Breech

Question 1

Head entrapment

Answer 1

1. manually push cervix around occiput
2. Durssen’s
3. 100 micrograms iv nitroglycerin (no good evidence that this actually works)
4. General anesthsia halogenated agents
5. Zavanelli’s
6. Symphisiotomy (increased pelvic diameter 2.5cm)

Question 2

Nuchal arm

Answer 2

1. Deliver posterior shoulder
2. Rotate fetal body to push hand towards face
3. Push fetus up maybe dislodge hand
4. force arm over shoulder (humerus/clavicle fx common)

Question 3

Pinard

Answer 3

For frank breech decomposition if downward traction does not work: (still inside uterus) fingers back of thigh up to back of knee, push thigh away from midline to grab foot…best if just ruptured bag, difficult with little amniotic fluid…may consider mag, terb (250micrograms subcutaneous)

Question 4

Internal podalic version

Answer 4

only for second twin
INTACT membranes
Grab feet, then transabdominally push fetal body in opposite direction, then breech delivery

Question 5

Mauriceau

Answer 5

Middle and forefinger on maxilla, other hand over neck/shoulders. Flexion of fetal head to deliver

Question 6

Should you do episiotomy

Answer 6

Yes! Very important for all breech extractions unless perineum is very flexible

Question 7

Modified Prague

Answer 7

Do it if fetus does not turn anteriorly: one hand grasps feet/ankles, other hand support baby’s shoulders…lift up the feet

Question 8

Pipers

Answer 8

Left blade (maternal left), right blade…place along parietal bone…to deliver fetal head, towel hammocking baby’s body

Question 9

Contraindications to scheduled breech vaginal delivery

Answer 9

1. doc inexperienced
2. preterm viable, healthy
3. severe IUGR
4. fetal anomaly where vag delivery may be difficult
5. h/o prior birth trauma/fetal perinatal death
6. mother requests c/s
7. big baby: >3800-4000g
8. Incomplete/footling breech
9. Pelvic contraction or unfavorable pelvic shape based on clinical exam/pelvimetry
10. hyperextended head
11. prior c/s