

Pre-operative details for this operation

  1. Type of breechFrank (extended legs)Complete (flexed legs)Footling / incomplete
  2. Singleton or twinSingletonTwin B, breechTwin B, transverse lieTwin A, breech
  3. Why vaginal breech deliverywoman's informed choice after counselling / came in advanced labour / second twin
  4. Estimated fetal weightclinical and USG; an Indian text suggests an upper limit of about 3500 g
  5. Exclusions checked on USGfootling, hyperextended fetal neck, growth restriction, fetal weight over limit, antenatal fetal compromise
  6. Pelvis assessed and previous deliveriesparity, weight of previous babies
  7. Labour detailsspontaneous onset, time of full dilatation, time anterior buttock visible; oxytocin augmentation, if any, and whether an epidural was running
  8. People presentobstetrician, assistant, paediatrician, anaesthetist, nurse; OT ready for caesarean
  9. Bladder emptiedYes

Anaesthesia and position

  1. Analgesia / anaesthesiaEpiduralNone, local for episiotomyGeneral (reason)
  2. Anaesthetist present in second stageYes
  3. Position at deliveryLithotomy at the edge of the bedDorsal
  4. Fetal monitoringContinuous CTGIntermittent auscultationfor twins, both heart rates

Operative findings

  1. Position of the sacrume.g. left sacroanterior
  2. LegsDelivered spontaneouslyExtended, disengaged at umbilicusBrought down (Pinard)
  3. ArmsFlexed across chestExtendedNuchal
  4. Aftercoming headFlexed, delivered easilyDeflexedEntrapped by cervix
  5. LiquorClearMeconium stained
  6. Babylive / stillborn, sex, time of birth, weight, APGAR at 1 and 5 min, handed to paediatrician, any visible injury
  7. For twin Blie and presentation after twin A (confirmed by bedside USG?), membranes intact or not, interval from twin A

Procedure (steps)

  1. EpisiotomyMediolateral, when buttock distending perineumNot given (lax perineum)side; local anaesthetic
  2. Breech allowed to deliver to the umbilicus with maternal effort, no tractionYesPartial breech extraction (reason)
  3. Legs disengaged and loop of cord pulled downtime umbilicus delivered
  4. Back kept anterior (facing up)body wrapped in a warm towel
  5. Arms deliveredFlipped out from across the chestLovset manoeuvreClassical method (posterior arm first, elbow flexed before traction)
  6. Aftercoming headBurns-MarshallMauriceau-Smellie-Veit with suprapubic pressureForceps to aftercoming head (Piper's or other)BrachtBurns-Marshall first; Mauriceau-Smellie-Veit or forceps if the mouth and nose cannot be freed; who gave suprapubic pressure
  7. Time head deliveredumbilicus-to-head interval in minutes
  8. Head entrapment manoeuvres (if needed)Not neededCervix slipped over headNitroglycerin IV for cervical relaxationDuhrssen incisions (positions)
  9. Second twin: lie correctedNot applicableExternal versionInternal podalic version (foot grasped, membranes then ruptured)hand used, which foot, fundus held by the other hand
  10. Second twin: deliveryNot applicableAssisted breechTotal breech extractiontime of birth, interval from twin A
  11. Third stageuterotonic drug, dose, route, time; placenta by controlled cord traction, complete?
  12. Cervix, vagina and perineum inspectedand uterine cavity explored after internal version

Closure, drains and dressing

  1. Episiotomy repairlayers and suture material; local anaesthetic used
  2. Tears repairedcervical, vaginal, perineal degree
  3. Uterine tone and bleeding at end
  4. Swab and needle count

