Describe the types, causes, diagnosis, complications and management of breech Presentation.

Definition

Breech presentation is a longitudinal lie in which the podalic pole (buttocks/lower limbs) occupies the lower pole of the uterus and presents at the pelvic brim, the head lying at the fundus. It is the commonest malpresentation, occurring in about 3–4% of term pregnancies.

Types of Breech Presentation

Types

• Frank (extended) breech — thighs flexed, legs extended over the abdomen; the commonest at term, especially in primigravidae.
• Complete (flexed) breech — thighs and legs both flexed; the fetus "sits" with buttocks and feet presenting.
• Footling / incomplete breech — one or both feet (or a knee) present below the buttocks; carries the highest risk of cord prolapse.

Causes

Factors favouring breech include prematurity, multiple pregnancy, polyhydramnios, placenta praevia, uterine anomalies (septate/bicornuate) and fibroids, fetal anomalies (hydrocephalus, anencephaly), contracted pelvis, a short cord and intra-uterine fetal death.

Diagnosis

Clinical — a hard, round, ballotable head felt at the fundus, the softer breech in the lower pole, and the fetal heart heard at or above the umbilicus. Ultrasound confirms the presentation and type, locates the placenta, estimates fetal weight and excludes anomalies.

Complications

Fetal — cord prolapse (especially footling), entrapment of the after-coming head, birth asphyxia, intracranial haemorrhage, and birth injuries (fractures of the humerus/ clavicle, brachial-plexus/Erb's palsy, visceral injury). Maternal — increased operative delivery, genital-tract trauma and infection.

Management

Antenatal — external cephalic version (ECV)

In a suitable case, ECV at 36–37 weeks converts the breech to cephalic and reduces the need for caesarean section.

Choice of delivery

The mode is individualised. Planned caesarean section is preferred for most term breeches — primigravida, estimated fetal weight > 3.5 kg or < 2 kg, footling presentation, hyperextended head, contracted pelvis, placenta praevia or a previous scar. Assisted vaginal breech delivery may be offered in carefully selected cases (flexed/frank breech, adequate pelvis, average-sized baby, flexed head, skilled attendant).

Assisted breech delivery (principles)

• Allow the breech to descend and deliver spontaneously up to the umbilicus ("hands-off"), avoiding traction.
• Deliver extended legs (Pinard manoeuvre) and the arms by Løvset's manoeuvre (rotation of the trunk).
• Deliver the after-coming head by the Mauriceau–Smellie–Veit manoeuvre (jaw flexion and shoulder traction) or with Burns–Marshall technique / forceps to the after-coming head; keep the head flexed and the delivery controlled.

There are three types of breech. In the frank (extended) breech — the commonest and the most favourable for vaginal delivery — the hips are flexed and the knees extended. In the complete (flexed) breech both hips and knees are flexed. In the footling breech a foot presents first, carrying the highest risk of cord prolapse and therefore requiring caesarean section. At term the options are external cephalic version, elective caesarean (usual) or, in selected cases, assisted breech delivery.

WHY the After-coming Head Is the Danger

The whole of breech management turns on a single fact: the danger is the after-coming head. In a cephalic delivery the head — the largest, least compressible part — comes first, moulding slowly over hours; once it is born, the rest of the body follows easily. In a breech the sequence is reversed: the soft, compressible buttocks and body deliver first — and they may pass through a pelvis that the head cannot. The head must then negotiate that pelvis rapidly, with no time to mould, and — critically — with the umbilical cord compressed between the head and the pelvic brim, so the fetus is being asphyxiated while the head is being delivered. There is thus a strict time limit, and any obstruction (or an unrecognised hydrocephalus, or an extended, deflexed head) may cause the head to become entrapped — an obstetric catastrophe. This is why breech delivery demands controlled, unhurried descent with 'hands off the breech' until the scapulae appear, and then a specific manoeuvre to deliver the head in flexion (Mauriceau-Smellie-Veit, or forceps applied to the after-coming head), and why the cord must never be pulled upon. Recognising that the head arrives last, quickly, and with the cord compressed explains every rule of breech delivery.

WHY Elective Caesarean Became the Norm — and WHY Ecv Is Offered First

Understanding why most breeches at term are delivered by caesarean, and why external cephalic version is nevertheless offered first, explains modern practice. The Term Breech Trial showed that planned caesarean significantly reduced perinatal mortality and serious neonatal morbidity compared with planned vaginal breech delivery, and — combined with the steady loss of the skills needed for assisted breech delivery — this made elective caesarean the standard of care at term. But caesarean carries its own costs: maternal morbidity, and a scarred uterus that jeopardises every subsequent pregnancy (rupture, placenta praevia and accreta). Hence the logic of external cephalic version: turning the fetus to cephalic at or after 36–37 weeks, under tocolysis and ultrasound guidance with CTG monitoring, succeeds in roughly half of cases — and each success converts a planned caesarean into a normal vaginal delivery. It is contraindicated wherever the uterus must not be manipulated or the fetus not left in utero (APH, ruptured membranes, multiple pregnancy, fetal compromise, a scarred uterus, oligohydramnios). Understanding that ECV is the one intervention that can avoid the caesarean altogether explains why it should be offered to every suitable woman with a breech at term.

• Breech types: frank/extended (commonest, ~65%; best for vaginal delivery), complete/flexed, and footling (highest risk of cord prolapse → caesarean).
• The danger is the after-coming head — it delivers last, rapidly, with the cord compressed, risking asphyxia and head entrapment.
• Offer external cephalic version at 36–37 weeks (success ~50%) unless contraindicated — it can avoid caesarean altogether.
• Planned caesarean is the usual mode at term (Term Breech Trial); assisted breech delivery only in selected cases.
• Assisted breech delivery: 'hands off the breech' until the scapulae appear; deliver the head in flexion (Mauriceau-Smellie-Veit or forceps); never pull on the cord.