breech presentation in labor

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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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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 .

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

Key Points |

Abnormal fetal lie or presentation may occur due to fetal size, fetal anomalies, uterine structural abnormalities, multiple gestation, or other factors. Diagnosis is by examination or ultrasonography. Management is with physical maneuvers to reposition the fetus, operative vaginal delivery , or cesarean delivery .

Terms that describe the fetus in relation to the uterus, cervix, and maternal pelvis are

Fetal presentation: Fetal part that overlies the maternal pelvic inlet; vertex (cephalic), face, brow, breech, shoulder, funic (umbilical cord), or compound (more than one part, eg, shoulder and hand)

Fetal position: Relation of the presenting part to an anatomic axis; for transverse presentation, occiput anterior, occiput posterior, occiput transverse

Fetal lie: Relation of the fetus to the long axis of the uterus; longitudinal, oblique, or transverse

Normal fetal lie is longitudinal, normal presentation is vertex, and occiput anterior is the most common position.

Abnormal fetal lie, presentation, or position may occur with

Fetopelvic disproportion (fetus too large for the pelvic inlet)

Fetal congenital anomalies

Uterine structural abnormalities (eg, fibroids, synechiae)

Multiple gestation

Several common types of abnormal lie or presentation are discussed here.

Transverse lie

Fetal position is transverse, with the fetal long axis oblique or perpendicular rather than parallel to the maternal long axis. Transverse lie is often accompanied by shoulder presentation, which requires cesarean delivery.

Breech presentation

There are several types of breech presentation.

Frank breech: The fetal hips are flexed, and the knees extended (pike position).

Complete breech: The fetus seems to be sitting with hips and knees flexed.

Single or double footling presentation: One or both legs are completely extended and present before the buttocks.

Types of breech presentations

Breech presentation makes delivery difficult ,primarily because the presenting part is a poor dilating wedge. Having a poor dilating wedge can lead to incomplete cervical dilation, because the presenting part is narrower than the head that follows. The head, which is the part with the largest diameter, can then be trapped during delivery.

Additionally, the trapped fetal head can compress the umbilical cord if the fetal umbilicus is visible at the introitus, particularly in primiparas whose pelvic tissues have not been dilated by previous deliveries. Umbilical cord compression may cause fetal hypoxemia.

Predisposing factors for breech presentation include

Preterm labor

Uterine abnormalities

Fetal anomalies

If delivery is vaginal, breech presentation may increase risk of

Umbilical cord prolapse

Birth trauma

Perinatal death

Face or brow presentation

In face presentation, the head is hyperextended, and position is designated by the position of the chin (mentum). When the chin is posterior, the head is less likely to rotate and less likely to deliver vaginally, necessitating cesarean delivery.

Brow presentation usually converts spontaneously to vertex or face presentation.

Occiput posterior position

The most common abnormal position is occiput posterior.

The fetal neck is usually somewhat deflexed; thus, a larger diameter of the head must pass through the pelvis.

Progress may arrest in the second phase of labor. Operative vaginal delivery or cesarean delivery is often required.

Position and Presentation of the Fetus

If a fetus is in the occiput posterior position, operative vaginal delivery or cesarean delivery is often required.

In breech presentation, the presenting part is a poor dilating wedge, which can cause the head to be trapped during delivery, often compressing the umbilical cord.

For breech presentation, usually do cesarean delivery at 39 weeks or during labor, but external cephalic version is sometimes successful before labor, usually at 37 or 38 weeks.

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What Is Breech?

When a fetus is delivered buttocks or feet first

Types of Presentation

Risk Factors

Complications.

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

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

Verywell / Jessica Olah

Types of Breech Presentation

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

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

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

The different types of breech presentations include:

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

Signs of Breech

There are no specific symptoms associated with a breech presentation.

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

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

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

These can include:

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

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

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

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

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

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

ECV is usually not recommended if the:

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

Recommendations for Previous C-Sections

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

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

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

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

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

A Word From Verywell

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

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

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

TeachMeObGyn. Breech presentation .

MedlinePlus. Breech birth .

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

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

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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.

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Chapter 25: Breech Presentation

Jessica Dy; Darine El-Chaar

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General considerations.

CLASSIFICATION
RIGHT SACRUM ANTERIOR
MECHANISMS OF LABOR: BREECH PRESENTATIONS
PROGNOSIS: BREECH PRESENTATIONS
INVESTIGATION OF BREECH PRESENTATION AT TERM
MANAGEMENT OF BREECH PRESENTATION DURING LATE PREGNANCY
MANAGEMENT OF DELIVERY OF BREECH PRESENTATION
ARREST IN BREECH PRESENTATION
BREECH EXTRACTION
HYPEREXTENSION OF THE FETAL HEAD
SELECTED READING
Full Chapter
Supplementary Content

Breech presentation is a longitudinal lie with a variation in polarity. The fetal pelvis is the leading pole. The denominator is the sacrum. A right sacrum anterior (RSA) is a breech presentation where the fetal sacrum is in the right anterior quadrant of the mother's pelvis and the bitrochanteric diameter of the fetus is in the right oblique diameter of the pelvis ( Fig. 25-1 ).

FIGURE 25-1.

Positions of breech presentation. LSA, left sacrum anterior; LSP, left sacrum posterior; LST, left sacrum transverse; RSA, right sacrum anterior; RSP, right sacrum posterior; RST, right sacrum transverse.

Breech presentation at delivery occurs in 3 to 4 percent of pregnancies. However, before 28 weeks of gestation, the incidence is about 25 percent. As term gestation approaches, the incidence decreases. In most cases, the fetus converts to the cephalic presentation by 34 weeks of gestation.

As term approaches, the uterine cavity, in most cases, accommodates the fetus best in a longitudinal lie with a cephalic presentation. In many cases of breech presentation, no reason for the malpresentation can be found and, by exclusion, the cause is ascribed to chance. Some women deliver all their children as breeches, suggesting that the pelvis is so shaped that the breech fits better than the head.

Breech presentation is more common at the end of the second trimester than near term; hence, fetal prematurity is associated frequently with this presentation.

Maternal Factors

Factors that influence the occurrence of breech presentation include (1) the uterine relaxation associated with high parity; (2) polyhydramnios, in which the excessive amount of amniotic fluid makes it easier for the fetus to change position; (3) oligohydramnios, in which, because of the small amount of fluid, the fetus is trapped in the position assumed in the second trimester; (4) uterine anomalies; (5) neoplasms, such as leiomyomata of the myometrium; (6) while contracted pelvis is an uncommon cause of breech presentation, anything that interferes with the entry of the fetal head into the pelvis may play a part in the etiology of breech presentation.

Placental Factors

Placental site: There is some evidence that implantation of the placenta in either cornual-fundal region tends to promote breech presentation. There is a positive association of breech with placenta previa.

Fetal Factors

Fetal factors that influence the occurrence of breech presentation include multiple pregnancy, hydrocephaly, anencephaly, chromosomal anomalies, and intrauterine fetal death.

Notes and Comments

The patient commonly feels fetal movements in the lower abdomen and may complain of painful kicking against the rectum, vagina, and bladder

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Breech Presentation

https://upload.medbullets.com/topic/120379/images/breech_ultrasound.jpg

A 28-year-old G1P0 woman at 37 weeks of gestation presents to her obstetrician for a prenatal care appointment. She describes feeling some soreness under her ribs in the past few weeks and feels her baby kicking in her lower abdomen. An ultrasound is performed and is seen in the image. The obstetrician describes management approaches, including an external cephalic version before labor.
flexion of the hips and knees
some deflexion of one hip and knee
flexion of both hips with extension of both knees
3-4% of all deliveries
22-25% of births before 28 weeks of gestation
7-15% of births at 32 weeks of gestation
3-4% of births at term
prematurity
uterine malformations
uterine fibroids
polyhydramnios
placenta previa
multiple gestations
subcostal discomfort (due to fetal head in the uterine fundus)
feeling of kicking in the lower abdomen
presence of soft mass (buttocks) and absence of hard fetal skull on transabdominal examination of the lower uterine segment
when cervix is dilated
detection of breech presentation prior to 37 weeks does not warrant intervention
fetal head in the uterine fundus
buttocks in the lower uterine segment
extension angle > 90 degrees
at 37 weeks gestation or later
perform trial of vaginal delivery if the version is successful
may be planned for breech presentation, without a trial of external cephalic version
may be performed if trial of vaginal delivery is unsuccessful after external cephalic labor
↑ up to 4-fold with breech presetnation
associated with malformations, prematurity, and intrauterine fetal demise
17% of preterm breech deliveries
9% of term breech deliveries
abnormalities include CNS malformations, neck masses, and aneuploidy
- Breech Presentation

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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.

Illustration of the head-down, face-up position

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.

Illustration of the frank breech position

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.

Illustration of a complete breech presentation

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

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

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

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

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

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

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

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

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

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

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

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Breech presentation

Highlights & basics, diagnostic approach, risk factors, history & exam, differential diagnosis.

Tx Approach

Emerging Tx

Complications.

PATIENT RESOURCES

Patient Instructions

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

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

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

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

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

Quick Reference

Key Factors

buttocks or feet as the presenting part

Fetal head under costal margin, fetal heartbeat above the maternal umbilicus.

Other Factors

subcostal tenderness

Pelvic or bladder pain.

Diagnostics Tests

1st Tests to Order

transabdominal/transvaginal ultrasound

Treatment options.

presumptive

<37 weeks' gestation

specialist evaluation

corticosteroid

magnesium sulfate

≥37 weeks' gestation not in labor

unsuccessful ECV with persistent breech

Classifications

Types of breech presentation

Baby's buttocks lead the way into the birth canal

Hips are flexed, knees are extended, and the feet are in close proximity to the head

65% to 70% of breech babies are in this position.

Baby presents with buttocks first

Both the hips and the knees are flexed; the baby may be sitting cross-legged.

One or both of the baby's feet lie below the breech so that the foot or knee is lowermost in the birth canal

This is rare at term but relatively common with premature fetuses.

Common Vignette

Epidemiology

33% of births less than 28 weeks' gestation

14% of births at 29 to 32 weeks' gestation

9% of births at 33 to 36 weeks' gestation

6% of births at 37 to 40 weeks' gestation.