Specimens and implants

  1. Placenta sent for HPENoYes (indication)
  2. Cord blood samplegrouping / gas, if taken

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. Vitals, uterine tone and PV bleedingfrequency as per the unit protocol; chart every reading
  2. Uterotonic infusionif ordered: drug, dose, rate
  3. Babypaediatric review; examine both arms, collar bones and hips; note any arm weakness
  4. Perineumcheck episiotomy for haematoma; analgesia with drug and dose
  5. Bladdernote time of first void
  6. Breastfeedingtime started, if baby well
  7. Hbif blood loss was more than usual
  8. After internal versionwatch for PPH and signs of uterine rupture; inform if pulse rises or abdominal pain

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Mrs. S.B., 29 years, G3P2 (two previous normal deliveries, babies 2.9 and 3.1 kg), at 38+4 weeks, came in labour at 8 cm with an undiagnosed frank breech. Bedside USG: frank breech, flexed head, estimated fetal weight 2.9 kg.

Case details

Date: 22/05/2026. Emergency. Labour room 1, OT kept ready.

Admitted 23:10 at 8 cm. Full dilatation 23:50. Anterior buttock visible 00:20. Umbilicus delivered 00:34. Head delivered 00:37. Placenta 00:44. Episiotomy repair completed 01:05.

Conducted by: Dr A. (3rd-year resident, OBGY). Assistant: Dr B. (1st-year resident). Consultant: Dr C., present.

Anaesthetist: Dr D., present in second stage. Paediatrician: Dr F. Staff nurse: Sr E.

Indication and pre-op

Frank breech in advanced labour, multipara with two normal deliveries of 2.9 and 3.1 kg babies. Clinically adequate pelvis.

USG in labour room: frank breech, left sacroanterior, flexed fetal head, no footling, estimated weight 2.9 kg. Liquor adequate. FHR 140/min, reactive.

Options explained: emergency caesarean or assisted vaginal breech delivery, with the risks to the baby (difficulty with arms or head, injury, lack of oxygen) and to her. She chose vaginal delivery. Consent taken in Hindi, husband as witness. Caesarean consent also signed in case needed.

Blood group B positive, 1 unit cross-matched. IV line 18G. Bladder emptied with catheter at 00:15. Continuous CTG.

Anaesthesia and position

No epidural (advanced labour). Anaesthetist present with GA drugs ready. Allowed to push in the position she chose. Lithotomy at the edge of the bed when the posterior buttock distended the perineum.

Perineum cleaned with povidone-iodine and draped. Right mediolateral episiotomy under local infiltration with lignocaine 1% as the buttock distended the perineum.

Procedure

Breech delivered to the umbilicus with maternal effort, no traction. Umbilicus born 00:34.

Extended legs disengaged. Loop of cord pulled down, pulsating. Back kept anterior. Body wrapped in a warm towel. Dr B.'s hand on the fundus.

When the scapulae appeared, both arms found flexed across the chest and flipped out.

Baby allowed to hang till the nape hairline was seen. Head delivered by Burns-Marshall method, perineum guarded, mouth and nose cleared, head delivered slowly. Head born 00:37: umbilicus-to-head interval 3 minutes.

Findings: live male, weight 2.85 kg, cried after 20 seconds, APGAR 7 and 9 at 1 and 5 min. Handed to Dr F. Liquor clear. Both arms moving, no visible injury.

Inj oxytocin 10 IU IM at 00:38. Placenta delivered by controlled cord traction at 00:44, complete with membranes.

Cervix and vagina inspected with good light: no tears. Episiotomy without extension.

Closure

Episiotomy repaired in layers: vaginal mucosa, perineal muscle, then skin, with rapid-absorbing polyglactin 910 (Vicryl Rapide). Local lignocaine 1% topped up before repair.

Per rectal examination: no suture in the rectum. Uterus well contracted. Swab and needle count correct.

End of procedure

Estimated blood loss 300 ml (measured in drape and weighed pads). No transfusion.

No maternal complications. Placenta not sent for HPE; disposed in the yellow bag.

Mother stable: pulse 90/min, BP 118/74 mmHg. Baby with mother after paediatric check.

Post-op orders

Pulse, BP, uterine tone and PV bleeding charted as per the unit protocol.

