breech presentation obs and gynae

• Management of breech presentation
• Uncategorized Obstetrics Management of breech presentation

Intrahepatic Cholestasis of Pregnancy / Obstetric Cholestasis

Menopause and hormone replacement therapy, management of breech presentation .

Dr Maheshie Obeysekera Specialist trainee O&G

Table of content

1. breech presentation, 2. term breech trial (tbt), 3. criticism of tbt, 4. patient counselling, 5. ecv-external cephalic version, 6. planned caesarean section, 7. planned breech delivery, 8. unplanned breech presentation in labour, 9. twin pregnancy with breech presentation, 10. recommendation, 11. reference, breech presentation.

Term Breech Trial (TBT)

• Randomised 2088 women to either caesarean section or vaginal birth
• Reduction in perinatal mortality with planned caesarean section (1.3 to 0.3%)
• Reduction in the composite outcome of serious neonatal morbidity
• Failed to identify group for whom morbidity was not increased
• 2 year follow-up (923) – no difference in death or neurodevelopmental delay

Criticism of TBT

• 31% had no ultrasound (exclude extended neck)
• Growth restricted babies included
• Woman randomised in violation of protocol
• 9% – senior obstetrician absent, 13% – any obstetrician absent
• EFM not used in most deliveries and prolonged active stage allowed
• Serious neonatal morbidity included benign outcomes
• Caesarean group delivered at 39/40

Other studies

• Dutch study evaluated effect following TBT
• 58320 babies- mortality reduced from 0.13 to 0.07%
• Perinatal mortality – 0.16% vaginal, 0% caesarean
• Caesarean section – reduced risk of low Apgars and neonatal trauma
• 338 extra caesarean sections for each perinatal death prevented
• 2526 vaginal breech vs 5579 ELLSCS
• Perinatal mortality – 0.12% vaginal, 0.08% caesarean
• No difference in NNU admissions or serious neonatal morbidity
• Increased risk of low Apgars (<7) and fetal injuries

Patient Counselling

• Offer ECV unless contra-indicated
• If unsuccessful or declined – discuss risks and benefits of vaginal breech delivery vs caesarean section
• Inform women of risk of perinatal mortality:
• 0.5/1000 with caesarean section after 39 weeks
• 2.0/1000 with planned vaginal breech birth
• 1.0/1000 with planned cephalic birth.
• Small increase in immediate complications for mother with caesarean sections
• Highest risk is associated with Emergency Caesarean section – needed in 40% of vaginal breech births

• 36/40 in nulliparous, 37/40 multiparous (no upper time limit)
• Low complication rate
• Placental abruption, uterine rupture, fetomaternal haemorrhage
• 5% Emergency caesarean section rate
• No increase in neonatal morbidity or mortality
• Perform in unit with facilities for fetal monitoring and immediate delivery
• Inform patient that may be painful

Planned Caesarean Section

• Small reduction in perinatal mortality
• avoidance of stillbirth after 39 weeks of gestation
• avoidance of intrapartum risks
• Avoidance of risks of vaginal breech birth
• Small increase in immediate complications for the mother
• Increases the risk of complications in future pregnancies
• Small increase in risk of stillbirth for subsequent pregnancies
• Increases risk of low Apgars and serious short term complications
• No increase in long term complications

Planned Breech delivery

• Safety depends on case selection,
• Risk factors for poorer outcomes: Hyperextended neck on ultrasound, High EFW (> 3.8 kg) or low EFW (< tenth centile), Footling presentation, Evidence of antenatal fetal compromise

Intrapartum Management

• Induction of labour not usually recommended
• Delivery in unit with facilities for immediate caesarean
• Augmentation with oxytocin should only be considered if infrequent contractions with an epidural
• Epidural – effect unclear but likely to increase the risk of intervention
• Continuous Electronic fetal monitoring likely to improve neonatal outcomes

Management of the first stage and passive second stage

• Semi recumbent or an all-fours position may be adopted for delivery
• Allow adequate descent of the breech to the perineum in the passive second stage
• If not visible within 2 hours do caesarean section

