View source for Breech delivery

==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, 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 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==
*Three Types<ref name="Silver" />
**'''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==
{{Emergency delivery DDX}}

==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<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>, though is associated with increased risk of soft tissue damage and sepsis<ref>Gabbe, Steven G. Obstetrics : normal and problem pregnancies (6th ed.). Philadelphia: Elsevier/Saunders. p. 412</ref>
*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<ref name="Silver" />
**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<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 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==
*[https://www.youtube.com/watch?v=2pmEsdZR7ig YouTube: Assisted Breech Delivery]

==References==
<references/>

[[Category:OBGYN]]