Breech presentation is when the fetus (unborn child) is placed inside the womb with the buttocks or feet closest to the cervix (mouth of the uterus), which is unlike the usual when the head is closest to the cervix. A breech presentation occurs in 3-4% of all deliveries.
There are three types of breech presentations:
- Frank breech (50-70%): The hips are flexed and knees are extended (pike position)
- Complete breech (5-10%): The hips and knees are flexed (cannonball position)
- Footling or incomplete (10-30%): One or both hips are extended with the foot presenting
A breech baby can be delivered in two ways:
- Vaginal breech delivery
- Cesarean delivery
There is an increased risk of perinatal mortality with breech presentation, irrespective of the mode of delivery. Death of the fetus is often associated with fetal malformations, prematurity, and intrauterine death (death of the fetus in the uterus).
How is a breech baby delivered?
A breech baby can be delivered vaginally or through a cesarean delivery.
Vaginal breech delivery:
There are three types of vaginal breech deliveries; the choice of which depends on the side of the baby, the gestational age, and the breech presentation of the baby:
- Spontaneous breech delivery: The baby is delivered spontaneously, without any traction or manipulation of the baby. This is commonly performed for very preterm babies due to their smaller size.
- Assisted vaginal breech delivery: This is the most common type of vaginal breech delivery. The baby delivers spontaneously up to the umbilicus, after which the doctor maneuvers and manipulates the baby to aid in the delivery of the rest of the baby’s body, arms, and head.
- Total breech extraction: The doctor grasps the baby’s feet, and the entire baby is extracted. Total breech extraction is usually only done to deliver the second twin in breech position in twin pregnancy. In the case of a single baby, total breech extraction is avoided because the cervix may not be adequately dilated for the fetal head to pass through.
Complications of vaginal breech delivery:
- The fetal head may get trapped due to an incompletely stretched uterine mouth, causing the head to get stuck at the cervix. A cervical cut may be required to relieve cervical entrapment.
- Nuchal arms (one or both arms are wrapped behind the neck)
- Trauma to the baby during delivery
- Cervical spine injury
- Umbilical cord prolapses (umbilical cord drops into the vagina through the cervix), causing umbilical cord compression resulting in decreased fetal heart rate.
- Infection in the mother
- Blood clots in the blood vessels of the mother
- Excessive bleeding from the uterus
Cesarean delivery for breech delivery:
Cesarean delivery is done when performing vaginal delivery would result in a high risk of complications to the baby or mother. If a low transverse (horizontal) uterine incision is made, the doctor would have to extract the baby quickly to deliver the head before the uterus starts contracting. In case of difficulty during delivery, the transverse incision may be extended vertically upwards (T incision). The horizontal transverse incision may also extend on either side and upwards. A medication called Nitroglycerin may be administered to relax the uterine muscles to facilitate delivery. The maneuvers and manipulation of the baby done by the doctor during Cesarean delivery are similar to that of a vaginal delivery.
Complications of Cesarean delivery:
- Fetal head entrapment
- Injury to the surrounding organs like the bowel or bladder, pelvic muscles, nerves, blood vessels, including major blood vessels like a uterine artery, and other tissues
- Infection in the mother
- Blood clots in the blood vessels of the mother
- Excessive bleeding from the uterus
Why does breech presentation occur?
Certain factors increase the risk of breech presentation:
Preterm delivery: Preterm babies have a higher risk for breech delivery because they are smaller and haven’t engaged (entered the pelvic brim or inlet) yet. The risk of breech presentation decreases with the increase in gestational age.
Uterine fibroids result in decreased space in the uterus for the baby
Anatomical malformations of the uterus
Polyhydramnios (increased amniotic fluid in the uterus), causing the baby to float within the uterus
Fetal abnormalities, such as neck masses
Multiple gestations (twins or triplets and more)
Placenta previa (low lying placenta, covering the cervix)
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