The Breech

One method of handling a breech baby

Anesthesia for Breech Presentation, notes from Chestnut

Breech – when fetal buttocks/lower extremities overlie pelvic inlet

Epidemiology
-25% incidence before 28wks
-3-4% remain in breech at term

 

Predisposing factors
-hydrocephalus, polyhydramnios, anencephaly, oligohydramnios
-multiaprity
-hypothyroid (even transient at 12wks)
-abnormal pelvis/uterus
-previa

 

OB complications
-vaginal breech is high risk for neonatal trauma, c/s less so
-16x intrapartum fetal death, 3.8x intrapartum asphyxia
-5-20x cord prolapse
-13x birth trauma
-5-8% increased risk of arrest of aftercoming head**
-1/5 get spinal cord injuries with deflexion
-6-18% congenital abnormalities
-1/8 to 1/3 preterm
-5% hyperextended head

Umbilical cord prolapse necessitates emergency c/s, highest risk with incomplete breech

 

OB Management

External cephalic version: best done after 36-37weeks
-58% success rate, varies widely
-chance for emergent delivery
-most women who get version undergoe vaginal delivery
-some tocolytics used (Terbutaline, Nitroglycerin)
-Epidural/spinal – reduces force and pain required for version, use an anesthetic dose

Mode of delivery: c/s (Term Breech Trial 2000 http://www.ncbi.nlm.nih.gov/pubmed/11052579) preferred
-in c/s lower perinatal and neotal morbidity and mortality (1.6% vs. 5%)
-though maternal outcomes at 2yrs similiar and some experienced vaginal breech deliverers as good
-C/S can be vertical incision before 32wks
Anesthetic management

-epidural or cse good choices
-patient must not push before fully dilated as increase change for fetal head entrapment, and breech gives earlier rectal pressure, so local with opioid (fent, sufent) to block sacral segments is good as will not fully block motor in second stage
-be prepared for general at any time
-cord compression common, use supplemental O2
-if going for forceps/operative vaginal delivery, convert analgesia epidural to anasthesia with 3% chloroprocain or 2% lidocaine +/- epi and bicarb
Fetal head entrapment!!
-greatest risk less than 32wks
-head trapped in cervix 3 options:

1. duhrssen incision of cervix
-radical incisions in cervix
-maternal morbidity (trauma, hemorrhage, peritoneal bleeding)
2. relax skeletal and cervical muscle
-RSI with 2-3 MAC of halogenated agent gets relaxation in 2-3 minutes
-once delivered, siwth to 1/2mac+nitrous as high MAC ==> uterine atony/hemorrhage
-More modern approach: Nitroglycerin IV 100mcg to 200mcg, sublingual 400-800mcg Watch for hypotension and HA, tx with neo
3. c/s
-spinal, epi or GA
-increase halogenated agent in GA for relaxation
-if Neuraxial, use IV/Sublinguqal nitroglycerin
-terbutaline can also provide relaxation
-convert to GA if needed

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