Breech Presentation
Dr Madhavi Kalidindi
Consultant Obstetrician & Gynaecologist
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.
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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
Hips and knees are
flexed.
Presenting part:
Buttocks and feet
One or both feet or
knees present
below the fetal
buttocks.
© Royal College of Obstetricians and Gynaecologists
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
Chart Title
35%
30%
25%
• Hence, breech is more common
in preterm labours.
20%
15%
10%
5%
0%
20 weeks
28 weeks
32 weeks
Term
© Royal College of Obstetricians and Gynaecologists
Risk factors for persistent
breech presentation
Maternal conditions
Fetal conditions
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Multiparity
Congenital uterine anomalies
Uterine fibroids
Previous breech presentation
Placenta previa or cornual
placenta
• Cephalo-pelvic disproportion
Preterm delivery
Polyhydramnios
Oligohydramnios
Fetal macrosomia
Multiple pregnancy
Fetal anomalies
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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?
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Management of Breech at
term
• Offer external cephalic version (ECV)
to all women with breech presentation, as it reduces
the chances of breech presentation at delivery and
thereby the caesarean section rate.
- RCOG GTG 2006
• ECV unsuccessful/declined/persistent breech at
term:
– Vaginal breech delivery or Caesarean section
© Royal College of Obstetricians and Gynaecologists
Vaginal breech delivery Vs
Caesarean section
Consider woman’s
wishes
Consider all of the
favourable factors for
vaginal breech delivery
Consider current
evidence
Document the discussion
and plan
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Favourable factors for vaginal
breech delivery
Maternal
• Multiparity
Fetal
Institutional
• Frank or complete
breech
• Continuous CTG
monitoring
• No hyperextension
of the fetal head
• Skilled practitioners
• Adequate pelvis
• No previous LSCS or
uterine scars
• Preference for
vaginal birth
• No placental
insufficiency or fetal
growth restriction
• Access for
caesarean section
• Fetal EFW < 3800
gm
© Royal College of Obstetricians and Gynaecologists
Current evidence
The Term Breech Trial
(TBT) Hannah et al 2000
A multicentre RCT across 121
centres in 26 countries
Planned caesarean section was
safer for the baby than the
planned vaginal breech delivery at
term.
Had an immediate & dramatic
effect in the clinical practice with
rapid rise in the LSCS rates and
attrition in the skills.
Review studies and sub
group analysis in the later
years heavily criticised the
Term Breech Trial…
Kotaska et al BMJ 2004 –
inappropriate use of the TBT
to evaluate complex
phenomenon.
Glezerman et al 2006
reviewed TBT –
Original recommendations
should be withdrawn.
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Current evidence
PREMODA study
Cochrane review 2015
Goffinet et al 2006
of planned caesarean section for
term breech deliveries reviewed
three trials with 2396 women
A multicentre, prospective,
descriptive study of 8105 women
in 174 centres in France & Belgium
No difference in the perinatal
mortality or serious neonatal
morbidity between the vaginal
breech and planned caesarean
section groups.
Reduction of the perinatal
mortality and serious neonatal
morbidity with planned
caesarean sections when
compared with planned vaginal
birth, at the expense of
somewhat increased maternal
morbidity.
© Royal College of Obstetricians and Gynaecologists
Current practice
• It is likely that the current practice of offering elective
caesarean section to women with breech presentation will
remain unchanged in the short term. However,
A
committed
mother
Healthy,
normally
grown fetus
in frank/
complete
breech with
flexed head
Skilled
practitioners
Team work and
effective
communication
Successful
vaginal
breech
delivery
with no
adverse
outcomes.
© Royal College of Obstetricians and Gynaecologists
Intrapartum management of
breech
•Vaginal breech birth should take place in a hospital with
facilities for emergency caesarean section.
Access the most experienced clinician early.
•Continuous electronic fetal heart rate monitoring should
be offered to all women with a breech presentation.
•Fetal blood sampling from the buttocks is not advised.
© Royal College of Obstetricians and Gynaecologists
Intrapartum management of
breech
Maternal position
Analgesia
Delay in progress or
descent
• The dorsal or lithotomy position is advised, as most
experience with vaginal breech birth is in this position.
- RCOG GTG 2006
• Upright maternal position aids descent, so delay placing
the mother in the lithotomy position until the fetal anus
is visible over the posterior fourchette.
• Women should have a choice of analgesia in labour.
• Epidural should not be routinely advised as no sufficient
evidence.
• Caesarean section should be considered if there is a
delay in the progress or descent of the breech at
anytime in the first / second stage of labour.
© Royal College of Obstetricians and Gynaecologists
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.
© Royal College of Obstetricians and Gynaecologists
Breech delivery techniques video
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Post delivery
• Cord bloods for blood gases
• Accurate documentation
• Debrief parents and staff
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Thank you
© Royal College of Obstetricians and Gynaecologists