BASICS
DESCRIPTION
At time of delivery, the sacrum or lower limbs are the presenting fetal part.
- Frank breech: Fetal hips flexed and knees extended with feet near the face. Sacrum presents first (40-60% of breech presentations at term).
- Footling or incomplete breech: Foot or knee presents first (25-35%).
- Complete breech: Hips and knees flexed. Feet and sacrum present together (5-15%).
EPIDEMIOLOGY
Prevalence
Early gestational age is highly associated with breech presentation, and risk decreases as gestational age advances.
- 22% of fetuses <28 weeks are breech.
- 3-4% of singleton term fetuses
- Less than 10% of breech fetuses at term will spontaneously vert to cephalic.
Genetics
Associated with many fetal anomalies, including anencephaly, head or neck tumors, hydrocephalus, trisomies 21 and 18, Potter syndrome, myotonic dystrophy
RISK FACTORS
- Early gestational age is number one risk factor.
- History of breech birth
- Low-birth-weight infant
- Female gender
- Fetal anomalies (9% of term breech and 17% of preterm breech)
- Advanced maternal age
- Oligohydramnios, polyhydramnios
- Nulliparity, multiple gestation
- Uterine anomalies, fibroids, or pelvic tumors
- Pelvic contractures or irregularly shaped pelvis, such as android or platypelloid
- Little evidence to support abnormal placentation (placenta previa, cornual-fundal) as a risk factor
GENERAL PREVENTION
- Prenatal folate therapy to decrease risk of neural tube defects
- Tight 1st-trimester glucose control in diabetics decreases anomalies.
- Prenatal screening to diagnose chromosomal or fetal anomalies
- Routine assessment of fetal presentation at 36 weeks to afford time for trial of external cephalic version
COMMONLY ASSOCIATED CONDITIONS
- Increased risk of cord prolapse (0.4% in cephalic presentation compared with 0.5% in frank breech, 4-6% in complete breech, and 15-18% in footling breech)
- Congenital hip dislocation has higher incidence in infants with breech presentation at term. More common in female infants than male.
DIAGNOSIS
HISTORY
- Often asymptomatic and discovered on exam or ultrasound (US)
- Often found emergently in preterm premature rupture of membranes (PPROM)
PHYSICAL EXAM
- Fetal anus/sacrum/genitals/feet palpable on vaginal exam
- Leopold maneuver or US reveals head in fundal region
- Terminal meconium found during vaginal exam after rupture of membranes
DIFFERENTIAL DIAGNOSIS
Facial, compound, asynclitic presentation on vaginal exam
DIAGNOSTIC TESTS & INTERPRETATION
US confirms presenting part. May reveal fetal anomalies and can be used to determine attitude of the fetal head (flexed, neutral, or extended).
Diagnostic Procedures/Other
- All women should be examined at 36 weeks to determine fetal lie. In some practices, the US is routinely done at 36 weeks to verify cephalic presentation.
- In breech presentation, on vaginal exam, the fetal greater trochanters and anus form a straight line. In facial presentation, the malar bones and mouth form a triangle.
TREATMENT
GENERAL MEASURES
- The options of external cephalic version (ECV), elective trial of labor (TOL), or elective cesarean section should be discussed with the patient (1)[C].
- Favorable characteristics for successful ECV may include adequate amniotic fluid index, normal estimated fetal weight (EFW), normal BMI, multiparity, double footling presentation, posterior placenta (1)[A], adequate regional anesthesia (e.g., spinal/epidural), and use of terbutaline tocolysis prior to trial of ECV (2)[B].
- Favorable characteristics for successful TOL may include multiparity, EFW of current fetus less than that of previous infant delivered vaginally, and flexed or neutral position of fetal head.
- Cord gases should be obtained following delivery, whether vaginal or by cesarean section.
- A large international, multicenter randomized clinical trial published in 2000, the Term Breech Trial, compared a policy of planned cesarean section with planned vaginal delivery; 591 delivered vaginally.
- Neonatal and perinatal morbidity and mortality were significantly lower in the planned cesarean section group compared with the vaginal delivery group (1.6% vs. 5%) with no difference in maternal morbidity or mortality.
- A 2-year follow-up study showed no significant difference in the risk of death or neurodevelopmental delay between the two modes of delivery.
- PREMODA study (2006) followed over 8,000 women and found no significant differences in neonatal morbidity or mortality in planned vaginal delivery or planned cesarean section groups (1.6% vs. 1.5%).
