Definition and Types
Breech presentation: buttocks or feet are the presenting fetal part
Types:
| Type | Description |
|---|---|
| Frank breech (most common type) | Buttocks presenting (flexed hips + extended knees) |
| Complete breech | Buttocks (+ feet) presenting (flexed hips + flexed knees) |
| Single (incomplete) footling breech | 1 foot presenting (one leg fully flexed + one leg fully extended) |
| Double (complete) footling breech | 2 feet presenting (both legs fully extended) |
Detection and Investigations
ALL women should be offered abdominal palpation to check the fetal presentation at 36 weeks to identify possible breech presentation
If breech is suspected clinically → perform an ultrasound
Breech presentation suspected / identified before 36 weeks is of limited significance, as the fetus is likely to spontaneously revert to cephalic presentation before 36 weeks.
Management
If breech presentation is confirmed at 36 weeks:
If a Caesarean section is already indicated for another reason (e.g. maternal request, placental praevia), there is no need to go down the following steps (i.e. offer ECV). Ultimately, the purpose of performing ECV is to allow vaginal delivery.
| Step | Recommended step |
|---|---|
| 1 | Offer external cephalic version (ECV) |
| 2 | If ECV is successful → vaginal delivery can proceed
If ECV is unsuccessful or the mother declines ECV (i.e. the baby remains breech), discuss the following options (see below for more details):
|
Caesarean Section vs Vaginal Breech Delivery
This applies to step 2 – i.e. baby remains breech from unsuccessful or declined ECV.
The guidelines stress that doctors must counsel women in an unbiased way (see exception below), balancing the immediate benefits of a C-section for the baby against the long-term risks a C-section poses to the mother’s future reproductive health.
| Delivery Option | Benefits | Risk |
|---|---|---|
| Caesarean section |
|
|
| Vaginal breech delivery |
|
|
Important exception – Vaginal breech birth is specifically NOT recommended if ANY of the following is present:
- Footling presentation
- Hyperextendd fetal neck
- High or low fetal weight
- Evidence of fetal compromise
These babies should be delivered by Caesarean section
External Cephalic Version (ECV)
Description of ECV: external manipulation (through the maternal abdomen) of the foetus into the cephalic presentation
Tocolysis with β-mimetics (e.g. terbutaline, salbutamol, ritodrine) is recommended to improve the success rate of ECV.
Timing to Offer
Timing to offer depends on the patient’s parity:
- Nulliparous
Parity is defined as the number of pregnancies in which the fetus has reached viability (commonly ≥20 or ≥24 weeks gestation), regardless of whether the infant was born alive or stillborn.
Nulliparous refers to a woman who has never given birth to a viable infant.
→ 36 weeks - Multiparous
Multiparous refers to a woman who has had one or more previous pregnancies resulting in a viable infant, i.e., she has given birth at least once before.
→ 37 weeks
Patient Counselling
Points outlined by RCOG:
- ~ 50% success rate
- After an unsuccessful ECV attempt at 36 weeks, it is unlikely the baby will spontaneously return to cephalic presentation
- Advise women that most people tolerate ECV but it can be a painful procedure
- Slightly increased rate of caesarean section and instrumental delivery
- But if ECV is successful, it reduces the chance of caesarean section
Contraindications
RCOG advises that there are no consensus contraindications:
- Presence of absolute indications for caesarean delivery (e.g. placental praevia, placenta accreata syndrome)
- Multiple pregnancy (except after delivery of a first twin), RCOG recommendations for delivery:
- 1st twin breech (ECV contraindicated) → C-section
- 2nd twin breech → Can attempt vaginal delivery (after delivery of first twin)
- Rhesus isoimmunisation
- Vaginal bleeding (e.g., antepartum haemorrhage) within 1 week
- Ruptured membrane
- Abnormal CTGCardiotocography
- Placental abruption
- Severe pre-eclampsia
- Caution if oligohydramnios / hypertension
ECV can only be offered prior to the onset of labour, provided there are no contraindications.
ECV is generally contraindicated once labour has begun, especially if membranes have ruptured (due to a markedly increased risk of umbilical cord prolapse).
References
NICE Antenatal care
RCOG Management of breech presentation
RCOG External cephalic version and reducing the incidence of term breech presentation