breech presentation fhs

An official website of the United States government

The .gov means it's official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings
• Browse Titles

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

StatPearls [Internet].

Breech presentation.

Caron J. Gray ; Meaghan M. Shanahan .

Affiliations

Last Update: November 6, 2022 .

• Continuing Education Activity

Breech presentation refers to the fetus in the longitudinal lie with the buttocks or lower extremity entering the pelvis first. The three types of breech presentation include frank breech, complete breech, and incomplete breech. In a frank breech, the fetus has flexion of both hips, and the legs are straight with the feet near the fetal face, in a pike position. This activity reviews the cause and pathophysiology of breech presentation and highlights the role of the interprofessional team in its management.

• Describe the pathophysiology of breech presentation.
• Review the physical exam of a patient with a breech presentation.
• Summarize the treatment options for breech presentation.
• Explain the importance of improving care coordination among interprofessional team members to improve outcomes for patients affected by breech presentation.
• Introduction

Breech presentation refers to the fetus in the longitudinal lie with the buttocks or lower extremity entering the pelvis first. The three types of breech presentation include frank breech, complete breech, and incomplete breech. In a frank breech, the fetus has flexion of both hips, and the legs are straight with the feet near the fetal face, in a pike position. The complete breech has the fetus sitting with flexion of both hips and both legs in a tuck position. Finally, the incomplete breech can have any combination of one or both hips extended, also known as footling (one leg extended) breech, or double footling breech (both legs extended). [1] [2] [3]

Clinical conditions associated with breech presentation include those that may increase or decrease fetal motility, or affect the vertical polarity of the uterine cavity. Prematurity, multiple gestations, aneuploidies, congenital anomalies, Mullerian anomalies, uterine leiomyoma, and placental polarity as in placenta previa are most commonly associated with a breech presentation.  Also, a previous history of breech presentation at term increases the risk of repeat breech presentation at term in subsequent pregnancies. [4] [5] These are discussed in more detail in the pathophysiology section.

• Epidemiology

Breech presentation occurs in 3% to 4% of all term pregnancies. A higher percentage of breech presentations occurs with less advanced gestational age. At 32 weeks, 7% of fetuses are breech, and 28 weeks or less, 25% are breech.

Specifically, following one breech delivery, the recurrence rate for the second pregnancy was nearly 10%, and for a subsequent third pregnancy, it was 27%. Prior cesarean delivery has also been described by some to increase the incidence of breech presentation two-fold.

• Pathophysiology

As mentioned previously, the most common clinical conditions or disease processes that result in the breech presentation are those that affect fetal motility or the vertical polarity of the uterine cavity. [6] [7]

Conditions that change the vertical polarity or the uterine cavity, or affect the ease or ability of the fetus to turn into the vertex presentation in the third trimester include:

• Mullerian anomalies: Septate uterus, bicornuate uterus, and didelphys uterus 
• Placentation: Placenta previa as the placenta is occupying the inferior portion of the uterine cavity. Therefore, the presenting part cannot engage
• Uterine leiomyoma: Mainly larger myomas located in the lower uterine segment, often intramural or submucosal, that prevent engagement of the presenting part.
• Prematurity
• Aneuploidies and fetal neuromuscular disorders commonly cause hypotonia of the fetus, inability to move effectively
• Congenital anomalies:  Fetal sacrococcygeal teratoma, fetal thyroid goiter
• Polyhydramnios: Fetus is often in unstable lie, unable to engage
• Oligohydramnios: Fetus is unable to turn to vertex due to lack of fluid
• Laxity of the maternal abdominal wall: Uterus falls forward, the fetus is unable to engage in the pelvis.

The risk of cord prolapse varies depending on the type of breech. Incomplete or footling breech carries the highest risk of cord prolapse at 15% to 18%, while complete breech is lower at 4% to 6%, and frank breech is uncommon at 0.5%.

• History and Physical

During the physical exam, using the Leopold maneuvers, palpation of a hard, round, mobile structure at the fundus and the inability to palpate a presenting part in the lower abdomen superior to the pubic bone or the engaged breech in the same area, should raise suspicion of a breech presentation.

During a cervical exam, findings may include the lack of a palpable presenting part, palpation of a lower extremity, usually a foot, or for the engaged breech, palpation of the soft tissue of the fetal buttocks may be noted. If the patient has been laboring, caution is warranted as the soft tissue of the fetal buttocks may be interpreted as caput of the fetal vertex.

Any of these findings should raise suspicion and ultrasound should be performed.

Diagnosis of a breech presentation can be accomplished through abdominal exam using the Leopold maneuvers in combination with the cervical exam. Ultrasound should confirm the diagnosis.

