The Difficult Delivery: Breech Presentation

A simplified approach to the breech delivery in the emergency department

Case

A 34 year old woman G5P4 at 39 weeks gestation is wheeled into your department, and your nurses tell you to get ready: she is crowning! You examine the patient, and sure enough she appears to be crowning, but something looks funny. That is a weird looking head. Oh wait, its a bum!

 

My approach

Call for help: Obstetrics and pediatrics STAT

Management of breech presentation is going to vary a great deal depending on your resources. At my main hospital, I have 24 hour obstetrics coverage, so for me this should end at “call for OBS”. I shouldn’t do anything. But occasionally I work elsewhere, so let’s review what to do if you don’t have access to an obstetrician:

As much as possible keep your hands off the patient. This allows the presenting part to maximally dilate the cervix. (Maximal patient pushing).

Once the umbilicus is visible, deliver leg one at a time. Apply pressure against the inner aspect of the knee, flexing the knee, and sweep it laterally out of vagina (Pinard maneuver).

Gently rotate the sacrum anterior. Encourage maximal patient effort to deliver to the level of the scapula/clavicle.

Rotate the baby so 1 arm is up. Rotate the arm across the chest to deliver.

Deliver other arm. (Can rotate baby 180 degrees to deliver like first arm).

Return the baby to sacrum up. Place your bottom fingers on the maxillary process to keep the head flexed. Apply traction with your top hand with the fingers over the baby’s shoulders.

Can add trans-abdominal pressure on the head by an assistant.

 

Notes

 breech from jacobi EM

The above applies to frank breech only. Footling and incomplete breech presentations are not considered safe for vaginal delivery.

Other FOAMed Resources

How You Do What You Do: Breech Delivery by Jacobi Medical Center Emergency Medicine

YouTube video: Vaginal breech delivery and symphysiotomy by the Reproductive Health Library

Another excellent YouTube Video: Vaginal Breech Birth by Maternal TrainingInternational

References

VanRooyen MJ, Scott JA. Chapter 105. Emergency Delivery. In: Tintinalli JE et al eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7e. New York: McGraw-Hill; 2011. http://accessmedicine.mhmedical.com/content.aspx?bookid=348&Sectionid=40381574

Pope, Jennifer V. and Tibbles, Carrie D. (2012). The difficult emergency delivery. In: Winters, M.E. (Ed). Emergency Department Resuscitations of the Critically Ill. Dallas, Tx: ACEP.

Author: Justin Morgenstern

Community emerg doc, FOAM enthusiast, evidence junkie “One special advantage of the skeptical attitude of mind is that a man is never vexed to find that after all he has been in the wrong.” - William Osler

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