Breech Presentation - Podcast Version 0:00 / 0:00 1x 0.25x 0.5x 0.75x 1x 1.25x 1.5x 1.75x 2x A breech presentation is when the fetus presents buttocks or feet first (rather than head first – a cephalic presentation). It has significant implications in terms of delivery, especially if it occurs at term (>37 weeks). Breech deliveries carry a higher perinatal mortality and morbidity, largely due to birth asphyxia/trauma, prematurity and an increased incidence of congenital malformations. In this article, we shall look at the risk factors, investigations and management of a breech presentation. Key Points Breech presentation = longitudinal lie with the fetal buttocks/feet presenting at the pelvic inlet. Types: frank, complete, and footling breech. Incidence decreases from ~20% at 28 weeks to ~3% at term due to spontaneous version. Diagnosis confirmed with USS; assess presentation subtype and associated pathology. ECV should be offered from 36 weeks in primiparous women and from 37 weeks in multiparous women. Major obstetric risks: cord prolapse, head entrapment, fetal hypoxia, and birth trauma. Types of Breech Presentation In a breech presentation, the fetus presents ‘bottom down’. There are three main types, depending on the position of the legs: Complete (flexed) breech – both legs are flexed at the hips and knees (fetus appears to be sitting ‘cross-legged’). Frank (extended) breech – both legs are flexed at the hip and extended at the knee. This is the most common type of breech presentation. Footling breech – one or both legs extended at the hip, so that the foot is the presenting part. Approximately 20% of babies are breech at 28 weeks gestation. The majority of these revert to a cephalic presentation (head down) spontaneously, and only 3% are breech at term. Aetiology and Risk Factors Most breech presentations seem to be chance occurrences. However, in up to 15% of cases, it may be due to fetal or uterine causes. The risk factors are listed below: Uterine Fetal Multiparity Uterine malformations (e.g. septate uterus) Fibroids Placenta praevia Prematurity Macrosomia Polyhydramnios (raised amniotic fluid index) Twin pregnancy (or higher order) Abnormality (e.g. anencephaly) Clinical Features The diagnosis of breech presentation is of limited significance prior to 32-35 weeks, as the fetus is likely to revert to a cephalic presentation before delivery. Breech presentation is usually identified on clinical examination. On palpating the abdomen, the round fetal head can be felt in the upper part of the uterus, and an irregular mass (fetal buttocks and legs) in the pelvis. Breech presentation can also be suspected if the fetal heart is auscultated higher on the maternal abdomen. In around 20% of cases, breech presentation is not diagnosed until labour. This can present with signs of fetal distress, such as meconium-stained liquor. On vaginal examination, the sacrum or foot may be felt through the cervical opening. Differential Diagnosis There are two main differential diagnoses for a breech presentation: Oblique lie – the fetus is positioned diagonally in the uterus, with the head or buttocks in one iliac fossa. Transverse lie – the fetus is positioned across the uterus, with the head on one side of the pelvis and the buttocks on the other. The shoulder is usually the presenting part. The other important diagnosis to consider is unstable lie. This is where the presentation of the fetus changes from day to day (and can include breech presentation). Unstable lie is more likely if there is known polyhydramnios or the woman is multiparous. Investigations Any suspected breech presentation should be confirmed by an ultrasound scan, which can also identify the type of breech (flexed/extended/footling). It can also reveal any fetal or uterine abnormalities that may predispose to breech presentation. Clinical abdominal palpation, Leopold manoeuvres to assess lie and presenting part US assessment Type of breech Assessment of whether the fetal head is flexed, neutral, or hyperextended Estimated fetal weight Amniotic fluid volume Fetal anomaly Management At term, the options for management of breech presentation are external cephalic version, caesarean section, or vaginal breech birth.2 External Cephalic Version External cephalic version is the manipulation of the fetus to a cephalic presentation through the maternal abdomen. This, if successful, can enable an attempt at vaginal delivery. It has an approximate 50% success rate (40% success rate in a primiparous woman, and 60% success rate in a multiparous woman).1 In contrast, only 8% of breech presentations spontaneously revert to cephalic in primiparous women.1 ECV should be offered from 36 weeks gestation in primiparous women, and from 37 weeks gestation in multiparous women. Complications of ECV include transient fetal heart abnormalities (which revert to normal), and rarer complications such as more persistent heart rate abnormalities (e.g. fetal bradycardia), and placental abruption. The risk of the woman needing an emergency caesarean is around 1/200.1 There is no consensus on the contraindications to ECV. Women should be informed that ECV after one caesarean section delivery has no greater risk compared to ECV performed on an unscarred uterus. Anti-D after ECV RhD-negative women should receive anti-D immunoglobulin following external cephalic version (ECV), as the procedure carries a small risk of fetomaternal haemorrhage, where fetal blood cells enter the maternal circulation. Tocolysis The use of a tocolytic agent, most commonly terbutaline, is recommended to improve the success of ECV. By promoting uterine relaxation, tocolysis facilitates fetal manipulation and increases the likelihood of a successful version. Informed consent and maternal choice Women should receive individualised