Breech Presentation

Breech Presentation Aida Owlia and Christina Sun

Objectives • 10588 List strategies for management of abnormal fetal presentations, As well as the relative timing of each intervention

Case A 32 yo G3T2P0A0L2 woman presents for routine prenatal care at 37 weeks. Her pregnancy is complicated by Rh-negative status, depression and a history of LSIL with normal colposcopy in first trimester. Today she reports good fetal movement and denies leaking fluid or contractions. During your examination you measure fundal height at an appropriate 37 cm, and find fetal heart tones located in the upper aspect of the uterus. A bedside ultrasound reveals frank breech presentation.

By the end of this lecture we will… • Review types of breech presentation • Discuss management of breech, antepartum and intrapartum • Review risk factors for breech presentation

Breech Presentation (Definition) • Delivery presentation is the position of the presenting part of the fetus (head, feet, etc.) as it comes down the birth canal • Breech presentation is a deviation from normal cephalic presentation (i.e. baby comes out head first) e.g. buttocks of the fetus enter the pelvis before the head

Main Types of Breech Presentation • Incomplete (10-40%): incomplete flexion of one or both hips, and one or both feet/knee lie below the breech • Complete (5-10%): flexion at both hips and knees • Frank (60%): flexion at both hips, extension at both knees; feet adjacent to fetal head • Most common type of breech presentation • Most common breech presentation to be delivered vaginally

Other Breech Presentations • Footling: incomplete breech with one or both feet below the breech • Kneeling (rare): incomplete breech with one or both knees below the breech

Epidemiology • Common in early pregnancy • Fetus is mobile within a relatively large volume of amniotic fluid • Incidence decreases with increasing GA • < 28 weeks: 20-25% • 32 weeks: 7-16% • Term: 3-4%

Risk Factors • In most pregnancies, breech presentation occurs by chance • < 15% are caused by abnormalities of uterus and/or fetus

Clinical Manifestations • Most women experience no symptoms • Subcostal discomfort • Fetal head occupies uterine fundus instead of the lower uterine segment (LUS) • Feel kicking in upper abdomen in frank breech

Clinical Assessment of Breech • Leopold maneuvers (Breech Presentation) • 1st maneuver: fetal head occupy the fundus • 2nd maneuver: fetal back on one side of the abdomen • 3rd maneuver: if not engaged, breech is movable above the pelvic inlet • 4th maneuver: if engaged, firm breech beneath the pelvic symphysis Leopold maneuvers (Cephalic Presentation)

Clinical Assessment of Breech • Vaginal exam • Incomplete breech: may feel one or both feet first before buttocks • Complete breech: may feel feet beside buttocks • Frank breech: can palpate ischial tuberosities, sacrum, and anus; may observe external genitalia

Imaging • Ultrasound • Confirm presentation and type of breech • Assess fetal growth and estimate weight • Assess degree of fetal neck flexion or extension • Exclude presence of fetal or placental abnormality • CT and MRI • Assess pelvic dimensions and architecture

Management • Vaginal breech births is associated with greater risks of • Prolonged umbilical cord compression • Delivery-related traumas (to both mom and baby) • Conversion to cesarean delivery • Management options • External cephalic version • Vaginal breech delivery • Cesarean breech delivery

External Cephalic Version • Repositioning of fetus within uterus to convert breech to cephalic presentation • Rationale: performed in non-laboring women at or near term to increase likelihood of vaginal birth • Good candidates: low-risk, ≥37 wks • Procedure • Tocolytic to relax uterine and abdominal wall muscles • WinRho to Rh- women • Disengage the breech and manipulate the fetus (optional U/S monitoring) • Consistent fetal heart monitoring Overall success rate: 58%

External Cephalic Version • Risks: reversion, abruption, cord compression, ROM, onset of labor, non-reassuring fetal status • In rare cases, ECV may lead to early labour • Contraindications • Indications for C-section (e.g. placenta previa) • Placental abruption • Oligohydramnios or ruptured membranes • Non-reassuring fetal monitoring test result • Hyperextended fetal head • Significant fetal or uterine anomaly • Multiple gestation

Vaginal Breech delivery • Trial of labour in appropriate obstetrical setting • Good candidates: low-risk mother, term (GA ≥36 wks), singleton, frank or complete breech, spontaneous labour • Additional criteria • EFW 2,500-3,800 g (5.5–8.5 lb) based on clinical and U/S assessment Fetal head flexed • Continuous fetal monitoring • Presence of an experienced obstetricians, an assistant, an anesthetist and individual trained in newborn resuscitation • Ability to perform emergency cesarean section within 30 min if required

Vaginal Breech Delivery • Delivery can be spontaneous or assisted (breech extraction) • Partial breech extraction: fetus is extracted after spontaneous delivery to level of umbilicus • Total breech extraction: entire body of fetus is extracted • In general • Episiotomy • Encourage effective maternal pushing efforts • Breech is delivered spontaneously to umbilicus • At delivery of aftercoming head, assistant applies suprapubic pressure to flex and engage fetal head

Partial Breech Extraction Left sacrum transverse Sacrum anterior Clockwise rotation Gentle downward traction to deliver scapula and arm

Cesarean Delivery • Recommendation for cesarean delivery • Preterm • Dystocia • Cord presentation • Incomplete or footling breech • Large fetus and/or pelvic contraction • Hyperextended fetal head • Uterine dysfunction • Severe fetal growth restrictions • Pervious perinatal death or birth trauma • Lack of experienced provider for vaginal breech delivery

Vaginal vs. Cesarean Delivery • Cesarean delivery is associated with reduction in short-term adverse outcomes (perinatal mortality, serious neonatal morbidity) compared to vaginal delivery • No significant difference in long-term maternal or child morbidity or mortality • SOGC Clinical Practice Guideline • Carefully case selection and labour management in modern obstetrical setting may achieve level of safety similar to elective Cesarean section • Planned vaginal delivery is reasonable in selected women with a term singleton breech fetus • Long-term neurological infant outcomes do not differ by planned mode of delivery

Prognosis • Breech delivery by any mode has increased adverse pregnancy outcomes for both mother and fetus

Case Revisited A 32 yo G3T2P0A0L2 woman presents for routine prenatal care at 37 weeks. Her pregnancy is complicated by Rh-negativestatus, depression and a history of LSILwith normal colposcopy in first trimester. Today she reports good fetal movement and denies leaking fluid or contractions. During your examination you measure fundal height at an appropriate 37 cm, and find fetal heart tones located in the upper aspect of the uterus. A bedside ultrasound reveals frank breech presentation.

Issue #1 : Breech Presentation • Attempt external cephalic version • Follow up with U/S to ensure cephalic presentation is maintained • Refer to obstetrical unit with experience in breech delivery • At labour • If cephalic presentation: proceed with planned delivery (either vaginal or cesarean) • If breeched presentation: attempt vagina delivery with back up cesarean

Issue #2: Follow Up on LSIL

Issue # 3: Isoimmunization • Small risk of fetomaternal bleed with external cephalic version • Potential isoimmunization as mom is Rh- and there is a chance of mixing of maternal and fetal blood • RhoGAM is indicated

Issue #4: Depression and Pregnancy • 10% of women will experience depression during pregnancy • Lifestyle modifications are effective in depression treatment (e.g. exercise, sleep management) • Seeking support plays a crucial role • Depression has implications for interactions of mothers with baby • Post partum depression is exaggerated in an already depressed mother

Breech Presentation