Breech Presentation

Breech Presentation

• Breech presentation is
when a fetus is in a
longitudinal lie with the
buttocks or feet present
in the lower uterine
segment.

• Most common
malpresentation.

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Three types of breech
Frank or extended Complete or flexed Footling breech:
breech: 65 to 70% breech: 30% 10%

Legs are flexed at the

Hips and knees are One or both feet or
hips and extended at
flexed. knees present
the knees.
Presenting part: below the fetal
Presenting part:
Buttocks and feet buttocks.
Buttocks
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 Incidence
• Incidence of breech presentation decreases with
gestation as spontaneous version happens.
– 20% at 28 weeks of gestation
– 16% at 32 weeks Chart Title
– 3-4% at term 35%

30%

25%

20%
• Hence, breech is more common
15%
in preterm labours.
10%

5%

0%
20 weeks 28 weeks 32 weeks Term

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 Risk factors for persistent
breech presentation
Maternal conditions
• Multiparity
• Congenital uterine anomalies
• Uterine fibroids
• Previous breech presentation
• Placenta previa or cornual
placenta
• Cephalo-pelvic disproportion
Fetal conditions
• Preterm delivery
• Polyhydramnios
• Oligohydramnios
• Fetal macrosomia
• Multiple pregnancy
• Fetal anomalies
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 Case
A 30 year old, para one woman at 36 weeks gestation
attends antenatal clinic appointment after a scan
confirming a frank breech presentation with normal
liquor.
She had a previous normal vaginal delivery and is
otherwise low risk.

How would you manage her care?

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Management of Breech at term

• Offer external cephalic version (ECV)

– Women with a breech presentation at term should be

offered external cephalic version (ECV) unless there is an
absolute contraindication.
– a successful ECV reduces the chance of caesarean section.

• External Cephalic Version and Reducing the

Incidence of Term Breech Presentation
• Management of Breech Presentation
Green-top Guidelines No. 20a & 20b 2017

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 ECV declined/unsuccessful/
persistent breech at term

• Offer planned vaginal breech delivery or

planned caesarean section and counsel on the
risks and benefits.

• Management of Breech Presentation

Green-top Guideline No. 20b 2017

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Vaginal breech delivery Vs
Caesarean section

Consider woman’s wishes

Consider all of the

Consider current
favourable factors for
evidence & guidelines
vaginal breech delivery

Document the discussion

and plan
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 Favourable factors for vaginal
breech delivery
Maternal Fetal Institutional
• Multiparity • Frank or complete • Continuous CTG
breech monitoring
• Adequate pelvis
• No hyperextension • Skilled practitioners
• No previous LSCS or of the fetal head
uterine scars • Access for
• No placental caesarean section
• Preference for insufficiency or fetal
vaginal birth growth restriction

• Fetal EFW < 3800

gm

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 Appropriate case
selection
Skilled practitioners
Healthy, normally
grown fetus in frank
Adherence to strict
/ complete breech
protocols
with flexed head
Team work and effective
communication

Successful vaginal
A
breech delivery with committed
no adverse outcomes mother

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Intrapartum management of
breech

•Vaginal breech birth should take place in a hospital with

facilities for emergency caesarean section.

Access the most experienced clinician early.

•Continuous electronic fetal heart rate monitoring should

be offered to all women with a breech presentation.
•Fetal blood sampling from the buttocks is not advised.

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Intrapartum management of
breech
• Either the semirecumbent or an all-fours position is
adopted, as per the experience of the practitioners.
Maternal position - RCOG GTG 2017
• Upright maternal position aids descent, so delay placing
the mother in the lithotomy position until the fetal anus
is visible over the posterior fourchette.

• Women should have a choice of analgesia in labour.

Analgesia
• Epidural should not be routinely advised as no sufficient
evidence.

• Caesarean section should be considered if there is a

Delay in progress
delay in the progress or descent of the breech at
or descent anytime in the first / second stage of labour.

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 Second stage management
• Delay active pushing until the breech
has descended to the pelvic floor.

• Episiotomy should be performed

when indicated to facilitate delivery.

• Avoid handling the breech or the

umbilical cord.

• Breech extraction should not be

used routinely, as it causes extension
of the arms and head.

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 Post delivery

• Cord bloods for blood gases

• Accurate documentation

• Debrief parents and staff

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