Breech Presentation


Article Author:
Caron Gray


Article Editor:
Meaghan Shanahan


Editors In Chief:
Tod Aeby


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes


Updated:
3/10/2019 11:04:29 AM

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]

Etiology

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.

Evaluation

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.

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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Breech Presentation - Questions

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What is the most common type of breech presentation?



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A 26-year-old G1P0 at 39 weeks EGA presents to labor and delivery with complaint of leaking of fluid but denies contractions. The evaluation is negative for rupture of membranes, however, on sterile vaginal exam, the cervix is difficult to reach and found to be 1 cm dilated with no presenting part palpated. Which of the following is the most appropriate next step in completing the evaluation of this patient?



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A 30-year-old G4P3 at 39 weeks EGA presents for a routine prenatal visit. Her past history includes three spontaneous vaginal deliveries with the largest delivery weight 4500 gm. On exam, Leopold maneuvers suggest breech presentation of the fetus which is confirmed by ultrasound with estimated fetal weight of 3000 gm. Which of the following is the most appropriate next step in the management of this patient?



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At what gestational age does it become less likely for a breech presentation to spontaneously convert to a vertex presentation?



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Which is true regarding breech position?



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Which of the following is not associated with a breech presentation?



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Which of the following is the least common fetal presentation?



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Breech Presentation - References

References

Hinnenberg P,Toijonen A,Gissler M,Heinonen S,Macharey G, Outcome of small for gestational age-fetuses in breech presentation at term according to mode of delivery: a nationwide, population-based record linkage study. Archives of gynecology and obstetrics. 2019 Feb 8;     [PubMed]
Schlaeger JM,Stoffel CL,Bussell JL,Cai HY,Takayama M,Yajima H,Takakura N, Moxibustion for Cephalic Version of Breech Presentation. Journal of midwifery     [PubMed]
Niles KM,Barrett JFR,Ladhani NNN, Comparison of cesarean versus vaginal delivery of extremely preterm gestations in breech presentation: retrospective cohort study. The journal of maternal-fetal     [PubMed]
Grabovac M,Karim JN,Isayama T,Liyanage SK,McDonald SD, What is the safest mode of birth for extremely preterm breech singleton infants who are actively resuscitated? A systematic review and meta-analyses. BJOG : an international journal of obstetrics and gynaecology. 2018 May;     [PubMed]
Andrews S,Leeman L,Yonke N, Finding the breech: Influence of breech presentation on mode of delivery based on timing of diagnosis, attempt at external cephalic version, and provider success with version. Birth (Berkeley, Calif.). 2017 Sep;     [PubMed]
Walker S,Breslin E,Scamell M,Parker P, Effectiveness of vaginal breech birth training strategies: An integrative review of the literature. Birth (Berkeley, Calif.). 2017 Jun;     [PubMed]
Hofmeyr GJ,Barrett JF,Crowther CA, Planned caesarean section for women with a twin pregnancy. The Cochrane database of systematic reviews. 2015 Dec 19;     [PubMed]
Ainsworth A,Sviggum HP,Tolcher MC,Weaver AL,Holman MA,Arendt KW, Lessons learned from a single institution's retrospective analysis of emergent cesarean delivery following external cephalic version with and without neuraxial anesthesia. International journal of obstetric anesthesia. 2017 May;     [PubMed]
Hutton EK,Simioni JC,Thabane L, Predictors of success of external cephalic version and cephalic presentation at birth among 1253 women with non-cephalic presentation using logistic regression and classification tree analyses. Acta obstetricia et gynecologica Scandinavica. 2017 Aug;     [PubMed]
Adjaoud S,Demailly R,Michel-Semail S,Rakza T,Storme L,Deruelle P,Garabedian C,Subtil D, Is trial of labor harmful in breech delivery? A cohort comparison for breech and vertex presentations. Journal of gynecology obstetrics and human reproduction. 2017 May;     [PubMed]
Poole KL,McDonald SD,Griffith LE,Hutton EK, Association of external cephalic version before term with late preterm birth. Acta obstetricia et gynecologica Scandinavica. 2017 Aug;     [PubMed]
Domingues AP,Belo A,Moura P,Vieira DN, Medico-legal litigation in Obstetrics: a characterization analysis of a decade in Portugal. Revista brasileira de ginecologia e obstetricia : revista da Federacao Brasileira das Sociedades de Ginecologia e Obstetricia. 2015 May;     [PubMed]
Delotte J,Oliver A,Boukaidi S,Mialon O,Breaud J,Benchimol D,Bongain A, [Who limit vaginal birth for breech presentation: medical practice or Law? Discussion between a medical doctor, a lawyer and the head chief of an university hospital]. Journal de gynecologie, obstetrique et biologie de la reproduction. 2011 Oct;     [PubMed]
Burke G, The end of vaginal breech delivery. BJOG : an international journal of obstetrics and gynaecology. 2006 Aug;     [PubMed]

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