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Breech Births

In the last weeks of pregnancy, a baby usually moves so his or her head is positioned to come out of the vagina first during birth. This is called a vertex presentation. A breech presentation occurs when the baby’s buttocks, feet, or both are positioned to come out first during birth. This happens in 3–4% of full-term births.

What are the different types of breech birth presentations?

• Complete breech: Here, the buttocks are pointing downward with the legs folded at the knees and feet near the buttocks.
• Frank breech: In this position, the baby’s buttocks are aimed at the birth canal with its legs sticking straight up in front of his or her body and the feet near the head.
• Footling breech: In this position, one or both of the baby’s feet point downward and will deliver before the rest of the body.

What causes a breech presentation?

The causes of breech presentations are not fully understood. However, the data show that breech birth is more common when:

• You have been pregnant before
• In pregnancies of multiples
• When there is a history of premature delivery
• When the uterus has too much or too little amniotic fluid
• When there is an abnormally shaped uterus or a uterus with abnormal growths, such as fibroids
• The placenta covers all or part of the opening of the uterus placenta previa

How is a breech presentation diagnosed?

A few weeks prior to the due date, the health care provider will place her hands on the mother’s lower abdomen to locate the baby’s head, back, and buttocks. If it appears that the baby might be in a breech position, they can use ultrasound or pelvic exam to confirm the position. Special x-rays can also be used to determine the baby’s position and the size of the pelvis to determine if a vaginal delivery of a breech baby can be safely attempted.

Can a breech presentation mean something is wrong?

Even though most breech babies are born healthy, there is a slightly elevated risk for certain problems. Birth defects are slightly more common in breech babies and the defect might be the reason that the baby failed to move into the right position prior to delivery.

Can a breech presentation be changed?

It is preferable to try to turn a breech baby between the 32nd and 37th weeks of pregnancy . The methods of turning a baby will vary and the success rate for each method can also vary. It is best to discuss the options with the health care provider to see which method she recommends.

Medical Techniques

External Cephalic Version (EVC)  is a non-surgical technique to move the baby in the uterus. In this procedure, a medication is given to help relax the uterus. There might also be the use of an ultrasound to determine the position of the baby, the location of the placenta and the amount of amniotic fluid in the uterus.

Gentle pushing on the lower abdomen can turn the baby into the head-down position. Throughout the external version the baby’s heartbeat will be closely monitored so that if a problem develops, the health care provider will immediately stop the procedure. ECV usually is done near a delivery room so if a problem occurs, a cesarean delivery can be performed quickly. The external version has a high success rate and can be considered if you have had a previous cesarean delivery.

ECV will not be tried if:

• You are carrying more than one fetus
• There are concerns about the health of the fetus
• You have certain abnormalities of the reproductive system
• The placenta is in the wrong place
• The placenta has come away from the wall of the uterus ( placental abruption )

Complications of EVC include:

• Prelabor rupture of membranes
• Changes in the fetus’s heart rate
• Placental abruption
• Preterm labor

Vaginal delivery versus cesarean for breech birth?

Most health care providers do not believe in attempting a vaginal delivery for a breech position. However, some will delay making a final decision until the woman is in labor. The following conditions are considered necessary in order to attempt a vaginal birth:

• The baby is full-term and in the frank breech presentation
• The baby does not show signs of distress while its heart rate is closely monitored.
• The process of labor is smooth and steady with the cervix widening as the baby descends.
• The health care provider estimates that the baby is not too big or the mother’s pelvis too narrow for the baby to pass safely through the birth canal.
• Anesthesia is available and a cesarean delivery possible on short notice

What are the risks and complications of a vaginal delivery?

In a breech birth, the baby’s head is the last part of its body to emerge making it more difficult to ease it through the birth canal. Sometimes forceps are used to guide the baby’s head out of the birth canal. Another potential problem is cord prolapse . In this situation the umbilical cord is squeezed as the baby moves toward the birth canal, thus slowing the baby’s supply of oxygen and blood. In a vaginal breech delivery, electronic fetal monitoring will be used to monitor the baby’s heartbeat throughout the course of labor. Cesarean delivery may be an option if signs develop that the baby may be in distress.

When is a cesarean delivery used with a breech presentation?

Most health care providers recommend a cesarean delivery for all babies in a breech position, especially babies that are premature. Since premature babies are small and more fragile, and because the head of a premature baby is relatively larger in proportion to its body, the baby is unlikely to stretch the cervix as much as a full-term baby. This means that there might be less room for the head to emerge.

Want to Know More?

• Creating Your Birth Plan
• Labor & Birth Terms to Know
• Cesarean Birth After Care

Compiled using information from the following sources:

• ACOG: If Your Baby is Breech
• William’s Obstetrics Twenty-Second Ed. Cunningham, F. Gary, et al, Ch. 24.
• Danforth’s Obstetrics and Gynecology Ninth Ed. Scott, James R., et al, Ch. 21.

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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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• 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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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.

Fetal Presentation, Position, and Lie (Including Breech Presentation)

• Variations in Fetal Position and Presentation |

During pregnancy, the fetus can be positioned in many different ways inside the mother's uterus. The fetus may be head up or down or facing the mother's back or front. At first, the fetus can move around easily or shift position as the mother moves. Toward the end of the pregnancy the fetus is larger, has less room to move, and stays in one position. How the fetus is positioned has an important effect on delivery and, for certain positions, a cesarean delivery is necessary. There are medical terms that describe precisely how the fetus is positioned, and identifying the fetal position helps doctors to anticipate potential difficulties during labor and delivery.

