Breech Presentation

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Breech presentation\: fetal head at uterine fundus, buttocks or feet over maternal pelvis; occurs in 3-4% of all fetuses in the
UK.
Aetiology\: mostly idiopathic.
Types of breech presentation\:
Complete (
Footling (incomplete) breech\: one or both feet below fetal buttocks, hips and knees extended.
Frank (extended) breech\: hips
Risk factors\:
Maternal\: multiparity,
Fetal\: preterm, macrosomia, fetal abnormalities, multiple pregnancy.
Placental\: placenta praevia, polyhydramnios, oligohydramnios, amniotic bands.
Clinical features\:
Breech common before 36 weeks, often asymptomatic, diagnosed incidentally.
20% breech at 28 weeks, 16% at 32 weeks, 3-4% at term.
Clinical examination\:
Longitudinal lie, head at fundus, irregular mass over pelvis, fetal heart auscultated higher, palpation of feet/sacrum at
cervical os during vaginal examination.
Investigations\: ultrasound scan to con
Management options\:
External cephalic version (ECV)\: manual rotation under ultrasound; success rate 40% in primiparous, 60% in multiparous;
contraindications include antepartum haemorrhage, ruptured membranes, previous caesarean, major uterine abnormality,
multiple pregnancy, abnormal CTG.
Vaginal delivery\: risks include head entrapment, birth asphyxia, intracranial haemorrhage, perinatal mortality, cord
prolapse, trauma; contraindications include footling breech, macrosomia, growth restriction, other complications of vaginal
birth, lack of trained sta
Caesarean section\: elective procedure at term, preferred for preterm babies, unsuccessful ECV, or maternal preference;
fewer risks than vaginal delivery.
Complications\:
Fetal complications\: developmental dysplasia of the hip, cord prolapse, fetal head entrapment, birth asphyxia, intracranial
haemorrhage, perinatal mortality.
ECV complications\: transient fetal heart abnormalities, fetomaternal haemorrhage, placental abruption (rare).
Article 🔍
A comprehensive topic overviewIntroduction
Breech presentation is a type of malpresentation and occurs when the fetal head lies over the uterine fundus and fetal
buttocks or feet present over the maternal pelvis (instead of cephalic/head presentation).
The incidence in the United Kingdom of breech presentation is 3-4% of all fetuses.
1

Aetiology

Breech presentation is most commonly idiopathic.
Types of breech presentation
The three types of breech presentation are\:
Complete (
Footling (incomplete) breech\: one or both feet present below the fetal buttocks, with hips and knees extended (Figure
2)
Frank (extended) breech\: both hips
developmental dysplasia of the hip (Figure 3)
Figure 1. Complete breech.
2Figure 2. Footling breech.
3Figure 3. Frank breech.
4

Risk factors

Risk factors for breech presentation can be divided into maternal, fetal and placental risk factors\:
Maternal\: multiparity,
Fetal\: preterm, macrosomia, fetal abnormalities (anencephaly, hydrocephalus, cystic hygroma), multiple pregnancy
Placental\: placenta praevia, polyhydramnios, oligohydramnios, amniotic bands

Clinical features

Before 36 weeks, breech presentation is not signi
will often be asymptomatic with the diagnosis being incidental.
The incidence of breech presentation is approximately 20% at 28 weeks gestation, 16% at 32 weeks gestation and 3-4% at
term. Therefore, breech presentation is more common in preterm labour. Most fetuses with breech presentation in the
early third trimester will turn spontaneously and be cephalic at term.
However, spontaneous version rates for nulliparous women with breech presentation at 36 weeks of gestation are less than
10%.Clinical examination
Typical clinical
Longitudinal lie
Head palpated at the fundus
Irregular mass over pelvis (feet, legs and buttocks)
Fetal heart auscultated higher on the maternal abdomen
Palpation of feet or sacrum at the cervical os during vaginal examination
For more information, see the Geeky Medics guide to obstetric abdominal examination.
Positions in breech presentation
There are multiple fetal positions in breech presentation which are described according to the relation of the fetal
sacrum to the maternal pelvis.
These are\: direct sacroanterior, left sacroanterior, right sacroanterior, direct sacroposterior, right sacroposterior, left
sacroposterior, left sacrotransverse and right sacrotranverse.
5

Investigations

An ultrasound scan is diagnostic for breech presentation. Growth, amniotic
to check for abnormalities.

