breech presentation anatomy definition

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Breech presentation

• Overview  
• Theory  
• Diagnosis  
• Management  
• Follow up  
• Resources  

Breech presentation refers to the baby presenting for delivery with the buttocks or feet first rather than head.

Associated with increased morbidity and mortality for the mother in terms of emergency cesarean section and placenta previa; and for the baby in terms of preterm birth, small fetal size, congenital anomalies, and perinatal mortality.

Incidence decreases as pregnancy progresses and by term occurs in 3% to 4% of singleton term pregnancies.

Treatment options include external cephalic version to increase the likelihood of vaginal birth or a planned cesarean section, the optimal gestation being 37 and 39 weeks, respectively.

Planned cesarean section is considered the safest form of delivery for infants with a persisting breech presentation at term.

Breech presentation in pregnancy occurs when a baby presents with the buttocks or feet rather than the head first (cephalic presentation) and is associated with increased morbidity and mortality for both the mother and the baby. [1] Cunningham F, Gant N, Leveno K, et al. Williams obstetrics. 21st ed. New York: McGraw-Hill; 1997. [2] Kish K, Collea JV. Malpresentation and cord prolapse. In: DeCherney AH, Nathan L, eds. Current obstetric and gynecologic diagnosis and treatment. New York: McGraw-Hill Professional; 2002. There is good current evidence regarding effective management of breech presentation in late pregnancy using external cephalic version and/or planned cesarean section.

History and exam

Key diagnostic factors.

• buttocks or feet as the presenting part
• fetal head under costal margin
• fetal heartbeat above the maternal umbilicus

Other diagnostic factors

• subcostal tenderness
• pelvic or bladder pain

Risk factors

• premature fetus
• small for gestational age fetus
• nulliparity
• fetal congenital anomalies
• previous breech delivery
• uterine abnormalities
• abnormal amniotic fluid volume
• placental abnormalities
• female fetus

Diagnostic tests

1st tests to order.

• transabdominal/transvaginal ultrasound

Treatment algorithm

<37 weeks' gestation and in labor, ≥37 weeks' gestation not in labor, ≥37 weeks' gestation in labor: no imminent delivery, ≥37 weeks' gestation in labor: imminent delivery, contributors, natasha nassar, phd.

Associate Professor

Menzies Centre for Health Policy

Sydney School of Public Health

University of Sydney

Disclosures

NN has received salary support from Australian National Health and a Medical Research Council Career Development Fellowship; she is an author of a number of references cited in this topic.

Christine L. Roberts, MBBS, FAFPHM, DrPH

Research Director

Clinical and Population Health Division

Perinatal Medicine Group

Kolling Institute of Medical Research

CLR declares that she has no competing interests.

Jonathan Morris, MBChB, FRANZCOG, PhD

Professor of Obstetrics and Gynaecology and Head of Department

JM declares that he has no competing interests.

Peer reviewers

John w. bachman, md.

Consultant in Family Medicine

Department of Family Medicine

Mayo Clinic

JWB declares that he has no competing interests.

Rhona Hughes, MBChB

Lead Obstetrician

Lothian Simpson Centre for Reproductive Health

The Royal Infirmary

RH declares that she has no competing interests.

Brian Peat, MD

Director of Obstetrics

Women's and Children's Hospital

North Adelaide

South Australia

BP declares that he has no competing interests.

Lelia Duley, MBChB

Professor of Obstetric Epidemiology

University of Leeds

Bradford Institute of Health Research

Temple Bank House

Bradford Royal Infirmary

LD declares that she has no competing interests.

Justus Hofmeyr, MD

Head of the Department of Obstetrics and Gynaecology

East London Private Hospital

East London

South Africa

JH is an author of a number of references cited in this topic.

Differentials

• Transverse lie
• Caesarean birth
• Mode of term singleton breech delivery

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Breech Presentation

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Introduction

Breech presentation is a type of malpresentation and occurs when the fetal head lies over the uterine fundus and fetal buttocks or feet present over the maternal pelvis (instead of cephalic/head presentation).

The incidence in the United Kingdom of breech presentation is 3-4% of all fetuses. 1

Breech presentation is most commonly idiopathic .

Types of breech presentation

The three types of breech presentation are:

• Complete (flexed) breech : one or both knees are flexed (Figure 1)
• Footling (incomplete) breech : one or both feet present below the fetal buttocks, with hips and knees extended (Figure 2)
• Frank (extended) breech : both hips flexed and both knees extended. Babies born in frank breech are more likely to have developmental dysplasia of the hip (Figure 3)

Risk factors

Risk factors for breech presentation can be divided into maternal , fetal and placental risk factors:

• Maternal : multiparity, fibroids, previous breech presentation, Mullerian duct abnormalities
• Fetal : preterm, macrosomia, fetal abnormalities (anencephaly, hydrocephalus, cystic hygroma), multiple pregnancy
• Placental : placenta praevia , polyhydramnios, oligohydramnios , amniotic bands

Clinical features

Before 36 weeks , breech presentation is not significant, as the fetus is likely to revert to a cephalic presentation. The mother will often be asymptomatic with the diagnosis being incidental.

The incidence of breech presentation is approximately 20% at 28 weeks gestation, 16% at 32 weeks gestation and 3-4% at term . Therefore, breech presentation is more common in preterm labour . Most fetuses with breech presentation in the early third trimester will turn spontaneously and be cephalic at term.

However, spontaneous version rates for nulliparous women with breech presentation at 36 weeks of gestation are less than 10% .

Clinical examination

Typical clinical findings of a breech presentation include:

• Longitudinal lie
• Head palpated at the fundus
• Irregular mass over pelvis (feet, legs and buttocks)
• Fetal heart auscultated higher on the maternal abdomen
• Palpation of feet or sacrum at the cervical os during vaginal examination

For more information, see the Geeky Medics guide to obstetric abdominal examination .

Positions in breech presentation

There are multiple fetal positions in breech presentation which are described according to the relation of the fetal sacrum to the maternal pelvis .

These are: direct sacroanterior, left sacroanterior, right sacroanterior, direct sacroposterior, right sacroposterior, left sacroposterior, left sacrotransverse and right sacrotranverse. 5

Investigations

An ultrasound scan is diagnostic for breech presentation. Growth, amniotic fluid volume and anatomy should be assessed to check for abnormalities.

There are three management options for breech presentation at term, with consideration of maternal choice: external cephalic version , vaginal delivery and Caesarean section .

External cephalic version

External cephalic version (ECV) involves manual rotation of the fetus into a cephalic presentation by applying pressure to the maternal abdomen under ultrasound guidance. Entonox and subcutaneous terbutaline are used to relax the uterus.

ECV has a 40% success rate in primiparous women and 60% in multiparous women . It should be offered to nulliparous women at 36 weeks and multiparous women at 37 weeks gestation. 

If ECV is unsuccessful, then delivery options include elective caesarean section or vaginal delivery. 

Contraindications for undertaking external cephalic version include:

• Antepartum haemorrhage
• Ruptured membranes
• Previous caesarean section
• Major uterine abnormality  
• Multiple pregnancy 
• Abnormal cardiotocography (CTG) 

Vaginal delivery

Vaginal delivery is an option but carries risks including head entrapment, birth asphyxia, intracranial haemorrhage, perinatal mortality, cord prolapse and fetal and/or maternal trauma.

The preference is to deliver the baby without traction and with an anterior sacrum during delivery to decrease the risk of fetal head entrapment .

The mother may be offered an epidural , as vaginal breech delivery can be very painful. 6

Contraindications for vaginal delivery in a breech presentation include:

• Footling breech: the baby’s head and trunk are more likely to be trapped if the feet pass through the dilated cervix too soon
• Macrosomia: usually defined as larger than 3800g
• Growth restricted baby: usually defined as smaller than 2000g
• Other complications of vaginal birth: for example, placenta praevia and fetal compromise
• Lack of clinical staff trained in vaginal breech delivery

Caesarean section

A caesarian section booked as an elective procedure at term is the most common management for breech presentation.

Caesarean section is preferred for preterm babies (due to an increased head to abdominal circumference ratio in preterm babies) and is used if the external cephalic version is unsuccessful or as a maternal preference. This option has fewer risks than a vaginal delivery. 

Complications

Fetal complications of breech presentation include:

• Developmental dysplasia of the hip (DDH)
• Cord prolapse
• Fetal head entrapment
• Birth asphyxia
• Intracranial haemorrhage
• Perinatal mortality

Complications of external cephalic version include:

• Transient fetal heart abnormalities (common)
• Fetomaternal haemorrhage
• Placental abruption (rare)
• There are three types of breech presentation: complete, incomplete and frank breech
• The most common clinical findings include: longitudinal lie, smooth fetal head-shape at the fundus, irregular masses over the pelvis and abnormal placement being required for fetal hear auscultation
• The diagnostic investigation is an ultrasound scan
• Breech presentation can be managed in three ways: external cephalic version , vaginal delivery or elective caesarean section
• Complications are more common in vaginal delivery , such as cord prolapse, fetal head entrapment, intracranial haemorrhage and birth asphyxia

Miss Saba Al Juboori

Consultant in Obstetrics and Gynaecology

Miss Neeraja Kuruba

Dr chris jefferies.

• Oxford Handbook of Obstetrics and Gynaecology. Breech Presentation: Overview. Published in 2011.
• Jemimah Thomas. Image: Complete breech.
• Bonnie Urquhart Gruenberg. Footling breech. Licence: [ CC BY-SA ]
• Bonnie Urquhart Gruenberg. Frank breech . Licence: [ CC BY-SA ]
• A Comprehensive Textbook of Obstetrics and Gynaecology. Chapter 50: Malpresentation and Malposition: Breech Presentation. Published in 2011.
• Diana Hamilton Fairley. Lecture Notes: Obstetrics and Gynaecology, Malpresentation, Breech Presentation. Published in 2009.

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Breech Presentation

• Author: Richard Fischer, MD; Chief Editor: Ronald M Ramus, MD  more...
• Sections Breech Presentation
• Vaginal Breech Delivery
• Cesarean Delivery
• Comparative Studies
• External Cephalic Version
• Conclusions
• Media Gallery

Breech presentation is defined as a fetus in a longitudinal lie with the buttocks or feet closest to the cervix. This occurs in 3-4% of all deliveries. The percentage of breech deliveries decreases with advancing gestational age from 22-25% of births prior to 28 weeks' gestation to 7-15% of births at 32 weeks' gestation to 3-4% of births at term. [ 1 ]

Predisposing factors for breech presentation include prematurity , uterine malformations or fibroids, polyhydramnios , placenta previa , fetal abnormalities (eg, CNS malformations, neck masses, aneuploidy), and multiple gestations . Fetal abnormalities are observed in 17% of preterm breech deliveries and in 9% of term breech deliveries.

Perinatal mortality is increased 2- to 4-fold with breech presentation, regardless of the mode of delivery. Deaths are most often associated with malformations, prematurity, and intrauterine fetal demise .

Types of breeches

The types of breeches are as follows:

Frank breech (50-70%) - Hips flexed, knees extended (pike position)

Complete breech (5-10%) - Hips flexed, knees flexed (cannonball position)

Footling or incomplete (10-30%) - One or both hips extended, foot presenting

Historical considerations

Vaginal breech deliveries were previously the norm until 1959 when it was proposed that all breech presentations should be delivered abdominally to reduce perinatal morbidity and mortality. [ 2 ]

Vaginal breech delivery

Three types of vaginal breech deliveries are described, as follows:

Spontaneous breech delivery: No traction or manipulation of the infant is used. This occurs predominantly in very preterm, often previable, deliveries.

Assisted breech delivery: This is the most common type of vaginal breech delivery. The infant is allowed to spontaneously deliver up to the umbilicus, and then maneuvers are initiated to assist in the delivery of the remainder of the body, arms, and head.

Total breech extraction: The fetal feet are grasped, and the entire fetus is extracted. Total breech extraction should be used only for a noncephalic second twin; it should not be used for a singleton fetus because the cervix may not be adequately dilated to allow passage of the fetal head. Total breech extraction for the singleton breech is associated with a birth injury rate of 25% and a mortality rate of approximately 10%. Total breech extractions are sometimes performed by less experienced accoucheurs when a foot unexpectedly prolapses through the vagina. As long as the fetal heart rate is stable in this situation, it is permissible to manage expectantly to allow the cervix to completely dilate around the breech (see the image below).

Technique and tips for assisted vaginal breech delivery

The fetal membranes should be left intact as long as possible to act as a dilating wedge and to prevent overt cord prolapse .

Oxytocin induction and augmentation are controversial. In many previous studies, oxytocin was used for induction and augmentation, especially for hypotonic uterine dysfunction. However, others are concerned that nonphysiologic forceful contractions could result in an incompletely dilated cervix and an entrapped head.

An anesthesiologist and a pediatrician should be immediately available for all vaginal breech deliveries. A pediatrician is needed because of the higher prevalence of neonatal depression and the increased risk for unrecognized fetal anomalies. An anesthesiologist may be needed if intrapartum complications develop and the patient requires general anesthesia .

Some clinicians perform an episiotomy when the breech delivery is imminent, even in multiparas, as it may help prevent soft tissue dystocia for the aftercoming head (see the images below).

The Pinard maneuver may be needed with a frank breech to facilitate delivery of the legs but only after the fetal umbilicus has been reached. Pressure is exerted in the popliteal space of the knee. Flexion of the knee follows, and the lower leg is swept medially and out of the vagina.

No traction should be exerted on the infant until the fetal umbilicus is past the perineum, after which time maternal expulsive efforts should be used along with gentle downward and outward traction of the infant until the scapula and axilla are visible (see the image below).

Use a dry towel to wrap around the hips (not the abdomen) to help with gentle traction of the infant (see the image below).

An assistant should exert transfundal pressure from above to keep the fetal head flexed.

Once the scapula is visible, rotate the infant 90° and gently sweep the anterior arm out of the vagina by pressing on the inner aspect of the arm or elbow (see the image below).

Rotate the infant 180° in the reverse direction, and sweep the other arm out of the vagina. Once the arms are delivered, rotate the infant back 90° so that the back is anterior (see the image below).

The fetal head should be maintained in a flexed position during delivery to allow passage of the smallest diameter of the head. The flexed position can be accomplished by using the Mauriceau Smellie Veit maneuver, in which the operator's index and middle fingers lift up on the fetal maxillary prominences, while the assistant applies suprapubic pressure (see the image below).

