Case 65: Breech presentation

 

Case 65: Breech presentation

CASE 65: BREECH PRESENTATION

History

You are asked to see a woman in the antenatal clinic. She is 37 years old and pregnant with

her third child. Her previous children were both born by vaginal delivery after induction of

labour for post dates.

First-trimester ultrasound confirmed her menstrual dates and she is now 37 weeks. At her

last appointment at 36 weeks’ gestation, the midwife suspected that the baby was in a breech

presentation. An appointment has been made for an ultrasound assessment and to discuss

the situation.

Examination

Blood pressure is 140/85 mmHg and abdominal examination suggests a breech presentation

with the sacrum not engaged.

INVESTIGATIONS

Urinalysis: negative

Ultrasound report:

Indication for scan: suspected breech presentation

Gestational age: 37 weeks 3 days

Frank breech presentation (hips flexed, knees straight)

Estimated fetal weight: 3.2 kg

Placenta: high anterior

Liquor volume: normal (amniotic fluid index 18 cm)

Questions

• What are the options available to the woman?

• What management would you recommend in this case?100 Cases in Obstetrics and Gynaecology

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ANSWER 65

At 30 weeks the incidence of breech presentation is around 14 per cent, but is only 2–4 per

cent by term.

! Causes and associations for breech presentation

• Grand multiparity (lax uterus)

• Uterine abnormality (bicornuate, septate, fibroids)

• Placenta praevia

• Polyhydramnios

• Oligohydramnios

• Multiple pregnancy

• Congenital fetal abnormality

• Prematurity

The three options available are:

1. external cephalic version

2. elective caesarean section

3. vaginal breech delivery.

All three options should be discussed with the woman and her partner with important counselling points.

• Vaginal breech delivery:

• found to be less safe for singleton term fetuses than planned caesarean section

• carries a high chance of necessitating an emergency caesarean section

• needs involvement of an experienced obstetrician with continuous fetal heart

monitoring and ideally an epidural

• should only be allowed if the labour progresses spontaneously – augmentation

of breech labour is generally not recommended

• contraindicated with placenta praevia, large baby, footling breech or maternal

condition such as pre-eclampsia.

• External cephalic version:

• involves using external manipulation of the fetus, encouraging the baby to turn

to the cephalic presentation by way of pressure on the maternal abdomen

• is often performed after giving a uterine relaxant such as terbutaline

• carries a very small chance of abnormal fetal heart rate during or after the procedure which could necessitate an emergency caesarean section

• has approximately 50 per cent success rate overall

• some fetuses revert to breech position even after successful external cephalic version

• contraindicated with previous caesarean section, other uterine surgery, preeclampsia, intrauterine growth retardation, oligohydramnios

• can be painful.

• Elective caesarean section:

• is safer than vaginal breech delivery

• is suitable where contraindications exist to external cephalic version

• can be planned for in advance, which women may find more convenient

• does not necessarily mean a woman would need a caesarean section for any

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In this case the woman should be recommended external cephalic version as soon as possible, with options for an elective caesarean section or possible trial of breech delivery if this

is unsuccessful.

Postnatal paediatric review should focus on the baby’s hips, with a neonatal ultrasound

arranged within 6 weeks to rule out congenital hip dislocation (10–15 times more common

in breech presentation).

KEY POINTS

• Breech presentation is associated with increased perinatal morbidity and mortality.

• If a woman has a frank breech at 37 weeks she should normally be offered external

cephalic version, and if unsuccessful an elective caesarean section or possibly a

vaginal breech delivery.