Presentation refers to the part of the fetus’s body that leads the way out through the birth canal (called the presenting part). Usually, the head leads the way, but sometimes the buttocks (breech presentation), shoulder, or face leads the way.

Position refers to whether the fetus is facing backward (occiput anterior) or forward (occiput posterior). The occiput is a bone at the back of the baby's head. Therefore, facing backward is called occiput anterior (facing the mother’s back and facing down when the mother lies on her back). Facing forward is called occiput posterior (facing toward the mother's pubic bone and facing up when the mother lies on her back).

Lie refers to the angle of the fetus in relation to the mother and the uterus. Up-and-down (with the baby's spine parallel to mother's spine, called longitudinal) is normal, but sometimes the lie is sideways (transverse) or at an angle (oblique).

For these aspects of fetal positioning, the combination that is the most common, safest, and easiest for the mother to deliver is the following:

Head first (called vertex or cephalic presentation)

Facing backward (occiput anterior position)

Spine parallel to mother's spine (longitudinal lie)

Neck bent forward with chin tucked

Arms folded across the chest

If the fetus is in a different position, lie, or presentation, labor may be more difficult, and a normal vaginal delivery may not be possible.

Variations in fetal presentation, position, or lie may occur when

The fetus is too large for the mother's pelvis (fetopelvic disproportion).

The uterus is abnormally shaped or contains growths such as fibroids .

The fetus has a birth defect .

There is more than one fetus (multiple gestation).

Position and Presentation of the Fetus

Variations in Fetal Position and Presentation

Some variations in position and presentation that make delivery difficult occur frequently.

Occiput posterior position

In occiput posterior position (sometimes called sunny-side up), the fetus is head first (vertex presentation) but is facing forward (toward the mother's pubic bone—that is, facing up when the mother lies on her back). This is a very common position that is not abnormal, but it makes delivery more difficult than when the fetus is in the occiput anterior position (facing toward the mother's spine—that is facing down when the mother lies on her back).

When a fetus faces up, the neck is often straightened rather than bent,which requires more room for the head to pass through the birth canal. Delivery assisted by a vacuum device or forceps or cesarean delivery may be necessary.

Breech presentation

In breech presentation, the baby's buttocks or sometimes the feet are positioned to deliver first (before the head).

When delivered vaginally, babies that present buttocks first are more at risk of injury or even death than those that present head first.

The reason for the risks to babies in breech presentation is that the baby's hips and buttocks are not as wide as the head. Therefore, when the hips and buttocks pass through the cervix first, the passageway may not be wide enough for the head to pass through. In addition, when the head follows the buttocks, the neck may be bent slightly backwards. The neck being bent backward increases the width required for delivery as compared to when the head is angled forward with the chin tucked, which is the position that is easiest for delivery. Thus, the baby’s body may be delivered and then the head may get caught and not be able to pass through the birth canal. When the baby’s head is caught, this puts pressure on the umbilical cord in the birth canal, so that very little oxygen can reach the baby. Brain damage due to lack of oxygen is more common among breech babies than among those presenting head first.

In a first delivery, these problems may occur more frequently because a woman’s tissues have not been stretched by previous deliveries. Because of risk of injury or even death to the baby, cesarean delivery is preferred when the fetus is in breech presentation, unless the doctor is very experienced with and skilled at delivering breech babies or there is not an adequate facility or equipment to safely perform a cesarean delivery.

Breech presentation is more likely to occur in the following circumstances:

Labor starts too soon (preterm labor).

The uterus is abnormally shaped or contains abnormal growths such as fibroids .

Other presentations

In face presentation, the baby's neck arches back so that the face presents first rather than the top of the head.

In brow presentation, the neck is moderately arched so that the brow presents first.

Usually, fetuses do not stay in a face or brow presentation. These presentations often change to a vertex (top of the head) presentation before or during labor. If they do not, a cesarean delivery is usually recommended.

In transverse lie, the fetus lies horizontally across the birth canal and presents shoulder first. A cesarean delivery is done, unless the fetus is the second in a set of twins. In such a case, the fetus may be turned to be delivered through the vagina.

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pregnancy health center / pregnancy a-z list / can you deliver a breech baby? article

Can You Deliver a Breech Baby?

• Medical Author: Rohini Radhakrishnan, ENT, Head and Neck Surgeon
• Medical Author: Pallavi Suyog Uttekar, MD

How is a breech baby delivered?

Why does breech presentation occur.

• Comments **COMMENTSTAGLIST**
• More **OTHERTAGLIST**

Breech presentation is when the fetus (unborn child) is placed inside the womb with the buttocks or feet closest to the cervix (mouth of the uterus), which is unlike the usual when the head is closest to the cervix. A breech presentation occurs in 3-4% of all deliveries.