Alternatively, Piper forceps can be used to maintain the head in a flexed position (see the image below).

In many early studies, routine use of Piper forceps was recommended to protect the head and to minimize traction on the fetal neck. Piper forceps are specialized forceps that are placed from below the infant and, unlike conventional forceps, are not tailored to the position of the fetal head (ie, it is a pelvic, not cephalic, application). The forceps are applied while the assistant supports the fetal body in a horizontal plane.

During delivery of the head, avoid extreme elevation of the body, which may result in hyperextension of the cervical spine and potential neurologic injury (see the images below).

Lower Apgar scores, especially at 1 minute, are more common with vaginal breech deliveries. Many advocate obtaining an umbilical cord artery and venous pH for all vaginal breech deliveries to document that neonatal depression is not due to perinatal acidosis.

Fetal head entrapment may result from an incompletely dilated cervix and a head that lacks time to mold to the maternal pelvis. This occurs in 0-8.5% of vaginal breech deliveries. [ 3 ] This percentage is higher with preterm fetuses (< 32 wk), when the head is larger than the body. Dührssen incisions (ie, 1-3 cervical incisions made to facilitate delivery of the head) may be necessary to relieve cervical entrapment. However, extension of the incision can occur into the lower segment of the uterus, and the operator must be equipped to deal with this complication. The Zavanelli maneuver has been described, which involves replacement of the fetus into the abdominal cavity followed by cesarean delivery. While success has been reported with this maneuver, fetal injury and even fetal death have occurred.

Nuchal arms, in which one or both arms are wrapped around the back of the neck, are present in 0-5% of vaginal breech deliveries and in 9% of breech extractions. [ 3 ] Nuchal arms may result in neonatal trauma (including brachial plexus injuries) in 25% of cases. Risks may be reduced by avoiding rapid extraction of the infant during delivery of the body. To relieve nuchal arms when it is encountered, rotate the infant so that the fetal face turns toward the maternal symphysis pubis (in the direction of the impacted arm); this reduces the tension holding the arm around the back of the fetal head, allowing for delivery of the arm.

Cervical spine injury is predominantly observed when the fetus has a hyperextended head prior to delivery. Ballas and Toaff (1976) reported 20 cases of hyperextended necks, defined as an angle of extension greater than 90° ("star-gazing"), discovered on antepartum radiographs. [ 4 ] Of the 11 fetuses delivered vaginally, 8 (73%) sustained complete cervical spinal cord lesions, defined as either transection or nonfunction.

Cord prolapse may occur in 7.4% of all breech labors. This incidence varies with the type of breech: 0-2% with frank breech, 5-10% with complete breech, and 10-25% with footling breech. [ 3 ] Cord prolapse occurs twice as often in multiparas (6%) than in primigravidas (3%). Cord prolapse may not always result in severe fetal heart rate decelerations because of the lack of presenting parts to compress the umbilical cord (ie, that which predisposes also protects).

Prior to the 2001 recommendations by the American College of Obstetricians and Gynecologists (ACOG), approximately 50% of breech presentations were considered candidates for vaginal delivery. Of these candidates, 60-82% were successfully delivered vaginally.

Candidates can be classified based on gestational age. For pregnancies prior to 26 weeks' gestation, prematurity, not mode of delivery, is the greatest risk factor. Unfortunately, no randomized clinical trials to help guide clinical management have been reported. Vaginal delivery can be considered, but a detailed discussion of the risks from prematurity and the lack of data regarding the ideal mode of delivery should take place with the parent(s). For example, intraventricular hemorrhage, which can occur in an infant of extremely low birth weight, should not be misinterpreted as proof of a traumatic vaginal breech delivery.

For pregnancies between 26 and 32 weeks, retrospective studies suggest an improved outcome with cesarean delivery, although these reports are subject to selection bias. In contrast, between 32 and 36 weeks' gestation, vaginal breech delivery may be considered after a discussion of risks and benefits with the parent(s).

After 37 weeks' gestation, parents should be informed of the results of a multicenter randomized clinical trial that demonstrated significantly increased perinatal mortality and short-term neonatal morbidity associated with vaginal breech delivery (see Comparative Studies). For those attempting vaginal delivery, if estimated fetal weight (EFW) is more than 4000 g, some recommend cesarean delivery because of concern for entrapment of the unmolded head in the maternal pelvis, although data to support this practice are limited.

A frank breech presentation is preferred when vaginal delivery is attempted. Complete breeches and footling breeches are still candidates, as long as the presenting part is well applied to the cervix and both obstetrical and anesthesia services are readily available in the event of a cord prolapse.

The fetus should show no neck hyperextension on antepartum ultrasound imaging (see the image below). Flexed or military position is acceptable.

Regarding prior cesarean delivery, a retrospective study by Ophir et al of 71 women with one prior low transverse cesarean delivery who subsequently delivered a breech fetus found that 24 women had an elective repeat cesarean and 47 women had a trial of labor. [ 5 ] In the 47 women with a trial of labor, 37 (78.7%) resulted in a vaginal delivery. Two infants in the trial of labor group had nuchal arms (1 with a transient brachial plexus injury) and 1 woman required a hysterectomy for hemorrhage due to a uterine dehiscence discovered after vaginal delivery. Vaginal breech delivery after one prior cesarean delivery is not contraindicated, though larger studies are needed.

Primigravida versus multiparous

It had been commonly believed that primigravidas with a breech presentation should have a cesarean delivery, although no data (prospective or retrospective) support this view. The only documented risk related to parity is cord prolapse, which is 2-fold higher in parous women than in primigravid women.

Radiographic and CT pelvimetry

Historically, radiograph pelvimetry was believed to be useful to quantitatively assess the inlet and mid pelvis. Recommended pelvimetry criteria included a transverse inlet diameter larger than 11.5 cm, anteroposterior inlet diameter larger than 10.5 cm, transverse midpelvic diameter (between the ischial spines) larger than 10 cm, and anteroposterior midpelvic diameter larger than 11.5 cm. However, radiographic pelvimetry is rarely, if ever, used in the United States.

CT pelvimetry , which is associated with less fetal radiation exposure than conventional radiographic pelvimetry, was more recently advocated by some investigators. It, too, is rarely used today.

Ultimately, if the obstetrical operator is not experienced or comfortable with vaginal breech deliveries, cesarean delivery may be the best choice. Unfortunately, with the dwindling number of experienced obstetricians who still perform vaginal breech deliveries and who can teach future generations of obstetricians, this technique may soon be lost due to attrition.

In 1970, approximately 14% of breeches were delivered by cesarean delivery. By 1986, that rate had increased to 86%. In 2003, based on data from the National Center for Health Statistics, the rate of cesarean delivery for all breech presentations was 87.2%. Most of the remaining breeches delivered vaginally were likely second twins, fetal demises, and precipitous deliveries. However, the rise in cesarean deliveries for breeches has not necessarily equated with an improvement in perinatal outcome. Green et al compared the outcome for term breeches prior to 1975 (595 infants, 22% cesarean delivery rate for breeches) with those from 1978-1979 (164 infants, 94% cesarean delivery rate for breeches). [ 6 ] Despite the increase in rates of cesarean delivery, the differences in rates of asphyxia, birth injury, and perinatal deaths were not significant.

Maneuvers for cesarean delivery are similar to those for vaginal breech delivery, including the Pinard maneuver, wrapping the hips with a towel for traction, head flexion during traction, rotation and sweeping out of the fetal arms, and the Mauriceau Smellie Veit maneuver.

An entrapped head can still occur during cesarean delivery as the uterus contracts after delivery of the body, even with a lower uterine segment that misleadingly appears adequate prior to uterine incision. Entrapped heads occur more commonly with preterm breeches, especially with a low transverse uterine incision. As a result, some practitioners opt to perform low vertical uterine incisions for preterm breeches prior to 32 weeks' gestation to avoid head entrapment and the kind of difficult delivery that cesarean delivery was meant to avoid. Low vertical incisions usually require extension into the corpus, resulting in cesarean delivery for all future deliveries.

If a low transverse incision is performed, the physician should move quickly once the breech is extracted in order to deliver the head before the uterus begins to contract. If any difficulty is encountered with delivery of the fetal head, the transverse incision can be extended vertically upward (T incision). Alternatively, the transverse incision can be extended laterally and upward, taking great care to avoid trauma to the uterine arteries. A third option is the use of a short-acting uterine relaxant (eg, nitroglycerin) in an attempt to facilitate delivery.

Only 3 randomized studies have evaluated the mode of delivery of the term breech. All other studies were nonrandomized or retrospective, which may be subject to selection bias.

In 1980, Collea et al randomized 208 women in labor with term frank breech presentations to either elective cesarean delivery or attempted vaginal delivery after radiographic pelvimetry. [ 7 ] Oxytocin was allowed for dysfunctional labor. Of the 60 women with adequate pelves, 49 delivered vaginally. Two neonates had transient brachial plexus injuries. Women randomized to elective cesarean delivery had higher postpartum morbidity rates (49.3% vs 6.7%).

In 1983, Gimovsky et al randomized 105 women in labor with term nonfrank breech presentations to a trial of labor versus elective cesarean delivery. [ 8 ] In this group of women, 47 had complete breech presentations, 16 had incomplete breech presentations (hips flexed, 1 knee extended/1 knee flexed), 32 had double-footling presentations, and 10 had single-footling presentations. Oxytocin was allowed for dysfunctional labor. Of the labor group, 44% had successful vaginal delivery. Most cesarean deliveries were performed for inadequate pelvic dimensions on radiographic pelvimetry. The rate of neonatal morbidity did not differ between neonates delivered vaginally and those delivered by cesarean delivery, although a higher maternal morbidity rate was noted in the cesarean delivery group.

In 2000, Hannah and colleagues completed a large, multicenter, randomized clinical trial involving 2088 term singleton fetuses in frank or complete breech presentations at 121 institutions in 26 countries. [ 9 ] In this study, popularly known as the Term Breech Trial, subjects were randomized into a planned cesarean delivery group or a planned vaginal birth group. Exclusion criteria were estimated fetal weight (EFW) more than 4000 g, hyperextension of the fetal head, lethal fetal anomaly or anomaly that might result in difficulty with delivery, or contraindication to labor or vaginal delivery (eg, placenta previa ).

Subjects randomized to cesarean delivery were scheduled to deliver after 38 weeks' gestation unless conversion to cephalic presentation had occurred. Subjects randomized to vaginal delivery were treated expectantly until labor ensued. Electronic fetal monitoring was either continuous or intermittent. Inductions were allowed for standard obstetrical indications, such as postterm gestations. Augmentation with oxytocin was allowed in the absence of apparent fetopelvic disproportion, and epidural analgesia was permitted.

Adequate labor was defined as a cervical dilation rate of 0.5 cm/h in the active phase of labor and the descent of the breech fetus to the pelvic floor within 2 hours of achieving full dilation. Vaginal delivery was spontaneous or assisted and was attended by an experienced obstetrician. Cesarean deliveries were performed for inadequate progress of labor, nonreassuring fetal heart rate, or conversion to footling breech. Results were analyzed by intent-to-treat (ie, subjects were analyzed by randomization group, not by ultimate mode of delivery).

Of 1041 subjects in the planned cesarean delivery group, 941 (90.4%) had cesarean deliveries. Of 1042 subjects in the planned vaginal delivery group, 591 (56.7%) had vaginal deliveries. Indications for cesarean delivery included: fetopelvic disproportion or failure to progress in labor (226), nonreassuring fetal heart rate tracing (129), footling breech (69), request for cesarean delivery (61), obstetrical or medical indications (45), or cord prolapse (12).

The composite measurement of either perinatal mortality or serious neonatal morbidity by 6 weeks of life was significantly lower in the planned cesarean group than in the planned vaginal group (5% vs 1.6%, P < .0001). Six of 16 neonatal deaths were associated with difficult vaginal deliveries, and 4 deaths were associated with fetal heart rate abnormalities. The reduction in risk in the cesarean group was even greater in participating countries with overall low perinatal mortality rates as reported by the World Health Organization. The difference in perinatal outcome held after controlling for the experience level of the obstetrician. No significant difference was noted in maternal mortality or serious maternal morbidity between the 2 groups within the first 6 weeks of delivery (3.9% vs 3.2%, P = .35).

A separate analysis showed no difference in breastfeeding, sexual relations, or depression at 3 months postpartum, though the reported rate of urinary incontinence was higher in the planned vaginal group (7.3% vs 4.5%).

Based on the multicenter trial, the ACOG published a Committee Opinion in 2001 that stated "planned vaginal delivery of a singleton term breech may no longer be appropriate." This did not apply to those gravidas presenting in advanced labor with a term breech and imminent delivery or to a nonvertex second twin.

A follow-up study by Whyte et al was conducted in 2004 on 923 children who were part of the initial multicenter study. [ 10 ] The authors found no differences between the planned cesarean delivery and planned vaginal breech delivery groups with regards to infant death rates or neurodevelopmental delay by age 2 years. Similarly, among 917 participating mothers from the original trial, no substantive differences were apparent in maternal outcome between the 2 groups. [ 11 ] No longer-term maternal effects, such as the impact of a uterine scar on future pregnancies, have yet been reported.

A meta-analysis of the 3 above mentioned randomized trials was published in 2015. The findings included a reduction in perinatal/neonatal death, reduced composite short-term outcome of perinatal/neonatal death or serious neonatal morbidity with planned cesarean delivery versus planned vaginal delivery. [ 12 ] However, at 2 years of age, there was no significant difference in death or neurodevelopmental delay between the two groups.  Maternal outcomes assessed at 2 years after delivery were not significantly different.

With regard to preterm breech deliveries, only one prospective randomized study has been performed, which included only 38 subjects (28-36 wk) with preterm labor and breech presentation. [ 13 ] Of these subjects, 20 were randomized to attempted vaginal delivery and 18 were randomized to immediate cesarean delivery. Of the attempted vaginal delivery group, 25% underwent cesarean delivery for nonreassuring fetal heart rate tracings. Five neonatal deaths occurred in the vaginal delivery group, and 1 neonatal death occurred in the cesarean delivery group. Two neonates died from fetal anomalies, 3 from respiratory distress, and 1 from sepsis.

