BREECH PRESENTATION 

Breech presentation is when the fetal head fails to occupy the birth canal - instead, the buttocks and legs are positioned to be delivered first. 

25% of pregnancies at 28 weeks are breech BUT the majority of cases correct spontaneously.

3% pregnancies are breech at term. 

Frank breech: hips flexed and knees fully extended (most common presentation)

Complete (flexed) breech – both legs are flexed at the hips and knees, fetus appears to be sitting crossed-legged

Footling breech: one or both feet come first with the bottom at a higher position (rare presentation but carries higher perinatal morbidity risk)

Risk Factors

Uterine 

• Uterine malformations

• Fibroids

• Placenta praevia

Fetal 

• Polyhydramnios or oligohydramnios

• Fetal abnormality (e.g. chromosomal disorders)

• Prematurity (due to increased incidence earlier in gestation)

Complications

• Cord prolapse

• PROM

• Birth asphyxia – usually secondary to delay in delivery

• Fetal head entrapment

• Intracranial haemorrhage – as a result of rapid compression of the head during delivery

Examination 

• Breech usually detected on palpation of maternal abdomen. 

• On auscultation: fetal heart is heard higher up 

• In 1/5 of cases it may present at labour

  • • Signs of fetal distress eg. meconium-stained liquor 

    • On vaginal examination, the sacrum or foot may be felt 

Investigation 

Confirmed by ultrasound 

• • • Confirms type of breech 

    • May indicate underlying cause of breech 

Management

• If < 36 weeks: majority of fetuses will turn spontaneously

• >36 weeks NICE then recommend external cephalic version (ECV)* - this has a success rate of around 50%. 

  • • offered from 36 weeks in nulliparous women 

    • offered from 37 weeks in multiparous women

• If unsuccessful then an elective caesarean section is recommended (carries reduced perinatal mortality and neonatal morbidity risk compared to vaginal delivery)

• Vaginal delivery may be carried out if the woman chooses. 

  • • May be only option if labour is too advanced

    • Contraindicated in footling breech 

*External cephalic version is the manipulation of the fetus to a cephalic presentation through the maternal abdomen, in order to allow a normal vaginal delivery. 

RCOG absolute contraindications to ECV:

• Where caesarean delivery is required

• Antepartum haemorrhage within the last 7 days

• Ruptured membranes

• Multiple pregnancy

• Abnormal cardiotocography

• Major uterine abnormalities