History

Fact Explanation
Epigastric or subcoastal discomfort The fetal head exerts pressure over the maternal ribs. [2]
Fetal movements in the pelvic region Some patients may complain that fetal movements are frequently felt in the pelvic region. [2]
Prematurity Prematurity is a recognized predisposing factor for breech presentation. [1]
History of breech delivery Breech presentation is known to recur in subsequent pregnancies. [3]
Twin pregnancy Multiple pregnancy is a risk factor for malpresentation.
References
  1. CRUIKSHANK DP. Breech presentation. Clin Obstet Gynecol [online] 1986; 29(2) 255–263. [viewed 17 April 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/3720061
  2. UMOH A. V, ABAH M. G, UMOIYOHO A.J. BREECH PRESENTATION-An overview. Ibom medical journal. [online] 2(1) [viewed 17 April 2014] Available from: http://ibommedicaljournal.com/index.php?option=com_content&view=article&id=190:breech-presentation-an-overview&catid=90&Itemid=593
  3. PAVOL ZUBOR, IMRICH ZIGO, JANA SIVAKOVA, PETRA MORICOVA, IVANA KAPUSTOVA, STEFAN KRIVUS, JAN DANKO. Repetitive Breech Presentations at Term. Case Reports in Obstetrics and Gynecology [online]2013: 2013 [viewed 17 April 2014] Available from: http://www.hindawi.com/journals/criog/2013/628572/

Examination

Fact Explanation
Fetal head is felt in the fundus Hard, round and ballotable mass is felt in the fundus. [3]
Fetal breech is in the lower pole [3] The breech is felt as a soft and less rounded mass.
Fetal heart sounds This is best heard at the level of maternal umbilicus. [3]
Clinical pelvimetry [2] Enables detection of feto-pelvic disproportion. [1]
Amount of liquor Polyhydroamnios [4] and oligohydroamnios [5] both are known risk factors for breech presentation. Fetal parts will be difficult to palpate due to the increased amount of liquor and will be easily palpable in oligohydroamnios.
References
  1. CRUIKSHANK DP. Breech presentation. Clin Obstet Gynecol [online] 1986; 29(2) 255–263. [viewed 17 April 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/3720061
  2. THE MANAGEMENT OF BREECH PRESENTATION. Green-top Guideline No. 20b [online] [viewed 17 April 2014] Available from: http://www.rcog.org.uk/files/rcog-corp/GtG%20no%2020b%20Breech%20presentation.pdf
  3. UMOH A. V, ABAH M. G, UMOIYOHO A.J. BREECH PRESENTATION-An overview. Ibom medical journal. [online] 2(1) [viewed 17 April 2014] Available from: http://ibommedicaljournal.com/index.php?option=com_content&view=article&id=190:breech-presentation-an-overview&catid=90&Itemid=593
  4. PAVOL ZUBOR, IMRICH ZIGO, JANA SIVAKOVA, PETRA MORICOVA, IVANA KAPUSTOVA, STEFAN KRIVUS, JAN DANKO. Repetitive Breech Presentations at Term. Case Reports in Obstetrics and Gynecology [online]2013: 2013 [viewed 17 April 2014] Available from: http://www.hindawi.com/journals/criog/2013/628572/
  5. MOSTELLO D, CHANG JJ, BAI F, WANG J, GUILD C, STAMPS K, LEET TL. Breech presentation at delivery: a marker for congenital anomaly? Journal of Perinatology [online]2014 34, 11–15; [viewed 17 April 2014] Available from: doi:10.1038/jp.2013.132

Differential Diagnoses

Fact Explanation
Face presentation On abdominal examination the head lies high and a distinct groove will be palpable between the fetal back and the head due to hyperextension of the head. The maxillary prominences, nose and mouth is palpable in vaginal examination. [1]
Brow presentation This is diagnosed during the labor. [2] The orbital ridge and the sagittal suture are felt.
References
  1. PATRICK D. diagnosis and management of face presentation. Obstetrics & Gynecology [online] January 1981 57(1) [viewed 17 April 2014] Available from:
  2. LOKENATH B. Brow Presentation. Br Med J. [online] Dec 2, 1961; 2(5265): 1469–1472. [viewed 17 April 2014] Available from:

Investigations - for Diagnosis

Fact Explanation
Ultrasound scan [5] Confirms the diagnosis and differentiate frank, complete and incomplete breech presentations. Detects polyhydroamnios, [4] placenta previa [2] and multiple pregnancy which are risk factors for breech presentation. [1]
References
  1. CRUIKSHANK DP. Breech presentation. Clin Obstet Gynecol [online] 1986; 29(2) 255–263. [viewed 17 April 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/3720061
  2. FIANU S, VACLAVINKOVA V. The site of placental attachment as a factor in the aetiology of breech presentation. Acta Obstet Gynecol Scand [online] 1978; 57: 371–372. [viewed 17 April 2014] Available from: DOI: 10.3109/00016347809154033
  3. LUTERKORT M, PERSSON P, WELDNER B. Maternal and fetal factors in breech presentation. Obstet Gynecol [online] 1984; 64: 55–59. [viewed 17 April 2014] Available from:
  4. PAVOL ZUBOR, IMRICH ZIGO, JANA SIVAKOVA, PETRA MORICOVA, IVANA KAPUSTOVA, STEFAN KRIVUS, JAN DANKO. Repetitive Breech Presentations at Term. Case Reports in Obstetrics and Gynecology [online]2013: 2013 [viewed 17 April 2014] Available from: http://www.hindawi.com/journals/criog/2013/628572/
  5. UMOH A. V, ABAH M. G, UMOIYOHO A.J. BREECH PRESENTATION-An overview. Ibom medical journal. [online] 2(1) [viewed 17 April 2014] Available from: http://ibommedicaljournal.com/index.php?option=com_content&view=article&id=190:breech-presentation-an-overview&catid=90&Itemid=593

Investigations - Fitness for Management

Fact Explanation
X-ray pelvimetry [3] Not done routinely. [2] Aids in detection of hyperextended neck of the fetus which is a contraindication for vaginal delivery. [2]
CT pelvimetry [3] Not done routinely. [2] However this is known to have lesser risk of radiation exposure to the fetus when compared with X-ray pelvimetry. Enable detection of feto-pelvic disproportion. [1]
Ultrasound scan [3] Confirms the diagnosis and differentiate frank, complete and incomplete breech presentations. In frank breech the hips are flexed and knees are extended. Both hips and knees are flexed in complete breech. Foot is the lowest and hence the presenting part in footling breech, in which either one or both hips are extended. Detects polyhydroamnios, [4] placenta previa [2] and multiple pregnancy which are risk factors for breech presentation. [1]
Blood grouping and cross match [3] This should be done prior to the caesarian section and prior to external cephalic version.
References
  1. CRUIKSHANK DP. Breech presentation. Clin Obstet Gynecol [online] 1986; 29(2) 255–263. [viewed 17 April 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/3720061
  2. THE MANAGEMENT OF BREECH PRESENTATION. Green-top Guideline No. 20b [online] [viewed 17 April 2014] Available from: http://www.rcog.org.uk/files/rcog-corp/GtG%20no%2020b%20Breech%20presentation.pdf
  3. UMOH A. V, ABAH M. G, UMOIYOHO A.J. BREECH PRESENTATION-An overview. Ibom medical journal. [online] 2(1) [viewed 17 April 2014] Available from: http://ibommedicaljournal.com/index.php?option=com_content&view=article&id=190:breech-presentation-an-overview&catid=90&Itemid=593

