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Understanding the Breech Presentation
In the world of obstetrics, you may come across various terms and scenarios. Among these, the term breech presentation might pop up quite often. It's crucial to understand what it means and why it's important, especially if you're pursuing a career in nursing. So, let's delve deeper into this subject.
Definition and Importance of Breech Presentation
Breech presentation refers to a situation where the baby is in a longitudinal lie, but the buttocks or feet are the presenting part of the baby at the bottom of the uterus, nearing the birth canal. This positioning is contrary to the usual vertex presentation, where the baby's head is the presenting part.
This situation is significant because it directly influences the management of labour and delivery. In breech presentation cases, the risk of complications such as cord prolapse, birth injuries, and even neonatal death, increase. Therefore, healthcare professionals, including nurses, need a thorough understanding of breech presentation to ensure the best possible care for the mother and the baby.
The prevalence of breech presentation decreases with gestational age, affecting about 25% of pregnancies at 28 weeks but only 3-4% at term. The higher risk factors for breech presentation include prematurity, multiparity (having given birth two or more times), uterine abnormalities and placenta previa.
Types of Breech Presentation
Breech presentations come in different forms, each with its unique characteristics. Understanding these types can help you in future clinical practices. They include:
- Frank Breech: Here, the baby's buttock presents first, with its legs folded at the hips and extended towards the shoulders. It is the most common type of breech presentation.
- Complete Breech: In this case, the baby's hips and knees are both flexed. So, the buttocks or feet may deliver first.
- Footling Breech: As the name suggests, one or both feet of the baby come first in this type of breech presentation. It is the least common variant.
Suppose a pregnant woman at 36 weeks of gestation comes for a routine check-up. On examination, if the presenting part is found to be the buttocks and the baby's legs are extended upwards, it would be a case of a Frank Breech presentation.
Thereby, understanding these variations can prepare you for different scenarios, thereby improving your efficiency and care as a nurse in managing cases of breech presentation.
The Causal Factors Behind Breech Presentation
To further your understanding of breech presentation, it's important to be aware of the factors contributing to this particular fetal position. By learning about these aspects, you can enhance your skills in prevention, management, and counselling of expectant mothers.
Common Causes of Breech Presentation
Several factors can influence the position of the baby in the uterus, leading to breech presentation. Some of the common causes include:
- Preterm Deliveries: Breech presentations are more common in preterm pregnancies because the baby might not have turned to the vertex position yet.
- Multiple Pregnancy: In pregnancies with more than one baby, there might not be enough space for all the babies to be in the vertex position.
- Uterine Abnormalities: Conditions such as bicornuate uterus can cause a breech presentation due to the irregular shape of the uterine cavity.
- Placenta Previa: When the placenta covers the cervix, known as placenta previa, it may prevent the baby from moving into the vertex position.
Placenta Previa is a complication in pregnancy where the placenta lies unusually low in the uterus, next to or covering the cervix. It can cause severe bleeding before or during delivery.
Role of Pregnancy Conditions in Breech Presentation
Specific conditions related to pregnancy can have a direct role in encouraging breech presentation. Conditions such as polyhydramnios, where excessive amniotic fluid accumulates in the uterus, and oligohydramnios, characterised by a deficiency in amniotic fluid, can influence the baby's position. This is due to the shifting dynamics of the intrauterine space.
| Condition | Description | Effect on Breech Presentation |
| Polyhydramnios | Condition characterised by excessive amniotic fluid. | Can cause instability of the fetus, leading to abnormal positions. |
| Oligohydramnios | Condition marked by a deficiency of amniotic fluid. | Can restrict fetal movements, causing abnormal positions. |
Another crucial condition is the short umbilical cord. A shorter than average umbilical cord may restrict the mobility of the fetus, preventing it from turning into the vertex position.
Consider a pregnancy complicated by oligohydramnios at 34 weeks of gestation. In such a case, the reduction in amniotic fluid can limit the space for the baby to move around, resulting in an atypical position such as the breech presentation.
Therefore, being familiar with these conditions and their influences on the fetus's position can significantly enhance your understanding and management of breech presentations in clinical practice.
Management and Treatment Options for Breech Presentation
Once a breech presentation is identified, there are several ways to manage and treat it. Understanding these methods is crucial as a nursing professional tasked with ensuring the safety of both the mother and baby. Let's explore these options in more detail.
Techniques in Breech Presentation Management
There are two fundamental approaches to managing breech presentation in obstetrics: expectant management and active intervention.
Expectant management involves monitoring the pregnancy and waiting for the baby to turn spontaneously into a vertex position. But after 37 weeks of pregnancy, if the baby remains in breech, active interventions might be considered.
Expectant Management is a healthcare approach where time is allowed to pass for a spontaneous resolution of a health condition or for clear indications of intervention to appear.
