INTRODUCTION

I. Definition

According to American Pregnancy Association (2015), most babies will move into
delivery position a few weeks prior to birth, with the head moving closer to the birth canal.
When this fails to happen, the baby’s buttocks and/or feet will be positioned to be delivered
first. This is referred to as “breech presentation.” Breech births occur in approximately 1 out
of 25 full-term births. There are three different types of breech birth presentations. In
complete breech, the buttocks are pointing downward with the legs folded at the knees and
feet near the buttocks. In Frank breech, the baby’s buttocks are aimed at the birth canal with
its legs sticking straight up in front of his or her body and the feet near the head. In Footling
breech, one or both of the baby’s feet point downward and will deliver before the rest of the
body. The causes of breech presentations are not fully understood. However, the data show
that breech birth is more common: In subsequent pregnancies, In pregnancies of multiples,
When there is a history of premature delivery, when the uterus has too much or too little
amniotic fluid , when there is an abnormally shaped uterus or a uterus with abnormal
growths, such as fibroids, and with women who have placenta previa.

According to Gray CJ and Shanahan MM (2019), breech presentation refers to the

fetus in the longitudinal lie with the buttocks or lower extremity entering the pelvis first. The
three types of breech presentation include frank breech, complete breech, and incomplete
breech. In a frank breech, the fetus has flexion of both hips, and the legs are straight with
the feet near the fetal face, in a pike position. The complete breech has the fetus sitting with
flexion of both hips and both legs in a tuck position. Finally, the incomplete breech, also
knwon as footling breech can have any combination of one or both hips extended.

As stated by Adele Pilliteri, a breech presentation means either the buttocks or the feet
are the first body parts that will contact the cervix. Breech presentations occur in
approximately 4% of births and are affected by fetal attitude and vertex presentation. Breech
can cause difficult birth, with the presenting point influencing the degree of difficulty. Three
types of breech presentation are possible. Complete breech, the fetus has the thighs tightly
flexed on the abdomen, both the buttocks and the tightly flexed feet present to the cervix. In
frank breech, attitude is moderate because the hips are flexed but the knees are extended to
the rest on the chest. The buttocks alone present to the cervix. In footling breech, neither the
thighs nor the lower legs are flexed. If one-foot presents, it is single-footling, if both present,
it is a double-footling breech.
II. LITERATURE REVIEW AND RELATED STUDIES

Epidemiological Statistics

Breech presentation occurs in 3% to 4% of all term pregnancies and is more common

preterm. According to Gray CJ and Shanahan MM (2019), a higher percentage of breech
presentations occurs with less advanced gestational age. At 32 weeks, 7% of fetuses are
breech, and 28 weeks or less, 25% are breech. Specifically, following one breech delivery,
the recurrence rate for the second pregnancy was nearly 10%, and for a subsequent third
pregnancy, it was 27%. Prior cesarean delivery has also been described by some to
increase the incidence of breech presentation two-fold. Furthermore, it is associated with
uterine and congenital abnormalities, has a significant recurrence risk and is more common
in nulliparous women. Term babies presenting by the breech have worse outcomes than
cephalic ones, irrespective of the mode of delivery. The contributing risk factors for breech
presentation are the following: lax uterus (usually associated with high maternal parity),
uterine anomalies (eg, bicornuate or septate uterus) or tumor, placenta previa, abnormal
pelvic brim, maternal smoking, maternal diabetes, fetal malformation (eg, hydrocephalus),
multiple pregnancy, polyhydramnios or oligohydramnios, low birth weight (preterm delivery
or intrauterine growth restriction) and previous breech delivery. On the other hand,
publication of the Term Breech Trial (TBT) was followed by a large reduction in the incidence
of planned vaginal birth. Nevertheless, vaginal breech births will continue, not merely
because of failure to detect breech presentation and the limitations of ECV, but for reasons
of maternal choice. Lack of experience has led to a loss of skills essential for these
deliveries. Conversely, caesarean section can have serious long‐term consequences.

Ideal Management

According to Gray CJ and Shanahan MM (2019), the current recommendation for the
breech presentation at term includes offering external cephalic version (ECV) to those
patients that meet criteria, and for those whom are not candidates or decline external
cephalic version, a planned cesarean section for delivery sometime after 39 weeks.
Regarding the premature breech, gestational age will determine the mode of delivery. Before
26 weeks, there is a lack of quality clinical evidence to guide mode of delivery. One large
retrospective cohort study recently concluded that from 28 to 31 6/7 weeks, there is a
significant decrease in perinatal morbidity and mortality in a planned cesarean delivery
versus intended vaginal delivery, while there is no difference in perinatal morbidity and
mortality in gestational age 32 to 36 weeks. Of note, due to lack of recruitment, no
prospective clinical trials are examining this issue. At term, the options for management of
breech presentation are external cephalic version; Caesarean section; or vaginal breech
birth. As stated by Alice Reid in Teach Me Obgyn, external cephalic version is the
manipulation of the fetus to a cephalic presentation through the maternal abdomen. This, if
successful, can enable an attempt at vaginal delivery. If the external cephalic version is
unsuccessful, contraindicated, or declined by the woman, current UK guidelines advise an
elective Caesarean delivery. A woman may still choose to aim for a vaginal breech delivery.
Additionally, a small proportion of women with breech presentation present in advanced
labour – with vaginal delivery the only option.

Prognosis

According to Dr. Jacqueline Payne, perinatal mortality is increased with breech

presentation by a factor of between 2 and 4 regardless of the mode of delivery. Deaths are
most often associated with malformations, which are more common in breech presentation,
prematurity and intrauterine fetal demise. Breech presentation is associated with an
increased risk of developmental dysplasia of the hip; an ultrasound of the hips should be
performed in all babies who were breech at 36 weeks irrespective of their presentation at
delivery or the mode of delivery. In the recent study, the risk of recurrent breech delivery is
8%, the risk increasing from 4% after one breech delivery to 28% after three. The effects of
recurrence may be due to recurring specific causal factors, either genetic or environmental in
origin.