ANATOMY AND PHYSIOLOGY OF BREECH PRESENTATION

The breech presentation is associated with abnormal fetal

conditions that may decrease fetal movement or mobility. An
increased incidence of breech or other abnormal presentations is
associated with primary neurologic disorders, neuromuscular
disorders (myotonic dystrophy), genetic abnormalities ( trisomies
13, 18, and 21), prematurity, fetal malformations such as
hydrocephalus or a cystic hygroma, and polar placentation.
Maternal abnormalities that increase the risk of an abnormal
fetal presentation include a small pelvis, small or abnormal
pelvic measurements, uterine anomalies, and lower segment
leiomyomata.
There are three main types of breech presentation. The most
common is the flank breech, accounting for 50 to 73 percent of
breech presentations. The fetus is flexed at the hips and
extended at the knees. The fetus is in the “pike” position. The
complete breech is the least common type and accounts for
approximately 5 to 11 percent of breech presentations. The fetus
is flexed at both the hips and the knees. The footling or
incomplete breech accounts for approximately 12 to 38 percent of
breech presentations. The fetus is incompletely deflexed at one
or both knees or hips.
Breech delivery is divided into three categories. These
include unassisted or spontaneous expulsion, partial breech
extraction, and total breech extraction. Unassisted or
spontaneous expulsion of the fetus occurs when there is no
assistance from the provider in delivery of the infant. This
generally occurs only with very premature infants or in
precipitous deliveries where baby delivers so rapidly as not
allow the provider to arrive.
Partial breech extraction is defined as spontaneous delivery
of the infant to the level of the umbilicus followed by
assistance from the provider. This is the usual manner of breech
delivery. Allowing the fetus to descend naturally into the pelvis
avoids an increased incidence of head entrapment, deflexion of
the fetal head, nuchal arms, and umbilical cord prolapse. This is
the preferred method of delivery for the Emergency Physician
confronted with an actively labouring breech presentation and
little hope of obtaining an Obstetrician before delivery.
Total breech extraction occurs when the provider reaches
into the uterus and literally pulls or extracts the fetal feet
into vagina and through the vulva, followed by assisted delivery
of the remainder of the infant. Total breech extraction is
indicated in the absence of an experienced Obstetrician to
perform a cesarian section and if performed for the breech
presentation of the second twin, acute and profound fetal
distress, and/or umbilical cord prolapsed.