Breech presentation refers to a longitudinally lying head-up fetus with its buttocks or feet lying in the pelvis. The incidence of the breech is 25% at 28 weeks or less and 7% at 32 weeks of gestation. This frequency decreases as the pregnancy progresses, with 3-4% of breech cases at term, and most breech babies naturally assume the correct position by 36 weeks.
What are the types?
The three identified types are:
- Frank (50-70% of all breech presentation): Baby’s legs are extended so that fetal feet are close to the face, and the buttocks are the presenting part.
- Footling/Incomplete (10-30%): One or both knees are bent with one or both feet lying lower than the buttocks so that the feet would deliver first.
- Complete (5-10%): Baby’s knees are bent, and the fetal feet and buttocks are the presenting parts.
What are the risk factors involved?
These include:
- Uterine abnormalities: Congenital (septate, bicornuate, or didelphys uterus) and uterine fibroids (submucosal, intramural)
- Previous breech
- Previous cesarean section
- Placenta previa
- Advanced maternal age
- Primiparity
- Multiple gestations
- Prematurity, small for gestation
- Fetal anomalies: Congenital (sacrococcygeal teratoma, goiter), aneuploidies, neuromuscular disorders (akinesia and hypotonia leading to difficulty in changing position)
- Amniotic fluid abnormalities: Polyhydramnios (too much amniotic fluid to stabilize lie), Oligohydramnios (too little amniotic fluid to facilitate movement)
- Lax maternal abdominal wall
- Maternal hip deformities
- Female fetus
- Previous stillbirth/spontaneous abortion
What complications may arise?
The most common complication with breech presentation is an increased risk of a cesarean section which in turn is associated with increased maternal morbidity and mortality.
The associated risk of cord prolapse has also been observed. An estimated 15-18% risk is seen with a footling, 4-6% with a complete breech, and 0.5% with a frank breech.
Additionally, the risk of head/shoulder entrapment, hip dislocation, and fetal distress has been documented, further leading to perinatal morbidity and mortality. Moreover, a 14% risk of hyperkinesis and learning impairment has been seen in children born with breech presentation.
Evaluation
Leopold maneuvers are used to determine intrauterine fetal positioning. The presence of a round hard part (head) at the fundus and the inability to palpate a presenting part in the pelvic region should raise doubt about a breech.
Cervical examination reveals palpation of a foot or buttocks as the presenting part. Diagnosis should be confirmed with an ultrasound.
Management
Maneuvers the mother can do:
Breech tilt exercise (lifting hips above the heart level), pelvic tilt exercise (kneeling forward with to and fro pelvic movements), music and light stimulation, and hot and cold stimuli can be used by the mother. However, no real documented evidence exists to support these.
Management by a physician:
The following treatment options are given:
- The Webster technique – is performed by a chiropractor.
- The external cephalic version (ECV) – is a maneuver performed by an experienced obstetrician, used to turn a breech into a cephalic (head down) presentation by applying per-abdominal pressure. Indications include gestational age of > 36 weeks and no contraindication to vaginal delivery. Most clinicians prefer performing ECV at 37 weeks to reduce the risk of preterm birth. Contraindications to vaginal delivery are considered contraindications to ECV. It has a 50% success rate with no influence of gravidity, the position of the placenta, and tocolytic use on the success. Fetal and Rh status determination, fetal monitoring, and ultrasound availability are required beforehand. Some clinicians prefer tocolytic use, while others choose to perform under spinal/epidural anesthesia. ECV starts with the patient lying on their back and the obstetrician lifting the fetal buttocks out of the pelvis with one hand and applying pressure to the back of the fetal head with the other hand in a forward roll. A backward roll is attempted if a forward roll fails. Intermittent fetal heart rate monitoring is done using ultrasound, and the procedure is stopped in case of fetal bradycardia (heart rate < 120 bpm) or significant patient discomfort. Post-ECV, patient monitoring is done for 30 minutes. Complications, though uncommon, include fetal heart rate abnormalities, emergency C-section, premature rupture of membranes, bleeding, cord prolapse, abruptio placentae, and stillbirth.
- Elective caesarean section – is considered the safest mode of delivery in cases of persistent breech presentation at full-term and is usually scheduled for after 39 weeks of gestation.
- Term breech trial – although associated with adverse outcomes, a trial for vaginal delivery may be given in the following cases: frank or complete breech, >37 weeks gestational age, roomy maternal pelvis, no fetal anomalies, and fetal weight of 2500-4000g.
An insight from mamahood
Breech presentation can be a cause of concern for you, mama, but ECV and elective C-sections effectively reduce the complications and negative birth outcomes associated with a breech baby. Trust your obstetrician to decide the correct management plan for you.