Active second stage

• Once buttocks passed perineum – significant cord compression
• ‘Hands off’ approach – tactile stimulation of the fetus may result in reflex extension of the arms or head
• Assistance, without traction, is required if there is a delay or evidence of poor fetal condition
• Grasp around pelvic girdle, not soft tissue
• Back should remain anterior – can use gentle rotation
• Once the scapula is visible, the arms can be hooked down by inserting a finger in the elbow and flexing the arms across the chest
• Lovset’s manoeuvre
• Trunk rotated with downward traction so posterior shoulder comes below symphysis pubis. Arm delivered by flexing the shoulder and elbow. Repeated by reverse rotation at 180 degrees to deliver anterior shoulder
• Mauriceau-Smellie-Veit manoeuvre:
• left hand in vagina, palpate the fetal maxilla using the index and middle finger and gently press on the maxilla, bringing the neck to a moderate flexion. The left hand’s palm should rest against the fetus’ chest, while the right hand can grab either shoulder of the fetus and pull in the direction of the fetus’ pelvis
• Suprapubic pressure will aid flexion if there is delay due to an extended neck.
• Bracht manoeuvre: Following spontaneous delivery to the level of the umbilicus, the body is grasped in both hands keeping the legs flexed against the baby’s abdomen and, without traction, is brought up against the symphysis pubis, frequently accompanied by suprapubic pressure

Unplanned breech presentation in labour

• Management depends on stage of labour, presence of risk factors, availability of clinical expertise and informed consent
• If near or in active 2nd stage – should not routinely offer caesarean
• If possible – Ultrasound to assess position of fetal neck and legs + EFW
• Appropriate counselling required

Preterm breech management

• Breech presentation more common
• Studies have shown no significant difference in outcomes
• Caesarean section should not be routinely offered in spontaneous labour or at the threshold of viability (22-25+6)
• Depends on stage of labour, fetal wellbeing and operator skill
• If planned delivery for maternal/fetal compromise – offer caesarean section

Preterm breech – intrapartum management

• Labour should be managed as with a term breech.
• Avoid routine amniotomy
• Trunk may deliver through and incompletely dilated cervix (14%)
• Where there is head entrapment, incisions in the cervix (vaginal birth) or vertical uterine incision extension (caesarean section) may be used

Twin pregnancy with breech presentation

• Recommend caesarean section where presenting twin is breech
• The mode of delivery should be individualised
• Routine Caesarean section is not recommended -If first twin is breech in spontaneous labour or breech presentation of the second twin if first twin is cephalic. The mode of delivery should be individualised based on cervical dilatation, station of the presenting part, type of breech presentation, fetal well being and availability of an operator skilled in vaginal breech delivery
• The chance of cephalic delivery may be improved by guiding the head of the second twin towards the pelvis during and immediately after delivery of the first twin.
• Alternatively delivery of the second twin can be expedited by internal podalic version and breech extraction

Recommendations

• Women should be adequately counselled and give informed consent
• Simulation equipment should be used to rehearse the skills that are needed during vaginal breech birth by all doctors and midwives.
• All obstetricians and midwives should be familiar with the techniques that can be used to assist vaginal breech birth.
• Guidance for the case selection and management of vaginal breech birth should be developed in each department by the healthcare professionals who supervise such births.
• Adherence to the guidelines is recommended to reduce the risk of intrapartum complications.

Related posts

Peri-mortem caesarean section, genital herpes in pregnancy, placenta praevia and placenta accreta.

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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

StatPearls [Internet].

Breech presentation.

Caron J. Gray ; Meaghan M. Shanahan .

Affiliations

Last Update: November 6, 2022 .

• Continuing Education Activity

Breech presentation refers to the fetus in the longitudinal lie with the buttocks or lower extremity entering the pelvis first. The three types of breech presentation include frank breech, complete breech, and incomplete breech. In a frank breech, the fetus has flexion of both hips, and the legs are straight with the feet near the fetal face, in a pike position. This activity reviews the cause and pathophysiology of breech presentation and highlights the role of the interprofessional team in its management.

