Breech Presentation in Pregnancy: A Clinical Case Study

When a pregnant woman arrives at 36 weeks for her routine antenatal check and the midwife suspects something unusual during abdominal palpation, it often marks the beginning of an important clinical decision-making journey. The discovery of a breech presentation-where the baby’s buttocks or feet are positioned to come out first instead of the head-requires careful assessment, thorough discussion, and a well-planned management approach to ensure the best outcomes for both mother and baby.

Understanding breech presentation through a clinical case 🔗

Consider Sarah, a 28-year-old first-time mother at 36 weeks of pregnancy. During her routine antenatal visit, her obstetrician noted that the firm, round fetal head was palpable in the upper part of her uterus rather than in the pelvis. An ultrasound scan confirmed a frank breech presentation, where the baby’s hips were flexed but the legs extended straight up toward the face. This scenario represents one of the most common types of breech presentation and illustrates the critical decision-making process that healthcare providers and expectant mothers navigate together.

Breech presentation occurs in approximately 3% to 4% of all term pregnancies. While many babies are in breech position earlier in pregnancy-about 25% at 28 weeks-most naturally turn head-down before delivery. When a baby remains breech at 36-37 weeks, healthcare providers must carefully evaluate the situation and discuss management options with the mother.

Types of breech presentation and their clinical significance 🔗

In Sarah’s case, the frank breech presentation is actually the most favorable type if vaginal delivery is considered. There are three main types of breech presentation, each with different implications for delivery planning. Frank breech, where both legs are extended straight up, accounts for most breech presentations. Complete breech occurs when the baby appears to be sitting cross-legged with both hips and knees flexed. Footling breech, where one or both feet point downward, poses the highest risk during vaginal delivery because the feet can slip through a partially dilated cervix, potentially trapping the larger head.

Understanding which type of breech presentation exists is essential for clinical decision-making. This is why ultrasound confirmation is recommended for any suspected breech presentation. The scan not only confirms the diagnosis but also reveals important details such as the exact fetal position, estimated fetal weight, amniotic fluid levels, and placental location-all factors that influence management decisions.

The decision-making process: external cephalic version 🔗

For Sarah, the first management option discussed was external cephalic version, commonly known as ECV. This non-surgical procedure involves an experienced obstetrician applying gentle but firm pressure on the mother’s abdomen to manually rotate the baby into a head-down position. The procedure is typically offered from 36 weeks in first-time mothers and from 37 weeks in women who have given birth before.

The success rate of ECV is approximately 58% overall, though this varies based on several factors. First-time mothers like Sarah have a success rate around 40%, while women who have given birth before have a higher success rate of about 60%. Several factors can influence success, including the amount of amniotic fluid, placental location, maternal body mass index, and whether the baby’s head is engaged in the pelvis.

Before proceeding with ECV, Sarah underwent a thorough assessment. The healthcare team checked her blood pressure, performed an ultrasound to confirm the baby’s position and assess the amniotic fluid, and monitored the fetal heart rate. A medication to relax the uterine muscles was administered to improve the chances of success. Throughout the procedure, continuous fetal heart monitoring ensured the baby’s wellbeing.

Risks and benefits of external cephalic version 🔗

Like any medical procedure, ECV carries both benefits and risks. The primary benefit is clear: successful ECV allows most women to attempt vaginal delivery, avoiding the need for cesarean section. Studies show that approximately 80% of women with successful ECVs deliver vaginally. This is significant because it helps reduce the overall cesarean delivery rate and avoids the surgical risks associated with cesarean section.

However, ECV is not without risks. The most common issue is temporary changes in fetal heart rate during the procedure, which typically resolve quickly. More serious complications are rare but can include placental abruption, premature rupture of membranes, and the need for emergency cesarean delivery. The risk of requiring emergency cesarean is approximately 1 in 200 procedures. These risks make it essential that ECV is performed only in facilities equipped for immediate cesarean delivery if needed.

In Sarah’s case, the first ECV attempt was unsuccessful. The baby briefly shifted but returned to breech position. Her obstetrician explained that ECV could be attempted again at a later date if she wished, as some women have successful versions on second or third attempts. However, Sarah and her healthcare team needed to discuss alternative delivery plans.

Evaluating delivery options: cesarean section versus vaginal breech birth 🔗

With the baby remaining in breech position after unsuccessful ECV, Sarah faced two main delivery options: planned cesarean section or vaginal breech delivery. Current clinical guidelines generally recommend cesarean delivery for breech presentation based on evidence showing lower perinatal morbidity and mortality with planned cesarean compared to planned vaginal breech delivery in term babies.

