Breech Presentation
NICE guideline [NG201] Antenatal care. Published: Aug 2021.
RCOG Green-top Guideline No. 20a External Cephalic Version and Reducing the Incidence of Term Breech Presentation. Last reviewed Mar 2017.
RCOG Green-top Guideline No. 20b Management of Breech Presentation. Last reviewed Mar 2017.
Background Information
Definition and Types
Breech presentation: buttocks or feet are the presenting fetal part
Types:
| Type | Description |
|---|---|
| Frank breech (most common type) | Buttocks presenting (flexed hips + extended knees) |
| Complete breech | Buttocks (+ feet) presenting (flexed hips + flexed knees) |
| Single (incomplete) footling breech | 1 foot presenting (one leg fully flexed + one leg fully extended) |
| Double (complete) footling breech | 2 feet presenting (both legs fully extended) |
Guidelines
Investigation and Diagnosis
ALL women should be offered abdominal palpation after 36 weeks to identify possible breech presentation.
- If breech suspected → confirm with ultrasound
Breech presentation suspected / identified before 36 weeks is of limited significance. The fetus is likely to spontaneously revert to cephalic presentation before 36 weeks.
Management
NICE recommends that if breech presentation is confirmed after 36 weeks → discuss the following options:
- External cephalic version (ECV) followed by vaginal birth (if successful)
- Vaginal breech birth – generally not recommended due to higher risk of complications
- Elective caesarean delivery
If the woman prefers vaginal delivery → offer an attempt of ECV (see below for more details)
- If ECV is successful (fetus in cephalic presentation) → proceed with vaginal delivery
If Caesarean section is planned or indicated, there is no need to offer ECV.
The purpose of performing ECV is to allow vaginal delivery.
ECV can only be offered prior to the onset of labour, provided there are no contraindications.
ECV is generally contraindicated once labour has begun, especially if membranes have ruptured (particularly due to a markedly increased risk of umbilical cord prolapse).
External Cephalic Version (ECV)
Contraindications
RCOG advises that there are no consensus contraindications but outlined the following:
- Presence of indications for caesarean delivery
- Multiple pregnancy (except after delivery of a first twin)
- RCOG recommendations for delivery
- 1st twin breech (ECV contraindicated) => C-section
- 2nd twin breech => Can attempt vaginal delivery (after delivery of first twin)
- RCOG recommendations for delivery
- Rhesus isoimmunisation
- Vaginal bleeding (e.g., antepartum haemorrhage) within 1 week
- Ruptured membrane
- Abnormal CTG
- Caution if oligohydramnios / hypertension
Independent indications for Caesarean section (making ECV inappropriate):
- Footling presentation
- Hyperextended neck on ultrasound
- High fetal weight (>3.8 kg)
- Low fetal weight (<10th centile)
- Evidence of fetal compromise
Timing and Description
Description: external manipulation (through the maternal abdomen) of the foetus into the cephalic presentation
Offer at:
- Nulliparous → 36 weeks
- Multiparous → 37 weeks
Tocolysis with betamimetics (e.g. terbutaline, salbutamol, ritodrine) is recommended by RCOG to improve the success rate of ECV.
Patient Counselling
Points outlined by RCOG:
- ~ 50% success rate
- After an unsuccessful ECV attempt at 36 weeks, it is unlikely the baby will spontaneously return to cephalic presentation
- Advise women that most people tolerate ECV but it can be a painful procedure
- Slightly increased rate of caesarean section and instrumental delivery
- But if ECV is successful, it reduces the chance of caesarean section
References
Original Guideline