Breech presentation

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DEFINITION
Breech presentation is defined as a fetus in a longitudinal lie with
the buttocks or feet closest to the cervix.

Introduction
3-4% of all deliveries.
The occurrence of breech presentation decreases with
advancing gestational age as most cases undergo
spontaneous cephalic version up to term
7% at 32 weeks
25% at 28 week
3-4% of foetus present by breech at term
Higher rate of developmental delay is seen in foetuses who
present as breech

Aetiology
In general, the foetus is adapted to the pyriform shape of the uterus with
the larger buttock in the fundus and smaller head in lower uterine segment
Any factor interfere with this adaptation, allows free mobility or prevents
spontaneous version.
They are:Maternal

Hydromnios (polyhydromnios,
oligohydromnios)
Uterine abnormalities
( abnormal
shape/didelphys/malformation
/ fibroids)
Abnormal placentation (PP)
Pelvic tumour
Abnormal shape of the pelvic
brim
Grand multipara

Fetal

Multifetal pregnancy
Prematurity (relatively small
foetus -7% at 32 weeks, 25%
at 28 week)
Fetal abnormalities
(anencephaly, hydrocephalus,
neck masses)

Position

Left sacro-anterior.
Right sacro-anterior.
Right sacro-posterior.
Left sacro-posterior.

Left and right sacro- transverse

(lateral).
Direct sacro-anterior and
posterior.
** Sacro anterior position are
common than sacro posterior

Diagnosis
Examination:-

Palpation

Longitudinal lie
Firm lower pole
Hard globular mass at the fundus

Auscultation

Fetal heart is best heard above the

umbilicus. However in case of frank,
FHS may be heard at or below the
umbilicus

Vaginal
examination

No head in the pelvis.

Soft buttocks felt.
Feet may be in the pelvis
The 3 bony landmarks of breech namely
2 ischial tuberosities and tip of the
sacrum.
Fresh meconium may be found on the
examining fingers.
Male genitalia may be felt.

Ultrasonography:

To confirm the diagnosis.

To detect the type of breech.
To detect gestational age and foetal weight: To exclude
hyperextension of the head.
To exclude congenital anomalies.
Diagnosis of unsuspected twins.

Clinical pathway of breech

presentation
Breech
detected

Health facility
without specialist

<32 week

- Confirm the
gestational age
- Review in 2
weeks
-if breech persist,
refer

32 34 week

- Confirm with
USG
- Exclude fetal
abnormalities and
placenta previa

Hospital with
specialist
28 36 weeks

Counsel patient on
options
-ECV >36 week
- Breech vaginal
delivery in no
contraindication
ELSC >37 week

External cephalic version (ECV)

Women with breech delivery should be informed regarding external cephalic

version (ECV) What is ECV ( manipulation of the foetus through the maternal abdomen to a
cephalic presentation)
ECV lower the chances of having caesarean section
Offered from 36 weeks in nulliparous, 37 week in multiparous
50% successful rate
ECV will be performed where facilities for monitoring and immediate delivery are
available.
In event of failed ECV inform the benefits and the risks for both the current and
future pregnancies,
Other available approaches : planned caesarean section Vs. planned vaginal
delivery for breech presentation at term ( perinatal mortality and morbidity is
reduced with ELSCS)

Contraindication
Absolute
Indication for caesarean section (ex:
rupture uterus, inadequate materal
pelvis, macrosomic baby)
Antepartum haemorrhage within last
7 days
Abnormal cardiotocography
Major uterine anomalies
Ruptured membrane
Multifetal pregnancy

Relative
Small for gestational age with
adnormal dopplers parameters
Pre-eclampsia
Oligohydromnios
Major fetal anomalies
Scarred uterus
Unstable lie

Breech
delivery
The essence of the vaginal breech delivery is
allowing as much spontaneous delivery by uterine
action and maternal effort as possible

Preparation and care in labour

IOL is not recommended
Clinical pelvic examination is done to ensure adequacy for vaginal delivery
Continous electronic fetal monitoring during first and second stage
In the absence of adequate progress in labour, Caesarean section is advised.
Augmentation is avoided.
Permit second stage without active pushing till the breech descends well into
the true pelvis
Active pushing at 2nd stage in delivering the fetus should not exceed 60
minutes.
Planned breech delivery is allowed in centres which have facilities for operative
delivery, neonatal resuscitation and can provide adequate obstetrics analgesia

Contraindications
History

- Mature primgravida >35 years

- Subfertility or recurrent miscarriage
- Medical disorder in current pregnancy
Previous obstetrics - Previous caesarean section
- Poor perinatal outcome (early neonatal death)
performance
- Macrosomia (> 3.8kg)
Examination
- Polyhydromnios
- Clinacally inadequate pelvis
- Footling/ kneeling breech ( risk of cord prolapse)
USG findings
- Hyperextended fetal neck (risk for cervical spine
injury)
- Placenta previa
- Estimated fetal weight <2.5 kg/ > 3.8 kg (local practice)

Breech delivery
1. Consider lithotomy position.
2. Delivery of the breech should be
hands off.Legs and abdomen are
born spontaneously.
3. Ensure that the fetal back rotates
uppermost by carefully grasping the
fetal pelvis with fingers & thumbs.Leg
delivery may need knee flexion by
pressure in popliteal fossa

4. The fetus should be allowed to

hang once the legs and
abdomen have emerged until
the
wings of the scapula are
seen.
5. Grasp the fetus around the
bony pelvis with the thumbs
across the sacrum.
6. The fetal back should then be
turned through 180 degrees
until the posterior arm comes
to lie anteriorly

7. The elbow will appear below

the symphysis pubis and the
arm is delivered by sweeping
it across the fetal body.
8. The manoeuvre is repeated in
reverse to deliver the other
arm.
9. Allow the fetus to hang from
the vulva until the nape of
the neck is visible.
10.Then carry out MauriceauSmellie-Veit manoeuvre

References

http://emedicine.medscape.com/article/262159-overview
http://sogc.org/wp-content/uploads/2013/01/gui226CPG0906.pdf
Obstetrics Illustrated, Kevin P. Hanretty
Obstetrics todays
Clinical protocol in obstetrics & gynaecology
Slides from multiple lectures
youtube