Breech Presentation

 

 

Considerations 

 

  • ↑ risk of maternal mortality, morbidity, & complications (infection, perineal trauma, hemorrhage) 

  • ↑ risk of fetal complications: 

    • ​Preterm delivery

    • Birth trauma

    • Major congenital anomalies

    • Umbilical cord prolapse

    • Hyperextension of the head

    • Spinal cord injuries with deflexion

    • Arrest of after-coming head

    • Intrapartum asphyxia

    • Intrapartum fetal death

  • Considerations of external cephalic version if performed

  • Recommended mode of delivery is cesarean section but vaginal delivery can be attempted with term singleton with adequate pre-planning (Canadian guidelines 2009)

  • Pregnancy considerations (difficult intubation, aspiration, ↓ time to desaturation, aortocaval compression, 2 patients)

 

 

Management

 

  • Analgesia for labor:

    • Early epidural if possible 

    • The patient MUST NOT PUSH IN 1st stage of labor → might push a lower extremity through her partially dilated cervix, which may result in fetal head entrapment

  • Anesthesia for vaginal breech delivery: 

    • Delivery preferred in the OR should emergency cesarean be required → always be ready to convert to GA!

    • Epidural strongly recommended

    • Very high risk including: 

      • Umbilical cord compression 

      • Fetal head entrapment 

  • Anesthesia for cesarean delivery:

    • Neuraxial or GA 

    • Possible need for uterine relaxation, have nitroglycerin available

    • May require larger incision or a vertical incision

  • Fetal head entrapment: 

    • Nitroglycerin IV 100-400mcg OR nitroglycerin SL 400-800mcg

    • Likely need STAT GA: RSI (propofol/succinylcholine) & start 2-3 MAC of volatile to relax uterus 

    • Be ready to support hemodynamics, control hemorrhage  

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