Breech DeliveryBreech DeliveryBreech DeliveryBreech Delivery

Dr. ??

December 12th, 2008

IntroductionIntroductionIntroductionIntroduction

1) Incidence of breecha) 3 - 4% at termb) 25% at 28 wks

2) Predisposing Factorsa) CNS (decreased tone,

hydrocephaly, anencephaly), fetal anomalies, hydramnios/oligo, multiple gestation)

b) Uterine anomalies, high parity, pelvic tumors

Types of Breech Types of Breech PresentationPresentation

Types of Breech Types of Breech PresentationPresentation

A. Frank Breech Hips flexed Knees extended

B. Complete Breech Hips flexed One or both knees flexed

C. Incomplete or Footling Breech

One or both hips NOT flexed One of both feet/knees lie

below butt

Most Common (Knees extended)

2nd Most Common

Least Common (Knees flexed)

Option of Cesarean Option of Cesarean Section – if Section – if

availableavailable

Option of Cesarean Option of Cesarean Section – if Section – if

availableavailable The “Term Breech Trial” released in 2000 (Lancet 356:1375-83) showed significantly lower adverse perinatal events with planned C/S vs planned vaginal delivery (1.6% vs 5%)

Breech Delivery Breech Delivery DangersDangers

Breech Delivery Breech Delivery DangersDangers

1. Perinatal morbidity and mortality

2. Cord Prolapse 0.5% - Frank 5% - Complete 15% - Footling or

Incomplete

3. Entrapped arms 6%4. Entrapped head

Vaginal Vaginal ExaminationExamination

Vaginal Vaginal ExaminationExamination

Position Based on sacrum Example: Sacrum anterior

Station Bi-trochanteric diameter Important in case of swollen buttocks or testicles

Vaginal Exam – Vaginal Exam – Differentiating Differentiating Between Face or Between Face or

Breech PresentationBreech Presentation

Vaginal Exam – Vaginal Exam – Differentiating Differentiating Between Face or Between Face or

Breech PresentationBreech PresentationFace

Firmer less-yielding jaws

No meconium from mouth

Mouth and malar eminences form a triangle

Breech Muscular resistance w/ anus

Meconium on finger from anus

Anus and ischial tuberosities are in a straight line

Ultrasound Ultrasound ConfirmationConfirmationUltrasound Ultrasound

ConfirmationConfirmation Any breech should be confirmed by ultrasound

What are you looking for on US if you are considering a vaginal delivery?

UltrasoundUltrasoundUltrasoundUltrasound

Confirm type of Breech Amniotic fluid and Fetal tone

Fetal sizeHC:AC ratio ~1Estimated wt 1500g to 4000g

Head flexionBeware the military or stargazer baby!

Fetal Anomalies Uterine or Pelvic anomalies

Labor ManagementLabor ManagementLabor ManagementLabor Management

Pelvic Adequacy Satisfactory progress in labor

Preparation Consent, US, IV Analgesia Fetal HR and contraction monitoring

Appropriate support staff Forceps: Piper Forceps

Basic Delivery Basic Delivery PrinciplesPrinciples

Basic Delivery Basic Delivery PrinciplesPrinciples

Don’t Panic!

Do NOT pull on the breech(Spontaneous descent to

umbilicus)

Maneuver to Deliver LegsManeuver to

Deliver LegsFacilitate delivery of legs IF

they don’t deliver spontaneously

Facilitate rotation to sacrum anterior position

Maneuver to Deliver Shoulder and Arms

Maneuver to Deliver Shoulder and Arms

Step 1: Rotate body

Step 2: Deliver arm over chest

Maneuver to Deliver Fetal Head

(Mauriceau Maneuver)

Maneuver to Deliver Fetal Head

(Mauriceau Maneuver)

Maneuver to Maneuver to Deliver Head if Deliver Head if

Fetal Chin Fetal Chin AnteriorAnterior

Maneuver to Maneuver to Deliver Head if Deliver Head if

Fetal Chin Fetal Chin AnteriorAnterior Indication

Failure of the fetal trunk to rotate anteriorly (i.e. chin up)

Maneuver 2-fingers of one hand grasping shoulders from below while the other hand draws the feet up over the maternal abdomen

Entrapped Head Entrapped Head Emergency Emergency ManeuversManeuvers

Entrapped Head Entrapped Head Emergency Emergency ManeuversManeuvers

Non-cervical Mauriceau Maneuver Piper Forceps

Cervical Gentle traction and try to slide cervix over occiput

Duhrssen Incision (Make incision into cervix

Zavanelli Maneuver (pushing fetal body back into vagina) and then do C-section

Symphysiotomy