breech presentation delivery maneuver

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INTRODUCTION

For patients who present in labor with a breech fetus, cesarean birth is the preferred approach in many hospitals in the United States and elsewhere. Cesarean is performed for over 90 percent of breech presentations, and this rate has increased worldwide [ 1,2 ]. However, even in institutions with a policy of routine cesarean birth for breech presentation, vaginal breech births occur because of situations such as patient preference, precipitous birth, out-of-hospital birth, and lethal fetal anomaly or fetal death. Therefore, it is essential for clinicians to maintain familiarity with the techniques required to assist in a vaginal breech birth.

In addition, some clinicians and patients consider vaginal breech birth preferable to cesarean birth. Recent trends, particularly in central Europe, support vaginal breech birth [ 3-5 ]. In selected cases, as described below and depicted in the algorithm ( algorithm 1 ), it is associated with a low risk of complications. The American College of Obstetricians and Gynecologists has opined that "Planned vaginal delivery of a term singleton breech fetus may be reasonable under hospital-specific protocol guidelines for eligibility and labor management" [ 6 ].

This topic will focus on vaginal birth of breech singletons, with a brief discussion of breech delivery at cesarean. Choosing the best route of birth for the fetus in breech presentation and delivery of the breech first or second twin are reviewed separately.

● (See "Overview of breech presentation", section on 'Approach to management at or near term' .)

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.

First, recognize breech presentation when the buttocks appear in the birth canal before the head does. Experienced providers can deliver some babies in frank or complete breech presentations. Have a cloth or surgical towel available as well as other instruments used for routine deliveries and prepare for what to do if vaginal delivery is unsuccessful.

This position is a frank breech.

This position is a complete breech.

And this position is an incomplete complete breech.

Allow delivery to the level of the umbilicus with maternal effort. If possible, do this without touching the infant. Anticipate umbilical cord compression and possibly fetal decelerations.

To deliver a leg, splint the medial thigh parallel to the femur and sweep the thigh laterally. Repeat this procedure to deliver the other leg.

Wrap a towel around the infant, putting your fingers on the anterior superior iliac spines and your thumbs on the sacrum.

Assist the mother’s efforts during contractions by applying gentle traction to help deliver the body to the level of the scapulas.

Rotate the body in either direction to make one shoulder anterior. Deliver the anterior arm by sweeping it across the chest. Rotate the infant 180 degrees in either direction. Deliver the arm that is now anterior the same way the other arm was delivered. Move the towel up to cover the arms and rotate the body to make the back anterior.

To deliver the head, place your index and middle fingers of one hand over the fetal maxilla to flex the head, while the body rests on your palm and forearm, as shown here. With your other hand, hook 2 fingers over the neck, grasp the shoulder, and apply gentle downward traction. Have an assistant apply suprapubic pressure to help maintain head flexion and deliver the head.

Procedure by Will Stone, MD, and Kate Leonard, MD, Walter Reed National Military Medical Center Residency in Obstetrics and Gynecology; and Shad Deering, COL, MD, Chair, Department of Obstetrics and Gynecology, Uniformed Services University. Assisted by Elizabeth N. Weissbrod, MA, CMI, Eric Wilson, 2LT, and Jamie Bradshaw at the Val G. Hemming Simulation Center at the Uniformed Services University.

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

Management of Breech Presentation (Green-top Guideline No. 20b)

Summary: The aim of this guideline is to aid decision making regarding the route of delivery and choice of various techniques used during delivery. It does not include antenatal or postnatal care. Information regarding external cephalic version is the topic of the separate Royal College of Obstetricians and Gynaecologists Green-top Guideline No. 20a,  External Cephalic Version and Reducing the Incidence of Term Breech Presentation .

Breech presentation occurs in 3–4% of term deliveries and is more common in preterm deliveries and nulliparous women. Breech presentation is associated with uterine and congenital abnormalities, and has a significant recurrence risk. Term babies presenting by the breech have worse outcomes than cephalic presenting babies, irrespective of the mode of delivery.

A large reduction in the incidence of planned vaginal breech birth followed publication of the Term Breech Trial. Nevertheless, due to various circumstances vaginal breech births will continue. Lack of experience has led to a loss of skills essential for these deliveries. Conversely, caesarean section can has serious long-term consequences.

