Breech delivery: Difference between revisions
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*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 does not first maximally dilate cervix → higher risk of head entrapment, cord prolapse, and death. | **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== | ==Clinical Features== | ||
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{{Emergency delivery DDX}} | {{Emergency delivery DDX}} | ||
== | ==Evaluation== | ||
*In ED precipitous delivery, this is a clinical 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. | *If time allows, ultrasound can reveal position of fetus, but often not possible in ED deliveries. | ||
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*Immediate OB/Gyn consult | *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. | **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>, 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 | *Place patient in lithotomy position | ||
*Have assistant maintain fundal pressure throughout delivery | *Have assistant maintain fundal pressure throughout delivery | ||
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**If between the legs, this must be reduced around the foot as it will definitely avulse if delivery continues | **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 | *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 ( | *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 | *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 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" /> | ||
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**If anterior arm and hand do not deliver spontaneously, grasp humerus and sweet downwards over thorax while maintaining downward 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. | *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. | *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. | **[[Nitroglycerin]] (50 to 200 mcg IV) is an alternative. | ||
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==External Links== | ==External Links== | ||
*[https://www.youtube.com/watch?v=2pmEsdZR7ig YouTube: Assisted Breech Delivery] | |||
==References== | ==References== | ||
<references/> | <references/> | ||
[[Category: | [[Category:OBGYN]] | ||
Revision as of 21:15, 27 May 2019
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.
- Breech presentations occur most commonly in preterm infants (25-30% of preterm deliveries <28 wks gestation).
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
- 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.
- 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
- Nitroglycerin (50 to 200 mcg IV) is an alternative.
Disposition
- Admit to L&D
See Also
External Links
References
- ↑ 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.
- ↑ 2.0 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.
- ↑ Timothy F Kirn. To Handle Breech Births, Know Two Maneuvers. ACEP News May 2008. ACEP News Accessed 08/03/15.
- ↑ Gabbe, Steven G. Obstetrics : normal and problem pregnancies (6th ed.). Philadelphia: Elsevier/Saunders. p. 412