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Definition
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The fetus lies longitudinally with the buttocks presenting in the lower pole of the uterus.
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- Frank breech: buttocks present first with flexed hips and legs extended on the abdomen
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- Complete breech: buttocks present first with flexed hips and flexed knees
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- Footling breech: one or both feet present as neither hips or knees are fully flexed.Feet are palpated lower than the buttocks
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Incidence
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- 3-4% of pregnancies present as breech at term (15% at 29-32 weeks)
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- Breech presentation is a normal finding in preterm pregnancies, when the fetus is more mobile, and should not be considered abnormal until late pregnancy.
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- 25% of breech presentations will still undergo spontaneous version after 35 weeks gestation. Such changes occur with decreasing frequency as gestational age advances.
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Associations and Causes
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Maternal factors
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- Uterine anomalies (bicornuate, septate)
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- space occupying lesions (e.g fibroids)
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- Placental abnormalities (praevia, cornual)
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- contracted maternal pelvis
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- Multiparity (in particular grand multips)
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Fetal factors
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- fetal anomalies (e.g neurological, hydrocephalus, anenecephaly)
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Diagnosis
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Suspect clinically:
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- abdominal palpation: if presenting part is irregular and not "ballotable", or if head ballotable at fundus of uterus
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- pelvic examination: head not felt in pelvis (buttocks and or feet may be felt)
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- very thick meconium present after ROM
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- cord prolapse abnormal CTG
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- fetal heart heard higher in abdomen
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Ultrasound scan will confirm diagnosis.
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Management
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Preterm (< 37 weeks)
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Antenatal
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- Breech presentation is a normal finding in the preterm pregnancy. No further management in the uncomplicated pregnancy is required until 37 completed weeks of pregnancy are reached.
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- If elective preterm delivery is indicated the mode of delivery will be dictated by clinical circumstances. Eg if the indication is for severe pre eclampsia then caesarean section would be the most appropriate mode, if however the indication was for fetal death in utero or lethal fetal anomaly, then induction of labour and vaginal delivery may be appropriate.
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In Labour
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- The optimal mode of delivery for preterm breech has not been fully evaluated in clinical trials and the relative risks for the preterm infant and mother remain unclear. Overall, decisions regarding mode of delivery will need to be made on an individual basis however with the evidence available to us at this time, Royal Women's Hospital recommended practice is to perform emergency caesarean section for any woman presenting in preterm labour with breech presentation except where;
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 | - vaginal delivery is imminent
| - The medical circumstances are such that survival (and least morbidity) of the fetus is assessed to be unchanged by mode of delivery (eg extremely premature infants-24-25 weeks, or lethal condition) and/or the maternal morbidity of caesarean section is judged to be too great for the relative potential fetal disadvantages.
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Term (< 37 completed weeks gestation)
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Antenatal (not in labour)
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Ultrasound (elective) to confirm diagnosis and exclude possible causative factors (eg polyhydraminos, low lying placenta, fetal anomaly).
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| Options for care
| - External Cephalic Version (ECV)
| | The current evidence would suggest that ECV where there are no contraindications, will reduce the number of breech (noncephalic) presentations in labour and the number of caesarean sections for breech presentation with no increase in the perinatal fetal or maternal morbidity1 (ECV CPG in development)
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| - Elective caesarean section
| | The Term Breech Trial found that compared to vaginal birth, planned caesarean section was associated with lower rates of perinatal and neonatal death, lower rates of short term neonatal morbidity or perinatal death and fewer 5 minutes Apgar scores <7. There was a small increase in the short term maternal morbidity and planned caesarean section decreased the opportunity for spontaneous version, although prelabour caesarean section was associated with a lower risk of adverse perinatal outcomes.There was no difference in outcome between the 2 groups at 2 year followup. The advantage therefore in a policy of planned elective caesarean section for breech presentation at term is to decrease the short term perinatal and neonatal morbidity and mortality.2
| It is recommended practice at the Royal Women's H ospital to offer women with breech presentation at term ECV (CPG in development). If this is unsuccessful or the woman declines ECV, elective caesarean section should be booked for 39 weeks gestation.