- Several international obstetric societies advocate the consideration of TOL for appropriate candidates when skilled staff is present and the hospital has appropriate institutional guidelines for management of vaginal breech delivery.
- With careful case selection and labor management, perinatal mortality occurs in 0.2% and serious short-term neonatal morbidity in 2% of breech births.
- Planned vaginal delivery is reasonable in selected women with a term singleton breech fetus.
- ACOG 2006 opinion on "Mode of Term Singleton Breech Delivery"ť recommends the following (3)[C]:
- Obstetricians should offer and perform ECV whenever possible.
- Decision for delivery mode should depend on the experience of the health care provider. Cesarean delivery will be the preferred mode of delivery for most physicians because of the diminishing expertise in vaginal breech delivery.
- Planned vaginal delivery of a term singleton breech fetus may be reasonable under hospital-specific protocol guidelines for both eligibility and labor management.
- No recent data support recommendation of cesarean delivery to patients whose second twin is in a nonvertex presentation, although a large multicenter randomized controlled trial is in progress.
ADDITIONAL THERAPIES
ECV should be offered to all women with breech presentation after 36 weeks.
- <50% of women with breech presentation pursue ECV; this technique is likely underutilized and might lead to increased rates of cesarean section (4).
- Fetal assessment before and after the procedure is recommended.
- Success rate range is 35-86% (average 58%), depending on provider skill and patient characteristics.
- RhoGAM should be given to all Rh-negative mothers prior to attempted ECV.
- ECV should only be attempted in settings where emergency cesarean delivery services are available.
- Contraindications to ECV (vary depending on the institution) include any contraindication to TOL (e.g., classic cesarean scar, placenta previa, active herpes simplex virus), abnormal fetal heart rate (FHR) tracing, major uterine anomaly, ruptured membranes, multiple pregnancy, major fetal anomaly, and evidence of uteroplacental insufficiency (intrauterine growth restriction, oligohydramnios).
- Nulliparity, advanced dilation, fetal weight <2,500 g, anterior placenta, and low station are all thought to be poor predictors of successful ECV, but no studies have validated these assumptions.
- Women continue to have increased risk of cesarean section (OR 2.2) or instrumented delivery (OR 1.4) even after successful ECV when compared to non-breech controls.
- Nonconventional techniques: acupuncture, moxibustion, and postural techniques are all popular alternatives. Only moxibustion has supporting data for success if performed before 34 weeks (RR 1.29) (5).
SURGERY/OTHER PROCEDURES
Breech delivery is accomplished either vaginally or by cesarean section.
- Cesarean section: Elective cesarean section via low transverse uterine incision is commonly planned for the 39th week of pregnancy or is performed with spontaneous onset of labor.
- Vaginal delivery labor management (6)[A]
- Consultation with a provider experienced in breech vaginal delivery should be obtained. Health care professionals skilled in neonatal resuscitation and cesarean section should be in attendance at the time of delivery.
- Pre- or early-labor US should be performed to assess type of breech presentation, EFW, and attitude of fetal head. A flexed head is reassuring. If the US is not available, cesarean section is recommended.
- Clinical pelvic examination should be performed to rule out pathologic pelvic contraction. Radiologic pelvimetry is not recommended. Good progress in labor is the best indicator of adequate fetal-pelvic proportions.
- Continuous electronic fetal monitoring during labor and continuous measurement of maternal pulse is recommended, ideally displayed on the same graph.
- When membranes rupture, immediate vaginal examination is recommended to rule out cord prolapse.
- In the absence of adequate progress in labor, cesarean section is advised.
- Induction of labor is usually not recommended for breech presentation.
- Oxytocin augmentation is acceptable during the first stage in the presence of labor dystocia.
- A passive second stage without active pushing for up to 90 minutes allows the breech to descend well into the pelvis. Once active pushing commences, if delivery is not imminent after 60 minutes, cesarean section is recommended.
- The active second stage of labor should take place in or near an operating room with equipment and personnel available to perform a timely cesarean section if necessary.
- Vaginal delivery techniques (6)[A]
- The delivering provider should have a rehearsed plan of action with the delivery team, especially the critical stage of delivering the fetal head.
- Avoid pulling traction on the fetus. Instead, support the body and, if necessary, use side-to-side gentle rotation to assist with body descent.
- Effective maternal pushing efforts are essential to safe delivery and should be encouraged once delivery is imminent.
- Maintain fetal body temperature with warm towels while body is exposed and head has not yet delivered.
