Breech Presentation

Question 1

Definition of breech presentation

Answer 1

When the presenting part of the foetus (the lowest part) is the legs and bottom

Question 2

Epidemiology of breech presentation

Answer 2

Breech presentation occurs in 3-4% of term deliveries and is more common preterm (suggested 1 in 4 are breech at 28 weeks). It has a significant recurrence risk (10% in second pregnancy then 27%) and is more common in nulliparous women

Question 3

Types of breech

Answer 3

• Complete (full) breech- where the legs are fully flexed at the hips and knees
• Extended (frank) breech- with both legs flexed at the hip and extended at the knee
• Footling breech- where a foot is presenting through the cervix with the leg extended
• Incomplete breech- one leg flexed at the hip and extended at the knee

Question 4

Risk factors for breech delivery

Answer 4

• Maternal- Fibroids, Congenital uterine anomalies e.g bicornuate uterus, placenta praevia, uterine surgery
• Foetal/ placental- Multiple gestation, Prematurity (more likely to change in utero position due to smaller size), placenta praevia, abnormality (anencephaly, hydrocephalus), foetal neuromuscular condition, olig/polyhydramnios

Question 5

Complications of breech presentation

Answer 5

• Umbilical cord prolapse- Major complication- occurs in 1%, compared to 0.5% in cephalic presentation (risk is doubled)
• Foetal head entrapment- may lead to birth asphyxia
• P-PROM
• Intracranial haemorrhage- due to rapid compression of the head during delivery

Question 6

Investigations/presentation of breech presentation

Answer 6

• May be identified by abdominal palpation- foetal head will lie under the costal margin and heartbeat will be above the maternal umbilicus. OR by vaginal examination during labour.

USS:
* If a breech is suspected at or after 36 weeks, it should be confirmed by ultrasound- to confirm diagnosis and identify the type of breech
* Assess the foetal biometry, amniotic fluid volume, placental size and position of foetal legs

In around 20% of breech cases, breech position is not identified until delivery (may present with foetal distress e.g meconium staining)

Question 7

Immediate management of breech presentation

Answer 7

• External cephalic version (ECV) unless there is an absolute contraindication
• ECV should be offered at term from 37+0 weeks, can be offered from 36+0 in nulliparous women

Question 8

What is the success rate of ECV

Answer 8

• The success rate of ECV is approximately 50%
• After an unsuccessful ECV attempt at 36+0 weeks or later, only a few babies will spontaneously turn to cephalic presentation. Few babies revert to breech after successful ECV

Question 9

Benefits and risks of ECV

Answer 9

• Successful ECV reduces the chance of C-Section. However, labour after ECV is associated with a slightly increased rate of C-section and instrumental delivery compared to spontaneous cephalic presentation.
• ECV has a very low complication rate (may include foetal distress, abruption etc.)

Question 10

What are some predictors of a successful ECV

Answer 10

Mulitparity, nonengagement, use of tocolytics, palpable foetal head, maternal weight less than 65Kg, amniotic fluid index >10
* Use of tocolysis with betamimetics improves the success rates of ECV.
* A Routine use of regional analgesia or neuraxial blockade is not recommended, but may be considered for a repeat attempt or for women unable to tolerate ECV without analgesia
* (give betamimetics- salbutamol or terbutaline)

Question 11

Describe the process of ECV

Answer 11

• Introduce, inform consent
• Ensure bladder is empty
• USS used to confirm position of baby (locate foetal poles)
• CTG (monitor HR before + after procedure) or USS used to monitor foetus
• Women are given subcutaneous terbutaline (Beta-agonist) to reduce myometrial contractility (makes it easier for baby to turn)
• Resus- D negative women require anti-D prophylaxis when ECV is performed
• A kleihauer test is used to quantify how much foetal blood is mixed with maternal blood to determine the dose of anti-D required
• No more than 4 attempts are advised, for a maximum of 10 minutes overall
• Although most women tolerate ECV, they should be informed that ECV can be a painful procedure
• Women may wish to consider the use of moxibustion for breech presentation at 33–35 weeks of gestation, under the guidance of a trained practitioner

Question 12

Management for breech presentation after an unsuccessful ECV

Answer 12

• Women should be informed that planned C-section leads to a small reduction in perinatal mortality compared with planned vaginal breech delivery (2-5x reduced risk of perinatal mortality)
• This is due to: Reduced risk of stillbirth after 39 weeks, Reduced intrapartum risk (foetal hypoxia, entrapment etc.)
• The risk of perinatal mortality is approximately 0.5/1000 with caesarean section after 39+0 weeks of gestation; and approximately 2.0/1000 with planned vaginal breech birth. This compares to approximately 1.0/1000 with planned cephalic birth
• Skilled intrapartum care may allow planned vaginal breech birth to be nearly as safe as planned vaginal cephalic birth
• Planned vaginal breech birth increases the risk of low Apgar scores and serious short-term complications, but has not been shown to increase the risk of long-term morbidity.
• Planned caesarean section for breech presentation at term carries a small increase in immediate complications for the mother compared with planned vaginal birth
• However, risk is reduced compared to emergency C-section (which is required in about 40% of cases)
• Need to inform about VBAC etc. Also increases risk of stillbirth slightly in future pregnancies