Nonanomalous infants who died were not acidotic at delivery and did not have birth trauma. Differences in Apgar scores were not significant, although the vaginal delivery group had lower scores. The small number of enrolled subjects precluded any definitive conclusions regarding the safety of vaginal breech delivery for a preterm breech.

Retrospective analyses showed a higher mortality rate in vaginal breech neonates weighing 750-1500 g (26-32 wk), but less certain benefit was shown with cesarean delivery if the fetal weight was more than 1500 g (approximately 32 wk). Therefore, this subgroup of very preterm infants (26-32 wk) may benefit from cesarean delivery, although this recommendation is based on potentially biased retrospective data.

A large cohort study was published in 2015 from the Netherlands Perinatal Registry, which included 8356 women with a preterm (26-36 6/7 weeks) breech from 2000 to 2011, over three quarters of whom intended to deliver vaginally. In this overall cohort, there was no significant difference in perinatal mortality between the planned vaginal delivery and planned cesarean delivery groups (adjusted odds ratio 0.97, 95% confidence interval 0.60 – 1.57).  However, the subgroup delivering at 28 to 32 weeks had a lower perinatal mortality with planned cesarean section (aOR 0.27, 95% CI 0.10 – 0.77).  After adding a composite of perinatal morbidity, planned cesarean delivery was associated with a better outcome than a planned vaginal delivery (aOR 0.77, 95% CI 0.63 – 0.93. [ 14 ]

A Danish study found that nulliparous women with a singleton breech presentation who had a planned vaginal delivery were at significantly higher risk for postoperative complications, such as infection, compared with women who had a planned cesarean delivery. This increased risk was due to the likelihood of conversion to an emergency cesarean section, which occurred in over 69% of the planned vaginal deliveries in the study. [ 15 ]

The Maternal-Fetal Medicine Units Network of the US National Institute of Child Health and Human Development considered a multicenter randomized clinical trial of attempted vaginal delivery versus elective cesarean delivery for 24- to 28-week breech fetuses. [ 16 ] However, it was not initiated because of anticipated difficulty with recruitment, inadequate numbers to show statistically significant differences, and medicolegal concerns. Therefore, this study is not likely to be performed.

External cephalic version (ECV) is the transabdominal manual rotation of the fetus into a cephalic presentation.

Initially popular in the 1960s and 1970s, ECV virtually disappeared after reports of fetal deaths following the procedure. Reintroduced to the United States in the 1980s, it became increasingly popular in the 1990s.

Improved outcome may be related to the use of nonstress tests both before and after ECV, improved selection of low-risk fetuses, and Rh immune globulin to prevent isoimmunization.

Prepare for the possibility of cesarean delivery. Obtain a type and screen as well as an anesthesia consult. The patient should have nothing by mouth for at least 8 hours prior to the procedure. Recent ultrasonography should have been performed for fetal position, to check growth and amniotic fluid volume, to rule out a placenta previa, and to rule out anomalies associated with breech. Another sonogram should be performed on the day of the procedure to confirm that the fetus is still breech.

A nonstress test (biophysical profile as backup) should be performed prior to ECV to confirm fetal well-being.

Perform ECV in or near a delivery suite in the unlikely event of fetal compromise during or following the procedure, which may require emergent delivery.

ECV can be performed with 1 or 2 operators. Some prefer to have an assistant to help turn the fetus, elevate the breech out of the pelvis, or to monitor the position of the baby with ultrasonography. Others prefer a single operator approach, as there may be better coordination between the forces that are raising the breech and moving the head.

ECV is accomplished by judicious manipulation of the fetal head toward the pelvis while the breech is brought up toward the fundus. Attempt a forward roll first and then a backward roll if the initial attempts are unsuccessful. No consensus has been reached regarding how many ECV attempts are appropriate at one time. Excessive force should not be used at any time, as this may increase the risk of fetal trauma.

Following an ECV attempt, whether successful or not, repeat the nonstress test (biophysical profile if needed) prior to discharge. Also, administer Rh immune globulin to women who are Rh negative. Some physicians traditionally induce labor following successful ECV. However, as virtually all of these recently converted fetuses are unengaged, many practitioners will discharge the patient and wait for spontaneous labor to ensue, thereby avoiding the risk of a failed induction of labor. Additionally, as most ECV’s are attempted prior to 39 weeks, as long as there are no obstetrical or medical indications for induction, discharging the patient to await spontaneous labor would seem most prudent.

In those with an unsuccessful ECV, the practitioner has the option of sending the patient home or proceeding with a cesarean delivery. Expectant management allows for the possibility of spontaneous version. Alternatively, cesarean delivery may be performed at the time of the failed ECV, especially if regional anesthesia is used and the patient is already in the delivery room (see Regional anesthesia). This would minimize the risk of a second regional analgesia.

In those with an unsuccessful ECV, the practitioner may send the patient home, if less than 39 weeks, with plans for either a vaginal breech delivery or scheduled cesarean after 39 weeks. Expectant management allows for the possibility of a spontaneous version. Alternatively, if ECV is attempted after 39 weeks, cesarean delivery may be performed at the time of the failed ECV, especially if regional anesthesia is used and the patient is already in the delivery room (see Regional anesthesia). This would minimize the risk of a second regional analgesia.

Success rate

Success rates vary widely but range from 35% to 86% (average success rate in the 2004 National Vital Statistics was 58%). Improved success rates occur with multiparity, earlier gestational age, frank (versus complete or footling) breech presentation, transverse lie, and in African American patients.

Opinions differ regarding the influence of maternal weight, placental position, and amniotic fluid volume. Some practitioners find that thinner patients, posterior placentas, and adequate fluid volumes facilitate successful ECV. However, both patients and physicians need to be prepared for an unsuccessful ECV; version failure is not necessarily a reflection of the skill of the practitioner.

Zhang et al reviewed 25 studies of ECV in the United States, Europe, Africa, and Israel. [ 17 ] The average success rate in the United States was 65%. Of successful ECVs, 2.5% reverted back to breech presentation (other estimates range from 3% to 5%), while 2% of unsuccessful ECVs had spontaneous version to cephalic presentation prior to labor (other estimates range from 12% to 26%). Spontaneous version rates depend on the gestational age when the breech is discovered, with earlier breeches more likely to undergo spontaneous version.

A prospective study conducted in Germany by Zielbauer et al demonstrated an overall success rate of 22.4% for ECV among 353 patients with a singleton fetus in breech presentation. ECV was performed at 38 weeks of gestation. Factors found to increase the likelihood of success were a later week of gestation, abundant amniotic fluid, fundal and anterior placental location, and an oblique lie. [ 18 ]

A systematic review in 2015 looked at the effectiveness of ECV with eight randomized trials of ECV at term. Compared to women with no attempt at ECV, ECV reduced non-cephalic presentation at birth by 60% and reduced cesarean sections by 40% in the same group. [ 19 ] Although the rate of cesarean section is lower when ECV is performed than if not, the overall rate of cesarean section remains nearly twice as high after successful ECV due to both dystocia and non-reassuring fetal heart rate patterns. [ 20 ]  Nulliparity was the only factor shown in follow-up to increase the risk of instrumental delivery following successful ECV. [ 21 ]

While most studies of ECV have been performed in university hospitals, Cook showed that ECV has also been effective in the private practice setting. [ 22 ] Of 65 patients with term breeches, 60 were offered ECV. ECV was successful in 32 (53%) of the 60 patients, with vaginal delivery in 23 (72%) of the 32 patients. Of the remaining breech fetuses believed to be candidates for vaginal delivery, 8 (80%) had successful vaginal delivery. The overall vaginal delivery rate was 48% (31 of 65 patients), with no significant morbidity.

Cost analysis

In 1995, Gifford et al performed a cost analysis of 4 options for breech presentations at term: (1) ECV attempt on all breeches, with attempted vaginal breech delivery for selected persistent breeches; (2) ECV on all breeches, with cesarean delivery for persistent breeches; (3) trial of labor for selected breeches, with scheduled cesarean delivery for all others; and (4) scheduled cesarean delivery for all breeches prior to labor. [ 23 ]

ECV attempt on all breeches with attempted vaginal breech delivery on selected persistent breeches was associated with the lowest cesarean delivery rate and was the most cost-effective approach. The second most cost-effective approach was ECV attempt on all breeches, with cesarean delivery for persistent breeches.

Uncommon risks of ECV include fractured fetal bones, precipitation of labor or premature rupture of membranes , abruptio placentae , fetomaternal hemorrhage (0-5%), and cord entanglement (< 1.5%). A more common risk of ECV is transient slowing of the fetal heart rate (in as many as 40% of cases). This risk is believed to be a vagal response to head compression with ECV. It usually resolves within a few minutes after cessation of the ECV attempt and is not usually associated with adverse sequelae for the fetus.

Trials have not been large enough to determine whether the overall risk of perinatal mortality is increased with ECV. The Cochrane review from 2015 reported perinatal death in 2 of 644 in ECV and 6 of 661 in the group that did not attempt ECV. [ 19 ]

A 2016 Practice Bulletin by ACOG recommended that all women who are near term with breech presentations should be offered an ECV attempt if there are no contraindications (see Contraindications below). [ 24 ]  ACOG guidelines issued in 2020 recommend that ECV should be performed starting at 37+0 weeks, in order to reduce the likelihood of reversion and to increase the rate of spontaneous version. [ 25 ]

ACOG recommends that ECV be offered as an alternative to a planned cesarean section for a patient who has a term singleton breech fetus, wishes to have a planned vaginal delivery of a vertex-presenting fetus, and has no contraindications. ACOG also advises that ECV be attempted only in settings where cesarean delivery services are available. [ 26 ]

ECV is usually not performed on preterm breeches because they are more likely to undergo spontaneous version to cephalic presentation and are more likely to revert to breech after successful ECV (approximately 50%). Earlier studies of preterm ECV did not show a difference in the rates of breech presentations at term or overall rates of cesarean delivery. Additionally, if complications of ECV were to arise that warranted emergent delivery, it would result in a preterm neonate with its inherent risks. The Early External Cephalic Version (ECV) 2 trial was an international, multicentered, randomized clinical trial that compared ECV performed at 34-35 weeks’ gestation compared with 37 weeks’ gestation or more. [ 27 ] Early ECV increased the chance of cephalic presentation at birth; however, no difference in cesarean delivery rates was noted, along with a nonstatistical increase in preterm births.

A systematic review looked at 5 studies of ECV completed prior to 37 weeks and concluded that compared with no ECV attempt, ECV commenced before term reduces the non-cephalic presentation at birth, however early ECV may increase the risk of late preterm birth. [ 28 ]

Given the increasing awareness of the risks of late preterm birth and early term deliveries, the higher success of earlier ECV should be weighed against the risks of iatrogenic prematurity should a complication arise necessitating delivery.

Contraindications

Absolute contraindications for ECV include multiple gestations with a breech presenting fetus, contraindications to vaginal delivery (eg, herpes simplex virus infection, placenta previa), and nonreassuring fetal heart rate tracing.

Relative contraindications include polyhydramnios or oligohydramnios , fetal growth restriction , uterine malformation , and major fetal anomaly.

Controversial candidates

Women with prior uterine incisions may be candidates for ECV, but data are scant. In 1991, Flamm et al attempted ECV on 56 women with one or more prior low transverse cesarean deliveries. [ 29 ] The success rate of ECV was 82%, with successful vaginal births in 65% of patients with successful ECVs. No uterine ruptures occurred during attempted ECV or subsequent labor, and no significant fetal complications occurred.

In 2010 ACOG acknowledged that although there is limited data in both the above study and one more recently, [ 30 ] no serious adverse events occurred in these series. A larger prospective cohort study that was published in 2014 reported similar success rates of ECV among women with and without prior cesarean section, although lower vaginal birth rates. There were, however, no cases of uterine rupture or other adverse outcomes. [ 31 ]

Another controversial area is performing ECV on a woman in active labor. In 1985, Ferguson and Dyson reported on 15 women in labor with term breeches and intact membranes. [ 32 ] Four patients were dilated greater than 5 cm (2 women were dilated 8 cm). Tocolysis was administered, and intrapartum ECV was attempted. ECV was successful in 11 of 15 patients, with successful vaginal births in 10 patients. No adverse effects were noted. Further studies are needed to evaluate the safety and efficacy of intrapartum ECV.

Data regarding the benefit of intravenous or subcutaneous beta-mimetics in improving ECV rates are conflicting.

In 1996, Marquette et al performed a prospective, randomized, double-blinded study on 283 subjects with breech presentations between 36 and 41 weeks' gestation. [ 33 ] Subjects received either intravenous ritodrine or placebo. The success rate of ECV was 52% in the ritodrine group versus 42% in the placebo group ( P = .35). When only nulliparous subjects were analyzed, significant differences were observed in the success of ECV (43% vs 25%, P < .03). ECV success rates were significantly higher in parous versus nulliparous subjects (61% vs 34%, P < .0001), with no additional improvement with ritodrine.

A systematic review published in 2015 of six randomized controlled trials of ECV that compared the use of parenteral beta-mimetic tocolysis during ECV concluded that tocolysis was effective in increasing the rate of cephalic presentation in labor and reducing the cesarean delivery rate by almost 25% in both nulliparous and multiparous women. [ 34 ] Data on adverse effects and other tocolytics was insufficient. A review published in 2011 on Nifedipine did not show an improvement in ECV success. [ 35 ]

Regional anesthesia

Regional analgesia, either epidural or spinal, may be used to facilitate external cephalic version (ECV) success. When analgesia levels similar to that for cesarean delivery are given, it allows relaxation of the anterior abdominal wall, making palpation and manipulation of the fetal head easier. Epidural or spinal analgesia also eliminates maternal pain that may cause bearing down and tensing of the abdominal muscles. If ECV is successful, the epidural can be removed and the patient sent home to await spontaneous labor. If ECV is unsuccessful, a patient can proceed to cesarean delivery under her current anesthesia, if the gestational age is more than 39 weeks.

The main disadvantage is the inherent risk of regional analgesia, which is considered small. Additionally, lack of maternal pain could potentially result in excessive force being applied to the fetus without the knowledge of the operator.

In 1994, Carlan et al retrospectively analyzed 61 women who were at more than 36 weeks' gestation and had ECV with or without epidural. [ 36 ] The success rate of ECV was 59% in the epidural group and 24% in the nonepidural group ( P < .05). In 7 of 8 women with unsuccessful ECV without epidural, a repeat ECV attempt after epidural was successful. No adverse effects on maternal or perinatal morbidity or mortality occurred.