counselling regarding the risks and benefits of ECV, planned vaginal breech birth, and elective caesarean section. This supports informed consent and shared decision-making, allowing management to be tailored to the woman’s preferences and clinical circumstances. Monitoring requirements for ECV ECV should be performed in an appropriate clinical setting where emergency caesarean delivery can be undertaken if required. Fetal wellbeing should be assessed with cardiotocography (CTG) before and after the procedure, alongside routine maternal observations. Women should also be monitored for complications, including vaginal bleeding, abdominal pain, rupture of membranes, and fetal distress. Caesarean Section If external cephalic version (ECV) is unsuccessful, contraindicated, or declined, women should be counselled regarding their options for birth, including both planned caesarean section and planned vaginal breech birth. Planned caesarean sections are associated with lower rates of perinatal mortality and short-term neonatal morbidity in term breech pregnancies. However, the absolute risk of adverse perinatal outcomes with a planned vaginal breech birth remains low when there are no additional risk factors and delivery is conducted by an experienced clinician. Women should receive clear information regarding the risks and benefits of each approach to support informed consent and shared decision-making. The evidence for preterm breech presentation is less clear. However, caesarean section is often preferred due to the relatively larger head-to-abdomen circumference ratio in preterm infants, which may increase the risk of head entrapment during vaginal delivery. Vaginal Breech Birth A woman may still choose to aim for a vaginal breech delivery. Additionally, a small proportion of women with breech presentation present in advanced labour, with vaginal delivery the only option. A contraindication to vaginal breech delivery is footling breech, as the feet and legs can slip through a non-fully dilated cervix, and the shoulders or head can then become trapped. The most important advice when conducting a vaginal breech delivery is “hands off the breech”. This is because putting traction on the baby during delivery can cause the fetal head to extend, getting it trapped during delivery. The fetal sacrum needs to be maintained anteriorly, which can be done by holding the fetal pelvis. However, occasionally the baby does not deliver spontaneously, and some specific manoeuvres are required: Flexing the fetal knees to enable delivery of the legs. Using Lovset’s manoeuvre to rotate the body and deliver the shoulders. Using the Mauriceau-Smellie-Veit (MSV) manoeuvre to deliver the head by flexion. The delivery of the aftercoming head can be challenging, but if MSV fails, forceps can be used. Planned vaginal breech birth may be considered in selected women following senior obstetric review and informed consent. Suitable candidates typically have: Frank or complete breech presentation An appropriately sized fetus No additional maternal or fetal risk factors Access to a clinician experienced in vaginal breech delivery Labour taking place in a unit with facilities for continuous fetal monitoring and immediate caesarean section if required Complications A major complication of breech presentation is cord prolapse, where the umbilical cord drops down below the presenting part of the baby and becomes compressed. The incidence of cord prolapse is 1% in breech presentations, compared to 0.5% in cephalic presentations. Other complications include: Fetal head entrapment Premature rupture of membranes Birth asphyxia, usually secondary to a delay in delivery Intracranial haemorrhage, as a result of rapid compression of the head during delivery Equity, Safety and Professionalism Management of breech presentation should be guided by maternal preferences and individual clinical circumstances. Women should receive balanced, non-directive counselling regarding the risks and benefits of available options to facilitate informed decision-making. Safe practice requires confirmation of breech presentation with ultrasound, appropriate risk assessment, involvement of clinicians experienced in breech management, and preparation for emergency caesarean delivery if required. Recent Changes and Controversies The increasing use of planned caesarean section for breech presentation has led to fewer opportunities for clinicians to gain experience in vaginal breech birth. As a result, the RCOG supports vaginal breech delivery only in carefully selected cases, where experienced clinicians are available, appropriate selection criteria are met, and facilities are in place for emergency caesarean delivery if required. References 1. Royal College of Obstetricians and Gynaecologists. External cephalic version and reducing the incidence of term breech presentation. Green-top Guideline No. 20a. BJOG. 2017;124:e178-e192. Available from: https://www.rcog.org.uk/guidance/browse-all-guidance/green-top-guidelines/gtg20a/ 2. Royal College of Obstetricians and Gynaecologists. Management of breech presentation. Green-top Guideline No. 20b. BJOG. 2017;124:e151-e177. Available from: https://www.rcog.org.uk/guidance/browse-all-guidance/green-top-guidelines/gtg20b/ Recommended Reading RCOG Green-top Guideline No. 20a – External Cephalic Version and Reducing the Incidence of Term Breech Presentation RCOG Green-top Guideline No. 20b – Management of Breech Presentation Do you think you’re ready? Take the quiz below QuizPro Feature Breech Presentation Question 1 of 3 Submitting... Skip Next Rate question: You scored 0% Skipped: 0/3 More Questions Available Upgrade to TeachMeObGyn Pro Test your knowledge with a wide range of high-quality multiple-choice questions. Learn More Rate This Article