definition footling breech presentation

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

• Key Points |

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

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

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

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

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

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

Abnormal fetal lie, presentation, or position may occur with

Fetopelvic disproportion (fetus too large for the pelvic inlet)

Fetal congenital anomalies

Uterine structural abnormalities (eg, fibroids, synechiae)

Multiple gestation

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

Transverse lie

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

Breech presentation

There are several types of breech presentation.

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

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

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

Types of breech presentations

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

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

Predisposing factors for breech presentation include

Preterm labor

Uterine abnormalities

Fetal anomalies

If delivery is vaginal, breech presentation may increase risk of

Umbilical cord prolapse

Birth trauma

Perinatal death

Face or brow presentation

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

Brow presentation usually converts spontaneously to vertex or face presentation.

Occiput posterior position

The most common abnormal position is occiput posterior.

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

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

Position and Presentation of the Fetus

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

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

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

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

StatPearls [Internet].

Breech presentation.

Caron J. Gray ; Meaghan M. Shanahan .

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Last Update: November 6, 2022 .

• Continuing Education Activity

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

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

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

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

• Epidemiology

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

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

• Pathophysiology

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

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

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

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

• History and Physical

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

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

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

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

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

• Treatment / Management

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

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

The initial criteria used in these reports were similar: gestational age greater than 37 weeks, frank or complete breech presentation, no fetal anomalies on ultrasound examination, adequate maternal pelvis, and estimated fetal weight between 2500 g and 4000 g. In addition, the protocol presented by one report required documentation of fetal head flexion and adequate amniotic fluid volume, defined as a 3-cm vertical pocket. Oxytocin induction or augmentation was not offered, and strict criteria were established for normal labor progress. CT pelvimetry did determine an adequate maternal pelvis.

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

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

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

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

• Enhancing Healthcare Team Outcomes

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

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

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

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

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

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

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Breech Births

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

What are the different types of breech birth presentations?

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

What causes a breech presentation?

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

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

How is a breech presentation diagnosed?

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

Can a breech presentation mean something is wrong?

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

Can a breech presentation be changed?

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

Medical Techniques

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

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

ECV will not be tried if:

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

Complications of EVC include:

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

Vaginal delivery versus cesarean for breech birth?

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

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

What are the risks and complications of a vaginal delivery?

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

When is a cesarean delivery used with a breech presentation?

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

Want to Know More?

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

Compiled using information from the following sources:

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

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Babies in utero spend most of their gestation head-up. As they get heavier and prepare for delivery, they turn head-down. This usually happens around 32 weeks. When it doesn’t, and baby is still head-up at term, we call this baby breech.

When the baby’s head is up by the mother’s heart, the baby may be curled up in any number of positions—all of which are breech.

A footling breech baby is presenting feet or foot first . If we could look through the cervix, the first thing we’d see would be a foot. If labor started and the baby was pushed out this way, the first thing to emerge would be a foot.

A single footling has one knee drawn up so that only one foot is down and a double footling breech has both her feet together over the cervix.

Most breech babies come butt-first–Frank breech or complete breech. In this case, when the mother pushes her baby out, it’s a butt that is crowning, not a head (often called ‘rumping’).

Only about 20% of breech babies are footling breeches.

Footling breeches are trickier vaginal births. For one thing, there isn’t anything nice and solid and heavy pressing on the cervix to help it dilate. With a butt or a head over the cervix, it’s likely to dilate quicker and more efficiently.

Another risk of footling breech birth is cord prolapse . If the water is broken and a part of the umbilical cord falls through the cervix, it can create a dangerous situation for the baby due to cord compression and congealing.

Extremely rare in head-down birth, the incidence of cord prolapse rises considerably with breeches. Footling breeches have the highest risk (10-25%) because there is no butt or head blocking the cervix.

For many providers who are comfortable delivering a breech baby normally, footling breech position is a contraindication . For vaginal breech birth to be considered safe, a number of conditions must be met. The baby’s position is high on the list of questions.

Frank breech babies are generally seen as the safest because they can be delivered like a baby tube, neatly packaged with bum over cervix. These babies tend to do well in labor.