On ultrasound, the fetal lie and presenting part should be visualized and documented. If breech presentation is diagnosed, specific information including the specific type of breech, the degree of flexion of the fetal head, estimated fetal weight, amniotic fluid volume, placental location, and fetal anatomy review (if not already done previously) should be documented.

• Treatment / Management

Expertise in the delivery of the vaginal breech baby is becoming less common due to fewer vaginal breech deliveries being offered throughout the United States and in most industrialized countries. The Term Breech Trial (TBT), a well-designed, multicenter, international, randomized controlled trial published in 2000 compared planned vaginal delivery to planned cesarean delivery for the term breech infant. The investigators reported that delivery by planned cesarean resulted in significantly lower perinatal mortality, neonatal mortality, and serious neonatal morbidity. Also, there was no significant difference in maternal morbidity or mortality between the two groups. Since that time, the rate of term breech infants delivered by planned cesarean has increased dramatically. Follow-up studies to the TBT have been published looking at maternal morbidity and outcomes of the children at two years. Although these reports did not show any significant difference in the risk of death and neurodevelopmental, these studies were felt to be underpowered. [8] [9] [10] [11]

Since the TBT, many authors since have argued that there are still some specific situations that vaginal breech delivery is a potential, safe alternative to planned cesarean. Many smaller retrospective studies have reported no difference in neonatal morbidity or mortality using these specific criteria.

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 2500 g and 4000 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. Oxytocin induction or augmentation was not offered, and strict criteria were established for normal labor progress. CT pelvimetry did determine an adequate maternal pelvis.

Despite debate on both sides, the current recommendation for the breech presentation at term includes offering external cephalic version (ECV) to those patients that meet criteria, and for those whom are not candidates or decline external cephalic version, a planned cesarean section for delivery sometime after 39 weeks.

Regarding the premature breech, gestational age will determine the mode of delivery. Before 26 weeks, there is a lack of quality clinical evidence to guide mode of delivery. One large retrospective cohort study recently concluded that from 28 to 31 6/7 weeks, there is a significant decrease in perinatal morbidity and mortality in a planned cesarean delivery versus intended vaginal delivery, while there is no difference in perinatal morbidity and mortality in gestational age 32 to 36 weeks. Of note, due to lack of recruitment, no prospective clinical trials are examining this issue.

• Differential Diagnosis
• Face and brow presentation
• Fetal anomalies
• Fetal death
• Grand multiparity
• Multiple pregnancies
• Oligohydramnios
• Pelvis Anatomy
• Preterm labor
• Primigravida
• Uterine anomalies
• Pearls and Other Issues

In light of the decrease in planned vaginal breech deliveries, thus the decrease in expertise in managing this clinical scenario, it is prudent that policies requiring simulation and instruction in the delivery technique for vaginal breech birth are established to care for the emergency breech vaginal delivery.

• Enhancing Healthcare Team Outcomes

A breech delivery is usually managed by an obstetrician, labor and delivery nurse, anesthesiologist and a neonatologist. The ultimate decison rests on the obstetrician. To prevent complications, today cesarean sections are performed and experienced with vaginal deliveries of breech presentation is limited. For healthcare workers including the midwife who has no experience with a breech delivery, it is vital to communicate with an obstetrician, otherwise one risks litigation if complications arise during delivery. [12] [13] [14]

• Review Questions
• Access free multiple choice questions on this topic.
• Comment on this article.

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

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

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Gray CJ, Shanahan MM. Breech Presentation. [Updated 2022 Nov 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

In this Page

Bulk download.

• Bulk download StatPearls data from FTP

Related information

• PMC PubMed Central citations
• PubMed Links to PubMed

Similar articles in PubMed

• [What effect does leg position in breech presentation have on mode of delivery and early neonatal morbidity?]. [Z Geburtshilfe Neonatol. 1997] [What effect does leg position in breech presentation have on mode of delivery and early neonatal morbidity?]. Krause M, Fischer T, Feige A. Z Geburtshilfe Neonatol. 1997 Jul-Aug; 201(4):128-35.
• The effect of intra-uterine breech position on postnatal motor functions of the lower limbs. [Early Hum Dev. 1993] The effect of intra-uterine breech position on postnatal motor functions of the lower limbs. Sival DA, Prechtl HF, Sonder GH, Touwen BC. Early Hum Dev. 1993 Mar; 32(2-3):161-76.
• The influence of the fetal leg position on the outcome in vaginally intended deliveries out of breech presentation at term - A FRABAT prospective cohort study. [PLoS One. 2019] The influence of the fetal leg position on the outcome in vaginally intended deliveries out of breech presentation at term - A FRABAT prospective cohort study. Jennewein L, Allert R, Möllmann CJ, Paul B, Kielland-Kaisen U, Raimann FJ, Brüggmann D, Louwen F. PLoS One. 2019; 14(12):e0225546. Epub 2019 Dec 2.
• Review Breech vaginal delivery at or near term. [Semin Perinatol. 2003] Review Breech vaginal delivery at or near term. Tunde-Byass MO, Hannah ME. Semin Perinatol. 2003 Feb; 27(1):34-45.
• Review [Breech Presentation: CNGOF Guidelines for Clinical Practice - Epidemiology, Risk Factors and Complications]. [Gynecol Obstet Fertil Senol. 2...] Review [Breech Presentation: CNGOF Guidelines for Clinical Practice - Epidemiology, Risk Factors and Complications]. Mattuizzi A. Gynecol Obstet Fertil Senol. 2020 Jan; 48(1):70-80. Epub 2019 Nov 1.

