SIM Session (Dr. Restivo):
- Breech delivery
- 2nd stage of labor is concerning- umbilical cord gets compressed –> acidosis
- Only 60 minutes before acidosis sets in on the baby
- Variations of breech presentation
- Frank Breech (hips flexed; legs extended at knees)- most common
- Incomplete Breech (one of baby’s knees bent; foot and bottom are closest to birthing canal)
- Complete Breech (baby’s legs are folded flat up against his head; bottom is at birthing canal)
- Management of breech delivery:
- Allow mother to do all the pushing
- Do NOT use oxytocin or prostaglandins
- Do NOT apply traction (can cause fetal head to be hyperextended or fetal arms to disengage making it harder to deliver)
- Allow baby to be delivered until umbilicus
- If legs are still trapped (frank or complete breech), perform a Pinard maneuver
- If legs are still trapped (frank or complete breech), perform a Pinard maneuver
- Feel for pulsation of umbilicus and pull out a small portion of the cord to decrease tension
- Wrap a dry towel around fetal pelvis (NOT abdomen to prevent squeezing the adrenals)
- At this point, fetus should be rotated face down
- Next step: delivery of head
- Do NOT apply traction
- Keep the head and neck in a flexed position
- Have an assistant perform the Bracht maneuver
- Once hairline is noticed, operator’s hand should cover vulva while other hand is placed below to receive the fetal face
- Some obstetricians recommend Mauriceau-Smellie-Veit Maneuver
- Fetus rests on forearm
- Index/middle fingers apply pressure to the maxillary prominences
- Do NOT pull on maxilla as it may cause TMJ dislocation
- Baby can be pulled up and out, over maternal abdomen
- Avoid an angle greater than 45 degrees above the horizontal (to avoid hyperextension of the cervical spine)
- What if the head is entrapped?
- Duhrssen’s Incision
- Incision at cervix at 5 and 7 o’clock or 2 and 8 o’clock
- Uterine relaxants
- Terbutaline 0.25mg SQ or 2.5-10mcg/min IV
- Nitroglycerin 50-200mcg IV
- Zavanelli maneuver (last ditch)
- Replace child back into uterus for emergent C-section
- No consensus but can give tocolytic agents (ex: Terbutaline or Nifedipine) to facilitate
- Duhrssen’s Incision
- Allow mother to do all the pushing
- Further reading on complicated deliveries at EMDocs
Cadaver Lab (Cricothyroidotomy):
- When should I do one?
- Can’t Intubate, Can’t Ventilate
- Are there any contraindications?
- Children < 10 years old
- More prone to laryngeal trauma
- Needle cricothyroidotomy preferred
- Trauma that renders cricothyroid membrane impractical
- Children < 10 years old
- Anatomy
- Extend neck in supine position: “Laryngeal handshake”
- Use non-dominant hand to stabilize the thyroid cartilage
- Use dominant hand to hold scalpel and rest hand on patient’s sternum
- ~4cm vertical incision through skin over cricothyroid membrane
- Palpate cricothyroid membrane and blunt dissect with fingers/back end of scalpel until membrane is readily identifiable
- Can have assistant help manage bleeding using suction
- Horizontal incision through membrane, 180 degree turn and horizontal incision other direction to ensure wide enough
- Use pinky finger of nondominant hand to palpate tracheal lumen (may feel tracheal ring)
- Pass bougie using dominant hand alongside pinky finger into trachea
- Bougie can usually advance ~10cm from the skin (until it is at carina)
- Introduce 6.0 ETT or trach over bougie
- Make sure balloon is fully deflated
- Twist ETT as it passes over skin
- Advance until balloon is within trachea
- Inflate balloon and confirm placement
- Watch a video on Bougie Guided Cricothyroidotomy
