1. Breech Presentation Dr Madhavi Kalidindi
Consultant Obstetrician & Gynaecologist
Barking, Havering and Redbridge University Hospitals NHS Trust

2. 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.

3. Frank or extended breech: 65 to 70% Complete or flexed breech: 30%
Three types of breech
Frank or extended breech: 65 to 70%
Complete or flexed breech: 30%
Footling breech: 10%
Legs are flexed at the hips and extended at the knees.
Presenting part: Buttocks
Hips and knees are flexed.
Presenting part: Buttocks and feet
One or both feet or knees present below the fetal buttocks.

4. Incidence
Incidence of breech presentation decreases with gestation as spontaneous version happens.
20% at 28 weeks of gestation
16% at 32 weeks
3-4% at term
Hence, breech is more common
in preterm labours.

5. Risk factors for persistent breech presentation
Maternal conditions
Fetal conditions
Multiparity
Congenital uterine anomalies
Uterine fibroids
Previous breech presentation
Placenta previa or cornual placenta
Cephalo-pelvic disproportion
Preterm delivery
Polyhydramnios
Oligohydramnios
Fetal macrosomia
Multiple pregnancy
Fetal anomalies

6. 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?

7. 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

8. 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

9. Vaginal breech delivery Vs Caesarean section
Consider woman’s wishes
Consider all of the favourable factors for vaginal breech delivery
Consider current evidence & guidelines
Document the discussion and plan

10. Favourable factors for vaginal breech delivery
Maternal
Multiparity
Adequate pelvis
No previous LSCS or uterine scars
Preference for vaginal birth
Fetal
Frank or complete breech
No hyperextension of the fetal head
No placental insufficiency or fetal growth restriction
Fetal EFW < 3800 gm
Institutional
Continuous CTG monitoring
Skilled practitioners
Access for caesarean section

11. Successful vaginal breech delivery with no adverse outcomes
Appropriate case selection
Healthy, normally grown fetus in frank / complete breech with flexed head
Skilled practitioners
Adherence to strict protocols
Team work and effective communication
Successful vaginal breech delivery with no adverse outcomes
A committed mother

12. 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.

13. Intrapartum management of breech
Either the semirecumbent or an all-fours position is adopted, as per the experience of the practitioners 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.
Maternal position
Women should have a choice of analgesia in labour.
Epidural should not be routinely advised as no sufficient evidence.
Analgesia
Caesarean section should be considered if there is a delay in the progress or descent of the breech at anytime in the first / second stage of labour.
Delay in progress or descent

14. 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.

15. Post delivery Cord bloods for blood gases Accurate documentation
Debrief parents and staff

16. Breech delivery techniques video