Breech Presentation

Caron J. Gray1; Meaghan M. Shanahan2.

1
Creighton University School of Medicine

2
Creighton University

Last Update: October 13, 2017.

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. These are discussed in more detail in the
pathophysiology section.

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
As mentioned previously, the most common clinical conditions or disease processes that result in
the breech presentation are those that affect fetal motility or the vertical polarity of the uterine
cavity.
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.

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.