Question 13

Which circumstaces increase the risk associated with planned vaginal breech birth

Answer 13

• Hyperextended neck on USS
• High estimated foetal weight (more than 3.8Kg) or low estimated weight (< 10th centile)
• Footling presentation
• Evidence of foetal compromise

Question 14

Contraindications for caesarean section in breech presentation

Answer 14

• Women near or in active second stage of labour SHOULD NOT routinely be offered caesarean section

Question 15

What position should women adopt for delivery

Answer 15

• Either a semi recumbent or an all-fours position may be adopted for delivery

Question 16

How should twin pregnnacy with a breech presentation be managed

Answer 16

• Planned caesarean section for a twin pregnancy where the presenting twin is breech is recommended
• HOWEVER, routine emergency c-section for a breech first twin in spontaneous labour is not recommended
• Routine caesarean section for breech presentation of the second twin is not recommended in either term or preterm deliveries
• The second twin is nonvertex at the time of delivery in around 40% of twin pregnancies
• However, the presentation of the second twin at delivery is not always predictable-the chance of cephalic delivery may be improved by routinely guiding the head of the second twin towards the pelvis during and immediately after delivery of the second twin (may also do internal version)

Question 17

Describe the process of vaginal breech delivery

Answer 17

Delivery of the Buttocks:
* Most of the time, full dilatation and descent of the breech will have occurred naturally
* The buttocks will lie in the anterior-posterior diameter
* An episiotomy can be cut once the anterior buttock is delivered and the anus is seen over the fourchette (frenulum of labia minora)

Delivery of the legs and lower body
* If the legs are flexed, they will deliver spontaneously
* If extended, they may need to be delivered with Pinard’s manoeuvre
* This involves using a finger to flex the leg at the knee and extend the hip, first anteriorly then posteriorly
* Maternal effort and contractions help

Delivery of the shoulders
* The baby is initially lying with the shoulders in the transverse diameter of the pelvic mid cavity
* As the anterior shoulder rotates into the anterior-posterior diameter, the spine or the scapula will become visible
* A finger can then be placed gently above the shoulder to help deliver the arm
* As the posterior arm reaches the pelvic floor, it will rotate anteriorly
* Once the spine becomes visible, the second arm will be delivered Loveset’s manoeuvre copies these natural movements, but is unnecessary to do routinely

Delivery of the head
* Delivered using Mauriceau-Smellie-Veit Manoeuvre
* The baby lies on the obstetrician’s arm with downward traction on the head via a finger in the mouth and one on each maxilla
* Delivery occurs with first downward then upward movement
* Forceps may be used if this manoeuvre is difficult

Question 18

Definition of face presentation

Answer 18

An abnormal form of cephalic presentation where the presenting part is the mentum. This typically occurs due to hyperextension of the neck an the occiput touching the foetal back.
* The presenting diameter is the submento-bregmatic which is around 9.5cm in diameter (roughly same dimensions as a normal suboccipito-bregmatic presentation)
* Engagement of the foetal head usually occurs late and progress in labour is usually slow
* A rare presentation- Accounts for approximately 1 in 600 presentations

Question 19

Risk factors for face presentation

Answer 19

• Maternal- preterm delivery, contracted maternal pelvis, multiparity, previous c-section
• Foetal- anencephaly, masses of the neck or loops of cord, macrosomia, polyhydramnios

Question 20

How can face presentation be diagnosed

Answer 20

By palpating the nose, mouth and eyes on vaginal examination

Question 21

Management of face presentation

Answer 21

• Spontaneous vaginal delivery may be possible
• HOWEVER, it is contraindicated if the mentum (chin) is lying posteriorly or in the transverse position
• Mento-anterior= vaginal delivery possible with delivery by flexion
• Mento-posterior= delivery by c-section

Question 22

Definition and management of brow presentation

Answer 22

Occurs when there is less extreme extension of the foetal neck than with face presentation. The presenting part is the area between the anterior fontanelle and the orbital ridges. Considered the rarest presentation (1 in 4000 of all presentations)
* The resenting diameter is mento-vertical (13.5 cm) and is incompatible with vaginal delivery
* Management: if this position persists, C-section is necessary

Question 23

Defintion and management of shoulder presentation

Answer 23

Occurs as a result of transverse or oblique lie of the foetus. Occurs in 1 in 300 pregnancies at term
* Can be caused by: placenta praevia, high parity, pelvic tumour, uterine abnormality
* Delay in diagnosing shoulder presentation could result in cord prolapse and uterine rupture
* Delivery should be done by C-section

Question 24

Definition and management of unstable lie

Answer 24

The frequent changing of foetal lie and presentation in late pregnancy (usually refers to pregnancies over 37 weeks). This is more likely where there is known polyhydramnios, or the woman is multiparous.
* Poses significant risk of cord prolapse
* With transverse, oblique, or unstable lie, elective admission to hospital after 37+0 weeks of gestation should be discussed and women in the community should be advised to present urgently
* Should consider ECV or elective C-section