Recent Activity

• Breech Presentation - StatPearls Breech Presentation - StatPearls

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

Connect with NLM

National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894

Web Policies FOIA HHS Vulnerability Disclosure

Help Accessibility Careers

Learn how UpToDate can help you.

Select the option that best describes you

• Medical Professional
• Resident, Fellow, or Student
• Hospital or Institution
• Group Practice
• Patient or Caregiver
• Find in topic

RELATED TOPICS

INTRODUCTION

This topic will provide an overview of major issues related to breech presentation, including choosing the best route for delivery. Techniques for breech delivery, with a focus on the technique for vaginal breech delivery, are discussed separately. (See "Delivery of the singleton fetus in breech presentation" .)

TYPES OF BREECH PRESENTATION

● Frank breech – Both hips are flexed and both knees are extended so that the feet are adjacent to the head ( figure 1 ); accounts for 50 to 70 percent of breech fetuses at term.

● Complete breech – Both hips and both knees are flexed ( figure 2 ); accounts for 5 to 10 percent of breech fetuses at term.

GFMER Geneva Foundation for Medical Education and Research

• Annual reports
• GFMER members
• Country coordinators
• Obstetric fistula
• Cervical cancer
• Emergency and surgical care
• Picture of the week
• Social media
• Free medical journals

Obstetrics Simplified - Diaa M. EI-Mowafi

Complex (Compound) Presentation Breech Presentation

It is the presence of a limb alongside the presenting part usually the arm presents with the head.

About 1:800 labours.

Interference of adaptation of the presenting part to the pelvic brim which may be:

• Malpresentations. 
• Prematurity.  
• Multiple pregnancy.
• Polyhydramnios.
• Contracted pelvis.
• Pelvis tumours.

Vaginal examination reveals limb beside the head.

• contracted pelvis and
• cord prolapse.

First stage

Nothing is done as in most cases the arm will be displaced spontaneously away from the head.

Second stage

• Forceps extraction with or without reposition of the arm: reposition of the arm is tried first, if difficult apply forceps without reposition but do not include the arm in the blades. This is done if the head is engaged.
• Nonengagement of the head.
• Other indications for caesarean section.
• Craniotomy: if the foetus is dead and labour is obstructed.

BREECH PRESENTATION

It is a longitudinal lie in which the buttocks is the presenting part with or without the lower limbs.

3.5% of term singleton deliveries and about 25% of cases before 30 weeks of gestation as most cases undergo spontaneous cephalic version up to term.

In general, the foetus is adapted to the pyriform shape of the uterus with the larger buttock in the fundus and smaller head in the lower uterine segment.

Any factor that interferes with this adaptation, allows free mobility or prevents spontaneous version, can be considered a cause for breech presentation as:

• relatively small foetal size,
• relatively excess amniotic fluid, and
• more globular shape of the uterus.
• Multiple pregnancy: one or both will present by the breech to adapt with the relatively small room.
• Poly-and oligohydramnios.
• Hydrocephalus.
• Intrauterine foetal death.
• Bicornuate and septate uterus.
• Uterine and pelvic tumours.
• Placenta praevia.
• The feet present beside the buttocks as both knees and hips are flexed.
• More common in multipara.
• It is breech with extended legs where the knees are extended while the hips are flexed.
• More common in primigravida.
• The hip and knee joints are extended on one or both sides.
• More common in preterm singleton breeches.
• The hip is partially extended and the knee is flexed on one or both sides.
• Left sacro-anterior.           
• Right sacro-anterior.
• Right sacro-posterior.           
• Left sacro-posterior.
• Left and right sacro- transverse (lateral).
• Direct sacro-anterior and posterior.

Sacro-anterior positions are more common than sacro-posterior as in the first the concavity of the foetal front fits into the convexity of the maternal spines.

