Case Study Reports: Breech Presentation

BREECH PRESENTATION

History

You are asked to see a woman in the antenatal clinic. She is 37 years old and pregnant with her third child. Her previous children were both born by vaginal delivery after induc- tion of labour for post dates.

First-trimester ultrasound confirmed her menstrual dates and she is now 37 weeks. At her last appointment at 36 weeks’ gestation, the midwife suspected that the baby was in a breech presentation. An appointment has been made for an ultrasound assessment and to discuss the situation.

Examination

Blood pressure is 140/85 mmHg and abdominal examination suggests a breech presenta- tion with the sacrum not engaged.

Questions

·              What are the options available to the woman?

·              What management would you recommend in this case?

Answer:

At 30 weeks the incidence of breech presentation is around 14 per cent, but is only 2–4 per cent by term.

The three options available are:

·              external cephalic version

·              elective Caesarean section

·              vaginal breech delivery.

All three options should be discussed with the woman and her partner with important counselling points.

Vaginal breech delivery:

·              found to be less safe for singleton term fetuses than planned Caesarean section

·              carries a high chance of necessitating an emergency Caesarean section

·              needs involvement of an experienced obstetrician with continuous fetal heart moni- toring and ideally an epidural

·              should only be allowed if the labour progresses spontaneously – augmentation of breech labour is generally not recommended

·              contraindicated with placenta praevia, large baby, footling breech or maternal con- dition such as pre-eclampsia

External cephalic version:

·              involves using external manipulation of the fetus, encouraging the baby to turn to the cephalic presentation by way of pressure on the maternal abdomen

·              is often performed after giving a uterine relaxant such as salbutamol

·              carries a very small chance of abnormal fetal heart rate during or after the proced- ure which could necessitate an emergency Caesarean section

·              has approximately 50 per cent success rate overall

·              some fetuses revert to breech position even after successful external cephalic version

·              contraindicated with previous Caesarean section, other uterine surgery, pre-eclampsia, intrauterine growth retardation, oligohydramnios

·              can be painful

Elective Caesarean section:

·              is safer than vaginal breech delivery

·              is suitable where contraindications exist to external cephalic version

·              can be planned for in advance, which women may find more convenient

·              does not necessarily mean a woman would need a Caesarean section for any future pregnancy.

In this case the woman should be recommended external cephalic version as soon as pos- sible, with options for an elective Caesarean section or possible trial of breech delivery if this is unsuccessful.

Postnatal paediatric review should focus on the baby’s hips, with a neonatal ultrasound arranged within 6 weeks to rule out congenital hip dislocation (10–15 times more com- mon in breech presentation).