Breech Birth – Causes, Symptoms, Diagnosis, Treatment and Ongoing care

Basics

Description

At the time of delivery, the fetal buttocks or lower limbs are the presenting part in the maternal pelvis:

  • Frank breech: Fetal hips flexed and knees extended with feet near the shoulders (45–60% of breech presentations at term)
  • Footling or incomplete breech: Foot or knee presenting (25–35% of breech presentations)
  • Complete breech: Hips and knees flexed (as if squatting) (5–15% of breech presentations)

Epidemiology

Prevalence

  • 3–4% of singleton term deliveries and up to 15–30% of low-birth-weight infants (<2,500 g)
  • Breech presentation is common in early pregnancy. At 25–26 weeks, ∼20–30% of singleton fetuses are in breech position, but this decreases near term.

Risk Factors

  • Previous history of breech birth
  • Fetal anomalies; see Genetics.
  • Low-birth-weight or premature infant
  • Oligohydramnios
  • Uterine anomalies, including bicornate uterus
  • Uterine relaxation associated with great parity
  • Uterine overdistention as in polyhydramnios or multiple gestation
  • Placenta previa
  • Placental implantation in cornual-fundal region
  • Pelvic contractures or irregularly shaped pelvis, such as android or platypelloid pelvis
  • Pelvic tumors

Genetics

Fetal anomalies, including anencephaly, hydrocephalus, trisomy 21 and 18, Potter syndrome, and myotonic dystrophy, have higher incidences of breech birth.

General Prevention

  • Antenatal folate therapy to decrease risk of neural tube defects
  • Prevention of fetal anomalies by tight glucose control in diabetics

Commonly Associated Conditions

  • See Risk Factors.
  • Congenital hip dislocation has higher incidence in infants with breech presentation at term.

Pregnancy, Caesarean section, Breech birth, External cephalic version, Childbirth, American Congress of Obstetricians and Gynecologists, Term Breech Trial, congenital hip dislocation, leopold maneuver, breech presentations, neural tube defects, frank breech, vaginal exam,

Diagnosis

History

Mother reports kicking in lower abdomen

Physical Exam

  • Anus palpable on digital vaginal exam
  • Leopold maneuver reveals ballottable head in fundal region.
  • Presenting part not palpable in pelvis near term

Diagnostic Tests & Interpretation

Imaging

Initial approach

Ultrasound confirms presenting part

Diagnostic Procedures/Surgery

  • Near-term women should be examined to determine presenting part.
  • If breech is suspected, an ultrasound should be done to confirm presenting part.
  • When breech presentation is confirmed, the options of external version or elective cesarean section should be discussed with the patient.

Pathological Findings

Congenital malformation among term breech infants: Overall incidence 6–9%

Differential Diagnosis

  • Face vs. breech presentation on vaginal exam
  • In breech presentation, greater trochanter and anus form a straight line. In face presentation, mouth and malar bones form a triangle.

Treatment

Additional Treatment

General Measures

  • Continuous electronic fetal monitoring during labor
  • Breech presentation may be converted to vertex by external version.
  • American College of Obstetricians and Gynecologists (ACOG) recommends external version at term. Decision for mode of delivery should depend on the experience of the health provider, with planned cesarean delivery for persistent breech presentation likely to be preferred.
  • In 2000, the Term Breech Trial showed decreased perinatal and neonatal morbidity and mortality in planned breech cesarean delivery (1) [NNT 30] vs. planned breech vaginal delivery. There was no difference in maternal morbidity or mortality (1)[B].
  • In 2005, a large observational prospective study showed no difference in neonatal outcomes when vaginal breech candidates were carefully selected and followed strict protocols (2).

Additional Therapies

External cephalic version:

  • Conversion of breech to vertex can be attempted after 36 weeks of gestation and, if successful, allows for vaginal vertex delivery. Success rates 48–78%, with reversion rates back to breech of 2% (3)[B].
  • External cephalic version associated with risk (1–2%) of umbilical cord entanglement, abruptio placenta, preterm labor, premature rupture of membranes, fetal brachycardia, fetal–maternal hemorrhage, and severe maternal discomfort.
  • Prior to procedure, tocolytics are usually administered and RhoGAM is given to Rh-negative mothers (3)[B].
  • External cephalic version should be attempted only with continuous fetal heart monitoring in the delivery suite, where immediate cesarean delivery can be done (3)[C].
  • Contraindications to external cephalic version include multiple pregnancy, nonreassuring fetal monitoring, placenta previa, premature rupture of membranes, placental abruption, uterine malformation, oligohydramnios, or major fetal anomalies.
  • Predictors of successful external cephalic version include multiparity, relaxed abdominal wall, adequate amniotic fluid, nonfrank breech, floating presenting part, posterior placenta, and average maternal body weight.