Management

There are three management options for breech presentation at term, with consideration of maternal choice\: external
cephalic version, vaginal delivery and Caesarean section.
External cephalic version
External cephalic version (ECV) involves manual rotation of the fetus into a cephalic presentation by applying pressure to
the maternal abdomen under ultrasound guidance. Entonox and subcutaneous terbutaline are used to relax the uterus.
ECV has a 40% success rate in primiparous women and 60% in multiparous women. It should be o
women at 36 weeks and multiparous women at 37 weeks gestation.
If ECV is unsuccessful, then delivery options include elective caesarean section or vaginal delivery.
Contraindications for undertaking external cephalic version include\:
Antepartum haemorrhage
Ruptured membranes
Previous caesarean section
Major uterine abnormality
Multiple pregnancy
Abnormal cardiotocography (CTG)
Vaginal delivery
Vaginal delivery is an option but carries risks including head entrapment, birth asphyxia, intracranial haemorrhage, perinatal
mortality, cord prolapse and fetal and/or maternal trauma.
The preference is to deliver the baby without traction and with an anterior sacrum during delivery to decrease the risk of
fetal head entrapment.
The mother may be o
6Contraindications for vaginal delivery in a breech presentation include\:
Footling breech\: the baby’s head and trunk are more likely to be trapped if the feet pass through the dilated cervix too
soon
Macrosomia\: usually de
Growth restricted baby\: usually de
Other complications of vaginal birth\: for example, placenta praevia and fetal compromise
Lack of clinical sta
Previous caesarean section
Caesarean section
A caesarian section booked as an elective procedure at term is the most common management for breech presentation.
Caesarean section is preferred for preterm babies (due to an increased head to abdominal circumference ratio in preterm
babies) and is used if the external cephalic version is unsuccessful or as a maternal preference. This option has fewer risks
than a vaginal delivery.

Complications

Fetal complications of breech presentation include\:
Developmental dysplasia of the hip (DDH)
Cord prolapse
Fetal head entrapment
Birth asphyxia
Intracranial haemorrhage
Perinatal mortality
Complications of external cephalic version include\:
Transient fetal heart abnormalities (common)
Fetomaternal haemorrhage
Placental abruption (rare)

References

Oxford Handbook of Obstetrics and Gynaecology. B r e e c h P r e s e n t a t i o n \: O v e r v i e w . Published in 2011.
Jemimah Thomas. I m a g e \: C o m p l e t e b r e e c h .
Bonnie Urquhart Gruenberg. F o o t l i n g b r e e c h . Licence\: [CC BY-SA]
Bonnie Urquhart Gruenberg. F r a n k b r e e c h . Licence\: [CC BY-SA]
A Comprehensive Textbook of Obstetrics and Gynaecology. C h a p t e r 5 0 \: M a l p r e s e n t a t i o n a n d M a l p o s i t i o n \: B r e e c h
P r e s e n t a t i o n . Published in 2011.
Diana 2009.
Hamilton Fairley. L e c t u r e N o t e s \: O b s t e t r i c s a n d G y n a e c o l o g y , M a l p r e s e n t a t i o n , B r e e c h P r e s e n t a t i o n . Published in

Reviewer

Miss Saba Al Juboori
Consultant in Obstetrics and Gynaecology
Miss Neeraja Kuruba
Consultant in Obstetrics and GynaecologyRelated notes
Amniotic Fluid Embolism
Antenatal Screening for Down’s Syndrome
Antepartum Haemorrhage (APH)
Caesarean Section
Cord Prolapse
Source\: geekymedics.com