There are three types of breech presentations:

• Frank breech (50-70%): The hips are flexed and knees are extended (pike position)
• Complete breech (5-10%): The hips and knees are flexed (cannonball position)
• Footling or incomplete (10-30%): One or both hips are extended with the foot presenting

A breech baby can be delivered in two ways:

• Vaginal breech delivery 
• Cesarean delivery

There is an increased risk of perinatal mortality with breech presentation, irrespective of the mode of delivery. Death of the fetus is often associated with fetal malformations, prematurity, and intrauterine death (death of the fetus in the uterus).

A breech baby can be delivered vaginally or through a cesarean delivery.

Vaginal breech delivery:

There are three types of vaginal breech deliveries; the choice of which depends on the side of the baby, the gestational age, and the breech presentation of the baby:

• Spontaneous breech delivery: The baby is delivered spontaneously, without any traction or manipulation of the baby. This is commonly performed for very preterm babies due to their smaller size.
• Assisted vaginal breech delivery: This is the most common type of vaginal breech delivery. The baby delivers spontaneously up to the umbilicus, after which the doctor maneuvers and manipulates the baby to aid in the delivery of the rest of the baby’s body, arms, and head.
• Total breech extraction: The doctor grasps the baby’s feet, and the entire baby is extracted. Total breech extraction is usually only done to deliver the second twin in breech position in twin pregnancy . In the case of a single baby, total breech extraction is avoided because the cervix may not be adequately dilated for the fetal head to pass through.

Complications of vaginal breech delivery:

• The fetal head may get trapped due to an incompletely stretched uterine mouth, causing the head to get stuck at the cervix. A cervical cut may be required to relieve cervical entrapment.
• Nuchal arms (one or both arms are wrapped behind the neck)
• Trauma to the baby during delivery
• Cervical spine injury
• Umbilical cord prolapses (umbilical cord drops into the vagina through the cervix), causing umbilical cord compression resulting in decreased fetal heart rate.
• Infection in the mother
• Blood clots in the blood vessels of the mother
• Excessive bleeding from the uterus

Cesarean delivery for breech delivery:

Cesarean delivery is done when performing vaginal delivery would result in a high risk of complications to the baby or mother. If a low transverse (horizontal) uterine incision is made, the doctor would have to extract the baby quickly to deliver the head before the uterus starts contracting. In case of difficulty during delivery, the transverse incision may be extended vertically upwards (T incision). The horizontal transverse incision may also extend on either side and upwards. A medication called Nitroglycerin may be administered to relax the uterine muscles to facilitate delivery. The maneuvers and manipulation of the baby done by the doctor during Cesarean delivery are similar to that of a vaginal delivery.

Complications of Cesarean delivery:

• Fetal head entrapment
• Injury to the surrounding organs like the bowel or bladder, pelvic muscles, nerves, blood vessels, including major blood vessels like a uterine artery, and other tissues 

Certain factors increase the risk of breech presentation:

Preterm delivery: Preterm babies have a higher risk for breech delivery because they are smaller and haven’t engaged (entered the pelvic brim or inlet) yet. The risk of breech presentation decreases with the increase in gestational age.

Uterine fibroids result in decreased space in the uterus for the baby

Anatomical malformations of the uterus

Polyhydramnios (increased amniotic fluid in the uterus), causing the baby to float within the uterus

Fetal abnormalities, such as neck masses

Multiple gestations (twins or triplets and more)

Placenta previa (low lying placenta, covering the cervix)

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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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• Labor & Delivery

What Causes Breech Presentation?

Learn more about the types, causes, and risks of breech presentation, along with how breech babies are typically delivered.

What Is Breech Presentation?

Types of breech presentation, what causes a breech baby, can you turn a breech baby, how are breech babies delivered.

FatCamera/Getty Images

Toward the end of pregnancy, your baby will start to get into position for delivery, with their head pointed down toward the vagina. This is otherwise known as vertex presentation. However, some babies turn inside the womb so that their feet or buttocks are poised to be delivered first, which is commonly referred to as breech presentation, or a breech baby.

As you near the end of your pregnancy journey, an OB-GYN or health care provider will check your baby's positioning. You might find yourself wondering: What causes breech presentation? Are there risks involved? And how are breech babies delivered? We turned to experts and research to answer some of the most common questions surrounding breech presentation, along with what causes this positioning in the first place.

During your pregnancy, your baby constantly moves around the uterus. Indeed, most babies do somersaults up until the 36th week of pregnancy , when they pick their final position in the womb, says Laura Riley , MD, an OB-GYN in New York City. Approximately 3-4% of babies end up “upside-down” in breech presentation, with their feet or buttocks near the cervix.

Breech presentation is typically diagnosed during a visit to an OB-GYN, midwife, or health care provider. Your physician can feel the position of your baby's head through your abdominal wall—or they can conduct a vaginal exam if your cervix is open. A suspected breech presentation should ultimately be confirmed via an ultrasound, after which you and your provider would have a discussion about delivery options, potential issues, and risks.

There are three types of breech babies: frank, footling, and complete. Learn about the differences between these breech presentations.

Frank Breech

With frank breech presentation, your baby’s bottom faces the cervix and their legs are straight up. This is the most common type of breech presentation.

Footling Breech

Like its name suggests, a footling breech is when one (single footling) or both (double footling) of the baby's feet are in the birth canal, where they’re positioned to be delivered first .

