Case 22 A 32-year-old woman with a fetus in the breech position at 37 weeks’ gestation

 Case 22 A 32-year-old woman with a fetus in

the breech position at 37 weeks’

gestation

Mrs Alvares is 37 weeks’ pregnant, this is her first

pregnancy. She comes to the antenatal clinic as she saw her

community midwife last week and although all was well her

midwife thought her baby may be breech. Her routine

antenatal check is reassuring but the baby does seem to be

in a breech presentation.

What will you tell Mrs Alvares?

Instead of the normal head down position her baby

seems to be presenting ‘ bottom first ’ . This is not uncommon, about 20% of babies are breech at 28 weeks but they

usually turn on their own so only about 3 – 4% are breech

at term.

The baby may still turn on its own but if it does not

the options include turning the baby to face head down

(external cephalic version [ECV]), elective caesarean

section or vaginal breech delivery.

What investigations are required?

An ultrasound scan should be performed to confirm the

presentation. In some cases a baby will adopt a breech

position because of a fetal or uterine abnormality,

reduced liquor volume or placenta praevia and these conditions need to be excluded.

Mrs Alvares has a scan which confirms that her baby is

breech with flexed legs. The baby is normally grown and has

a normal liquor volume. The placenta is normally located

and there is no obvious uterine or fetal abnormality to

account for the breech presentation (Fig. 22.1; Box 22.1).

What information should you give Mrs

Alvares about delivery?

She should be informed that planned caesarean section

carries a reduced perinatal mortality and early neonatal

morbidity for babies with a breech presentation at term

compared with a planned vaginal birth. There is no evidence that the long - term health of babies with a breech

presentation delivered at term is influenced by how the

baby is born.

She should be advised that planned caesarean section

for breech presentation carries a small increase in serious

immediate complications for her compared with planned

vaginal birth. It does not carry any additional risk to her

long - term health outside pregnancy. The long - term effect

of planned caesarean section on future pregnancy outcomes is uncertain.

Mrs Alvares would prefer not to have a cesarean section but

is worried about the risk to the baby of a vaginal breech

delivery. She remembers that you mentioned that it might

be possible to turn the baby to face head down and would

like some further information about this.

What will you tell her?

The procedure called external cephalic version (ECV)

involves external manipulation of the baby through the

maternal abdomen to turn the baby to a cephalic presentation. It should be performed after 36 weeks with a first

baby and after 37 weeks in parous women. The success

rate is aproximately 40% with a first baby and approximately 60% in parous women. If it is successful, less than

5% of babies will turn back to breech.

The risks to the baby include acute fetal distress, spontaneous rupture of the fetal membranes and placental

abruption which may require emergency cesarean section

but these occur very uncommonly. It can cause a significant amount of maternal discomfort.

She thinks she would like to have an ECV performed. An

appointment is made for the following day and she returns

to labour ward. She wants to know exactly what will

happen.

Obstetrics and Gynaecology: Clinical Cases Uncovered.

By M. Cruickshank and A. Shetty. Published 2009 by Blackwell

Publishing. ISBN 978-1-4051-8671-1.Case 22 145

PART 2: CASES

Figure 22.1 Fetal malpresentation.

Vertex Shoulder

Extended breech Flexed breech

Footling breech

Chin anterior Chin posterior

Brow presentation

Box 22.1 Fetal malpresentation

By 37 weeks >95% of babies will be in a longitudinal lie

and vertex presentation. The remainder will be breech, face

or brow presentations (also longitudinal lie) and oblique,

transverse or unstable (variable) lies. Of these the breech

and face presentations are, at least in theory, able to be

delivered vaginally.

The risks of malpresentation are related to obstructed

labour and the risk of uterine rupture secondary to

prolonged contractions without any prospect of delivery. The

other major risk with a non-longitudinal lie is of umbilical

cord or a limb prolapsing through the cervix when the

fetal membranes rupture. In view of this, women with

non-longitudinal or unstable lies will normally be managed

as inpatients from about 36 weeks until delivery or until

the fetal lie stabilizes.

Maternal causes of malpresentation include uterine

abnormality (e.g. fibroids or a placental praevia) and high

parity also increases the risk. Fetal causes include multiple

pregnancy, reduced liquor volume or fetal abnormality

preventing a cephalic presentation.

What would you discuss with her?

She will be monitored by cardiotocogram (CTG) to check

the baby ’ s heart rate before the procedure is commenced.

An ultrasound scan will be performed to check baby is

still breech and to identify where the fetal back is positioned. Tocolysis (uterine relaxation) will be offered as it

has been proven to improve success rates (usually by IV

or subcutaneous beta - sympathomimetics).

She will be positioned in a slightly head down position

(to try to elevate the breech out of the pelvis) with a146 Part 2: Cases

PART 2: CASES

wedge under her right hip (to prevent aorto - caval

compression from the pregnant uterus when lying

flat). Pressure will be used on the maternal abdomen to

try to elevate the breech out of the pelvis and turn the

baby through a forward or backward roll to a cephalic

presentation. Ultrasound can be used to guide the

procedure.

Following the procedure, whether successful or not,

she will be put back on the CTG to make sure the baby

is healthy.

RCOG guidelines recommend that women undergoing ECV do not need to be prepared for caesarean section

as the chance of this being required as an emergency is

very small (Fig. 22.2 ).

There are three attempts at ECV with tocolysis but

unfortunately the baby remains breech. The post-ECV CTG is

reassuring. Mrs Alvares is sure she does not want a vaginal

breech delivery and would like some further information

about caesarean section.

What will you tell her?

To reduce the risks of breathing problems in the baby,

elective caesarean sections are usually carried out after 39

weeks. She would normally be admitted on the morning

of her section. She would be asked to fast from midnight

the night before and take some antacid tablets (to reduce

the risks of aspiration if general anaesthetic became

necessary).

Prior to the caesarean section, the lie of the baby would

be checked on ultrasound to confirm it was still in the

breech position. If it was found to be head down she

would be advised to go home to await normal labour. She

would normally receive a spinal anaesthetic for her

section as this is associated with reduced risks to mother

and baby, and would allow her to be awake to see her baby

at birth.

Once her anaesthetic is working a catheter will be

placed in her bladder and her section will be carried out

through a ‘ bikini - line ’ incision. The baby and placenta are

delivered through the incision and then the uterus and

layers of the abdominal wall are repaired, the procedure

usually takes 45 – 60 minutes. Afterwards she will be given

painkillers as necessary and will usually be fit to go home

after 3 – 5 days.

Having a baby, either vaginally or by caesarean section,

carries a risk of excess bleeding sometimes requiring

blood transfusion and a risk of infection. Caesarean

section carries an increased risk of thrombosis (DVT)

and damage to bladder and ureters compared with

vaginal delivery. In order to minimize these risks antibiotic prophylaxis is given during the procedure and

thromboprophylaxis is given postnatally.

The positive and negative effects of caesarean section

have been extensively investigated. The NICE guideline

on caesarean section summarizes these in one of its

appendices.

Mrs Alvares is happy with the explanation and is booked for

an elective section at 39 weeks. She is admitted as planned

and, as the baby remains in a breech presentation, has an

uncomplicated elective section. She has a female baby in

good condition weighing 3.24kg and is fit for discharge

after 3 days.

Figure 22.2 External cephalic version.

(a) (b) (c)Case 22 147

PART 2: CASES

Further reading

RCOG Green Top Clinical Guideline (no 20a). External cephalic

version and reducing the incidence of breech presentation.

December 2006