Breech presentation

Published on 09/03/2015 by admin

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Chapter 34 Breech presentation

Incidence. There is an increase in incidence with decreasing gestation. At 20–25 weeks gestation, 30%–40% of fetuses are breech, and at 32 weeks gestation the incidence is 15%, while at term 2%–4% of fetuses are in the breech presentation.

Types

• frank/extended at knee: 65% of breech presentations

• complete/flexed at knee: 10% of breech presentations

• footling: 25% of breech presentations

Risk factors

Fetal and maternal risk factors are listed in Table 34.1.

Table 34.1 Risk factors for breech presentation

Fetal	Maternal
Prematurity	Past history
Multiple pregnancy	Primigravida
Abnormality	Uterine abnormalities
Intrauterine fetal death	Pelvic tumour
Raised or lowered amniotic fluid volume	Contracted pelvis
Placenta praevia	Drugs: anticonvulsants, drugs of abuse
Reduced growth or activity	Idiopathic

External cephalic version

Spontaneous changes in fetal polarity are reduced with increasing gestation. The likelihood of spontaneous version at 32 weeks is about 55%, compared with 25% at 36 weeks. The risks of external cephalic version include tocolytic side effects, placental abruption, cord accidents and premature labour.

The absolute contraindications to external cephalic version include multiple pregnancy, antepartum haemorrhage, placenta praevia, rupture of membranes, labour and fetal abnormalities. Relative contraindications include previous caesarean section, intrauterine growth restriction (IUGR) and oligohydramnios. Tocolysis improves success of external version. Anti-D is required in women who are Rhesus-negative. The success rate is 50%–90%, but there appears to be no significant decrease in overall caesarean section rates.

Management of breech presentation

Diagnosis

• Perform a clinical examination.

• If remote from term, document and observe.

• If after 36 weeks gestation, perform an ultrasound scan to confirm diagnosis; assess fetal anatomy, position of legs and estimated weight; assess amniotic fluid volume.

Term Breech Trial

This randomised multicentre trial compared the policy of elective caesarean section with vaginal birth for selected breech deliveries. The results were:

• no difference in maternal morbidity or mortality in both treatment arms

• statistically significant increase in perinatal/neonatal morbidity in planned vaginal birth group compared with elective caesarean section

The best method of delivering breech singleton is the planned caesarean section.

Delivery of the breech presentation diagnosed in late labour

• The common method is assisted breech delivery.

• Lithotomy position: clean the perineum and drape.

• Catheterise the bladder.

• Employ analgesia.

• Perform episiotomy.

Breech born by maternal expulsive efforts up to the umbilicus

After the knees have delivered, flex the knees by pressing on the popliteal fossa to deliver the legs. Place a warm cloth over the breech and with the next contraction place hands on the baby’s pelvis and pull down towards the floor until the anterior shoulder is delivered. The anterior arm is delivered by hooking a finger onto the cubital fossa and pulling the arm down over the baby’s abdomen.

Lovset’s manoeuvre

Rotating the posterior shoulder to the anterior allows the other arm to be delivered in the same manner as the first. The head is delivered by various ways, including forceps, the Mauriceau-Smellie-Veit manoeuvre, the Wigand-Martin manoeuvre of suprapubic pressure and lateral rotation of head in pelvis, or the Bracht manoeuvre of grasping feet and placing the body onto the maternal abdomen with the symphysis acting as fulcrum.

Possible hazards in vaginal delivery

• occipital bone trauma during vaginal breech delivery from the impact on the maternal pubis

• intra/periventricular injury, secondary haemorrhage or ischaemia (avoiding vaginal delivery does not necessarily prevent intracranial haemorrhage)

• bruising resulting in jaundice

• trauma to internal organs, with the accoucheur placing hands over the baby’s abdomen rather than the pelvis

• entrapment of the head, especially in the woman who commences active pushing before the second stage or with a footling breech

Preterm breech presentation

• If not in labour, there is no benefit from external version prior to 37 weeks gestation.

• Term Breech Trial findings may not be applicable to preterm.

• Studies published are all retrospective, and individual decision making is therefore appropriate.

• They are mostly handled by caesarean section.

Further reading

Hannah ME, Hannah WJ, Hewson SA et al (for the Term Breech Trial Collaborative Group) 2000 Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicenter trial. Lancet 356:1375-1383

Hofmeyr G.J., Kulier R. External cephalic version for breech presentation at term. Cochrane Database of Systematic Reviews. 1996. Issue 1. Art. No.: CD000083. DOI: 10.1002/14651858

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