eMedicine Specialties > Emergency Medicine > Obstetrics & Gynecology

Pregnancy, Breech Delivery: Treatment & Medication

Author: Andrew D Jenis, MD, Chair, Department of Emergency Medicine, Cortland Regional Medical Center
Contributor Information and Disclosures

Updated: Oct 26, 2009

Treatment

Prehospital Care

• Secondary to the high risk of fetal and maternal morbidity and mortality, transport the mother to the nearest facility with neonatal intensive care.
• If the mother is in second-stage labor or if amniotic membranes have ruptured, take the mother to the nearest hospital or urgent care center for emergency delivery.
• Administer supportive oxygen and IV fluids.
• Transport the mother in a comfortable position or in the left lateral decubitus position.
• Inform the hospital of an impending arrival and of the clinical situation.

Emergency Department Care

• Provide supportive care, including IV, oxygen, monitor, complete blood count (CBC), and blood type and screen.
• Consult an obstetrician and neonatologist.
• Alert labor & delivery.
• Three types of vaginal breech delivery exist:
  • Spontaneous breech (rare): No manipulation of the infant is necessary, other than supporting the infant.
  • Partial breech extraction: Fetus descends spontaneously to where umbilicus is at the vaginal introitus; then, the fetus is further extracted.
  • Total breech extraction: The entire body is extracted. This is indicated only if there is evidence of fetal distress unresponsive to routine maneuvers and a cesarean delivery is not possible. As mentioned earlier, it is imperative that the cervix be fully dilated and effaced before the infant is delivered past its umbilicus. Note: The presence of the feet at the vulva is not an indication to the physician to proceed with active extraction.
• Technique for footling extraction

• Advance the hand into the vagina and grasp the feet. Place a finger between the legs and apply gentle traction.
• After the feet are pulled through the vulva, make a wide episiotomy.

• Wrap the legs with a towel to aid in grasping the fetus.

• Perform gentle downward traction to deliver the hips, and, then, the buttocks. At this point, the fetus's back should rotate anteriorly.
• Adjust grip so that the thumbs overlay the sacrum. With the fingers over the hips, continue gentle downward traction.
• As the scapulae are delivered, the fetus's back rotates laterally. If this does not occur spontaneously, gently rotate the fetus.
• Once the lower halves of the scapula have passed the vulva and the axillae are identified, deliver the shoulders by 1 of 2 maneuvers:

• In the first method, rotate the trunk posteriorly until the anterior arm and shoulder are delivered; then, rotate the body in the reverse direction to deliver the other shoulder and arm beneath the symphysis pubis.
• If the rotation and counter-rotation method is unsuccessful, deliver the posterior shoulder first. Grasp the feet of the fetus in one hand and, with upward traction, pull the fetus over the mother's groin. The posterior shoulder and extremity slide out above the perineum. Afterward, deliver the anterior shoulder and upper extremity with downward traction.
• If the arm does not pass with the shoulder, deliver the upper extremity manually. Slide two fingers along the humerus until the elbow is reached. Use fingers to splint the humerus, and sweep the forearm of the fetus across the chest and out of the vagina.
• The last part to pass is the head. Typically, the fetal chin is posterior. The head is extracted using the Mauriceau maneuver, as follows:

• With the fetus resting on your hand and forearm, insert index and middle fingers into the vagina to rest upon the fetal maxilla.
• This maneuver accomplishes flexion of the head. Use caution to avoid placing fingers into the mouth or pushing hard on the neck, as tears may occur.
• Hook 2 fingers from the other hand on either side of the fetus's neck. Grasp the shoulders and apply downward traction until the fetal subocciput appears beneath the symphysis pubis.
• The fetus subsequently is elevated toward the maternal abdomen with delivery of the mouth, nose, brow, and occiput beyond the perineum.
• An assistant may apply suprapubic pressure during the Mauriceau maneuver to aid in delivery of the head.
• Technique for frank delivery
  • After episiotomy, allow breech birth to proceed spontaneously as far as possible. Then, apply posterior traction with a finger from each hand placed around the hips of the fetus and into each inguinal region.
  • Once the knees appear, flex the legs gently to assist in delivery.

Consultations

• Inform an obstetrician skilled in breech delivery of its possibility. Their presence at the bedside is imperative.
• As most infants delivered breech are premature, notify a neonatologist or a pediatric intensivist.
• Premature infants do not have great pulmonary reserve. Thus, airway support and intubation may be necessary.

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