Complete Breech

In a complete breech presentation, baby’s bottom faces the cervix. Their legs are bent at the knees, and their feet are near their bottom. A complete breech is the least common type of breech presentation.

Other Types of Mal Presentations

The baby can also be in a transverse position, meaning that they're sideways in the uterus. Another type is called oblique presentation, which means they're pointing toward one of the pregnant person’s hips.

Typically, your baby's positioning is determined by the fetus itself and the shape of your uterus. Because you can't can’t control either of these factors, breech presentation typically isn’t considered preventable. And while the cause often isn't known, there are certain risk factors that may increase your risk of a breech baby, including the following:

• The fetus may have abnormalities involving the muscular or central nervous system
• The uterus may have abnormal growths or fibroids
• There might be insufficient amniotic fluid in the uterus (too much or too little)
• This isn’t your first pregnancy
• You have a history of premature delivery
• You have placenta previa (the placenta partially or fully covers the cervix)
• You’re pregnant with multiples
• You’ve had a previous breech baby

In some cases, your health care provider may attempt to help turn a baby in breech presentation through a procedure known as external cephalic version (ECV). This is when a health care professional applies gentle pressure on your lower abdomen to try and coax your baby into a head-down position. During the entire procedure, the fetus's health will be monitored, and an ECV is often performed near a delivery room, in the event of any potential issues or complications.

However, it's important to note that ECVs aren't for everyone. If you're carrying multiples, there's health concerns about you or the baby, or you've experienced certain complications with your placenta or based on placental location, a health care provider will not attempt an ECV.

The majority of breech babies are born through C-sections . These are usually scheduled between 38 and 39 weeks of pregnancy, before labor can begin naturally. However, with a health care provider experienced in delivering breech babies vaginally, a natural delivery might be a safe option for some people. In fact, a 2017 study showed similar complication and success rates with vaginal and C-section deliveries of breech babies.

That said, there are certain known risks and complications that can arise with an attempt to deliver a breech baby vaginally, many of which relate to problems with the umbilical cord. If you and your medical team decide on a vaginal delivery, your baby will be monitored closely for any potential signs of distress.

Ultimately, it's important to know that most breech babies are born healthy. Your provider will consider your specific medical condition and the position of your baby to determine which type of delivery will be the safest option for a healthy and successful birth.

ACOG. If Your Baby Is Breech .

American Pregnancy Association. Breech Presentation .

Gray CJ, Shanahan MM. Breech Presentation . [Updated 2022 Nov 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.

Mount Sinai. Breech Babies .

Takeda J, Ishikawa G, Takeda S. Clinical Tips of Cesarean Section in Case of Breech, Transverse Presentation, and Incarcerated Uterus . Surg J (N Y). 2020 Mar 18;6(Suppl 2):S81-S91. doi: 10.1055/s-0040-1702985. PMID: 32760790; PMCID: PMC7396468.

Shanahan MM, Gray CJ. External Cephalic Version . [Updated 2022 Nov 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. 

Fonseca A, Silva R, Rato I, Neves AR, Peixoto C, Ferraz Z, Ramalho I, Carocha A, Félix N, Valdoleiros S, Galvão A, Gonçalves D, Curado J, Palma MJ, Antunes IL, Clode N, Graça LM. Breech Presentation: Vaginal Versus Cesarean Delivery, Which Intervention Leads to the Best Outcomes? Acta Med Port. 2017 Jun 30;30(6):479-484. doi: 10.20344/amp.7920. Epub 2017 Jun 30. PMID: 28898615.

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Mode of Term Singleton Breech Delivery

• Committee Opinion CO
• Number 745
• August 2018

Recommendations

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Number 745 (Replaces Committee Opinion Number 340, July 2006. Reaffirmed 2023)

Committee on Obstetric Practice

This Committee Opinion was developed by the American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice.

INTERIM UPDATE: This Committee Opinion is updated as highlighted to reflect a limited, focused change in the evidence regarding external cephalic version for breech presentation at term. Additional updates have been made to reflect current practice regarding vaginal breech delivery.

ABSTRACT: There is a trend in the United States to perform cesarean delivery for term singleton fetuses in a breech presentation. The number of practitioners with the skills and experience to perform vaginal breech delivery has decreased. The decision regarding the mode of delivery should consider patient wishes and the experience of the health care provider. Obstetrician–gynecologists and other obstetric care providers should offer external cephalic version as an alternative to planned cesarean for a woman who has a term singleton breech fetus, desires a planned vaginal delivery of a vertex-presenting fetus, and has no contraindications. External cephalic version should be attempted only in settings in which cesarean delivery services are readily available. Planned vaginal delivery of a term singleton breech fetus may be reasonable under hospital-specific protocol guidelines for eligibility and labor management. If a vaginal breech delivery is planned, a detailed informed consent should be documented—including risks that perinatal or neonatal mortality or short-term serious neonatal morbidity may be higher than if a cesarean delivery is planned.

The decision regarding the mode of delivery should consider patient wishes and the experience of the health care provider.

Obstetrician–gynecologists and other obstetric care providers should offer external cephalic version as an alternative to planned cesarean for a woman who has a term singleton breech fetus, desires a planned vaginal delivery of a vertex-presenting fetus, and has no contraindications. External cephalic version should be attempted only in settings in which cesarean delivery services are readily available.