- When umbilicus is delivered, gently reduce 3 to 4 cm of umbilical cord to avoid cord traction. The neonatal provider should palpate umbilical cord pulse and communicate FHR to team, as Doppler tones become very difficult to obtain at this point.
- Nuchal arms may be delivered by the L ¸vset or Bickenbach maneuver.
- At the time of delivery of the after-coming head, an assistant should be present to apply suprapubic pressure to favor flexion and engagement of the fetal head.
- For the rare circumstance of a trapped after-coming head or irreducible nuchal arms, nitroglycerine or general anesthesia with isoflurane to relax the uterus, generous episiotomy, pubic symphysiotomy, or emergency abdominal rescue can be lifesaving.
- The fetal head often delivers spontaneously with the assistance of suprapubic pressure, by Mauriceau-Smellie-Veit maneuver, or with the assistance of Piper forceps.
- Contraindications to vaginal breech delivery (6)[A]:
- Any presentation other than a frank or complete breech (e.g., footling breech or cord presentation)
- Fetal growth restriction or macrosomia (<2,500 g or >4,000 g)
- Fetal weight <1,500 g or gestational age <32 weeks due to high risk of head entrapment. Limited data exists to guide decision between 32 and 37 weeks.
- Any fetal head attitude other than flexed or neutral
- Any usual contraindication to vaginal delivery, such as some fetal anomalies
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Bilateral hip US of the neonate at 6 weeks corrected gestational age of life to rule out developmental dysplasia of the hip (7)[B]. However, dysplasia is 3.72 times more likely to spontaneously resolve at 9 weeks in breech infants than in nonbreech infants (8).
PATIENT EDUCATION
- In the absence of a contraindication to vaginal delivery, a woman with a breech presentation should be informed of the risks and benefits of a TOL versus elective cesarean section, and informed consent should be obtained.
- Theoretical and hands-on breech birth training simulation should be a part of basic obstetric skills training programs, such as Advanced Life Support in Obstetrics (ALSO), to prepare health providers for unexpected vaginal breech births.
PROGNOSIS
- Successful ECV at term significantly lowers cesarean rate (9)[A].
- For infants <1,500 g or <32 weeks gestational age, a higher rate of cerebral hemorrhage and perinatal death is associated with vaginal compared with cesarean delivery. This is due, in large part, to delivery of the fetal body through an incompletely dilated cervix and subsequent entrapment of fetal head.
- Careful case selection and labor management in a modern obstetric setting may achieve a level of safety similar to elective cesarean section.
- Planned cesarean section is not associated with a reduction in risk of death or neurodevelopmental delay in infants meeting criteria for planned vaginal delivery.
COMPLICATIONS
- Complications associated with breech presentation:
- Fetal asphyxia secondary to cord prolapse or compression
- Congenital hip dislocation
- Complications of ECV:
- Abnormal FHR pattern (5.7%), persisting pathologic FHR pattern (0.37%), vaginal bleeding (0.47%), placental abruption (0.12%), perinatal mortality (0.16%), emergency cesarean section (0.43%)
- Complications of vaginal delivery:
- Trauma to the head, soft tissue, brachial plexus, and spinal cord; not always prevented by cesarean section
- Entrapment of fetal head
- Complications of cesarean section:
- Bleeding, infection, damage to maternal bowel or bladder, increased risk of placenta previa or accreta in future pregnancies, and hysterectomy
- Increased risk of maternal mortality compared with vaginal delivery
- Maternal recovery time is often longer following a cesarean section.
REFERENCES
11 Burgos J, Melchor JC, Pijo ˇn JI, et al. A prospective study of the factors associated with the success rate of external cephalic version for breech presentation at term. Int J Gynaecol Obstet. 2011;112(1):48-51.22 Goetzinger KR, Harper LM, Tuuli MG, et al. Effect of regional anesthesia on the success rate of external cephalic version: a systematic review and meta-analysis. Obstet Gynecol. 2011;118(5):1137-1144.33 ACOG Committee on Obstetric Practice. ACOG Committee Opinion No. 340. Mode of term singleton breech delivery. Obstet Gynecol. 2006;108(1):235-237.44 Caughey AB, Cahill AG, Guise JM, et al. Safe prevention of the primary cesarean delivery. Am J Obstet Gynecol. 2014;210(3):179-193.55 Zhang QH, Yue JH, Liu M, et al. Moxibustion for the correction of nonvertex presentation: a systematic review and meta-analysis of randomized controlled trials. Evid Based Complement Alternat Med. 2013;2013:241027.66 Kotaska A, Menticoglou S, Gagnon R, et al. SOGC clinical practice guideline: vaginal delivery of breech presentation: no. 226, June 2009. Int J Gynaecol Obstet. 2009;107(2):169-176.77 Quan T, Kent AL, Carlisle H. Breech preterm infants are at risk of developmental dysplasia of the hip. J Paediatr Child Health. 2013;49(8):658-663.88 Sarkissian EJ, Sankar WN, Baldwin K, et al. Is there a predilection for breech infants to demonstrate spontaneous stabilization of DDH instability? J Pediatr Orthop. 2014;34(5):509-513.99 Hofmeyr GJ, Kulier R. External cephalic version for breech presentation at term. Cochrane Database Syst Rev. 2012;(10):CD000083.
