Breech presentation

• Breech presentation is a type of malpresentation and occurs when the fetal head lies over the uterine fundus and fetal buttocks or feet present over the maternal pelvis
• Breech presentation is most commonly idiopathic.
• Types:

  • Complete (flexed) - one or both knees are flexed
  • Footling (incomplete) - one or both feet present below the fetal buttocks, with hips and knees extended
  • Frank (extended) - both hips flexed and both knees extended. Babies born in frank breech are more likely to have development dysplasia of the hip
• Risk factors:

  • Maternal: multiparity, fibroids, previous breech presentation
  • Fetal: preterm, macrosomia, fetal structural abnormalities, multiple pregnancy
  • Placental: placenta praevia, polyhydramnios, oligohydramnios, amniotic bands
• Before 36 weeks, breech presentation is not significant - fetus is likely to revert to cephalic presentation

  Breech presentation more common in preterm labour
• Clinical findings:

  • Longitudinal lie
  • Head palpated at the fundus
  • Irregular mass over pelvis (feet, leg and buttocks)
  • Fetal heart auscultated higher on maternal abdomen
  • Palpation of feet or sacrum at the cervical os during examination
• There are three management options for breech presentation at term, with consideration of maternal choice: external cephalic version, vaginal delivery and Caesarean section.
• External cephalic version:

  • Manual rotation of the fetus into a cephalic presentation by applying pressure to the maternal abdomen under ultrasound guidance
  • Entonox and subcutaneous terbutaline are used to relax the uterus (beta agonist)
  • Should be offered to nulliparous women at 36 weeks and multiparous women at 37 weeks gestation
• Contraindications for ECV:

  • Ruptured membranes
  • Antepartum haemorrhage
  • Previous caesarean section
  • Major uterine abnormality
  • Multiple pregnancy
  • Abnormal CTG
• Vaginal delivery:

  • Carries risks - head entrapment, birth asphyxia, intracranial haemorrhage, perinatal mortality, cord prolapse
  • Preference is to deliver the baby without traction and with an anterior sacrum during delivery to decrease the risk of fetal head entrapment
  • Mother may be offered an epidural, as vaginal breech delivery can be very painful
• Contraindications for vaginal delivery:

  • Footling breech - head and trunk more likely to be trapped if the feet pass through the dilated cervix too soon
  • Macrosomia or growth restricted baby
  • Other complications of vaginal birth - placenta praevia, fetal compromise
  • Previous caesarean section
• Caesarean section:

  • Caesarean section booked as an elective procedure at term is the most common management for breach presentation
  • Preferred for preterm babies and is used if the external cephalic version is unsuccessful
  • Fewer risks than vaginal delivery
• Fetal complications of breech presentation include:

  • Developmental dysplasia of the hip (DDH)
  • Cord prolapse
  • Fetal head entrapment
  • Birth asphyxia
  • Intracranial haemorrhage
  • Perinatal mortality
• Complications of external cephalic version include:

  • Transient fetal heart abnormalities (common)
  • Fetomaternal haemorrhage
  • Placental abruption (rare)