Breech

Question 1

What is the definition of breech presentation?

Answer 1

When the presenting part is the buttocks, feet, knee or hip

Question 2

What are the different types of breech and how frequent do they occur?

Answer 2

Frank breech (65%)- legs crossed but feet by head
Complete breech (10%) - legs fully crossed 
Incomplete breech (25%)- footling or knee

Question 3

What is the incidence of breech?

Answer 3

3-4% at term

20% at 28 weeks

Question 4

List predisposing factors for breech

Answer 4

Multiparity
Multiple birth
Polyhydramnios/oligohydramnious 
Uterine abnormalities 
Fetal neuromuscular disorders 
Anencephaly/hydrocephaly

Question 5

Describe the term breech trial

Answer 5

Large scale trial where women with breech presentation were randomly assigned to either Caesarean section or vaginal breech birth.
Hannah et al. 2001 produced a paper with findings. Findings were that there were more incidences with vaginal breech birth and babies were born with poor APGARs. This had a massive impact on practice and led to a decline in vaginal breech births.
There have been criticisms of the study:
Vaginal breech births did not have skilled attendants
Incidences were not related to mode of birth
At the 2 year follow up there was no difference in outcomes

Question 6

What is the RCOG recommendation for the safety of vaginal breech birth?

Answer 6

If appropriate and there are skilled birth attendants vaginal breech birth is almost as safe at caesarean section.

Question 7

What are the rates of perinatal mortality for breech?

Answer 7

Caesarean section - 0.5/1000

Vaginal breech birth - 2/1000

Question 8

Discuss recommendations for premature and twin breech deliveries?

Answer 8

RCOG
Caesarean section is not routinely offered for preterm or twin deliveries unless it is a twin delivery where the presenting twin is breech presentation.

Question 9

How can breech be diagnosed?

Answer 9

AN - palpation and auscultation. If >36/40 USS can be used to confirm it.
In labour - vaginal examination can find buttocks, no suture lines and meconium is more likely to be present

Question 10

When are women offered external version?

Answer 10

Primiparous women - 36 weeks

Multiparous women - 37 weeks

Question 11

Define external cephalic version

Answer 11

Manipulation of the fetus through the maternal abdomen to from breech to cephalic presentation

Question 12

What is the success rate of external cephalic version?

Answer 12

Approximately 50% but more likely to work in multiparous women, frank breech and women with normal or higher amounts of amniotic fluid.

Question 13

What does RCOG state about postural methods?

Answer 13

Postural methods and methods such as moxibustion can be used but there is no evidence that their use alone can turn baby.

Question 14

Why are tocolytics used in ECV?

Answer 14

To relax the uterine muscle and allow for better manipulation of the fetus.

Question 15

What would you need to prepare prior to a vaginal breech birth?

Answer 15

• Inform senior midwife, obstetrician, anaesthetist, paediatrician and theatre staff
• Ensure there is access to Caesarean section facilities Gain IV access and take FBC and Group and Save
• Discuss again with woman and gain consent. Discuss manoeuvres and discuss analgesia. Make woman aware that epidural may increase risk of intervention. Consider pudendal block.
• Set up room and resuscitaire (warm blankets, operative delivery set, forceps, lithotomy supports)

Question 16

Describe management in the active first stage of labour

Answer 16

RCOG recommends CTG monitoring
Normal IP monitoring
Augmentation with oxytocin is not recommended but may be used with caution if epidural is in situ and contractions are <4:10 (RCOG)
ARM to be done with caution as risk of cord prolapse
Following rupture of membranes, vaginal examination to be done to exclude cord prolapse.

Question 17

Management in 2nd stage of labour

Answer 17

A hands off approach to delivery is preferable
Baby should be in sacroanterior position
Woman should be encouraged to actively push once buttocks are at perineum.
Traction should be avoided as it increases the chance of nuchal arms.
Legs may need to be released by pressing on the popliteal fossae
Active pushing should be encouraged until scapulae is visible
Episiotomy should be used selectively
If arms do not release lovsett manoeuvre can be used to rotate baby by bony prominences of pelvis.
Baby should be supported until the nape of the neck is visible and then weight of the baby should be used to increase flexion.
Suprapibic pressure can help release the occipital from under the symphysis pubis.
Mariceau smellie veit manoeuvre can help to increase flexion and the birth of the head

Question 18

Discuss delay in labour

Answer 18

Baby’s head should be born with 5 minutes of the buttocks or 3 minutes of the umbillicus. If not , delay can be diagnosed. Birth may also need to be expidited if baby lacks colour or tone.

Question 19

Fetal risks associated with vaginal breech birth?

Answer 19

Head entrapment 
Nuchal arms 
Cord prolapse
Asphyxia 
Intrapartum death 
Inter racial haemorrhage 
HIE 
brachial plexus injury 
Fractured clavicle, humerus or femur
Rupture of the liver kidney and spleen

Question 20

How should you hold a baby during breech delivery?

Answer 20

Hands off initially
On bony prominences to avoid internal organ damage
Avoid touching cord due to risk of vasospasm