During pregnancy

• A transverse groove may be seen above the umbilicus in sacro-anterior corresponds to the neck.
• If the patient is thin, the head may be seen as a localised bulge in one hypochondrium.
• Fundal grip: the head is felt as a smooth, hard, round ballottable mass which is often tender.
• Umbilical grip: the back is identified and a depression corresponds to the neck may be felt.
• First pelvic grip: the breech is felt as a smooth, soft mass continuous with the back. Trial to do ballottement to the breech shows that the movement is transmitted to the whole trunk.
• FHS is heard above the level of the umbilicus. However in frank breech it may be heard at or below the level of the umbilicus.
• To confirm the diagnosis.
• To detect the type of breech.
• To detect gestational age and foetal weight:  Different measures can be taken to determine the foetal weight as the biparietal diameter with chest or abdominal circumference using a special equation.
• To exclude hyperextension of the head.
• To exclude congenital anomalies.
• Diagnosis of unsuspected twins.

During Labour

In addition to the previous findings, vaginal examination reveals;

• The 3 bony landmarks of breech namely 2 ischial tuberosities and tip of the sacrum.
• The feet are felt beside the buttocks in complete breech.
• Fresh meconium may be found on the examining fingers.
• Male genitalia may be felt.

Mechanism of Labour

Delivery of the buttocks

• The engagement diameter is the bitrochanteric diameter 10 cm which enters the pelvis in one of the oblique diameters.
• The anterior buttock meets the pelvic floor first so it rotates 1/8 circle anteriorly.
• The anterior buttock hinges below the symphysis and the posterior buttock is delivered first by lateral flexion of the spines followed by the anterior buttock.
• External rotation occurs so that the sacrum comes anteriorly.

Delivery of the shoulders

• The shoulders enter the same oblique diameter with the biacromial diameter 12 cm (between the acromial processes of the scapulae).
• The anterior shoulder meets the pelvic floor first, rotates 1/8 circle anteriorly, hinges under the symphysis, then the posterior shoulder is delivered first followed by the anterior shoulder.

Delivery of the after-coming head

• The head enters the pelvis in the opposite oblique diameter.
• The occiput rotates 1/8 circle anteriorly, in case of sacro- anterior position and 3/8 circle anteriorly in case of sacro- posterior position.
• Rarely, the occiput rotates posteriorly and this should be prevented by the obstetrician.

The head is delivered by movement of flexion in:

• Direct occipito-posterior (face to pubis).
• Face mento-anterior.
• The after coming head in breech presentation.

The head is delivered by extension in normal labour only i.e. occipito - anterior positions.

Management of Breech Presentation

External Cephalic Version

It regains its importance after increased rate of caesarean sections nowadays.

Timing: After the 32nd weeks up to the 37th week and some authors extend it to the early labour as long as the membranes are intact and there is no contraindications.

Version is not done earlier because:

• Spontaneous version is liable to occur.
• Return to breech presentation is liable to occur.
• If labour occurs the foetus will have a lesser chance for survival.

Version is difficult after 37th weeks due to:

• Larger foetal size.
• Relatively less liquor.
• More irritability of the uterus.
• To detect cephalo-pelvic disproportion.
• Cephalic delivery is safer for the mother and foetus.

Success rate: 50-70%.

Causes of failure:

• Large sized foetus.
• Oligo- or polyhydramnios. 
• Short umbilical cord.
• Uterine anomalies as bicornuate or septate uterus.
• Irritable uterus. Tocolytic drugs may be started 15 minutes before the procedure to overcome this.
• Rigid abdominal wall.  
• Frank breech because the legs act as a splint.

Contraindications:

• Multiple pregnancy.    
• Antepartum haemorrhage.   
• Uterine scar.
• Hypertension as the placenta is more susceptible to separation.
• Elderly primigravida.
• Ruptured membranes.
• Anaesthesia during version is contraindicated as pain is a safeguard against rough manipulations.

Complications:

• Accidental haemorrhage due to separation of the placenta.
• Rupture of membranes .       
• Preterm labour.  
• Foetal distress.
• Cord presentation or prolapse.    
• Entangling of the cord around the foetus.
• Isoimmunisation in Rh-negative mothers due to foeto-maternal transfusion.

Caesarean Section

Indications:

• Large foetus i.e. > 3.75 kg estimated by ultrasound.
• Preterm foetus but estimated weight is still more than 1.25 kg.
• Less reflex stimulation of uterine contractions.
• Susceptibility to cord prolapse.
• Early bearing down as the foot passes through partially dilated cervix and reaches the perineum.
• Hyperextended head: diagnosed by ultrasound or X-ray.
• Contracted pelvis: of any degree.
• Uterine dysfunction.
• Hypertension.
• Diabetes mellitus.       
• Pre - labour rupture of membranes for ≥ 12 hours.
• Intrauterine growth retardation.
• Placental insufficiency.
• Primigravidas: breech in primigravida equals caesarean section in opinion of most obstetricians as the maternal passages were not tested for delivery before.