Investigations - Followup

Fact Explanation
Cardiotocogram [1] Fetal heart rate should be monitored continuously during the labor.[3]
Ultrasound scan of the pelvic organs Uterine abnormalities are associated with breech presentation. [1,2] (uterine septum, bicornuate uterus, unicornuate uterus, large fibroids)
References
  1. CRUIKSHANK DP. Breech presentation. Clin Obstet Gynecol [online] 1986; 29(2) 255–263. [viewed 17 April 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/3720061
  2. PAVOL ZUBOR, IMRICH ZIGO, JANA SIVAKOVA, PETRA MORICOVA, IVANA KAPUSTOVA, STEFAN KRIVUS, JAN DANKO. Repetitive Breech Presentations at Term. Case Reports in Obstetrics and Gynecology [online]2013: 2013 [viewed 17 April 2014] Available from: http://www.hindawi.com/journals/criog/2013/628572/
  3. THE MANAGEMENT OF BREECH PRESENTATION. Green-top Guideline No. 20b [online] [viewed 17 April 2014] Available from: http://www.rcog.org.uk/files/rcog-corp/GtG%20no%2020b%20Breech%20presentation.pdf

Investigations - Screening/Staging

Fact Explanation
Anomaly scan Various congenital anomalies are associated with breech presentation. [1,2] (Anencephaly, hydrocephalus) Features suggestive of trisomy 21,13 and 18 may also present.
Fetal karyotype Although not routinely done if anomaly scan is suggestive of fetal karyotyping can be done to diagnose chromosomal abnormalities like trisomy 21, 18 and 13. [1]
References
  1. CRUIKSHANK DP. Breech presentation. Clin Obstet Gynecol [online] 1986; 29(2) 255–263. [viewed 17 April 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/3720061
  2. PAVOL ZUBOR, IMRICH ZIGO, JANA SIVAKOVA, PETRA MORICOVA, IVANA KAPUSTOVA, STEFAN KRIVUS, JAN DANKO. Repetitive Breech Presentations at Term. Case Reports in Obstetrics and Gynecology [online]2013: 2013 [viewed 17 April 2014] Available from: http://www.hindawi.com/journals/criog/2013/628572/

Management - General Measures

Fact Explanation
Patient education Patient should be aware of all the possible options of delivery and risks and benefits of each of them. The elective Cesarean section carries its own risks to the mother, but it reduces the perinatal and immediate postnatal complications to the newborn. However the mode of delivery does not influence long term adverse consequences to the baby, [4] but the woman might have risk of abnormal placentation, uterine rupture and postpartum hemorrhage. [2,3] Women with any contraindication for a vaginal breech delivery should be advised to proceed to a cesarean section.
Analgesia Adequate analgesia should be supplied, depending on the patient’s request. [1,2]
References
  1. GINA LOWDON. Breech Presentation: Caesarean operation versus normal birth. AIMS Journal Autumn [online] 1998: 10 (3) [viewed 17 April 2014] Available from: http://www.aims.org.uk/Journal/Vol10No3/breechCSvsNormal.htm
  2. THE MANAGEMENT OF BREECH PRESENTATION. Green-top Guideline No. 20b [online] [viewed 17 April 2014] Available from: http://www.rcog.org.uk/files/rcog-corp/GtG%20no%2020b%20Breech%20presentation.pdf
  3. KOK N, RUITER L, HOF M, et al. Risk of maternal and neonatal complications in subsequent pregnancy after planned caesarean section in a first birth, compared with emergency caesarean section: a nationwide comparative cohort study. BJOG. [online] 2014;121(2):216-23. [viewed 17 April 2014] Available from: DOI: 10.1111/1471-0528.12483
  4. HOFMEYR GJ, HANNAH ME. Planned caesarean section for term breech delivery (Review) Cochrane Database of Systematic Reviews [online] 2003: 2. [viewed 18 April 2014] Available from: DOI: 10.1002/14651858.CD000166.