Part of the reason they do well is that the baby’s compacted body ‘opens the door’ for the head to pass through easily. With a footling, the baby’s feet can come down anytime and the birth canal may not be stretched as fully. Sometimes this makes birthing the head more difficult or dangerous.

Sometimes it does no such thing.

Check out some of the great footling breech birth stories  and videos here.

Sometimes a footling will convert to a complete breech and come down butt-first once contractions begin. Keep this in mind when thinking about and discussing your options.

Finding a provider to attend and assist at your vaginal breech birth is already hard. Finding one who feels comfortable with a footling breech is even more difficult.

Some people do think it is easier to turn a footling . If you’re interested in ways to help a breech baby flip , it may just work. An ECV is safe and does reduce the likelihood a mother will end up with a cesarean.

Only you can make the decision, and I hope that if you feel comfortable with it you will convince your doctor to get some training or even consider traveling to avoid a cesarean.

Breech Presentation

• Author: Richard Fischer, MD; Chief Editor: Ronald M Ramus, MD  more...
• Sections Breech Presentation
• Vaginal Breech Delivery
• Cesarean Delivery
• Comparative Studies
• External Cephalic Version
• Conclusions
• Media Gallery

Breech presentation is defined as a fetus in a longitudinal lie with the buttocks or feet closest to the cervix. This occurs in 3-4% of all deliveries. The percentage of breech deliveries decreases with advancing gestational age from 22-25% of births prior to 28 weeks' gestation to 7-15% of births at 32 weeks' gestation to 3-4% of births at term. [ 1 ]

Predisposing factors for breech presentation include prematurity , uterine malformations or fibroids, polyhydramnios , placenta previa , fetal abnormalities (eg, CNS malformations, neck masses, aneuploidy), and multiple gestations . Fetal abnormalities are observed in 17% of preterm breech deliveries and in 9% of term breech deliveries.

Perinatal mortality is increased 2- to 4-fold with breech presentation, regardless of the mode of delivery. Deaths are most often associated with malformations, prematurity, and intrauterine fetal demise .

Types of breeches

See the list below:

Frank breech (50-70%) - Hips flexed, knees extended (pike position)

Complete breech (5-10%) - Hips flexed, knees flexed (cannonball position)

Footling or incomplete (10-30%) - One or both hips extended, foot presenting

Historical considerations

Vaginal breech deliveries were previously the norm until 1959 when it was proposed that all breech presentations should be delivered abdominally to reduce perinatal morbidity and mortality. [ 2 ]

Vaginal breech delivery

Three types of vaginal breech deliveries are described, as follows:

Spontaneous breech delivery: No traction or manipulation of the infant is used. This occurs predominantly in very preterm, often previable, deliveries.

Assisted breech delivery: This is the most common type of vaginal breech delivery. The infant is allowed to spontaneously deliver up to the umbilicus, and then maneuvers are initiated to assist in the delivery of the remainder of the body, arms, and head.

Total breech extraction: The fetal feet are grasped, and the entire fetus is extracted. Total breech extraction should be used only for a noncephalic second twin; it should not be used for a singleton fetus because the cervix may not be adequately dilated to allow passage of the fetal head. Total breech extraction for the singleton breech is associated with a birth injury rate of 25% and a mortality rate of approximately 10%. Total breech extractions are sometimes performed by less experienced accoucheurs when a foot unexpectedly prolapses through the vagina. As long as the fetal heart rate is stable in this situation, it is permissible to manage expectantly to allow the cervix to completely dilate around the breech (see the image below).

Technique and tips for assisted vaginal breech delivery

The fetal membranes should be left intact as long as possible to act as a dilating wedge and to prevent overt cord prolapse .

Oxytocin induction and augmentation are controversial. In many previous studies, oxytocin was used for induction and augmentation, especially for hypotonic uterine dysfunction. However, others are concerned that nonphysiologic forceful contractions could result in an incompletely dilated cervix and an entrapped head.

An anesthesiologist and a pediatrician should be immediately available for all vaginal breech deliveries. A pediatrician is needed because of the higher prevalence of neonatal depression and the increased risk for unrecognized fetal anomalies. An anesthesiologist may be needed if intrapartum complications develop and the patient requires general anesthesia .