Pathophysiology

Natasha Nassar, PhD
Christine L. Roberts, MBBS, FAFPHM, DrPH
Jonathan Morris, MBChB, FRANZCOG, PhD
John W. Bachman, MD
Rhona Hughes, MBChB
Brian Peat, MD
Lelia Duley, MBChB
Justus Hofmeyr, MD

Clinical exam

Palpation of the abdomen to determine the position of the baby's head

Palpation of the abdomen to confirm the position of the fetal spine on one side and fetal extremities on the other

Palpation of the area above the symphysis pubis to locate the fetal presenting part

Palpation of the presenting part to confirm presentation, to determine how far the fetus has descended and whether the fetus is engaged.

Ultrasound examination

Premature fetus.

Prematurity is consistently associated with breech presentation. [ 6 ] [ 9 ] This may be due to the smaller size of preterm infants, who are more likely to change their in utero position.

Increasing duration of pregnancy may allow breech-presenting fetuses time to grow, turn spontaneously or by external cephalic version, and remain cephalic-presenting.

Larger fetuses may be forced into a cephalic presentation in late pregnancy due to space or alignment constraints within the uterus.

small for gestational age fetus

Low birth-weight is a risk factor for breech presentation. [ 9 ] [ 11 ] [ 12 ] [ 13 ] [ 14 ] Term breech births are associated with a smaller fetal size for gestational age, highlighting the association with low birth-weight rather than prematurity. [ 6 ]

nulliparity

Women having a first birth have increased rates of breech presentation, probably due to the increased likelihood of smaller fetal size. [ 6 ] [ 9 ]

Relaxation of the uterine wall in multiparous women may reduce the odds of breech birth and contribute to a higher spontaneous or external cephalic version rate. [ 10 ]

fetal congenital anomalies

Congenital anomalies in the fetus may result in a small fetal size or inappropriate fetal growth. [ 9 ] [ 12 ] [ 14 ] [ 15 ]

Anencephaly, hydrocephaly, Down syndrome, and fetal neuromuscular dysfunction are associated with breech presentation, the latter due to its effect on the quality of fetal movements. [ 9 ] [ 14 ]

previous breech delivery

The risk of recurrent breech delivery is 8%, the risk increasing from 4% after one breech delivery to 28% after three. [ 16 ]

The effects of recurrence may be due to recurring specific causal factors, either genetic or environmental in origin.

uterine abnormalities

Women with uterine abnormalities have a high incidence of breech presentation. [ 14 ] [ 17 ] [ 18 ] [ 19 ]

female fetus

Fifty-four percent of breech-presenting fetuses are female. [ 14 ]

abnormal amniotic fluid volume

Both oligohydramnios and polyhydramnios are associated with breech presentation. [ 1 ] [ 12 ] [ 14 ]

Low amniotic fluid volume decreases the likelihood of a fetus turning to a cephalic position; an increased amniotic fluid volume may facilitate frequent change in position.

placental abnormalities

An association between placental implantation in the cornual-fundal region and breech presentation has been reported, although some studies have not found it a risk factor. [ 8 ] [ 20 ] [ 21 ] [ 22 ] [ 10 ] [ 14 ]

The association with placenta previa is also inconsistent. [ 8 ] [ 9 ] [ 22 ] Placenta previa is associated with preterm birth and may be an indirect risk factor.

Pelvic or vaginal examination reveals the buttocks and/or feet, felt as a yielding, irregular mass, as the presenting part. [ 26 ] In cephalic presentation, a hard, round, regular fetal head can be palpated. [ 26 ]

The Leopold maneuver on examination suggests breech position by palpation of the fetal head under the costal margin. [ 26 ]

The baby's heartbeat should be auscultated using a Pinard stethoscope or a hand-held Doppler to indicate the position of the fetus. The fetal heartbeat lies above the maternal umbilicus in breech presentation. [ 1 ]

Tenderness under one or other costal margin as a result of pressure by the harder fetal head.

Pain due to fetal kicks in the maternal pelvis or bladder.

breech position

Visualizes the fetus and reveals its position.

Used to confirm a clinically suspected breech presentation. [ 28 ]

Should be performed by practitioners with appropriate skills in obstetric ultrasound.

Establishes the type of breech presentation by imaging the fetal femurs and their relationship to the distal bones.

Transverse lie

Differentiating Signs/Symptoms

Fetus lies horizontally across the uterus with the shoulder as the presenting part.

Similar predisposing factors such as placenta previa, abnormal amniotic fluid volume, and uterine anomalies, although more common in multiparity. [ 1 ] [ 2 ] [ 29 ]

Differentiating Tests

Clinical examination and fetal auscultation may be indicative.

Ultrasound confirms presentation.

Treatment Approach

Breech presentation <37 weeks' gestation.

The UK Royal College of Obstetricians and Gynaecologists (RCOG) recommends that corticosteroids should be offered to women between 24 and 34+6 weeks' gestation, in whom imminent preterm birth is anticipated. Corticosteroids should only be considered after discussion of risks/benefits at 35 to 36+6 weeks. Given within 7 days of preterm birth, corticosteroids may reduce perinatal and neonatal death and respiratory distress syndrome. [ 32 ] The American College of Obstetricians and Gynecologists (ACOG) recommends a single course of corticosteroids for pregnant women between 24 and 33+6 weeks' gestation who are at risk of preterm delivery within 7 days, including those with ruptured membranes and multiple gestations. It may also be considered for pregnant women starting at 23 weeks' gestation who are at risk of preterm delivery within 7 days. A single course of betamethasone is recommended for pregnant women between 34 and 36+6 weeks' gestation at risk of preterm birth within 7 days, and who have not received a previous course of prenatal corticosteroids. Regularly scheduled repeat courses or serial courses (more than two) are not currently recommended. A single repeat course of prenatal corticosteroids should be considered in women who are less than 34 weeks' gestation, who are at risk of preterm delivery within 7 days, and whose prior course of prenatal corticosteroids was administered more than 14 days previously. Rescue course corticosteroids could be provided as early as 7 days from the prior dose, if indicated by the clinical scenario. [ 33 ]

Magnesium sulfate given before anticipated early preterm birth reduces the risk of cerebral palsy in surviving infants. Physicians electing to use magnesium sulfate for fetal neuroprotection should develop specific guidelines regarding inclusion criteria, treatment regimens, and concurrent tocolysis. [ 34 ]

Breech presentation from 37 weeks' gestation, before labor

ECV is the initial treatment for a breech presentation at term when the patient is not in labor. It involves turning a fetus presenting by the breech to a cephalic (head-down) presentation to increase the likelihood of vaginal birth. [ 35 ] [ 36 ] Where available, it should be offered to all women in late pregnancy, by an experienced clinician, in hospitals with facilities for emergency delivery, and no contraindications to the procedure. [ 35 ] There is no upper time limit on the appropriate gestation for ECV, with success reported at 42 weeks.

There is no general consensus on contraindications to ECV. Contraindications include multiple pregnancy (except after delivery of a first twin), ruptured membranes, current or recent (<1 week) vaginal bleeding, rhesus isoimmunization, other indications for cesarean section (e.g., placenta previa or uterine malformation), or abnormal electronic fetal monitoring. [ 35 ] One systematic review of relative contraindications for ECV highlighted that most contraindications do not have clear empirical evidence. Exceptions include placental abruption, severe preeclampsia/HELLP syndrome, or signs of fetal distress (abnormal cardiotocography and/or Doppler flow). [ 36 ]

The procedure involves applying external pressure and firmly pushing or palpating the mother's abdomen to coerce the fetus to somersault (either forward or backward) into a cephalic position. [ 37 ]

The overall ECV success rate varies but, in a large series, 47% of women following an ECV attempt had a cephalic presentation at birth. [ 35 ] [ 38 ] Various factors influence the success rate. One systematic review found ECV success rates to be 68% overall, with the rate significantly higher for women from African countries (89%) compared with women from non-African countries (62%), and higher among multiparous (78%) than nulliparous women (48%). [ 39 ] Overall, the ECV success rates for nulliparous and multiparous non-African women were 43% and 73%, respectively, while for nulliparous and multiparous African women rates were 79% and 91%, respectively. Another study reported no difference in success rate or rate of cesarean section among women with previous cesarean section undergoing ECV compared with women with previous vaginal birth. However, numbers were small and further studies in this regard are required. [ 40 ]

Women's preference for vaginal delivery is a major contributing factor in their decision for ECV. However, studies suggest women with a breech presentation at term may not receive complete and/or evidence-based information about the benefits and risks of ECV. [ 41 ] [ 42 ] Although up to 60% of women reported ECV to be painful, the majority highlighted the benefits outweigh the risks (71%) and would recommend ECV to their friends or be willing to repeat for themselves (84%). [ 41 ] [ 42 ]

Cardiotocography and ultrasound should be performed before and after the procedure. Tocolysis should be used to facilitate the maneuver, and Rho(D) immune globulin should be administered to women who are Rhesus negative. [ 35 ] Tocolytic agents include adrenergic beta-2 receptor stimulants such as albuterol, terbutaline, or ritodrine (widely used with ECV in some countries, but not yet available in the US). One Cochrane review of tocolytic beta stimulants demonstrates that these are less likely to be associated with failed ECV, and are effective in increasing cephalic presentation and reducing cesarean section. [ 43 ] There is no current evidence to recommend one beta-2 adrenergic receptor agonist over another. Until these data are available, adherence to a local protocol for tocolysis is recommended. The Food and Drug Administration has issued a warning against using injectable terbutaline beyond 48 to 72 hours, or acute or prolonged treatment with oral terbutaline, in pregnant women for the prevention or prolonged treatment of preterm labor, due to potential serious maternal cardiac adverse effects and death. [ 44 ] Whether this warning applies to the subcutaneous administration of terbutaline in ECV is still unclear; however, studies currently support this use. The European Medicines Agency (EMA) recommends that injectable beta agonists should be used for up to 48 hours between the 22nd and 37th week of pregnancy only. They should be used under specialist supervision with continuous monitoring of the mother and unborn baby owing to the risk of adverse cardiovascular effects in both the mother and baby. The EMA no longer recommends oral or rectal formulations for obstetric indications. [ 45 ]

If ECV is successful, pregnancy care should continue as usual for any cephalic presentation. One systematic review assessing the mode of delivery after a successful ECV found that these women were at increased risk for cesarean section and instrumental vaginal delivery compared with women with spontaneous cephalic pregnancies. However, they still had a lower rate of cesarean section following ECV (i.e., 47%) compared with the cesarean section rate for those with a persisting breech (i.e., 85%). With a number needed to treat of three, ECV is still considered to be an effective means of preventing the need for cesarean section. [ 46 ]

Planned cesarean section should be offered as the safest mode of delivery for the baby, even though it carries a small increase in serious immediate maternal complications compared with vaginal birth. [ 24 ] [ 25 ] [ 31 ] In the US, most unsuccessful ECV with persistent breech will be delivered via cesarean section.