COVID disclaimer: This guideline was developed as part of the regular updates to programme of Green-top Guidelines, as outlined in our document  Developing a Green-top Guideline: Guidance for developers , and prior to the emergence of COVID-19.

Version history: This is the fourth edition of this guideline.

Please note that the RCOG Guidelines Committee regularly assesses the need to update the information provided in this publication. Further information on this review is available on request.

Developer declaration of interests:

Mr M Griffiths  is a member of Doctors for a Woman's right to Choose on Abortion. He is an unpaid member of a Quality Standards Advisory Committee at NICE, for which he does receive expenses for related travel, accommodation and meals.

Mr LWM Impey  is Director of Oxford Fetal Medicine Ltd. and a member of the International Society of Ultrasound in Obstetrics and Gynecology. He also holds patents related to ultrasound processing, which are of no relevance to the Breech guidelines.

Professor DJ Murphy  provides medicolegal expert opinions in Scotland and Ireland for which she is remunerated.

Dr LK Penna:  None declared.

• Access the PDF version of this guideline on Wiley
• Access the web version of this guideline on Wiley

This page was last reviewed 16 March 2017.

• 2022 New Pearls of Exxcellence Articles

Management of the Breech Presenting at the Introitus

Author: Joseph E. Peterson, MD

Mentor: Julie DeCesare, MD Editor: Daniel Martingano, DO, PhD, FACOG

Registered users can also download a PDF or listen to a podcast of this Pearl. Log in now , or create a free account to access bonus Pearls features.

Breech presentation occurs in 2-3% of pregnancies at term. Frank breech accounts for over 50% of breech presentations. Risk factors vary by gestational age, with at term include advanced maternal age, nulliparity, mullerian abnormalities. maternal hypothyroidism, pre-gestational diabetes, placenta previa, prelabor rupture of membranes, oligohydramnios, and fetal congenital anomalies

Intended cesarean delivery may reduce the risk of perinatal mortality/morbidity as well as maternal morbidity compared with intended vaginal delivery, thus most breech presentations are managed via cesarean delivery.  However, if the patient presents with fetal breech at the introitus, it is unlikely that a cesarean delivery can be accomplished without causing equal or greater complications than a breech vaginal delivery.

Maternal expulsive efforts alone should accomplish the delivery of the fetal umbilicus to the perineum without traction. The Pinard maneuver is performed to assist delivery of the legs by applying pressure in the popliteal space of the knee, which results in external rotation of the thigh and flexion of the knee. Afterward, the fetus should be supported in the prone position with a dry towel wrapped around the fetal pelvis. The clinician should only manipulate the fetal bony parts, such as the pelvic bones, as opposed to soft tissues.

Once both scapulae have passed through the introitus, the arms are delivered using the Lovset maneuver by splinting the humerus and sweeping the arm downward across the fetal thorax, which should be rotated. Hence, the shoulder of the arm being delivered is anterior. The fetus is then rotated 180 degrees to accomplish delivery of the other arm similarly.

Efforts should be made to ensure that flexion of the fetal head is maintained throughout. This may be accomplished using the Mauriceau-Smellie-Veit maneuver by supporting the fetus on the forearm with the middle and index fingers on the fetal maxillae and using the other hand to apply pressure to the fetal occiput. Other options include performing the modified Prague maneuver by holding the fetal body with one hand, elevating fetal lower limbs with the other hand and rotating the baby around the maternal symphysis pubis to achieve flexion of the fetal head and ultimately delivery.

Preparations for potential head entrapment should be made promptly and include alerting anesthesia personnel, Piper forceps, and required surgical instruments to perform Duhrssen’s incisions.

When using Piper forceps, the blades of the forceps should not be applied until the fetal head is in engaged in the pelvis. Because the forceps blades are directed upward from the level of the perineum, some clinicians use a one-knee kneeling position. Once in place, the blades are articulated, and the fetal body rests across the shanks. The head is delivered by pulling gently outward and raising the handle simultaneously.

The clinician should be familiar with the technique of performing Duhrssen’s incisions of the cervix in order to decrease the risk of injury to the cervical blood vessels. The incisions are performed at the 2 and 10 o’clock location, with occasionally needing a third incision at the 6 o’clock position.

