- 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).
- 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
- Emergent delivery
- Umbilical cord prolapse
- Breech delivery
- Shoulder dystocia
- Perimortem cesarean delivery
- 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.
- 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
- 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.
- Admit to L&D
- 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.
- 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