Paediatrician to examine both arms, collar bones and hips of the baby and record the findings.

Breastfeeding started in the labour room.

Check episiotomy for haematoma before shifting. Oral analgesia as charted.

Record time of first void.

Signature

Dr A., JR-3, OBGY. Reg. no. ________. 23/05/2026, 01:20.

Must document for this operation

  • Why the breech was delivered vaginally, and that the options were explained. Planned caesarean is the default in many units, so the note must show counselling and the woman's choice, or the clinical reason such as advanced labour or a second twin.
  • Estimated fetal weight, type of breech and fetal neck checked before delivery. These are the selection checks; a footling breech, a large baby or a hyperextended neck argue against vaginal delivery.
  • Time the umbilicus was born and time the head was born. The umbilicus-to-head interval is linked to the baby's condition and is the first thing reviewed if the baby has asphyxia.
  • Each manoeuvre used for the arms and the head, and who gave suprapubic pressure. If the baby has a fracture or a nerve injury, the paediatrician and any later review need to know what was done.
  • People present: obstetrician, anaesthetist, paediatrician. Having these people present is part of safe practice for vaginal breech delivery and is checked in any review.
  • For twins: lie of twin B after twin A, method of version, and the interval between the births. A long interval or a change of lie explains a combined vaginal and caesarean delivery and a depressed second twin.
  • Inspection of the cervix and vagina, and of the uterine cavity after internal version. Internal manipulation can tear the cervix, vault or uterus, and a missed tear causes postpartum haemorrhage (PPH).

Common mistakes in these notes

  • Writing 'assisted breech delivery done' with no manoeuvres named.
  • No times for full dilatation, umbilicus and head.
  • Not recording that the arms and legs of the baby were examined after a difficult delivery.
  • Not recording the counselling and the woman's choice of vaginal delivery.
  • For a second twin, not recording the lie after twin A or the time between the two births.
  • Leaving out the episiotomy and the check of cervix and vagina.

Indian practice and paperwork

  • Consent must be in a language the woman understands and explain the risks, benefits, alternatives (here caesarean) and who will conduct the delivery. (NABH 5th ed., PRE.4(c))
  • If an extra procedure is needed on the spot (for example Duhrssen incisions or caesarean for the second twin), write whether it was covered by the consent or was done because it was needed to save life or health and could not wait (Samira Kohli v. Dr Prabha Manchanda, Supreme Court, 2008). ((2008) 2 SCC 1)
  • The placenta counts as human anatomical waste. If it is not sent for HPE, it goes in the yellow bag. (Bio-Medical Waste Management Rules 2016, DGHS/CPCB guidelines, Yellow (a))
  • Write the name of every anaesthetist present. A hospital was held negligent when the operation notes did not name the anaesthetist. (Thomas J. Indian J Urol 2009;25(3):384-8)

Sources

  • Apuzzio JJ, Vintzileos AM, Berghella V, Alvarez-Perez JR, eds. Operative Obstetrics. 4th ed. CRC Press; 2017, Ch 25, Fetal malpresentations (breech delivery, total breech extraction, internal version); Ch 26, Delivery of twins and higher-order multiples, pp. 335-339, 347-349.
  • Misra R, ed. Ian Donald's Practical Obstetric Problems. 8th ed. Wolters Kluwer Health (India); 2020, Ch 26, Abnormal labour: 3.1 Breech presentation (management of breech delivery, complications), pp. 542-547.
  • Operative Obstetrics 4e, Ch 22 Postpartum hemorrhage, p. 280 (oxytocin 10 IU IM for the third stage).
  • Arulkumaran S, ed. Best Practice in Labour and Delivery. 3rd ed. Cambridge University Press. Episiotomy and obstetric perineal trauma, pp. 236-237 (lidocaine 1% 20 ml infiltrated into the perineal wound before repair; rapidly absorbing synthetic suture such as polyglactin 910).

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

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