Breech Presentation

ECV belongs where a cesarean can happen - Fetal heart rate abnormalities complicate about 4.7% of versions and are usually transient, but under 1% end in emergency cesarean, premature rupture of membranes, cord prolapse, vaginal bleeding, abruption, or fetomaternal hemorrhage. Have IV access, aspiration precautions matched to their NPO status, and the OR team aware before the obstetrician puts hands on the abdomen.

Neuraxial improves version success - Anesthetic-dose spinal or epidural blockade — not a light analgesic dose — raises ECV success, and it is the option when tocolysis alone has not worked. The trade is maternal hypotension and postdural puncture headache, so this is a shared decision, not a reflex.

Hypotension after the block - Maternal hypotension in this setting has been reported as high as 64%, and it hits uteroplacental perfusion directly, driving fetal hypoxia and acidosis. Start a vasopressor infusion with the block rather than chasing pressures, and keep left uterine displacement with a wedge — the patient is supine on a flat table for the whole maneuver.

Remifentanil as the IV alternative - A meta-analysis of five RCTs (602 patients) found remifentanil during ECV moderately increased success, cut pain scores by about 2 points on a 0 to 10 scale, reduced transient fetal bradycardia, and raised maternal satisfaction, without changing cesarean, instrumental, or spontaneous delivery rates. It is cleared by nonspecific blood and tissue esterases in both mother and fetus. No effective dose has been established — the review could not recommend one.

Tocolysis - Terbutaline 0.25 mg subcutaneously 15 to 30 minutes before the version is the common choice; expect the beta-agonist tachycardia and do not chase it as something else. The data does not support calcium channel blockers or nitroglycerin for tocolysis in this setting.

Cord prolapse is the emergency - Footling and incomplete breech carry a 15% to 18% cord prolapse risk. If the tracing craters, this becomes a crash cesarean: extend an existing epidural if it is dense and there is time, otherwise it is general anesthesia with rapid sequence induction.

Planned cesarean after 39 weeks - Since the Term Breech Trial the standard route for the term breech is planned cesarean, and the rate has climbed sharply. Most of these are elective spinal or CSE cases and the ordinary obstetric anesthetic applies — the point is that they are scheduled, not urgent, and should be treated that way.

Vaginal breech is rare and unpracticed - Where it is offered, the criteria are 37 weeks or more, frank or complete breech, estimated fetal weight 2,500 to 4,000 g, an adequate pelvis on CT pelvimetry, a documented flexed fetal head, adequate amniotic fluid, and no oxytocin induction or augmentation. Expertise has thinned enough that institutions now run simulation for it. Assume the delivery can convert to an emergency cesarean without warning and staff the room accordingly.

Premature breech - Gestational age sets the route: from 28 to 31 6/7 weeks planned cesarean lowers perinatal morbidity and mortality, while from 32 to 36 weeks there is no difference, and below 26 weeks there is no quality evidence to guide it. Plan for a preterm neonate and a neonatal team in the room.

Breech presentation is a longitudinal lie with the buttocks or a lower extremity entering the pelvis first: frank (both hips flexed, legs extended toward the face), complete (hips and knees flexed, fetus tucked), or incomplete/footling (one or both hips extended). It occurs in 3% to 4% of term pregnancies, 7% at 32 weeks, and 25% at or before 28 weeks, so prematurity is the largest single driver; multiple gestation, aneuploidy, congenital and Mullerian anomalies, uterine leiomyoma, and placenta previa also restrict fetal motility or change the vertical polarity of the uterine cavity. It reaches anesthesia through cord prolapse — 15% to 18% with footling or incomplete breech, 4% to 6% with complete, 0.5% with frank — and through the two care pathways it generates: external cephalic version (ECV) at 36 to 37 weeks, then planned cesarean after 39 weeks if version fails or is declined.