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In labour
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Vaginal breech delivery:
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- confirm with ultrasound (RTS on labour ward)
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- review history (risk factors such as placenta praevia, twins) full examination (including vaginal speculum and/or digital)
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- continuous CTG monitoring until delivery
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- if delivery not imminent, caesarean section to be arranged
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Vaginal delivery should only be undertaken where:
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- senior medical, anaesthetics, paediatric and midwifery staff have been called to attend
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- there is no absolute contraindication to vaginal birth (eg placenta praevia)
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NB. Current formatting does not permit an acceptible print version.
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| Types of breech presentation.
| | Breech with extended legs (frank)
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| | Breech with flexed legs (complete)
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| | The breech is presenting as a right sacroanterior.
The Bitrochanteric diameter of the buttocks has entered the pelvis in the transverse diameter of the pelvic brim.
With full dilatation of the cervix, the buttocks descend deeply into the pelvis.
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| | When the buttocks reach the pelvic floor, the pelvic 'gutter' causes the buttocks to rotate internally so that the bitrochanteric diameter lies in the anteroposterior diameter of the pelvic outlet.
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| | The anterior buttock appears at the vulva. With further uterine contractions the buttocks distend the vaginal outlet.
Lateral flexion of the fetal trunk takes place and the shoulders rotate so that they may enter the pelvis.
At this stage the attending doctor or nurse-midwife has donned gown and gloves and is prepared to aid the delivery.
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| | If the buttocks make no advance during the next several contractions, an episiotomy is made and the buttocks are born by groin traction.
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| | The buttocks have been born and the shoulders have entered the pelvis in its transverse diameter.
This causes the external rotation of the buttocks so that the fetal back becomes uppermost.
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| | If the fetus has extended legs, the attendant may have to slip a hand along the anterior leg of the fetus and deliver it by flexion and abduction, so that the rest of the birth may proceed.
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| | The fetal shoulders have reached the pelvic 'gutter' and have rotated internally so that the bisacromial diameter lies in the anteroposterior diameter of the outlet.
Simultaneously, the buttocks have rotated anterioraly through 90o. The fetal head is now entering the pelvic brim, its sagittal suture lying in the brim's transverse diameter.
Descent into the pelvis occurs with flexion of the fetal head.
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| | The baby has been born to beyond its umbilicus.
A loop of umbilical cord is pulled down to make sure that it is not holding back the birth.
Gentle traction downwards and backwards is made by the attendant, so that the anterior shoulder and arm are born.
The baby is now lifted upwards in a circle so that the posterior shoulder and arm may be born.Sometimes one arm is extended and has to be dislodged downwards.
The procedure requires skill otherwise a fractured clavicle or humerus may result.
Once the anterior arm has been born, the baby's body and the posterior arm are freed in a similar manner.
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| | (a) The baby hangs unsupported from the mother's vulva. The doctor applies slight suprapubic pressure to encourage further flexion of the head. When the nape of the baby's neck has appeared, the attendant holds the baby by the feet and swings it upwards through an arc.
(b) This manoeuvre, by using the lower border of the sacrum, pulls the head down and rotates it through the pelvic outlet so that the chin, nose and forehead appear
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| | An alternative is to deliver the fetal head by forceps.
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Diagrams and accompanying text gratefully used with the permission of Professor Jeremy Oats and Professor Suzanne Abraham.
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References
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1. Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willlan AR. Planned caesarean section versus vaginal birth from: Breech presentation at term: a randomised multicentre trial. Term Breech trial Collaborative group. Lancet 2000; 356 (9239): 1375-83.
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2. Hofmeyr GJ, Kulier R. External cephalic version for breech presentation at term. The Cochrane Database of Systematic Reviews 1996, Issue 1. Art. No.: CD000083.
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3. Jeremy Oats and Suzanne Abraham, Llewellyn-Jones Fundamentals of Obstetrics and Gynaecology 8th Edition, Elsevier Mosby, Edinburgh 2005: 168-171
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Royal Women's Hospital Clinical Practice Guidelines (CPGs) are intended to provide guidance to health care professionals, based on a thorough evaluation of research evidence, on the practical assessment and management of specific clinical issues or situations. The guidelines allow some flexibility on the part of the health care professional based on the needs of the specific patient for whom they are caring.
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