breech presentation meaning medical

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

What Is Breech?

When a fetus is delivered buttocks or feet first

• Types of Presentation

Risk Factors

Complications.

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

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

Verywell / Jessica Olah

Types of Breech Presentation

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

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

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

The different types of breech presentations include:

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

Signs of Breech

There are no specific symptoms associated with a breech presentation.

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

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

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

These can include:

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

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

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

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

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

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

ECV is usually not recommended if the:

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

Recommendations for Previous C-Sections

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

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

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

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

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

A Word From Verywell

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

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

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

TeachMeObGyn. Breech presentation .

MedlinePlus. Breech birth .

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

By Christine Zink, MD Dr. Christine Zink, MD, is a board-certified emergency medicine with expertise in the wilderness and global medicine. She completed her medical training at Weill Cornell Medical College and residency in emergency medicine at New York-Presbyterian Hospital. She utilizes 15-years of clinical experience in her medical writing.

Learn how UpToDate can help you.

Select the option that best describes you

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

RELATED TOPICS

INTRODUCTION

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

TYPES OF BREECH PRESENTATION

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

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

Enter search terms to find related medical topics, multimedia and more.

Advanced Search:

• Use “ “ for exact phrases.
• For example: “pediatric abdominal pain”
• Use – to remove results with certain keywords.
• For example: abdominal pain -pediatric
• Use OR to account for alternate keywords.
• For example: teenager OR adolescent

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

, MD, Children's Hospital of Philadelphia

• 3D Models (0)
• Calculators (0)

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 Operative Vaginal Delivery Operative vaginal delivery involves application of forceps or a vacuum extractor to the fetal head to assist during the second stage of labor and facilitate delivery. Indications for forceps... read more , or cesarean delivery Cesarean Delivery Cesarean delivery is surgical delivery by incision into the uterus. The rate of cesarean delivery was 32% in the United States in 2021 (see March of Dimes: Delivery Method). The rate has fluctuated... read more .

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 Preterm Labor Labor (regular uterine contractions resulting in cervical change) that begins before 37 weeks gestation is considered preterm. Risk factors include prelabor rupture of membranes, uterine abnormalities... read more

Multiple gestation Multifetal Pregnancy Multifetal pregnancy is presence of > 1 fetus in the uterus. Multifetal (multiple) pregnancy occurs in up to 1 of 30 deliveries. Risk factors for multiple pregnancy include Ovarian stimulation... read more

Uterine abnormalities

Fetal anomalies

If delivery is vaginal, breech presentation may increase risk of

Umbilical cord prolapse

Perinatal death

It is best to detect abnormal fetal lie or presentation before delivery. During routine prenatal care, clinicians assess fetal lie and presentation with physical examination in the late third trimester. Ultrasonography can also be done. If breech presentation is detected, external cephalic version can sometimes move the fetus to vertex presentation before labor, usually at 37 or 38 weeks. This technique involves gently pressing on the maternal abdomen to reposition the fetus. A dose of a short-acting tocolytic ( terbutaline 0.25 mg subcutaneously) may help. The success rate is about 50 to 75%. For persistent abnormal lie or presentation, cesarean delivery is usually done at 39 weeks or when the woman presents in labor.

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 Operative Vaginal Delivery Operative vaginal delivery involves application of forceps or a vacuum extractor to the fetal head to assist during the second stage of labor and facilitate delivery. Indications for forceps... read more or cesarean delivery Cesarean Delivery Cesarean delivery is surgical delivery by incision into the uterus. The rate of cesarean delivery was 32% in the United States in 2021 (see March of Dimes: Delivery Method). The rate has fluctuated... read more 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.

Was This Page Helpful?

Test your knowledge

Brought to you by Merck & Co, Inc., Rahway, NJ, USA (known as MSD outside the US and Canada) — dedicated to using leading-edge science to save and improve lives around the world. Learn more about the MSD Manuals and our commitment to Global Medical Knowledge.

• Permissions
• Cookie Settings
• Terms of use
• Veterinary Manual

• IN THIS TOPIC

Enter search terms to find related medical topics, multimedia and more.

Advanced Search:

• Use “ “ for exact phrases.
• For example: “pediatric abdominal pain”
• Use – to remove results with certain keywords.
• For example: abdominal pain -pediatric
• Use OR to account for alternate keywords.
• For example: teenager OR adolescent

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

, MD, Children's Hospital of Philadelphia

Variations in Fetal Position and Presentation

• 3D Models (0)
• Calculators (0)
• Lab Test (0)

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 fetus has a birth defect Overview of Birth Defects Birth defects, also called congenital anomalies, are physical abnormalities that occur before a baby is born. They are usually obvious within the first year of life. The cause of many birth... read more .

There is more than one fetus (multiple gestation).

Position and Presentation of the Fetus

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).

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.

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

Labor starts too soon (preterm labor).

Sometimes the doctor can turn the fetus to be head first before labor begins by doing a procedure that involves pressing on the pregnant woman’s abdomen and trying to turn the baby around. Trying to turn the baby is called an external cephalic version and is usually done at 37 or 38 weeks of pregnancy. Sometimes women are given a medication (such as terbutaline ) during the procedure to prevent contractions.

Other presentations

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

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

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

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

Drugs Mentioned In This Article

Was This Page Helpful?

Test your knowledge

Brought to you by Merck & Co, Inc., Rahway, NJ, USA (known as MSD outside the US and Canada)—dedicated to using leading-edge science to save and improve lives around the world. Learn more about the Merck Manuals and our commitment to Global Medical Knowledge .

• Permissions
• Cookie Settings
• Terms of use
• Veterinary Edition

• IN THIS TOPIC

• Help & Feedback
• About epocrates

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

Other Presentations

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 ]

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 ]

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 ]

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 ]

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

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.

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

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 ]

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]

Referenced Articles

1. Cunningham F, Gant N, Leveno K, et al. Williams obstetrics. 21st ed. New York: McGraw-Hill; 1997.

2. Kish K, Collea JV. Malpresentation and cord prolapse. In: DeCherney AH, Nathan L, eds. Current obstetric and gynecologic diagnosis and treatment. New York: McGraw-Hill Professional; 2002.