A vaginal mode of delivery may be considered by some clinicians as an option, particularly when maternal request is provided, senior and experienced staff are available, there is no absolute contraindication to vaginal birth (e.g., placenta previa, compromised fetal condition), and with optimal fetal growth (estimated weight above the tenth centile and up to 3800 g). Other factors that make planned vaginal birth higher risk include hyperextended neck on ultrasound and footling presentation. [ 24 ]

Breech presentation from 37 weeks' gestation, during labor

The first option should be a planned cesarean section.

There is a small increase in the risk of serious immediate maternal complications compared with vaginal birth (RR 1.29, 95% CI 1.03 to 1.61), including pulmonary embolism, infection, bleeding, damage to the bladder and bowel, slower recovery from the delivery, longer hospitalization, and delayed bonding and breast-feeding. [ 23 ] [ 31 ] [ 47 ] [ 48 ] [ 49 ] [ 50 ] [ 51 ] [ 52 ] [ 53 ] [ 54 ] [ 55 ] [ 56 ] [ 57 ] [ 58 ] Consider using antimicrobial triclosan-coated sutures for wound closure to reduce the risk of surgical site infection. [ 59 ]

Planned cesarean section is safer for babies, but is associated with increased neonatal respiratory distress. The risk is reduced when the section is performed at 39 weeks' gestation. [ 64 ] [ 65 ] [ 66 ] For women undergoing a planned cesarean section, RCOG recommends an informed discussion about the potential risks and benefits of a course of prenatal corticosteroids between 37 and 38+6 weeks' gestation. Although prenatal corticosteroids may reduce admission to the neonatal unit for respiratory morbidity, it is uncertain if there is any reduction in respiratory distress syndrome, transient tachypnea of the newborn, or neonatal unit admission overall. In addition, prenatal corticosteroids may result in harm to the neonate, including hypoglycemia and potential developmental delay. [ 32 ] ACOG does not recommend corticosteroids in women >37 weeks' gestation. [ 33 ]

Undiagnosed breech in labor generally results in cesarean section after the onset of labor, higher rates of emergency cesarean section associated with the least favorable maternal outcomes, a greater likelihood of cord prolapse, and other poor infant outcomes. [ 23 ] [ 67 ] [ 49 ] [ 68 ] [ 69 ] [ 70 ] [ 71 ]

This mode of delivery may be considered by some clinicians as an option for women who are in labor, particularly when delivery is imminent. Vaginal breech delivery may also be considered, where suitable, when delivery is not imminent, maternal request is provided, senior and experienced staff are available, there is no absolute contraindication to vaginal birth (e.g., placenta previa, compromised fetal condition), and with optimal fetal growth (estimated weight above the tenth centile and up to 3800 g). Other factors that make planned vaginal birth higher risk include hyperextended neck on ultrasound and footling presentation. [ 24 ]

Findings from one systematic review of 27 observational studies revealed that the absolute risks of perinatal mortality, fetal neurologic morbidity, birth trauma, 5-minute Apgar score <7, and neonatal asphyxia in the planned vaginal delivery group were low at 0.3%, 0.7%, 0.7%, 2.4%, and 3.3%, respectively. However, the relative risks of perinatal mortality and morbidity were 2- to 5-fold higher in the planned vaginal than in the planned cesarean delivery group. Authors recommend ongoing judicious decision-making for vaginal breech delivery for selected singleton, term breech babies. [ 72 ]

ECV may also be considered an option for women with breech presentation in early labor, when delivery is not imminent, provided that the membranes are intact.

A woman presenting with a breech presentation <37 weeks is an area of clinical controversy. Optimal mode of delivery for preterm breech has not been fully evaluated in clinical trials, and the relative risks for the preterm infant and mother remain unclear. In the absence of good evidence, if diagnosis of breech presentation prior to 37 weeks' gestation is made, prematurity and clinical circumstances should determine management and mode of delivery.

Primary Options

12 mg intramuscularly every 24 hours for 2 doses

6 mg intramuscularly every 12 hours for 4 doses

The UK Royal College of Obstetricians and Gynaecologists recommends that corticosteroids should be offered to women between 24 and 34+6 weeks' gestation, in whom imminent preterm birth is anticipated. Corticosteroids should only be considered after discussion of risks/benefits at 35 to 36+6 weeks. Given within 7 days of preterm birth, corticosteroids may reduce perinatal and neonatal death and respiratory distress syndrome. [ 32 ]

The American College of Obstetricians and Gynecologists recommends a single course of corticosteroids for pregnant women between 24 and 33+6 weeks' gestation who are at risk of preterm delivery within 7 days, including those with ruptured membranes and multiple gestations. It may also be considered for pregnant women starting at 23 weeks' gestation who are at risk of preterm delivery within 7 days. A single course of betamethasone is recommended for pregnant women between 34 and 36+6 weeks' gestation at risk of preterm birth within 7 days, and who have not received a previous course of prenatal corticosteroids. Regularly scheduled repeat courses or serial courses (more than two) are not currently recommended. A single repeat course of prenatal corticosteroids should be considered in women who are less than 34 weeks' gestation, who are at risk of preterm delivery within 7 days, and whose prior course of prenatal corticosteroids was administered more than 14 days previously. Rescue course corticosteroids could be provided as early as 7 days from the prior dose, if indicated by the clinical scenario. [ 33 ]

consult specialist for guidance on dose

external cephalic version (ECV)

There is no upper time limit on the appropriate gestation for ECV; it should be offered to all women in late pregnancy by an experienced clinician in hospitals with facilities for emergency delivery and no contraindications to the procedure. [ 35 ] [ 36 ]

ECV involves applying external pressure and firmly pushing or palpating the mother's abdomen to coerce the fetus to somersault (either forward or backward) into a cephalic position. [ 37 ]

Cardiotocography and ultrasound should be performed before and after the procedure.

If ECV is successful, pregnancy care should continue as usual for any cephalic presentation. A systematic review assessing the mode of delivery after a successful ECV found that these women were at increased risk for cesarean section and instrumental vaginal delivery compared with women with spontaneous cephalic pregnancies. However, they still had a lower rate of cesarean section following ECV (i.e., 47%) compared with the cesarean section rate for those with a persisting breech (i.e., 85%). With a number needed to treat of 3, ECV is still considered to be an effective means of preventing the need for cesarean section. [ 46 ]

tocolytic agents

see local specialist protocol for dosing guidelines

Tocolytic agents include adrenergic beta-2 receptor stimulants such as albuterol, terbutaline, or ritodrine (widely used with external cephalic version [ECV] in some countries, but not yet available in the US). They are used to delay or inhibit labor and increase the success rate of ECV. There is no current evidence to recommend one beta-2 adrenergic receptor agonist over another. Until these data are available, adherence to a local protocol for tocolysis is recommended.

The Food and Drug Administration has issued a warning against using injectable terbutaline beyond 48-72 hours, or acute or prolonged treatment with oral terbutaline, in pregnant women for the prevention or prolonged treatment of preterm labor, due to potential serious maternal cardiac adverse effects and death. [ 44 ] Whether this warning applies to the subcutaneous administration of terbutaline in ECV is still unclear; however, studies currently support this use. The European Medicines Agency (EMA) recommends that injectable beta agonists should be used for up to 48 hours between the 22nd and 37th week of pregnancy only. They should be used under specialist supervision with continuous monitoring of the mother and unborn baby owing to the risk of adverse cardiovascular effects in both the mother and baby. The EMA no longer recommends oral or rectal formulations for obstetric indications. [ 45 ]

A systematic review found there was no evidence to support the use of nifedipine for tocolysis. [ 73 ]

There is insufficient evidence to evaluate other interventions to help ECV, such as fetal acoustic stimulation in midline fetal spine positions, or epidural or spinal analgesia. [ 43 ]

Rho(D) immune globulin

300 micrograms intramuscularly as a single dose

Nonsensitized Rh-negative women should receive Rho(D) immune globulin. [ 35 ]

The indication for its administration is to prevent rhesus isoimmunization, which may affect subsequent pregnancy outcomes.

Rho(D) immune globulin needs to be given at the time of external cephalic version and should be given again postpartum to those women who give birth to an Rh-positive baby. [ 74 ]

It is best administered as soon as possible after the procedure, usually within 72 hours.

Dose depends on brand used. Dose given below pertains to most commonly used brands. Consult specialist for further guidance on dose.

elective cesarean section/vaginal breech delivery

Mode of delivery (cesarean section or vaginal breech delivery) should be based on the experience of the attending clinician, hospital policies, maternal request, and the presence or absence of complicating factors. In the US, most unsuccessful external cephalic version (ECV) with persistent breech will be delivered via cesarean section.

Cesarean section, at 39 weeks or greater, has been shown to significantly reduce perinatal mortality and neonatal morbidity compared with vaginal breech delivery (RR 0.33, 95% CI 0.19 to 0.56). [ 31 ] Although safer for these babies, there is a small increase in serious immediate maternal complications compared with vaginal birth (RR 1.29, 95% CI 1.03 to 1.61), as well as long-term risks for future pregnancies, including pulmonary embolism, bleeding, infection, damage to the bladder and bowel, slower recovery from the delivery, longer hospitalization, and delayed bonding and breast-feeding. [ 23 ] [ 31 ] [ 47 ] [ 48 ] [ 49 ] [ 50 ] [ 51 ] [ 52 ] [ 53 ] [ 54 ] [ 55 ] [ 56 ] [ 57 ] [ 58 ] Consider using antimicrobial triclosan-coated sutures for wound closure to reduce the risk of surgical site infection. [ 59 ]

Vaginal delivery may be considered by some clinicians as an option, particularly when maternal request is provided, when senior and experienced staff are available, when there is no absolute contraindication to vaginal birth (e.g., placenta previa, compromised fetal condition), and with optimal fetal growth (estimated weight above the tenth centile and up to 3800 g). Other factors that make planned vaginal birth higher risk include hyperextended neck on ultrasound and footling presentation. [ 24 ]

For women undergoing a planned cesarean section, the UK Royal College of Obstetricians and Gynaecologists recommends an informed discussion about the potential risks and benefits of a course of prenatal corticosteroids between 37 and 38+6 weeks' gestation. Although prenatal corticosteroids may reduce admission to the neonatal unit for respiratory morbidity, it is uncertain if there is any reduction in respiratory distress syndrome, transient tachypnea of the newborn, or neonatal unit admission overall. In addition, prenatal corticosteroids may result in harm to the neonate, including hypoglycemia and potential developmental delay. [ 32 ] The American College of Obstetricians and Gynecologists does not recommend corticosteroids in women >37 weeks' gestation. [ 33 ]

It is best administered as soon as possible after delivery, usually within 72 hours.

