Learning objectives

• Types of breech presentation
• Management of breech presentation

Definition and mechanisms

• Breech presentation refers to the fetus in the longitudinal lie with the buttocks or lower extremity entering the pelvis first
• Three types:
  • Frank breech: fetus has flexion of both hips, and the legs are straight with the feet near the fetal face, in a pike position
  • Complete breech: fetus sits with flexion of both hips and both legs in a tuck position
  • Incomplete breech: can have any combination of one or both hips extended, also known as footling (one leg extended) breech, or double footling breech (both legs extended)
• Occurs in 3-4% of all term pregnancies
  • A higher percentage of breech presentations occurs with less advanced gestational age 
  • At 32 weeks, 7% of fetuses are breech
  • At 28 weeks or less, 25% are breech
• Clinical conditions associated with a breech presentation include those that may increase or decrease fetal motility, or affect the vertical polarity of the uterine cavity
• It is unsafe for a breech baby to be born vaginally due to the risk of injury (dislocated or broken bones) or umbilical cord problems (flattening or twisting)
• Turning the baby into the head-first position and/or a planned C-section are the safest option

Etiology

• Prematurity
• Multiple gestations
• Aneuploidies
• Congenital anomalies: fetal sacrococcygeal teratoma, fetal thyroid goiter
• Mullerian anomalies
• Uterine leiomyoma
• Placental polarity as in placenta previa
• Polyhydramnios
• Oligohydramnios
• Previous history of breech presentation (recurrence rate is 10% for the second pregnancy and 27% in the third pregnancy)

Evaluation

• Physical exam: palpation of a hard, round, mobile structure at the fundus and the inability to palpate a presenting part in the lower abdomen superior to the pubic bone or the engaged breach in the same area, should raise suspicion of a breech presentation
• Cervical exam: the lack of a palpable presenting part, palpation of a lower extremity, usually a foot, or for the engaged breech, palpation of the soft tissue of the fetal buttocks may be noted
• Note that the soft tissue of the fetal buttocks may be interpreted as caput of the fetal vertex if the patient has been laboring
• Ultrasound confirms the diagnosis

Management

Suggested reading

• Gray CJ, Shanahan MM. 2022. Breech presentation. StatPearls. 
• Hofmeyer GD. 2022. Overview of breech presentation. Up to date.
• 2017. Management of Breech Presentation. BJOG: An International Journal of Obstetrics & Gynaecology 124, e151–e177.
• Stitely ML, Gherman RB. Labor with abnormal presentation and position. Obstet Gynecol Clin North Am. 2005;32(2):165-179.
• Pratt SD. Anesthesia for breech presentation and multiple gestation. Clin Obstet Gynecol. 2003;46(3):711-729.
• Pollack KL, Chestnut DH. 1990. Anesthesia for complicated vaginal deliveries. Anesthesiology clinics of North America. 8;1:115-129.