3. Scheer K, Nubar J. Variation of fetal presentation with gestational age. Am J Obstet Gynecol. 1976 May 15;125(2):269-70. [Abstract]

4. Nassar N, Roberts CL, Cameron CA, et al. Diagnostic accuracy of clinical examination for detection of non-cephalic presentation in late pregnancy: cross sectional analytic study. BMJ. 2006 Sep 16;333(7568):578-80. [Abstract] [Full Text]

5. Roberts CL, Peat B, Algert CS, et al. Term breech birth in New South Wales, 1990-1997. Aust N Z J Obstet Gynaecol. 2000 Feb;40(1):23-9. [Abstract]

6. Roberts CL, Algert CS, Peat B, et al. Small fetal size: a risk factor for breech birth at term. Int J Gynaecol Obstet. 1999 Oct;67(1):1-8. [Abstract]

7. Brar HS, Platt LD, DeVore GR, et al. Fetal umbilical velocimetry for the surveillance of pregnancies complicated by placenta previa. J Reprod Med. 1988 Sep;33(9):741-4. [Abstract]

8. Kian L. The role of the placental site in the aetiology of breech presentation. J Obstet Gynaecol Br Commonw. 1963 Oct;70:795-7. [Abstract]

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

10. Westgren M, Edvall H, Nordstrom L, et al. Spontaneous cephalic version of breech presentation in the last trimester. Br J Obstet Gynaecol. 1985 Jan;92(1):19-22. [Abstract]

11. Brenner WE, Bruce RD, Hendricks CH. The characteristics and perils of breech presentation. Am J Obstet Gynecol. 1974 Mar 1;118(5):700-12. [Abstract]

12. Hall JE, Kohl S. Breech presentation. Am J Obstet Gynecol. 1956 Nov;72(5):977-90. [Abstract]

13. Morgan HS, Kane SH. An analysis of 16,327 breech births. JAMA. 1964 Jan 25;187:262-4. [Abstract]

14. Luterkort M, Persson P, Weldner B. Maternal and fetal factors in breech presentation. Obstet Gynecol. 1984 Jul;64(1):55-9. [Abstract]

15. Braun FH, Jones KL, Smith DW. Breech presentation as an indicator of fetal abnormality. J Pediatr. 1975 Mar;86(3):419-21. [Abstract]

16. Albrechtsen S, Rasmussen S, Dalaker K, et al. Reproductive career after breech presentation: subsequent pregnancy rates, interpregnancy interval, and recurrence. Obstet Gynecol. 1998 Sep;92(3):345-50. [Abstract]

17. Zlopasa G, Skrablin S, Kalafatić D, et al. Uterine anomalies and pregnancy outcome following resectoscope metroplasty. Int J Gynaecol Obstet. 2007 Aug;98(2):129-33. [Abstract]

18. Acién P. Breech presentation in Spain, 1992: a collaborative study. Eur J Obstet Gynecol Reprod Biol. 1995 Sep;62(1):19-24. [Abstract]

19. Michalas SP. Outcome of pregnancy in women with uterine malformation: evaluation of 62 cases. Int J Gynaecol Obstet. 1991 Jul;35(3):215-9. [Abstract]

20. Fianu S, Vaclavinkova V. The site of placental attachment as a factor in the aetiology of breech presentation. Acta Obstet Gynecol Scand. 1978;57(4):371-2. [Abstract]

21. Haruyama Y. Placental implantation as the cause of breech presentation [in Japanese]. Nihon Sanka Fujinka Gakkai Zasshi. 1987 Jan;39(1):92-8. [Abstract]

22. Filipov E, Borisov I, Kolarov G. Placental location and its influence on the position of the fetus in the uterus [in Bulgarian]. Akush Ginekol (Sofiia). 2000;40(4):11-2. [Abstract]

23. Waterstone M, Bewley S, Wolfe C. Incidence and predictors of severe obstetric morbidity: case-control study. BMJ. 2001 May 5;322(7294):1089-93. [Abstract] [Full Text]

24. 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]

25. American College of Obstetricians and Gynecologists Committee on Obstetric Practice. ACOG committee opinion no. 745: mode of term singleton breech delivery. Obstet Gynecol. 2018 Aug;132(2):e60-3. [Abstract] [Full Text]

26. Beischer NA, Mackay EV, Colditz P, eds. Obstetrics and the newborn: an illustrated textbook. 3rd ed. London: W.B. Saunders; 1997.

27. Royal College of Obstetricians and Gynaecologists. Antepartum haemorrhage: green-top guideline no. 63. November 2011 [internet publication]. [Full Text]

28. American College of Obstetricians and Gynecologists. Practice bulletin no. 175: ultrasound in pregnancy. Obstet Gynecol. 2016 Dec;128(6):e241-56. [Abstract]

29. Enkin M, Keirse MJNC, Neilson J, et al. Guide to effective care in pregnancy and childbirth. 3rd ed. Oxford: Oxford University Press; 2000.

30. Hofmeyr GJ, Kulier R, West HM. External cephalic version for breech presentation at term. Cochrane Database Syst Rev. 2012 Oct 17;(10):CD000083. [Abstract] [Full Text]

31. 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]

32. Stock SJ, Thomson AJ, Papworth S, et al. Antenatal corticosteroids to reduce neonatal morbidity and mortality: Green-top Guideline No. 74. BJOG. 2022 Jul;129(8):e35-60. [Abstract] [Full Text]

33. American College of Obstetricians and Gynaecologists Committee on Obstetric Practice. Committee opinion no. 713: antenatal corticosteroid therapy for fetal maturation. August 2017 (reaffirmed 2020) [internet publication]. [Full Text]

34. American College of Obstetricians and Gynecologists Committee on Obstetric Practice. Committee opinion no. 455: magnesium sulfate before anticipated preterm birth for neuroprotection. March 2010 (reaffirmed 2020) [internet publication]. [Full Text]

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

36. Rosman AN, Guijt A, Vlemmix F, et al. Contraindications for external cephalic version in breech position at term: a systematic review. Acta Obstet Gynecol Scand. 2013 Feb;92(2):137-42. [Abstract]

37. Hofmeyr GJ. Effect of external cephalic version in late pregnancy on breech presentation and caesarean section rate: a controlled trial. Br J Obstet Gynaecol. 1983 May;90(5):392-9. [Abstract]

38. Beuckens A, Rijnders M, Verburgt-Doeleman GH, et al. An observational study of the success and complications of 2546 external cephalic versions in low-risk pregnant women performed by trained midwives. BJOG. 2016 Feb;123(3):415-23. [Abstract]

39. Nassar N, Roberts CL, Barratt A, et al. Systematic review of adverse outcomes of external cephalic version and persisting breech presentation at term. Paediatr Perinat Epidemiol. 2006 Mar;20(2):163-71. [Abstract]

40. Sela HY, Fiegenberg T, Ben-Meir A, et al. Safety and efficacy of external cephalic version for women with a previous cesarean delivery. Eur J Obstet Gynecol Reprod Biol. 2009 Feb;142(2):111-4. [Abstract]

41. Pichon M, Guittier MJ, Irion O, et al. External cephalic version in case of persisting breech presentation at term: motivations and women's experience of the intervention [in French]. Gynecol Obstet Fertil. 2013 Jul-Aug;41(7-8):427-32. [Abstract]

42. Nassar N, Roberts CL, Raynes-Greenow CH, et al. Evaluation of a decision aid for women with breech presentation at term: a randomised controlled trial [ISRCTN14570598]. BJOG. 2007 Mar;114(3):325-33. [Abstract] [Full Text]

43. 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]

44. US Food & Drug Administration. FDA Drug Safety Communication: new warnings against use of terbutaline to treat preterm labor. Feb 2011 [internet publication]. [Full Text]

45. European Medicines Agency. Restrictions on use of short-acting beta-agonists in obstetric indications - CMDh endorses PRAC recommendations. October 2013 [internet publication]. [Full Text]

46. 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]

47. Lydon-Rochelle M, Holt VL, Martin DP, et al. Association between method of delivery and maternal rehospitalisation. JAMA. 2000 May 10;283(18):2411-6. [Abstract]

