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Toronto Notes 2019 Multi-Fetal Gestation and Malpresentation Breech Presentation
Definition
• fetalbuttocksorlowerextremityisthepresentingpartasdeterminedonU/S • complete(10%):hipsandkneesbothflexed
• frank(60%):hipsflexed,kneesextended,buttockspresentatcervix
■ most common type of breech presentation
■ most common breech presentation to be delivered vaginally
• incomplete(30%):bothoronehippartiallyflexedandbothoronekneepresentbelowthebuttocks,feet
or knees present first (footling breech, kneeling breech)
Epidemiology
• occursin3-4%ofpregnanciesatterm(25%<28wk)
Risk Factors
• maternal:pelvis(contracted),uterus(shapeabnormalities,intrauterinetumours,fibroids,previous breech), pelvic tumours causing compression, grand multiparity
• placental: placenta previa
• fetal:prematurity,amnioticfluid(poly-/oligohydramnios),multiplegestation,congenitalmalformations
(found in 6% of breeches; 2-3% if in vertex presentations), abnormalities in fetal tone and movement, aneuploidy, hydrocephalus, anencephalus
Management
• ECV:repositioningofsingletonfetuswithinuterusunderU/Sguidance
■ overall success rate of ~60%
■ criteria: >36 wk GA, singleton, unengaged presenting part, reactive NST, not in labour
■ absolute contraindications: where C/S is required (placenta previa, previous classical C/S), previous
myomectomy, PROM, uteroplacental insufficiency, nuchal cord, active labour, non-reactive NST,
multiple gestation
■ relative contraindications: mild/moderate oligohydramnios, suspected IUGR, HTN, previous T3
bleed
■ risks: abruption, cord compression, cord accident, ROM, labour, fetal bradycardia requiring C/S
(<1% risk), alloimmunization, fetal death (1:5,000)
■ method: tocometry, followed by U/S guided transabdominal manipulation of fetus with constant
fetal heart monitoring
■ if patient Rh negative, give Rhogam® prior to procedure
■ better prognosis if multiparous good fluid volume, small baby, skilled obstetrician, posterior
placenta
• pre-or early-labour U/S to assess type of breech presentation, fetal growth, estimated weight, placenta
position, attitude of fetal head (flexed is preferable); if U/S unavailable, recommend C/S
• ECVandelectiveC/Sshouldbepresentedasoptionswiththerisksandbenefitsoutlined;obtain
informed consent
• methodforvaginalbreechdelivery
■ encourage effective maternal pushing efforts
■ at delivery of head (after feet), assistant must apply suprapubic pressure to flex and engage fetal head ■ delivery can be spontaneous or assisted; avoid fetal traction
■ apply fetal manipulation only after spontaneous delivery to level of umbilicus
• contraindications to vaginal breech delivery
■ cord presentation
■ clinically inadequate maternal pelvis
■ fetal factors incompatible with vaginal delivery (e.g. hydrocephalus, macrosomia, fetal growth
restriction)
• C/Srecommendedif:thebreechhasnotdescendedtotheperineuminthesecondstageoflabourafter
2 h, in the absence of active pushing, or if vaginal delivery is not imminent after 1 h of active pushing
Prognosis
• regardlessofrouteofdelivery,breechinfantshavelowerbirthweightsandhigherratesofperinatal mortality, congenital anomalies, abruption, and cord prolapse
Obstetrics OB23
A. Complete Breech
B. Frank Breech
C. Incomplete Breech
© Crista Mason 2004
Figure 5. Types of breech presentation
Criteria for Vaginal Breech Delivery
• Frank or complete breech, GA >36 wk • EFW 2,500-3,800 g based on clinical and
U/S assessment (5.5–8.5 lb)
• Fetal head flexed
• Continuous fetal monitoring
• 2 experienced obstetricians, assistant, and
anesthetist present
• Ability to perform emergency C/S within 30
min if required