Breech delivery: Difference between revisions

(Updated background, features, and management)
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==Background==
==Background==
*3-4% of term deliveries.<ref name="Silver">Silver DW, Sabatino F. Precipitous and difficult deliveries. Emerg Med Clin North Am. 2012 Nov;30(4):961-75. doi: 10.1016/j.emc.2012.08.004.</ref> (Most common fetal malpresentation<ref name="Mercado">Mercado J. Critical obstetric and gynecologic procedures in the emergency department. Emerg Med Clin North Am. 2013 Feb;31(1):207-36.</ref>)
*3-4% of term deliveries.<ref name="Silver">Silver DW, Sabatino F. Precipitous and difficult deliveries. Emerg Med Clin North Am. 2012 Nov;30(4):961-75. doi: 10.1016/j.emc.2012.08.004.</ref> (Most common fetal malpresentation<ref name="Mercado">Mercado J, Brea I, Mendez B, et al. Critical obstetric and gynecologic procedures in the emergency department. Emerg Med Clin North Am. 2013 Feb;31(1):207-36.</ref>)
*In normal delivery, head dilates cervix and allows body to pass relatively easily.  
*In normal delivery, head dilates cervix and allows body to pass relatively easily.  
**In breech delivery, body first does not first maximally dilate cervix → higher risk of head entrapment, cord prolapse, and death.
**In breech delivery, body first does not first maximally dilate cervix → higher risk of head entrapment, cord prolapse, and death.
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**If OB/Gyn immediately available and delivery has not progressed, Zavanelli maneuver has been described for breech births and may be considered.
**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<ref>Timothy F Kirn. To Handle Breech Births, Know Two Maneuvers. ACEP News May 2008. [http://www.acep.org/Clinical---Practice-Management/To-Handle-Breech-Births,-Know-Two-Maneuvers/ ACEP News] Accessed 08/03/15.</ref>
***Zavanelli maneuver - pushing presenting fetal part back into vagina until C-Section can be performed<ref>Timothy F Kirn. To Handle Breech Births, Know Two Maneuvers. ACEP News May 2008. [http://www.acep.org/Clinical---Practice-Management/To-Handle-Breech-Births,-Know-Two-Maneuvers/ ACEP News] Accessed 08/03/15.</ref>
*Place patient in lithotomy position
*Allow delivery to proceed spontaneously until fetal umbilicus is at perineum
*If legs and feet are still extended, perform Pinard maneuver to deliver fetal legs<ref name="Silver" />
**Place hand behind and parallel to fetal leg, then sweep laterally (away from midline) to deliver leg
**Repeat for opposite leg
*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<ref name="Mercado" />
**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 maxilla 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 (0.25 mg SQ '''or''' 2.5-10 μg/min IV) to relax uterus


==Disposition==
==Disposition==

Revision as of 08:45, 3 August 2015

Background

  • 3-4% of term deliveries.[1] (Most common fetal malpresentation[2])
  • In normal delivery, head dilates cervix and allows body to pass relatively easily.
    • In breech delivery, body first does not first maximally dilate cervix → higher risk of head entrapment, cord prolapse, and death.

Clinical Features

Three Types of Breech Delivery[1]

  • 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

Diagnosis

  • 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[3]
  • Place patient in lithotomy position
  • Allow delivery to proceed spontaneously until fetal umbilicus is at perineum
  • If legs and feet are still extended, perform Pinard maneuver to deliver fetal legs[1]
    • Place hand behind and parallel to fetal leg, then sweep laterally (away from midline) to deliver leg
    • Repeat for opposite leg
  • 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[2]
    • 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 maxilla 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 (0.25 mg SQ or 2.5-10 μg/min IV) to relax uterus

Disposition

  • Admit to L&D.

See Also

External Links

References

  1. ↑ 1.0 1.1 1.2 Silver DW, Sabatino F. Precipitous and difficult deliveries. Emerg Med Clin North Am. 2012 Nov;30(4):961-75. doi: 10.1016/j.emc.2012.08.004.
  2. ↑ 2.0 2.1 Mercado J, Brea I, Mendez B, et al. Critical obstetric and gynecologic procedures in the emergency department. Emerg Med Clin North Am. 2013 Feb;31(1):207-36.
  3. ↑ Timothy F Kirn. To Handle Breech Births, Know Two Maneuvers. ACEP News May 2008. ACEP News Accessed 08/03/15.
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