Administration of postpartum Rho (D) immune globulin should not be affected by previous routine prenatal prophylaxis or previous administration for a potentially sensitizing event. [ 74 ]

≥37 weeks' gestation in labor: no imminent delivery

planned cesarean section

For women with breech presentation in labor, planned cesarean section at 39 weeks or greater has been shown to significantly reduce perinatal mortality and neonatal morbidity compared with vaginal breech delivery (RR 0.33, 95% CI 0.19 to 0.56). [ 31 ]

Although safer for these babies, there is a small increase in serious immediate maternal complications compared with vaginal birth (RR 1.29, 95% CI 1.03 to 1.61), as well as long-term risks for future pregnancies, including pulmonary embolism, infection, bleeding, damage to the bladder and bowel, slower recovery from the delivery, longer hospitalization, and delayed bonding and breast-feeding. [ 23 ] [ 31 ] [ 47 ] [ 48 ] [ 49 ] [ 50 ] [ 51 ] [ 52 ] [ 53 ] [ 54 ] [ 55 ] [ 56 ] [ 57 ] [ 58 ] Consider using antimicrobial triclosan-coated sutures for wound closure to reduce the risk of surgical site infection. [ 59 ]

Continuous cardiotocography monitoring should continue until delivery. [ 24 ] [ 25 ]

vaginal breech delivery

This mode of delivery may be considered by some clinicians as an option, particularly when maternal request is provided, when senior and experienced staff are available, when there is no absolute contraindication to vaginal birth (e.g., placenta previa, compromised fetal condition), and with optimal fetal growth (estimated weight above the tenth centile and up to 3800 g). Other factors that make planned vaginal birth higher risk include hyperextended neck on ultrasound and footling presentation. [ 24 ]

For women with persisting breech presentation, planned cesarean section has, however, been shown to significantly reduce perinatal mortality and neonatal morbidity compared with vaginal breech delivery (RR 0.33, 95% CI 0.19 to 0.56). [ 31 ]

ECV may also be considered an option for women with breech presentation in early labor, provided that the membranes are intact.

There is no upper time limit on the appropriate gestation for ECV. [ 35 ]

Involves applying external pressure and firmly pushing or palpating the mother's abdomen to coerce the fetus to somersault (either forward or backward) into a cephalic position. [ 37 ]

Relative contraindications include placental abruption, severe preeclampsia/HELLP syndrome, and signs of fetal distress (abnormal cardiotocography and/or abnormal Doppler flow). [ 35 ] [ 36 ]

Rho(D) immune globulin needs to be given at the time of ECV and should be given again postpartum to those women who give birth to an Rh-positive baby. [ 74 ]

≥37 weeks' gestation in labor: imminent delivery

cesarean section

For women with persistent breech presentation, planned cesarean section has been shown to significantly reduce perinatal mortality and neonatal morbidity compared with vaginal breech delivery (RR 0.33, 95% CI 0.19 to 0.56). [ 31 ] Although safer for these babies, there is a small increase in serious immediate maternal complications compared with vaginal birth (RR 1.29, 95% CI 1.03 to 1.61), as well as long-term risks for future pregnancies, including pulmonary embolism, infection, bleeding, damage to the bladder and bowel, slower recovery from the delivery, longer hospitalization, and delayed bonding and breast-feeding. [ 23 ] [ 31 ] [ 47 ] [ 48 ] [ 49 ] [ 50 ] [ 51 ] [ 52 ] [ 53 ] [ 54 ] [ 55 ] [ 56 ] [ 57 ] [ 58 ] Consider using antimicrobial triclosan-coated sutures for wound closure to reduce the risk of surgical site infection. [ 59 ]

This mode of delivery may be considered by some clinicians as an option, particularly when delivery is imminent, maternal request is provided, when senior and experienced staff are available, when there is no absolute contraindication to vaginal birth (e.g., placenta previa, compromised fetal condition), and with optimal fetal growth (estimated weight above the tenth centile and up to 3800 g). Other factors that make planned vaginal birth higher risk include hyperextended neck on ultrasound and footling presentation. [ 24 ]

It is best administered as soon as possible after the delivery, usually within 72 hours.

External cephalic version before term

Moxibustion, postural management, follow-up overview, perinatal complications.

Compared with cephalic presentation, persistent breech presentation has increased frequency of cord prolapse, abruptio placentae, prelabor rupture of membranes, perinatal mortality, fetal distress (heart rate <100 bpm), preterm delivery, lower fetal weight. [ 10 ] [ 11 ] [ 67 ]

complications of cesarean section

The long-term risks include potential compromise of future obstetric performance, increased risk of repeat cesarean section, infertility, uterine rupture, placenta accreta, placental abruption, and emergency hysterectomy. [ 60 ] [ 61 ] [ 62 ] [ 63 ] The evidence suggests that using sutures, rather than staples, for wound closure after cesarean section reduces the incidence of wound dehiscence. [ 59 ]

Emergency cesarean section, compared with planned cesarean section, has demonstrated a higher risk of severe obstetric morbidity, intra-operative complications, postoperative complications, infection, blood loss >1500 mL, fever, pain, tiredness, and breast-feeding problems. [ 23 ] [ 48 ] [ 50 ] [ 70 ] [ 81 ]

Key Articles

Impey LWM, Murphy DJ, Griffiths M, et al; Royal College of Obstetricians and Gynaecologists. Management of breech presentation: green-top guideline no. 20b. BJOG. 2017 Jun;124(7):e151-77. [Full Text]

Hofmeyr GJ, Hannah M, Lawrie TA. Planned caesarean section for term breech delivery. Cochrane Database Syst Rev. 2015 Jul 21;(7):CD000166. [Abstract] [Full Text]

Royal College of Obstetricians and Gynaecologists. External cephalic version and reducing the incidence of term breech presentation. March 2017 [internet publication]. [Full Text]

Cluver C, Gyte GM, Sinclair M, et al. Interventions for helping to turn term breech babies to head first presentation when using external cephalic version. Cochrane Database Syst Rev. 2015 Feb 9;(2):CD000184. [Abstract] [Full Text]

de Hundt M, Velzel J, de Groot CJ, et al. Mode of delivery after successful external cephalic version: a systematic review and meta-analysis. Obstet Gynecol. 2014 Jun;123(6):1327-34. [Abstract]

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Mechanism of Labour

First Online: 02 August 2023

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Vinayachandran S. 2 , 3 &
Sajala Vimalraj 2

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Labour and delivery, the process by which the mature foetus is expelled from the uterus, is not a passive process. It involves a complex interaction of uterine activity, the foetus and the maternal pelvis, to achieve a successful negotiation of this start of the human life. This chapter describes the Mechanism of Labour - the positional changes in the presenting part of the foetus to achieve a successful passage through the birth canal - with a brief look at the passenger (the foetus), the passage (the pelvis) and the powers (the uterine activity) and the complex interaction between them, resulting in the six cardinal movements – descent, flexion, internal rotation, extension, restitution and external rotation. It also gives an overview of the normal progression of Labour and the evolution from the traditional model described by Friedman to the contemporary partogram, influenced by the pioneering work of Zhang et al, according to which more time can be given to the labouring woman to achieve natural childbirth, provide maternal and foetal condition remains good. All of this has been incorporated into the WHO Labour Care Guide, designed to encourage Respectable Maternity Care. Intrapartum USG can also help guide the Obstetrician about the progress of Labour and the need for Caesarean Delivery

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S., V., Vimalraj, S. (2023). Mechanism of Labour. In: Garg, R. (eds) Labour and Delivery. Springer, Singapore. https://doi.org/10.1007/978-981-19-6145-8_2

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Evidence review for breech presenting in labour

Evidence review O

NICE Guideline, No. 121

National Guideline Alliance (UK) .

Intrapartum care for women with breech presenting in labour – mode of birth

Review question.

What is the optimal mode of birth (emergency caesarean section or continuation of labour) for women with breech presenting in the first or second stage of labour?

Introduction

The aim of this review is to determine the optimal mode of birth (emergency caesarean section or continuation of labour) for women with breech presenting in the first or second stage of labour. The NICE guideline on caesarean section (CG132) recommends that women who have an uncomplicated singleton breech pregnancy at 36 weeks of gestation should be offered external cephalic version, and that pregnant women with a singleton breech presentation at term, for whom external cephalic version is contraindicated or has been unsuccessful, should be offered a caesarean section. This review addresses mode of birth for women with breech presentation in labour who have declined an offer of caesarean section or in whom labour starts before a planned caesarean section is performed.

Preterm labour and birth are excluded from this review question because breech presentation in preterm labour and birth is covered in the NICE guideline on preterm labour and birth (NG25).

Summary of the protocol

See Table 1 for a summary of the population, intervention, comparison and outcome (PICO) characteristics of this review.

Summary of the protocol (PICO table).

For further details see the full review protocol in Appendix A – Review protocol . The search strategies are presented in Appendix B – Literature search strategies .

Clinical evidence

Included studies.

Seventeen publications reporting 15 prospective cohort studies were included in this review (see ‘ Summary of clinical studies included in the evidence review ’).

Of these, 14 ( Alshaheen 2010 , Barlov 1986 , Bird 1975 , Capeless 1985 , Collea 1980 , De Leeuw 2002 , Gimovsky 1983 , Jaffa 1981 , Maier 2011 , Molkenboer 2007 , Sarno 1989 , Singh 2012 , van Loon 1997 , Zatuchni 1967 ) compared emergency caesarean section in labour to continuation of labour; the remainder ( Su 2003 , Su 2004 , Su 2007 ; 3 publications that reported different outcomes from the same study) compared emergency caesarean section in early labour to continuation of labour, and emergency caesarean section in active labour to continuation of labour.