In 1997, Schorr et al randomized 69 subjects who were at least 37 weeks' gestation to either epidural or control groups prior to attempted ECV. [ 37 ] Those in whom ECV failed underwent cesarean delivery. The success rate of ECV was 69% in the epidural group and 32% in the control group (RR, 2.12; 95% CI, 1.24-3.62). The cesarean delivery rate was 79% in the control group and 34% in the epidural group ( P = .001). No complications of epidural anesthesia and no adverse fetal effects occurred.

In 1999, Dugoff et al randomized 102 subjects who were at more than 36 weeks' gestation with breech presentations to either spinal anesthesia or a control group. [ 38 ] All subjects received 0.25 mg terbutaline subcutaneously. The success rate of ECV was 44% in the spinal group and 42% in the nonspinal group, which was not statistically significant.

In contrast, a 2007 randomized clinical trial of spinal analgesia versus no analgesia in 74 women showed a significant improvement in ECV success (66.7% vs 32.4%, p = .004), with a significantly lower pain score by the patient. [ 39 ]

The 2015 systematic review asserted that regional analgesia in combination with a tocolytic was more effective than the tocolytic alone for increasing ECV success; however there was no difference in cephalic presentation in labor. Data from the same review was insufficient to assess regional analgesia without tocolysis [ 34 ]

Acoustic stimulation

Johnson and Elliott performed a randomized, blinded trial on 23 subjects to compare acoustic stimulation prior to ECV with a control group when the fetal spine was in the midline (directly back up or back down). [ 40 ] Of those who received acoustic stimulation, 12 of 12 fetuses shifted to a spine-lateral position after acoustic stimulation, and 11 (91%) underwent successful ECV. In the control group, 0 of 11 shifts and 1 (9%) successful ECV ( P < .0001) occurred. Additional studies are needed.

Amnioinfusion

Although an earlier study reported on the utility of amnioinfusion to successfully turn 6 fetuses who initially failed ECV, [ 41 ] a subsequent study was published of 7 women with failed ECV who underwent amniocentesis and amnioinfusion of up to 1 liter of crystalloid. [ 42 ] Repeat attempts of ECV were unsuccessful in all 7 cases. Amnioinfusion to facilitate ECV cannot be recommended at this time.

Vaginal delivery rates after successful version

The rate of cesarean delivery ranges from 0-31% after successful external cephalic version (ECV). Controversy has existed on whether there is a higher rate of cesarean delivery for labor dystocia following ECV. In 1994, a retrospective study by Egge et al of 76 successful ECVs matched with cephalic controls by delivery date, parity, and gestational age failed to note any significant difference in the cesarean delivery rate (8% in ECV group, 6% in control group). [ 43 ]

However, in 1997, Lau et al compared 154 successful ECVs to 308 spontaneously occurring cephalic controls (matched for age, parity, and type of labor onset) with regard to the cesarean delivery rate. [ 44 ] Cesarean delivery rates were higher after ECV (16.9% vs 7.5%, P < .005) because of higher rates of cephalopelvic disproportion and nonreassuring fetal heart rate tracings. This may be related to an increased frequency of compound presentations after ECV. Immediate induction of labor after successful ECV may also contribute to an increase in the cesarean delivery rate due to failed induction in women with unripe cervices and unengaged fetal heads.

Further, in another cohort study from 2015, factors were described which decreased the vaginal delivery rate after successful ECV including labor induction, less than 2 weeks between ECV and delivery, high body mass index, and previous cesarean. [ 45 ] The overall caesarean delivery rate in this cohort was 15%.

Vaginal breech delivery requires an experienced obstetrician and careful counseling of the parents. Although studies on the delivery of the preterm breech are limited, the multicenter Term Breech Trial found an increased rate of perinatal mortality and serious immediate perinatal morbidity, though no differences were seen in infant outcome at 2 years of age.

Parents must be informed about potential risks and benefits to the mother and neonate for both vaginal breech delivery and cesarean delivery. Discussion of risks should not be limited only to the current pregnancy. The risks of a cesarean on subsequent pregnancies, including uterine rupture and placental attachment abnormalities ( placenta previa , abruption , accreta), as well as maternal and perinatal sequelae from these complications, should be reviewed as well.

It remains concerning that the dearth of experienced physicians to teach younger practitioners will lead to the abandonment of vaginal breeches altogether. For those wishing to learn the art of vaginal breech deliveries, simulation training with pelvic models has been advocated to familiarize trainees with the procedure in a nonthreatening environment. [ 46 ] Once comfortable with the appropriate maneuvers, vaginal delivery of the second, noncephalic twin, may be attempted under close supervision by an experienced physician. The cervix will already be fully dilated, and, assuming the second twin is not significantly larger, the successful vaginal delivery rate has been quoted to be as high as 96%.

External cephalic version (ECV) is a safe alternative to vaginal breech delivery or cesarean delivery, reducing the cesarean delivery rate for breech by 50%. ACOG recommends offering ECV to all women with a breech fetus near term. [ 24 ] Adjuncts such as tocolysis, regional anesthesia, and acoustic stimulation when appropriate may improve ECV success rates.

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• Footling breech presentation. Once the feet have delivered, one may be tempted to pull on the feet. However, a singleton gestation should not be pulled by the feet because this action may precipitate head entrapment in an incompletely dilated cervix or may precipitate nuchal arms. As long as the fetal heart rate is stable and no physical evidence of a prolapsed cord is evident, management may be expectant while awaiting full cervical dilation.
• Assisted vaginal breech delivery. Thick meconium passage is common as the breech is squeezed through the birth canal. This is usually not associated with meconium aspiration because the meconium passes out of the vagina and does not mix with the amniotic fluid.
• Assisted vaginal breech delivery. The Ritgen maneuver is applied to take pressure off the perineum during vaginal delivery. Episiotomies are often performed for assisted vaginal breech deliveries, even in multiparous women, to prevent soft tissue dystocia.
• Assisted vaginal breech delivery. No downward or outward traction is applied to the fetus until the umbilicus has been reached.
• Assisted vaginal breech delivery. With a towel wrapped around the fetal hips, gentle downward and outward traction is applied in conjunction with maternal expulsive efforts until the scapula is reached. An assistant should be applying gentle fundal pressure to keep the fetal head flexed.
• Assisted vaginal breech delivery. After the scapula is reached, the fetus should be rotated 90° in order to deliver the anterior arm.
• Assisted vaginal breech delivery. The anterior arm is followed to the elbow, and the arm is swept out of the vagina.
• Assisted vaginal breech delivery. The fetus is rotated 180°, and the contralateral arm is delivered in a similar manner as the first. The infant is then rotated 90° to the backup position in preparation for delivery of the head.
• Assisted vaginal breech delivery. The fetal head is maintained in a flexed position by using the Mauriceau maneuver, which is performed by placing the index and middle fingers over the maxillary prominence on either side of the nose. The fetal body is supported in a neutral position, with care to not overextend the neck.
• Piper forceps application. Piper forceps are specialized forceps used only for the after-coming head of a breech presentation. They are used to keep the fetal head flexed during extraction of the head. An assistant is needed to hold the infant while the operator gets on one knee to apply the forceps from below.
• Assisted vaginal breech delivery. Low 1-minute Apgar scores are not uncommon after a vaginal breech delivery. A pediatrician should be present for the delivery in the event that neonatal resuscitation is needed.
• Assisted vaginal breech delivery. The neonate after birth.
• Ultrasound demonstrating a fetus in breech presentation with a hyperextended head (ie, "star gazing").

Contributor Information and Disclosures

Richard Fischer, MD Professor, Division Head, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Cooper University Hospital Richard Fischer, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists , American Institute of Ultrasound in Medicine , Association of Professors of Gynecology and Obstetrics , Society for Maternal-Fetal Medicine Disclosure: Stock ownership for: Pfizer Pharmaceuticals (< 5% of portfolio); Johnson & Johnson (< 5% of portfolio).

Alisa B Modena, MD, FACOG Assistant Professor, Cooper Medical School of Rowan University; Attending Physician, Division of Maternal-Fetal Medicine, Cooper University Hospital Alisa B Modena, MD, FACOG is a member of the following medical societies: American College of Obstetricians and Gynecologists , American Institute of Ultrasound in Medicine , Philadelphia Perinatal Society, Society for Maternal-Fetal Medicine Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Received salary from Medscape for employment. for: Medscape.

Richard S Legro, MD Professor, Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology, Pennsylvania State University College of Medicine; Consulting Staff, Milton S Hershey Medical Center Richard S Legro, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists , Society of Reproductive Surgeons , American Society for Reproductive Medicine , Endocrine Society , Phi Beta Kappa Disclosure: Received honoraria from Korea National Institute of Health and National Institute of Health (Bethesda, MD) for speaking and teaching; Received honoraria from Greater Toronto Area Reproductive Medicine Society (Toronto, ON, CA) for speaking and teaching; Received honoraria from American College of Obstetrics and Gynecologists (Washington, DC) for speaking and teaching; Received honoraria from National Institute of Child Health and Human Development Pediatric and Adolescent Gynecology Research Thi.

Ronald M Ramus, MD Professor of Obstetrics and Gynecology, Director, Division of Maternal-Fetal Medicine, Virginia Commonwealth University School of Medicine Ronald M Ramus, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists , American Institute of Ultrasound in Medicine , Medical Society of Virginia , Society for Maternal-Fetal Medicine Disclosure: Nothing to disclose.

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What Is Breech?

When a fetus is delivered buttocks or feet first

• Types of Presentation

Risk Factors

Complications.

Breech concerns the position of the fetus before labor . Typically, the fetus comes out headfirst, but in a breech delivery, the buttocks or feet come out first. This type of delivery is risky for both the pregnant person and the fetus.

This article discusses the different types of breech presentations, risk factors that might make a breech presentation more likely, treatment options, and complications associated with a breech delivery.

Verywell / Jessica Olah

Types of Breech Presentation

During the last few weeks of pregnancy, a fetus usually rotates so that the head is positioned downward to come out of the vagina first. This is called the vertex position.

In a breech presentation, the fetus does not turn to lie in the correct position. Instead, the fetus’s buttocks or feet are positioned to come out of the vagina first.

At 28 weeks of gestation, approximately 20% of fetuses are in a breech position. However, the majority of these rotate to the proper vertex position. At full term, around 3%–4% of births are breech.

The different types of breech presentations include:

• Complete : The fetus’s knees are bent, and the buttocks are presenting first.
• Frank : The fetus’s legs are stretched upward toward the head, and the buttocks are presenting first.
• Footling : The fetus’s foot is showing first.

Signs of Breech

There are no specific symptoms associated with a breech presentation.

Diagnosing breech before the last few weeks of pregnancy is not helpful, since the fetus is likely to turn to the proper vertex position before 35 weeks gestation.

A healthcare provider may be able to tell which direction the fetus is facing by touching a pregnant person’s abdomen. However, an ultrasound examination is the best way to determine how the fetus is lying in the uterus.

Most breech presentations are not related to any specific risk factor. However, certain circumstances can increase the risk for breech presentation.

These can include:

• Previous pregnancies
• Multiple fetuses in the uterus
• An abnormally shaped uterus
• Uterine fibroids , which are noncancerous growths of the uterus that usually appear during the childbearing years
• Placenta previa, a condition in which the placenta covers the opening to the uterus
• Preterm labor or prematurity of the fetus
• Too much or too little amniotic fluid (the liquid that surrounds the fetus during pregnancy)
• Fetal congenital abnormalities

Most fetuses that are breech are born by cesarean delivery (cesarean section or C-section), a surgical procedure in which the baby is born through an incision in the pregnant person’s abdomen.

In rare instances, a healthcare provider may plan a vaginal birth of a breech fetus. However, there are more risks associated with this type of delivery than there are with cesarean delivery. 

Before cesarean delivery, a healthcare provider might utilize the external cephalic version (ECV) procedure to turn the fetus so that the head is down and in the vertex position. This procedure involves pushing on the pregnant person’s belly to turn the fetus while viewing the maneuvers on an ultrasound. This can be an uncomfortable procedure, and it is usually done around 37 weeks gestation.

ECV reduces the risks associated with having a cesarean delivery. It is successful approximately 40%–60% of the time. The procedure cannot be done once a pregnant person is in active labor.

Complications related to ECV are low and include the placenta tearing away from the uterine lining, changes in the fetus’s heart rate, and preterm labor.

ECV is usually not recommended if the:

• Pregnant person is carrying more than one fetus
• Placenta is in the wrong place
• Healthcare provider has concerns about the health of the fetus
• Pregnant person has specific abnormalities of the reproductive system

Recommendations for Previous C-Sections

The American College of Obstetricians and Gynecologists (ACOG) says that ECV can be considered if a person has had a previous cesarean delivery.

During a breech delivery, the umbilical cord might come out first and be pinched by the exiting fetus. This is called cord prolapse and puts the fetus at risk for decreased oxygen and blood flow. There’s also a risk that the fetus’s head or shoulders will get stuck inside the mother’s pelvis, leading to suffocation.

Complications associated with cesarean delivery include infection, bleeding, injury to other internal organs, and problems with future pregnancies.

A healthcare provider needs to weigh the risks and benefits of ECV, delivering a breech fetus vaginally, and cesarean delivery.

In a breech delivery, the fetus comes out buttocks or feet first rather than headfirst (vertex), the preferred and usual method. This type of delivery can be more dangerous than a vertex delivery and lead to complications. If your baby is in breech, your healthcare provider will likely recommend a C-section.

A Word From Verywell

Knowing that your baby is in the wrong position and that you may be facing a breech delivery can be extremely stressful. However, most fetuses turn to have their head down before a person goes into labor. It is not a cause for concern if your fetus is breech before 36 weeks. It is common for the fetus to move around in many different positions before that time.

At the end of your pregnancy, if your fetus is in a breech position, your healthcare provider can perform maneuvers to turn the fetus around. If these maneuvers are unsuccessful or not appropriate for your situation, cesarean delivery is most often recommended. Discussing all of these options in advance can help you feel prepared should you be faced with a breech delivery.

American College of Obstetricians and Gynecologists. If your baby is breech .