48. Yokoe DS, Christiansen CL, Johnson R, et al. Epidemiology of and surveillance for postpartum infections. Emerg Infect Dis. 2001 Sep-Oct;7(5):837-41. [Abstract]

49. van Ham MA, van Dongen PW, Mulder J. Maternal consequences of caesarean section. A retrospective study of intra-operative and postoperative maternal complications of caesarean section during a 10-year period. Eur J Obstet Gynecol Reprod Biol. 1997 Jul;74(1):1-6. [Abstract]

50. Murphy DJ, Liebling RE, Verity L, et al. Early maternal and neonatal morbidity associated with operative delivery in second stage of labour: a cohort study. Lancet. 2001 Oct 13;358(9289):1203-7. [Abstract]

51. Lydon-Rochelle MT, Holt VL, Martin DP. Delivery method and self-reported postpartum general health status among primiparous women. Paediatr Perinat Epidemiol. 2001 Jul;15(3):232-40. [Abstract]

52. Wilson PD, Herbison RM, Herbison GP. Obstetric practice and the prevalence of urinary incontinence three months after delivery. Br J Obstet Gynaecol. 1996 Feb;103(2):154-61. [Abstract]

53. Persson J, Wolner-Hanssen P, Rydhstroem H. Obstetric risk factors for stress urinary incontinence: a population-based study. Obstet Gynecol. 2000 Sep;96(3):440-5. [Abstract]

54. MacLennan AH, Taylor AW, Wilson DH, et al. The prevalence of pelvic disorders and their relationship to gender, age, parity and mode of delivery. BJOG. 2000 Dec;107(12):1460-70. [Abstract]

55. Thompson JF, Roberts CL, Currie M, et al. Prevalence and persistence of health problems after childbirth: associations with parity and method of birth. Birth. 2002 Jun;29(2):83-94. [Abstract]

56. Australian Institute of Health and Welfare. Australia's mothers and babies 2015 - in brief. October 2017 [internet publication]. [Full Text]

57. Mutryn CS. Psychosocial impact of cesarean section on the family: a literature review. Soc Sci Med. 1993 Nov;37(10):1271-81. [Abstract]

58. DiMatteo MR, Morton SC, Lepper HS, et al. Cesarean childbirth and psychosocial outcomes: a meta-analysis. Health Psychol. 1996 Jul;15(4):303-14. [Abstract]

59. National Institute for Health and Care Excellence. Caesarean birth. Mar 2021 [internet publication]. [Full Text]

60. Greene R, Gardeit F, Turner MJ. Long-term implications of cesarean section. Am J Obstet Gynecol. 1997 Jan;176(1 Pt 1):254-5. [Abstract]

61. Coughlan C, Kearney R, Turner MJ. What are the implications for the next delivery in primigravidae who have an elective caesarean section for breech presentation? BJOG. 2002 Jun;109(6):624-6. [Abstract]

62. Hemminki E, Merilainen J. Long-term effects of cesarean sections: ectopic pregnancies and placental problems. Am J Obstet Gynecol. 1996 May;174(5):1569-74. [Abstract]

63. Gilliam M, Rosenberg D, Davis F. The likelihood of placenta previa with greater number of cesarean deliveries and higher parity. Obstet Gynecol. 2002 Jun;99(6):976-80. [Abstract]

64. Morrison JJ, Rennie JM, Milton PJ. Neonatal respiratory morbidity and mode of delivery at term: influence of timing of elective caesarean section. Br J Obstet Gynaecol. 1995 Feb;102(2):101-6. [Abstract]

65. Annibale DJ, Hulsey TC, Wagner CL, et al. Comparative neonatal morbidity of abdominal and vaginal deliveries after uncomplicated pregnancies. Arch Pediatr Adolesc Med. 1995 Aug;149(8):862-7. [Abstract]

66. Hook B, Kiwi R, Amini SB, et al. Neonatal morbidity after elective repeat cesarean section and trial of labor. Pediatrics. 1997 Sep;100(3 Pt 1):348-53. [Abstract]

67. Nassar N, Roberts CL, Cameron CA, et al. Outcomes of external cephalic version and breech presentation at term: an audit of deliveries at a Sydney tertiary obstetric hospital, 1997-2004. Acta Obstet Gynecol Scand. 2006;85(10):1231-8. [Abstract]

68. Nwosu EC, Walkinshaw S, Chia P, et al. Undiagnosed breech. Br J Obstet Gynaecol. 1993 Jun;100(6):531-5. [Abstract]

69. Flamm BL, Ruffini RM. Undetected breech presentation: impact on external version and cesarean rates. Am J Perinatol. 1998 May;15(5):287-9. [Abstract]

70. Cockburn J, Foong C, Cockburn P. Undiagnosed breech. Br J Obstet Gynaecol. 1994 Jul;101(7):648-9. [Abstract]

71. Leung WC, Pun TC, Wong WM. Undiagnosed breech revisited. Br J Obstet Gynaecol. 1999 Jul;106(7):638-41. [Abstract]

72. Berhan Y, Haileamlak A. The risks of planned vaginal breech delivery versus planned caesarean section for term breech birth: a meta-analysis including observational studies. BJOG. 2016 Jan;123(1):49-57. [Abstract] [Full Text]

73. Wilcox C, Nassar N, Roberts C. Effectiveness of nifedipine tocolysis to facilitate external cephalic version: a systematic review. BJOG. 2011 Mar;118(4):423-8. [Abstract]

74. Qureshi H, Massey E, Kirwan D, et al. BCSH guideline for the use of anti-D immunoglobulin for the prevention of haemolytic disease of the fetus and newborn. Transfus Med. 2014 Feb;24(1):8-20. [Abstract] [Full Text]

75. Hutton EK, Hofmeyr GJ, Dowswell T. External cephalic version for breech presentation before term. Cochrane Database Syst Rev. 2015 Jul 29;(7):CD000084. [Abstract] [Full Text]

76. Coyle ME, Smith CA, Peat B. Cephalic version by moxibustion for breech presentation. Cochrane Database Syst Rev. 2012 May 16;(5):CD003928. [Abstract] [Full Text]

77. Hofmeyr GJ, Kulier R. Cephalic version by postural management for breech presentation. Cochrane Database Syst Rev. 2012 Oct 17;(10):CD000051. [Abstract] [Full Text]

78. Hannah ME, Whyte H, Hannah WJ, et al. Maternal outcomes at 2 years after planned cesarean section versus planned vaginal birth for breech presentation at term: the International Randomized Term Breech Trial. Am J Obstet Gynecol. 2004 Sep;191(3):917-27. [Abstract]

79. Eide MG, Oyen N, Skjaerven R, et al. Breech delivery and Intelligence: a population-based study of 8,738 breech infants. Obstet Gynecol. 2005 Jan;105(1):4-11. [Abstract]

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

81. Brown S, Lumley J. Maternal health after childbirth: results of an Australian population based survey. Br J Obstet Gynaecol. 1998 Feb;105(2):156-61. [Abstract]

Published by

American College of Obstetricians and Gynecologists

2016 (reaffirmed 2022)

Royal College of Obstetricians and Gynaecologists (UK)