ADDITIONAL READING
- American College of Obstetricians and Gynecologists. External cephalic version. ACOG Practice Bulletin No. 13. Obstet Gynecol. 2000;95(2):1-7.
- Goffinet F, Carayol M, Foidart JM, 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(4):1002-1011.
- 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(9239):1375-1383.
- Whyte H, Hannah ME, Saigal S, et al. Outcomes of children at 2 years after planned cesarean birth versus planned vaginal birth for breech presentation at term: the international randomized Term Breech Trial. Am J Obstet Gynecol. 2004;191(3):864-871.
SEE ALSO
Placenta Previa; Preterm Labor
CODES
ICD10
- O32.1XX0 Maternal care for breech presentation, unsp
- O64.1XX0 Obstructed labor due to breech presentation, unsp
- O32.8XX0 Maternal care for other malpresentation of fetus, not applicable or unspecified
- O32.1XX9 Maternal care for breech presentation, other fetus
- O32.1XX1 Maternal care for breech presentation, fetus 1
- O32.8XX5 Maternal care for other malpresentation of fetus, fetus 5
- O64.1XX9 Obstructed labor due to breech presentation, other fetus
- O64.1XX5 Obstructed labor due to breech presentation, fetus 5
- O64.1XX1 Obstructed labor due to breech presentation, fetus 1
- O64.8XX9 Obstructed labor due to oth malposition and malpresent, oth
- O64.1XX3 Obstructed labor due to breech presentation, fetus 3
- O32.8XX2 Maternal care for other malpresentation of fetus, fetus 2
- O32.8XX4 Maternal care for other malpresentation of fetus, fetus 4
- O32.8XX1 Maternal care for other malpresentation of fetus, fetus 1
- O32.1XX2 Maternal care for breech presentation, fetus 2
- O64.8XX4 Obstructed labor due to oth malpos and malpresent, fetus 4
- O64.8XX3 Obstructed labor due to oth malpos and malpresent, fetus 3
- O32.1XX4 Maternal care for breech presentation, fetus 4
- O32.8XX9 Maternal care for other malpresentation of fetus, other fetus
- O32.1XX5 Maternal care for breech presentation, fetus 5
- O64.8XX5 Obstructed labor due to oth malpos and malpresent, fetus 5
- O64.8XX2 Obstructed labor due to oth malpos and malpresent, fetus 2
- O64.1XX4 Obstructed labor due to breech presentation, fetus 4
- O32.1XX3 Maternal care for breech presentation, fetus 3
- O32.8XX3 Maternal care for other malpresentation of fetus, fetus 3
- O64.1XX2 Obstructed labor due to breech presentation, fetus 2
ICD9
- 652.20 Breech presentation without mention of version, unspecified as to episode of care or not applicable
- 652.21 Breech presentation without mention of version, delivered, with or without mention of antepartum condition
- 652.23 Breech presentation without mention of version, antepartum condition or complication
- 652.10 Breech or other malpresentation successfully converted to cephalic presentation, unspecified as to episode of care or not applicable
- 652.11 Breech or other malpresentation successfully converted to cephalic presentation, delivered, with or without mention of antepartum condition
- 652.13 Breech or other malpresentation successfully converted to cephalic presentation, antepartum condition or complication
SNOMED
- Breech presentation
- Frank breech presentation
- Footling breech presentation
- Incomplete breech presentation
- Complete breech presentation
CLINICAL PEARLS
- ECV should be offered to all women without contraindications with a breech presentation, ideally at 37 weeks.
- Planned vaginal delivery by an experienced provider is reasonable in selected women with a term singleton fetus using a specific protocol for labor and delivery management.
- Long-term outcomes of neonatal death or neurodevelopmental delay are not reduced by planned cesarean section.