Some clinicians perform an episiotomy when the breech delivery is imminent, even in multiparas, as it may help prevent soft tissue dystocia for the aftercoming head (see the images below).

The Pinard maneuver may be needed with a frank breech to facilitate delivery of the legs but only after the fetal umbilicus has been reached. Pressure is exerted in the popliteal space of the knee. Flexion of the knee follows, and the lower leg is swept medially and out of the vagina.

No traction should be exerted on the infant until the fetal umbilicus is past the perineum, after which time maternal expulsive efforts should be used along with gentle downward and outward traction of the infant until the scapula and axilla are visible (see the image below).

Use a dry towel to wrap around the hips (not the abdomen) to help with gentle traction of the infant (see the image below).

An assistant should exert transfundal pressure from above to keep the fetal head flexed.

Once the scapula is visible, rotate the infant 90° and gently sweep the anterior arm out of the vagina by pressing on the inner aspect of the arm or elbow (see the image below).

Rotate the infant 180° in the reverse direction, and sweep the other arm out of the vagina. Once the arms are delivered, rotate the infant back 90° so that the back is anterior (see the image below).

The fetal head should be maintained in a flexed position during delivery to allow passage of the smallest diameter of the head. The flexed position can be accomplished by using the Mauriceau Smellie Veit maneuver, in which the operator's index and middle fingers lift up on the fetal maxillary prominences, while the assistant applies suprapubic pressure (see the image below).

Alternatively, Piper forceps can be used to maintain the head in a flexed position (see the image below).

In many early studies, routine use of Piper forceps was recommended to protect the head and to minimize traction on the fetal neck. Piper forceps are specialized forceps that are placed from below the infant and, unlike conventional forceps, are not tailored to the position of the fetal head (ie, it is a pelvic, not cephalic, application). The forceps are applied while the assistant supports the fetal body in a horizontal plane.

During delivery of the head, avoid extreme elevation of the body, which may result in hyperextension of the cervical spine and potential neurologic injury (see the images below).

Lower Apgar scores, especially at 1 minute, are more common with vaginal breech deliveries. Many advocate obtaining an umbilical cord artery and venous pH for all vaginal breech deliveries to document that neonatal depression is not due to perinatal acidosis.

Fetal head entrapment may result from an incompletely dilated cervix and a head that lacks time to mold to the maternal pelvis. This occurs in 0-8.5% of vaginal breech deliveries. [ 3 ] This percentage is higher with preterm fetuses (< 32 wk), when the head is larger than the body. Dührssen incisions (ie, 1-3 cervical incisions made to facilitate delivery of the head) may be necessary to relieve cervical entrapment. However, extension of the incision can occur into the lower segment of the uterus, and the operator must be equipped to deal with this complication. The Zavanelli maneuver has been described, which involves replacement of the fetus into the abdominal cavity followed by cesarean delivery. While success has been reported with this maneuver, fetal injury and even fetal death have occurred.

Nuchal arms, in which one or both arms are wrapped around the back of the neck, are present in 0-5% of vaginal breech deliveries and in 9% of breech extractions. [ 3 ] Nuchal arms may result in neonatal trauma (including brachial plexus injuries) in 25% of cases. Risks may be reduced by avoiding rapid extraction of the infant during delivery of the body. To relieve nuchal arms when it is encountered, rotate the infant so that the fetal face turns toward the maternal symphysis pubis (in the direction of the impacted arm); this reduces the tension holding the arm around the back of the fetal head, allowing for delivery of the arm.

Cervical spine injury is predominantly observed when the fetus has a hyperextended head prior to delivery. Ballas and Toaff (1976) reported 20 cases of hyperextended necks, defined as an angle of extension greater than 90° ("star-gazing"), discovered on antepartum radiographs. [ 4 ] Of the 11 fetuses delivered vaginally, 8 (73%) sustained complete cervical spinal cord lesions, defined as either transection or nonfunction.