Active interventions include procedures like External Cephalic Version (ECV) and planned Caesarean Section (C-Section).
- External Cephalic Version (ECV): This manual procedure tries to turn the baby into a vertex position by applying pressure on the mother's abdomen.
- Planned C-Section: If ECV is unsuccessful or contraindicated, or the mother doesn't consent for a trial of labour, a planned C-Section might be the management choice.
The TERM Breech Trial, the largest randomised controlled trial in this aspect, found that planned C-sections significantly decreased neonatal mortality and morbidity compared to planned vaginal birth for breech presentation at term. However, subsequent studies, surveys and meta-analyses have produced conflicting results, making the choice of delivery mode a subject of ongoing debate.
Understanding External Cephalic Version
External Cephalic Version (ECV) is a significant procedure in managing breech presentation. It involves manually turning the fetus to a head-down position by applying specific pressure points on the mother's belly.
Studies show a successful ECV can prevent many C-Sections. However, the procedure comes with risks like abruptio placentae (premature detachment of a normally located placenta) and emergency C-Section. Therefore, it should be attempted in a setting where an immediate C-Section is possible.
For an ECV, the mother would be positioned on her back with a wedge under one side to prevent supine hypotension. A healthcare practitioner, typically a trained obstetrician or midwife, would apply pressure on the mother's belly, manipulating the baby's position. By identifying the baby's head and buttocks' positions, the practitioner applies a forward somersault motion to turn the baby's head down.
Application of Breech Birth Scenarios in Treatment
Specifically planning labour and delivery routes in breech presentation involves considering various factors like the type of breech presentation, estimated fetal weight and gestational age, maternal pelvis size, availability of an experienced healthcare provider and the mother's preference.
Estimated Fetal Weight (EFW) is the weight of the unborn baby calculated before birth. This estimation helps in managing and planning the route of delivery in cases of breech presentations.
Following are some scenarios and their potential treatment:
| Breech Scenario | Potential Treatment |
| Frank Breech, Estimated Fetal Weight less than 4000g, adequate pelvic size, no other complications | Vaginal delivery can be considered under health practitioner supervision. |
| Any type of breech, Estimated Fetal Weight more than 4000g or less than 2500g, inadequate pelvic size, other risk factors present | A C-Section might be the safest route of delivery. |
| Woman opts for ECV, but it fails or is contraindicated | A planned C-Section would be the next step. |
For instance, if a pregnant woman presents at full term with a frank breech baby whose estimated weight is 3500g and she has adequate pelvic size, she may consent to a trial of vaginal delivery. However, if the same woman has had a previous C-Section or any other risk factor that creates a contraindication to vaginal birth, she should opt for a planned C-Section instead.
By applying this understanding of breech presentation management in clinical practice, you would be well-equipped to provide optimal care and make informed decisions.
Complications and Risks Associated with Breech Presentation
Despite the possible management strategies, breech presentation is associated with several complications and risks that can affect both the mother and the baby. It's essential for nursing professionals like you to be well-versed with these risks, to provide the best care possible for the patients.
Identifying Potential Breech Presentation Complications
Various complications can arise when a baby is in a breech position at term. This is especially true when it comes to vaginal delivery in these instances. These complications can involve both the mother and the baby, and can occur during labour, delivery, or even postpartum.
Labour complications associated with breech presentation include prolonged first and second stages of labour, and abnormal fetal heart rate patterns indicating fetal distress.
- Umbilical Cord Prolapse: This is when the umbilical cord drops (prolapses) through the open cervix into the vagina ahead of the baby. It is a severe condition that can compress the cord during contractions, reducing the baby's oxygen supply.
- Birth Injuries: In breech delivery, the baby's head is the last part to be born, which increases the risk of getting stuck in the birth canal leading to birth injuries.
- Complicated Labour: Breech can cause difficulties during labour, often resulting in operative intervention such as a C-Section.
Umbilical Cord Prolapse refers to a complication where the umbilical cord slips out of the cervix before the baby during labour and delivery. It can cause serious complications as the umbilical cord provides oxygen and nutrients from the placenta to the baby.
Risks in Breech Presentation and Delivery
When it comes to delivery, whether it be a C-Section or a vaginal delivery, a breech presentation still holds multiple risks. These risks can impact both the immediate and long-term outcomes for the mother and baby.
For instance, with vaginal delivery, the baby's lower body, the largest part, is delivered first with a risk that the smaller upper body and head could get stuck. In a scenario where the baby's arm is extended over its head (known as an extended arm), it may cause difficulties in delivery. Moreover, emergency C-Sections, often required in labour complications, also come with associated surgical risks like infection or bleeding.
| Risk | Impact |
| Neonatal Morbidity and Mortality | Despite modern technological advancements, breech delivery is still correlated with a higher risk of neonatal morbidity and even mortality. |
| Trauma during Delivery | The risk of birth trauma, including brachial plexus injury and trauma to the head, is higher in vaginal breech delivery. |
| Maternal Morbidity | Maternal risks include complications associated with operative delivery and longer hospital stays. |
As a nurse, it's crucial to monitor and assess the progress of labour closely in cases of breech presentation. Prompt recognition of complications and quick action can prevent adverse outcomes and ensure the best possible health for both the mother and baby.
