Frank breech, William Smellie, 1792
|Classification and external resources|
|ICD-10||O32.1, O64.1, O80.1, O83.0, P03.0|
||This article possibly contains original research. (February 2011)|
A breech birth is the birth of a baby from a breech presentation, in which the baby exits the pelvis with the buttocks or feet first as opposed to the normal head-first presentation. In breech presentation, fetal heart sounds are heard just above the umbilicus.
The bottom-down position presents some hazards to the baby during the process of birth, and the mode of delivery (vaginal versus Caesarean) is controversial in the fields of obstetrics and midwifery.
Though vaginal birth is possible for the breech baby, certain fetal and maternal factors influence the safety of vaginal breech birth. The majority of breech babies born in the United States are delivered by Caesarean section as studies have shown increased risks of morbidity and mortality for vaginal breech delivery, and most hospital policies do not permit vaginal breech birth for this reason. As a result of reduced numbers of vaginal breech deliveries, most obstetricians do not receive training in the skill set required for safe vaginal breech delivery anymore.
With regard to the fetal presentation during human gestation, three periods have been distinguished. During first period which lasts until the 24th gestational week, the incidence of a longitudinal lie increases with the equal proportion of a breech and cephalic presentation within this lie. This period is characterized by frequent changes of presentations. The fetuses in breech presentation during this period have the same probability for breech and cephalic presentation at delivery. The incidence of cephalic presentation increases during the second period, lasting from the 25th to the 35th gestational week, with a proportional decrease of breech presentation. The period following the 25th gestational week is characterized by a higher than random probability that the fetal presentation during this period will also be present at the time of delivery. The increase of this probability is gradual and identical for breech and cephalic presentation during this period. In the third period from the 36th gestational week onward, the incidence of cephalic and breech presentation remain stable, i.e. breech presentation around 3-4% and cephalic presentation approximately 95%. In general population, incidence of breech presentation at preterm birth corresponds to incidence of breech presentation for this particular period of gestation when birth occurs.
A breech presentation at delivery occurs when the fetus did not turn to a cephalic presentation. This failure to change its presentation can result from endogenous and exogenous factors. The endogenous factors involve fetal inability to adequately move, whereas the exogenous factors refer to insufficient intrauterine space available for fetal movements.
Incidence of breech presentation among diseases and medical conditions with the incidence of breech presentation higher than that occurs in the general population, shows that the probability of breech presentation is between 4% and 50%. These data are related to: 1. single series of medical entities; 2. collections of series for some particular medical entity; 3. data obtained from repeated observations under the same conditions; 4. series of two concomitant medical conditions.
Incidence of breech presentation at delivery in various medical conditions and diseases: FETAL ENTITIES: First twin 17-30%; Second twin 28-39%; Stillborn 26%; Prader-Willi syndrome 50%, Werdnig-Hoffman syndrome 10%; Smith-Lemli-Opitz syndrome 40%; Fetal alcohol syndrome 40%; Potter anomaly 36%; Zellweger syndrome 27%; Myotonic dystrophy 21%, 13 trisomy syndrome 12%; 18 trisomy syndrome 43%; 21 trisomy syndrome 5%; de Lange syndrome 10%; Anencephalus 6-18%, Spina bifida 20-30%; Congenital Hydrocephalus 24-37%; Osteogenesis imperfecta 33.3%; Amyoplasia 33.3%; Achondrogenesis 33.3%; Amelia 50%; Craniosynostosis 8%; Sacral agenesis 30.4%; Arthrogriposis multiplex congenita 33.3; Congenital dislocation of the hip 33.3%; Hereditary sensory neuropathy type III 25%; Centronuclear myoptathy 16.7%; Multiple pituitary hormone deficiency 50%; Isolated pituitary hormone deficiency 20%; Ectopic posterior pituitary gland 33.3%; Congenital bilateral perisilvian syndrome 33.3; Symmetric fetal growth restriction 40%; Asymmetric fetal growth restriction 40%; Nonimmune hydrops fetalis 15%; Atresio ani 18.2%; Microcephalus 15.4%; Omphalocele 12.5%; Prematurity 40%; PLACENTAL AND AMNIOTIC FLUID ENTITIES: Amniotic sheet perpendicular to the placenta 50%; Cornual-fundal implantation of the placenta 30%; Placenta previa 12.5%; Oligohydramnios 17%; Polyhydramnios 15.8%; MATERNAL ENTITIES: Uterus arcuatus 22.6%; Uterus unicornuatus 33.3%; Uterus bicornuatus 34.8%; Uterus didelphys 30-41%; Uterus septus 45.8%; Leimyoma uteri 9-20%; Spinal cord injury 10%; Carriers of Duchenne muscular dystrophy 17%; COMBINATION OF TWO MEDICAL ENTITIES: First twin in uterus with two bodies 14.29%; Second twin in uterus with two bodies 18.52%.