Cord prolapse may occur in 7.4% of all breech labors. This incidence varies with the type of breech: 0-2% with frank breech, 5-10% with complete breech, and 10-25% with footling breech. [ 3 ] Cord prolapse occurs twice as often in multiparas (6%) than in primigravidas (3%). Cord prolapse may not always result in severe fetal heart rate decelerations because of the lack of presenting parts to compress the umbilical cord (ie, that which predisposes also protects).

Prior to the 2001 recommendations by the American College of Obstetricians and Gynecologists (ACOG), approximately 50% of breech presentations were considered candidates for vaginal delivery. Of these candidates, 60-82% were successfully delivered vaginally.

Candidates can be classified based on gestational age. For pregnancies prior to 26 weeks' gestation, prematurity, not mode of delivery, is the greatest risk factor. Unfortunately, no randomized clinical trials to help guide clinical management have been reported. Vaginal delivery can be considered, but a detailed discussion of the risks from prematurity and the lack of data regarding the ideal mode of delivery should take place with the parent(s). For example, intraventricular hemorrhage, which can occur in an infant of extremely low birth weight, should not be misinterpreted as proof of a traumatic vaginal breech delivery.

For pregnancies between 26 and 32 weeks, retrospective studies suggest an improved outcome with cesarean delivery, although these reports are subject to selection bias. In contrast, between 32 and 36 weeks' gestation, vaginal breech delivery may be considered after a discussion of risks and benefits with the parent(s).

After 37 weeks' gestation, parents should be informed of the results of a recent multicenter randomized clinical trial that demonstrated significantly increased perinatal mortality and short-term neonatal morbidity associated with vaginal breech delivery (see Comparative Studies). For those attempting vaginal delivery, if estimated fetal weight (EFW) is more than 4000 g, some recommend cesarean delivery because of concern for entrapment of the unmolded head in the maternal pelvis, although data to support this practice are limited.

A frank breech presentation is preferred when vaginal delivery is attempted. Complete breeches and footling breeches are still candidates, as long as the presenting part is well applied to the cervix and both obstetrical and anesthesia services are readily available in the event of a cord prolapse.

The fetus should show no neck hyperextension on antepartum ultrasound imaging (see the image below). Flexed or military position is acceptable.

Regarding prior cesarean delivery, a retrospective study by Ophir et al of 71 women with one prior low transverse cesarean delivery who subsequently delivered a breech fetus found that 24 women had an elective repeat cesarean and 47 women had a trial of labor. [ 5 ] In the 47 women with a trial of labor, 37 (78.7%) resulted in a vaginal delivery. Two infants in the trial of labor group had nuchal arms (1 with a transient brachial plexus injury) and 1 woman required a hysterectomy for hemorrhage due to a uterine dehiscence discovered after vaginal delivery. Vaginal breech delivery after one prior cesarean delivery is not contraindicated, though larger studies are needed.

Primigravida versus multiparous

It had been commonly believed that primigravidas with a breech presentation should have a cesarean delivery, although no data (prospective or retrospective) support this view. The only documented risk related to parity is cord prolapse, which is 2-fold higher in parous women than in primigravid women.

Radiographic and CT pelvimetry

Historically, radiograph pelvimetry was believed to be useful to quantitatively assess the inlet and mid pelvis. Recommended pelvimetry criteria included a transverse inlet diameter larger than 11.5 cm, anteroposterior inlet diameter larger than 10.5 cm, transverse midpelvic diameter (between the ischial spines) larger than 10 cm, and anteroposterior midpelvic diameter larger than 11.5 cm. However, radiographic pelvimetry is rarely, if ever, used in the United States.

CT pelvimetry , which is associated with less fetal radiation exposure than conventional radiographic pelvimetry, was more recently advocated by some investigators. It, too, is rarely used today.

Ultimately, if the obstetrical operator is not experienced or comfortable with vaginal breech deliveries, cesarean delivery may be the best choice. Unfortunately, with the dwindling number of experienced obstetricians who still perform vaginal breech deliveries and who can teach future generations of obstetricians, this technique may soon be lost due to attrition.