• Describe the pathophysiology of breech presentation.
• Review the physical exam of a patient with a breech presentation.
• Summarize the treatment options for breech presentation.
• Explain the importance of improving care coordination among interprofessional team members to improve outcomes for patients affected by breech presentation.
• Introduction

Breech presentation refers to the fetus in the longitudinal lie with the buttocks or lower extremity entering the pelvis first. The three types of breech presentation include frank breech, complete breech, and incomplete breech. In a frank breech, the fetus has flexion of both hips, and the legs are straight with the feet near the fetal face, in a pike position. The complete breech has the fetus sitting with flexion of both hips and both legs in a tuck position. Finally, the incomplete breech can have any combination of one or both hips extended, also known as footling (one leg extended) breech, or double footling breech (both legs extended). [1] [2] [3]

Clinical conditions associated with breech presentation include those that may increase or decrease fetal motility, or affect the vertical polarity of the uterine cavity. Prematurity, multiple gestations, aneuploidies, congenital anomalies, Mullerian anomalies, uterine leiomyoma, and placental polarity as in placenta previa are most commonly associated with a breech presentation.  Also, a previous history of breech presentation at term increases the risk of repeat breech presentation at term in subsequent pregnancies. [4] [5] These are discussed in more detail in the pathophysiology section.

• Epidemiology

Breech presentation occurs in 3% to 4% of all term pregnancies. A higher percentage of breech presentations occurs with less advanced gestational age. At 32 weeks, 7% of fetuses are breech, and 28 weeks or less, 25% are breech.

Specifically, following one breech delivery, the recurrence rate for the second pregnancy was nearly 10%, and for a subsequent third pregnancy, it was 27%. Prior cesarean delivery has also been described by some to increase the incidence of breech presentation two-fold.

• Pathophysiology

As mentioned previously, the most common clinical conditions or disease processes that result in the breech presentation are those that affect fetal motility or the vertical polarity of the uterine cavity. [6] [7]

Conditions that change the vertical polarity or the uterine cavity, or affect the ease or ability of the fetus to turn into the vertex presentation in the third trimester include:

• Mullerian anomalies: Septate uterus, bicornuate uterus, and didelphys uterus 
• Placentation: Placenta previa as the placenta is occupying the inferior portion of the uterine cavity. Therefore, the presenting part cannot engage
• Uterine leiomyoma: Mainly larger myomas located in the lower uterine segment, often intramural or submucosal, that prevent engagement of the presenting part.
• Prematurity
• Aneuploidies and fetal neuromuscular disorders commonly cause hypotonia of the fetus, inability to move effectively
• Congenital anomalies:  Fetal sacrococcygeal teratoma, fetal thyroid goiter
• Polyhydramnios: Fetus is often in unstable lie, unable to engage
• Oligohydramnios: Fetus is unable to turn to vertex due to lack of fluid
• Laxity of the maternal abdominal wall: Uterus falls forward, the fetus is unable to engage in the pelvis.

The risk of cord prolapse varies depending on the type of breech. Incomplete or footling breech carries the highest risk of cord prolapse at 15% to 18%, while complete breech is lower at 4% to 6%, and frank breech is uncommon at 0.5%.

• History and Physical

During the physical exam, using the Leopold maneuvers, palpation of a hard, round, mobile structure at the fundus and the inability to palpate a presenting part in the lower abdomen superior to the pubic bone or the engaged breech in the same area, should raise suspicion of a breech presentation.

During a cervical exam, findings may include the lack of a palpable presenting part, palpation of a lower extremity, usually a foot, or for the engaged breech, palpation of the soft tissue of the fetal buttocks may be noted. If the patient has been laboring, caution is warranted as the soft tissue of the fetal buttocks may be interpreted as caput of the fetal vertex.

Any of these findings should raise suspicion and ultrasound should be performed.

Diagnosis of a breech presentation can be accomplished through abdominal exam using the Leopold maneuvers in combination with the cervical exam. Ultrasound should confirm the diagnosis.