Evidence from the studies included in the review is summarised below (see ‘ Quality assessment of clinical studies included in the evidence review ’).

Data was reported on the critical outcomes, major maternal morbidities (obstetric anal sphincter injury (OASI), postpartum haemorrhage and systemic infection), mortality and major morbidities in the baby (hypoxic ischaemic encephalopathy (HIE), respiratory complications, and birth injury), and on the important outcome, admission to the neonatal intensive care unit (NICU). Data was also reported on 2 composite outcomes, maternal morbidity and adverse perinatal outcome, which included some outcomes in the guideline review protocol, but also outcomes that were not in the protocol. There was no evidence identified for the following outcomes for the woman: pelvic floor injury (critical outcome), admission to a high dependency unit (HDU) or the intensive therapy unit (ITU) and duration of hospital stay (important outcomes). In relation to woman’s experience of labour and birth, including experience of her birth companion(s), separation of the woman and the baby and breastfeeding initiation (important outcomes), only evidence on breastfeeding initiation and on a proxy (indirect) outcome (early postpartum depression) was identified. There was no evidence identified for the following critical outcome for the baby: sepsis.

See also the study selection flow chart in Appendix C – Clinical evidence study selection .

Excluded studies

Studies not included in this review with reasons for their exclusion are listed in Appendix D – Excluded studies .

Summary of clinical studies included in the evidence review

Table 2 provides a brief summary of the included studies.

Summary of included studies.

See also the study evidence tables in Appendix E – Clinical evidence tables . No meta-analysis was undertaken for this review (and so there are no forest plots in Appendix F – Forest plots ).

Quality assessment of clinical studies included in the evidence review

The clinical evidence profiles for this review question are presented in Appendix G – GRADE tables .

Economic evidence

No economic evidence was identified for this review.

See the study selection flow chart in Supplement 2 (Health economics) .

Studies not included in this review with reasons for their exclusion are listed in Supplement 2 (Health economics) .

Summary of studies included in the economic evidence review

No economic evidence was identified for this review (and so there are no economic evidence tables in Supplement 2 (Health economics) ).

Economic model

No economic modelling was undertaken for this review because of the high risk of selection bias in the studies included in the clinical evidence review (see Supplement 2 (Health economics) ).

Evidence statements

Emergency caesarean section in labour versus continuation of labour, outcomes for the woman, third-degree perineal laceration.

Very low quality evidence from 1 prospective cohort study in women with breech presentation in labour (N=189) found no clinically important difference in the incidence of third-degree perineal laceration between women who had an emergency caesarean section and those who had a vaginal birth.

Blood loss greater than 500 ml

Very low quality evidence from 1 prospective cohort study in women with breech presentation in labour (N=189) found no clinically important difference in the incidence of blood loss > 500 ml between women who had an emergency caesarean section and those who had a vaginal birth.

Blood loss greater than 1000 ml

Very low quality evidence from 1 prospective cohort study in women with breech presentation in labour (N=189) found no clinically important difference in the incidence of blood loss > 1000 ml between the group of women who had an emergency caesarean section and those who had a vaginal birth.

Mean blood loss

Very low quality evidence from 1 prospective cohort study in women with breech presentation in labour (N=125) reported that mean blood loss at birth was 522.7 ml (range 100 to 1200 ml) in the group who had an emergency caesarean section in labour and 255.2 ml (range 50 to 775 ml) in the group who had a vaginal birth. Due to insufficient data no confidence interval (CI) for the difference between groups could be calculated.

Breastfeeding

Very low quality evidence from 1 prospective cohort study in women with breech presentation in labour (N=140) found a clinically important higher incidence of women who breastfed in the group who had an emergency caesarean section compared to the group who had a vaginal birth.

Outcomes for the baby

Perinatal mortality.

Very low quality evidence from 2 prospective cohort studies in women with breech presentation in labour (N=277 and N=66) reported no perinatal deaths in the group who had an emergency caesarean section in labour or those who had a vaginal birth. Due to zero events in both groups no risk estimate could be calculated. Very low quality evidence from 1 prospective cohort study in women with breech presentation in labour (N=154) found no clinically important difference in the incidence of perinatal mortality between women who had an emergency caesarean section and those who had a vaginal birth.

Very low quality evidence from 1 prospective cohort study in women with breech presentation in labour (N=210, including n=104 nulliparous and 106 multiparous) reported no stillbirths in either nulliparous or multiparous women who had an emergency caesarean section in labour or in either nulliparous or multiparous women who had a vaginal birth. Due to zero events in both groups no risk estimate could be calculated. Very low quality evidence from 1 prospective cohort study in women with breech presentation in labour (N=290) reported no stillbirths in the group who had an emergency caesarean section in labour or those who had a vaginal birth. Due to zero events in both groups no risk estimate could be calculated. Very low quality evidence from 2 prospective cohort studies in women with breech presentation in labour (N=170 and N=139) found no clinically important difference in the incidence of stillbirth between the group who had an emergency caesarean section and those who had a vaginal birth.

Early neonatal mortality

Very low quality evidence from 1 prospective cohort study in women with breech presentation in labour (N=210, including n=104 nulliparous and 106 multiparous) reported a clinically important lower incidence of early neonatal death in the group of nulliparous women who had emergency CS in labour compared to nulliparous women who had a vaginal birth. The same study found no clinically important difference in the incidence of early neonatal death between multiparous women who had emergency caesarean section in labour and multiparous women who had a vaginal birth. Very low quality evidence from 1 prospective cohort study in women with breech presentation in labour (N=170) reported no early neonatal deaths in the group who had an emergency caesarean section in labour or in those who had a vaginal birth. Due to zero events in both groups no risk estimate could be calculated.

Neonatal mortality (not further specified as early or late)

Very low quality evidence from 2 prospective cohort studies in women in labour with singleton breech presentation (N=290 and N=46) found no clinically important difference in the incidence of neonatal deaths between the group who had an emergency caesarean section and those who had a vaginal birth. Very low quality evidence from 2 prospective cohort studies in women with breech presentation in labour (N=125 and N=27; in the second study the 27 women also had a previous caesarean section) reported no neonatal deaths in the group who had an emergency caesarean section in labour or in those who had a vaginal birth. Due to zero events in both groups no risk estimate could be calculated.

Late neonatal mortality

Very low quality evidence from 1 prospective cohort study in women with breech presentation in labour (N=170) reported no late neonatal deaths in the group who had an emergency caesarean section in labour or in those who had a vaginal birth. Due to zero events in both groups no risk estimate could be calculated.

Birth asphyxia

Very low quality evidence from 1 prospective cohort study in women with breech presentation in labour (N=210) found no clinically important difference in the incidence of birth asphyxia between the group who had an emergency caesarean section and those who had a vaginal birth.

Requirement for resuscitation

Very low quality evidence from 1 prospective cohort study in women with breech presentation in labour (N=290) found a clinically important lower incidence of babies requiring resuscitation in the group who had an emergency caesarean section compared to those who had a vaginal birth.

Cardiorespiratory depression

Very low quality evidence from 1 prospective cohort study in women with breech presentation in labour (N=290) found a possibly clinically important lower incidence of babies with cardiorespiratory depression in the group who had an emergency caesarean section compared to those who had a vaginal birth. (‘Possibly’ clinically important means that this result was not statistically significant at the 95% confidence level, but it was statistically significant at the 90% confidence level. Moreover the risk ratio was below 0.80, which is the default minimally important difference.)

Neonatal pulmonary insufficiency necessitating C-PAP

Very low quality evidence from 1 prospective cohort study in women with breech presentation in labour (N=125) found no clinically important difference in the incidence of neonatal pulmonary insufficiency necessitating continuous positive airway pressure (C-PAP) between the group who had an emergency caesarean section and those who had a vaginal birth.

Spontaneous bilateral pneumothorax

Very low quality evidence from 1 prospective cohort study in women with breech presentation in labour (N=66) found no clinically important difference in the incidence of spontaneous bilateral pneumothorax between the group who had an emergency caesarean section and those who had a vaginal birth.

Brachial palsy and brachial plexus lesion or injury

Very low quality evidence from 2 prospective cohort studies in women with breech presentation in labour (N=125 and N=139) found no clinically important difference in the incidence of brachial palsy between the group who had an emergency caesarean section and those who had a vaginal birth. Very low quality evidence from 3 prospective cohort studies in women in labour with singleton breech presentation (N=210, N=66, and N=189) found no clinically important difference in the incidence of brachial plexus lesion or injury between the group of women who had an emergency caesarean section and those who had a vaginal birth.

Fractured humerus

Very low quality evidence from 1 prospective cohort study in women with breech presentation in labour (N=125) found no clinically important difference in the incidence of fractured humerus in the baby between the group who had an emergency caesarean section and those who had a vaginal birth. Very low quality evidence from 1 prospective cohort study in women with breech presentation in labour (N=154) reported no events of fractured humerus in the group who had an emergency caesarean section in labour and those who had a vaginal birth. Due to zero events in both groups no risk estimate could be calculated.

Fractured clavicle

Very low quality evidence from 3 prospective cohort studies in women with breech presentation in labour (N=210, N=125, and N=290) found no clinically important difference in the incidence of fractured clavicle in the baby between the group who had an emergency caesarean section and those who had a vaginal birth. Very low quality evidence from 1 prospective cohort study in women with breech presentation in labour (N=154) reported no events of fractured clavicle in the group who had an emergency caesarean section in labour and those who had a vaginal birth. Due to zero events in both groups no risk estimate could be calculated.

Depressed skull fracture

Very low quality evidence from 1 prospective cohort study in women with breech presentation in labour (N=290) found no clinically important difference in the incidence of depressed skull fracture in the baby between the group who had an emergency caesarean section and those who had a vaginal birth.

Facial palsy

Very low quality evidence from 1 prospective cohort study in women with breech presentation in labour (N=86) found no clinically important difference in the incidence of facial palsy between the group who had an emergency caesarean section and those who had a vaginal birth.

Erb’s palsy

Very low quality evidence from 1 prospective cohort study in women with breech presentation in labour and previous caesarean section (N=27) found no clinically important difference in the incidence of Erb’s palsy between the group who had an emergency caesarean section and those who had a vaginal birth. Very low quality evidence from 1 prospective cohort study in women with breech presentation in labour (N=154) reported no events of Erb’s palsy in the group who had an emergency caesarean section in labour and those who had a vaginal birth. Due to zero events in both groups no risk estimate could be calculated.