Breech Presentation in the Scope of Midwifery
Within the realm of maternity care, breech presentation offers significant challenges. Midwives play a crucial role in the management and care of women with breech presentations. Their intimate interaction with mothers-to-be places them in a unique position to provide consistent support, education and guidance during this time. Being well-informed about breech presentations is therefore critically important for midwives.
Role of Midwifery in Breech Presentation Cases
Midwives form a critical part of the healthcare team dedicated to managing breech presentations. Their role extends beyond the delivery room, providing support throughout the pregnancy term and postnatal period. In the context of a breech presentation, your duties as a midwife can range from early detection, counselling, performing or assisting in interventions to postnatal care.
A Midwife is a trained health professional who helps healthy women during labour, delivery, and after the birth of their babies. Midwives may deliver babies at birthing centres or at home, but most can also deliver babies at a hospital.
- Detection of Breech Presentation: Early detection of a breech presentation facilitates timely decision-making regarding management. It also provides ample time for counselling the expectant mother. A midwife can detect breech presentation through palpation during antenatal checks or suspect it based on the reported fetal movements.
- Counselling: As a midwife, you have the chance to discuss the benefits and risks of the various management options with the mother. This helps the mother make an informed decision about the preferred mode of delivery.
- Performing Interventions: Assistance in External Cephalic Version (ECV), if within the midwife’s scope of practice in their respective healthcare system, can be a part of the role.
- Intrapartum Care: During delivery, the midwife's duties include monitoring the labour progress, recognising complications, and providing pain relief measures. If a vaginal breech delivery is underway, midwife-led care can be particularly helpful in improving the mother’s birth experience.
- Postnatal Care: Postnatal care involves monitoring the recovery and well-being of both mother and baby after birth.
Research supports the role of midwives in improving maternal satisfaction. A study published in 'Birth: Issues in Perinatal Care', found that women who received midwife-led continuity models of care were less likely to use pain relief analgesia and more likely to be satisfied with their care. They were also less likely to have a preterm birth compared to women who received other models of care.
Midwife's Guide to Breech Births
As you navigate the realm of breech births as a midwife, there are certain elements you need to consider. Familiarise yourself with different breech positions, clinical skills for breech birth, risk factors and indicators for referral, and psychological support techniques.
A Breech Birth occurs when a baby is born bottom first instead of head first. Most babies in the breech position are born by a caesarean section because it is seen as safer than being born vaginally.
- Breech Positions: Understanding the nuances of different breech positions – frank, complete, incomplete – helps in predicting possible delivery outcomes and counselling.
- Clinical Skills: From assessing fetal lie and position during antenatal checks through palpation, to recognising the progress of breech labour, a skilful midwife can contribute significantly to care.
- Indicators for Referral: Recognising when it is necessary to involve an obstetrician or other specialists helps ensure optimal care.
- Psychological Support: Providing emotional support and addressing the concerns of a mother with breech presentation is an integral aspect of care.
Imagine you are a midwife attending a routine 36-week antenatal visit. On abdominal palpation, you suspect the baby is in a breech position, a diagnosis later confirmed by an ultrasound scan. You discuss this with the expectant mother, explaining the condition and possible implications. You provide patient-centred care, offering clear information on both the risks and benefits of ECV and breech vaginal birth compared to caesarean delivery. Your support continues through the chosen mode of birth, helping the woman navigate her experiences confidently and calmly.
Being thoroughly informed, supportive, and communicative is vital. Remember, your role as a midwife is integral in ensuring a safe and satisfactory pregnancy and delivery experience, even in complex cases like breech presentation.
Breech Presentation - Key takeaways
- Breech Presentation: A condition where the baby is positioned in the uterus to be born feet-first rather than head-first.
- Causes of Breech Presentation: Common causes include preterm deliveries, multiple pregnancies, uterine abnormalities, and placenta previa.
- Management of Breech Presentation: Mainly involves expectant management and active intervention. An active intervention could be external cephalic version and planned caesarean sections.
- Complications and Risks: Breech presentation can lead to complications like umbilical cord prolapse, and birth injuries. Risks are both maternal and neonatal morbidity and trauma during delivery.
- External Cephalic Version (ECV): A manual procedure that tries to turn the baby into a vertex position by applying pressure on the mother's abdomen.
- Breech Birth Scenarios: Delivery routes in breech presentation involves considering various factors like the type of breech presentation, estimated fetal weight and gestational age, and maternal pelvis size.
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