TeachMeObGyn. Breech presentation .

MedlinePlus. Breech birth .

Hofmeyr GJ, Kulier R, West HM. External cephalic version for breech presentation at term . Cochrane Database Syst Rev . 2015 Apr 1;2015(4):CD000083. doi:10.1002/14651858.CD000083.pub3

By Christine Zink, MD Dr. Zink is a board-certified emergency medicine physician with expertise in the wilderness and global medicine.

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6.1 Breech presentation

Presentation of the feet or buttocks of the foetus.

6.1.1 The different breech presentations

• In a complete breech presentation, the legs are tucked, and the foetus is in a crouching position (Figure 6.1a).
• In a frank breech presentation, the legs are extended, raised in front of the torso, with the feet near the head (Figure 6.1b).
• In a footling breech presentation (rare), one or both feet present first, with the buttocks higher up and the lower limbs extended or half-bent (Figure 6.1c).

6.1.2 Diagnosis

• The cephalic pole is palpable in the uterine fundus; round, hard, and mobile; the indentation of the neck can be felt.
• The inferior pole is voluminous, irregular, less hard, and less mobile than the head.
• During labour, vaginal examination reveals a “soft mass” divided by the cleft between the buttocks, with a hard projection at end of the cleft (the coccyx and sacrum).
• After rupture of the membranes: the anus can be felt in the middle of the cleft; a foot may also be felt.
• The clinical diagnosis may be difficult: a hand may be mistaken for a foot, a face for a breech.

6.1.3 Management

Route of delivery.

Before labour, external version (Chapter 7, Section 7.7 ) may be attempted to avoid breech delivery.

If external version is contra-indicated or unsuccessful, the breech position alone – in the absence of any other anomaly – is not, strictly speaking, a dystocic presentation, and does not automatically require a caesarean section. Deliver vaginally, if possible – even if the woman is primiparous.

Breech deliveries must be done in a CEmONC facility, especially for primiparous women.

Favourable factors for vaginal delivery are:

• Frank breech presentation;
• A history of vaginal delivery (whatever the presentation);
• Normally progressing dilation during labour.

The footling breech presentation is a very unfavourable position for vaginal delivery (risk of foot or cord prolapse). In this situation, the route of delivery depends on the number of previous births, the state of the membranes and how far advanced the labour is.

During labour

• Monitor dilation every 2 to 4 hours. 
• If contractions are of good quality, dilation is progressing, and the foetal heart rate is regular, an expectant approach is best. Do not rupture the membranes unless dilation stops.
• If the uterine contractions are inadequate, labour can be actively managed with oxytocin.

Note : if the dilation stales, transfer the mother to a CEmONC facility unless already done, to ensure access to surgical facility for potential caesarean section.

At delivery

• Insert an IV line before expulsion starts.
• Consider episiotomy at expulsion. Episiotomy is performed when the perineum is sufficiently distended by the foetus's buttocks.
• Presence of meconium or meconium-stained amniotic fluid is common during breech delivery and is not necessarily a sign of foetal distress.
• The infant delivers unaided , as a result of the mother's pushing, simply supported by the birth attendant who gently holds the infant by the bony parts (hips and sacrum), with no traction. Do not pull on the legs.

Once the umbilicus is out, the rest of the delivery must be completed within 3 minutes, otherwise compression of the cord will deprive the infant of oxygen. Do not touch the infant until the shoulder blades appear to avoid triggering the respiratory reflex before the head is delivered.

• Monitor the position of the infant's back; impede rotation into posterior position.

Figures 6.2 - Breech delivery

6.1.4 Breech delivery problems

Posterior orientation.

If the infant’s back is posterior during expulsion, take hold of the hips and turn into an anterior position (this is a rare occurrence).

Obstructed shoulders

The shoulders can become stuck and hold back the infant's upper chest and head. This can occur when the arms are raised as the shoulders pass through the mother's pelvis. There are 2 methods for lowering the arms so that the shoulders can descend:

1 - Lovset's manoeuvre

• With thumbs on the infant's sacrum, take hold of the hips and pelvis with the other fingers.
• Turn the infant 90° (back to the left or to the right), to bring the anterior shoulder underneath the symphysis and engage the arm. Deliver the anterior arm.
• Then do a 180° counter-rotation (back to the right or to the left); this engages the posterior arm, which is then delivered.

Figures 6.3 - Lovset's manoeuvre

6.3c  - Delivering the anterior arm and shoulder

2 - Suzor’s manoeuvre

In case the previous method fails:

• Turn the infant 90° (its back to the right or to the left).
• Pull the infant downward: insert one hand along the back to look for the anterior arm. With the operator thumb in the infant armpit and middle finger along the arm, bring down the arm (Figure 6.4a).
• Lift infant upward by the feet in order to deliver the posterior shoulder (Figure 6.4b).

Figures 6.4 - Suzor's manoeuvre

6.4b  - Delivering the posterior shoulder

Head entrapment

The infant's head is bulkier than the body, and can get trapped in the mother's pelvis or soft tissue.

There are various manoeuvres for delivering the head by flexing it, so that it descends properly, and then pivoting it up and around the mother's symphysis. These manoeuvres must be done without delay, since the infant must be allowed to breathe as soon as possible. All these manoeuvres must be performed smoothly, without traction on the infant.

1 - Bracht's manoeuvre

• After the arms are delivered, the infant is grasped by the hips and lifted with two hands toward the mother's stomach, without any traction, the neck pivoting around the symphysis.
• Having an assistant apply suprapubic pressure facilitates delivery of the aftercoming head.

2 - Modified Mauriceau manoeuvre

• Infant's head occiput anterior.
• Kneel to get a good traction angle: 45° downward.
• Support the infant on the hand and forearm, then insert the index and middle fingers, placing them on the infant’s maxilla. Placing the index and middle fingers into the infant’s mouth is not recommended, as this can fracture the mandible.
• Place the index and middle fingers of the other hand on either side of the infant's neck and lower the infant's head to bring the sub-occiput under the symphysis (Figure 6.6a).
• Tip the infant’s head and with a sweeping motion bring the back up toward the mother's abdomen, pivoting the occiput around her symphysis pubis (Figure 6.6b).
• Suprapubic pressure on the infant's head along the pelvic axis helps delivery of the head.
• As a last resort, symphysiotomy (Chapter 5, Section 5.7 ) can be combined with this manoeuvre.

Figures 6.6 - Modified Mauriceau manoeuvre

6.6a - Step 1 Infant straddles the birth attendant's forearm; the head, occiput anterior, is lowered to bring the occiput in contact with the symphysis.

6.6b  - Step 2 The infant's back is tipped up toward the mother's abdomen.

3 - Forceps on aftercoming head 

This procedure can only be performed by an operator experienced in using forceps.

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• Identification of breech presentation

Evidence review L

NICE Guideline, No. 201

National Guideline Alliance (UK) .

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Review question

What is the effectiveness of routine scanning between 36+0 and 38+6 weeks of pregnancy compared to standard care regarding breech presentation?

Introduction

Breech presentation in late pregnancy may result in prolonged or obstructed labour for the woman. There are interventions that can correct or assist breech presentation which are important for the woman’s and the baby’s health. This review aims to determine the most effective way of identifying a breech presentation in late pregnancy.

Summary of the protocol

Please see Table 1 for a summary of the Population, Intervention, Comparison and Outcome (PICO) characteristics of this review.

Summary of the protocol (PICO table).

For further details see the review protocol in appendix A .

Methods and process

This evidence review was developed using the methods and process described in Developing NICE guidelines: the manual 2014 . Methods specific to this review question are described in the review protocol in appendix A .

Declarations of interest were recorded according to NICE’s conflicts of interest policy .

Clinical evidence

Included studies.

One single centre randomised controlled trial (RCT) was included in this review ( McKenna 2003 ). The study was carried out in Northern Ireland, UK. The study compared ultrasound examination at 30-32 and 36-37 weeks with maternal abdomen palpation during the same gestation period. The intervention group in the study had the ultrasound scans in addition to the abdomen palpation, while the control group had only the abdomen palpation. Clinical management options reported in the study based on the ultrasound scan or the abdomen palpation include referral for full biophysical assessment which included umbilical artery Doppler ultrasound, early antenatal review, admission to antenatal ward, and induction of labour.

The included study is summarised in Table 2 .

See the literature search strategy in appendix B and study selection flow chart in appendix C .

Excluded studies

Studies not included in this review are listed, and reasons for their exclusion are provided in appendix K .

Summary of clinical studies included in the evidence review

Summaries of the studies that were included in this review are presented in Table 2 .

Summary of included studies.

See the full evidence tables in appendix D . No meta-analysis was conducted (and so there are no forest plots in appendix E ).

Quality assessment of clinical outcomes included in the evidence review

See the evidence profiles in appendix F .

Economic evidence

One study, a cost utility analysis was included ( Wastlund 2019 ).

See the literature search strategy in appendix B and economic study selection flow chart in appendix G .

Studies not included in this review with reasons for their exclusions are provided in appendix K .

Summary of studies included in the economic evidence review

For full details of the economic evidence, see the economic evidence tables in appendix H and economic evidence profiles in appendix I .

Wastlund (2019) assessed the cost effectiveness of universal ultrasound scanning for breech presentation at 36 weeks’ gestational age in nulliparous woman (N=3879). The comparator was selective ultrasound scanning which was reported as current practice. In this instance, fetal presentation was assessed by palpation of the abdomen by a midwife, obstetrician or general practitioner. The sensitivity of this method ranges between 57%-70% whereas ultrasound scanning is detected with 100% sensitivity and 100% specificity. Women in the selective ultrasound scan arm only received an ultrasound scan after detection of a breech presentation by abdominal palpation. Where a breech was detected, a woman was offered external cephalic version (ECV). The structure of the model undertook a decision tree, with end states being the mode of birth; either vaginal, elective or emergency caesarean section. Long term health outcomes were modelled based on the mortality risk associated with each mode of birth. Average lifetime quality-adjusted life years (QALYs) were estimated from Euroqol general UK population values.

Only the probabilistic results (n=100000 simulations) were reported which showed that on average, universal ultrasound resulted in an absolute decrease in breech deliveries by 0.39% compared with selective ultrasound scanning. The expected cost per person with breech presentation of universal ultrasound was £2957 (95% Credibility Interval [CrI]: £2922 to £2991), compared to £2,949 (95%CrI: £2915 to £2984) from selective ultrasound. The expected QALYs per person was 24.27615 in the universal ultrasound cohort and 24.27582 in the selective ultrasound cohort. The incremental cost effectiveness ratio (ICER) from the probabilistic analysis was £23611 (95%CrI: £8184 to £44851).

A series of one-way sensitivity analysis were conducted which showed that the most important cost parameter was the unit cost of a universal ultrasound scan. This parameter is particularly noteworthy as the study costed this scan at a much lower value than the ‘standard antenatal ultrasound’ scan in NHS reference costs on the basis that such a scan can be performed by a midwife during a routine antenatal care visit in primary care. According to the NICE guideline manual economic evaluation checklist this model was assessed as being directly applicable with potentially severe limitations. The limitations were mostly attributable to the limitations of the clinical inputs.

Economic model

No economic modelling was undertaken for this review because the committee agreed that other topics were higher priorities for economic evaluation.

Evidence statements

Clinical evidence statements, comparison 1. routine ultrasound scan versus selective ultrasound scan, critical outcomes, unexpected breech presentation in labour.

No evidence was identified to inform this outcome.

Mode of birth

• Moderate quality evidence from 1 RCT (N=1993) showed that there is no clinically important difference between routine ultrasound scan at 36-37 weeks and selective ultrasound scan on the number of women who had elective caesarean section: RR 1.22 (95% CI 0.91 to 1.63).
• Moderate quality evidence from 1 RCT (N=1993) showed that there is no clinically important difference between routine ultrasound scan at 36-37 weeks and selective ultrasound scan on number of women who had emergency caesarean section: RR 1.20 (95% CI 0.90 to 1.60).
• High quality evidence from 1 RCT (N=1993) showed that there is no clinically important difference between routine ultrasound scan at 36-37 weeks and selective ultrasound scan on number of women who had vaginal birth: RR 0.95 (95% CI 0.89 to 1.01).

Important outcomes

Maternal anxiety, women’s experience and satisfaction of care, gestational age at birth.

• High quality evidence from 1 RCT (N=1993) showed that there is no clinically important difference between routine ultrasound scan at 36-37 weeks and selective ultrasound scan on the number of babies’ born between 39-42 gestational weeks: RR 0.98 (95% CI 0.94 to 1.02).

Admission to neonatal unit

• Low quality evidence from 1 RCT (N=1993) showed that there is no clinically important difference between routine ultrasound scan at 36-37 weeks and selective ultrasound scan on the number of babies admitted into the neonatal unit: RR 0.83 (95% CI 0.51 to 1.35).

Economic evidence statements

One directly applicable cost-utility analysis from the UK with potentially serious limitations compared universal ultrasound scanning for breech presentation at 36 weeks’ gestational age with selective ultrasound scanning, stated as current practice. Universal ultrasound scanning was found to be borderline cost effective; the incremental cost-effectiveness ratio was £23611 per QALY gained. The cost of the scan was seen to be a key driver in the cost effectiveness result.

The committee’s discussion of the evidence

Interpreting the evidence, the outcomes that matter most.

Unexpected breech presentation in labour and mode of birth were prioritised as critical outcomes by the committee. This reflects the different options available to women with a known breech presentation in pregnancy and the different choices that women make. There are some women and/or clinicians who may feel uncomfortable with the risks of aiming for vaginal breech birth, and for these women and/or clinicians avoiding an unexpected breech presentation in labour would be the preferred option.

As existing evidence suggests that aiming for vaginal breech birth carries greater risk to the fetus than planned caesarean birth, it is important to consider whether earlier detection of the breech presentation would reduce the risk of these outcomes.

The committee agreed that maternal anxiety and women’s experience and satisfaction of care were important outcomes to consider as the introduction of an additional routine scan during pregnancy could have a treatment burden for women. Gestational age at birth and admission to neonatal unit were also chosen as important outcomes as the committee wanted to find out whether earlier detection of breech presentation would have an impact on whether the baby was born preterm, and as a consequence admitted to the neonatal unit. These outcomes were agreed to be important rather than critical as they are indirect outcomes of earlier detection of breech presentation.