Birth trauma (due to a trapped head)

Genital haematoma

with breech presentation in labour (N=85) found no clinically important difference in the incidence of genital haematoma between the group who had an emergency caesarean section and those who had a vaginal birth.

Cephalic haematoma

Very low quality evidence from 1 prospective cohort study in women with breech presentation in labour (N=85) found no clinically important difference in the incidence of cephalic haematoma between the group who had an emergency caesarean section and those who had a vaginal birth.

Damage to soft tissue and laceration

Very low quality evidence from 1 prospective cohort study in women with breech presentation in labour (N=154) found no clinically important difference in the incidence of damage to the baby’s soft tissue and laceration between the group who had an emergency caesarean section and those who had a vaginal birth.

Dislocation of the hip

Very low quality evidence from 1 prospective cohort study in women with breech presentation in labour (N=154) reported no events of dislocation of the baby’s hip in the group who had an emergency caesarean section in labour and those who had a vaginal birth. Due to zero events in both groups no risk estimate could be calculated.

Peripheral nerve injury

Very low quality evidence from 1 prospective cohort study in women with breech presentation in labour (N=46) reported no events of peripheral nerve injury for the group who had an emergency caesarean section in labour and those who had a vaginal birth. Due to zero events in both groups no risk estimate could be calculated.

Severe neonatal morbidity

Very low quality evidence from 1 prospective cohort study in women with breech presentation in labour (N=139) found no clinically important difference in the incidence of severe neonatal morbidity (including anoxia, pneumonia and pneumothorax) between the group who had an emergency caesarean section and those who had a vaginal birth. The same study found no clinically important difference in the incidence of severe neonatal morbidity (including VII nerve palsy, apneic episodes and convulsions) between the 2 groups.

Admission to neonatal intensive care unit

Very low quality evidence from 1 prospective cohort study in women with breech presentation in labour (N=210) found a clinically important lower incidence of NICU admissions in the group who had an emergency caesarean section compared to those who had a vaginal birth. Very low quality evidence from 2 prospective cohort studies in women with breech presentation in labour (N=86 and N=85) found no clinically important difference in the incidence of NICU admissions between the group who had an emergency caesarean section and those who had a vaginal birth.

Emergency caesarean section in early labour versus continuation of labour

Postpartum haemorrhage.

Very low quality evidence from 1 prospective cohort study in women with breech presentation in labour (N=937) found no clinically important difference in the incidence of postpartum haemorrhage >1500 ml between the group who had an emergency caesarean section in early labour and those who had a vaginal birth.

Maternal systemic infection, postpartum fever >= 38.5⁰C

This outcome was included in the review as a proxy for sepsis (which was an outcome specified in the review protocol). Very low quality evidence from 1 prospective cohort study in women with breech presentation in labour (N=937) found no clinically important difference in the incidence of postpartum fever >= 38.5⁰C between the group who had an emergency caesarean section in early labour and those who had a vaginal birth.

Maternal morbidity

Very low quality evidence from 1 prospective cohort study in women with breech presentation in labour (N=937) found a clinically important higher odds of ‘maternal morbidity’ during the first 6 weeks postpartum in the group who had an emergency caesarean section in early labour compared to those who had a vaginal birth. Maternal morbidity was defined as any of the following: death; postpartum haemorrhage of more than 1500 ml or a need for blood transfusion; dilatation and curettage for bleeding or retained placental tissue; hysterectomy; cervical laceration involving the lower uterine segment (in the case of vaginal birth); vertical uterine incision or serious extension to a transverse uterine incision (in the case of caesarean section); vulvar or perineal haematoma requiring evacuation; deep vein thrombophlebitis or pulmonary embolism requiring anticoagulant therapy; pneumonia; adult respiratory distress syndrome; wound infection requiring prolonged hospital care as an inpatient or outpatient or readmission to hospital; wound dehiscence or breakdown; maternal fever of at least 38.5⁰C on 2 occasions at least 24 hours apart and not including the first 24 hours after the birth; bladder, ureteric, or bowel injury requiring repair; genital tract fistula; bowel obstruction; or other serious maternal morbidity as judged by members of the steering committee for the study (masked to allocation group and if possible to mode of birth).

Early postpartum depression

This outcome was included in the review as a proxy for the woman’s experience (which was an outcome specified in the review protocol). Very low quality evidence from 1 prospective cohort study in women with breech presentation in labour (N=937) found no clinically important difference in the incidence of early postpartum depression between the group who had an emergency caesarean section in early labour and those who had a vaginal birth.

Very low quality evidence from 1 prospective cohort study in women with breech presentation in labour (N=938) found no clinically important difference in the incidence of stillbirth between the group who had an emergency caesarean section in early labour and those who had a vaginal birth.

Neonatal mortality

with breech presentation in labour (N=938) found no clinically important difference in the incidence of neonatal mortality between the group who had an emergency caesarean section in early labour and those who had a vaginal birth.

Ventilation required

Very low quality evidence from 1 prospective cohort study in women with breech presentation in labour (N=938) found no clinically important difference in the incidence of requirement for ventilation between the group who had an emergency caesarean section in early labour and those who had a vaginal birth.

Birth injury

Very low quality evidence from 1 prospective cohort study in women with breech presentation in labour (N=938) found no clinically important difference in the incidence of birth injury between the group who had an emergency caesarean section in early labour and those who had a vaginal birth.

Very low quality evidence from 1 prospective cohort study in women with breech presentation in labour (N=938) found no clinically important difference in the incidence of admission to NICU between the group who had an emergency caesarean section in early labour and those who had a vaginal birth.

Adverse perinatal outcome

Very low quality evidence from 1 prospective cohort study in women with breech presentation in labour (N=856) found a clinically important lower odds of ‘adverse perinatal outcome’ in the group who had an emergency caesarean section in early labour compared to those who had a vaginal birth. Adverse perinatal outcome was defined as any of the following: perinatal or neonatal mortality within 28 days of the birth (excluding lethal congenital anomalies); birth trauma, including subdural haematoma, intracerebral or intraventricular haemorrhage, spinal cord injury, basal skull fracture, peripheral nerve injury present at discharge from hospital, or clinically important genital injury; seizures occurring within 24 hours of the birth or requiring 2 or more drugs to control them; Apgar score of less than 4 at 5 minutes; cord blood base deficit of at least 15; hypotonia for at least 2 hours; stupor, decreased response to pain, or coma; intubation and ventilation for at least 24 hours; tube feeding for 4 days or more; or admission to NICE for longer than 4 days.

Emergency caesarean section in active labour versus continuation of labour

Very low quality evidence from 1 prospective cohort study in women with breech presentation in labour (N=1288) found no clinically important difference in the incidence of postpartum haemorrhage >1500 ml between the group who had an emergency caesarean section in active labour and those who had a vaginal birth.

Maternal systemic infection, postpartum fever >= 38.5°C

This outcome was included in the review as a proxy for sepsis (which was specified as an outcome in the review protocol). Very low quality evidence from 1 prospective cohort study in women with breech presentation in labour (N=1288) found a clinically important higher incidence of postpartum fever >= 38.5⁰C in the group who had an emergency caesarean section in active labour compared to those who had a vaginal birth.

Very low quality evidence from 1 prospective cohort study in women with breech presentation in labour (N=1288) found a clinically important higher odds of ‘maternal morbidity’ during the first 6 weeks postpartum in the group who had an emergency caesarean section in active labour compared to those who had a vaginal birth. Maternal morbidity was defined as any of the following: death; postpartum haemorrhage of more than 1500 ml or a need for blood transfusion; dilatation and curettage for bleeding or retained placental tissue; hysterectomy; cervical laceration involving the lower uterine segment (in the case of vaginal birth); vertical uterine incision or serious extension to a transverse uterine incision (in the case of caesarean section); vulvar or perineal haematoma requiring evacuation; deep vein thrombophlebitis or pulmonary embolism requiring anticoagulant therapy; pneumonia; adult respiratory distress syndrome; wound infection requiring prolonged hospital care as an inpatient or outpatient or readmission to hospital; wound dehiscence or breakdown; maternal fever of at least 38.5⁰C on 2 occasions at least 24 hours apart and not including the first 24 hours after the birth; bladder, ureteric, or bowel injury requiring repair; genital tract fistula; bowel obstruction; or other serious maternal morbidity as judged by members of the study’s steering committee (masked to allocation group and if possible to mode of birth).

This outcome was included in the review as a proxy for the woman’s experience (which was specified as an outcome in the review protocol). Very low quality evidence from 1 prospective cohort study in women with breech presentation in labour (N=1288) found no clinically important difference in the incidence of early postpartum depression between the group who had an emergency caesarean section in active labour and those who had a vaginal birth.

Very low quality evidence from 1 prospective cohort study in women with breech presentation in labour (N=1285) found no clinically important difference in the incidence of stillbirth between the group who had an emergency caesarean section in active labour and those who had a vaginal birth.

Very low quality evidence from 1 prospective cohort study in women with breech presentation in labour (N=1285) found no clinically important difference in the incidence of neonatal mortality between the group who had an emergency caesarean section in active labour and those who had a vaginal birth.

with breech presentation in labour (N=1285) found no clinically important difference in the incidence of requirement for ventilation between the group who had an emergency caesarean section in active labour and those who had a vaginal birth.

Very low quality evidence from 1 prospective cohort study in women with breech presentation in labour (N=1285) found no clinically important difference in the incidence of birth injury between the group who had an emergency caesarean section in active labour and those who had a vaginal birth.

Admission to neonatal intensive care

Very low quality evidence from 1 prospective cohort study in women with breech presentation in labour (N=1285) found no clinically important difference in the incidence of admission to NICU between the group who had an emergency caesarean section in active labour and those who had a vaginal birth.

Very low quality evidence from 1 prospective cohort study in women with breech presentation in labour (N=1158) found a possibly clinically important lower odds of ‘adverse perinatal outcome’ in the group who had an emergency caesarean section in active labour compared to those who had a vaginal birth. (‘Possibly’ clinically important means that this result was not statistically significant at the 95% confidence level but it was statistically significant at the 90% confidence level. Moreover the risk ratio was below 0.80, which is the default minimally important difference.) Adverse perinatal outcome was defined as any of the following: perinatal or neonatal mortality within 28 days of the birth (excluding lethal congenital anomalies); birth trauma, including subdural haematoma, intracerebral or intraventricular haemorrhage, spinal cord injury, basal skull fracture, peripheral nerve injury present at discharge from hospital, or clinically important genital injury; seizures occurring within 24 hours of the birth or requiring 2 or more drugs to control them; Apgar score of less than 4 at 5 minutes; cord blood base deficit of at least 15; hypotonia for at least 2 hours; stupor, decreased response to pain, or coma; intubation and ventilation for at least 24 hours; tube feeding for 4 days or more; or admission to NICU for longer than 4 days.

