Breech presentation

Question 1

A G2P1 presents at 38 weeks in active 1st stage labour and is found to have unexpected breech. How would you assess and manage the patient?

Answer 1

Impression
Breech presentation is when foetal buttocks or lower extremities are the presenting part in lower pelvis. Main concerns with Breech are risk of obstetric complications during labour (obstructed labour), and risk of neonatal morbidity and mortality.

Conduct targeted Hx/Ex/Ix, notify O&G in case of emergency CS required, manage supportively and definitively.

Types of Breech:
- Complete: hipes flexed and knees flexed
- Frank: hips flexed knees extended
- footling: can be single or double
- incomplete: hips flexed but one knee extended

Complete and Frank can have trial of NVD if appropriate.

Question 2

Breech presentation - History

Answer 2

History
- sx: fetal movements, any maternal complaints
- RISK: previous breech, fam history, grand multip, uterine abnormalities, placenta praevia, polyhydramnios
- O&G Hx: GTPAL, yellow book, other screening, vaccinations, scans to date, any complications (GDM, HTN, etc)
- Rest of medical history

Question 3

Breech presentation - Examination

Answer 3

Examination
- General appearance + vitals
- Antenatal assessment: particularly abdo palp for fetal lie and presentation

Question 4

Breech presentation - Investigations

Answer 4

Investigations
- Continuous CTG monitoring
- Pre-op bloods if for emergent Caesar
- Pelvic/abdo ultrasound for fetal lie and presentation

Question 5

Breech presentation - Management

Answer 5

Management
- MDT: involve O&G early, ensure patient centred decision making process
- patient education about risks and type of breech, implications for delivery.

Definitive (if already in labour)
- C-section delivery
- NVD is only for frank/complete breech presentations, perhaps only in high-risk unit/tertiary centre with copious resources
Postpartum: neonatal hip assessment at 6wks, (ultrasound), neonatology review

For women not in labour:
- consider external cephalic version
- C-section for high-risk/unsuccessful external cephalic version

Ongoing:
- 6 weeks ultrasound of babies hips for DDH (closer monitoring)