The quality of the evidence

The quality of the evidence ranged from low to high. Most of the evidence was rated high or moderate, with only 1 outcome rated as low. The quality of the evidence was downgraded due to imprecision around the effect estimates for emergency caesarean section, elective caesarean section and admissions to neonatal unit.

No evidence was identified for the following outcomes: unexpected breech presentation in labour, maternal anxiety, women’s experiences and satisfaction of care.

The committee had hoped to find evidence that would inform whether early identification of breech presentation had an impact on preterm births, and although the review reported evidence for gestational age as birth, the available evidence was for births 39-42 weeks of gestation.

Benefits and harms

The available evidence compared routine ultrasound scanning with selective ultrasound scanning, and found no clinically important differences for mode of birth, gestational age at birth, or admissions to the neonatal unit. However, the committee discussed that it was important to note that the study did not focus on identifying breech presentation. The committee discussed the differences between the intervention in the study, which was an ultrasound scan to assess placental maturity, liquor volume, and fetal weight, to an ultrasound scan used to detect breech presentation. Whilst the ultrasound scan in the study has the ability to determine breech presentation, there are additional and costlier training required for the assessment of the other criteria. As such, it is important to separate the interventions. The committee also highlighted that the study did not look at whether an identification of breech presentation had an impact on the outcomes which were selected for this review.

In light of this, the committee felt that they were unable to reach a conclusion as to whether routine scanning to identify breech presentation, was associated with any benefits or harms. The committee agreed that while this review suggests routine ultrasound scanning to be no more effective than selective scanning, it does not definitively establish equivalence. Therefore, the committee agreed to recommend a continuation of the current practice with selective scanning and make a research recommendation to compare the clinical and cost effectiveness of routine ultrasound scanning versus selective ultrasound scanning from 36 weeks to identify fetal breech presentation.

Cost effectiveness and resource use

The committee acknowledged that there was included economic evidence on the effectiveness of routine scanning between 36+0 and 38+6 weeks of pregnancy compared to standard care regarding breech presentation.

The 1 included study suggested that offering a routine scan for breech is borderline cost effective. A key driver of cost effectiveness was the cost of the scan, which was substantially lower in the economic model than the figure quoted in NHS reference costs for routine ultrasound scanning. The committee noted that a scan for breech presentation only is a simpler technique and uses a cheaper machine. The committee agreed that the other costing assumptions presented in the study seemed appropriate.

However, the committee expressed concerns about the cohort study which underpinned the economic analysis which had a high risk of bias. The committee noted that a number of assumptions in the model which were key drivers of cost effectiveness, including the palpation diagnosis rates and prevalence of breech position, were from this 1 cohort study. This increased the uncertainty around the cost effectiveness of the routine scan. The committee also noted that, whilst the cost of the scan was fairly inexpensive, the resource impact would be substantial if a routine scan for breech presentation was offered to all pregnant women.

Overall, the committee felt that the clinical and cost effectiveness evidence presented was not strong enough to recommend offering a routine ultrasound scan given the potential for a significant resource impact. The recommendation to offer abdominal palpation to all pregnant women, and to offer an ultrasound scan where breech is suspected reflects current practice and so no substantial resource impact is anticipated.

McKenna 2003

Wastlund 2019

Appendix A. Review protocols

Review protocol for review question: What is the effectiveness of routine scanning between 36+0 and 38+6 weeks of pregnancy compared to standard care regarding breech presentation? (PDF, 244K)

Appendix B. Literature search strategies

Literature search strategies for review question: What is the effectiveness of routine scanning between 36+0 and 38+6 weeks of pregnancy compared to standard care regarding breech presentation? (PDF, 370K)

Appendix C. Clinical evidence study selection

Clinical study selection for review question: What is the effectiveness of routine scanning between 36+0 and 38+6 weeks of pregnancy compared to standard care regarding breech presentation? (PDF, 117K)

Appendix D. Clinical evidence tables

Clinical evidence tables for review question: What is the effectiveness of routine scanning between 36+0 and 38+6 weeks of pregnancy compared to standard care regarding breech presentation? (PDF, 213K)

Appendix E. Forest plots

Forest plots for review question: what is the effectiveness of routine scanning between 36+0 and 38+6 weeks of pregnancy compared to standard care regarding breech presentation.

This section includes forest plots only for outcomes that are meta-analysed. Outcomes from single studies are not presented here, but the quality assessment for these outcomes is provided in the GRADE profiles in appendix F .

Appendix F. GRADE tables

GRADE tables for review question: What is the effectiveness of routine scanning between 36+0 and 38+6 weeks of pregnancy compared to standard care regarding breech presentation? (PDF, 196K)

Appendix G. Economic evidence study selection

Economic evidence study selection for review question: what is the effectiveness of routine scanning between 36+0 and 38+6 weeks of pregnancy compared to standard care regarding breech presentation.

A single economic search was undertaken for all topics included in the scope of this guideline. One economic study was identified which was applicable to this review question. See supplementary material 2 for details.

Appendix H. Economic evidence tables

Economic evidence tables for review question: What is the effectiveness of routine scanning between 36+0 and 38+6 weeks of pregnancy compared to standard care regarding breech presentation? (PDF, 143K)

Appendix I. Economic evidence profiles

Economic evidence profiles for review question: What is the effectiveness of routine scanning between 36+0 and 38+6 weeks of pregnancy compared to standard care regarding breech presentation? (PDF, 129K)

Appendix J. Economic analysis

Economic evidence analysis for review question: what is the effectiveness of routine scanning between 36+0 and 38+6 weeks of pregnancy compared to standard care regarding breech presentation.

No economic analysis was conducted for this review question.

Appendix K. Excluded studies

Excluded clinical and economic studies for review question: what is the effectiveness of routine scanning between 36+0 and 38+6 weeks of pregnancy compared to standard care regarding breech presentation, clinical studies, table 8 excluded studies and reasons for their exclusion.

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Economic studies

A single economic search was undertaken for all topics included in the scope of this guideline. No economic studies were identified which were applicable to this review question. See supplementary material 2 for details.

Appendix L. Research recommendations

Research recommendations for review question: What is the effectiveness of routine scanning between 36+0 and 38+6 weeks of pregnancy compared to standard care regarding breech presentation? (PDF, 164K)

Evidence reviews underpinning recommendations 1.2.36 to 1.2.37

These evidence reviews were developed by the National Guideline Alliance, which is a part of the Royal College of Obstetricians and Gynaecologists

Disclaimer : The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.

Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.

NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government , Scottish Government , and Northern Ireland Executive . All NICE guidance is subject to regular review and may be updated or withdrawn.

• Cite this Page National Guideline Alliance (UK). Identification of breech presentation: Antenatal care: Evidence review L. London: National Institute for Health and Care Excellence (NICE); 2021 Aug. (NICE Guideline, No. 201.)
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• Review Management of breech presentation: Antenatal care: Evidence review M [ 2021] Review Management of breech presentation: Antenatal care: Evidence review M National Guideline Alliance (UK). 2021 Aug
• Vaginal delivery of breech presentation. [J Obstet Gynaecol Can. 2009] Vaginal delivery of breech presentation. Kotaska A, Menticoglou S, Gagnon R, MATERNAL FETAL MEDICINE COMMITTEE. J Obstet Gynaecol Can. 2009 Jun; 31(6):557-566.
• [The effect of the woman's age on the course of pregnancy and labor in breech presentation]. [Akush Ginekol (Sofiia). 1996] [The effect of the woman's age on the course of pregnancy and labor in breech presentation]. Dimitrov A, Borisov S, Nalbanski B, Kovacheva M, Chintolova G, Dzherov L. Akush Ginekol (Sofiia). 1996; 35(1-2):7-9.
• Review Cephalic version by moxibustion for breech presentation. [Cochrane Database Syst Rev. 2005] Review Cephalic version by moxibustion for breech presentation. Coyle ME, Smith CA, Peat B. Cochrane Database Syst Rev. 2005 Apr 18; (2):CD003928. Epub 2005 Apr 18.
• Review Hands and knees posture in late pregnancy or labour for fetal malposition (lateral or posterior). [Cochrane Database Syst Rev. 2005] Review Hands and knees posture in late pregnancy or labour for fetal malposition (lateral or posterior). Hofmeyr GJ, Kulier R. Cochrane Database Syst Rev. 2005 Apr 18; (2):CD001063. Epub 2005 Apr 18.

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• 1 Creighton University School of Medicine
• 2 Creighton University
• PMID: 28846227
• Bookshelf ID: NBK448063

Breech presentation refers to the fetus in the longitudinal lie with the buttocks or lower extremity entering the pelvis first. The 3 types of breech presentation are frank, complete, and incomplete. In a frank breech, the fetus has flexion of both hips, and the legs are straight with the feet near the fetal face, in a pike position. The complete breech has the fetus sitting with flexion of both hips and both legs in a tuck position. Finally, the incomplete breech can have any combination of 1 or both hips extended, also known as footling (one leg extended) or double footling breech (both legs extended).

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Disclosure: Caron Gray declares no relevant financial relationships with ineligible companies.

Disclosure: Meaghan Shanahan declares no relevant financial relationships with ineligible companies.

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• Pearls and Other Issues
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• [What effect does leg position in breech presentation have on mode of delivery and early neonatal morbidity?]. Krause M, Fischer T, Feige A. Krause M, et al. Z Geburtshilfe Neonatol. 1997 Jul-Aug;201(4):128-35. Z Geburtshilfe Neonatol. 1997. PMID: 9410517 German.
• The effect of intra-uterine breech position on postnatal motor functions of the lower limbs. Sival DA, Prechtl HF, Sonder GH, Touwen BC. Sival DA, et al. Early Hum Dev. 1993 Mar;32(2-3):161-76. doi: 10.1016/0378-3782(93)90009-j. Early Hum Dev. 1993. PMID: 8486118
• The influence of the fetal leg position on the outcome in vaginally intended deliveries out of breech presentation at term - A FRABAT prospective cohort study. Jennewein L, Allert R, Möllmann CJ, Paul B, Kielland-Kaisen U, Raimann FJ, Brüggmann D, Louwen F. Jennewein L, et al. PLoS One. 2019 Dec 2;14(12):e0225546. doi: 10.1371/journal.pone.0225546. eCollection 2019. PLoS One. 2019. PMID: 31790449 Free PMC article.
• Breech vaginal delivery at or near term. Tunde-Byass MO, Hannah ME. Tunde-Byass MO, et al. Semin Perinatol. 2003 Feb;27(1):34-45. doi: 10.1053/sper.2003.50003. Semin Perinatol. 2003. PMID: 12641301 Review.
• [Breech Presentation: CNGOF Guidelines for Clinical Practice - Epidemiology, Risk Factors and Complications]. Mattuizzi A. Mattuizzi A. Gynecol Obstet Fertil Senol. 2020 Jan;48(1):70-80. doi: 10.1016/j.gofs.2019.10.027. Epub 2019 Nov 1. Gynecol Obstet Fertil Senol. 2020. PMID: 31682966 Review. French.
• Hinnenberg P, Toijonen A, Gissler M, Heinonen S, Macharey G. Outcome of small for gestational age-fetuses in breech presentation at term according to mode of delivery: a nationwide, population-based record linkage study. Arch Gynecol Obstet. 2019 Apr;299(4):969-974. - PubMed
• Schlaeger JM, Stoffel CL, Bussell JL, Cai HY, Takayama M, Yajima H, Takakura N. Moxibustion for Cephalic Version of Breech Presentation. J Midwifery Womens Health. 2018 May;63(3):309-322. - PubMed
• Niles KM, Barrett JFR, Ladhani NNN. Comparison of cesarean versus vaginal delivery of extremely preterm gestations in breech presentation: retrospective cohort study. J Matern Fetal Neonatal Med. 2019 Apr;32(7):1142-1147. - PubMed
• Grabovac M, Karim JN, Isayama T, Liyanage SK, McDonald SD. What is the safest mode of birth for extremely preterm breech singleton infants who are actively resuscitated? A systematic review and meta-analyses. BJOG. 2018 May;125(6):652-663. - PubMed
• Andrews S, Leeman L, Yonke N. Finding the breech: Influence of breech presentation on mode of delivery based on timing of diagnosis, attempt at external cephalic version, and provider success with version. Birth. 2017 Sep;44(3):222-229. - PubMed

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• Pregnancy week by week
• Fetal presentation before birth

The way a baby is positioned in the uterus just before birth can have a big effect on labor and delivery. This positioning is called fetal presentation.

Babies twist, stretch and tumble quite a bit during pregnancy. Before labor starts, however, they usually come to rest in a way that allows them to be delivered through the birth canal headfirst. This position is called cephalic presentation. But there are other ways a baby may settle just before labor begins.

Following are some of the possible ways a baby may be positioned at the end of pregnancy.

Head down, face down

When a baby is head down, face down, the medical term for it is the cephalic occiput anterior position. This the most common position for a baby to be born in. With the face down and turned slightly to the side, the smallest part of the baby's head leads the way through the birth canal. It is the easiest way for a baby to be born.

Head down, face up

When a baby is head down, face up, the medical term for it is the cephalic occiput posterior position. In this position, it might be harder for a baby's head to go under the pubic bone during delivery. That can make labor take longer.

Most babies who begin labor in this position eventually turn to be face down. If that doesn't happen, and the second stage of labor is taking a long time, a member of the health care team may reach through the vagina to help the baby turn. This is called manual rotation.

In some cases, a baby can be born in the head-down, face-up position. Use of forceps or a vacuum device to help with delivery is more common when a baby is in this position than in the head-down, face-down position. In some cases, a C-section delivery may be needed.

Frank breech

When a baby's feet or buttocks are in place to come out first during birth, it's called a breech presentation. This happens in about 3% to 4% of babies close to the time of birth. The baby shown below is in a frank breech presentation. That's when the knees aren't bent, and the feet are close to the baby's head. This is the most common type of breech presentation.

If you are more than 36 weeks into your pregnancy and your baby is in a frank breech presentation, your health care professional may try to move the baby into a head-down position. This is done using a procedure called external cephalic version. It involves one or two members of the health care team putting pressure on your belly with their hands to get the baby to roll into a head-down position.

If the procedure isn't successful, or if the baby moves back into a breech position, talk with a member of your health care team about the choices you have for delivery. Most babies in a frank breech position are born by planned C-section.