The committee’s discussion of the evidence

Interpreting the evidence, the outcomes that matter most.

The committee prioritised major maternal morbidities (pelvic floor injury, obstetric anal sphincter injury (OASI), postpartum haemorrhage, or sepsis) as critical outcomes because these may occur with either caesarean section or vaginal birth. For the baby, the committee prioritised mortality and major morbidities (hypoxic ischaemic encephalopathy, respiratory complications, sepsis, or birth injury) as critical outcomes because both mortality and morbidity can be influenced by mode of birth.

Important outcomes were maternal admission to HDU or ITU and duration of hospital stay, and the woman’s experience of labour and birth, including experience of her birth companion(s), separation of the woman and the baby and breastfeeding initiation. The committee considered admission to HDU or ITU and duration of hospital stay to be important because if the intervention is surgery then admission is more likely. With regard to the woman’s experience, the committee discussed that currently some women with breech presenting in labour can feel that their choice is limited regarding mode of birth.

The committee considered admission to NICU and duration of hospital stay as important outcomes because these are proxies for neonatal morbidity.

The quality of the evidence

No studies were found that randomised women to caesarean section in labour or continuation of labour. Secondary analyses of data from randomised controlled trials (RCTs) that aimed to answer a different question from the guideline review were treated as prospective cohort studies.

All studies included in this review had a high risk of selection bias because women in the emergency caesarean section group had clinical indications for emergency caesarean section. These indications might, in turn, be associated with adverse outcomes. Most of the studies also had high risk of comparability bias because they did not adjust for any factor. Only one study adjusted for confounders (in relation to the composite outcomes of maternal morbidity and adverse perinatal outcome), however it was unclear what variables were included in the final analysis.

Many outcomes were downgraded for imprecision, which is related to sample size. The committee noted that the study with the biggest sample size was the secondary analysis of the Term Breech Trial reported in 3 publications ( Su 2003 , Su 2004 , Su 2007 ). Considering that most of the outcomes in the review are rare events, it is possible that in many studies the lack of clinical importance is due to small sample size. The committee noted that 1 study found no clinically important difference in the incidence of third-degree perineal laceration between the group of women who had an emergency caesarean section and those who had a vaginal birth. The committee argued that this was contrary to their clinical experience which suggested that third-degree perineal lacerations are generally due to a vaginal birth. They noted that this result was likely to be due to the small numbers of women and events in the study ( Van Loon 1997 ; 0 events among 63 women who had an emergency caesarean section in labour and 1 event in 126 women who had a vaginal birth).

The following outcomes were downgraded for indirectness: maternal morbidity and adverse perinatal outcome, which were composite outcomes that included some outcomes in the guideline review protocol but also outcomes that were not in the protocol; early postpartum depression, which was included as a proxy for the woman’s experience of labour and birth. The committee noted that postpartum depression had serious limitations as a proxy outcome, as it could be due to reasons completely different from a poor experience of labour and birth. Finally, neonatal morbidity, as a composite outcome including convulsions and apneic episodes as well as VII nerve palsy, was downgraded for indirectness. While VII nerve palsy can be considered as a birth injury, convulsions and apneic episodes were not included in the protocol. The committee did not feel they could separate out the individual outcomes incorporated in the composite outcomes for the woman and the baby when drafting the recommendations.

The committee noted that the Term Breech Trial was conducted in multiple countries, some of which may have different clinical practice compared to the UK. Although there was a trial protocol for the management of labour, differences in standard care of women and babies across participating centres may have had an impact on outcomes. Moreover the study is now relatively dated, therefore some treatments included may not be relevant to current practice. However the committee agreed that women should be informed of the results.

The committee noted that a study from Iraq ( Alshaheen 2010 ) showed a clinically important lower incidence of NICU admission in the group who had an emergency caesarean section compared to those who had a vaginal birth, and a clinically important reduction in incidence of early neonatal death in the group of nulliparous women who had an emergency caesarean section in labour compared to nulliparous women who had a vaginal birth. The committee argued that a study from Iraq would not reflect clinical practice in the UK and decided to disregard this study in formulating recommendations. Likewise, a study from 1975 ( Bird 1975 ) showed a clinically important reduction in incidence of babies requiring resuscitation in among women who had an emergency caesarean section compared to those who had a vaginal birth. The committee argued that clinical practice in 1975 would not be representative of current practice. For example, ventilation practices have changed; moreover, in the 1970s early cord clamping was common practice and this may be associated with an additional need for immediate resuscitation. Therefore, the committee decided not to base their recommendations on this study.

Benefits and harms

The committee noted that the included study with the largest sample size, that is, the secondary analysis of the Term Breech Trial, showed no clinically important difference in maternal infection between caesarean section in early labour and vaginal birth, but a clinically important increase in maternal infection with caesarean section in active labour compared to vaginal birth. The same study showed a clinically important increase in maternal morbidity (a composite outcome including multiple morbidities and complications) during the first 6 weeks after caesarean section in either early or active labour compared with vaginal birth. This was in line with the committee’s experience. Therefore the committee wanted healthcare professionals to discuss with women presenting with a breech position in labour that there is an increase in the chance of serious medical problems for the woman with caesarean section. The committee acknowledged that the available evidence was of very low quality, but they agreed that the consistency between the evidence and their experience reduced the uncertainty in making recommendations.

The secondary analysis of the Term Breech Trial showed no increased mortality in the baby or morbidity in either group based on each individual outcome included in the guideline review protocol (stillbirth, neonatal mortality, ventilation required, birth injury and admission to NICU). However this study showed a clinically important decrease in a composite adverse perinatal outcome with emergency caesarean section in early labour compared to vaginal birth. This adverse perinatal outcome included not only all the aforementioned outcomes in the review protocol, but also additional outcomes outside of the protocol, therefore it was downgraded for indirectness. However the committee noted that all the outcomes included in the composite outcome were of interest overall. Moreover, the committee recognised that some adverse outcomes could occur only with a vaginal birth for example, the baby’s head getting stuck. Therefore, based on the results from the Term Breech Trial and the committee’s clinical experience and expertise, they agreed that healthcare professionals should discuss with women that there is an increased chance of serious medical problems for the baby with vaginal birth. The committee noted that the absolute risk is low and it would be helpful to mention this in such discussions. Again, the committee acknowledged that the available evidence was of very low quality, but they agreed that the consistency between the evidence and their experience reduced the uncertainty in making recommendations.

Based on the composite adverse perinatal outcome, the Term Breech Trial showed clinically important benefits for the baby from a caesarean section in early labour but only a possibility of clinically important benefits for the baby from a caesarean section in active labour. The committee debated whether there should be 2 separate recommendations, one for labour that is not yet established and one for established labour, but they noted that there is a continuum of risk for the baby over time. They also noted that if the baby’s presentation were quite low in more advanced labour then performing a caesarean section could be problematic. Therefore the committee recommended advising women that any benefit of emergency caesarean section in reducing the chance of complications for the baby may be greater in early labour.

The committee acknowledged that offering a choice between continuing labour and emergency caesarean section may differ from the advice that women with breech presentation receive antenatally. This is because the balance of risks to the woman and baby will have changed, with different considerations coming into play when the woman is in labour. For example, considerations will be different when breech presentation is first identified in labour, or when labour is more advanced. The committee wished to ensure that healthcare professionals give women an opportunity to make an informed choice about mode of birth in this situation. The committee was aware that the risk of serious medical problems for the woman or the baby depends on the whole clinical picture. The committee noted that when assessing benefits and risks in relation to mode of birth with women presenting with a breech position in labour, it is important to take account of individual circumstances such as parity, previous obstetric history and medical history. They agreed not to recommend one mode of birth over another, but that following discussion of the likely benefits and risks a woman should choose what is right for her based on her individual circumstances and preferences.

The committee noted the importance of healthcare professionals feeling confident and competent to support women in labour and giving birth vaginally with a baby in the breech position. Ensuring that women who attempt a vaginal breech birth are adequately supported to give birth safely and achieve a positive experience is also important. The committee noted that most healthcare professionals currently practise very few vaginal breech births and it might be helpful to take this into account when balancing risks. Adequate training would be needed to ensure healthcare professionals have the skills to support breech birth.

The committee noted that 1 study found a clinically important increased incidence of breastfeeding among women who had an emergency caesarean section compared to those who had a vaginal birth. The committee agreed that a caesarean section is usually seen as a barrier to breastfeeding initiation because of separation of the woman and the baby. However, they argued that for this reason women might receive extra support for breastfeeding after a caesarean section and speculated that this might be the reason for the finding in the study.

Based on their knowledge and experience, the committee agreed that healthcare professionals should follow recommendations on assessing progress of labour in the NICE guideline on intrapartum care for healthy women and babies (CG190) to avoid unnecessary intervention when there is a delay in labour. The committee’s intention was that healthcare professionals should not assume that progress in labour should be assessed differently just because of breech presentation in labour. Without this consideration, healthcare professionals might assume that with breech presentation in labour intervention should be made sooner. The committee recognised that subsequent management if there is a delay in labour may be different.

Cost effectiveness and resource use

The committee was aware that emergency caesarean section is more expensive than a vaginal birth. However, a breech vaginal birth is more complicated than a cephalic vaginal birth and, therefore, more resource intensive.

The included studies in the clinical evidence review had a high risk of bias and the committee did not think that cost effectiveness could be readily assessed from differences in adverse outcomes for the woman and the baby and, therefore, the committee agreed it was reasonable to offer women a choice between continuation of labour and an emergency caesarean section. It is estimated that approximately 3-5% of pregnancies are breech at term ( Hofmeyr 2015 ) although breech presenting in labour represents a relatively small subset of such pregnancies. The committee did not anticipate a significant resource impact given the relatively small number of women affected and because the recommendations do not represent a substantial change from current practice, which is varied, although currently caesarean section is often recommended for these women.

However, the committee recognised that their recommendations might have training implications in order to support more widespread vaginal breech birth.