Vaginal Delivery

Prerequisites:

• Frank breech.
• Estimated foetal weight not more than 3.75 kg.
• Gestational age: 36-42 weeks.
• Flexed head.
• Adequate pelvis.
• Normal progress of labour by using the partogram.
• Uncomplicated pregnancy.
• Multiparas.
• An experienced obstetrician.
• In case of intrauterine foetal death.

During vaginal delivery, prematures are more susceptible to:

• trauma, and
• retained after-coming head as the partially dilated cervix allows the passage of the body but the less compressible relatively larger head will be retained.

However, caesarean section should only be done if the premature foetus has a reasonable chance of post - natal survival.

Management of Vaginal Breech Delivery

First stage: as other malpresentations.

Second stage: The foetus may be delivered by one of the following methods:

• This is rarely occurs in multipara with adequate pelvis, strong uterine contractions and small sized baby. The baby is delivered spontaneously without any assistance but perineal lacerations may occur.
• This is the method of delivery in far majority of cases.
• The golden rule is to "Keep your hands off".
• The patient is asked to bear down during uterine contractions and relax in between until the perineum is distended by the buttocks.
• An episiotomy is done especially in primigravida to avoid much lateral flexion of the spines, perineal lacerations and intracranial haemorrhage due to sudden compression and decompression of the after - coming head.
• The legs are hooked out but without traction.
• When the umbilicus appears, a loop of the cord is hooked to prevent traction or compression of the cord and detect its pulsation.
• The foetus is covered with warm towel to prevent premature stimulation of respiration.
• Gentle steady downward traction is applied to the foetal pelvic girdle during uterine contractions with gradual rotation of the foetus to bring the shoulders in the antero-posterior diameter of the pelvis.
• When the anterior scapula appears below the symphysis, both arms are delivered by hooking the index finger at the elbow and sweep the forearm across the chest of the foetus
• The back is rotated anteriorly.
• Kristeller manoeuvre: gentle fundal pressure is done during uterine contractions to guide the head into the pelvis and maintain its flexion.
• Two fingers of the left hand, (as originally described) or better on the malar eminencies (the maxillae) to avoid dislocation of the jaw.
• The index and ring finger of the right hand are placed on each shoulder while the middle finger is pressing against the occiput to promote flexion and act as a splint for the neck, preventing hyperextension and hence cervical spine injury.
• Traction is commenced downwards and backwards till the nape of the foetus appears, the body is lifted towards the mother’s abdomen.
• The foetus is left hanging so that its weight exerts gentle downwards and backwards traction. When the nape appears, grasp the feet and left the body towards the mother’s abdomen.
• Piper’s forceps is more suitable than the ordinary forceps as it has a perineal but not pelvic curve and has longer shanks. It is applied from the ventral aspect of the foetus.
• Traction is applied downwards and backwards till the nape appears, then downwards and forwards to deliver the head by flexion.
• It promotes flexion of the head.
• Traction is applied on the head and not on the neck.
• It prevents sudden compression and decompression of the head.
• It protects the head from compression by pelvic bones or rigid perineum.
• Maternal or foetal distress.
• Prolonged second stage.
• To shorten the second stage in maternal respiratory and heart diseases.
• Prolapsed pulsating cord with fully dilated cervix.
• It is done under general anaesthesia.
• Both legs are bringing down.
• Traction on the legs is done helped by fundal pressure to deliver the breech and the trunk.
• The after - coming head is delivered by jaw flexion - shoulder traction or forceps.

Complicated Breech Delivery

Arrest of the buttocks at the pelvic brim

Arrest of the buttocks at the pelvic outlet

Groin traction:

• traction is done by the index or the index and middle fingers put in the anterior groin in a downward and backward direction.
• The traction is done towards the trunk to avoid dislocation of the femur.
• Traction is done during uterine contractions and aided by fundal pressure.
• When the posterior buttock appears traction is done by the 2 index fingers in both groins in a downward and forward direction.
• Dead foetus:

Groin traction is done by breech hook.

• Under general anaesthesia.
• Press by 2 fingers in the popliteal fossa of the anterior leg to flex it then grasp the ankle and bring it down. This will prevent the anterior buttock from over-riding the symphysis pubis.
• If the posterior leg was brought down first it must be rotated anteriorly with the trunk then bring the other leg which is now becomes posterior.

N.B. The foot has the following features differentiating it from the hand:

• Presence of the heel.
• Absence of the mobile thumb.
• The toes are shorter than the fingers.