Complete and incomplete breech

A complete breech presentation, as shown below, is when the baby has both knees bent and both legs pulled close to the body. In an incomplete breech, one or both of the legs are not pulled close to the body, and one or both of the feet or knees are below the baby's buttocks. If a baby is in either of these positions, you might feel kicking in the lower part of your belly.

If you are more than 36 weeks into your pregnancy and your baby is in a complete or incomplete breech presentation, your health care professional may try to move the baby into a head-down position. This is done using a procedure called external cephalic version. It involves one or two members of the health care team putting pressure on your belly with their hands to get the baby to roll into a head-down position.

If the procedure isn't successful, or if the baby moves back into a breech position, talk with a member of your health care team about the choices you have for delivery. Many babies in a complete or incomplete breech position are born by planned C-section.

When a baby is sideways — lying horizontal across the uterus, rather than vertical — it's called a transverse lie. In this position, the baby's back might be:

• Down, with the back facing the birth canal.
• Sideways, with one shoulder pointing toward the birth canal.
• Up, with the hands and feet facing the birth canal.

Although many babies are sideways early in pregnancy, few stay this way when labor begins.

If your baby is in a transverse lie during week 37 of your pregnancy, your health care professional may try to move the baby into a head-down position. This is done using a procedure called external cephalic version. External cephalic version involves one or two members of your health care team putting pressure on your belly with their hands to get the baby to roll into a head-down position.

If the procedure isn't successful, or if the baby moves back into a transverse lie, talk with a member of your health care team about the choices you have for delivery. Many babies who are in a transverse lie are born by C-section.

If you're pregnant with twins and only the twin that's lower in the uterus is head down, as shown below, your health care provider may first deliver that baby vaginally.

Then, in some cases, your health care team may suggest delivering the second twin in the breech position. Or they may try to move the second twin into a head-down position. This is done using a procedure called external cephalic version. External cephalic version involves one or two members of the health care team putting pressure on your belly with their hands to get the baby to roll into a head-down position.

Your health care team may suggest delivery by C-section for the second twin if:

• An attempt to deliver the baby in the breech position is not successful.
• You do not want to try to have the baby delivered vaginally in the breech position.
• An attempt to move the baby into a head-down position is not successful.
• You do not want to try to move the baby to a head-down position.

In some cases, your health care team may advise that you have both twins delivered by C-section. That might happen if the lower twin is not head down, the second twin has low or high birth weight as compared to the first twin, or if preterm labor starts.

• Landon MB, et al., eds. Normal labor and delivery. In: Gabbe's Obstetrics: Normal and Problem Pregnancies. 8th ed. Elsevier; 2021. https://www.clinicalkey.com. Accessed May 19, 2023.
• Holcroft Argani C, et al. Occiput posterior position. https://www.updtodate.com/contents/search. Accessed May 19, 2023.
• Frequently asked questions: If your baby is breech. American College of Obstetricians and Gynecologists https://www.acog.org/womens-health/faqs/if-your-baby-is-breech. Accessed May 22, 2023.
• Hofmeyr GJ. Overview of breech presentation. https://www.updtodate.com/contents/search. Accessed May 22, 2023.
• Strauss RA, et al. Transverse fetal lie. https://www.updtodate.com/contents/search. Accessed May 22, 2023.
• Chasen ST, et al. Twin pregnancy: Labor and delivery. https://www.updtodate.com/contents/search. Accessed May 22, 2023.
• Cohen R, et al. Is vaginal delivery of a breech second twin safe? A comparison between delivery of vertex and non-vertex second twins. The Journal of Maternal-Fetal & Neonatal Medicine. 2021; doi:10.1080/14767058.2021.2005569.
• Marnach ML (expert opinion). Mayo Clinic. May 31, 2023.

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Breech Delivery

• Author: Philippe H Girerd, MD; Chief Editor: Ronald M Ramus, MD  more...
• Sections Breech Delivery
• Practice Essentials
• Pathophysiology
• Epidemiology
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• Physical Examination
• Prehospital Care
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An appropriate axiom to keep in mind when considering a planned vaginal breech delivery is well stated by the American College of Obstetricians and Gynecologists (ACOG) Committee Opinion "Mode of Term Singleton Breech Delivery" [ 1 ] :

"The decision regarding the mode of delivery should depend on the experience of the healthcare provider. Cesarean delivery will be the preferred mode of delivery for most physicians because of the diminishing expertise in vaginal breech delivery."

In the modern landscape of obstetrics, vaginal breech delivery has become a rarity. The following factors have led to this reality:

• Known risks of vaginal breech delivery when strict selection criteria are not applied
• Lack of training in vaginal breech delivery owing to few remaining experienced teachers of the art
• Patient fear of vaginal breech delivery
• Superficial understanding of the literature 
• Fear of litigation

Of course, these factors are entirely understandable in an era when cesarean section has become very safe. In developed nations, great strides in risk reduction have been made in obstetrics so that even small differences in outcomes have come to the forefront. For this reason, post-cesarean complications, both immediate and long term, have risen to the forefront and should be considered in the decision.

Breech presentation occurs when the fetus presents to the birth canal with buttocks or feet first. This presentation may create a mechanical problem in delivery of the fetus.

Singleton breech delivery

Breech delivery has become increasingly rare both in the United States and globally. In recent decades, the perceived relative safety of cesarean delivery has made this route of delivery increasingly common for breech presentation.

This trend was accelerated by a 2000 study by Hannah et al. [ 2 ]  This randomized study of 2083 patients compared planned cesarean delivery (1041 patients) with planned vaginal birth (1042 patients) for breech presentation. The authors concluded, "Planned caesarean section is better than planned vaginal birth for the term fetus in the breech presentation; serious maternal complications are similar between the groups." [ 2 ] This conclusion was made on the basis of a significantly lower fetal and neonatal morbidity and mortality in the planned cesarean group. Of course, it is understandable that this conclusion would dampen any remaining enthusiasm for vaginal breech delivery. Giving strength to this trend was the 2001 ACOG Committee on Obstetric Practice recommendation, which stated that "planned vaginal delivery of a singleton breech is no longer appropriate." [ 3 ]

Those who are proponents of vaginal delivery point out that since this was a randomized controlled trial, none of the accepted selection criteria for safe vaginal breech delivery were employed. Thus, decisions based on extant prognostic factors were not applied to inclusion of patients in the planned vaginal breech delivery arm. In other words, no well-known selection criteria were applied to ascertain the safety of vaginal breech delivery. Had those been applied, results may have been more favorable.

In a follow-up study, the same group   who conducted the 2000 study found that "the risk of death or neurodevelopmental delay was no different in the planned cesarean delivery group compared with the planned vaginal delivery group." [ 4 ] Other studies have, as well, tempered the findings of the initial study described above.

ACOG recommends that external cephalic version be offered as an alternative to a planned cesarean section for a patient who has a term singleton breech fetus, wishes to have a planned vaginal delivery of a vertex-presenting fetus, and has no contraindications. ACOG also advises that external cephalic version be attempted only in settings where cesarean delivery services are available. [ 1 , 5 ]

Twin breech delivery

In twins with a cephalic leading twin and a breech second twin, it is reasonable to expect that the dynamics of the delivery of the second twin in breech presentation would differ significantly from that of a singleton breech presentation. Indeed, a Cochrane database review that looked at 2864 combined cases concluded: "There is insufficient evidence to support the routine use of planned caesarean section for term twin pregnancy with leading cephalic presentation, except in the context of further randomised trials." [ 6 ]

A review by Aviram et al concluded that breech extraction performed by an experienced obstetrician offers a greater likelihood of successful vaginal delivery of the noncephalic second twin than does external cephalic version. [ 7 ]

The buttocks and feet of the fetus do not provide an effective wedge to dilate the cervix so that the after-coming head might get trapped during delivery. Also, the umbilical cord may prolapse due to the increased space between the presenting buttocks and feet without the benefit of a fetal part well applied to the cervix .

The 3 types of breech presentation are as follows:

Frank (65%): Hips of the fetus are flexed, and knees are extended.

Complete (10%): The hips and knees of the fetus are flexed.

Incomplete (25%): The feet or knees of the fetus are the lowermost presenting part.

Single footling: One of the lower extremities is lowermost.

Double footling: Both of the lower extremities are lowermost.

Risk factors for breech presentation at delivery include the following:

Preterm gestational age: Prior to the onset of labor, the fetus typically turns into a cephalic presentation. If labor occurs abruptly or unexpectedly (eg, following trauma), the fetus may not have yet shifted position.

Increased maternal parity may cause stretching or laxity of the uterus, predisposing the fetus to breech deliveries.

Multiple fetuses: As a result of limited space in the uterus, fetuses may position themselves head to foot.

Hydramnios, ie, too much amniotic fluid, may allow the fetus too much movement.

Oligohydramnios , ie, too little amniotic fluid, may impede the final shift of the fetus into a cephalic presentation. [ 8 ]

Placenta previa , ie, placental implantation over the cervical os, allows the fetus too much space for movement within the uterus.

Hydrocephalus , ie, enlarged head in the fetus, makes it more difficult for the fetus to make shift to cephalic presentation prior to the onset of labor.

Previous breech deliveries may increase likelihood of another one secondary to an anatomical anomaly.

Uterine anomalies include uterine scarring from a previous cesarean section, bicornuate uterus, or a septate uterus.

Pelvic tumors may impede fetal movement and trap the fetus in a breech presentation.

United States data

Incidence is correlated to gestational age (see the Table below). However, the overall frequency is 3-4% at delivery. [ 9 ]

Table. Gestational age and frequency of breech birth (Open Table in a new window)

International data

The international incidence has been reported at 3-4%. [ 2 ]

Age-related demographics

Older maternal age is a consideration. [ 10 ]  A Finnish study found that advanced maternal age (≥35 years) is a risk factor for breech presentation in moderate to late preterm pregnancies (32-36 weeks’ gestation) as well as in term pregnancies. [ 11 ]

Fetal and maternal morbidity and mortality increase with breech delivery. Fetus and infant mortality increases to 9%, compared with 3% in cephalic presentations.

A rise in the number of cesarean deliveries increases the maternal morbidity and mortality (eg, wound infection, aspiration, anesthesia risk), especially with emergency delivery.

A Danish study found that nulliparous women with a singleton breech presentation who had a planned vaginal delivery were at significantly higher risk for postoperative complications, compared with women who had a planned cesarean delivery, owing to the likelihood of conversion to an emergency cesarean section, which occurred in over 69% of planned vaginal deliveries. [ 12 ]

The average Apgar score, especially at 1 minute, is lower. Congenital abnormalities increase to 6%, compared with 2.4% in infants with cephalic presentations.

Factors for increased adverse fetal outcome include the following [ 9 ] :

Older mothers

Footling presentation

Hyperextended fetal head

Birth weight less than 2500 g or greater than 4000 g

Prolonged labor

Nonexperienced clinician

Morbidity/mortality

Various complications are associated with a breech presentation in labor. This may be due to the underlying etiology of the breech presentation, such as fetal anomalies or polyhydramnios. In addition, complications can occur as a result of umbilical cord compression due to the unusual presentation to the maternal pelvis.

The inexperienced provider when faced with a slowing fetal heart rate from cord compression  is more likely to apply traction on the fetus prematurely, increasing the risk of birth trauma and nuchal arms. Nuchal arms lead to complications with delivery of the head by increasing the diameter required for delivery.

The incidence of  prolapsed umbilical cord  depends on the type of breech presentation, as follows:

Footling – 17% incidence

Complete – 5% incidence

Frank – 0.5% incidence

Umbilical cord abnormalities  can occur. Cord length may be reduced, and, in footling breeches, there is an increased risk of the cord coiling around a leg of the fetus.

Complications

Traumatic mortality to the fetus is 12 times more likely. Intracranial fetal hemorrhage is the most common injury in breech delivery. In decreasing order of frequency, the spinal cord, liver, adrenals, and spleen also are injured.

Patient education is an essential part of all medical practice. This is especially true for breech delivery.

Early prenatal care can identify patients at risk for breech delivery.

ACOG Committee on Obstetric Practice. ACOG Committee Opinion No. 745: Mode of Term Singleton Breech Delivery. Obstet Gynecol . 2018 Aug; reaffirmed 2023. 132 (2):e60-e63. [QxMD MEDLINE Link] . [Full Text] .

Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group. Lancet . 2000 Oct 21. 356(9239):1375-83. [QxMD MEDLINE Link] .

Committee on Obstetric Practice. ACOG committee opinion. Mode of term singleton breech delivery. Number 265, December 2001. American College of Obstetricians and Gynecologists. Int J Gynaecol Obstet . 2002 Apr. 77 (1):65-6. [QxMD MEDLINE Link] .

Whyte H, Hannah ME, Saigal S, Hannah WJ, Hewson S, Amankwah K, et al. Outcomes of children at 2 years after planned cesarean birth versus planned vaginal birth for breech presentation at term: the International Randomized Term Breech Trial. Am J Obstet Gynecol . 2004 Sep. 191 (3):864-71. [QxMD MEDLINE Link] .

External Cephalic Version: ACOG Practice Bulletin Summary, Number 221. Obstet Gynecol . 2020 May. 135 (5):1239-41. [QxMD MEDLINE Link] .

Hofmeyr GJ, Barrett JF, Crowther CA. Planned caesarean section for women with a twin pregnancy. Cochrane Database Syst Rev . 2015 Dec 19. 12:CD006553. [QxMD MEDLINE Link] .

Aviram A, Barrett JFR, Melamed N, Mei-Dan E. Mode of delivery in multiple pregnancies. Am J Obstet Gynecol MFM . 2022 Mar. 4 (2S):100470. [QxMD MEDLINE Link] .

Roecker CB. Breech repositioning unresponsive to Webster technique: coexistence of oligohydramnios. J Chiropr Med . 2013 Jun. 12(2):74-8. [QxMD MEDLINE Link] . [Full Text] .

Tunde-Byass MO, Hannah ME. Breech vaginal delivery at or near term. Semin Perinatol . 2003 Feb. 27(1):34-45. [QxMD MEDLINE Link] .

Rayl J, Gibson PJ, Hickok DE. A population-based case-control study of risk factors for breech presentation. Am J Obstet Gynecol . 1996 Jan. 174(1 Pt 1):28-32. [QxMD MEDLINE Link] .

