The breech presentation exists when the cephalic pole of the fetus is positioned in a longitudinal lie and the buttocks or feet of the fetus enter the maternal pelvis before the head.1 Management of the breech presentation in labor is an area of much trepidation and controversy, even among seasoned clinicians. A breech delivery is considered a high-risk obstetric complication that is best handled by an Obstetrician. There are unavoidable situations when a pregnant woman will present to the Emergency Department in active labor with a fetus in the breech position.2
A vaginal breech delivery may be the best delivery option in situations such as advanced labor with eminent delivery, the absence of obstetrical assistance, fetal distress, or umbilical cord prolapse. Knowledge and preparedness facilitate comfort and promote success in approaching emergent procedures. The breech delivery is no exception to this rule.
ANATOMY AND PATHOPHYSIOLOGY
The breech presentation may be associated with a variety of maternal and fetal conditions.1,3,4 Maternal variants that increase the risk of a breech presentation include a small pelvis and uterine anomalies (e.g., bicornuate or septate uterus and uterine fibroids). Fetal conditions associated with a breech presentation include fetal malformations (e.g., hydrocephalus, anencephaly, and fetal masses), genetic abnormalities, low birth weight, neurologic disorders, oligohydramnios, prematurity, and polyhydramnios. Other associated factors include multiparity, multiple gestations, placental abnormalities (e.g., placenta previa), and previous breech presentations.
Prematurity is a risk factor for a breech presentation. The incidence of breech presentations is inversely related to the fetal gestational age.1,3 Approximately 24% of fetuses are in the breech presentation at 28 weeks of gestation. The fetus usually turns spontaneously to a cephalic presentation so that at term only 3% to 4% are in the breech presentation.1,3,5
There are three main types of breech presentation (Figure 165-1).4,5 The most common is the frank breech which accounts for 50% to 73% of breech presentations. The fetus is flexed at the hips and extended at the knees (Figure 165-1A). The fetus is in the “pike” position. The complete breech is the least common type and accounts for approximately 5% to 11% of breech presentations. The fetus is flexed at both the hips and the knees (Figure 165-1B). The footling or incomplete breech accounts for approximately 12% to 38% of breech presentations. The fetus is not completely flexed at one or both knees or hips (Figure 165-1C). This results in one or both feet presenting before the buttocks. The risks of umbilical cord prolapse and prematurity associated with the breech presentation are listed in Table 165-1.
The main types of breech presentations. A. The frank breech. B. The complete breech. C. The incomplete breech.