Also, women with previous cesarean deliveries have a risk of breech presentation at term twice that of women with previous vaginal deliveries.
The highest possible probability of breech presentation of 50% indicates that breech presentation is a consequence of at random filling of the intrauterine space, with the same probability of breech and cephalic presentation in a longitudinally elongated uterus.
There are either three or four main categories of breech births, depending upon the source:
- Frank breech – the baby's bottom comes first, and his or her legs are flexed at the hip and extended at the knees (with feet near the ears); 65–70% of breech babies are in the frank breech position
- Complete breech – the baby's hips and knees are flexed so that the baby is sitting crosslegged, with feet beside the bottom
- Footling breech – one or both feet come first, with the bottom at a higher position; this is rare at term but relatively common with premature fetuses
- Kneeling breech – the baby is in a kneeling position, with one or both legs extended at the hips and flexed at the knees; this is extremely rare, and is excluded from many classifications
In addition to the above, breech births in which the sacrum is the fetal denominator can be classified by the position of a fetus. Thus sacro-anterior, sacro-transverse and sacro-posterior positions all exist, but left sacro-anterior is the commonest presentation. Sacro-anterior indicates an easier delivery compared to other forms.
Umbilical cord prolapse may occur, particularly in the complete, footling, or kneeling breech. This is caused by the lowermost parts of the baby not completely filling the space of the dilated cervix. When the waters break the amniotic sac, it is possible for the umbilical cord to drop down and become compressed. This complication severely diminishes oxygen flow to the baby and the baby must be delivered immediately (usually by Caesarean section) so that he or she can breathe. If there is a delay in delivery, the brain can be damaged. Among full-term, head-down babies, cord prolapse is quite rare, occurring in 0.4 percent. Among frank breech babies the incidence is 0.5 percent, among complete breeches 4 to 6 percent, and among footling breeches 15 to 18 percent.
Head entrapment is caused by the failure of the fetal head to negotiate the maternal midpelvis. At full term, the fetal bitrochanteric diameter (the distance between the outer points of the hips) is about the same as the biparietal diameter (the transverse diameter of the skull)—simply put the size of the hips are the same as the size of the head. The relatively larger buttocks dilate the cervix as effectively as the head does in the typical head-down presentation. In contrast, the relative head size of a preterm baby is greater than the fetal buttocks. If the baby is preterm, it may be possible for the baby’s body to emerge while the cervix has not dilated enough for the head to emerge.
Because the umbilical cord—the baby’s oxygen supply—is significantly compressed while the head is in the pelvis during a breech birth, it is important that the delivery of the aftercoming fetal head not be delayed. The head only just fits through the pelvis, and if the arm is extended alongside the head, delivery will not occur. If this occurs, the Løvset manoeuvre may be employed, or the arm may be manually brought to a position in front of the chest. The Løvset manoeuvre involves rotating the fetal body by holding the fetal pelvis. Twisting the body such that an arm trails behind the shoulder, it will tend to cross down over the face to a position where it can be reached by the obstetrician's finger, and brought to a position below the head. A similar rotation in the opposite direction is made to deliver the other arm. In order to present the smallest diameter (9.5 cm) to the pelvis, the baby’s head must be flexed (chin to chest). If the head is in a deflexed position, the risk of entrapment is increased. Uterine contractions and maternal muscle tone encourage the head to flex. If the birth attendant pulls on the baby’s body, this action may deflex the head.
Oxygen deprivation may occur from either cord prolapse or prolonged compression of the cord during birth, as in head entrapment. If oxygen deprivation is prolonged, it may cause permanent neurological damage (for instance, cerebral palsy) or death.
Injury to the brain and skull may occur due to the rapid passage of the baby's head through the mother's pelvis. This causes rapid decompression of the baby's head. In contrast, a baby going through labor in the head-down position usually experiences gradual molding (temporary reshaping of the skull) over the course of a few hours. This sudden compression and decompression in breech birth may cause no problems at all, but it can injure the brain. This injury is more likely in preterm babies. The fetal head may be controlled by a special two-handed grip call the Mariceau-Smellie-Veit manoeuvre or the elective application of forceps. This will be of value in controlling the rate of delivery of the head and reduce decompression. Related to potential head trauma, researchers have identified a relationship between breech birth and autism.
Squeezing the baby’s abdomen can damage internal organs. Positioning the baby incorrectly while using forceps to deliver the aftercoming head can damage the spine or spinal cord. It is important for the birth attendant to be knowledgeable, skilled, and experienced with all variations of breech birth. In the United States, because Cesarean section is increasingly being used for breech babies, fewer and fewer birth attendants are developing these skills.
Factors influencing the safety
|This section does not cite any references or sources. (March 2009)|
- Birth attendant's skill (and experience with breech birth) – The skill of the doctor or midwife and the number of breech births previously assisted is of crucial importance. Many of the dangers in vaginal birth for breech babies come from mistakes made by birth attendants.
