Breech presentation

Learning objectives

Breech presentation refers to the fetus in the longitudinal lie with the buttocks or lower extremity entering the pelvis first
Three types:
- Frank breech: fetus has flexion of both hips, and the legs are straight with the feet near the fetal face, in a pike position
- Complete breech: fetus sits with flexion of both hips and both legs in a tuck position
- Incomplete breech: can have any combination of one or both hips extended, also known as footling (one leg extended) breech, or double footling breech (both legs extended)
Occurs in 3-4% of all term pregnancies
- A higher percentage of breech presentations occurs with less advanced gestational age
- At 32 weeks, 7% of fetuses are breech
- At 28 weeks or less, 25% are breech
Clinical conditions associated with a breech presentation include those that may increase or decrease fetal motility, or affect the vertical polarity of the uterine cavity
It is unsafe for a breech baby to be born vaginally due to the risk of injury (dislocated or broken bones) or umbilical cord problems (flattening or twisting)
Turning the baby into the head-first position and/or a planned C-section are the safest option

Prematurity
Multiple gestations
Aneuploidies
Congenital anomalies: fetal sacrococcygeal teratoma, fetal thyroid goiter
Mullerian anomalies
Uterine leiomyoma
Placental polarity as in placenta previa
Polyhydramnios
Oligohydramnios
Previous history of breech presentation (recurrence rate is 10% for the second pregnancy and 27% in the third pregnancy)

Physical exam: palpation of a hard, round, mobile structure at the fundus and the inability to palpate a presenting part in the lower abdomen superior to the pubic bone or the engaged breach in the same area, should raise suspicion of a breech presentation
Cervical exam: the lack of a palpable presenting part, palpation of a lower extremity, usually a foot, or for the engaged breech, palpation of the soft tissue of the fetal buttocks may be noted
Note that the soft tissue of the fetal buttocks may be interpreted as caput of the fetal vertex if the patient has been laboring
Ultrasound confirms the diagnosis