Breech Presentation

• ↑ perinatal mortality (3-5x)/ morbidity
• Maternal morbidity b/c ↑ operative delivery
• Buttocks/feet occupy the pelvic brim
• Breech presentation occurs in 3-4% at term
• 25% of births prior to 28 weeks' gestation to 7% of births at 32 weeks' gestation.

Defined by the attitude of limbs at the hip and knee joint

• Frank breech (50-70%) - Hips flexed, knees extended –more in primigravida
• Complete breech (5-10%) - Hips flexed, knees flexed
• Footling breech (10-30%) - One or both hips extended, foot presenting

Fetal factors:

• Prematurity
• Multiple pregnancy
• Fetal abnormalities e.g. CNS malformations like anencephaly, hydropcephalus
• Neck tumors

Uterine factors:

• Uterine malformations e.g. bicornuate
• Fibroids
• Uterine surgery
• Oligo- or polyhydramnios
• Placental position e.g. cornual implantation, placenta previa.

• Usually no major feature
• Some clues on previous history and abdominal examination

Clinical findings of a hard ballotable head in the upper segment of the uterus with the soft round buttock in the lower uterine pole.

Ultrasonography is very important. Diagnosis is confirmed with the ultrasound scan, which may also show the presence of other associated abnormalities such as placenta previa, abnormal liquor volume, fetal anomalies and/or pelvic tumors.

• Assisted vaginal delivery
• External cephalic version
• Elective caesarean section

• This is the most common type of vaginal breech delivery.
• Leave the fetal membranes intact as long as possible
• An anesthesiologist and pediatrician should be present for all vaginal breech deliveries.
• Assistance offered at particular points during delivery
• Complications occur when assistance is not timed or baby not handled properly.

Factors that favor ABD

• Average size baby (2.5-3.5kg)
• Adequate pelvis (anthropoid/gynecoid pelvis)
• Good obstetric performance previously
• Spontaneous labor
• Skilled obstetrician
• Flexed fetal head
• Positive mental attitude of mother

Factors against vaginal breech delivery

• Large or small baby
• Small pelvis on pelvimetry or very flat sacrum
• Primigravid
• Previous cesarean section
• Poor obstetric history
• Long history of subferitlity/assisted conception
• Advanced maternal age
• Extended neck

Mechanism of labor

• Buttocks
• Shoulder
• Head at Brim, Midcavity, Outlet

Points of assistance

• Episiotomy
• Delivery of extended legs
• Pull down the cord
• Delivery of shoulder
• Lovset’s manouver when the arms are extended
• Delivery of after coming head
• Forceps- piper’s forcep
• Mauriceau-Smellie-Veit Technique
• Burns-Marshall Method

Risks of vaginal breech deliveries

• Fetal head entrapment: incompletely dilated cervix and head that lacks time to mold to the maternal pelvis.
• Sudden uncontrolled delivery of the head may lead to intracranial hemorrhage
• Difficulty in delivering the shoulders may lead to damage to the brachial plexus
• Prolapse of the umbilical cord especially in footling breech.

• Manipulation via anterior abdominal wall of breech presenting baby into cephalic presentation
• Usually done at term.
• Should only be done where facilities for EMCS is available.

Risks of ECV

• Uncommon
• Fetal bradycardia
• Precipitation of labor or premature rupture of membranes
• Abruptio placentae
• Fetomaternal hemorrhage (0-5%)
• Cord accident (<1.5%)
• Rhesus isoimmunisation
• Uterine trauma
• Severe maternal discomfort

Contraindications to ECV

• Placenta previa
• Oligo- or polyhydraminous
• History of antepartum hemorrhage
• Previous cesarean section or myomectomy scar on the uterus
• Multiple gestation
• Pre-eclampsia or hypertension
• Plan to deliver by cesarean section anyway!

Complications

• Perinatal asphyxia
• Fractures of long bones
• Intracranial hemorrhage
• Blunt trauma to intra-abdominal organs
• Head entrapment.
• Brachial nerve injury; palsies
• Klumpke’s palsy: C8 and T1 nerves injury, usually associated with breech. Paralysis of intrinsic hand muscles. Patient present with a ‘claw hand’.
• Erb’s palsy: C5, C6, ± C7, commoner with shoulder dystocia. Muscles of the shoulder and arm are affected. The shoulder is adducted and internally rotated (waiter’s tip position).
• Cervical spine injury

Conclusions

Vaginal breech delivery requires an experienced obstetrician and careful selection and counselling for the couple.

Parents must be informed about potential risks and benefits to the mother and neonate for both vaginal breech delivery and cesarean delivery.

ECV is a safe alternative to vaginal breech delivery or cesarean delivery, and can help reduce caesarean section rate but patients must be carefully selected.

▶ Videos: Breech Presentation and Birth