Breech delivery

Background

Twins with one in breech position.

• 3-4% of term deliveries. (Most common fetal malpresentation)
• In normal delivery, head dilates cervix and allows body to pass relatively easily.
  • In breech delivery, body does not first maximally dilate cervix → higher risk of head entrapment, cord prolapse, and death.
• Breech presentations occur most commonly in preterm infants (25-30% of preterm deliveries <28 wks gestation).

Clinical Features

Incomplete ("footling") breech presentation.

• Three Types
  • Frank - Buttocks deliver first, hips flexed, knees extended (most common type)
  • Complete - Buttocks deliver first, hips and knees flexed
  • Incomplete - (aka "footling") One or both feet deliver first

Differential Diagnosis

Emergent delivery and related complications

• Emergent delivery
• Umbilical cord prolapse
• Breech delivery
• Shoulder dystocia
• Perimortem cesarean delivery

Evaluation

• In ED precipitous delivery, this is a clinical diagnosis.
• If time allows, ultrasound can reveal position of fetus, but often not possible in ED deliveries.

Management

• Immediate OB/Gyn consult
  • If OB/Gyn immediately available and delivery has not progressed, Zavanelli maneuver has been described for breech births and may be considered.
    • Zavanelli maneuver - pushing presenting fetal part back into vagina until C-Section can be performed, though is associated with increased risk of soft tissue damage and sepsis
• Place patient in lithotomy position
• Have assistant maintain fundal pressure throughout delivery
• Grab legs together with one hand if feet deliver spontaneously
• Make sure baby is sacral anterior - meaning baby's back to mother's anterior
  • Head will need to be delivered with baby's face looking to mother's posterior
  • If not sacral anterior, make it that way along delivery
• If legs and feet are still extended, perform Pinard maneuver to deliver fetal legs
  • Place hand behind and parallel to fetal leg, then sweep laterally (away from midline) to deliver leg
  • Repeat for opposite leg
• Check for cord:
  • If around the neck, try to reduce it by pushing it over baby's head or just deliver baby through quickly
  • If between the legs, this must be reduced around the foot as it will definitely avulse if delivery continues
• Allow delivery to proceed spontaneously until fetal umbilicus is at perineum
• Once torso begins to deliver, hold legs in one hand and hold bony pelvis with other (do not rupture spleen)
• Allow delivery to progress until axilla is visible
• If shoulders do not deliver spontaneously, apply gentle upward traction on fetal body using other hand to apply leverage and deliver posterior shoulder/arm/hand, then apply downward traction on fetal body to deliver anterior shoulder/arm/hand
  • If posterior arm and hand do not deliver spontaneously, grasp humerus and sweep downwards while still applying upward traction on fetal body.
  • If anterior arm and hand do not deliver spontaneously, grasp humerus and sweet downwards over thorax while maintaining downward traction on fetal body.
• To deliver head, have assistant apply suprapubic pressure and rest fetal body on provider's forearm while reaching into vaginal canal to grasp fetal maxillae in order to flex head. (Mauriceau maneuver) - stabilize with other hand/forearm on fetal back and shoulders - avoid excessive angulation or traction of fetal body.
• If fetal head becomes entrapped, administer terbutaline (0.25mg SQ or 2.5-10 μg/min IV) to relax uterus
  • Nitroglycerin (50 to 200 mcg IV) is an alternative.

Disposition

• Admit to L&D

See Also

• Emergent delivery

External Links

• YouTube: Assisted Breech Delivery