Breech presentation and delivery

Question 1

What is breech presentation?

Answer 1

Breech presentation occurs when the fetus is positioned with the buttocks or feet closest to the birth canal instead of the head. Types include complete, frank, and footling breech.

Question 2

What are the possible causes of breech presentation?

Answer 2

Placenta praevia.
Congenital fetal abnormalities.
Uterine abnormalities (e.g., bicornuate uterus).
Uterine masses.

Question 3

How is breech presentation diagnosed?

Answer 3

Breech presentation is diagnosed by palpating a ballotable mass consistent with the fetal head in the fundus and a broad irregular mass in the lower pole. Ultrasound is used to confirm the presentation and rule out fetal abnormalities.

Question 4

What is external cephalic version (ECV) and when is it performed?

Answer 4

ECV is a procedure where the fetus is manually rotated from a breech to a cephalic (head-down) presentation. It is usually attempted at ≥ 36 weeks gestation if there are no contraindications to vaginal delivery.

Question 5

What are the absolute and relative contraindications to external cephalic version (ECV)?

Answer 5

Absolute: Rh-negative status, uterine scar, abnormal placentation, suspected fetal compromise.
Relative: Oligohydramnios, anterior placenta, HIV infection.

Question 6

What are the delivery options for breech presentation?

Answer 6

Cesarean section: Preferred, especially for large babies, nulliparous women, footling breech, extended head, or when there are other indications for cesarean.
Assisted vaginal breech delivery: Can be attempted in selected cases with experienced staff, preferably with spontaneous onset and progress of labor.

Question 7

What are the key considerations during an assisted vaginal breech delivery?

Answer 7

Ensure spontaneous onset and progress of labor.
IV access and group and save blood.
Delivery should be conducted by experienced personnel.
Consider episiotomy and be prepared for maneuvers such as the Lovset maneuver for extended arms or Mauriceau-Smellie-Veit maneuver for delivery of the after-coming head.

Question 8

What are the indications for choosing a cesarean delivery over a vaginal breech delivery?

Answer 8

Estimated fetal weight (EFW) ≥ 3.5 kg.
BPD > 9.5 cm.
Footling breech.
Extended fetal head.
Clinically small pelvis.
Nulliparity.
Other complications like preeclampsia.