In 1970, approximately 14% of breeches were delivered by cesarean delivery. By 1986, that rate had increased to 86%. In 2003, based on data from the National Center for Health Statistics, the rate of cesarean delivery for all breech presentations was 87.2%. Most of the remaining breeches delivered vaginally were likely second twins, fetal demises, and precipitous deliveries. However, the rise in cesarean deliveries for breeches has not necessarily equated with an improvement in perinatal outcome. Green et al compared the outcome for term breeches prior to 1975 (595 infants, 22% cesarean delivery rate for breeches) with those from 1978-1979 (164 infants, 94% cesarean delivery rate for breeches). [ 6 ] Despite the increase in rates of cesarean delivery, the differences in rates of asphyxia, birth injury, and perinatal deaths were not significant.

Maneuvers for cesarean delivery are similar to those for vaginal breech delivery, including the Pinard maneuver, wrapping the hips with a towel for traction, head flexion during traction, rotation and sweeping out of the fetal arms, and the Mauriceau Smellie Veit maneuver.

An entrapped head can still occur during cesarean delivery as the uterus contracts after delivery of the body, even with a lower uterine segment that misleadingly appears adequate prior to uterine incision. Entrapped heads occur more commonly with preterm breeches, especially with a low transverse uterine incision. As a result, some practitioners opt to perform low vertical uterine incisions for preterm breeches prior to 32 weeks' gestation to avoid head entrapment and the kind of difficult delivery that cesarean delivery was meant to avoid. Low vertical incisions usually require extension into the corpus, resulting in cesarean delivery for all future deliveries.

If a low transverse incision is performed, the physician should move quickly once the breech is extracted in order to deliver the head before the uterus begins to contract. If any difficulty is encountered with delivery of the fetal head, the transverse incision can be extended vertically upward (T incision). Alternatively, the transverse incision can be extended laterally and upward, taking great care to avoid trauma to the uterine arteries. A third option is the use of a short-acting uterine relaxant (eg, nitroglycerin) in an attempt to facilitate delivery.

Only 3 randomized studies have evaluated the mode of delivery of the term breech. All other studies were nonrandomized or retrospective, which may be subject to selection bias.

In 1980, Collea et al randomized 208 women in labor with term frank breech presentations to either elective cesarean delivery or attempted vaginal delivery after radiographic pelvimetry. [ 7 ] Oxytocin was allowed for dysfunctional labor. Of the 60 women with adequate pelves, 49 delivered vaginally. Two neonates had transient brachial plexus injuries. Women randomized to elective cesarean delivery had higher postpartum morbidity rates (49.3% vs 6.7%).

In 1983, Gimovsky et al randomized 105 women in labor with term nonfrank breech presentations to a trial of labor versus elective cesarean delivery. [ 8 ] In this group of women, 47 had complete breech presentations, 16 had incomplete breech presentations (hips flexed, 1 knee extended/1 knee flexed), 32 had double-footling presentations, and 10 had single-footling presentations. Oxytocin was allowed for dysfunctional labor. Of the labor group, 44% had successful vaginal delivery. Most cesarean deliveries were performed for inadequate pelvic dimensions on radiographic pelvimetry. The rate of neonatal morbidity did not differ between neonates delivered vaginally and those delivered by cesarean delivery, although a higher maternal morbidity rate was noted in the cesarean delivery group.

In 2000, Hannah and colleagues completed a large, multicenter, randomized clinical trial involving 2088 term singleton fetuses in frank or complete breech presentations at 121 institutions in 26 countries. [ 9 ] In this study, popularly known as the Term Breech Trial, subjects were randomized into a planned cesarean delivery group or a planned vaginal birth group. Exclusion criteria were estimated fetal weight (EFW) more than 4000 g, hyperextension of the fetal head, lethal fetal anomaly or anomaly that might result in difficulty with delivery, or contraindication to labor or vaginal delivery (eg, placenta previa ).

Subjects randomized to cesarean delivery were scheduled to deliver after 38 weeks' gestation unless conversion to cephalic presentation had occurred. Subjects randomized to vaginal delivery were treated expectantly until labor ensued. Electronic fetal monitoring was either continuous or intermittent. Inductions were allowed for standard obstetrical indications, such as postterm gestations. Augmentation with oxytocin was allowed in the absence of apparent fetopelvic disproportion, and epidural analgesia was permitted.