National Institute for Health and Care Excellence (UK)

Topic last updated: 2024-03-05

Natasha Nassar , PhD

Associate Professor

Menzies Centre for Health Policy

Sydney School of Public Health

University of Sydney

Christine L. Roberts , MBBS, FAFPHM, DrPH

Research Director

Clinical and Population Health Division

Perinatal Medicine Group

Kolling Institute of Medical Research

Jonathan Morris , MBChB, FRANZCOG, PhD

Professor of Obstetrics and Gynaecology and Head of Department

Peer Reviewers

John W. Bachman , MD

Consultant in Family Medicine

Department of Family Medicine

Mayo Clinic

Rhona Hughes , MBChB

Lead Obstetrician

Lothian Simpson Centre for Reproductive Health

The Royal Infirmary

Brian Peat , MD

Director of Obstetrics

Women's and Children's Hospital

North Adelaide

South Australia

Lelia Duley , MBChB

Professor of Obstetric Epidemiology

University of Leeds

Bradford Institute of Health Research

Temple Bank House

Bradford Royal Infirmary

Justus Hofmeyr , MD

Head of the Department of Obstetrics and Gynaecology

East London Private Hospital

East London

South Africa

We have a new app!

Take the Access library with you wherever you go—easy access to books, videos, images, podcasts, personalized features, and more.

Download the Access App here: iOS and Android . Learn more here!

• Remote Access
• Save figures into PowerPoint
• Download tables as PDFs

Chapter 25:  Breech Presentation

Jessica Dy; Darine El-Chaar

• Download Chapter PDF

Disclaimer: These citations have been automatically generated based on the information we have and it may not be 100% accurate. Please consult the latest official manual style if you have any questions regarding the format accuracy.

Download citation file:

• Search Book

Jump to a Section

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

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.

Please Wait

• Pregnancy Classes

Breech Births

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

What are the different types of breech birth presentations?

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

What causes a breech presentation?

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

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

How is a breech presentation diagnosed?

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

Can a breech presentation mean something is wrong?

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

Can a breech presentation be changed?

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

Medical Techniques

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

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

ECV will not be tried if:

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

Complications of EVC include:

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

Vaginal delivery versus cesarean for breech birth?

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

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

What are the risks and complications of a vaginal delivery?

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

When is a cesarean delivery used with a breech presentation?

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

Want to Know More?

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

Compiled using information from the following sources:

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

BLOG CATEGORIES

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

Share this post:

Similar post.

Episiotomy: Advantages & Complications

Retained Placenta

What is Dilation in Pregnancy?

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

• The Bumpy Truth Blog
• Fertility Products Resource Guide

Pregnancy Tools

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

Pregnancy Journeys

• Partner With Us
• Corporate Sponsors

An official website of the United States government

Here’s how you know

Official websites use .gov A .gov website belongs to an official government organization in the United States.

Secure .gov websites use HTTPS A lock ( Lock Locked padlock icon ) or https:// means you’ve safely connected to the .gov website. Share sensitive information only on official, secure websites.

• Health Topics
• Drugs & Supplements
• Medical Tests
• Medical Encyclopedia
• About MedlinePlus
• Customer Support

Breech - series—Types of breech presentation

• Go to slide 1 out of 7
• Go to slide 2 out of 7
• Go to slide 3 out of 7
• Go to slide 4 out of 7
• Go to slide 5 out of 7
• Go to slide 6 out of 7
• Go to slide 7 out of 7

There are three types of breech presentation: complete, incomplete, and frank.

Complete breech is when both of the baby's knees are bent and his feet and bottom are closest to the birth canal.

Incomplete breech is when one of the baby's knees is bent and his foot and bottom are closest to the birth canal.

Frank breech is when the baby's legs are folded flat up against his head and his bottom is closest to the birth canal.

There is also footling breech where one or both feet are presenting.

Review Date 11/21/2022

Updated by: LaQuita Martinez, MD, Department of Obstetrics and Gynecology, Emory Johns Creek Hospital, Alpharetta, GA. Also reviewed by David C. Dugdale, MD, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.

Related MedlinePlus Health Topics

• Childbirth Problems

• More from M-W
• To save this word, you'll need to log in. Log In

breech presentation

Definition of breech presentation

Examples of breech presentation in a sentence.

These examples are programmatically compiled from various online sources to illustrate current usage of the word 'breech presentation.' Any opinions expressed in the examples do not represent those of Merriam-Webster or its editors. Send us feedback about these examples.

Word History

1801, in the meaning defined above

Dictionary Entries Near breech presentation

breech plug

Cite this Entry

“Breech presentation.” Merriam-Webster.com Dictionary , Merriam-Webster, https://www.merriam-webster.com/dictionary/breech%20presentation. Accessed 3 Apr. 2024.

Medical Definition

Medical definition of breech presentation, more from merriam-webster on breech presentation.

Britannica.com: Encyclopedia article about breech presentation

Subscribe to America's largest dictionary and get thousands more definitions and advanced search—ad free!

Can you solve 4 words at once?

Word of the day.

See Definitions and Examples »

Get Word of the Day daily email!

Popular in Grammar & Usage

The tangled history of 'it's' and 'its', more commonly misspelled words, why does english have so many silent letters, your vs. you're: how to use them correctly, every letter is silent, sometimes: a-z list of examples, popular in wordplay, the words of the week - mar. 29, 10 scrabble words without any vowels, 12 more bird names that sound like insults (and sometimes are), 8 uncommon words related to love, 9 superb owl words, games & quizzes.

6.1 Breech presentation

Presentation of the feet or buttocks of the foetus.

6.1.1 The different breech presentations

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

6.1.2 Diagnosis

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

6.1.3 Management

Route of delivery.

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

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

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

Favourable factors for vaginal delivery are:

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

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

During labour

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

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

At delivery

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

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

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

Figures 6.2 - Breech delivery

6.1.4 Breech delivery problems

Posterior orientation.

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

Obstructed shoulders

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

1 - Lovset's manoeuvre

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

Figures 6.3 - Lovset's manoeuvre

6.3c  - Delivering the anterior arm and shoulder

2 - Suzor’s manoeuvre

In case the previous method fails:

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

Figures 6.4 - Suzor's manoeuvre

6.4b  - Delivering the posterior shoulder

Head entrapment

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

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

1 - Bracht's manoeuvre

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

2 - Modified Mauriceau manoeuvre

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

Figures 6.6 - Modified Mauriceau manoeuvre

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

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

3 - Forceps on aftercoming head 

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

An official website of the United States government

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

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

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Case Rep Obstet Gynecol
• v.2013; 2013

Repetitive Breech Presentations at Term

Pavol zubor.

Department of Obstetrics and Gynecology, Jessenius Faculty of Medicine, Comenius University, Kollarova 2, 03601 Martin, Slovakia

Imrich Zigo

Jana sivakova, petra moricova, ivana kapustova, stefan krivus.

The authors present a case of 38-year-old laboring woman with four-time repetitive breech presentation of the fetus at term. This rare condition affects the mode of delivery and represents serious obstetrical problem as it is associated with increased perinatal morbidity or mortality. The authors give details on risk factors for breech presentation, its diagnosis, and the discussion points on possible causes leading to repetitive breeches in laboring women.