Arrest of the shoulders

Classical method:

• Under epidural or general anaesthesia.
• As there is more space posteriorly, bring down the posterior arm first by using 2 fingers pressing against the cubital fossa and sweep the arm in front of the foetal body to avoid fracture humerus.
• The anterior arm is then brought down by the same manoeuvre. If this is difficult rotate the body180o to make the anterior arm posterior and bring it down.

Lövset method:

• Gentle downward and backward traction is applied to the foetus by grasping its pelvis till the inferior angle of the anterior scapula appears, the foetal trunk is rotated 180o to bring the posterior shoulder anteriorly emerging beneath the symphysis pubis. So the arm can be brought down.
• The trunk is again rotated 180o in the opposite direction to bring the other shoulder anteriorly emerging beneath the symphysis so the second arm can be brought down.
• The back should be kept always anterior during rotation.

Arrest of the after - coming head

Prague manoeuvre:

• When the occiput rotates posteriorly and the head extends, the chin hangs above the symphysis pubis.
• Foetus is grasped from its feet and flexed towards the mother’s abdomen, while the other hand is doing simultaneous traction on the shoulders to deliver the head by flexion.

Complications of Breech Delivery

• Prolonged labour with maternal distress.
• Obstructed labour with its sequelae may occur as in impacted breech with extended legs.
• Laceration especially perineal.
• Postpartum haemorrhage due to prolonged labour and lacerations.
• Puerperal sepsis.
• Forceps delivery of the after -coming head.
• Episiotomy.
• Slow delivery of the head.
• Vitamin K to the mother early in labour.
• Fracture dislocation of the cervical spines prevented by avoiding lifting the body towards the mother’s abdomen until the nape appears below the symphysis.
• Cord prolapse or compression by the head.
• Premature stimulation of respiration leading to inhalation of mucus, liquor or blood. This can be avoided by covering the body of the foetus with warm towels during delivery.
• Rupture of an abdominal organ: from rough manipulations avoided by grasping the foetus from its hips only.
• Fracture femur, humerus or clavicle.
• Dislocation of joints or lower jaw.
• Injury to the external genitalia.
• Brachial plexus injury.
• Lacerations to the sternomastoid muscles.
• Breech presentation : Guidelines, reviews

• Type 2 Diabetes
• Heart Disease
• Digestive Health
• Multiple Sclerosis
• COVID-19 Vaccines
• Occupational Therapy
• Healthy Aging
• Health Insurance
• Public Health
• Patient Rights
• Caregivers & Loved Ones
• End of Life Concerns
• Health News
• Thyroid Test Analyzer
• Doctor Discussion Guides
• Hemoglobin A1c Test Analyzer
• Lipid Test Analyzer
• Complete Blood Count (CBC) Analyzer
• What to Buy
• Editorial Process
• Meet Our Medical Expert Board

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.

Variation in fetal presentation

• Report problem with article
• View revision history

Citation, DOI, disclosures and article data

At the time the article was created The Radswiki had no recorded disclosures.

At the time the article was last revised Yuranga Weerakkody had no financial relationships to ineligible companies to disclose.

• Delivery presentations
• Variation in delivary presentation
• Abnormal fetal presentations

There can be many variations in the fetal presentation which is determined by which part of the fetus is projecting towards the internal cervical os . This includes:

cephalic presentation : fetal head presenting towards the internal cervical os, considered normal and occurs in the vast majority of births (~97%); this can have many variations which include

left occipito-anterior (LOA)

left occipito-posterior (LOP)

left occipito-transverse (LOT)

right occipito-anterior (ROA)

right occipito-posterior (ROP)

right occipito-transverse (ROT)

straight occipito-anterior

straight occipito-posterior

breech presentation : fetal rump presenting towards the internal cervical os, this has three main types

frank breech presentation  (50-70% of all breech presentation): hips flexed, knees extended (pike position)

complete breech presentation  (5-10%): hips flexed, knees flexed (cannonball position)

footling presentation  or incomplete (10-30%): one or both hips extended, foot presenting

other, e.g one leg flexed and one leg extended

shoulder presentation

cord presentation : umbilical cord presenting towards the internal cervical os

• 1. Fox AJ, Chapman MG. Longitudinal ultrasound assessment of fetal presentation: a review of 1010 consecutive cases. Aust N Z J Obstet Gynaecol. 2006;46 (4): 341-4. doi:10.1111/j.1479-828X.2006.00603.x - Pubmed citation
• 2. Merz E, Bahlmann F. Ultrasound in obstetrics and gynecology. Thieme Medical Publishers. (2005) ISBN:1588901475. Read it at Google Books - Find it at Amazon

Incoming Links

• Obstetric curriculum
• Cord presentation
• Polyhydramnios
• Footling presentation
• Normal obstetrics scan (third trimester singleton)

Promoted articles (advertising)

ADVERTISEMENT: Supporters see fewer/no ads

By Section:

• Artificial Intelligence
• Classifications
• Imaging Technology
• Interventional Radiology
• Radiography
• Central Nervous System
• Gastrointestinal
• Gynaecology
• Haematology
• Head & Neck
• Hepatobiliary
• Interventional
• Musculoskeletal
• Paediatrics
• Not Applicable

Radiopaedia.org

• Feature Sponsor
• Expert advisers

• Pregnancy Classes

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.