Further reading:

Wängberg Nordborg J, Svanberg T, Strandell A, Carlsson Y. Term breech presentation-Intended cesarean section versus intended vaginal delivery-A systematic review and meta-analysis . Acta Obstet Gynecol Scand. 2022 Jun;101(6):564-576. doi: 10.1111/aogs.14333. PMID: 35633052; PMCID: PMC9564601.

Toijonen AE, Heinonen ST, Gissler MVM, Macharey G. A comparison of risk factors for breech presentation in preterm and term labor: a nationwide, population-based case-control study. Arch Gynecol Obstet. 2020 Feb;301(2):393-403. doi: 10.1007/s00404-019-05385-5. Epub 2019 Nov 18. PMID: 31741046; PMCID: PMC7033046.

Ayres-de-Campos D, Ayres-de-Campos D. Retention of the After-Coming Head. Obstetric Emergencies: A Practical Guide. 2017:41-50.

Cunningham F, Leveno KJ, Bloom SL, et. Al; Breech Delivery.   Williams Obstetrics, 25e New York, NY: McGraw-Hill; 2018.

Initial Approval May 2016; Reaffirmed September 2017; Revised March 2019. Reaffirmed September 2020, Reaffirmed March 2022, Revised January 2024.

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The Society for Academic Specialists in General Obstetrics and Gynecology, Inc. (“SASGOG”) is committed to accuracy and will review and validate all Pearls on an ongoing basis to reflect current practice.

This document is designed to aid practitioners in providing appropriate obstetric and gynecologic care. Recommendations are derived from major society guidelines and high-quality evidence when available, supplemented by the opinion of the author and editorial board when necessary. It should not be construed as dictating an exclusive course of treatment or procedure to be followed.

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Chapter 134. Breech Delivery

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• Introduction
• Anatomy and Pathophysiology
• Indications
• Contraindications
• Patient Preparation
• Assisted Vaginal Frank Breech Delivery
• Delivery of the Fetal Head
• Total Breech Extraction
• Complete and Incomplete Breech Deliveries
• Complications
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The breech presentation exists when the cephalic pole of the fetus is positioned in a longitudinal lie and the buttocks or feet of the fetus enter the maternal pelvis before the head. 1 Management of the breech presentation in labor is an area of much trepidation and controversy, even among seasoned clinicians. A breech delivery is considered a high-risk obstetric complication that is best handled by an Obstetrician.

There are, however, unavoidable situations when a pregnant woman will present to the Emergency Department in active labor with a fetus in the breech position. A vaginal breech delivery may be the best delivery option in situations such as advanced labor, the absence of surgical assistance, the presence of an acute situation, fetal distress, or umbilical cord prolapse. Knowledge and preparedness facilitate comfort and promote success in approaching any emergent procedure. The breech delivery is no exception to this rule.

The breech presentation may be associated with a variety of maternal and fetal conditions. 1 , 2 Maternal abnormalities that increase the risk of a breech presentation include a small pelvis and uterine anomalies. Fetal conditions associated with a breech presentation include low birth weight, prematurity, abnormal amniotic fluid volume, fetal malformations (e.g., hydrocephalus, cystic hygroma, and anencephaly), neurologic disorders, and genetic abnormalities.

Prematurity is a risk factor for a breech presentation. The incidence of breech presentations is inversely related to the fetal gestational age. 1 , 2 At 28 weeks of gestation, 24% of fetuses are in the breech presentation. The fetus usually turns spontaneously to a cephalic presentation so that at term, only 3% to 4% are in the breech presentation. 1 , 2

There are three main types of breech presentation ( Figure 134-1 ). The most common is the frank breech, accounting for 50% to 73% of breech presentations. The fetus is flexed at the hips and extended at the knees ( Figure 134-1 A ). The fetus is in the “pike” position. The complete breech is the least common type and accounts for approximately 5% to 11% of breech presentations. The fetus is flexed at both the hips and the knees ( Figure 134-1 B ). The footling or incomplete breech accounts for approximately 12% to 38% of breech presentations. The fetus is incompletely deflexed at one or both knees or hips ( Figure 134-1 C ). This results in one or both feet presenting before the buttocks. The risks of umbilical cord prolapse and prematurity associated with the breech presentation are listed in Table 134-1 .

Figure 134-1.

The main types of breech presentations. A. The frank breech. B. The complete breech. C. The incomplete breech.

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