1. Introduction

The breech presentation is defined as the initial entrance of the gluteal region of the fetus into the maternal pelvis and is the most common abnormal fetal presentation. Breech delivery is a challenge in obstetric management and is associated with increased perinatal morbidity and mortality [ 1 – 3 ]. The prevalence of breeches ranges from 3% to 4% at term [ 4 ]. The predisposing factors for breech presentation are prematurity, multiple gestation, multiparity, fetal hydrocephalus, oligohydramnios, polar placentation, placenta previa, gestational diabetes, history of breech delivery, short umbilical cord, low birth weight, uterine anomalies, congenital anomaly, previous cesarean delivery, and pelvic tumors. As these factors explain only 15% of the variance of breech presentation [ 5 – 7 ], the etiology of breech delivery (causes of failure of spontaneous cephalic version) is not clear. Moreover, when fetal malposition in the form of breech presentation is repetitively presented in the same women. Thus, further research into the mechanism of breech presentation is needed.

The current study describes unusual case of repetitive (4 times) recurrence of breech delivery in the same women with hypothesis describing possible etiology of such rare case.

2. Case Report

A 38-years-old quadrugravida 168 cm tall Caucasian woman with singleton pregnancy at term (38 + 5 g.w.) was admitted to the delivery room due to regular uterine contractions every 5 minutes and sharp pain perception in scar after previous cesarean section. Gynecology examination revealed breech (Frank) presentation and vaginal findings showed 1 cm long cervix, dilated to 3 cm without signs of bleeding. A fetal predelivery ultrasonography was done with term corresponding biometry and EFW 3420 grams. The fetal monitor consisted of a baseline 140 bpm, accelerations, and good variability. Increased pain perception in lower uterine segment below the scar was the reason for pregnancy termination by uncomplicated cesarean section (Joel-Cohen incision with Misgav Ladach method) 3.5 hrs after admission. The intraoperative finding on the uterus was negative, without myoma, septum, or adhesions ( Figure 1 ). Her past history was uneventful except the obstetrical history of repetitive breech presentation of all previous deliveries (2 times spontaneously, once by low transverse cesarean section, Table 1 ). A 3500 g weighted male neonate with 9, 10, 10 Apgar score was delivered and discharged home with mother on 5th day after uncomplicated postpartum recovery.

The intraoperative findings on the uterus.

The clinical data of all deliveries.

3. Discussion

The breech delivery may represent the obstetrical problem that necessitates increased patience because of it possible complications. Thus many pregnancies with fetuses in breech lie are terminated for prevention by cesarean section. On the other side there exist obstetricians that can deliver breeches without fetal injury. However, despite their wide clinical practice, few of them faced the situation as described by our case: four-time repetitive breech presentation in one laboring woman giving the probability of such event at 0.045. In this section we will try to explain some possible reasons of this rare obstetric situation.

There are several maternal and fetal factors that predispose to a breech presentation, for example, uterine anomalies, myomas, pelvic tumors, fetal anomalies, changes of amniotic fluid, placental localization, or length of umbilical cord [ 8 ] that solely or in combination provoke fetal malpresentation. Moreover, some studies have found a relationship between placenta previa and polar fundal localization of the placenta and the breech presentation [ 9 , 10 ]. For example, cornu-fundal localization of the placenta occurred in 70% of breech presentations, but only in about 5% of cephalic presentations. In our case we have revealed 3-time fundal and one anterior wall placenta localizations on antepartum ultrasound what confirms the above-mentioned risk factors for breech presentations.

Adinma's study, in which 1000 cases were observed, found that breech fetuses had shorter umbilical cords than those of cephalic fetuses and that the average umbilical cord length is about 51 cm (range, 15–130) [ 11 ]. The lengths of umbilical cords in our case were as follows for subsequent pregnancies: 34 cm, 53 cm, 42 cm, and 57 cm, respectively. The relative short cords in pregnancies may explain the repetitive breeches in our case.

Specificity for higher breech presentation is body mass index (BMI) and maternal weight gain during pregnancy. It was revealed that higher BMI at term and increased body weight gain might be related to persistent breech presentation [ 12 ]. The last pregnancy of our case was associated with 13 kg body weight gain and 34 kg/m 2 BMI score. Another study revealed significantly higher incidence of breech deliveries in fetuses with increased placenta weight; however the reason was not revealed [ 13 ]. The weights of placentas in our case were in the range 430–560 g what represent the normal findings. Thus, did not confirm the above presented reasons associated with an increased risk for breech presentation.

Rayl et al. [ 14 ] highlighted smoking as a risk factor for breech presentation. In the current study we found no smoking history in any of the presented pregnancies. Similarly, Vendittelli et al. [ 15 ] reported that women with previous cesarean deliveries were at twice the risk of breech presentation at term than women with previous vaginal deliveries, which was in agreement with our data. Interestingly, Kuppens et al. [ 16 ] have provided data that women with higher TSH levels (>2.5 mIU/L) in pregnancy may exhibit higher rate of breech deliveries. This cannot be confirmed by our case as we did not make a hormonal profile in all of the pregnancies.

Nordtveit et al. [ 17 ] showed that breech delivery may exhibit partly inherited patterns as both men and women delivered in breech presentation at term contribute to increased risk of breech delivery in their offspring. Thus, this supports the theory that some genes on the specific environmental background passed on from the father or the mother seem to be closely related to breech delivery. Furthermore, the congenital pattern of breech delivery is supported by the findings from race-targeted studies, which have proved that white women have 69% higher risk for breech delivery than black women [ 18 ].

Finally, the congenital disorders in cerebellum cannot be omitted in the fetuses when describing the reason for breech delivery [ 19 ]. However, this theory has to be proved in the future. In general, there exists approximately 15% risk of repetitive breech delivery after the previous one, and this risk is higher for cesarean sections [ 20 ]. The relative risk of breech recurrence in a second pregnancy is 3.2 and in a third consecutive breech pregnancy 13.9 [ 21 ]. Any other breeches are extremely rare. Thus our case of four forthcoming breeches are worthy for presentation and for closer investigation of the causes.

In summary, we conclude that shorter umbilical cord, higher placental weight, increased maternal term BMI, cornu-fundal placenta localization, smoking, thyroid hormone disbalance, race, and genetics may be causative factors for repetitive breech presentations as described by our case and that it is the persistence of maternal risk factors rather than first pregnancy fetal or infant factors that play a role in repeating breech presentations at term. Thus, the consistently elevated recurrence rates highlight the need for women with a history of breech delivery to be closely monitored in the later stages of pregnancy (e.g., attempt for external cephalic version or prevention of cord prolapse after PROM).

Conflict of Interests

The authors declare that there is no conflict of interests.

Acknowledgments

This work was supported by the project centre of excellence for perinatal research (CEPV II, ITMS code: 26220120036) cofinanced by EU sources.

Abbreviations

Click through the PLOS taxonomy to find articles in your field.

For more information about PLOS Subject Areas, click here .