Planned vaginal delivery of a term singleton breech fetus may be reasonable under hospital-specific protocol guidelines for eligibility and labor management.

If a vaginal breech delivery is planned, a detailed informed consent should be documented—including risks that perinatal or neonatal mortality or short-term serious neonatal morbidity may be higher than if a cesarean delivery is planned.

There is a trend in the United States to perform cesarean delivery for term singleton fetuses in a breech presentation. In 2002, the rate of cesarean deliveries for women in labor with breech presentation was 86.9% 1 . The number of practitioners with the skills and experience to perform vaginal breech delivery has decreased. Even in academic medical centers where faculty support for teaching vaginal breech delivery to residents remains high, there may be insufficient volume of vaginal breech deliveries to adequately teach this procedure 2 .

In 2000, researchers conducted a large, international multicenter randomized clinical trial comparing a policy of planned cesarean delivery with planned vaginal delivery (Term Breech Trial) 3 . These investigators noted that perinatal mortality, neonatal mortality, and serious neonatal morbidity were significantly lower among the planned cesarean delivery group compared with the planned vaginal delivery group (17/1,039 [1.6%] versus 52/1,039 [5%]), although there was no difference in maternal morbidity or mortality observed between the groups 3 . The benefits of planned cesarean delivery remained for all subgroups identified by the baseline variables (eg, older and younger women, nulliparous and multiparous women, frank and complete type of breech presentation). They found that the reduction in risk attributable to planned cesarean delivery was greatest among centers in industrialized nations with low overall perinatal mortality rates (0.4% versus 5.7%). In countries with low perinatal mortality rates, the reduction in risk was driven primarily by the pooled rates of perinatal or neonatal mortality and serious neonatal morbidity, rather than by the rates of mortality alone (0% versus 0.6%). Given the results of this exceptionally large and well-controlled clinical trial, the American College of Obstetricians and Gynecologists' Committee on Obstetric Practice in 2001 recommended that planned vaginal delivery of a term singleton breech was no longer appropriate.

Since that time, there have been additional publications that modify the original conclusions of the 2000 Term Breech Trial. The same researchers have published three follow-up studies examining maternal outcomes at 3 months postpartum, as well as outcomes for mothers and children 2 years after the births 4 5 6 . At 3 months postpartum, the risk of urinary incontinence was lower for women in the planned cesarean delivery group; however, there was no difference at 2 years. At 2 years postpartum, the majority of women (79.1%) did not report a difference for most maternal parameters, including breastfeeding, pain, depression, menstrual problems, fatigue, and distressing memories of the birth experience 5 .

The follow-up study to address outcomes of the children at 2 years involved 85 centers (with both high and low perinatal mortality rates) that were chosen at the start of the original trial. Most children, 923 of 1,159 (79.6%) of the infants born in the original study, were assessed first by a screening questionnaire (Ages and Stages) that was completed by their parents 4 . All abnormal results were further evaluated with a clinical neurodevelopment assessment. The risk of death or neurodevelopmental delay was no different in the planned cesarean delivery group compared with the planned vaginal delivery group (14 children [3.1%] versus 13 children [2.8%]; relative risk, 1.09; 95% CI, 0.52–2.30; P =0.85). There are several explanations for this seemingly contradictory finding. The follow-up study was underpowered to show a clinically important benefit from cesarean delivery if this were true. Only 6 of the 16 infants who died in the neonatal period were from centers participating in the follow-up to 2 years (one in the planned cesarean delivery group, five in the planned vaginal delivery group), and most of the children with serious neonatal morbidity after birth survived and developed normally. In this cohort, 17 out of 18 children with serious morbidity in the original study were normal at this 24-month follow-up. Another explanation is that the use of pooled mortality and morbidity data at the time of birth overstated the true long-term risks of vaginal delivery 7 .

A recent retrospective observational report reviewed neonatal outcomes in the Netherlands before and after the publication of the Term Breech Trial 8 . Between 1998 and 2002, 35,453 term infants were delivered. The cesarean delivery rate for breech presentation increased from 50% to 80% within 2 months of the trial's publication and remained elevated. The combined neonatal mortality rate decreased from 0.35% to 0.18%, and the incidence of reported birth trauma decreased from 0.29% to 0.08%. Of interest, a decrease in mortality also was seen in the emergency cesarean delivery group and the vaginal delivery group, a finding that the authors attribute to better selection of candidates for vaginal breech delivery.

Obstetrician–gynecologists and other obstetric care providers should offer external cephalic version as an alternative to planned cesarean for a woman who has a term singleton breech fetus, desires a planned vaginal delivery of a vertex-presenting fetus, and has no contraindications 9 . A meta-analysis of eight randomized controlled trials demonstrated that performing external cephalic version led to a statistically and clinically significant reduction in cesarean delivery of 43% (95% CI, 40–82%) with no significant differences in maternal or fetal complications 10 . The studies included in this meta-analysis did not employ analgesia for the external cephalic version. A systematic review and meta-analysis of six randomized controlled trials found that using epidural or spinal anesthesia significantly increased the success rate of external cephalic version from 37.6% to 59.7% (odds ratio, 1.58; 95% CI, 1.29–1.93), number needed to treat=5. The frequency of adverse events was not significantly different between groups receiving and not receiving regional anesthesia for external cephalic version 11 . External cephalic version should be attempted only in settings in which cesarean delivery services are readily available 9 .

