In a breech presentation the caudal end of the fetus occupies the lower segment. Whilst around 25% of pregnancies at 28 weeks are breech it only occurs in 3% of babies near term. A frank breech is the most common presentation with the hips flexed and knees fully extended. A footling breech, where one or both feet come first with the bottom at a higher position, is rare but carries a higher perinatal morbidity

Risk factors for breech presentation

• uterine malformations, fibroids
• placenta praevia
• polyhydramnios or oligohydramnios
• fetal abnormality (e.g. CNS malformation, chromosomal disorders)
• prematurity (due to increased incidence earlier in gestation)

Management

• if < 36 weeks: many fetuses will turn spontaneously
• if still breech at 36 weeks NICE recommend external cephalic version (ECV)- this has a success rate of around 60%. The RCOG recommend ECV should be offered from 36 weeks in nulliparous women and from 37 weeks in multiparous women
  • ECV is usually carried out under ultrasound guidance.
  • The mother is given analgesia, tocolytics and anti-D immunoglobulin (if required) during the procedure.
• if the baby is still breech then delivery options include planned caesarean section or vaginal delivery

Information to help decision making - the RCOG recommend:

• 'Women should be informed that planned caesarean section carries a reduced perinatal mortality and early neonatal morbidity for babies with a breech presentation at term compared with planned vaginal birth.'
• 'Women should be informed that there is no evidence that the long term health of babies with a breech presentation delivered at term is influenced by how the baby is born.'

RCOG absolute contraindications to ECV:

• where caesarean delivery is required
• antepartum haemorrhage within the last 7 days
• abnormal cardiotocography