BLOG CATEGORIES

• Can I get pregnant if… ? 3
• Child Adoption 19
• Fertility 54
• Pregnancy Loss 11
• Breastfeeding 29
• Changes In Your Body 5
• Cord Blood 4
• Genetic Disorders & Birth Defects 17
• Health & Nutrition 2
• Is it Safe While Pregnant 54
• Labor and Birth 65
• Multiple Births 10
• Planning and Preparing 24
• Pregnancy Complications 68
• Pregnancy Concerns 62
• Pregnancy Health and Wellness 149
• Pregnancy Products & Tests 8
• Pregnancy Supplements & Medications 14
• The First Year 41
• Week by Week Newsletter 40
• Your Developing Baby 16
• Options for Unplanned Pregnancy 18
• Paternity Tests 2
• Pregnancy Symptoms 5
• Prenatal Testing 16
• The Bumpy Truth Blog 7
• Uncategorized 4
• Abstinence 3
• Birth Control Pills, Patches & Devices 21
• Women's Health 34
• Thank You for Your Donation
• Unplanned Pregnancy
• Getting Pregnant
• Healthy Pregnancy
• Privacy Policy

Share this post:

Similar post.

Episiotomy: Advantages & Complications

Retained Placenta

What is Dilation in Pregnancy?

Track your baby’s development, subscribe to our week-by-week pregnancy newsletter.

• The Bumpy Truth Blog
• Fertility Products Resource Guide

Pregnancy Tools

• Ovulation Calendar
• Baby Names Directory
• Pregnancy Due Date Calculator
• Pregnancy Quiz

Pregnancy Journeys

• Partner With Us
• Corporate Sponsors

Breech Presentation

INTRODUCTION :

• In breech presentation, the lie is longitudinal and the podalic pole presents at the pelvic brim.
• Most common breech presentation is Left sacroanterior
• Breech presentation is mostly mistaken for  Face presentation
• Percentage of breech at term is 3 %

Complete (Flexed breech):

• Commonly present in multiparae(10%).
• Presenting part :2 buttocks, external genitalia and two feet

Incomplete :

• Breech with extended legs (Frank breech):
• Presenting part:2 buttocks and external genitalia
• Present in primigravidae(70%).
• Least chances of cord prolapse  
• In breech, engagement takes places earliest in frank 

Footling presentation (25%):

• Both thighs and legs are partially extended bringing the legs to present at brim.

Knee presentation: 

• Thighs are extended but the knees are flexed, bringing the knees down to present at the brim. 

Clinical varieties:

• Uncomplicated:no other associated obstetric complications
• Complicated:associated with conditions which adversely influence prognosis such as prematurity, twins, contracted pelvis, placenta previa
• Prematurity
• Factors preventing spontaneous version:
• Breech with extended legs
• Oligohydramnios
• Septate or bicornuate uterus
• Short cord, relative or absolute
• IUD of fetus.

Favorable adaptation:

• Hydrocephalus
• Placenta previa
• Contracted pelvis
• Cornu-fundal attachment of the placenta
• Undue mobility of the fetus
• Hydramnios ,
• Multiparae with lax abdominal wall.
• Fetal abnormality : Trisomies 13, 18, 21, anencephaly and myotonic dystrophy

    ULTRASONOGRAPHY:

• Detect fetal congenital abnormality
• Detect primigravidae with engaged frank breech or with tense abdominal wall and irritable uterus
• Type of breech
• It measures biparietal diameter, gestational age and estimated weight of the fetus
• Localizes the placenta
• Assessment of liquor volume
• Attitude of the head
• First position: Left sacroanterior (LSA)—being the most common
• Second position: Right sacroanterior (RSA)
• Third position: Right sacroposterior (RSP)
• Fourth position: Left sacroposterior (LSP).