Adequate labor was defined as a cervical dilation rate of 0.5 cm/h in the active phase of labor and the descent of the breech fetus to the pelvic floor within 2 hours of achieving full dilation. Vaginal delivery was spontaneous or assisted and was attended by an experienced obstetrician. Cesarean deliveries were performed for inadequate progress of labor, nonreassuring fetal heart rate, or conversion to footling breech. Results were analyzed by intent-to-treat (ie, subjects were analyzed by randomization group, not by ultimate mode of delivery).

Of 1041 subjects in the planned cesarean delivery group, 941 (90.4%) had cesarean deliveries. Of 1042 subjects in the planned vaginal delivery group, 591 (56.7%) had vaginal deliveries. Indications for cesarean delivery included: fetopelvic disproportion or failure to progress in labor (226), nonreassuring fetal heart rate tracing (129), footling breech (69), request for cesarean delivery (61), obstetrical or medical indications (45), or cord prolapse (12).

The composite measurement of either perinatal mortality or serious neonatal morbidity by 6 weeks of life was significantly lower in the planned cesarean group than in the planned vaginal group (5% vs 1.6%, P < .0001). Six of 16 neonatal deaths were associated with difficult vaginal deliveries, and 4 deaths were associated with fetal heart rate abnormalities. The reduction in risk in the cesarean group was even greater in participating countries with overall low perinatal mortality rates as reported by the World Health Organization. The difference in perinatal outcome held after controlling for the experience level of the obstetrician. No significant difference was noted in maternal mortality or serious maternal morbidity between the 2 groups within the first 6 weeks of delivery (3.9% vs 3.2%, P = .35).

A separate analysis showed no difference in breastfeeding, sexual relations, or depression at 3 months postpartum, though the reported rate of urinary incontinence was higher in the planned vaginal group (7.3% vs 4.5%).

Based on the multicenter trial, the ACOG published a Committee Opinion in 2001 that stated "planned vaginal delivery of a singleton term breech may no longer be appropriate." This did not apply to those gravidas presenting in advanced labor with a term breech and imminent delivery or to a nonvertex second twin.

A follow-up study by Whyte et al was conducted in 2004 on 923 children who were part of the initial multicenter study. [ 10 ] The authors found no differences between the planned cesarean delivery and planned vaginal breech delivery groups with regards to infant death rates or neurodevelopmental delay by age 2 years. Similarly, among 917 participating mothers from the original trial, no substantive differences were apparent in maternal outcome between the 2 groups. [ 11 ] No longer-term maternal effects, such as the impact of a uterine scar on future pregnancies, have yet been reported.

A meta-analysis of the 3 above mentioned randomized trials was published in 2015. The findings included a reduction in perinatal/neonatal death, reduced composite short-term outcome of perinatal/neonatal death or serious neonatal morbidity with planned cesarean delivery versus planned vaginal delivery. [ 12 ] However, at 2 years of age, there was no significant difference in death or neurodevelopmental delay between the two groups.  Maternal outcomes assessed at 2 years after delivery were not significantly different.

With regard to preterm breech deliveries, only one prospective randomized study has been performed, which included only 38 subjects (28-36 wk) with preterm labor and breech presentation. [ 13 ] Of these subjects, 20 were randomized to attempted vaginal delivery and 18 were randomized to immediate cesarean delivery. Of the attempted vaginal delivery group, 25% underwent cesarean delivery for nonreassuring fetal heart rate tracings. Five neonatal deaths occurred in the vaginal delivery group, and 1 neonatal death occurred in the cesarean delivery group. Two neonates died from fetal anomalies, 3 from respiratory distress, and 1 from sepsis.

Nonanomalous infants who died were not acidotic at delivery and did not have birth trauma. Differences in Apgar scores were not significant, although the vaginal delivery group had lower scores. The small number of enrolled subjects precluded any definitive conclusions regarding the safety of vaginal breech delivery for a preterm breech.