Loading metrics

Open Access

Peer-reviewed

Research Article

Maternal outcomes of planned mode of delivery for term breech in nulliparous women

Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Visualization, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliations Department of Gynecology and Obstetrics, University of Copenhagen, Holbaek Hospital, Holbaek, Denmark, Department of Gynecology and Obstetrics, Herlev Hospital, Herlev, Denmark

Roles Data curation, Software

Affiliation Department of Gynecology and Obstetrics, University of Copenhagen, Amager Hvidovre Hospital, Hvidovre, Denmark

Roles Conceptualization, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Validation, Writing – original draft, Writing – review & editing

Affiliations Department of Gynecology and Obstetrics, University of Copenhagen, Amager Hvidovre Hospital, Hvidovre, Denmark, Department of Clinical Medicine, University of Copenhagen, Copenhagen N, Denmark

• Malene Mie Caning, 
• Steen Christian Rasmussen, 

• Published: April 3, 2024
• https://doi.org/10.1371/journal.pone.0297971
• Reader Comments

To estimate short- and long-term maternal complications in relation to planned mode of term breech delivery in first pregnancy.

Register-based cohort study

Nulliparous women with singleton breech delivery at term between 1991 and 2018 (n = 30,778).

We used data from the Danish national health registries to identify nulliparous women with singleton breech presentation at term and their subsequent pregnancies. We performed logistic regression to compare the risks of maternal complications by planned mode of delivery. All data were proceeded and statistical analyses were performed in SAS 9.4 (SAS Institute Inc. Cary, NC, USA).

Main outcome measures

Postpartum hemorrhage, operative complications, puerperal infections in first pregnancy and uterine rupture, placenta previa, post-partum hemorrhage, hysterectomy and stillbirth in the subsequent two pregnancies.

We identified 19,187 with planned cesarean and 9,681 with planned vaginal breech delivery of which 2,970 (30.7%) delivered vaginally. Planned cesarean significantly reduced the risk of postoperative infections (2.4% vs 3.9% adjusted odds ratio (aOR): 0.54 95% confidence interval (CI) 0.44–0.66) and surgical organ lesions (0.06% vs 0.1%; (aOR): 0.29 95% CI 0.11–0.76) compared to planned vaginal breech delivery. Planned cesarean delivery in the first pregnancy was associated with a significantly higher risk of uterine rupture in the subsequent pregnancies but not with risk of postpartum hemorrhage, placenta previa, hysterectomy, or stillbirth.

Compared to planned vaginal breech delivery at term, nulliparous women with planned cesarean breech delivery have a significantly reduced risk of postoperative complications but a higher risk of uterine rupture in their subsequent pregnancies.

Citation: Caning MM, Rasmussen SC, Krebs L (2024) Maternal outcomes of planned mode of delivery for term breech in nulliparous women. PLoS ONE 19(4): e0297971. https://doi.org/10.1371/journal.pone.0297971

Editor: Abera Mersha, Arba Minch University, ETHIOPIA

Received: June 28, 2023; Accepted: January 15, 2024; Published: April 3, 2024

Copyright: © 2024 Caning et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: Data used to calculate means and odds ratios are available in S1 Dataset . All data were obtained from the Danish Medical Birth Registry, and be accessed by applying for access to relevant data from the Danish Health Data Authority. All researchers can apply for access. The authors of this study did not have any special access privileges.

Funding: This study was supported by grants from the Health Research Foundation of Region Zealand and Carsten Lenstrup’s research foundation for Danish obstetrics. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Breech presentation at term occurs in 3–4% of all singleton pregnancies [ 1 , 2 ].

Up until the 1960´s women were expected to deliver vaginally regardless presentation. During the 1960´s and 1970´the rate of cesarean for breech increased and during the 1980´s and 1990´s the rate was about 80% in Denmark [ 3 ]. After the publication of the results of the Term Breech Trial in 2000 the rate of cesarean at term breech increased and has since been around 90% with small variations between birthplaces in Denmark [ 4 , 5 ]. Thus, at present, the majority of term breech deliveries are by planned cesarean delivery (CD); in Denmark, approximately 10% are vaginal deliveries (VD) [ 3 , 6 ].

Planned vaginal breech delivery is associated with a small increased risk of perinatal and neonatal morbidity and mortality. Several descriptive studies and a meta-analysis published after 2015 report a higher relative risk of low Apgar scores, neonatal birth trauma, admission to Neonatal Intensive Care Unit (NICU), and neonatal mortality [ 7 – 11 ] in association with planned vaginal delivery compared to planned cesarean delivery.

In some countries, obstetricians still point out that the neonatal risks can be reduced by following strict criteria regarding which women are suitable for an attempt at vaginal breech delivery as well as a strict awareness of normal progression during vaginal delivery [ 12 – 14 ].

The neonatal risks should be weighed against the risks of maternal complications associated with a cesarean delivery as well as the risk of complications in the woman’s future pregnancies. It is well documented that cesarean delivery increases the risk of maternal short-term complications including postpartum bleeding and wound infections [ 15 , 16 ]. However, these risks are increased when the cesarean is performed during labour, compared to a planned cesarean delivery [ 17 ]. Cesarean delivery entails a risk of uterine rupture, abnormal invasive placenta, placenta previa, and hysterectomy in subsequent pregnancies [ 15 , 18 , 19 ]. Some studies furthermore, indicate an increased risk of antepartum fetal death [ 20 ]. Also, a higher rate of subfertility, ectopic pregnancies, and miscarriages has been linked to a history of a previous cesarean [ 21 – 23 ].

However, the high risk of an emergency cesarean during an attempted vaginal breech delivery is important to bear in mind and include when discussing mode of delivery with the pregnant woman and her partner.

The aim of this study was to investigate short- and long-term maternal complications in present and future pregnancies in relation to planned mode of delivery of breech babies at term in the first pregnancy.

Materials and methods

We conducted a retrospective register-based cohort study using data from the Danish Medical Birth Registry (DMBR) and the Danish National Patient Registry (DNPR).

The DMBR is a population-based registry. It was established in 1968, computerized since 1973. The registry links together the personal ID number of mother, father, and child. The DNPR was established in 1977 and is the key Danish health register. It covers all inpatient, and since 1995 also all outpatient activity, in Danish public and private hospitals or clinics. Information in the DNPR is based on the codes according to the International Statistical Classification of Diseases (ICD-coding) and Related Health Problems Information regarding any procedure is based on the codes according to the Nordic Medico-statistical Committee classification of surgical procedures [ 24 ]. Since 2012, blood loss during delivery has been reported to the DMBR in millilitres (mL). All information regarding maternal characteristics and pregnancy and delivery outcomes was retrieved from the DMBR and the DNPR [ 6 ].

We retrieved data from all women with singleton pregnancies who delivered their first child in breech presentation at term in Denmark from 1991 to 2018, both years included. Additional inclusion criterion was pregnancies with no congenital malformations. All information regarding maternal characteristics and pregnancy and delivery outcomes was retrieved from the DMBR and the DNPR.

Women with stillbirth at first delivery or unknown planned mode of first delivery were excluded ( Fig 1 ). Women who fulfilled the inclusion criteria were identified in the registry, and information on their first and subsequent pregnancies and deliveries was obtained.