On ultrasound, the fetal lie and presenting part should be visualized and documented. If breech presentation is diagnosed, specific information including the specific type of breech, the degree of flexion of the fetal head, estimated fetal weight, amniotic fluid volume, placental location, and fetal anatomy review (if not already done previously) should be documented.

• Treatment / Management

Expertise in the delivery of the vaginal breech baby is becoming less common due to fewer vaginal breech deliveries being offered throughout the United States and in most industrialized countries. The Term Breech Trial (TBT), a well-designed, multicenter, international, randomized controlled trial published in 2000 compared planned vaginal delivery to planned cesarean delivery for the term breech infant. The investigators reported that delivery by planned cesarean resulted in significantly lower perinatal mortality, neonatal mortality, and serious neonatal morbidity. Also, there was no significant difference in maternal morbidity or mortality between the two groups. Since that time, the rate of term breech infants delivered by planned cesarean has increased dramatically. Follow-up studies to the TBT have been published looking at maternal morbidity and outcomes of the children at two years. Although these reports did not show any significant difference in the risk of death and neurodevelopmental, these studies were felt to be underpowered. [8] [9] [10] [11]

Since the TBT, many authors since have argued that there are still some specific situations that vaginal breech delivery is a potential, safe alternative to planned cesarean. Many smaller retrospective studies have reported no difference in neonatal morbidity or mortality using these specific criteria.

The initial criteria used in these reports were similar: gestational age greater than 37 weeks, frank or complete breech presentation, no fetal anomalies on ultrasound examination, adequate maternal pelvis, and estimated fetal weight between 2500 g and 4000 g. In addition, the protocol presented by one report required documentation of fetal head flexion and adequate amniotic fluid volume, defined as a 3-cm vertical pocket. Oxytocin induction or augmentation was not offered, and strict criteria were established for normal labor progress. CT pelvimetry did determine an adequate maternal pelvis.

Despite debate on both sides, the current recommendation for the breech presentation at term includes offering external cephalic version (ECV) to those patients that meet criteria, and for those whom are not candidates or decline external cephalic version, a planned cesarean section for delivery sometime after 39 weeks.

Regarding the premature breech, gestational age will determine the mode of delivery. Before 26 weeks, there is a lack of quality clinical evidence to guide mode of delivery. One large retrospective cohort study recently concluded that from 28 to 31 6/7 weeks, there is a significant decrease in perinatal morbidity and mortality in a planned cesarean delivery versus intended vaginal delivery, while there is no difference in perinatal morbidity and mortality in gestational age 32 to 36 weeks. Of note, due to lack of recruitment, no prospective clinical trials are examining this issue.

• Differential Diagnosis
• Face and brow presentation
• Fetal anomalies
• Fetal death
• Grand multiparity
• Multiple pregnancies
• Oligohydramnios
• Pelvis Anatomy
• Preterm labor
• Primigravida
• Uterine anomalies
• Pearls and Other Issues

In light of the decrease in planned vaginal breech deliveries, thus the decrease in expertise in managing this clinical scenario, it is prudent that policies requiring simulation and instruction in the delivery technique for vaginal breech birth are established to care for the emergency breech vaginal delivery.

• Enhancing Healthcare Team Outcomes

A breech delivery is usually managed by an obstetrician, labor and delivery nurse, anesthesiologist and a neonatologist. The ultimate decison rests on the obstetrician. To prevent complications, today cesarean sections are performed and experienced with vaginal deliveries of breech presentation is limited. For healthcare workers including the midwife who has no experience with a breech delivery, it is vital to communicate with an obstetrician, otherwise one risks litigation if complications arise during delivery. [12] [13] [14]

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Disclosure: Caron Gray declares no relevant financial relationships with ineligible companies.