- Type of breech presentation – the frank breech has the most favorable outcomes in vaginal birth, with many studies suggesting no difference in outcome compared to head down babies. (Some studies, however, find that planned caesarean sections for all breech babies improve outcome. The difference may rest in part on the skill of the doctors who delivered babies in different studies.) Complete breech presentation is the next most favorable position, but these babies sometimes shift and become footling breeches during labour. Footling and kneeling breeches have a higher risk of cord prolapse and head entrapment.
- Parity – Parity refers to the number of times a woman has given birth before. If a woman has given birth vaginally, her pelvis has "proven" it is big enough to allow a baby of that baby's size to pass through it. However, a head-down baby's head often molds (shifts its shape to fit the maternal pelvis) and so may present a smaller diameter than the same-size baby born breech. Research on the issue has been contradictory as far as whether vaginal breech birth is safer when the mother has given birth before, or not.
- Fetal size in relation to maternal pelvic size – If the mother's pelvis is roomy and the baby is not large, this is favorable for vaginal breech delivery. However, prenatal estimates of the size of the baby and the size of the pelvis are unreliable.
- Hyperextension of the fetal head – this can be evaluated with ultrasound. Less than 5% of breech babies have their heads in the "star-gazing" position, face looking straight upwards and the back of the head resting against the back of the neck. Caesarean delivery is absolutely necessary, because vaginal birth with the baby's head in this position confers a high risk of spinal cord trauma and death.
- Maturity of the baby – Premature babies appear to be at higher risk of complications if delivered vaginally than if delivered by caesarean section.
- Progress of labor – A spontaneous, normally progressing, straightforward labor requiring no intervention is a favorable sign.
- Second twins – If a first twin is born head down and the second twin is breech, the chances are good that the second twin can have a safe breech birth.
As in labour with a baby in a normal head-down position, uterine contractions typically occur at regular intervals and gradually cause the cervix to become thinner and to open. In the more common breech presentations, the baby’s bottom (rather than feet or knees) is what is first to descend through the maternal pelvis and emerge from the vagina.
At the beginning of labour, the baby is generally in an oblique position, facing either the right or left side of the mother's back. The baby's bottom is the same size in the term baby as the baby's head. Descent is thus as for the presenting fetal head and delay in descent is a cardinal sign of possible problems with the delivery of the head.
In order to begin the birth, descent of podalic pole along with compaction and internal rotation needs to occur. This happens when the mother's pelvic floor muscles cause the baby to turn so that it can be born with one hip directly in front of the other. At this point the baby is facing one of the mother's inner thighs. Then, the shoulders follow the same path as the hips did. At this time the baby usually turns to face the mother's back. Next occurs external rotation, which is when the shoulders emerge as the baby’s head enters the maternal pelvis. The combination of maternal muscle tone and uterine contractions cause the baby’s head to flex, chin to chest. Then the back of the baby's head emerges and finally the face.
Due to the increased pressure during labour and birth, it is normal for the baby's leading hip to be bruised and genitalia to be swollen. Babies who assumed the frank breech position in utero may continue to hold their legs in this position for some days after birth.
Turning the baby
There are many methods which have been attempted with the aim of turning breech babies, with varying degrees of success:
- External cephalic version where a midwife or doctor turns the baby by manipulating the baby through the mother's abdomen. ECV has a success rate between 40–70% depending on practitioner. The fetal heart is monitored after the turn attempt, usually in the context of an institutional protocol. Studies show that turning the baby at term (after 36 weeks) is effective in reducing the number of babies born in the breech position. Complications from external cephalic version are rare. Studies have also shown that attempting to turn the baby prior to this point has no impact on the presentation at term.
Using hypothetical scenarios, a small study in the Netherlands found that few obstetric practitioners would attempt ECV in the presence of oligohydramnios. A case report of treating oligohydramnios with amnioinfusion, followed by ECV, was successful in turning the fetus.
Various maneuvers are suggested to assist spontaneous version of a breech presenting pregnancy. These include maternal positioning or other exercises. A study has shown that there is insufficient evidence as to the benefit of maternal positioning in reducing the incidence of breech presentation.
Breech birth versus Caesarean section
Caesarean section is the most common way to deliver a breech baby in Australia, the United Kingdom, and the United States. Like any major surgery, it involves risks. Maternal mortality is increased by a Caesarean section, but still remains a rare complication in developed countries. Third World statistics are dramatically different, and mortality is increased significantly. There is remote risk of injury to the mother's internal organs, injury to the baby, and severe hemorrhage requiring hysterectomy with resultant infertility.
One large study has confirmed that elective Cesarean section has lower risk to the fetus and a slightly increased risk to the mother than planned vaginal delivery of the breech because the mortality was 0.6% of fetuses in cesarean section planned births versus 1.6% of fetuses in planned vaginal births. Elements of the methodology used have undergone some criticism.
People born breech
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