Clinical Communications: OB/GYN A NOVEL TECHNIQUE FOR A DIFFICULT BREECH DELIVERY Danielle E. Hart, MD,* Ben Dolan, BA,† and Robert F. Reardon, MD* *Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota and †Michigan State Medical School, East Lansing, Michigan Reprint Address: Danielle E. Hart, MD, Department of Emergency Medicine, Hennepin County Medical Center, 701 Park Avenue South, R-2 Skyway, Minneapolis, MN 55415 , Abstract—Background: Breech presentation and deliv- ery are important complications of labor and delivery, which, although dealt with by the emergency physician infrequently, can represent major morbidity and mortality to both the mother and fetus if techniques are not performed correctly. Objectives: We aim to describe a technique for breech delivery that was used successfully when all conven- tional techniques had failed. To our knowledge, this technique has not been described in previous literature. Case Report: A 36-year-old woman presented to an urban emergency department in active labor. The physicians were called to the triage area, and found the patient lying on the floor with a limp, cyanotic-appearing fetus delivered to the level of the mid thorax. The arms and shoulders were delivered successfully, but after all traditional maneuvers to deliver the head were unsuccessful, a novel approach was used successfully and is described in this report. Conclusion: We have described a novel, seemingly safe, and effective technique to use in breech delivery when traditional tech- niques have failed. Ó 2012 Elsevier Inc. , Keywords—breech; delivery; labor; obstetrics; obste- trical INTRODUCTION Breech presentation and delivery are important complica- tions of labor and delivery, and there are techniques and basic principles for breech delivery with which all emer- gency physicians should be familiar. We had a case in which these traditional techniques were unsuccessful, and aim to describe a successful and safe technique for breech delivery that, to our knowledge, has not been described in previous literature. CASE REPORT A 36-year-old woman presented to an urban emergency department in active labor at 37 weeks gestation. The physicians were called to the triage area, where she was found lying adjacent to the entryway with a partially de- livered limp and cyanotic breech fetus, spontaneously delivered to the level of the mid thorax. The posterior arm and both shoulders were easily delivered by an emergency physician, after which the child was in an occiput-anterior position. Several attempts were made to deliver the head, utilizing multiple maneuvers, includ- ing the Mauriceau maneuver (two fingers placed on infant’s maxilla with subsequent flexion of fetal head), McRoberts positioning (hyperflexion of maternal hips and knees to straighten the lumbosacral lordosis and pel- vic outlet, more commonly used in shoulder dystocia), suprapubic pressure (posterior pressure exerted just above the pubic symphysis), and an episiotomy, all without success. The fetus was becoming progressively more blue, and had no signs of life and no palpable brachial or cord pulse. Only 3 min had passed, so the on-call obstetrician who had been immediately paged when the patient arrived was not yet present. Due to the urgency of the situation and the lack of forceps or other equipment, a novel technique was RECEIVED: 11 July 2011; FINAL SUBMISSION RECEIVED: 22 August 2011; ACCEPTED: 22 January 2012 e325 The Journal of Emergency Medicine, Vol. 43, No. 5, pp. e325–e326, 2012 Copyright Ó 2012 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter doi:10.1016/j.jemermed.2012.01.056