• PPT PowerPoint slide
• PNG larger image
• TIFF original image

https://doi.org/10.1371/journal.pone.0297971.g001

The women were categorized according to the planned mode of their first delivery. The definitions of planned mode of delivery were based on the Danish coding system. The four codes for cesarean delivery are (1) emergency CD prelabour, (2) planned (= elective) CD performed prelabour, (3) planned elective CD performed in labour, and (4) emergency CD performed in labour. Planned is in the coding system defined as scheduled >8 hours before the procedure, regardless of whether this was before or during labour. Planned vaginal delivery included all vaginal deliveries and emergency cesarean deliveries in labour (code 4). Planned cesarean delivery included both prelabour and in labour elective cesarean delivery (codes 2 and 3). Due to this design, we were not able to identify women with planned CD who delivered vaginally as they would hence be characterized as planned VD.

Outcome measures related to first delivery were postpartum hemorrhage (a blood loss of 1000 mL or more); infections; surgical organ lesions; re-laparotomy; and postoperative complications defined as a composite outcome including infection, surgical organ lesions (bladder or bowl injuries), or re-laparotomy. In relation to the subsequent pregnancies, the outcome measures included cesarean delivery, placenta previa, uterine rupture, postpartum hemorrhage, hysterectomy, and stillbirth. As data on postpartum hemorrhage before year 2012 are of poor quality, we only included this variable in cases where information on blood loss in mL was available (from 2012). Information on maternal body mass index (BMI) was introduced in the DMBR in 2004.

Supporting information S1 Table includes a detailed list describing codes and specifications for maternal and neonatal morbidity outcomes.

Statistical analyses

Clinical characteristics and demographic data were reported based on their distribution using counts (percentages) for categorical variables and means (range or standard deviation) for numerical variables.

Outcome measures were compared between cases and controls. Odds ratios (OR) with 95% confidence intervals (95% CI) were calculated by use of marginal two-by-two contingency tables.

Multiple logistic regression was used to adjust for the effect of possible confounding by maternal characteristics, including maternal age, BMI, and smoking. In the regression models any cases with missing values on one or more of the variables were eliminated. The results were expressed as adjusted odds ratios (aOR) with corresponding CIs. All analyses were performed in SAS 9.4 (SAS Institute Inc. Cary, NC, USA).

Ethical approval

The study was approved by the Danish Data Protection agency (PFI, Region Zealand); REG-209-2016. As a register-based study, no approval from the Danish Research Ethics Committee was obtained, as this was not required according to Danish legislation. For same reason informed consent was not required. All data were fully anonymized upon data analysis.

We identified a total of 30,778 nulliparous women with a singleton fetus in breech presentation at term during a period from 1991 to 2018. After exclusion of stillbirths (n = 189) and women with unknown planned mode of first delivery (n = 1,721), 28,868 women were included in the analysis and characterized by planned mode of first delivery ( Fig 1 ). A total of 9,681 (33.5%) women had planned vaginal delivery, 2,970 (30.7%) of which delivered vaginally and 6,711 (69.3%) delivered by intrapartum cesarean. Among 19,187 women with planned cesarean delivery, 17,078 (89.0%) delivered by elective cesarean and 2109 (11.0%) by an intrapartum cesarean prior to the planned cesarean delivery. Of the women with planned cesarean delivery in first pregnancy, 12,410 had a second and 2,907 a third pregnancy. In women with planned cesarean in first pregnancy, rates of cesarean in second and third delivery were 35.8% and 40.0%. In women with planned vaginal breech delivery, 6,709 had a second and 1,835 a third delivery. The corresponding cesarean rates were 20.5% and 26.1% ( Fig 1 ).

Maternal characteristics in the first pregnancy by planned mode of delivery are given in Table 1 . Compared with women with planned vaginal delivery, women with planned cesarean breech delivery more often had a Body Mass Index (BMI) of 35 or more, were non-smokers, or less than 160 cm in height. The gestational ages (GA) of children born to women with planned cesarean delivery were lower than in children born to women with planned vaginal delivery, and more children were born after 41 gestational weeks in women with planned vaginal delivery.

https://doi.org/10.1371/journal.pone.0297971.t001

Table 2 presents the risk of short-term complications in nulliparous with breech delivery at term by intended mode of delivery.

https://doi.org/10.1371/journal.pone.0297971.t002

Planned vaginal delivery was associated with a significantly higher risk of infection and surgical organ lesions compared to planned cesarean delivery. There was also a reduced risk of re-laparotomy, although this was not statistically significant. Using a composite outcome for postoperative complications (infection, surgical organ lesion and re-laparotomy), the risk of a postoperative complication was significantly reduced in women with planned cesarean delivery (373 (3.9%) versus 456 (2.4%); aOR of 0.54 [CI 0.44–0.66]). There was no statistical difference between planned mode of delivery regarding postpartum hemorrhage (>1000 ml).

Table 3 presents the risk of maternal complications in subsequent pregnancies. The women with planned cesarean breech delivery in the first pregnancy had a higher risk of repeated cesarean delivery in their subsequent pregnancies, 4,443 (35.8%) versus 1,375 (20.5%); aOR 5.3 (CI 4.1–7.1) in second pregnancy and 1,163 (40.0%) versus 479 (26.1%); aOR of 4.5 (CI 3.5–5.8) in third pregnancy. Women with planned cesarean breech delivery in first pregnancy had a significantly higher risk of uterine rupture compared to women with planned vaginal breech delivery, 195 (1.6%) versus 57 (0.9); aOR of 1.85 (CI: 1.37–2.50) in second pregnancy and 20 (0.69%) versus 4 (0.22%); aOR 3.15 (1.08–9.24) in third pregnancy.

https://doi.org/10.1371/journal.pone.0297971.t003

There was no significant association between planned mode of breech delivery and postpartum hemorrhage, placenta previa, and hysterectomy in second or third pregnancies.

Planned vaginal breech delivery was significantly related to stillbirth in third but not in second pregnancy.

Supporting information S2 Table presents a sub analysis for risk of complications based on actual mode of delivery.

Main findings

In this retrospective register-based cohort study among 28,868 nulliparous Danish women with breech delivery at term, we found that 66.5% intended to deliver by cesarean. Among the women who planned vaginal breech delivery, 69.3% delivered by emergency cesarean. Due to the high risk of secondary cesarean, women with planned vaginal breech delivery were at increased risk of postoperative complications in terms of infections, surgical organ lesions, and re-laparotomy, compared to women with planned cesarean delivery. Having a planned cesarean breech delivery in first pregnancy was associated with a significantly higher risk of uterine rupture in subsequent pregnancies but not to placenta previa, postpartum hemorrhage or hysterectomy. Women with planned vaginal delivery in first pregnancy had a significantly higher risk of stillbirth in their third pregnancy but not in their second. Planned cesarean breech delivery in first pregnancy was associated with a significantly higher risk of repeated cesarean in the two subsequent pregnancies.

Strength and limitations

This study has the major strength of including a large number of women with information on their complete obstetric history of both intended and actual mode of delivery as well as information on second and third pregnancies and deliveries.