Planned vaginal delivery of a term singleton breech fetus may be reasonable under hospital-specific protocol guidelines for both eligibility and labor management. There are many retrospective reports of vaginal breech delivery that follow very specific protocols and note excellent neonatal outcomes. One report noted 298 women in a vaginal breech trial with no perinatal morbidity and mortality 12 . Another report noted similar outcomes in 481 women with planned vaginal delivery 13 . Although they are not randomized trials, these reports detail the outcomes of specific management protocols and document the potential safety of a vaginal delivery in the properly selected patient. The initial criteria used in these reports were similar: gestational age greater than 37 weeks, frank or complete breech presentation, no fetal anomalies on ultrasound examination, adequate maternal pelvis, and estimated fetal weight between 2,500 g and 4,000 g. In addition, the protocol presented by one report required documentation of fetal head flexion and adequate amniotic fluid volume, defined as a 3-cm vertical pocket 12 . Oxytocin induction or augmentation was not offered, and strict criteria were established for normal labor progress. If a vaginal breech delivery is planned, a detailed informed consent should be documented—including risks that perinatal or neonatal mortality or short-term serious neonatal morbidity may be higher than if a cesarean delivery is planned.

Current evidence demonstrates short-term benefits in neonatal and maternal morbidity and mortality from planned cesarean delivery of the term fetus with a breech presentation. Long-term benefits of planned cesarean delivery for these infants and women are less clear 14 15 . Offering external cephalic version provides an opportunity to potentially reduce cesarean delivery for these pregnancies 10 16 . Finally, a planned vaginal delivery of a term singleton breech fetus may be reasonable under hospital-specific guidelines 12 13 . The decision regarding the mode of delivery should consider patient wishes and the experience of the health care provider.

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

Obstetricians should offer and perform external cephalic version whenever possible.

Planned vaginal delivery of a term singleton breech fetus may be reasonable under hospital-specific protocol guidelines for both eligibility and labor management.

In those instances in which breech vaginal deliveries are pursued, great caution should be exercised, and detailed patient informed consent should be documented.

Before embarking on a plan for a vaginal breech delivery, women should be informed that the risk of perinatal or neonatal mortality or short-term serious neonatal morbidity may be higher than if a cesarean delivery is planned.

There are no recent data to support the recommendation of cesarean delivery to patients whose second twin is in a nonvertex presentation, although a large multicenter randomized controlled trial is in progress (http://www.utoronto.ca/ miru/tbs).

• Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Menacker F, Munson ML. Births: final data for 2002. Natl Vital Stat Rep 2003; 52( 10): 1– 113. Article Locations: Article Location
• Lavin JPJr, Eaton J, Hopkins M. Teaching vaginal breech delivery and external cephalic version. A survey of faculty attitudes. J Reprod Med 2000; 45: 808– 12. Article Locations: Article Location
• 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; 356: 1375– 83. Article Locations: Article Location Article Location
• 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. Term Breech Trial Collaborative Group. Am J Obstet Gynecol 2004; 191: 864– 71. Article Locations: Article Location Article Location
• Hannah ME, Whyte H, Hannah WJ, Hewson S, Amankwah K, Cheng M, et al. Maternal outcomes at 2 years after planned cesarean section versus planned vaginal birth for breech presentation at term: the international randomized Term Breech Trial. Term Breech Trial Collaborative Group. Am J Obstet Gynecol 2004; 191: 917– 27. Article Locations: Article Location Article Location
• Su M, Hannah WJ, Willan A, Ross S, Hannah ME. Planned caesarean section decreases the risk of adverse perinatal outcome due to both labour and delivery complications in the Term Breech Trial. Term Breech Trial Collaborative Group. BJOG 2004; 111: 1065– 74. Article Locations: Article Location
• Kotaska A. Inappropriate use of randomised trials to evaluate complex phenomena: case study of vaginal breech delivery [published erratum appears in BMJ 2004;329:1385]. BMJ 2004; 329: 1039– 42. Article Locations: Article Location
• Rietberg CC, Elferink-Stinkens PM, Visser GH. The effect of the Term Breech Trial on medical intervention behaviour and neonatal outcome in The Netherlands: an analysis of 35,453 term breech infants. BJOG 2005; 112: 205– 9. Article Locations: Article Location
• External cephalic version. Practice Bulletin No. 161. American College of Obstetricians and Gynecologists. Obstet Gynecol 2016; 127: e54– 61. Article Locations: Article Location Article Location
• Hofmeyr GJ, Kulier R, West HM. External cephalic version for breech presentation at term. Cochrane Database of Systematic Reviews 2015, Issue 4. Art. No.: CD000083. DOI: 10.1002/14651858.CD000083.pub3. Article Locations: Article Location Article Location
• Goetzinger KR, Harper LM, Tuuli MG, Macones GA, Colditz GA. Effect of regional anesthesia on the success rate of external cephalic version: a systematic review and meta-analysis. Obstet Gynecol 2011; 118: 1137– 44. Article Locations: Article Location
• Alarab M, Regan C, O'Connell MP, Keane DP, O'Herlihy C, Foley ME. Singleton vaginal breech delivery at term: still a safe option. Obstet Gynecol 2004; 103: 407– 12. Article Locations: Article Location Article Location Article Location
• Guiliani A, Scholl WM, Basver A, Tamussino KF. Mode of delivery and outcome of 699 term singleton breech deliveries at a single center. Am J Obstet Gynecol 2002; 187: 1694– 8. Article Locations: Article Location Article Location
• Berhan Y, Haileamlak A. The risks of planned vaginal breech delivery versus planned caesarean section for term breech birth: a meta-analysis including observational studies. BJOG 2016; 123: 49– 57. Article Locations: Article Location
• Hofmeyr GJ, Hannah M, Lawrie TA. Planned caesarean section for term breech delivery. Cochrane Database of Systematic Reviews 2015, Issue 7. Art. No.: CD000166. DOI: 10.1002/14651858.CD000166.pub2. Article Locations: Article Location
• Magro-Malosso ER, Saccone G, Di Tommaso M, Mele M, Berghella V. Neuraxial analgesia to increase the success rate of external cephalic version: a systematic review and meta-analysis of randomized controlled trials [published erratum appears Am J Obstet Gynecol. 2017;216:315]. Am J Obstet Gynecol 2016; 215: 276– 86. Article Locations: Article Location