Toijonen AE, Heinonen ST, Gissler MVM, Macharey G. A comparison of risk factors for breech presentation in preterm and term labor: a nationwide, population-based case-control study. Arch Gynecol Obstet . 2020 Feb. 301 (2):393-403. [QxMD MEDLINE Link] .

Caning MM, Rasmussen SC, Krebs L. Maternal outcomes of planned mode of delivery for term breech in nulliparous women. PLoS One . 2024. 19 (4):e0297971. [QxMD MEDLINE Link] . [Full Text] .

Bergenhenegouwen LA, Meertens LJ, Schaaf J, Nijhuis JG, Mol BW, Kok M, et al. Vaginal delivery versus caesarean section in preterm breech delivery: a systematic review. Eur J Obstet Gynecol Reprod Biol . 2013 Oct 16. [QxMD MEDLINE Link] .

Knights S, Prasad S, Kalafat E, et al. Impact of point-of-care ultrasound and routine third trimester ultrasound on undiagnosed breech presentation and perinatal outcomes: An observational multicentre cohort study. PLoS Med . 2023 Apr. 20 (4):e1004192. [QxMD MEDLINE Link] . [Full Text] .

Miwa I, Sase M, Nakamura Y, Hasegawa K, Kawasaki M, Ueda K. Congenital high airway obstruction syndrome in the breech presentation managed by ex utero intrapartum treatment procedure after intraoperative external cephalic version. J Obstet Gynaecol Res . 2012 Mar 22. [QxMD MEDLINE Link] .

• Footling breech presentation. Once the feet have delivered, one may be tempted to pull on the feet. However, a singleton gestation should not be pulled by the feet because this action may precipitate head entrapment in an incompletely dilated cervix or may precipitate nuchal arms. As long as the fetal heart rate is stable and no physical evidence of a prolapsed cord is evident, management may be expectant while awaiting full cervical dilation.
• Assisted vaginal breech delivery. Thick meconium passage is common as the breech is squeezed through the birth canal. This is usually not associated with meconium aspiration because the meconium passes out of the vagina and does not mix with the amniotic fluid.
• Assisted vaginal breech delivery. The Ritgen maneuver is applied to take pressure off the perineum during vaginal delivery. Episiotomies are often performed for assisted vaginal breech deliveries, even in multiparous women, to prevent soft tissue dystocia.
• Assisted vaginal breech delivery. No downward or outward traction is applied to the fetus until the umbilicus has been reached.
• Assisted vaginal breech delivery. With a towel wrapped around the fetal hips, gentle downward and outward traction is applied in conjunction with maternal expulsive efforts until the scapula is reached. An assistant should be applying gentle fundal pressure to keep the fetal head flexed.
• Assisted vaginal breech delivery. After the scapula is reached, the fetus should be rotated 90° in order to deliver the anterior arm.
• Assisted vaginal breech delivery. The anterior arm is followed to the elbow, and the arm is swept out of the vagina.
• Assisted vaginal breech delivery. The fetus is rotated 180°, and the contralateral arm is delivered in a similar manner as the first. The infant is then rotated 90° to the backup position in preparation for delivery of the head.
• Assisted vaginal breech delivery. The fetal head is maintained in a flexed position by using the Mauriceau maneuver, which is performed by placing the index and middle fingers over the maxillary prominence on either side of the nose. The fetal body is supported in a neutral position, with care to not overextend the neck.
• Piper forceps application. Piper forceps are specialized forceps used only for the after-coming head of a breech presentation. They are used to keep the fetal head flexed during extraction of the head. An assistant is needed to hold the infant while the operator gets on one knee to apply the forceps from below.
• Assisted vaginal breech delivery. Low 1-minute Apgar scores are not uncommon after a vaginal breech delivery. A pediatrician should be present for the delivery in the event that neonatal resuscitation is needed.
• Assisted vaginal breech delivery. The neonate after birth.
• Ultrasound demonstrating a fetus in breech presentation with a hyperextended head (ie, "star gazing").
• Table. Gestational age and frequency of breech birth

Contributor Information and Disclosures

Philippe H Girerd, MD Associate Professor, Department of Obstetrics and Gynecology, Virginia Commonwealth University, Medical College of Virginia Philippe H Girerd, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists , Association of Professors of Gynecology and Obstetrics , Medical Society of Virginia , AAGL Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Received salary from Medscape for employment. for: Medscape.

John G Pierce, Jr, MD Chairman of Women’s Health and Medical Specialties, Liberty University College of Osteopathic Medicine; Obstetrician/Gynecologist, Women’s Health of Central Virginia John G Pierce, Jr, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists , Association of Professors of Gynecology and Obstetrics , Christian Medical and Dental Associations , Medical Society of Virginia , Society of Laparoscopic and Robotic Surgeons Disclosure: Nothing to disclose.

Ronald M Ramus, MD Professor of Obstetrics and Gynecology, Director, Division of Maternal-Fetal Medicine, Virginia Commonwealth University School of Medicine Ronald M Ramus, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists , American Institute of Ultrasound in Medicine , Medical Society of Virginia , Society for Maternal-Fetal Medicine Disclosure: Nothing to disclose.

Assaad J Sayah, MD, FACEP President and Chief Executive Officer, Cambridge Health Alliance Assaad J Sayah, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians , Massachusetts Medical Society Disclosure: Nothing to disclose.

Andrew D Jenis, MD Chair, Department of Emergency Medicine, Memorial Hospital, York, PA

Andrew D Jenis, MD is a member of the following medical societies: American College of Emergency Physicians and Medical Society of the State of New York

Disclosure: Nothing to disclose.

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What Does It Mean to Have a Frank Breech Baby?

Frank breech is the most common type of breech position. Learn what this position means for you and your baby.

• Types of Breech Positions

How To Tell If Your Baby Is Breech

Causes of breech presentations, treatment for breech presentations, complications of a breech birth, what happens if my baby is breech.

If your baby is in a frank breech position, that means that their bottom is facing down towards the birth canal instead of their head. The part of the baby that is nearest to the cervix is called the presenting part. The presenting part, which is the part of the baby's body that is born first in a vaginal delivery , is usually the baby's head (known as vertex presentation).

In a small number of deliveries, however, a baby’s bottom or feet are in a position to be born first. This is called a breech presentation, and frank breech (bottom first, with feet up near the head) is the most common type.

Learn about the types of breech presentation including frank breech, what causes a baby to be breech, how it's treated, and what to expect with a breech delivery.

Jamie Grill / Getty Images 

Frank Breech and Other Types of Breech Positions

Babies can be in all sorts of positions during pregnancy, but most babies eventually turn head down in late pregnancy. As pregnancy progresses, the more likely it is that the baby will turn and the head will be down near the cervix when it's time for delivery.

Breech Presentation Statistics

• Before the 28th week of pregnancy, about 20% to 25% of babies are breech.
• By the 34th week of pregnancy, most babies will turn and approximately 5% to 7% will be breech.
• By full term, only 3% to 4% of babies (3 or 4 out of every 100 births) are breech.

Sometimes, however, babies are in a breech (bottom or leg down) position when labor begins. There are several types of breech positions.

Frank breech

A frank breech position is when the baby’s bottom is down, but their legs are straight up with their feet near their head. The presenting part is the buttocks.

A frank breech is the most common breech presentation, especially when a baby is born at full term. Of the 3% to 4% of term breech births, babies are in the frank breech position 50% to 70% of the time.

Complete breech

In this position, the bottom is down, but the baby's knees are also bent, so the feet are also down near the buttocks. The presenting part is not only the bottom but both feet as well. At delivery, about 10% of breech babies are in a complete breech position.

Incomplete (footling) breech

A footling breech position is when the baby’s legs are extended and facing straight down. Instead of the bottom, the presenting part is one foot (a single footling) or both feet (a double footling). Approximately 25% of breech deliveries are incomplete.

As your pregnancy progresses, your prenatal health care provider will examine you and keep track of your baby’s position . You might even be able to figure out how your baby is positioned on your own.

Here are some of the techniques you and your health care provider can use to tell which way your baby is facing.

• Kicks : You can feel where your baby is kicking you and judge their general position. If you feel kicks in your lower pelvis, then the baby hasn’t turned head down yet. But if the kicks are up toward your ribs and the top of your uterus, then the baby’s head is most likely facing down.
• Palpation : At your prenatal visits, your doctor or midwife will check your baby's position by palpating or feeling your belly to find the baby’s head, back, and bottom.
• Heartbeat : Listening to the baby’s heartbeat is another way to tell where your baby is in the uterus. By finding the heartbeat's location, the doctor or midwife can get a better idea of the baby’s position.
• Ultrasound : An ultrasound provides the best position information. It shows you and your health care team a picture of the baby and their exact position in your uterus. If your baby is breech, the ultrasound can determine the type of breech position your baby is in, such as frank breech or complete breech.
• Pelvic exam : During labor, your health care provider can perform a pelvic examination . They will be able to feel whether the baby’s head or their bottom and feet are in the birth canal.

The size of the baby, amount of amniotic fluid , and amount of space inside the uterus are all factors that can contribute to a baby’s ability to move around.

The most common reason for a breech presentation is prematurity, but other factors could lead to a baby in a breech position:

• Premature delivery : A premature baby is smaller and has more room inside the uterus to move around, which increases the chances that they will be in a breech presentation if you go into preterm labor .
• Multiples : Twins or other multiples have less room in the uterus to move around and get into the head-down position for delivery.
• Uterine issues : Fibroids or a heart-shaped uterus can get in the way of the baby’s ability to turn.
• Shortened umbilical cord : If the umbilical cord is very short, the baby may not be able to move and turn.
• Too much or too little amniotic fluid : Too much amniotic fluid gives the baby the ability to move around freely in the uterus. As they grow, they may still be able to flip and turn rather than turning head down and staying head down. Too little amniotic fluid , on the other hand, may prevent a baby from moving into the head-down position as they get closer to full-term.
• Location of the placenta : When the placenta is low and covers all or part of the cervix, it’s called placenta previa . When the placenta is in this position, it takes up the room at the bottom of the uterus and can make it difficult for the baby to turn head down.
• Congenital abnormalities in the baby : Some congenital abnormalities can affect the baby’s ability to move into the head-down position. These conditions are usually not a surprise at delivery since they are typically seen during prenatal ultrasound examinations .

If your baby is breech, you will face four possible outcomes to your pregnancy:

• Your baby may turn on its own . Especially if it's early in your pregnancy, there is a chance your baby will turn from a breech position to a head-down position. Many prenatal health care providers will take a wait-and-see approach early on.
• Your doctor may attempt to manually turn your baby . If there are no complications in your pregnancy and the baby has not yet turned on its own by the 36th or 37th week, your doctor may attempt to turn the baby using a manual procedure called external cephalic version (ECV). ECV works approximately 60% of the time.
• Your doctor may schedule a C-section . For a baby that remains in a breech position in late pregnancy, most doctors will recommend a surgical birth via a C-section .
• Your doctor may agree to help you attempt a vaginal delivery . The majority of pregnancy care providers will not deliver a breech baby vaginally, but a small percentage of doctors may be willing to work with you having a vaginal delivery with a breech baby.

You can also do some things to encourage your baby to turn head down , such as acupuncture and exercises like pelvic tilts and even walking.

Most babies who are born breech are healthy. But when a baby is frank breech or in any other breech position, there is a higher chance of a complicated labor and delivery. Here are some of the complications associated with breech birth.

Umbilical cord prolapse

During a vaginal breech delivery, there is a chance that the umbilical cord will come down through the cervix before the baby is born. As the baby comes through the birth canal, their body and head can press on the cord and cut off the supply of blood and oxygen that the cord is carrying.

This can affect the baby’s heart rate and the flow of oxygen and blood to the baby’s brain. The danger of a prolapsed cord is greater with a footling breech and a complete breech.

The risk of cord prolapse is less when the baby is in the frank breech position.

Head entrapment

The baby’s head can get stuck during the delivery if the baby’s body is born before the cervix fully dilates. This situation is dangerous since the head can press against the umbilical cord and cause asphyxia or a lack of oxygen.

Head entrapment is more common in premature deliveries because the baby’s head is typically bigger than their body.

Physical injuries to the baby

The risk of injury to the baby during delivery is higher when the baby is breech compared to when the baby is not breech. Preemies are more likely to injure their head and skull. Bruising, broken bones, and dislocated joints can also occur depending on the baby's position during birth.

Additionally, after a baby is born, breech newborns have a higher incidence of neonatal hip instability, also called developmental dysplasia of the hip (DDH). This complication occurs in between 12% to 24% of breech babies.

Physical injury to the gestational parent

The vaginal delivery of a breech baby can require an episiotomy and the use of forceps, which can cause injury to the birthing person's genital area.

Many babies will turn to the head-down position before labor begins. However, if your baby is still breech when labor begins, you and your doctor will have to decide between having a C-section or trying a vaginal birth.

Whenever possible, the standard choice is to deliver any breech baby who is premature or in distress via cesarean section. Since vaginal deliveries, even when all the above criteria are met, come with a higher risk of a difficult birth and birth injuries, most doctors prefer to deliver all breech presentations by C-section.

However, when there are no other complications, a baby in the frank breech position may be delivered vaginally if the doctor agrees to it and certain conditions are met:

• Emergency resources are available
• The baby is at least 36 weeks
• The baby is not too big or too small
• The baby’s head is in the right position (flexed)
• The health care team has experience with breech deliveries
• The size of your pelvis is large enough
• There is continuous monitoring of the baby
• You have delivered vaginally before

If any complications arise during the delivery, you may still need an emergency C-section .

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A comparison of risk factors for breech presentation in preterm and term labor: A nationwide, population-based case-control study . Arch Gynecol Obstet . 2020.

Breech presentation: Vaginal versus cesarean delivery, which intervention leads to the best outcomes? . Acta Med Port. 2017.

Breech presentation . Medscape . 2022.

Breech presentation: CNGOF Guidelines for Clinical Practice - Information and management . Gynecol Obstet Fertil Senol. 2020.

Mode of Term Singleton Breech Delivery . American College of Obstetricians and Gynecologists . 2023.

Umbilical Cord Prolapse . StatPearls . 2023.

Incidence of acetabular dysplasia in breech infants following initially normal ultrasound: the effect of variable diagnostic criteria . J Child Orthop . 2017.

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