The incidence of emergency cesarean among nulliparous was as high as 69% in the present study, which may be a result of misclassification of categories of cesarean delivery in the register, which of course should be considered as a limitation of the study. In the regression analyses we were able to adjust for some maternal characteristics including maternal age, BMI, and smoking. However, the results may have been affected by other unknown or unmeasured confounders.

Another weakness of the study is that the material is too small to truly evaluate risk of severe and rarely occurring long-term maternal complications such as abnormal invasive placenta and hysterectomies in subsequent pregnancies.

Interpretation

The present study confirms the findings of a previous study among Danish women showing a very low overall risk of maternal short- and long-term complications regardless of planned mode of breech delivery in first pregnancy [ 19 ]. Our data underline the importance of informing women with breech presentation at term about outcomes in relation not only to planned but also to actual mode of delivery and thus take the high risk of an intrapartum cesarean during an attempt of vaginal breech delivery into account. Furthermore, personal counselling should include an individualized assessment of the woman’s chance of having a successful attempt of vaginal breech delivery and include information on short- as well as long-term maternal complications.

What is the best mode of delivery for breech presentation at term has been debated since the 1950s [ 3 ]. The vast majority of the analyses are based on descriptive studies. Only a few prospective studies have been conducted. In the Term Breech Trial [ 4 ] in 2000, there were no significant differences in short-term maternal mortality or morbidity between groups with planned cesarean delivery and planned vaginal delivery. However, a relatively high percentage (56.7%) of the women randomized to the planned vaginal delivery group actually delivered vaginally and only 36.1% delivered by emergency cesarean.

A French/Belgian observational prospective study (PREMODA) [ 13 ] reported a high rate of vaginal deliveries (71%) among women with planned vaginal breech delivery. Unfortunately, this study did not evaluate any maternal outcomes. A secondary analysis of the data from the PREMODA study by Korb et al. [ 25 ] focused on short-term severe acute maternal morbidity (maternal death, maternal transfer to intensive care unit, severe postpartum hemorrhage involving blood transfusion, reoperation or pulmonary embolism), and found no differences between the groups with planned cesarean and planned vaginal breech delivery.

An Australian study [ 8 ] comparing 10,133 women with term breech presentation used strict criteria for selecting women eligible for vaginal delivery. Of 5,197 women found eligible for vaginal breech delivery, only 352 (6.8%) had planned vaginal delivery. Compared to the group with planned cesarean, the risk of postpartum hemorrhage was higher among the women with planned vaginal delivery (RR 1.69 CI: 1.07–2.68). No difference was found in severe maternal morbidity including cardiac arrest, cerebrovascular hemorrhage, hysterectomy, mechanical ventilation, or post-partum re-admission.

Mattila et al. [ 26 ] also compared term breech deliveries according to planned mode of delivery. Of 1,418 term breech deliveries, 406 (28.6%) planned vaginal birth following strict selection criteria. Of these, 338 (83.3%) delivered vaginally. In the group with planned cesarean delivery, 6.5% had postpartum hemorrhage >1000 mL compared to 3.8% in the group with planned vaginal delivery. This difference was not statistically significant. Women in the planned cesarean delivery group more often had puerperal infections including wound infections compared to the women with planned vaginal delivery.

In a Finnish observational study [ 27 ] from 2004, 2910 breech deliveries were compared to 133,680 deliveries in cephalic presentation. In the breech group, 56.4% delivered by elective cesarean versus 3.7% in the cephalic group, and 11.4% delivered by emergency cesarean versus 2.8% in the cephalic group. Maternal death occurred only in the cephalic presentation group (3 deaths versus none). Women in the cephalic vaginal delivery group had a higher risk of perineal tears compared to those in the vaginal breech delivery group (OR 0.38 [0.24–0.62]). There were no other differences in maternal morbidity between the groups.

In the secondary analysis of the PREMODA data, Korb et al. [ 25 ] also compared vaginal breech deliveries with a control group with cephalic presentation. Not surprisingly, the rate of cesarean was higher in the breech presentation group. The risk of severe acute maternal morbidity was significantly higher in the breech compared to the cephalic presentation group (RR 1.80 [1.02–3.17].

A recently published systematic review and meta-analysis [ 11 ] of 32 articles including only studies that focused on the intended mode of breech delivery reports a reduced risk of perinatal morbidity for intended cesarean delivery compared to intended vaginal delivery. The data were sparse on maternal short-term as well as long-term outcomes, hence no conclusions could be drawn.

The present study illustrates the importance of considering the high risk of secondary cesarean during a planned vaginal breech delivery.

Compared to previous studies, we find a high rate of planned vaginal deliveries, thus also a high rate of secondary cesarean. This could be due to an in Denmark cautious approach during attempted vaginal delivery of breech presentation where subacute cesarean is performed if the condition for a successful vaginal delivery is considered poor.

In Denmark, it is recommended that a trial of labour after cesarean be preferred if no other contraindications are present [ 28 ]. In this study, 64.2% of the women who gave birth by cesarean in first delivery had a vaginal delivery in their second pregnancy, while 35.8% had a repeated cesarean delivery in their second pregnancy and 40.0% in their third pregnancy. The risk of uterine rupture was twice as high in the second delivery in women with a prior cesarean.

Women with planned vaginal delivery in first pregnancy had a significantly higher risk of stillbirth in their third pregnancy but not in their second. We have no explanation for this finding but based on our results we find it very unlikely that caesarean for breech in first pregnancy is associated to stillbirth in subsequent pregnancies. No other statistical differences in risk of complications in the third pregnancy could be detected.

Women with breech presentation considering planned mode of delivery should be counselled regarding the risk of both neonatal and maternal complications. Overall, planned vaginal as well as planned cesarean breech delivery are safe procedures for the mother and there are only minor differences in maternal the outcomes in the subsequent pregnancies. Future research should evaluate the ability of machine learning models to predict successful vaginal breech delivery and thereby minimize the risk of secondary cesarean in women who wish a vaginal breech delivery.

Also, long-term health effects of planned mode of breech delivery on infant outcomes including auto-immune diseases such as diabetes type-1, asthma and allergies should be further investigated.

Compared to planned vaginal breech delivery at term, nulliparous women with planned cesarean breech delivery have a significantly reduced risk of postoperative complications in terms of infections and surgical organ lesions but a higher risk of uterine rupture in their subsequent pregnancies.

Supporting information

S1 table. detailed list describing codes and specifications for maternal and neonatal morbidity outcomes..

https://doi.org/10.1371/journal.pone.0297971.s001

S2 Table. Risk of complications in first, second and third pregnancy by actual mode of breech delivery in first pregnancy.

https://doi.org/10.1371/journal.pone.0297971.s002

S1 Dataset. Dataset Maternal Outcome Breech.

https://doi.org/10.1371/journal.pone.0297971.s003

• View Article
• Google Scholar
• PubMed/NCBI
• 6. Fødselsregisteret (MFR)—Sundhedsdatastyrelsen [Internet]. Available from: http://sundhedsdatastyrelsen.dk/da/registre-og-services/om-de-nationale-sundhedsregistre/graviditet-foedsler-og-boern/foedselsregisteret