Published online on July 25, 2018.

Copyright 2018 by the American College of Obstetricians and Gynecologists. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, posted on the Internet, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher.

Requests for authorization to make photocopies should be directed to Copyright Clearance Center, 222 Rosewood Drive, Danvers, MA 01923, (978) 750-8400.

American College of Obstetricians and Gynecologists 409 12th Street, SW, PO Box 96920, Washington, DC 20090-6920

Mode of term singleton breech delivery. ACOG Committee Opinion No. 745. American College of Obstetricians and Gynecologists. Obstet Gynecol 2018;132:e60–3.

This information is designed as an educational resource to aid clinicians in providing obstetric and gynecologic care, and use of this information is voluntary. This information should not be considered as inclusive of all proper treatments or methods of care or as a statement of the standard of care. It is not intended to substitute for the independent professional judgment of the treating clinician. Variations in practice may be warranted when, in the reasonable judgment of the treating clinician, such course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or technology. The American College of Obstetricians and Gynecologists reviews its publications regularly; however, its publications may not reflect the most recent evidence. Any updates to this document can be found on www.acog.org or by calling the ACOG Resource Center.

While ACOG makes every effort to present accurate and reliable information, this publication is provided “as is” without any warranty of accuracy, reliability, or otherwise, either express or implied. ACOG does not guarantee, warrant, or endorse the products or services of any firm, organization, or person. Neither ACOG nor its officers, directors, members, employees, or agents will be liable for any loss, damage, or claim with respect to any liabilities, including direct, special, indirect, or consequential damages, incurred in connection with this publication or reliance on the information presented.

All ACOG committee members and authors have submitted a conflict of interest disclosure statement related to this published product. Any potential conflicts have been considered and managed in accordance with ACOG's Conflict of Interest Disclosure Policy. The ACOG policies can be found on acog.org . For products jointly developed with other organizations, conflict of interest disclosures by representatives of the other organizations are addressed by those organizations. The American College of Obstetricians and Gynecologists has neither solicited nor accepted any commercial involvement in the development of the content of this published product.

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Breech Position: What It Means if Your Baby Is Breech

Medically reviewed for accuracy.

What does it mean if a baby is breech?

What are the different types of breech positions, what causes a baby to be breech, recommended reading, how can you tell if your baby is in a breech position, what does it mean to turn a breech baby, how can you turn a breech baby, how does labor usually start with a breech baby.

If your cervix dilates too slowly, if your baby doesn’t move down the birth canal steadily or if other problems arise, you’ll likely have a C-section. Talk your options over with your practitioner now to be prepared. Remember that though you may feel disappointed things didn’t turn out exactly as you envisioned, these feelings will melt away once your bundle of joy safely enters the world.

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• Breech delivery
• 1 Background
• 2 Clinical Features
• 3.1 Emergent delivery and related complications
• 4 Evaluation
• 5 Management
• 6 Disposition
• 8 External Links
• 9 References

• 3-4% of term deliveries. [1] (Most common fetal malpresentation [2] )
• In breech delivery, body does not first maximally dilate cervix → higher risk of head entrapment, cord prolapse, and death.
• Breech presentations occur most commonly in preterm infants (25-30% of preterm deliveries <28 wks gestation).

Clinical Features

• Frank - Buttocks deliver first, hips flexed, knees extended (most common type)
• Complete - Buttocks deliver first, hips and knees flexed
• Incomplete - (aka "footling") One or both feet deliver first

Differential Diagnosis

Emergent delivery and related complications.

