Updated: 5/14/2021

Breech Presentation

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https://upload.medbullets.com/topic/120379/images/breech_ultrasound.jpg
https://upload.medbullets.com/topic/120379/images/hyperextension_fetal_neck.jpg
https://upload.medbullets.com/topic/120379/images/frank.jpg
https://upload.medbullets.com/topic/120379/images/05122020vldbreechbirthpositions.jpg
  • Snapshot
    • A 28-year-old G1P0 woman at 37 weeks of gestation presents to her obstetrician for a prenatal care appointment. She describes feeling some soreness under her ribs in the past few weeks and feels her baby kicking in her lower abdomen. An ultrasound is performed and is seen in the image. The obstetrician describes management approaches, including an external cephalic version before labor.
  • Introduction
    • Overview
      • breech presentation occurs when a fetus is positioned logitudinally with the buttocks or feet closest to the mother's cervix
        • complete breech
          • flexion of the hips and knees
        • incomplete (footling) breech
          • some deflexion of one hip and knee
        • frank breech
          • flexion of both hips with extension of both knees
  • Epidemiology
    • Incidence
      • 3-4% of all deliveries
      • ↓ with advancing gestational age
        • 22-25% of births before 28 weeks of gestation
        • 7-15% of births at 32 weeks of gestation
        • 3-4% of births at term
    • Risk factors
      • prematurity
      • uterine malformations
      • uterine fibroids
      • polyhydramnios
      • placenta previa
      • multiple gestations
  • Presentation
    • Symptoms
      • subcostal discomfort (due to fetal head in the uterine fundus)
      • feeling of kicking in the lower abdomen
    • Physical exam
      • presence of soft mass (buttocks) and absence of hard fetal skull on transabdominal examination of the lower uterine segment
      • observation of the soft buttocks or feet on transvaginal examination
        • when cervix is dilated
  • Imaging
    • Ultrasound
      • indications
        • monitoring of fetal presentation
          • detection of breech presentation prior to 37 weeks does not warrant intervention
      • findings
        • fetal head in the uterine fundus
        • buttocks in the lower uterine segment
        • hyperextension of the fetal head, if present, is a contradiction of vaginal delivery
          • extension angle > 90 degrees
  • Treatment
    • Procedural
      • external cephalic version before labor
        • at 37 weeks gestation or later
        • perform trial of vaginal delivery if the version is successful
    • Surgical
      • cesarean delivery
        • may be planned for breech presentation, without a trial of external cephalic version
        • may be performed if trial of vaginal delivery is unsuccessful after external cephalic labor
  • Complications
    • Perinatal mortality
      • incidence
        • ↑ up to 4-fold with breech presetnation
      • associated with malformations, prematurity, and intrauterine fetal demise
    • Fetal abnormalities
      • incidence
        • 17% of preterm breech deliveries
        • 9% of term breech deliveries
      • abnormalities include CNS malformations, neck masses, and aneuploidy

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(M2.OB.17.4817) A 25-year-old G1P0000 presents to her obstetrician’s office for a routine prenatal visit at 32 weeks gestation. At this visit, she feels well and has no complaints. Her pregnancy has been uncomplicated, aside from her Rh negative status, for which she received Rhogam at 28 weeks gestation. The patient has a past medical history of mild intermittent asthma and migraine headaches. She currently uses her albuterol inhaler once a week and takes a prenatal vitamin. Her temperature is 98.6°F (37.0°C), pulse is 70/min, blood pressure is 117/68 mmHg, and respirations are 13/min. Cardiopulmonary exam is unremarkable, and abdominal exam reveals a gravid uterus with fundal height at 30 centimeters. Bedside ultrasound reveals that the fetus is in transverse lie. The patient states that she prefers to have a vaginal delivery. Which of the following is the best next step in management?

QID: 109397
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Expectant management

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(26/32)

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Weekly ultrasound

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(5/32)

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External cephalic version

3%

(1/32)

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Internal cephalic version

0%

(0/32)

5

Caesarean section at 38 weeks

0%

(0/32)

M 7 E

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