A malpresentation of the fetus at near term or during obstetric labor with the fetal cephalic pole in the fundus of the uterus. There are three types of breech: The complete breech with flexed hips and knees; The incomplete breech with one or both hips partially or fully extended; The Frank breech with flexed hips and extended knees.

Introduction

Breech presentation refers to the fetus in the longitudinal lie with the buttocks or lower extremity entering the pelvis first. The three types of breech presentation include frank breech, complete breech, and incomplete breech. In a frank breech, the fetus has flexion of both hips, and the legs are straight with the feet near the fetal face, in a pike position. The complete breech has the fetus sitting with flexion of both hips and both legs in a tuck position. Finally, the incomplete breech can have any combination of one or both hips extended, also known as footling (one leg extended) breech, or double footling breech (both legs extended).

Etiology

Clinical conditions associated with breech presentation include those that may increase or decrease fetal motility, or affect the vertical polarity of the uterine cavity. Prematurity, multiple gestations, aneuploidies, congenital anomalies, Mullerian anomalies, uterine leiomyoma, and placental polarity as in placenta previa are most commonly associated with a breech presentation.  Also, a previous history of breech presentation at term increases the risk of repeat breech presentation at term in subsequent pregnancies.

Epidemiology

Breech presentation occurs in 3% to 4% of all term pregnancies. A higher percentage of breech presentations occurs with less advanced gestational age. At 32 weeks, 7% of fetuses are breech, and 28 weeks or less, 25% are breech.

Specifically, following one breech delivery, the recurrence rate for the second pregnancy was nearly 10%, and for a subsequent third pregnancy, it was 27%. Prior cesarean delivery has also been described by some to increase the incidence of breech presentation two-fold.

Pathophysiology

Conditions that change the vertical polarity or the uterine cavity, or affect the ease or ability of the fetus to turn into the vertex presentation in the third trimester include:

• Mullerian anomalies: Septate uterus, bicornuate uterus, and didelphys uterus 

• Placentation: Placenta previa as the placenta is occupying the inferior portion of the uterine cavity. Therefore, the presenting part cannot engage

• Uterine leiomyoma: Mainly larger myomas located in the lower uterine segment, often intramural or submucosal, that prevent engagement of the presenting part.

• Prematurity

• Aneuploidies and fetal neuromuscular disorders commonly cause hypotonia of the fetus, inability to move effectively

• Congenital anomalies:  Fetal sacrococcygeal teratoma, fetal thyroid goiter

• Polyhydramnios: Fetus is often in unstable lie, unable to engage

• Oligohydramnios: Fetus is unable to turn to vertex due to lack of fluid

• Laxity of the maternal abdominal wall: Uterus falls forward, the fetus is unable to engage in the pelvis.

The risk of cord prolapse varies depending on the type of breech. Incomplete or footling breech carries the highest risk of cord prolapse at 15% to 18%, while complete breech is lower at 4% to 6%, and frank breech is uncommon at 0.5%.

History and Physical

During the physical exam, using the Leopold maneuvers, palpation of a hard, round, mobile structure at the fundus and the inability to palpate a presenting part in the lower abdomen superior to the pubic bone or the engaged breech in the same area, should raise suspicion of a breech presentation.

During a cervical exam, findings may include the lack of a palpable presenting part, palpation of a lower extremity, usually a foot, or for the engaged breech, palpation of the soft tissue of the fetal buttocks may be noted. If the patient has been laboring, caution is warranted as the soft tissue of the fetal buttocks may be interpreted as caput of the fetal vertex.

Any of these findings should raise suspicion and ultrasound should be performed.

Evaluation

Diagnosis of a breech presentation can be accomplished through abdominal exam using the Leopold maneuvers in combination with the cervical exam. Ultrasound should confirm the diagnosis.

On ultrasound, the fetal lie and presenting part should be visualized and documented. If breech presentation is diagnosed, specific information including the specific type of breech, the degree of flexion of the fetal head, estimated fetal weight, amniotic fluid volume, placental location, and fetal anatomy review (if not already done previously) should be documented.

Treatment / Management

Expertise in the delivery of the vaginal breech baby is becoming less common due to fewer vaginal breech deliveries being offered throughout the United States and in most industrialized countries. The Term Breech Trial (TBT), a well-designed, multicenter, international, randomized controlled trial published in 2000 compared planned vaginal delivery to planned cesarean delivery for the term breech infant. The investigators reported that delivery by planned cesarean resulted in significantly lower perinatal mortality, neonatal mortality, and serious neonatal morbidity. Also, there was no significant difference in maternal morbidity or mortality between the two groups. Since that time, the rate of term breech infants delivered by planned cesarean has increased dramatically. Follow-up studies to the TBT have been published looking at maternal morbidity and outcomes of the children at two years. Although these reports did not show any significant difference in the risk of death and neurodevelopmental, these studies were felt to be underpowered.

Since the TBT, many authors since have argued that there are still some specific situations that vaginal breech delivery is a potential, safe alternative to planned cesarean. Many smaller retrospective studies have reported no difference in neonatal morbidity or mortality using these specific criteria.

