How You Do What You Do: Breech Delivery

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Baby butt

Yup…that’s what you see coming at you…it’s butt!!! You are alone in an ER in the middle of nowhere and the Obstetrician is nestled in their bed hearing that little buzzing sound of their beeper off in the distance. What is a lonely ER doctor do?

To start out let’s review some definitions:
1. Frank Breech – hips are flexed and legs are extended at the knees (most common)
2. Incomplete Breech – one of the baby’s knees is bent and foot and bottom are closest to the birthing canal
3. Complete Breech – baby’s legs are folded flat up against his head and bottom is at birthing canal

There are 3 stages of labor:

1. The first stage of labor is marked by the onset of labor and completes with full cervical dilation and descent of the fetus
2. The Second stage of labor is the expulsive phase of the fetus
3. The Third stage of labor is in reference to the time from delivery of the baby to the separation and expulsion of the placenta

For Breech Delivery the Second stage of labor is where we become concerned because this is the time the umbilical cord gets compressed and acidosis may ensue (especially in a small fetus). Perinatal outcomes are affected if the second stage of labor lasts longer than 60 minutes.

How to manage 2nd stage of Delivery in a Breech Presentation

1. The clock has been started as you have only 60 minutes before acidosis sets in on the baby.

2. Allow mother to do all the pushing as the addition of oxytocin and/or prostaglandins (birth augmenters) can cause for adverse perinatal outcomes. DO NOT apply traction as this may cause for the fetal head to become hyperextended or the fetal arms to disengage making it more difficult to deliver.

3. Allow the baby to be delivered until the umbilicus at which point if the legs are still trapped (frank and complete breech) perform a Pinard maneuver

a. Pinard maneuver is the sweeping/external rotation of each thigh combined with rotating the pelvis in the opposite direction resulting in the flexion of the knee and the delivery of each leg

4. At this point you should feel for pulsation of the umbilicus and pull out a small portion of the cord so as not to create tension.

5. Wrap a dry towel around the fetal pelvis (not abdomen to prevent squeezing the adrenals) or only handle the bony pelvis

6. Delivery of the arms is next. Sometimes the mother with her expulsive efforts will help move the baby on its own passed this stage. Fundal pressure (Bracht maneuver) should be applied at this step to keep the head engaged and flexed. If the arms are reluctant to deliver, rotate the fetus 180 degrees to bring the baby’s arm in front of its face, then with your forefingers the arm may be swept down, across the face, to free it (known as the Lovset maneuver). The action can be repeated on the opposite side to free the other arm. [Note: if the arms is behind the head, the child can be rotated toward the pelvis to disengage it]

7. Delivery of the head is the next step and once again we have to avoid the urge to apply traction. Keeping the head and neck in a flexed position reduces perinatal morbidity. An assistant will maintain the Bracht maneuver (fundal pressure). The baby is turned to face the floor. Once the hairline is noticed, the operator’s hand should cover the vulva while the other hand is placed below to receive the fetal face. Some obstetricians recommend the Mariceau-Smellie-Veit Maneuver where the fetus rests on the forearm, and the index and middle fingers apply pressure to the maxillary prominences. [Note: Do not pull on maxilla as it may cause TMJ dislocation]

8. At this point the baby can be pulled up and out, over the maternal abdomen. It is important to avoid an angle greater than 45 degrees above the horizontal to avoid hyperextension of the cervical spine.

9. Head entrapment is a very serious complication of breech delivery. Since no one should feel comfortable with symphysiotomy (inserting a scalpel through the skin overlying the pubic symphysis and cutting the supporting ligments to increase the pelvic diameter as much as 12%) you may have to rely on giving uterine relaxants. Administering terbutaline (0.25mg SQ or 2.5 to 10mcg/min IV) or possibly nitroglycerin (50 to 200 mcg IV) may do the trick. If all else fails perform the Zavanelli maneuver.

a. The Zavanelli maneuver – the child is replaced back into the uterus to allow for emergent C-section. This has to be done in a timely manner because fetal oxygenation may be compromised if prolonged time to delivery. Giving tocolytic agents like Terbutaline or Nifedipine can help facilitate this maneuver. There is some debate on whether this is a safe procedure. Reports have shown success with inexperienced providers.

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Reference:
Westgren et al., Hyperextension of the Fetal Head in Breech Presentation A Study with Long-Term Follow-Up, Br Journ of Obstetrics and Gynecology, 1981; 88:101-104.

Alarab, M, et al., Singleton Vaginal Breech Delivery at Term: Still a Safe Option, Obst Gynecol 2004; 103;407.

Hofmeyr, JG, Kulier R, Expedited versus conservative approaches for vaginal delivery in breech presentation, Cochrane Review, 2012.

Kotaska et al., Vaginal Delivery of Breech Presentation, SOGC Clinical Practice Guideline, JOGC 2009; 226:557-566.

Bjorklund, Kenneth, Minimally invasive surgery for obstructed labour: a review of symphysiotomy during the twentieth century (including 5000 cases), BJOG: an International Journal of Ob and Gyn, 2002; 109:236-48.

Sandberg, E., The Zavanelli maneuver: 12 years of recorded experience, Obst and Gyn, 1999; 93(2):312-17

Min Su, BM, et al. Factors associated with adverse perinatal outcome in the Term Breech Trial., Am J Obstet Gynecol 2003; 189:740-5.

Plentl, AA and Stone RE, The Bracht Maneuver, Obstet and Gynecol Survey, 1953;8(3):313-25.

Gebbe, SG et al., Obstetrics: Normal and Problem Pregnancies, 4th ed, Churchill Livingstone New York 2003.

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