Breech delivery

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 does not first maximally dilate cervix → higher risk of head entrapment, cord prolapse, and death.

Clinical Features

  • Three Types[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

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[3]
  • 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[1]
    • 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[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 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

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.