Retrospective analyses showed a higher mortality rate in vaginal breech neonates weighing 750-1500 g (26-32 wk), but less certain benefit was shown with cesarean delivery if the fetal weight was more than 1500 g (approximately 32 wk). Therefore, this subgroup of very preterm infants (26-32 wk) may benefit from cesarean delivery, although this recommendation is based on potentially biased retrospective data.

A large cohort study was published in 2015 from the Netherlands Perinatal Registry, which included 8356 women with a preterm (26-36 6/7 weeks) breech from 2000 to 2011, over three quarters of whom intended to deliver vaginally. In this overall cohort, there was no significant difference in perinatal mortality between the planned vaginal delivery and planned cesarean delivery groups (adjusted odds ratio 0.97, 95% confidence interval 0.60 – 1.57).  However, the subgroup delivering at 28 to 32 weeks had a lower perinatal mortality with planned cesarean section (aOR 0.27, 95% CI 0.10 – 0.77).  After adding a composite of perinatal morbidity, planned cesarean delivery was associated with a better outcome than a planned vaginal delivery (aOR 0.77, 95% CI 0.63 – 0.93. [ 14 ]

The Maternal-Fetal Medicine Units Network of the US National Institute of Child Health and Human Development considered a multicenter randomized clinical trial of attempted vaginal delivery versus elective cesarean delivery for 24- to 28-week breech fetuses. [ 15 ] However, it was not initiated because of anticipated difficulty with recruitment, inadequate numbers to show statistically significant differences, and medicolegal concerns. Therefore, this study is not likely to be performed.

External cephalic version (ECV) is the transabdominal manual rotation of the fetus into a cephalic presentation.

Initially popular in the 1960s and 1970s, ECV virtually disappeared after reports of fetal deaths following the procedure. Reintroduced to the United States in the 1980s, it became increasingly popular in the 1990s.

Improved outcome may be related to the use of nonstress tests both before and after ECV, improved selection of low-risk fetuses, and Rh immune globulin to prevent isoimmunization.

Prepare for the possibility of cesarean delivery. Obtain a type and screen as well as an anesthesia consult. The patient should have nothing by mouth for at least 8 hours prior to the procedure. Recent ultrasonography should have been performed for fetal position, to check growth and amniotic fluid volume, to rule out a placenta previa, and to rule out anomalies associated with breech. Another sonogram should be performed on the day of the procedure to confirm that the fetus is still breech.

A nonstress test (biophysical profile as backup) should be performed prior to ECV to confirm fetal well-being.

Perform ECV in or near a delivery suite in the unlikely event of fetal compromise during or following the procedure, which may require emergent delivery.

ECV can be performed with 1 or 2 operators. Some prefer to have an assistant to help turn the fetus, elevate the breech out of the pelvis, or to monitor the position of the baby with ultrasonography. Others prefer a single operator approach, as there may be better coordination between the forces that are raising the breech and moving the head.

ECV is accomplished by judicious manipulation of the fetal head toward the pelvis while the breech is brought up toward the fundus. Attempt a forward roll first and then a backward roll if the initial attempts are unsuccessful. No consensus has been reached regarding how many ECV attempts are appropriate at one time. Excessive force should not be used at any time, as this may increase the risk of fetal trauma.

Following an ECV attempt, whether successful or not, repeat the nonstress test (biophysical profile if needed) prior to discharge. Also, administer Rh immune globulin to women who are Rh negative. Some physicians traditionally induce labor following successful ECV. However, as virtually all of these recently converted fetuses are unengaged, many practitioners will discharge the patient and wait for spontaneous labor to ensue, thereby avoiding the risk of a failed induction of labor. Additionally, as most ECV’s are attempted prior to 39 weeks, as long as there are no obstetrical or medical indications for induction, discharging the patient to await spontaneous labor would seem most prudent.

In those with an unsuccessful ECV, the practitioner has the option of sending the patient home or proceeding with a cesarean delivery. Expectant management allows for the possibility of spontaneous version. Alternatively, cesarean delivery may be performed at the time of the failed ECV, especially if regional anesthesia is used and the patient is already in the delivery room (see Regional anesthesia). This would minimize the risk of a second regional analgesia.

