Breech Delivery: 

Background: Fetal buttocks enters pelvis first.  A quick look with the ultrasound transabdominally can confirm Types of Breech:
- Frank - pike position; baby creates a wedge
- Complete
- Variable
- Incomplete
- Footling (single or double) – cord can drop down; no wedging part for dilation 

Risk factors: prematurity, multiparity; multiple gestation     

Steps for Success:
1. Call for help! Notify OB and NICU teams.
2. Collect all equipment as you tend to have some time: 
        a. Use a catheter to empty the bladder: create space!
        b. Prep the perineum
3. Do Nothing – the hardest part - Be patient, allow the patient to push the baby out to the level of the umbilicus
4. Support the baby’s body. DON’T PULL!
5. If required, rotate the baby to make the fetal spine upwards; Hold at the hips 
6. Once the umbilicus is out, sweep the legs out if they do not delivery on their own
        a. Manually flex the knee and bring the thigh out laterally
        b. Repeat with the other side
7. Again, support and do not pull 
        a. Wrap the abdomen in a towel for warmth and grip
8. Wait until at the level of the scapula
        a. Rotate the baby to sweep out the arms; sweep across the face
9. Delivery of the head is more difficult and requires your help
        a. Apply your index and middle fingers to the maxilla
        b. Keep the baby in a flexed position 
        c. Delivery the head in an upward motion (rotate the fetal buttocks upward and towards the mother)

Here is a great video highlight the breech delivery technique using simulation. The first three minutes are helpful to us as emergency physicians: https://www.youtube.com/watch?v=EPklRwlMV1Y