1. Breech Delivery Dr. ?? December 12 th, 2008

2. IntroductionIntroduction 1)Incidence of breech a)3 - 4% at term b)25% at 28 wks 2)Predisposing Factors a)CNS (decreased tone, hydrocephaly, anencephaly), fetal anomalies, hydramnios/oligo, multiple gestation) b)Uterine anomalies, high parity, pelvic tumors

3. Types of Breech Presentation 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

4. Most Common (Knees extended) 2nd Most Common Least Common (Knees flexed)

5. Option of Cesarean Section – if available  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%)

6. Breech Delivery Dangers 1.Perinatal morbidity and mortality 2.Cord Prolapse  0.5% - Frank  5% - Complete  15% - Footling or Incomplete 3.Entrapped arms 6% 4.Entrapped head

7. Vaginal Examination  Position  Based on sacrum  Example: Sacrum anterior  Station  Bi-trochanteric diameter  Important in case of swollen buttocks or testicles

8. Vaginal Exam – Differentiating Between Face or Breech Presentation Face  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

9. Ultrasound Confirmation  Any breech should be confirmed by ultrasound  What are you looking for on US if you are considering a vaginal delivery?

10. UltrasoundUltrasound  Confirm type of Breech  Amniotic fluid and Fetal tone  Fetal size  HC:AC ratio ~1  Estimated wt 1500g to 4000g  Head flexion  Beware the military or stargazer baby!  Fetal Anomalies  Uterine or Pelvic anomalies

11. Labor Management  Pelvic Adequacy  Satisfactory progress in labor  Preparation  Consent, US, IV  Analgesia  Fetal HR and contraction monitoring  Appropriate support staff  Forceps: Piper Forceps

12. Basic Delivery Principles Don’t Panic! Do NOT pull on the breech ( Spontaneous descent to umbilicus)

13. Maneuver to Deliver Legs Facilitate delivery of legs IF they don’t deliver spontaneously Facilitate rotation to sacrum anterior position

14. Maneuver to Deliver Shoulder and Arms Step 1: Rotate body Step 2: Deliver arm over chest

15. Maneuver to Deliver Fetal Head (Mauriceau Maneuver)

16. Maneuver to Deliver Head if Fetal Chin Anterior  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

17. Entrapped Head Emergency Maneuvers  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