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Breech presentation occurs when a fetus lies with buttocks or feet positioned downwards in the uterus, often requiring careful management. There are three main types: Frank breech (65-70%), Complete breech (30%), and Footling breech (10%). The likelihood of breech decreases with gestational age. At term, external cephalic version (ECV) is recommended unless contraindicated, potentially lowering the risk of cesarean delivery. In cases of persistent breech, planned delivery options should be discussed, considering maternal wishes and available evidence for vaginal delivery. Effective intrapartum management is crucial for positive outcomes.
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Breech Presentation Dr Madhavi Kalidindi Consultant Obstetrician & Gynaecologist Barking, Havering and Redbridge University Hospitals NHS Trust
Breech Presentation • Breech presentation is when a fetus is in a longitudinal lie with the buttocks or feet present in the lower uterine segment. • Most common malpresentation.
Three types of breech Frank or extended breech: 65 to 70% Complete or flexed breech: 30% Footling breech: 10% • Legs are flexed at the hips and extended at the knees. • Presenting part: Buttocks • One or both feet or knees present below the fetal buttocks. • Hips and knees are flexed. • Presenting part: Buttocks and feet
Incidence • Incidence of breech presentation decreases with gestation as spontaneous version happens. • 20% at 28 weeks of gestation • 16% at 32 weeks • 3-4% at term • Hence, breech is more common in preterm labours.
Risk factors for persistent breech presentation Maternal conditions Fetal conditions Preterm delivery Polyhydramnios Oligohydramnios Fetal macrosomia Multiple pregnancy Fetal anomalies • Multiparity • Congenital uterine anomalies • Uterine fibroids • Previous breech presentation • Placenta previa or cornual placenta • Cephalo-pelvic disproportion
Case A 30 year old, para one woman at 36 weeks gestation attends antenatal clinic appointment after a scan confirming a frank breech presentation with normal liquor. She had a previous normal vaginal delivery and is otherwise low risk. How would you manage her care?
Management of Breech at term • Offer external cephalic version (ECV) • Women with a breech presentation at term should be offered external cephalic version (ECV) unless there is an absolute contraindication. • a successful ECV reduces the chance of caesarean section. • External Cephalic Version and Reducing the Incidence of Term Breech Presentation • ManagementofBreechPresentation Green-top Guidelines No. 20a & 20b 2017
ECV declined/unsuccessful/ persistent breech at term • Offer planned vaginal breech delivery or planned caesarean section and counsel on the risks and benefits. • ManagementofBreechPresentation Green-top Guideline No. 20b 2017
Vaginal breech delivery Vs Caesarean section Consider woman’s wishes Consider all of the favourable factors for vaginal breech delivery Consider current evidence & guidelines Document the discussion and plan
Appropriate case selection Healthy, normally grown fetus in frank / complete breech with flexed head Skilled practitioners Adherence to strict protocols Team work and effective communication Successful vaginal breech delivery with no adverse outcomes A committed mother
Second stage management • Delay active pushing until the breech has descended to the pelvic floor. • Episiotomy should be performed when indicated to facilitate delivery. • Avoid handling the breech or the umbilical cord. • Breech extraction should not be used routinely, as it causes extension of the arms and head.
Post delivery Cord bloods for blood gases Accurate documentation Debrief parents and staff
