Overview

• Breech Delivery → opposed to cephalic presentation. Bottom is face down and head is up.
  • 25% of babies are breech at 28 weeks, however only 3% are at term.
  • Risk Factors → uterine malformation, fibroids, previous uterine surgery, placenta praevia, oligo/polyhydramnios, multiple pregnancy, fetal abnormality, prematurity.
  • Cord prolapse is more common in breech presentations.
  • 3 Types → frank breech (hips flexed, knees extended [so legs reach shoulders] - most common), footling breech (most risky form, feet born first inside of pelvis), complete breech (both hips and knees are flexed).
• Unstable Lie → transverse lie.
  • 80% revert to longitudinal lie before labour.
  • Transverse lie increases risk of cord prolapse.

Making Diagnosis

Clinical Features

• Breech → palpable head at fundus, soft breech in pelvis.
  • Head is harder and ballotable. Bottom is softer.
• Transverse Lie → uterus appears wide, fundal height may be low, no presenting part in pelvis.
  • CAN DO ECV FOR TRANSVERSE LIE IF MEMBRANES NOT YET RUPTURED.

Investigations

• USS to confirm.

Management Plan

Breech Delivery

• <36 weeks → most will turn spontaneously.
  • Still breech at 36 weeks → external cephalic version (ECV). (Move baby from outside trying to turn it back into its normal position, using their hands. Will do ultrasound before and after to confirm position of baby. Will do on labour ward with continuous CTG monitoring to make sure baby is okay. May be a bit uncomfortable)
    • Nulliparous Woman → offer at 36 weeks.
    • Multiparous Woman → offer at 37 weeks.
      • If ECV fails → elective caesarean or vaginal breech delivery.
        • C-Section → reduction in foetal mortality (slightly better outcomes for baby). Small increase in risks for mother (bleeding, infection, damage to surrounding structures). Implications on future pregnancies (VBAC, uterine rupture and placenta praevia).
        • Vaginal Breech Delivery → 40% risk of needing emergency c-section. Slightly increased risk to baby compared to c-section.
          • Footling Breech → absolute contraindication to vaginal breech delivery.
  • ECV ⇒
    • Contraindications → antepartum haemorrhage in last 7 days, abnormal CTG, ruptured membranes, multiple pregnancy, major uterine abnormality, other reason for caesarean section.
    • 50% success rate.
      • Risks → 1 in 200 risk of emergency c-section (0.5%), foetal distress.
    • Give anti-D if woman is rhesus negative.
    • Tocolytic agent with beta-mimetic effect (ie. beta-2 receptor agonists such as terbutaline, ritodrine and salbutamol) can be used to improve the success rate of external cephalic version, as they cause relaxation of uterine muscles.

Unstable Lie

• Transverse Lie → caesarean section.
  • Increased risk of cord prolapses.

Complications →