MECHANISM OF LABOR IN BREECH PRESENTATION:

SACROANTERIOR POSITION:

Principal movements occur at three places

• Engaging diameter is bitrochanteric (10 cm or 4″)
• Breech is engaged when diameter passes through the pelvic brim
• Descent of the buttocks: Till anterior buttock touches the pelvic floor
• Internal rotation of the anterior buttock(1/8th of a circle)
• Further descent with lateral ! exion of the trunk
• Delivery of the trunk and the lower limbs
• Restitution 

Shoulders :

• Bisacromial diameter (12 cm or 4 3/4″) engages
• Descent occurs with internal rotation of the shoulders bringing the shoulders to lie in the anteroposterior diameter of the pelvic outlet
• Ttrunk simultaneously rotates externally through 1/8th of a circle
• Delivery of the posterior shoulder followed by the anterior 
• Restitution and external rotation
• Engagement:Engaging diameter of the head is suboccipitofrontal (10 cm).
• Descent with increasing # exion occurs
• Internal rotation of the occiput(anteriorly, through 1/8th or 2/8th of a circle)
• Further descent occurs until the subocciput hinges under the symphysis pubis
• Head is born by ! exion—chin, mouth, nose, forehead, vertex and occiput appearing successively.

Sacroposterior position:

• In sacroposterior position, the mechanism is not substantially modified.
• The head has to rotate through 3/8th of a circle to bring the occiput behind the symphysis pubis.
• Fetal malformation , Uterine anomaly & Cornual implantation of placenta are associated with breech presentation at normal full term pregnancy
• Prematurity  is the commonest cause for breech presentation
•  LEAST chances of cord prolapse are seen in Frank breech
• Causes of breech presentation are Hydramnios,Septate uterus,Hydrocephalus, Placenta praevia & Pelvic contracture
• Recurrent breech presentation is seen In Congenital uterine anomaly
•  Breech presentation is mostly mistaken for  Face presentation

Share this:

Leave a reply cancel reply, discover more from new.

Subscribe now to keep reading and get access to the full archive.

Type your email…

Continue reading

eCommons@AKU

• < Previous

Home > East Africa > Faculty of Health Sciences > FHS > 56

Faculty of Health Sciences, East Africa

Breech delivery at a university hospital in tanzania.

Ulf Högberg , Uppsala University, Sweden Catrin Claeson , Karolinska University Hospital, Sweden Lone Krebs , University of Copenhagen, and Holbæk Hospital, Denmark Agneta Skoog Svanberg , Uppsala University, Sweden Hussein Kidanto , Aga Khan University Follow

Document Type

Obstetrics and Gynaecology (East Africa)

Background There is a global increase in rates of Cesarean delivery (CD). A minor factor in this increase is a shift towards CD for breech presentation. The aim of this study was to analyze breech births by mode of delivery and investigate short-term fetal and maternal outcomes in a low-income setting.

Methods The study design was cross-sectional and the setting was Muhimbili National Hospital (MNH), Dar-es-Salaam, Tanzania. Subjects were drawn from a clinical database (1999–2010) using the following inclusion criteria: breech presentation, birth weight ≥ 2,500 g, single pregnancy, fetal heart sound at admission, and absence of pregnancy-related complication as indication for CD. Of 2,765 mothers who had a breech delivery, 1,655 met the inclusion criteria. Analyses were stratified by mode of delivery, taking into account also other birth characteristics. The outcome measures were perinatal death (stillbirths + in-hospital neonatal deaths) and moderate asphyxia. Maternal outcomes, such as death, hemorrhage, and length of hospital stay, were also described.

Results The CD rate for breech presentation increased from 28 % in 1999 to 78 % in 2010. Perinatal deaths were associated with vaginal delivery (VD) (adjusted odds ratio (aOR) 6.2; 95 % confidence interval (CI) 3.0–12.6) and referral (aOR 2.1; 95 % CI 1.1–3.9), but not with parity, birth weight, or delivery year. Overall perinatal mortality was 5.8 % and this did not decline, due to an increase in stillbirths among vaginal breech deliveries. Mothers with CD had more hemorrhage compared to those with VD. One mother died in association with CD, and one died in association with VD.

Conclusion A breech VD, compared to a breech CD, in this setting was associated with adverse perinatal outcome. However, despite a significant increase in CD rate, no overall improvement was observed due to an increase in stillbirths among VDs

This work was published before the author joined Aga Khan University .

Publication ( Name of Journal)

BMC Pregnancy and Childbirth

Recommended Citation

Högberg, U., Claeson, C., Krebs, L., Svanberg, A. S., & Kidanto, H. (2016). Breech delivery at a University Hospital in Tanzania. BMC pregnancy and childbirth , 16 (1), 1-8.

Creative Commons License

Since February 01, 2021

Included in

Obstetrics and Gynecology Commons , Pediatrics Commons

Advanced Search

• Notify me via email or RSS
• Departments
• Disciplines
• Aga Khan University
• Aga Khan University Libraries
• SAFARI (AKU Libraries’ Catalogue)

Home | About | FAQ | My Account | Accessibility Statement

Privacy Copyright