Breech Presentation

Question 1

What is meant by breech position?

Answer 1

occurs when the presenting part of the fetus is the legs / bottom

occurs in < 5% pregnancies at term

this occurs instead of cephalic presentation - in which the head presents first

Question 2

What are the 4 different types of breech position?

Answer 2

• complete / flexed
• incomplete
• Frank / extended
• footling

Question 3

What is meant by a complete breech?

Who is more prone to this?

Answer 3

• both legs are fully flexed at the hips and knees
• more common in a multigravida
• this is because there is less tone in the abdominal muscles, allowing more space for the legs to fall down lower

Question 4

What is meant by an incomplete breech?

Answer 4

• one leg is fully flexed at the hip and knee
• one leg is flexed at the hip and extended at the knee

Question 5

What is meant by an extended / Frank breech?

Who is more prone to this?

Answer 5

• both legs are flexed at the hip and extended at the knee
• this is more common in primigravida women
• they have more tone in their abdominal muscles, which holds the legs in place

Question 6

What is the management for breech babies before 36 weeks?

Answer 6

no intervention

• most babies will turn spontaneously prior to 36 weeks

Question 7

What is the management for breech babies after 36 weeks?

Answer 7

• USS to confirm the breech position
• external cephalic version (ECV) can be used at 37 weeks
• if this fails, women are offered a choice between vaginal delivery and elective C-section

Question 8

What should women who want a vaginal delivery with a breech baby be told about?

Answer 8

• there is around a 40% chance that an emergency C-section may be required when vaginal birth is attempted

overall, vaginal birth is safer for the mother and C-section safer for the baby

Question 9

What is different about management of birth when twins are involved?

Answer 9

if the first baby in a twin pregnancy is breech, caesarean-section is required

Question 10

What is involved in external cephalic version (ECV)?

What is the success rate?

Answer 10

• this is a technique used to attempt to turn the fetus from the breech position to the cephalic position
• gentle pressure is applied to the abdomen to turn the fetus

it is about 50% successful

a CTG must be performed prior to any ECV procedure

Question 11

Who is offered external cephalic version (ECV)?

Answer 11

• after 36 weeks for nulliparous women (who have never given birth before)
• after 37 weeks for women who have given birth before

Question 12

What medication must be given to women prior to external cephalic version (ECV)?

Answer 12

tocolysis with subcutaneous terbutaline

• this is a beta-agonist
• it reduces the contractility of the myometrium, making it easier for the baby to turn

Question 13

What are the complications associated with ECV?

Answer 13

• pain
• transient fetal bradycardia
• feto-maternal haemorrhage
• antepartum haemorrhage (APH) / abruption

Question 14

What is given to some women prior to ECV in case of feto-maternal haemorrhage?

Answer 14

anti-D prophylaxis

• typically 500 IU
• this is given to Rhesus-negative women

Question 15

What monitioring is required during external cephalic version (ECV)?

Answer 15

• CTG should be performed prior to ECV
• continuous US monitoring with a probe on the baby’s heart is performed
• if there is PROLONGED bradycardia, the procedure is stopped
• an emergency C-section is required

transient fetal bradycardia resolves spontaneously and the procedure can continue

Question 16

What are the absolute contraindications to ECV?

Answer 16

• placenta praevia
• uterine malformations
• ruptured membranes
• abnormal CTG / Doppler
• severe pre-eclampsia
• abruption

if there are ruptured membranes, there is not enough space to turn the baby

Question 17

What are the relative contraindications to ECV?

Answer 17

• active labour
• oligohydraminos
• fetal abnormality
• maternal cardiac disease