1. Adam Fogel, Christopher Elliot, Miso Gostimir
Breech Presentation
Adam Fogel, Christopher Elliot, Miso Gostimir

2. 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.

3. Outline & Objective
Objective: List strategies for management of abnormal fetal presentations, as well as the relative timing of each intervention.
Specific Goals:
Review Types of Breech presentation
Review Risk Factors for Breech presentation
Discuss Management of Breech, antepartum and intrapartum

4. What is Breech Presentation?

5. What is Breech Presentation?
Breech Presentation:  the presenting fetal part is the buttocks
60%
10%
30%
Legs folded with feet at the level of the buttocks (Knees flexed)
Legs Point up with feet by baby’s head (knees extended)
One or both feet point down so the legs would emerge first

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

7. Breech vs Cephalic Presentation
Increased neonatal morbidity
Increased perinatal or neonatal mortality
Increased short-term maternal morbidity
But Why?
High prevalence of fetal anomalies
Higher risk of prematurity
Higher chance of umbilical cord prolapse
Higher birth traumas

9. Diagnosis & Management - Antepartum
Leopold Maneuver – find head in upper abdomen
Ultrasound Assessment – confirm breech position
If NO U/S available C-section recommended
Management:
External Cephalic Version
Vaginal Delivery Considered
Consider booking a C-section date

10. Management – Antepartum - ECV
External Cephalic Version (ECV)
Push on mothers abdomen to turn fetus to achieve a vertex presentation
~50% ECV procedures are successful (5-10% flip back to breech)
Criteria:
< 37 weeks
Singleton pregnancy
Unengaged presenting part
Reactive Non-stress test
Anti-D recommended in RH negative women
ECV = Reduced non-cephalic vaginal birth, RR 0.46 (95% CI 0.33 to 0.62)

11. External Cephalic Version (ECV)

12. Management – Antepartum - ECV
Contraindications:
Risks of the procedure:
Previous T3 bleed
Prior C-section
Previous myomectomy (removal of fibroids)
Oligohydramnios
PROM
Placenta Previa
Abnormal U/S or suspected IUGR
Nuchal cord
Hypertension
Uteroplacental insufficiency
Rupture of membranes
Placental abruption
Preterm birth
Cord accidents

13. How to get from:

14. Management – Intrapartum –Vaginal Delivery
GA > 37 weeks & fetal weight between g
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

15. 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)

16. Management?
Music
Breech tilt – raise hips 30 cm off floor for min 3x a day & concentrate on baby without tensing your body
Chiropractic care
Moxibustion – burn “mugowrt” near acupressure point of pinky toes
Hypnosis

17. Moxibustion

18. 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.

19. 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?

21. References SOGC Guidelines – Vaginal Delivery of Breech Presentation
Obstetrics and Gynecology 6th edition by Beckmann
UpToDate – Breech Presentation
Americanpregnacy.org
Toronto Notes 2014