Breech Presentation

Definition | Aetiology | Pathophysiology | Risk Factors | Signs and Symptoms | Investigations | Management | References

Definition

Breech Presentation occurs when the fetus is positioned in the uterus with the buttocks or feet nearest the cervix, instead of the head. Breech presentation is common in early pregnancy, but most fetuses turn to a head-first (cephalic) position by the time of delivery. Breech presentation is typically diagnosed at around 36 weeks of gestation.

Aetiology

Several factors can contribute to a breech presentation, including:

• Prematurity: Breech presentation is more common in preterm pregnancies.
• Uterine Abnormalities: Conditions such as fibroids, septate uterus, or bicornuate uterus can restrict fetal movement.
• Multiple Pregnancies: Twins or other multiples are more likely to have one or more fetuses in a breech position.
• Polyhydramnios or Oligohydramnios: Abnormal amniotic fluid volumes can affect fetal positioning.
• Placental Abnormalities: Placenta previa or other abnormalities can lead to breech presentation.

Pathophysiology

Breech presentation occurs due to the inability of the fetus to rotate into the cephalic position before delivery. This may be influenced by uterine shape, the amount of amniotic fluid, or the presence of multiple fetuses. The most common types of breech presentations are:

• Frank Breech: The buttocks present first with the legs extended straight up towards the head.
• Complete Breech: The buttocks present first, but the fetus has its legs folded at the knees, similar to a sitting position.
• Footling Breech: One or both feet present first, making vaginal delivery more complicated and risky.

Risk Factors

• Premature birth (before 37 weeks of gestation).
• Previous breech delivery.
• Multiple pregnancies.
• Uterine abnormalities (e.g., fibroids).
• Polyhydramnios or oligohydramnios.
• Placental abnormalities, such as placenta previa.

Signs and Symptoms

• On abdominal examination, the fetal head is palpable in the upper abdomen, and the softer, less defined buttocks are felt in the lower abdomen.
• Vaginal examination during labour may reveal the buttocks or feet as the presenting part.
• Ultrasound confirmation of fetal position, typically around 36 weeks gestation.

Investigations

• Ultrasound: The primary tool for confirming breech presentation and assessing fetal anatomy and amniotic fluid levels.
• Fetal Monitoring: Continuous monitoring may be needed during labour to assess fetal well-being, particularly if vaginal delivery is attempted.
• Pelvimetry: May be considered to assess the maternal pelvis's suitability for vaginal breech delivery, though it is not routinely performed.

Management

• Primary Care:
  • Referral to Obstetrics: Women with breech presentation identified after 36 weeks of gestation should be referred to an obstetrician for further evaluation and management.
  • Education and Counselling: Provide information on the risks and benefits of different management options, including external cephalic version (ECV) and the possibility of caesarean section.
• Specialist Care:
  • External Cephalic Version (ECV): ECV is an option where the obstetrician attempts to manually turn the fetus into the cephalic position. It is usually performed around 37 weeks of gestation. Success rates vary, and the procedure carries some risks, including fetal distress and premature rupture of membranes.
  • Vaginal Breech Delivery: In carefully selected cases and with experienced practitioners, a vaginal breech delivery may be attempted. However, the risks of complications, such as cord prolapse or fetal injury, are higher than with a cephalic delivery.
  • Planned Caesarean Section: Most cases of breech presentation at term are managed with a planned caesarean section to reduce the risks associated with vaginal breech delivery. This is particularly recommended for footling breech presentations and in cases where ECV is unsuccessful or contraindicated.
  • Intrapartum Care: Close monitoring during labour is essential, with the availability of immediate caesarean section if complications arise during a vaginal breech delivery.
• Postpartum Care:
  • Neonatal Care: Newborns delivered in breech presentations should be closely monitored for complications such as hip dysplasia, which is more common in breech births.
  • Follow-Up: Ensure follow-up care for the mother and newborn, including checking for any complications related to the delivery.

References

1. NHS (2024) Breech Birth. Available at: https://www.nhs.uk/conditions/breech-birth/ (Accessed: 24 June 2024).
2. National Institute for Health and Care Excellence (2024) Breech Presentation: Management and Outcomes. Available at: https://cks.nice.org.uk/topics/breech-presentation/ (Accessed: 24 June 2024).
3. British Medical Journal (2024) Breech Presentation: Diagnosis and Management. Available at: https://www.bmj.com/content/350/bmj.h619 (Accessed: 24 June 2024).
4. Royal College of Obstetricians and Gynaecologists (2024) Green-top Guideline No. 20: Management of Breech Presentation. Available at: https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg20/ (Accessed: 24 June 2024).

Back to Top