The initial criteria used in these reports were similar: gestational age greater than 37 weeks, frank or complete breech presentation, no fetal anomalies on ultrasound examination, adequate maternal pelvis, and estimated fetal weight between 2500 g and 4000 g. In addition, the protocol presented by one report required documentation of fetal head flexion and adequate amniotic fluid volume, defined as a 3-cm vertical pocket. Oxytocin induction or augmentation was not offered, and strict criteria were established for normal labor progress. CT pelvimetry did determine an adequate maternal pelvis.

Despite debate on both sides, the current recommendation for the breech presentation at term includes offering external cephalic version (ECV) to those patients that meet criteria, and for those whom are not candidates or decline external cephalic version, a planned cesarean section for delivery sometime after 39 weeks.

Regarding the premature breech, gestational age will determine the mode of delivery. Before 26 weeks, there is a lack of quality clinical evidence to guide mode of delivery. One large retrospective cohort study recently concluded that from 28 to 31 6/7 weeks, there is a significant decrease in perinatal morbidity and mortality in a planned cesarean delivery versus intended vaginal delivery, while there is no difference in perinatal morbidity and mortality in gestational age 32 to 36 weeks. Of note, due to lack of recruitment, no prospective clinical trials are examining this issue.

Differential Diagnosis

• Face and brow presentation

• Fetal anomalies

• Fetal death

• Grand multiparity

• Multiple pregnancies

• Oligohydramnios

• Pelvis Anatomy

• Preterm labor

• Primigravida

• Uterine anomalies

Pearls and Other Issues

In light of the decrease in planned vaginal breech deliveries, thus the decrease in expertise in managing this clinical scenario, it is prudent that policies requiring simulation and instruction in the delivery technique for vaginal breech birth are established to care for the emergency breech vaginal delivery.

Enhancing Healthcare Team Outcomes

A breech delivery is usually managed by an obstetrician, labor and delivery nurse, anesthesiologist and a neonatologist. The ultimate decison rests on the obstetrician. To prevent complications, today cesarean sections are performed and experienced with vaginal deliveries of breech presentation is limited. For healthcare workers including the midwife who has no experience with a breech delivery, it is vital to communicate with an obstetrician, otherwise one risks litigation if complications arise during delivery.

The baby is in the wrong position. Most often when this occurs, the baby is breech, or in a breech presentation, meaning that the baby is coming out feet first instead of head first. The baby may also be in a transverse (sideways) or oblique (diagonal) position.

What is a breech presentation?

Towards the end of pregnancy, most babies will move into a position to allow them to be born headfirst through the birth canal. 

This normal head first presentation is the safest and easiest position for birth and in most cases, will occur naturally.

Some babies however may present in a:

• breech position (bottom first)
• transverse position (lying sideways).

Breech presentation is when the baby is positioned bottom first before birth.

It is common in premature or twin pregnancies.

Preparation for birth

If your baby is in a breech position 4 to 5 weeks before you are due to give birth, your obstetrician (doctor) may recommend turning your baby into a normal head first position. This procedure is called external cephalic version (ECV).

ECVs take place after 36 weeks gestation.

Turning the baby

Before your ECV you will need an ultrasound to:

• check the position and wellbeing of your baby
• make sure the doctor can go ahead with the procedure.

There are a number of reasons why your doctor may not decide to do an ECV, such as the position of the placenta and the size of your baby. For you and your baby’s safety, your doctor may recommend a caesarean section instead.

The ECV procedure is usually performed in the Maternal Fetal Assessment Unit where a midwife can care for you.

You will need to empty your bladder before the procedure can take place and will be given an injection 20 to 30 minutes prior to the procedure in your leg. The injection contains a medication called terbutaline which will relax the muscles of your uterus and make it easier to turn your baby.

Your doctor will ask you to either:

• lie on your back with your knees slightly bent
• position yourself on all fours.

The doctor will use both hands to gently turn the baby. Another ultrasound is performed to make sure you baby is in the normal head first position.

If the baby remains in the new position, a vaginal birth will be much easier.

Sometimes the baby will turn back to a breech position, either immediately or within several days. The doctor may discuss with you the possibility of repeating the ECV.

The procedure can take up to 2 or more hours.

What are the risks?

When an ECV is performed by a doctor as described above, the risks are very low. However, as with any medical procedure complications may occur.

These include:

• failure to successfully turn the baby
• bleeding from the placenta (this may mean an urgent caesarean is needed)
• decreased movements of the baby.

Discharge advice

Whether the procedure was successful or not, it is important that you contact your doctor or Hospital if you notice any of the following changes:

• vaginal bleeding
• baby is less active than usual
• vaginal fluid loss
• contractions
• abdominal (stomach) pain.

Remember

• Most babies move into a normal head down position 4 to 5 weeks before their due date.
• Breech presentation is when the baby is positioned bottom first.
• Your doctor may recommend moving your baby into a normal head down position.
• This procedure is called external cephalic version (ECV).