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Breech Presentation - Obstetrics & Gynaecology

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1. Definition & Incidence

• Incidence is 3-4% of all deliveries at term
• Frequency decreases with advancing gestation:
  • 24% at 18-22 weeks
  • 8% at 28-30 weeks
  • 7% at 34 weeks
  • 2.8% at 38-40 weeks
• ~25-30% of all preterm infants (<28 weeks) present as breech

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2. Types of Breech Presentation

A. Frank Breech (most common, ~65-70%)

B. Complete Breech (~10%)

C. Incomplete / Footling Breech (~20-25%)

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3. Etiology / Predisposing Factors

• Term breech is associated with fundal-cornual placental implantation - the fetus may adopt breech because it is more "comfortable" given limited space
• Infants with neuromuscular disorders have disproportionately high rates of breech presentation (reduced ability to spontaneously rotate)
• Importantly, 5-year motor skill scores in children born breech are lower regardless of delivery route, suggesting the breech position itself may reflect an underlying fetal issue

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4. Risks / Complications

Fetal/Neonatal Risks

Maternal Risks

• Higher caesarean section rate
• Complications of operative delivery

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5. Diagnosis

Leopold's Maneuvers

• 1st maneuver (fundal grip): Hard, round, ballotable head felt at the fundus
• 3rd maneuver (Pawlik's grip): Soft, irregular, non-ballotable buttocks in the lower pole
• 4th maneuver: Confirms presenting part above pelvic inlet

Vaginal Examination

• Feel soft irregular surface (buttocks), anal orifice (flanked by bone on only two sides - vs. fetal face with complete bony ring)
• If no fontanel is identified, suspect breech

Ultrasound (most reliable)

• Confirms type of breech, fetal position, estimated weight, degree of head flexion/extension, placental location, amniotic fluid volume, fetal anomalies
• Hyperextended fetal neck on USS = contraindication to vaginal delivery (high risk of spinal cord injury)

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6. Management

Step 1: External Cephalic Version (ECV)

• Success rate: ~65% at 36 weeks
• Reduces caesarean risk by 50% overall for breech patients
• Technique: Tocolysis (e.g. terbutaline/ritodrine) is used to relax the uterus. The fetus is gently rotated to cephalic position through the maternal abdomen under continuous CTG and ultrasound monitoring.
• Epidural analgesia may improve success rate after a failed first attempt

Contraindications to ECV:

• Uterine anomalies
• Third-trimester bleeding
• Multiple gestation
• Oligohydramnios
• Uteroplacental insufficiency
• Nuchal cord on USS
• Previous caesarean or significant uterine surgery
• Obvious cephalopelvic disproportion (CPD)

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Step 2: Mode of Delivery

ACOG Recommendation

• Significantly greater perinatal morbidity and mortality with planned vaginal delivery
• No significant difference in maternal mortality or serious morbidity
• Led to a worldwide shift toward elective CS for term breech

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Criteria for Allowing Vaginal Breech Delivery (selected cases only)

• Oxytocin use is controversial in breech labor; 64% of perinatal deaths in the Hannah trial's vaginal arm occurred in induced/augmented labors

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7. Mechanism of Labor in Breech (Vaginal Delivery)

1. Engagement - Bitrochanteric diameter engages in an oblique diameter of the pelvic inlet
2. Descent - Anterior hip descends more rapidly
3. Internal rotation - Bitrochanteric diameter assumes the AP position
4. Lateral flexion - Anterior hip catches beneath symphysis pubis; posterior hip born first
5. Shoulder engagement - Shoulders engage in an oblique orientation; rotate to AP diameter at outlet; anterior shoulder appears beneath symphysis, posterior shoulder delivered first
6. Head delivery - Head engages in same diameter as shoulders; flexion, descent, and rotation bring posterior neck under symphysis; head is born in flexion

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8. Types of Breech Delivery

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9. Delivery Technique (Emergency / Assisted Vaginal Breech)

1. Do NOT apply traction until the infant delivers to the umbilicus spontaneously
2. Once umbilicus is visible: thumbs on sacrum, grasp fetal pelvis; keep trunk at ≤45° to horizontal
3. Maintain sacrum anterior; allow arms to deliver with slight oblique rotation
4. For the after-coming head:
   • Mauriceau maneuver: One hand on occiput/shoulders applying flexing pressure; fingers of other hand on maxillae to maintain cervical flexion. Assistant applies suprapubic pressure.
   • Only attempt once fetal elbows and chin have entered the pelvic inlet (to avoid Moro reflex)
   • Piper forceps may be applied to the after-coming head if there is difficulty (reduces neonatal mortality from breech)
5. Episiotomy may be needed for full-term infant

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10. Special Situations

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11. Prognosis / Long-term Outcome

• Long-term developmental outcome at 5 years does not differ significantly between infants delivered vaginally vs. by CS for breech presentation
• Higher rates of instrumental delivery and emergency CS occur even after successful ECV - the underlying breech etiology may persist as a risk factor
• Neonatal mortality risk: ~3/1000 with planned vaginal delivery; neurological injury ~7/1000; birth trauma ~7/1000 (meta-analysis data)

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Quick Summary Table

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