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History
You are asked to see a woman in the antenatal clinic. She is 37 years old and pregnant with her third child. Her previous children were both born by vaginal delivery after induc-tion of labour for post dates.
First-trimester ultrasound confirmed her menstrual dates and she is now 37 weeks. At her last appointment at 36 weeks’ gestation, the midwife suspected that the baby was in a breech presentation. An appointment has been made for an ultrasound assessment and to discuss the situation.
Examination
Blood pressure is 140/85 mmHg and abdominal examination suggests a breech presenta- tion with the sacrum not engaged.
Questions
• What are the options available to the woman?
• What management would you recommend in this case?
Medicine
At 30 weeks the incidence of breech presentation is around 14 per cent, but is only 2–4 per cent by term.
The three options available are:
1 external cephalic version
2 elective Caesarean section
3 vaginal breech delivery.
All three options should be discussed with the woman and her partner with important counselling points.
• Vaginal breech delivery:
• found to be less safe for singleton term fetuses than planned Caesarean section
• carries a high chance of necessitating an emergency Caesarean section
• needs involvement of an experienced obstetrician with continuous fetal heart moni-toring and ideally an epidural
• should only be allowed if the labour progresses spontaneously – augmentation of breech labour is generally not recommended
• contraindicated with placenta praevia, large baby, footling breech or maternal con-dition such as pre-eclampsia
• External cephalic version:
• involves using external manipulation of the fetus, encouraging the baby to turn to the cephalic presentation by way of pressure on the maternal abdomen
• is often performed after giving a uterine relaxant such as salbutamol
• carries a very small chance of abnormal fetal heart rate during or after the proced-ure which could necessitate an emergency Caesarean section
• has approximately 50 per cent success rate overall
• some fetuses revert to breech position even after successful external cephalic version
• contraindicated with previous Caesarean section, other uterine surgery, pre-eclampsia, intrauterine growth retardation, oligohydramnios
• can be painful
• Elective Caesarean section:
• is safer than vaginal breech delivery
• is suitable where contraindications exist to external cephalic version
• can be planned for in advance, which women may find more convenient
• does not necessarily mean a woman would need a Caesarean section for any future pregnancy.
In this case the woman should be recommended external cephalic version as soon as pos-sible, with options for an elective Caesarean section or possible trial of breech delivery if this is unsuccessful.
Postnatal paediatric review should focus on the baby’s hips, with a neonatal ultrasound arranged within 6 weeks to rule out congenital hip dislocation (10–15 times more com-mon in breech presentation).
KEY POINTS
• Breech presentation is associated with increased perinatal morbidity and mortality.
• If a woman has a frank breech at 37 weeks she should normally be offered external cephalic version, and if unsuccessful an elective Caesarean section or possibly a vaginal breech delivery.
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