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Breech Presentation

Breech is the most commonly encountered malpresentation. Its incidence decreases with gestational age: at 32 weeks' gestatation approximately 20 per cent of fetuses present with breech but the incidence decreases to 3-4 per cent at term.

The four types of breech position are:

  • Breech with extended legs (frank breech) [Figure 1]
  • Complete breech [Figure 2]
  • Footling breech [Figure 3]
  • Knee presentation [Figure 4]

 

 

Figure 1. Breech with extended legs              Figure 2. Complete breech

 

 

 

Figure 3. Footling breech                                 Figure 4. Knee presentation

 

Often no cause is identified, but the following factors favour breech presentation:

  • Extended legs
  • Preterm labour
  • Multiple pregnancy
  • Polyhydramnios
  • Hydrocephaly
  • Uterine abnormalities
  • Placenta praevia

Antenatally it can be diagnosed by abdominal palpation, during auscultation (the fetal heart is auscultated higher) or with ultrasound. During labour it is diagnosed by abdominal examination, vaginal examination (where the breech is felt as soft and irregular with no sutures palpable; the anus may be felt and fresh meconium on the examining finger is usually diagnostic). If the legs are extended, the external genitalia are very evident; and a foot may be differentiated from a hand. Careful assessment should be made at the start of labour, and anticipated labour management should be reviewed. A consultant obstetrician should be informed. Types of vaginal breech birth

  • Spontaneous (little or no assistance from the attendant)
  • Assisted (the buttocks are born spontaneously but some assistance is necessary for delivery of extended legs or arms and the head)
  • Breech extraction (manipulative delivery carried out by an obstetrician to hasten delivery in an emergency situation such as fetal compromise)

In the first stage of labour, meconium-stained liquor is sometimes found due to compression of the fetal abdomen, and is not always a sign of fetal compromise. A vaginal examination should be performed to exclude cord prolapse. In a hospital setting, the obstetrician should be informed at the onset of second stage, and a paediatrician should be present for the birth. Full dilatation of the cervix should be confirmed before the woman starts to push. Active pushing is commenced when the buttocks are distending the vulva. Failure of the breech to descend onto the perineum despite good contracts may indicate the need for caesarean section. The buttocks should be born spontaneously. If the legs are flexed, the feet disengage at the vulva and the baby is born as far as the umbilicus. If the legs are extended, intervention is needed to ease their delivery, by placing a finger in the popliteal fossa and gently flexing the knee. The midwife should feel for the elbows, which are usually on the chest. If so, they will escape at the next contraction. If the arms are not felt, they are extended. Since the arms and head cannot be delivered together, interventions such as the Loveset manoeuvre may need to be performed. (See Loveset manoeuvre) There are three methods of delivering the head - the Burns Marshall Method, the Mauriceau-Smellie-Veit manoeuvre (see individual entries), and forceps. Most breech births are performed by an obstetrician who will apply forceps to the after-coming head to achieve a controlled delivery.

The Practising Midwife featured articles

Breech birth: an unusual normal 2012; 15(3): 18-21 Author: Shawn Walker

 

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