Other factors the committee took into account

The committee was aware of existing guidance on other aspects of intrapartum care for women with breech presenting in labour (see the Royal College of Gynaecologists (RCOG) management of breech presentation (Green-top Guideline No. 20b) ) such as the woman’s position during labour and birth and use of epidural analgesia, and felt that the committee’s recommendations would complement the existing guidance. The committee agreed that appropriate support for breech birth includes practices that are likely to reduce unnecessary interventions during labour and birth, such as external cephalic version if the membranes are intact, and encouraging women to be mobile and to adopt positions they feel comfortable in (including upright positions), consistent with the NICE guideline on intrapartum care for healthy women and babies (CG190).

Alshaheen 2010

Barlov 1986

Capeless 1985

Collea 1980

DeLeeuw 2002

Gimovsky 1983

Hofmeyr 2015

Molkenboer 2007

van Loon 1997

Zatuchni 1967

Appendix A. Review protocol

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AMSTAR: Assessing the Methodological Quality of Systematic Reviews; CDSR: Cochrane Database of Systematic Reviews; CENTRAL: Cochrane Central Register of Controlled Trials; DARE: Database of Abstracts of Reviews of Effects; GRADE: Grading of Recommendations Assessment, Development and Evaluation; HDU: high dependency unit; HTA: Health Technology Assessment; ITU: intensive therapy unit; MID: minimally important difference; NGA: National Guideline Alliance; NICE: National Institute for Health and Care Excellence; NICU: neonatal intensive care unit; RCT: randomised controlled trial; RoB: risk of bias; SD: standard deviation; ROBIS: Risk of Bias in Systematic Reviews

Appendix B. Literature search strategies

Database: Medline; Medline EPub Ahead of Print; and Medline In-Process & Other Non-Indexed Citations

Database: Cochrane Central Register of Controlled Trials

Database: Cochrane Database of Systematic Reviews

Database: Database of Abstracts of Reviews of Effects

Database: Health Technology Assessment

Database: Embase

Appendix C. Clinical evidence study selection

Figure 1. Flow diagram of clinical article selection for intrapartum care for women with breech presenting in labour – mode of birth

Appendix D. Excluded studies

Clinical studies, economic studies.

See Supplement 2 (Health economics) for details of economic evidence reviews and health economic modelling.

Appendix E. Clinical evidence tables

Intrapartum care for women with breech presenting in labour – mode of birth (PDF, 752K)

Appendix F. Forest plots

No meta-analysis was undertaken for this review and so there are no forest plots.

Appendix G. GRADE tables

Table 3. Clinical evidence profile for emergency caesarean section versus continuation of labour for women with breech presenting in labour, outcomes for the woman

Table 4. Clinical evidence profile for emergency caesarean section versus continuation of labour for women with breech presenting in labour, outcomes for the baby

Table 5. Clinical evidence profile for emergency caesarean section in early labour versus vaginal birth for women with breech presenting in labour, outcomes for the woman

Table 6. Clinical evidence profile for emergency caesarean section in early labour versus vaginal birth for women with breech presenting in labour, outcomes for the baby

Table 7. Clinical evidence profile for emergency caesarean section in active labour versus vaginal birth for women with breech presenting in labour, outcomes for the woman

Table 8. Clinical evidence profile for emergency caesarean section in active labour versus vaginal birth for women with breech presenting in labour, outcomes for the baby

Appendix H. Economic evidence study selection

Appendix i. economic evidence tables, appendix j. health economic evidence profiles, appendix k. health economic analysis, appendix l. research recommendations.

No research recommendations were made for this review.

Evidence reviews for women at high risk of adverse outcomes for themselves and/or their baby because of existing maternal medical conditions

Developed by the National Guideline Alliance hosted by the Royal College of Obstetricians and Gynaecologists

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

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

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

Cite this Page National Guideline Alliance (UK). Evidence review for breech presenting in labour: Intrapartum care for women with existing medical conditions or obstetric complications and their babies: Evidence review O. London: National Institute for Health and Care Excellence (NICE); 2019 Mar. (NICE Guideline, No. 121.)
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Breech Presentation
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.
Breech Presentation
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.
Overview of breech presentation
The main types of breech presentation are: 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.
Fetal Presentation, Position, and Lie (Including Breech Presentation
Breech presentation is more likely to occur in the following circumstances: Labor starts too soon (preterm labor). There is more than one fetus (multiple gestation). The uterus is abnormally shaped or contains abnormal growths such as fibroids. The fetus has a birth defect.
Fetal Presentation, Position, and Lie (Including Breech Presentation
In breech presentation, the presenting part is a poor dilating wedge, which can cause the head to be trapped during delivery, often compressing the umbilical cord. For breech presentation, usually do cesarean delivery at 39 weeks or during labor, but external cephalic version is sometimes successful before labor, usually at 37 or 38 weeks.
Breech Baby: Causes, Complications, Turning & Delivery
A breech baby, or breech birth, is when your baby's feet or buttocks are positioned to come out of your vagina first. Your baby's head is up closest to your chest and its bottom is closest to your vagina. Most babies will naturally move so their head is positioned to come out of the vagina first during birth. Breech is common in early ...
Breech presentation management: A critical review of leading clinical
This pamphlet explains what a breech presentation is, the different types of breech presentation, discusses ECV and provides balanced information related to birth mode options along with visual representations of statistics comparing the perinatal mortality rate between cephalic vaginal birth, VBB and C/S. This pamphlet was also developed in ...
Breech: Types, Risk Factors, Treatment, Complications
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.
Management of breech presentation
Introduction. Breech presentation of the fetus in late pregnancy may result in prolonged or obstructed labour with resulting risks to both woman and fetus. Interventions to correct breech presentation (to cephalic) before labour and birth are important for the woman's and the baby's health. The aim of this review is to determine the most ...
Management of Breech Presentation
Observational, usually retrospective, series have consistently favoured elective caesarean birth over vaginal breech delivery. A meta-analysis of 27 studies examining term breech birth, 5 which included 258 953 births between 1993 and 2014, suggested that elective caesarean section was associated with a two- to five-fold reduction in perinatal mortality when compared with vaginal breech ...
Identification of breech presentation
The expected cost per person with breech presentation of universal ultrasound was £2957 (95% Credibility Interval [CrI]: £2922 to £2991), compared to £2,949 (95%CrI: £2915 to £2984) from selective ultrasound. The expected QALYs per person was 24.27615 in the universal ultrasound cohort and 24.27582 in the selective ultrasound cohort.
Breech Presentation: Types, Causes, Risks
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 ...
Breech Presentation
Breech presentation at delivery occurs in 3 to 4 percent of pregnancies. However, before 28 weeks of gestation, the incidence is about 25 percent. As term gestation approaches, the incidence decreases. In most cases, the fetus converts to the cephalic presentation by 34 weeks of gestation.
Breech Presentation
breech presentation occurs when a fetus is positioned logitudinally with the buttocks or feet closest to the mother's cervix. complete breech. flexion of the hips and knees. incomplete (footling) breech. some deflexion of one hip and knee. frank breech. flexion of both hips with extension of both knees. Epidemiology.
Fetal presentation before birth
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.
Breech in Labor
1 Overview and Purpose. 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 presentation decreases with advancing gestational age from 22-25% of births prior to 28 weeks' gestation to 7-15% of births at 32 weeks ...
Breech presentation
For women with breech presentation in labor, planned cesarean section at 39 weeks or greater has been shown to significantly reduce perinatal mortality and neonatal morbidity compared with vaginal breech delivery (RR 0.33, 95% CI 0.19 to 0.56).
Induction of labor in breech presentations ‐ a retrospective cohort
Induction of labor was an approved option in the hospital guidelines, and the indications for induction were similar for cephalic and breech presentations. The induction procedure started with a balloon catheter, misoprostol or dinoprostone administered vaginally in women with an unripe cervix.
Fetal Positions For Birth: Presentation, Types & Function
Occiput or cephalic anterior: This is the best fetal position for childbirth. It means the fetus is head down, facing the birth parent's spine (facing backward). Its chin is tucked towards its chest. The fetus will also be slightly off-center, with the back of its head facing the right or left. This is called left occiput anterior or right ...
Delivery of the singleton fetus in breech presentation
(See "Overview of breech presentation" and "External cephalic version".) 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 . However, even in ...
Risk factors for adverse outcomes in vaginal preterm breech labor
In preterm labor breech presentation is more common than in term and every fourth of all fetuses born extremely preterm are in breech presentation at birth [3-6]. Breech presentation in preterm and term pregnancies is associated with obstetric risk factors for adverse neonatal outcomes, such as oligohydramnios, fetal growth restriction, and ...
Mechanism of Labour
breech is bulkier than the cephalic pole, and hence it usually occupies the roomier fundus of the piriform-shaped uterus. Breech —the podalic pole overlies the pelvic outlet. It is seen in 2-3% cases at term, though at 28 weeks almost 25% foetuses present as breech. In transverse lie, it is the shoulder that usually presents. Attitude
A comparison of risk factors for breech presentation in preterm and
Breech presentation in preterm labor is associated with obstetric risk factors compared to cephalic presentation. These risks decrease linearly with the gestational age. In moderate to late preterm delivery, breech presentation is a high-risk state and some obstetric risk factors are yet visible in early preterm delivery. Breech presentation in ...
Management of malposition and malpresentation in labour
The most common fetal malpresentation in longitudinal lie is breech presentation which itself can be further subdivided into subtypes. Other malpresentations in longitudinal lie include face, brow and compound. The fetus in non-longitudinal lie may be oblique or transverse, with shoulder, arm or cord presentations. Malpositions, such as ...
Evidence review for breech presenting in labour
Very low quality evidence from 1 prospective cohort study in women with breech presentation in labour (N=125) reported that mean blood loss at birth was 522.7 ml (range 100 to 1200 ml) in the group who had an emergency caesarean section in labour and 255.2 ml (range 50 to 775 ml) in the group who had a vaginal birth.

Breech Births

What are the different types of breech birth presentations?

What causes a breech presentation?

How is a breech presentation diagnosed?

Can a breech presentation mean something is wrong?

Can a breech presentation be changed?

Medical Techniques

ECV will not be tried if:

Complications of EVC include:

Vaginal delivery versus cesarean for breech birth?

What are the risks and complications of a vaginal delivery?

When is a cesarean delivery used with a breech presentation?

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