The obstetrician thoroughly discussed both options with Sarah, explaining that cesarean section eliminates certain risks associated with breech vaginal delivery, such as head entrapment, birth trauma, and umbilical cord prolapse. However, cesarean section is major abdominal surgery and carries its own risks, including bleeding, infection, longer recovery time, and implications for future pregnancies.

Considerations for vaginal breech delivery 🔗

Some women, including Sarah, express interest in attempting vaginal breech delivery despite the recommendations for cesarean section. This option requires careful consideration of multiple factors. The healthcare team must evaluate whether the woman is a suitable candidate, considering factors such as the type of breech presentation, estimated fetal weight, pelvic adequacy, and the presence of any other complications.

Vaginal breech delivery is generally not recommended if the baby is in footling breech position, if the estimated fetal weight exceeds 4000 grams, if there is evidence of fetal compromise, or if the mother has certain complications like placenta previa. Additionally, vaginal breech delivery requires an experienced obstetrician or midwife skilled in breech delivery techniques and immediate access to cesarean section if complications arise.

The key principle in vaginal breech delivery is maintaining a “hands-off” approach, allowing the baby to deliver spontaneously without applying traction. Pulling on the baby during delivery can cause the head to extend backward, potentially leading to head entrapment-one of the most serious complications of breech delivery. Specific maneuvers may be needed if spontaneous delivery does not occur, including techniques to deliver the arms, shoulders, and head.

The importance of thorough antenatal assessment and planning 🔗

Sarah’s case illustrates why comprehensive antenatal assessment is crucial when managing breech presentation. Beyond confirming the diagnosis, ultrasound examination provides essential information about fetal well-being, growth, amniotic fluid volume, and anatomical details. Some breech presentations occur due to fetal abnormalities or uterine conditions, so thorough evaluation helps identify any underlying issues.

The assessment also involves discussing the woman’s preferences, concerns, and understanding of the various options. Shared decision-making is essential, as the woman must make informed choices about her care. Healthcare providers should present information about risks and benefits objectively, support the woman’s decision, and ensure she understands what to expect with each option.

In Sarah’s situation, after detailed discussions and careful consideration, she opted for a planned cesarean section at 39 weeks. Her obstetrician scheduled the procedure, provided clear instructions about what to expect, and ensured Sarah felt supported in her decision. The healthcare team also discussed what would happen if Sarah went into labor before the scheduled cesarean date, including the possibility of proceeding with vaginal delivery if birth was imminent.

Outcomes and follow-up care 🔗

Optimal outcomes in breech presentation cases result from careful planning, clear communication, and individualized care. Whether delivery occurs via cesarean section or vaginal breech birth, the focus remains on maternal and neonatal safety. Neonatal care teams should be prepared for delivery, particularly in vaginal breech births where babies may require additional observation or support.

For mothers who deliver by cesarean section, appropriate postoperative care includes pain management, early mobilization, and monitoring for complications. Recovery takes longer than vaginal delivery, and mothers need support with infant care while healing. For those who have vaginal breech deliveries, careful monitoring during labor and immediate postnatal period is essential to detect any complications early.

Long-term considerations include counseling about future pregnancies. Women who have had one breech presentation have a higher recurrence risk in subsequent pregnancies-approximately 10% in the second pregnancy and 27% in the third pregnancy. This information helps women and healthcare providers plan appropriately for future pregnancies.

Key lessons from clinical case management 🔗

Sarah’s case demonstrates several important principles in managing breech presentation. First, early detection through routine antenatal care allows time for proper evaluation and planning. Second, offering ECV when appropriate provides women an opportunity to avoid cesarean section. Third, thorough counseling about all options enables informed decision-making. Finally, individualized care that respects maternal preferences while prioritizing safety leads to better outcomes.

The management of breech presentation continues to evolve as research provides new insights. While current evidence supports cesarean delivery for most breech presentations at term, the importance of offering ECV and respecting maternal autonomy in delivery decisions remains paramount. Healthcare providers must stay current with evidence-based guidelines while maintaining the clinical skills needed to manage both cesarean and vaginal breech deliveries safely.

What do you think? How can healthcare providers best balance evidence-based recommendations with patient preferences when counseling women about breech presentation? What strategies might improve the success rates of external cephalic version while maintaining safety?

References

1. https://teachmeobgyn.com/pregnancy/fetal-abnormality/breech-presentation/
2. https://www.ncbi.nlm.nih.gov/books/NBK448063/
3. https://www.nhs.uk/pregnancy/labour-and-birth/what-happens/if-your-baby-is-breech/
4. https://www.ncbi.nlm.nih.gov/books/NBK482475/
5. https://evidencebasedbirth.com/what-is-the-evidence-for-using-an-external-cephalic-version-to-turn-a-breech-baby/