Surgery/Other Procedures

  • Breech delivery is accomplished either vaginally or by cesarean section (4).
  • Most physicians and patients opt for elective cesarean delivery for breech presentation near term, which is usually planned for the 39th week of pregnancy.
  • When a patient presents in labor with the fetus in breech position, a decision about a trial of labor or immediate cesarean section must be made. Ideally, this decision is made prior to onset of labor.
  • Obtain ultrasound to document fetal presentation, check for fetal abnormalities, and estimate fetal weight in deciding candidacy for vaginal delivery.
  • Vaginal breech delivery may be appropriate in the following situations:
    • Breech presentation in advanced labor
    • Delivery of a 2nd twin in nonvertex presentation
    • Fetus too immature to survive
    • Fetus with congenital defects incompatible with life
    • Multiparous mother, estimated fetal weight not greater than that of siblings delivered by uncomplicated SVD
  • Cesarean section procedure:
    • Prepare for cesarean section by starting IV fluids and obtaining blood type and screen, in all patients, in case needed for emergency.
    • A low transverse cesarean section may need to be extended vertically if there is difficulty with head entrapment (this extension produces a weak scar).
    • General anesthesia with isoflurane can rapidly relax the uterus and allow delivery of an entrapped after-coming head.
    • Delivery is usually accomplished with spinal anesthesia.
    • Cord blood gases should be obtained following delivery.
  • Vaginal delivery procedures:
    • The candidate for vaginal delivery needs to be attended by a birth attendant skilled in breech delivery, a scrubbed assistant, an anesthesiologist capable of rapid induction of general anesthesia, and an individual skilled in neonatal resuscitation.
    • Epidural is preferred anesthesia.
    • Leave membranes intact as long as possible to prevent possible cord prolapse.
    • The patient should not push until fully dilated due to risk of partial delivery through a cervix that is not fully dilated, which can lead to head entrapment.
    • Consider cutting a large episiotomy to allow sufficient room for delivery.
    • Use abdominal guidance of fetal head to keep it flexed as it descends into the pelvis.
    • The infant should not be touched before the umbilicus crosses the maternal perineum. Traction prior to this point constitutes a complete breech extraction and is associated with higher risk of perinatal morbidity and mortality.
    • With the fetal back anterior, maintain downward traction while grasping the fetal hips until the scapula becomes visible.
    • Check for nuchal arm.
    • As 1 axilla becomes visible, rotate the infant until the shoulders are oriented anteriorly and posteriorly, allowing their delivery.
    • The fetal head is delivered in a face-down position with either piper forceps or manual flexion of the head.
    • Cord blood gases should be obtained following delivery.

In-Patient Considerations

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Admission Criteria

  • For planned C-section
  • For labor and delivery

IV Fluids

Maintain IV access and hydration status with lactated Ringer’s or saline solution.

Discharge Criteria

  • After delivery once stable
  • 1–4 days after delivery depending on vaginal vs. breech delivery

Ongoing Care

Follow-Up Recommendations

Routine postpartum care

Patient Monitoring

Continuous electronic fetal monitoring during labor

Diet

NPO

Patient Education

Educate patient about increased risk of fetal distress and fetal trauma in both cesarean and vaginal breech delivery compared to vaginal vertex delivery.

Prognosis

  • Perinatal morbidity and mortality are much higher in breech births. A large proportion of the deaths are related to congenital abnormalities.
  • Successful external cephalic version at term significantly lowers cesarean rate (15)[A].
  • For infants 750–1,500 g or <32 weeks gestational age, a much higher rate of cerebral hemorrhage and perinatal death is associated with vaginal compared to cesarean delivery.

Complications

  • Trauma to the head, soft tissue, brachial plexus, and spinal cord; not always prevented by cesarean
  • Entrapment of fetal head
  • Asphyxia secondary to cord compression or prolapse
  • Congenital hip dislocation

References

1. Hannah ME, Hannah WJ, Hewson SA et al. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group.Lancet. 2000;356:1375–83.

2. Goffinet F, Carayol M, Foidart J et al. Is planned vaginal delivery for breech presentation at term still an option? Results of an observational prospective survey in France and Belgium. Am J Obstet Gynecol. 2006;194:1002–11.

3. American College of Obstetricians and Gynecologists. External cephalic version. Practice Bulletin No. 13. February, 2000.

4. American College of Obstetricians and Gynecologists, Committee on Obstetric Practice. ACOG committee opinion. Mode of term singleton breech delivery. Practice Bulletin No. 340. July, 2006. American College of Obstetricians and Gynecologists.

5. Tan JM, Macario A, Carvalho B et al. Cost-effectiveness of external cephalic version for term breech presentation. BMC Pregnancy Childbirth. 2010;10:3.

Additional Reading

Kotaska A, Menticoglou S, Gagnon R et al. Vaginal delivery of breech presentation. J Obstet Gynaecol Can. 2009;31.

See Also (Topic, Algorithm, Electronic Media Element)

Placenta Previa; Preterm Labor

Codes

ICD9

  • 652.10 Breech or other malpresentation successfully converted to cephalic presentation, unspecified as to episode of care
  • 652.20 Breech presentation without mention of version, unspecified as to episode of care
  • 652.80 Other specified malposition or malpresentation, unspecified as to episode of care

Snomed

6096002 Breech presentation (finding)

Clinical Pearls

  • Vaginal breech delivery is associated with increased risk of prolapsed cord and/or cord compression; fetal hypoxia; nuchal arm, with attendant risk of trauma, including humerus fracture, clavicle fracture, and nerve palsies; and entrapment of fetal head.
  • External version after 36 weeks gestation may allow for vaginal vertex delivery with decreased risk of infant and maternal morbidity.
  • If a patient goes into labor prior to a planned elective cesarean breech delivery, which is usually scheduled at 39–40 weeks gestation, she should go immediately to the hospital.
  • Risks of cesarean delivery include infection, bleeding, and possible damage to maternal bladder or bowel; there is a slightly increased risk of maternal mortality compared with vaginal vertex delivery. Maternal recovery time is almost always longer with cesarean delivery.

 

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