Disclosure: Meaghan Shanahan declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Gray CJ, Shanahan MM. Breech Presentation. [Updated 2022 Nov 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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Similar articles in PubMed

• [What effect does leg position in breech presentation have on mode of delivery and early neonatal morbidity?]. [Z Geburtshilfe Neonatol. 1997] [What effect does leg position in breech presentation have on mode of delivery and early neonatal morbidity?]. Krause M, Fischer T, Feige A. Z Geburtshilfe Neonatol. 1997 Jul-Aug; 201(4):128-35.
• The effect of intra-uterine breech position on postnatal motor functions of the lower limbs. [Early Hum Dev. 1993] The effect of intra-uterine breech position on postnatal motor functions of the lower limbs. Sival DA, Prechtl HF, Sonder GH, Touwen BC. Early Hum Dev. 1993 Mar; 32(2-3):161-76.
• The influence of the fetal leg position on the outcome in vaginally intended deliveries out of breech presentation at term - A FRABAT prospective cohort study. [PLoS One. 2019] The influence of the fetal leg position on the outcome in vaginally intended deliveries out of breech presentation at term - A FRABAT prospective cohort study. Jennewein L, Allert R, Möllmann CJ, Paul B, Kielland-Kaisen U, Raimann FJ, Brüggmann D, Louwen F. PLoS One. 2019; 14(12):e0225546. Epub 2019 Dec 2.
• Review Breech vaginal delivery at or near term. [Semin Perinatol. 2003] Review Breech vaginal delivery at or near term. Tunde-Byass MO, Hannah ME. Semin Perinatol. 2003 Feb; 27(1):34-45.
• Review [Breech Presentation: CNGOF Guidelines for Clinical Practice - Epidemiology, Risk Factors and Complications]. [Gynecol Obstet Fertil Senol. 2...] Review [Breech Presentation: CNGOF Guidelines for Clinical Practice - Epidemiology, Risk Factors and Complications]. Mattuizzi A. Gynecol Obstet Fertil Senol. 2020 Jan; 48(1):70-80. Epub 2019 Nov 1.

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When viewing this topic in a different language, you may notice some differences in the way the content is structured, but it still reflects the latest evidence-based guidance.

Breech presentation

• Overview  
• Theory  
• Diagnosis  
• Management  
• Follow up  
• Resources  

Breech presentation refers to the baby presenting for delivery with the buttocks or feet first rather than head.

Associated with increased morbidity and mortality for the mother in terms of emergency cesarean section and placenta previa; and for the baby in terms of preterm birth, small fetal size, congenital anomalies, and perinatal mortality.

Incidence decreases as pregnancy progresses and by term occurs in 3% to 4% of singleton term pregnancies.

Treatment options include external cephalic version to increase the likelihood of vaginal birth or a planned cesarean section, the optimal gestation being 37 and 39 weeks, respectively.

Planned cesarean section is considered the safest form of delivery for infants with a persisting breech presentation at term.

Breech presentation in pregnancy occurs when a baby presents with the buttocks or feet rather than the head first (cephalic presentation) and is associated with increased morbidity and mortality for both the mother and the baby. [1] Cunningham F, Gant N, Leveno K, et al. Williams obstetrics. 21st ed. New York: McGraw-Hill; 1997. [2] Kish K, Collea JV. Malpresentation and cord prolapse. In: DeCherney AH, Nathan L, eds. Current obstetric and gynecologic diagnosis and treatment. New York: McGraw-Hill Professional; 2002. There is good current evidence regarding effective management of breech presentation in late pregnancy using external cephalic version and/or planned cesarean section.

History and exam

Key diagnostic factors.

• buttocks or feet as the presenting part
• fetal head under costal margin
• fetal heartbeat above the maternal umbilicus

Other diagnostic factors

• subcostal tenderness
• pelvic or bladder pain

Risk factors

• premature fetus
• small for gestational age fetus
• nulliparity
• fetal congenital anomalies
• previous breech delivery
• uterine abnormalities
• abnormal amniotic fluid volume
• placental abnormalities
• female fetus

Diagnostic investigations

1st investigations to order.

