Further Inpatient Care

Warm and dry the infant. Place him or her in an infant incubator. If the infant is younger than 37 weeks' gestation, the lungs may be premature. Consider endotracheal intubation with mechanical ventilation. Even infants older than 37 weeks' gestation still should be placed in a hospital with a nursery.

Inspect the maternal birth canal, and repair lacerations of the cervix and vagina, as required. Administer 300 mcg RhoGAM IM if the mother is Rh negative.

When the infant is stable, transfer him or her to the nearest hospital with pediatric intensive care. Otherwise, transfer the infant and mother to a hospital with newborn facilities.

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Media Gallery

Footling breech presentation. Once the feet have delivered, one may be tempted to pull on the feet. However, a singleton gestation should not be pulled by the feet because this action may precipitate head entrapment in an incompletely dilated cervix or may precipitate nuchal arms. As long as the fetal heart rate is stable and no physical evidence of a prolapsed cord is evident, management may be expectant while awaiting full cervical dilation.
Assisted vaginal breech delivery. Thick meconium passage is common as the breech is squeezed through the birth canal. This is usually not associated with meconium aspiration because the meconium passes out of the vagina and does not mix with the amniotic fluid.
Assisted vaginal breech delivery. The Ritgen maneuver is applied to take pressure off the perineum during vaginal delivery. Episiotomies are often performed for assisted vaginal breech deliveries, even in multiparous women, to prevent soft tissue dystocia.
Assisted vaginal breech delivery. No downward or outward traction is applied to the fetus until the umbilicus has been reached.
Assisted vaginal breech delivery. With a towel wrapped around the fetal hips, gentle downward and outward traction is applied in conjunction with maternal expulsive efforts until the scapula is reached. An assistant should be applying gentle fundal pressure to keep the fetal head flexed.
Assisted vaginal breech delivery. After the scapula is reached, the fetus should be rotated 90° in order to deliver the anterior arm.
Assisted vaginal breech delivery. The anterior arm is followed to the elbow, and the arm is swept out of the vagina.
Assisted vaginal breech delivery. The fetus is rotated 180°, and the contralateral arm is delivered in a similar manner as the first. The infant is then rotated 90° to the backup position in preparation for delivery of the head.
Assisted vaginal breech delivery. The fetal head is maintained in a flexed position by using the Mauriceau maneuver, which is performed by placing the index and middle fingers over the maxillary prominence on either side of the nose. The fetal body is supported in a neutral position, with care to not overextend the neck.
Piper forceps application. Piper forceps are specialized forceps used only for the after-coming head of a breech presentation. They are used to keep the fetal head flexed during extraction of the head. An assistant is needed to hold the infant while the operator gets on one knee to apply the forceps from below.
Assisted vaginal breech delivery. Low 1-minute Apgar scores are not uncommon after a vaginal breech delivery. A pediatrician should be present for the delivery in the event that neonatal resuscitation is needed.
Assisted vaginal breech delivery. The neonate after birth.
Ultrasound demonstrating a fetus in breech presentation with a hyperextended head (ie, "star gazing").

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Author

Philippe H Girerd, MD Associate Professor, Department of Obstetrics and Gynecology, Virginia Commonwealth University, Medical College of Virginia

Philippe H Girerd, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, Association of Professors of Gynecology and Obstetrics, Medical Society of Virginia, AAGL

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

John G Pierce, Jr, MD Chairman of Women’s Health and Medical Specialties, Liberty University College of Osteopathic Medicine; Obstetrician/Gynecologist, Women’s Health of Central Virginia

John G Pierce, Jr, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, Association of Professors of Gynecology and Obstetrics, Christian Medical and Dental Associations, Medical Society of Virginia, Society of Laparoscopic and Robotic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Ronald M Ramus, MD Professor of Obstetrics and Gynecology, Director, Division of Maternal-Fetal Medicine, Virginia Commonwealth University School of Medicine

Ronald M Ramus, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, Medical Society of Virginia, Society for Maternal-Fetal Medicine

Disclosure: Nothing to disclose.

Additional Contributors

Assaad J Sayah, MD, FACEP President and Chief Executive Officer, Cambridge Health Alliance

Assaad J Sayah, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, Massachusetts Medical Society

Disclosure: Nothing to disclose.

Acknowledgements

Andrew D Jenis, MD Chair, Department of Emergency Medicine, Memorial Hospital, York, PA

Andrew D Jenis, MD is a member of the following medical societies: American College of Emergency Physicians and Medical Society of the State of New York

Disclosure: Nothing to disclose.