Management - Specific Treatments

Fact Explanation
Vaginal breech delivery [2] Either spontaneous, assisted or total breech extraction is practiced. Footling breech, kneeling breech, large babies (more than 4000g) [6], intrauterine growth retardation (smaller than 2000g) [6], hyperextended fetal neck and past cesarean section are contraindications for vaginal breech delivery. [1,3] Frank and complete breech presentations are favorable for vaginal breech delivery. [2] The woman should be in dorsal or lithotomy position. [3] A wide episiotomy should be done with the crowning of breech. The arms should be delivered using the Lovset manoeuvre (baby’s arms are swept across the face.) The flexion of the after coming head is facilitated by applying supra-pubic pressure or by Mauriceau-Smellie-Veit manoeuvre (head is pushed up in to the uterine cavity and rotated to facilitate better engagement.) Burns-Marshall method (holding the feet of the baby swing it towards the mothers abdomen after the hair becomes visible) , Mariceau-Smellie-Veit manoeuvre (while one person is applying supra-pubic pressure the other one should palpate the baby’s maxillary prominences from the left index and middle fingers. Pressure is applied over the maxillary prominences and gentle flexion of the head is achieved.) or forceps can also be used to deliver the after coming head. If all the above failed symphysiotomy or caesarean section can be done. [3]
Cesarean delivery Presentations that are not suitable for a vaginal breech delivery (footling breech) and fetal compromise which need immediate delivery are indications for cesarean delecery. [1] Planned cesarean section is found to be cost effective when compared with planned vaginal delivery for a singleton in breech presentation at term. [7]
External cephalic version (ECV) and vaginal delivery [8] An attempt is made to rotate the fetus in to the cephalic presentation trans abdominally. This is done during the 34 to 36 weeks of period of amenorrhea. [4] Multiple pregnancy, intrauterine growth retardation, vaginal bleeding in the third-trimester, uterine malformations, placenta previa, maternal cardiac disease, maternal hypertension (Either pregnancy induced or chronic hypertension) fetus at-risk and major fetal anomalies are contraindications for external cephalic version. [5] The breech is disengaged from the pelvis and the fetal head is guided to the maternal pelvis using either the back flip or forward roll. [5]
References
  1. MARY E. H., WALTER J. H., SHEILA A. H., ELLEN D. H., SAROJ S., ANDREW R. W., Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. The Lancet [online] 2000: 356 (9239) 1375-1383. [viewed 17 April 2014] Available from: doi:10.1016/S0140-6736(00)02840-3
  2. IRION O, ALMAGBALY PH, MORABIA A. Planned vaginal delivery versus electve casearean section: a study of 705 singleton term breech presentations. Br. J Obstet Gynaecol [online] 1998; 105: 710-717. [viewed 17 April 2014] Available from: DOI: 10.1111/j.1471-0528.1998.tb10200.x
  3. THE MANAGEMENT OF BREECH PRESENTATION. Green-top Guideline No. 20b [online] [viewed 17 April 2014] Available from: http://www.rcog.org.uk/files/rcog-corp/GtG%20no%2020b%20Breech%20presentation.pdf
  4. UMOH A. V, ABAH M. G, UMOIYOHO A.J. BREECH PRESENTATION-An overview. Ibom medical journal. [online] 2(1) [viewed 17 April 2014] Available from: http://ibommedicaljournal.com/index.php?option=com_content&view=article&id=190:breech-presentation-an-overview&catid=90&Itemid=593
  5. ANDREW S. C., STEPHANIE D. S. External Cephalic Version. Am Fam Physician. [online] 1998 Sep 1;58(3):731-738 [viewed 17 April 2014] Available from: http://www.aafp.org/afp/1998/0901/p731.html
  6. BETTY-A. D., KENNETH C. J., ANDRÉ B. L. Evolving Evidence Since the Term Breech Trial: Canadian Response, European Dissent, and Potential Solutions. J Obstet Gynaecol Can [online] 2010;32(3):217–224. [viewed 17 April 2014] Available from: http://jogc.ca/abstracts/full/201003_Obstetrics_2.pdf
  7. ROBERTO P. AMIRAM G., MARY E. H., SUSAN R., et al. The costs of planned cesarean versus planned vaginal birth in the Term Breech Trial. CMAJ [online] April 11, 2006: 174 (8) [viewed 18 April 2014] Available from: doi: 10.1503/cmaj.050796
  8. HOFMEYR GJ, HANNAH ME. Planned caesarean section for term breech delivery (Review) Cochrane Database of Systematic Reviews [online] 2003: 2. [viewed 18 April 2014] Available from: DOI: 10.1002/14651858.CD000166.