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Breech Presentation. Dr Madhavi Kalidindi Consultant Obstetrician & Gynaecologist Barking, Havering and Redbridge University Hospitals NHS Trust. Breech Presentation. Breech presentation is when a fetus is in a longitudinal lie with the buttocks or feet present in the lower uterine segment.
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Breech Presentation Dr Madhavi Kalidindi Consultant Obstetrician & Gynaecologist Barking, Havering and Redbridge University Hospitals NHS Trust
Breech Presentation • Breech presentation is when a fetus is in a longitudinal lie with the buttocks or feet present in the lower uterine segment. • Most common malpresentation.
Three types of breech Frank or extended breech: 65 to 70% Complete or flexed breech: 30% Footling breech: 10% • Legs are flexed at the hips and extended at the knees. • Presenting part: Buttocks • One or both feet or knees present below the fetal buttocks. • Hips and knees are flexed. • Presenting part: Buttocks and feet
Incidence • Incidence of breech presentation decreases with gestation as spontaneous version happens. • 20% at 28 weeks of gestation • 16% at 32 weeks • 3-4% at term • Hence, breech is more common in preterm labours.
Risk factors for persistent breech presentation Maternal conditions Fetal conditions Preterm delivery Polyhydramnios Oligohydramnios Fetal macrosomia Multiple pregnancy Fetal anomalies • Multiparity • Congenital uterine anomalies • Uterine fibroids • Previous breech presentation • Placenta previa or cornual placenta • Cephalo-pelvic disproportion
Case A 30 year old, para one woman at 36 weeks gestation attends antenatal clinic appointment after a scan confirming a frank breech presentation with normal liquor. She had a previous normal vaginal delivery and is otherwise low risk. How would you manage her care?
Management of Breech at term • Offer external cephalic version (ECV) • Women with a breech presentation at term should be offered external cephalic version (ECV) unless there is an absolute contraindication. • a successful ECV reduces the chance of caesarean section. • External Cephalic Version and Reducing the Incidence of Term Breech Presentation • ManagementofBreechPresentation Green-top Guidelines No. 20a & 20b 2017
ECV declined/unsuccessful/ persistent breech at term • Offer planned vaginal breech delivery or planned caesarean section and counsel on the risks and benefits. • ManagementofBreechPresentation Green-top Guideline No. 20b 2017
Vaginal breech delivery Vs Caesarean section Consider woman’s wishes Consider all of the favourable factors for vaginal breech delivery Consider current evidence & guidelines Document the discussion and plan
Appropriate case selection Healthy, normally grown fetus in frank / complete breech with flexed head Skilled practitioners Adherence to strict protocols Team work and effective communication Successful vaginal breech delivery with no adverse outcomes A committed mother
Second stage management • Delay active pushing until the breech has descended to the pelvic floor. • Episiotomy should be performed when indicated to facilitate delivery. • Avoid handling the breech or the umbilical cord. • Breech extraction should not be used routinely, as it causes extension of the arms and head.
Post delivery Cord bloods for blood gases Accurate documentation Debrief parents and staff
