eMedicine Specialties > Emergency Medicine > Obstetrics & Gynecology

Pregnancy, Breech Delivery

Author: Andrew D Jenis, MD, Chair, Department of Emergency Medicine, Cortland Regional Medical Center
Contributor Information and Disclosures

Updated: Oct 26, 2009

Introduction

Background

Breech presentation occurs when the fetus presents to the birth canal with buttocks or feet first. This presentation creates a mechanical problem in delivery of the fetus.

Pathophysiology

The buttocks and feet of the fetus do not provide an effective wedge to block and dilate the cervix. The umbilical cord may prolapse, and/or the head may get trapped during delivery.

The 3 types of breech presentation are as follows:

• Frank (65%): Hips of the fetus are flexed, and knees are extended.
• Complete (10%): The hips and knees of the fetus are flexed.
• Incomplete (25%): The feet or knees of the fetus are the lowermost presenting part.
  • Single footling: One of the lower extremities is lowermost.
  • Double footling: Both of the lower extremities are lowermost.

Frequency

United States

Incidence is correlated to gestational age (Table 1). However, the overall frequency is 3-4% at delivery.¹

Table 1. Gestational age and frequency of breech birth

Open table in new window

Mortality/Morbidity

• Many complications can result from breech presentation. They are generally related to complications of the fetal abnormalities that may be the primary reason for the breech presentation and those related to umbilical cord compression resultant from abnormal progression through the maternal pelvis.
• Increased birth trauma: As the duration of umbilical cord compression increases, the practitioner tries to deliver the infant more rapidly than advisable, thus increasing the incidence of birth trauma.
• Incidence of prolapsed umbilical cord depends on type of breech presentation.
  • Footling, 17% incidence
  • Complete, 5% incidence
  • Frank, 0.5% incidence
• Umbilical cord abnormalities: Cord length may be reduced, and, in footlings, there is an increased risk of the cord coiling around the legs of the fetus.

Clinical

History

• Factors that increase likelihood of breech delivery include the following:
  • Preterm delivery
  • Increased parity
  • Multiple gestations
  • Previous breech delivery
  • Pelvic tumors

Physical

• Leopold maneuvers: During the first maneuver, the hard fetal head can be palpated at the uterine fundus.
• Auscultation: Heart sounds can be heard above the umbilicus.
• Vaginal examination
  • In frank breech presentations, the ischial tuberosities, sacrum, anus, and/or genitals may be palpated. In addition, meconium staining of the examiner's digit may occur.
  • In complete breech presentations, the feet of the fetus may be palpated with the buttocks.
  • In incomplete breech presentations, one or both of the feet/knees may be palpated.
• During frank breech delivery, the following conditions make vaginal delivery less risky:
  • Favorable pelvis - Gynecoid (ie, round) or anthropoid (ie, elliptical)
  • Fetal weight less than 3600 g - The larger the fetus, the larger the head, as well as other noncompressible body parts, thereby leading to increased chance for fetal hypoxia and birth trauma
  • Complete dilation and effacement of the cervix - Provides the head a better chance to pass through the pelvis
  • Availability of skilled obstetrician, neonatal resuscitation equipment, and anesthesia
• The following conditions are unfavorable for delivery:
  • Fetal weight more than 3600 g
  • Unfavorable pelvis - Breech delivery does not allow sufficient time for molding of the fetal head; thus, a platypelloid (ie, anteroposterior flat) or android (ie, heart-shaped) pelvis decreases the fetal head's ability to navigate the maternal pelvis.
  • Hyperextension of the head - Increases risk of cervical spine injury
  • Footlings - Incidence of umbilical cord prolapse increases with coiling of the umbilical cord around the legs of the fetus

Causes

• Risk factors for breech presentation include the following:
  • Premature gestational age: Prior to onset of labor, the fetus turns into cephalic presentation. If labor occurs abruptly or unexpectedly (eg, following trauma), the fetus may not have shifted position.
  • Increased maternal parity may cause stretch or laxity of the uterus, predisposing the fetus to breech deliveries.
  • Multiple fetuses: As a result of limited space in the uterus, fetuses may position themselves head to foot.
  • Hydramnios, ie, too much amniotic fluid, may allow the fetus too much movement.
  • Oligohydramnios, ie, too little amniotic fluid, may impede final shift of the fetus to cephalic presentation.
  • Placenta previa, ie, placental implantation over the cervical os, allows the fetus too much space for movement within the uterus.
  • Hydrocephalus, ie, enlarged head in the fetus, makes it more difficult for the fetus to make final shift to cephalic presentation prior to onset of labor.
  • Previous breech deliveries may increase likelihood of another one secondary to an anatomical anomaly.
    • Uterine anomalies include uterine scarring from previous cesarean section, bicornuate uterus, and septate uterus.
    • Pelvic tumors may impede fetal movement and trap the fetus in breech presentation position.
  • Placental cornual-fundal implantation increases risk of breech presentation.

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