• transabdominal/transvaginal ultrasound

Treatment algorithm

<37 weeks' gestation, ≥37 weeks' gestation not in labor, ≥37 weeks' gestation in labor: no imminent delivery, ≥37 weeks' gestation in labor: imminent delivery, contributors, natasha nassar, phd.

Associate Professor

Menzies Centre for Health Policy

Sydney School of Public Health

University of Sydney

Disclosures

NN has received salary support from Australian National Health and a Medical Research Council Career Development Fellowship; she is an author of a number of references cited in this topic.

Christine L. Roberts, MBBS, FAFPHM, DrPH

Research Director

Clinical and Population Health Division

Perinatal Medicine Group

Kolling Institute of Medical Research

CLR declares that she has no competing interests.

Jonathan Morris, MBChB, FRANZCOG, PhD

Professor of Obstetrics and Gynaecology and Head of Department

JM declares that he has no competing interests.

Peer reviewers

John w. bachman, md.

Consultant in Family Medicine

Department of Family Medicine

Mayo Clinic

JWB declares that he has no competing interests.

Rhona Hughes, MBChB

Lead Obstetrician

Lothian Simpson Centre for Reproductive Health

The Royal Infirmary

RH declares that she has no competing interests.

Brian Peat, MD

Director of Obstetrics

Women's and Children's Hospital

North Adelaide

South Australia

BP declares that he has no competing interests.

Lelia Duley, MBChB

Professor of Obstetric Epidemiology

University of Leeds

Bradford Institute of Health Research

Temple Bank House

Bradford Royal Infirmary

LD declares that she has no competing interests.

Justus Hofmeyr, MD

Head of the Department of Obstetrics and Gynaecology

East London Private Hospital

East London

South Africa

JH is an author of a number of references cited in this topic.

Differentials

• Transverse lie
• Antenatal corticosteroids to reduce neonatal morbidity and mortality
• Caesarean birth

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• Mammary Glands
• Fallopian Tubes
• Supporting Ligaments
• Reproductive System
• Gametogenesis
• Placental Development
• Maternal Adaptations
• Menstrual Cycle
• Antenatal Care
• Small for Gestational Age
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• Breech Presentation
• Abnormal lie, Malpresentation and Malposition
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• Introduction to Infertility
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• Female Genital Mutilation
• Barrier Contraception
• Combined Hormonal
• Progesterone Only Hormonal
• Intrauterine System & Device
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• Obstetric History
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• Sexual History
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Postpartum Endometritis

Retained Products of Conception

Postpartum Anaemia

Postnatal Depression

Postpartum Thyroiditis

Sheehan's Syndrome

RCOG World Congress 2024

#RCOG2024 offers global doctors working in women’s health unique opportunities including networking and collaboration with colleagues, learning from global experts and meeting old friends. Secure your discounted place by Monday 15 July!

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Latest at the RCOG

Gynaecology waiting times

As part of our project to address the long waits faced by those waiting for planned gynaecology services, we would like to hear from women and people with lived experience and health professionals working across the NHS.

RCOG stories

Share the latest developments in women's health at #RCOG2024, make new connections with global colleagues and discover innovative research through thousands of unique abstracts. Book your discounted place Monday 15 July and take advantage of our early bird offer.

We are delighted to introduce our newly revised O&G Curriculum 2024 and are preparing to transition to the new curriculum in August 2024 (GMC approved).

The RCOG aims to inspire and promote excellence in women’s healthcare, supporting research and clinical practice across the world. Discover a range of opportunities for individuals at all career stages and apply for a prestigious award by Thursday 23 May .

This annual conference is a must-attend for O&G trainees, offering a unique opportunity for learning, networking and inspiration.

Our helpful bite-size videos series has been designed to provide potential candidates with key information about the MRCOG exam and what you can expect.

Our internationally accredited training programmes are designed to empower healthcare professionals, enhancing their knowledge and skills and setting the gold standard in women's health.

The RCOG highly values the diverse expertise of our membership and other stakeholders to help shape the future direction of its work. Find out more about volunteering with us and the opportunities that are currently available.

RCOG events and courses