Alhadi Araibi
Alkhadra Hospital
BREECH PRESENTATION
What you need to know about
Breech Presentation
 What is Breech Presentation?
 Types of Breech Presentation
 Importance of Breech Presentation
 Causes of Breech Presentation
 Diagnosis of Breech Presentation
 Management Options
What is Breech Presentation?
Breech Presentation is a fetus in a longitudinal
lie with the buttocks or feet closest to the
cervix.
Cephalic presentation is the best fit
presentation
Incidence :
 3-4% at term.
 22% at 28 weeks and 7% at 32 weeks.
Types of Breech Presentation
 Frank Breech
50-70%
Flexed Hips,
extended knees
(pike position)
Types of Breech Presentation
 Complete Breech
5-10%
Flexed Hips
Flexed Knees
(cannonball
position)
Types of Breech Presentation
 Incomplete
(Footling)
10-30%
One or both hips
extended
Foot presenting
Importance of Breech
Presentation
 May indicate Pathology/Abnormality
 See causes/predisposing factors.
 Affect Perinatal Mortality and Morbidity
 Perinatal mortality is increased 2- 4 folds with breech
presentation regardless of the mode of delivery.
 Affect mode of delivery
 Perinatal mortality and neonatal morbidity are
significantly lower in planned cesarean section than in
planned vaginal delivery (5% vs 1.6%).
Causes of Breech Presentation
Fetal
Maternal
 Idiopathic
 Idiopathic
 Fetal abnormality (CNS)
 Pre-term labour
 Oligo- polyhydramnios
 Placenta previa/ Corneal pl
 Fetal growth restriction
 Uterine abnormalities
 Short umbilical cord
 Contracted pelvis
 Extended legs
 Maternal anticonvulsants
 Multiple pregnancy
 Maternal substance abuse
Diagnosis of Breech Presentation
 Clinical Examination
 Abdominal Palpation;
Hard round ballotable structure at the fundus.
The fetal heart commonly heard above the umbilicus.
 Vaginal Examination;
 Soft compressible structures.
 Fetal ischial tuberosites, anus, genitalia & foot may
provide a landmarks.
 ~ 30% of breech presentation are not diagnosed
until labour.
 Ultrasound scan
Management Options
 Term Breech
 Pre-term Breech
 Second Twin Breech
Management Options of Term Breech
 Spontaneous Version
 External Cephalic Version
 Elective Cesarean Section vs. Vaginal
Delivery
Management Options of Term Breech
Spontaneous Version
•It is less frequent as third trimester progress (<25%).
•More likely in multiparous.
•Less likely in nulliparous and breech with extended legs.
Promotion of Spontaneous Version
•Full Bladder.
•Knee-Chest position 10 minutes everyday.
• Pelvis elevation, thighs abduction and relaxed
breathing.
All the above techniques are harmless, worth trying
but can’t be recommended in the absence of supporting
evidence.
Management Options of Term Breech
External Cephalic Version (ECV)
• ECV is the transabdominal manual rotation of the fetus into
a cephalic presentation.
• Every 100 ECV attempt prevent 34 breech births and 14
cesarean sections.
• Success rate 50-60%.
• Higher success rate with:
― Multiparous
― Flexed head and knees
―Use of tocolytics
―Use of regional anesthesia
External Cephalic Version (ECV)
 Prerequisites
 More than 36 weeks gestation.
 Ultrasound, to confirm breech, enough liquor &
out rule contraindication.
 CTG pre & post ECV.
 Facilities to perform emergency cesarean section.
 Informed consent for the procedure & possible
cesarean section.
 Patient fasting more than 6 hours.
 Anti D for Rh negative women.
External Cephalic Version
(ECV)
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Absolute
Contraindications
Relative
Contraindications
Multiple pregnancy.
Antepartum hemorrhage.
Placenta previa.
Ruptured membranes.
Fetal Anomalies.
Deflexed head.
Other indications for
cesarean section.
 Previous cesarean section.
 IUGR.
 Severe preeclampsia.
 Rhesus Isoimmunization.
 Obesity.
 Macrosomia .
Management Options of Term Breech
Elective Cesarean Section
 Elective cesarean section should be offered to all
singleton term breech and planned Vaginal
delivery may no longer be appropriate, based on
Hannah et al multicentre randomised clinical trial 2001.
 The perinatal mortalities and neonatal
morbidities were significantly lower in planned
cesarean section than in planned vaginal
delivery. (5% vs 1.6%)
Management Options of Term Breech
Elective Cesarean Section
 Prerequisites
 Informed consent
 At 39 weeks
 Ultrasound pre section to out rule:
 spontaneous cephalic version.
 Intrauterine fetal death.
 Congenital anomalies uncompatible with life.
Management Options of Term Breech
Planned Vaginal Delivery
 Vaginal breech delivery was the norm until 1959
 Prerequisites
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Out rule contraindications.
Informed consent.
Facilities where emergency cesarean section can be done.
Experience with vaginal breech delivery.
Continuous monitoring.
Augmentation of labour is controversial.
Low threshold for cesarean section.
Management Options of Term Breech
Planned Vaginal Delivery
Types of Vaginal breech delivery:
 Spontaneous breech delivery: No tractions or
manipulations.
 Assisted breech delivery: The infant is allowed to
deliver spontaneously up to the umbilicus, then
maneuvers are initiated to assist in the delivery of the
remainder of the body, arms & head (Pinard, Lovset &
Mauriceau Smellie maneuvers).
 Breech extraction: Fetal feet are grasped, the
entire fetus is extracted. Only for second twin.
Management Options of Term Breech
Planned Vaginal Delivery
Benefits
 Reduction in the risk of
newborn Idiopathic
Pulmonary Hypertension.
 Less maternal morbidity
and mortality than
cesarean section.
Risks
 Cord prolapse .
 Nuchal arms → brachial plexus
injuries
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Cervical spine injury.
Rupture of internal organs.
Bone fracture.
Low apgar score at 1 min.
Intracranial hemorrhage.
Difficult birth experience.
Management Options of Term Breech
Planned Vaginal Delivery
Contraindications of Vaginal breech delivery:
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Other indications for cesarean section.
Compromised fetal condition.
Footling & Complete breech.
Estimated fetal weight ≥ 4kg.
Hyperextended head.
Previous cesarean section.
Lack of experience.
Management Options
Pre-term Breech
 Not an indication for cesarean section. No data.
 Prematurity is the main concern regardless of
the mode of delivery.
 Individualized approach regarding mode of
delivery & parent’s wishes should be considered
Management Options
Second-twin Breech
 Breech extraction
 Internal podalic version