Management of the Frank Breech Presenting at the Introitus
Dec 2013 – by J. Repke, MD
A 26 y.o. G1P0 presents in active labor at 37 5/7 weeks gestation and has had no complications during the current pregnancy. One week ago you estimated the fetal weight to be 3100 grams and clinical pelvimetry was deemed adequate. A frank breech is presenting at the introitus at +5/5 station with approximately 5-6 cm of the breech visible through the introitus. What is the best course of action for the management of this delivery?
Breech presentation at term occurs with an incidence of 3-4 %, with frank breech presentations accounting for over 50% of these. Factors predisposing to persistent breech presentation at term include congenital or acquired uterine anomalies, fetal anomalies, abnormalities of amniotic fluid volume and abnormalities of placentation. In the United States it is generally accepted that breech presentations be delivered by cesarean delivery. In the above circumstance the pertinent questions to be asked by the physician are:
1. Are there any uterine or fetal anomalies?
2. Are there any congenital or acquired uterine anomalies?
3. Is the estimated fetal weight appropriate for a possible vaginal breech delivery?
4. Am I sufficiently trained to perform a vaginal breech delivery?
5. Is emergent cesarean delivery able to be safely accomplished in a timely manner?
6. Are there any contraindications to vaginal delivery?
In this case, it is unlikely that cesarean delivery can be accomplished in a fast enough timeframe, leaving vaginal delivery as the only viable option. In a frank breech delivery, patience is a virtue. Maternal expulsive efforts should be encouraged, but no manipulation of the fetus should occur until the fetal umbilicus appears over the perineum. At this point, the obstetrician may perform the 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). Once both legs are delivered, the fetus is supported in the prone position, sometimes using a dry towel wrapped around the fetal pelvis. Minimal, if any, traction should be applied Further descent relies on maternal expulsive efforts.
Once the lower parts of both scapulae have passed through the introitus, evaluation for a possible nuchal arm is performed. If there is none then one arm is delivered by splinting the humerus and sweeping the arm downward across the fetal thorax. The fetus is then rotated 180 degrees to accomplish delivery of the other arm. If a nuchal arm is encountered then the fetus must be rotated in a manner that will bring the elbow anteriorly toward the fetal thorax so that reduction and delivery can occur.
Lastly, delivery of the fetal head must be accomplished. Often spontaneous delivery will occur but efforts should be made to insure that flexion of the fetal head is maintained which may be accomplished using the Mauriceau maneuver (fetus supported on the forearm with the middle finger in the fetal mouth) with an assistantís hand helping to maintain flexion by applying mild pressure over the pubic symphysis.
In the rare instance of head entrapment several important maneuvers must take place:
1. Anesthesia personnel should be present to provide both maternal analgesia or anesthesia, and uterine relaxation.
2. Piper Forceps should be available.
3. Familiarity with the technique of performing Duhrssenís incisions is desirable.
While performance of symphysiotomy or a variant of the Zavanelli maneuver have been described, the need for either is exceedingly rare and probably should not be attempted without additional experienced personnel. To gain greater familiarity with the maneuvers required for the performance of a vaginal breech delivery, they should be practiced at the time of cesarean delivery for breech presentation.
Kopelman JN, Maslow AS, Markenson GR, Foley KS: Malpresentation. in Intrapartum Obstetrics, ed. Repke JT. pp 141-63; Churchill Livingstone, New York 1996