Exxcellence pearls: frank breech presenting at the introitus

Question 0

What factors predispose to breech presentation at term?

Answer 0

Congenital or acquired uterine anomalies, fetal anomalies, abnormalities of amniotic fluid volume, abnormalities of placentation

Question 1

What is the incidence of breech presentation?

What percentage of these are frank breech presentations?

Answer 1

3-4%

Over 50%

Question 2

How should immenent vaginal breech delivery be managed?

Answer 2

Maternal expulsive efforts should be encouraged but no manipulation of the fetus until the fetal umbilicus appears over the perineum.
Pinard maneuver: pressure in the popliteal space of the knee which results in external rotation of the thigh, flexion of the knee and delivery of the leg and foot.
Evaluate for nuchal harm.
if none, one arm is delivered by splinting the humorous and sweeping the arm downward across the fetal thorax.
The fetus is rotated 180° to accomplish delivery of the second arm.
Fetal head is delivered by maintaining neck flexion and using the Mauriceau maneuver: fetus supported on forearm with the middle finger in the fetal mouth.
Birth assistant can help maintain flexion by applying pressure over the pubic symphysis.

Question 3

How is head entrapment managed?

Answer 3

Anesthesia personnel should be present for maternal analgesia and uterine relaxation.
Piper forceps should be available.
Be able to perform Duhrssen’s incisions if necessary. (cervical incisions at 2, 6, and 10 o’clock)

Question 4

What other heroic efforts have been described for fetal head entrapment?

Answer 4

Symphysiotomy and Zavanelli maneuver. These should not be attempted without experienced personnel.