Precipitous Breech Deliveries…Oh My!

Image: https://www.patheos.com/blogs/rogerwolsey/2019/10/oh-my-g-od/omg-funny-baby-face-picture/

In this post, I will cover some of the basics regarding breech deliveries. This topic may cause tachycardia in many resident physicians (including myself) so let’s try and increase our preparedness with a review of the topic.

Breech Presentation

Definition

• Feet first or bottom first presentation

Background

• 3-4% of term deliveries
• Most common fetal malpresentation
• Occur most frequently in the delivery of premature infants
• In normal deliveries the head, acts as a wedge to help dilate the cervical opening clearing space for the body. Breech presentations are prone to poor cervical dilation.
  • Leads to higher risk of cord prolapse, head entrapment, and asphyxia
• Three types
  • Frank – Buttocks delivers first, hips flexed, knees extended
    • Most common
    • 0.5% incidence of cord prolapse
  • Complete – Buttocks deliver first, hips and knees flexed
    • 5-6% incidence of cord prolapse
  • Incomplete – Footling. One or both feet deliver first
    • 15-18% incidence of cord prolapse
• Improper attempts at delivery can cause fetal head and neck trauma from traction. Therefore, cesarean section is the preferred method of delivery when possible.

Diagnosis

• Prenatal US scans throughout prenatal care
• In ED precipitous delivery this is a clinical diagnosis as the presenting part will not be the head
• If time allows, US can reveal position of fetus in ED

Initial Management

• Prepare for delivery
  • Call for help
  • Emergent OB/Gyn consult
  • Obstetrician and pediatric provider should be alerted
  • Obtain infant warmer, supplies for delivery and neonatal care, and resuscitation equipment
• If the fetus has not yet emerged from the vagina, the mother should be instructed not to push. This may allow enough time to be transported to labor and delivery or allow for OB to arrive in ED.
• If any part of the fetus has emerged from the vagina, delivery must proceed
  • Allow the delivery to happen spontaneously

Vaginal Delivery Maneuvers

• Place patient in lithotomy position
• Evaluate for rupture of membranes and prolapsed cord
• Have assistant maintain fundal pressure throughout
• If feet have not delivered spontaneously, grasp the thigh to allow delivery of the leg, grasp the other leg to allow its delivery
  • Place hand behind and parallel to fetal leg, then sweep laterally to deliver leg

• Grasp the legs at the ankles and rotate so the sacrum is anterior
  • Baby’s back to the mother’s anterior

• Check for cord
  • If between the legs, this must be reduced around the foot as it will avulse if delivery continues
  • If around the neck, try to reduce it by pushing it over baby’s head or just deliver baby through quickly
• Allow the delivery to proceed spontaneously until fetal umbilicus is at perineum
  • Wrap the trunk and legs in a towel.
  • Support the fetus’s body after the umbilicus appears but do not apply traction or squeeze the waist and abdominal organs.
• Allow delivery to progress until axilla is visible
  • Encourage mother to bear down strongly until visible
• If shoulders do not deliver spontaneously
  • Apply gentle rotation and upward traction on fetal body using other hand to apply leverage and deliver posterior shoulder and arm, then apply downward traction on the fetal body to deliver anterior shoulder and arm.

• Utilize the pinard maneuver if needed to facilitate deliver of arms. This is Performed by grasping each humerus and sweeping downwards

• To deliver the head, perform the Mauriceau-Smellie-Veit maneuver
  • Once the fetal chin is at the pelvic inlet, the provider’s arm is placed under the fetus with the middle fingers on the fetal maxilla and the fetal legs straddling the forearm. The maxillary fingers plus occipital pressure with the other hand promote head flexion and descent as the body is slightly elevated 
  • Stabilize with other and/forearm on the fetal back and shoulders avoiding excessive angulation or traction of fetal body
  • Assistant applies suprapubic pressure to aid in delivery of head
  • Keep body parallel to horizontal to avoid neck hyperextension
  • Do not pull

Complications

• The head can become entrapped in a partially dilated cervix.
  • The skull does not have as much time under pressure to mold as it would in a vertex delivery
  • Uterine relaxants can be administered to facilitate delivery of the head
  • Terbutaline 0.25mg SQ or 2.5-10ug/min IV or Nitroglycerin 50-200 mcg IV as an alternative
• Do not hold the fetal trunk more than 45 degrees above horizontal during delivery, which could apply damaging traction on the cervical spine.

References

Linker, J. (2020, April 22). The Complicated Delivery: What do you do? EmDOCs.Net – Emergency Medicine Education. http://www.emdocs.net/the-complicated-delivery-what-do-you-do/

Breech delivery – WikEM. (2019). Wiki EM. https://wikem.org/wiki/Breech_delivery

Tintinalli, J., Ma, J. O., Yealy, D., Meckler, G., Stapczynski, J., Cline, D., & Thomas, S. (2019). Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9th Edition (9th ed.). McGraw-Hill Education / Medical.

Author: Eric Polich, DO