Breech presentation by DR THENMOLEE SUBRAMONIE

• The definition of breech presentation is when the buttocks, foot or feet are presenting instead of the head

classifications• Frank breech where the hips are flexed and

legs extended• Complete breech where the hips and knees

are flexed and the feet are not below the level of the fetal buttocks

• Footling breech where one or both feet are presenting as the lowest part of the fetus

Associations and Causes

Maternal factors

• Polyhydraminos• Uterine anomalies (bicornuate, septate)• Space occupying lesions (e.g fibroids)• Placental abnormalities (praevia, cornual)• Multiparity (in particular grand multips)

Fetal factors

• Prematurity• Fetal anomalies (e.g neurological,

hydrocephalus, anenecephaly)• Multiple pregnancy• Fetal death• Short umbilical cord

• The incidence of breech presentation decreases from about 20% at 28 weeks of gestation to 3–4% at term, as most babies turn spontaneously to the cephalic presentation

What information should be given to women with breech presentation regarding mode of

delivery?

Term Breech Trial 2000

• trials with 2396 participant• Caesarean delivery 1060/1169 (91%) of those

women allocated to planned caesarean section

• 550/1227 (45%) of allocated to a vaginal delivery protocol

• Perinatal or neonatal death(excluding fatal anomalies) or short-term neonatal morbidity was reduced with a policy of planned CS(RR 0.33, 95% CI 0.19–0.56) and perinatal or neonatal death alone (excluding fatal anomalies) was reduced with a policy of planned caesarean section (RR 0.29, 95% CI 0.10–0.86)

• After excluding ,perinatal mortality, neonatal mortality or serious neonatal morbidity with planned caesarean section compared with planned vaginal birth was 16/1006 (1.6%) compared with 23/704 (3.3%) (RR 0.49; CI 0.26–0.91); P = 0.02).

adverse perinatal outcome was lowest with prelabour caesarean section and increased with caesarean section in labour

• In the latter study, of the 2526 women with planned vaginal deliveries, 1796 delivered vaginally (71%)

• The rate of neonatal morbidity or death was considerably lower than the 5% in the Term Breech Trial (1.60%; 95% CI 1.14–2.17), and not significantly different from the planned caesarean section group

• death or neurodevelopmental delayat age 2 years, was similar between the two groups.

Summary of TBT

• lower rates of perinatal and neonatal death • lower rates of short term neonatal morbidity

or perinatal death • fewer 5 minutes Apgar scores <7 • lower risk of adverse perinatal outcomes • small increase in the short term maternal

morbidity

What factors affect the safety of vaginal breech delivery

should be assessed

carefully before selection for vaginal breech birth

unfavourable for vaginal breech birth

• ● other contraindications to vaginal birth (e.g. placenta praevia, compromised fetal condition)

• ● clinically inadequate pelvis• ● footling or kneeling breech presentation• ● large baby (usually defined as larger than 3800 g)• ● growth-restricted baby (usually defined as smaller than 2000 g)• ● Hyperextended fetal neck in labour (diagnosed with ultrasound or X-ray

where ultrasound is not available)• ● lack of presence of a clinician trained in vaginal breech delivery• ● previous caesarean section.

Intrapartum management

• should take place in a hospital with facilities for emergency caesarean section

• Labour induction for breech presentation may be considered if individual circumstances are favourable

• Labour augmentation is not recommended

• Epidural analgesia should not be routinely advised; women should have a choice of analgesia during breech labour and birth.

• Continous electronic fetal heart rate monitoring should be offered to women with a breech presentation in labour.

• Fetal blood sampling from the buttocks during labour is not advised.

• Caesarean section should be considered if there is delay in the descent of the breech at any stage in the second stage of labour.

• Episiotomy should be performed when indicated to facilitate delivery.

• Three types of vaginal breech deliveries

Spontaneous breech delivery

Assisted breech delivery

Total breech extraction

Total breech extraction

• only with 2nd non vextex twin delivery

• procedure in which the infant's feet are grasped by the operator and the fetus is extracted from the uterine cavity through the vagina.

ECV

• External cephalic version (ECV) is the transabdominal manual rotation of the fetus into a cephalic presentation.

• after ECV successful rate 35-86%

• breech presentation at term, after ECV 1 - 1.5%• indications for urgent caesarean after ECV 1 - 3%• The risk of intrauterine death of foetus after ECV

is about 0.0001%

contraindication to ECV• preterm• Multiple pregnancy• significant third trimester bleeding • IUGR,• oligohydramnion• PROM• PIH• nonreassuring foetal monitoring patterns • all contraindications to vaginal birth are concerned to

execute ECV

Risk of ECV

• umbilical cord entanglement• abruptio placenta• premature rupture of the membranes (PROM)• severe maternal discomfort

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