Breech Presentation

Question 1

Is breech presentation the commonest malpresentation?

Answer 1

Yes

Question 2

What is a breech presentation?

Answer 2

When the caudal end of the fetus occupies the lower segment

Question 3

What percentage are breech at 20,28 and term?

Answer 3

20 weeks = 40%
28 weeks = 20%
Term = 3%

Question 4

What types are there?

Answer 4

Extended breech - flexion at hips but extension and knees
Flexed breech - hips and knees both flexed, so presenting part a mixture of buttocks, external genitalia and feet
Footling breech - when one or both feet presenting as lowest part

Question 5

Which type of breech presentation is commonest?

Answer 5

Extended breech - 70%

Flexed - 15%
Footling - 15%

Question 6

Which type has greatest risk of cord prolapse?

Answer 6

Footling breech

Question 7

Which type of breech presentation carries the highest rate of perinatal mortality?

Answer 7

A footling breech

Question 8

What risk factors are there for breech presentation?

Answer 8

Uterine malformations, fibroids
Placenta praevia
Polyhydramnios or oligohydramnios
Fetal abnormality - CNS malformation or chromosomal disorder
Prematurity - increased incidence early in gestation

Question 9

How is it diagnosed?

Answer 9

Try and diagnose antenatally - but 30% present undiagnosed in labour
Pain under ribs
On palpitation the lie is longitudinal, no head felt in pelvis, in fundus there is a smooth round mass (the head) which can be ballotted
Ultimately diagnosis via USS or if labouring, feeling the breech vaginally

Question 10

What is external cephalic version?

Answer 10

Turning the breech by manoeuvring it through a (usually) forward somersault
Turn only if vaginal delivery planned
After 36 weeks
Success rate = 40% primips, 60% multips

Question 11

How is it managed?

Answer 11

If less than 36w many turn spontaneously
If still breech at 36w NICE recommends ECV at 36w in nulliparous and 37 mutliparous
If still breech then delivery options include planned c section (majority) or vaginal delivery

Question 12

What contraindications are there to vaginal delivery?

Answer 12

Inexperienced clinician
Footling or kneeling breech 
Estimated fetal weight > 3800 or <2000g 
Previous LSCS
Hyperextended fetal neck

Question 13

What ECV contraindications are there?

Answer 13

Placenta praevia
Multiple pregnancy 
APH in last 7 days 
Ruptured membranes 
Growth restricted babies
Abnormal CTG 
Uterine scars, uterine abnormality 
Pre -eclampsia or HTN (risk of abruption increased) 

Monitor CTG and five anti-D to rhesus neg patients

Question 14

What information should be given to help women in the decision with regards to delivery?

Answer 14

Inform them that planned Caesarean sections carry a reduced perinatal mortality and early neonatal morbidity for babies with breech presentation at term compared with vaginal birth
There is no evidence that the long term health of babies with a breech presentation delivered at term is influenced by how baby is born

Question 15

Because most breeches are delivered by LSCS, there is…

Answer 15

Less experience with vaginal breech delivery

Question 16

How should vaginal delivery be done?

Answer 16

Hands off technique - baby not touched until scapulae visible
Encourage baby to remain with spine anterior
Once scapula visible, hook arms at the elbow
Allow body to hang once nape of neck visible, 2 fingers over maxilla and 2 fingers over occiput to flex the head (if fails, forceps used to deliver the head)

Question 17

What should be checked after vaginal delivery?

Answer 17

Check for hip dislocation at birth and by USS at 6 weeks
Klumpke’s paralysis check for
Signs of CNS injury