To Handle Breech Births, Know Two Maneuvers

ACEP News
May 2008

By Timothy F. Kirn
Elsevier Global Medical News

INCLINE VILLAGE, NEV. - Emergency physicians who encounter a woman in labor with a baby in a breech position should place the mother on all fours, put a hand on the baby's bottom, and push it back in.

Then, hold it there until obstetric help comes, Dr. John R. Richards said in a talk about emergency deliveries at an emergency medicine conference sponsored by the University of California, Davis.

"It's not a great long-term solution," Dr. Richards said, but "the Zavanelli maneuver is something you all should know."

In the Zavanelli maneuver, a fetus that has begun to show is pushed back into the vagina until it can be delivered by cesarean section. First described in the 1970s, it is used both for breech presentations and for cases in which the baby has a cephalic presentation but the shoulders are stuck.

In a paper reviewing 103 cases in which it was used, the maneuver was successful 92% of the time and was successful in 11 of 11 cases in which the baby had a breech presentation, said Dr. Richards, professor of emergency medicine at the University of California, Davis. "Most were done by first-time operators, like all of us," he said.

When the maneuver is performed, it can be a good idea to calm the contractions with terbutaline or magnesium sulfate, he added.

If an emergency physician does not have an obstetrician available on call, the Pinard maneuver can be an alternative to a cesarean, Dr. Richards said.

First, the physician should perform a generous episiotomy to create room. Then, make sure the cord is not compressed.

In the Pinard maneuver, the infant is allowed to come out until the fetal umbilicus is reached. The physician then inserts a hand to push on the inner aspect of the knee of the lower leg, to bend it, so it can be swept medially and out of the vagina. The physician next delivers the other leg.

No traction should be applied until the fetal umbilicus is past the perineum. Then, the traction should be gentle and applied until the scapula and axilla are visible.

At that point, the physician takes the infant by the hips and rotates 90 degrees. Once the infant is rotated, the physician reaches up and sweeps the anterior arm out by applying pressure to the inner aspect of the elbow, hooking the elbow and sweeping the arm out. The physician rotates the infant 180 degrees and repeats the process with the other arm.

Finally, the physician rotates the infant back 90 degrees, so that the infant is occiput anterior, and attempts to deliver the head. Keep the head flexed, perhaps with fingers on the maxillary prominences, so that the head passes at its smallest diameter.

"If you are out in the middle of nowhere, you may have to use this maneuver," Dr. Richards said. "But just remember: Deliver the legs first, then deliver the arms, and then you can work on the head. You have to do it stepwise."

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