Breech PresentationAdam Fogel, Christopher Elliot, Miso Gostimir

Case

A 32 yo G3T2P0A0L2 woman presents for routine prenatal care at 37 weeks. Her pregnancy is complicated by Rh-negative status, depression and a history of LSIL with normal colposcopy in first trimester. Today she reports good fetal movement and denies leaking fluid or contractions. During your examination you measure fundal height at an appropriate 37 cm, and find fetal heart tones located in the upper aspect of the uterus. A bedside ultrasound reveals frank breech presentation.

Outline & Objective

Objective: List strategies for management of abnormal fetal presentations, as well as the relative timing of each intervention.

Specific Goals:1. Review Types of Breech presentation2. Review Risk Factors for Breech presentation3. Discuss Management of Breech, antepartum and intrapartum

What is Breech Presentation?

What is Breech Presentation?• Breech Presentation: the presenting fetal part is the buttocks

Legs folded with feet at the level of the buttocks (Knees flexed)

One or both feet point down so the legs would emerge first

Legs Point up with feet by baby’s head (knees extended)

60%10% 30%

Epidemiology• Occurs in 3-4% of term pregnancies• Higher incidence in early pregnancy (14%)

• Many of these cases will spontaneously convert to vertex by term

• Risk Factors:1. Previous breech delivery 2. Preterm gestation (25% < 28 weeks, only 3-4% at term)3. Uterine anomalies (septate Uterus, Fibroids)4. Placental Anomalies (Placenta previa, Polyhydramnios, Oligohydramnios)5. Congenital anomalies (Hydrocephaly, Anencephaly )6. Multiparity 7. Advanced Maternal Age8. Aneuploidy9. Low birth weight (20-30% of breech babies)

Breech vs Cephalic Presentation

• Increased neonatal morbidity• Increased perinatal or neonatal mortality• Increased short-term maternal morbidity

But Why?1. High prevalence of fetal anomalies2. Higher risk of prematurity3. Higher chance of umbilical cord prolapse4. Higher birth traumas

Diagnosis & Management - AntepartumDiagnosis:1. Leopold Maneuver – find head in upper abdomen 2. Ultrasound Assessment – confirm breech position

1. If NO U/S available C-section recommended

Management: 3. External Cephalic Version4. Vaginal Delivery Considered 5. Consider booking a C-section date

Management – Antepartum - ECV

1. External Cephalic Version (ECV)1. Push on mothers abdomen to turn fetus to achieve a vertex presentation2. ~50% ECV procedures are successful (5-10% flip back to breech)3. Criteria:

1. < 37 weeks2. Singleton pregnancy3. Unengaged presenting part4. Reactive Non-stress test 5. Anti-D recommended in RH negative women

External Cephalic Version (ECV)

https://www.youtube.com/watch?v=qT2jBxVoOQc

Management – Antepartum - ECVContraindications:

1. Previous T3 bleed2. Prior C-section3. Previous myomectomy (removal of fibroids)4. Oligohydramnios5. PROM6. Placenta Previa7. Abnormal U/S or suspected IUGR8. Nuchal cord9. Hypertension10. Uteroplacental insufficiency

Risks of the procedure:

1. Rupture of membranes2. Placental abruption3. Preterm birth 4. Cord accidents

How to get from:

Management – Intrapartum –Vaginal Delivery• GA > 37 weeks & fetal weight between 2500-3800g• Induction of labour NOT recommended. • Contraindications:

• Cord presentation• Fetal growth restriction or macrosomia • Any presentation other than frank or complete with flexed or neutral head attitude• Inadequate maternal pelvic (can be clinically measured)• Fetal anomaly not compatible with vaginal delivery

• Continuous Fetal heart rate monitoring suggested in 1st stage, and required in second stage of labour • If absence or inadequate process of labour C-section • Near OR & must be able to perform C-section in 30 minutes

Management – Intrapartum –C-section• Indications:• Footling presentation• Dystocia• Any contraindication for vaginal delivery • Patient preference (informed consent)

• Planned C-sections vs Breech Delivery have:• Reduced neonatal morbidity, RR 0.33 (95% CI 0.19 to 0.56)• Reduced perinatal or neonatal death, RR 0.29 (95% CI 0.10 to 0.86)• increased short-term maternal morbidity RR 1.29 (95% CI 1.03 to 1.61)

Management?

1. Music2. Breech tilt – raise hips 30 cm off floor for 10-15 min 3x a day &

concentrate on baby without tensing your body 3. Chiropractic care 4. Moxibustion – burn “mugowrt” near acupressure point of pinky

toes5. Hypnosis

Moxibustion

Case

A 32 yo G3T2P0A0L2 woman presents for routine prenatal care at 37 weeks. Her pregnancy is complicated by Rh-negative status, depression and a history of LSIL with normal colposcopy in first trimester. Today she reports good fetal movement and denies leaking fluid or contractions. During your examination you measure fundal height at an appropriate 37 cm, and find fetal heart tones located in the upper aspect of the uterus. A bedside ultrasound reveals frank breech presentation.

Case Review

• At 37 weeks – can consider External Cephalic Version• RH negative = would need to give WinRHO

• Frank Breech = can consider vaginal delivery (assume no contraindications met)• Discussion with the patient about options• What would you recommend?

References

• SOGC Guidelines – Vaginal Delivery of Breech Presentation • http://sogc.org/guidelines/vaginal-delivery-of-breech-presentation/

• Obstetrics and Gynecology 6th edition by Beckmann • UpToDate – Breech Presentation• Americanpregnacy.org• http://americanpregnancy.org/labor-and-birth/breech-presentation/

• Toronto Notes 2014