• Emergent delivery
• Umbilical cord prolapse
• Shoulder dystocia
• Perimortem cesarean delivery
• In ED precipitous delivery, this is a clinical diagnosis.
• If time allows, ultrasound can reveal position of fetus, but often not possible in ED deliveries.
• Zavanelli maneuver - pushing presenting fetal part back into vagina until C-Section can be performed [3] , though is associated with increased risk of soft tissue damage and sepsis [4]
• Place patient in lithotomy position
• Have assistant maintain fundal pressure throughout delivery
• Grab legs together with one hand if feet deliver spontaneously
• Head will need to be delivered with baby's face looking to mother's posterior
• If not sacral anterior, make it that way along delivery
• Place hand behind and parallel to fetal leg, then sweep laterally (away from midline) to deliver leg
• Repeat for opposite leg
• If around the neck, try to reduce it by pushing it over baby's head or just deliver baby through quickly
• If between the legs, this must be reduced around the foot as it will definitely avulse if delivery continues
• Allow delivery to proceed spontaneously until fetal umbilicus is at perineum
• Once torso begins to deliver, hold legs in one hand and hold bony pelvis with other (do not rupture spleen)
• Allow delivery to progress until axilla is visible
• If posterior arm and hand do not deliver spontaneously, grasp humerus and sweep downwards while still applying upward traction on fetal body.
• If anterior arm and hand do not deliver spontaneously, grasp humerus and sweet downwards over thorax while maintaining downward traction on fetal body.
• To deliver head, have assistant apply suprapubic pressure and rest fetal body on provider's forearm while reaching into vaginal canal to grasp fetal maxillae in order to flex head. (Mauriceau maneuver) - stabilize with other hand/forearm on fetal back and shoulders - avoid excessive angulation or traction of fetal body.
• Nitroglycerin (50 to 200 mcg IV) is an alternative.

Disposition

• Admit to L&D

External Links

• YouTube: Assisted Breech Delivery
• ↑ 1.0 1.1 1.2 Silver DW, Sabatino F. Precipitous and difficult deliveries. Emerg Med Clin North Am. 2012 Nov;30(4):961-75. doi: 10.1016/j.emc.2012.08.004.
• ↑ 2.0 2.1 Mercado J, Brea I, Mendez B, et al. Critical obstetric and gynecologic procedures in the emergency department. Emerg Med Clin North Am. 2013 Feb;31(1):207-36.
• ↑ Timothy F Kirn. To Handle Breech Births, Know Two Maneuvers. ACEP News May 2008. ACEP News Accessed 08/03/15.
• ↑ Gabbe, Steven G. Obstetrics : normal and problem pregnancies (6th ed.). Philadelphia: Elsevier/Saunders. p. 412
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pregnancy center

Is Breech Delivery Safe?

What are symptoms of breech delivery, what causes breech delivery, how is breech delivery diagnosed, what is the treatment for breech delivery.

In the last weeks of pregnancy , a fetus normally moves so the head is positioned to come out of the vagina first during birth. If a fetus presents ‘bottom down,’ so the buttocks, feet , or both are in place to come out first during birth, this is called a breech presentation. About 3 to 4 percent of full-term births are breech.

What Are the Breech Positions?

There are three main types of breech presentation:

• Both legs are flexed at the hip and extended at the knee
• The most common breech presentation
• Both legs are flexed at the hips and knees (fetus appears to be sitting cross-legged)
• One or both legs extended at the hip, so that the foot is the presenting part

Can You Deliver Vaginally for a Breech Presentation?

In general, attempting a vaginal delivery for a breech presentation is avoided due to risks to the baby. Usually, the doctor will attempt to turn the fetus into the head down position to prepare for a vaginal birth, or a Caesarean ( C-section ) will be recommended. Situations in which a breech delivery may be considered include: 

• A breech labor progresses too quickly, in which a vaginal birth may be the only option
• During a twin birth in which the first twin is head-down and the second twin is breech, both babies may be delivered vaginally

What Are the Risks for Breech Delivery?

Risks to the baby if delivered breech include: 

• The baby’s body may not stretch the cervix enough to allow room for the baby’s head to come out easily, and the baby’s head or shoulders may become wedged against the bones of the mother’s pelvis
• Prolapsed umbilical cord, in which the umbilical cord drops down below the presenting part of the baby, and becomes compressed, which can decrease the flow of blood and oxygen through the cord to the baby
• Premature rupture of membranes
• Suffocation, due to a delay in delivery
• Brain hemorrhage due to rapid compression of the head during delivery

Symptoms of carrying a fetus in breech presentation may include: 

• Discomfort just below the ribs 
• Feeling of kicking in the lower abdomen 

It is not always known what causes a breech presentation. Factors that may contribute to a breech presentation include:

• Previous pregnancy
• Pregnancy with multiples (twins or more)
• Too much or too little amniotic fluid
• Abnormal shape to the uterus 
• Abnormal growths such as fibroids in the uterus
• Placenta covers all or part of the opening of the uterus ( placenta previa )
• Preterm fetus
• The fetus has certain birth defects

A doctor may be able to diagnose the fetus is in a breech presentation by palpating certain points on the abdomen to feel where the fetus's head, back, and buttocks are. 

A transabdominal/ transvaginal ultrasound exam or pelvic exam may be used to confirm the diagnosis.

In general, attempting a vaginal delivery for a breech presentation is avoided due to risks to the baby. 

Usually, the doctor will try to turn the fetus so that he or she is head down in what is called the external cephalic version (ECV). 

Most of the time, fetuses that are breech are born by planned Cesarean delivery (C-section). There are risks to both vaginal delivery and Cesarean birth when a fetus is in breech presentation but the risk of complications is higher with a planned vaginal breech delivery than with a planned cesarean delivery.