In those with an unsuccessful ECV, the practitioner may send the patient home, if less than 39 weeks, with plans for either a vaginal breech delivery or scheduled cesarean after 39 weeks. Expectant management allows for the possibility of a spontaneous version. Alternatively, if ECV is attempted after 39 weeks, cesarean delivery may be performed at the time of the failed ECV, especially if regional anesthesia is used and the patient is already in the delivery room (see Regional anesthesia). This would minimize the risk of a second regional analgesia.

Success rate

Success rates vary widely but range from 35% to 86% (average success rate in the 2004 National Vital Statistics was 58%). Improved success rates occur with multiparity, earlier gestational age, frank (versus complete or footling) breech presentation, transverse lie, and in African American patients.

Opinions differ regarding the influence of maternal weight, placental position, and amniotic fluid volume. Some practitioners find that thinner patients, posterior placentas, and adequate fluid volumes facilitate successful ECV. However, both patients and physicians need to be prepared for an unsuccessful ECV; version failure is not necessarily a reflection of the skill of the practitioner.

Zhang et al reviewed 25 studies of ECV in the United States, Europe, Africa, and Israel. [ 16 ] The average success rate in the United States was 65%. Of successful ECVs, 2.5% reverted back to breech presentation (other estimates range from 3% to 5%), while 2% of unsuccessful ECVs had spontaneous version to cephalic presentation prior to labor (other estimates range from 12% to 26%). Spontaneous version rates depend on the gestational age when the breech is discovered, with earlier breeches more likely to undergo spontaneous version.

A prospective study conducted in Germany by Zielbauer et al demonstrated an overall success rate of 22.4% for ECV among 353 patients with a singleton fetus in breech presentation. ECV was performed at 38 weeks of gestation. Factors found to increase the likelihood of success were a later week of gestation, abundant amniotic fluid, fundal and anterior placental location, and an oblique lie. [ 17 ]

A systematic review in 2015 looked at the effectiveness of ECV with eight randomized trials of ECV at term. Compared to women with no attempt at ECV, ECV reduced non-cephalic presentation at birth by 60% and reduced cesarean sections by 40% in the same group. [ 18 ] Although the rate of cesarean section is lower when ECV is performed than if not, the overall rate of cesarean section remains nearly twice as high after successful ECV due to both dystocia and non-reassuring fetal heart rate patterns. [ 19 ]  Nulliparity was the only factor shown in follow-up to increase the risk of instrumental delivery following successful ECV. [ 20 ]

While most studies of ECV have been performed in university hospitals, Cook showed that ECV has also been effective in the private practice setting. [ 21 ] Of 65 patients with term breeches, 60 were offered ECV. ECV was successful in 32 (53%) of the 60 patients, with vaginal delivery in 23 (72%) of the 32 patients. Of the remaining breech fetuses believed to be candidates for vaginal delivery, 8 (80%) had successful vaginal delivery. The overall vaginal delivery rate was 48% (31 of 65 patients), with no significant morbidity.

Cost analysis

In 1995, Gifford et al performed a cost analysis of 4 options for breech presentations at term: (1) ECV attempt on all breeches, with attempted vaginal breech delivery for selected persistent breeches; (2) ECV on all breeches, with cesarean delivery for persistent breeches; (3) trial of labor for selected breeches, with scheduled cesarean delivery for all others; and (4) scheduled cesarean delivery for all breeches prior to labor. [ 22 ]

ECV attempt on all breeches with attempted vaginal breech delivery on selected persistent breeches was associated with the lowest cesarean delivery rate and was the most cost-effective approach. The second most cost-effective approach was ECV attempt on all breeches, with cesarean delivery for persistent breeches.

Uncommon risks of ECV include fractured fetal bones, precipitation of labor or premature rupture of membranes , abruptio placentae , fetomaternal hemorrhage (0-5%), and cord entanglement (< 1.5%). A more common risk of ECV is transient slowing of the fetal heart rate (in as many as 40% of cases). This risk is believed to be a vagal response to head compression with ECV. It usually resolves within a few minutes after cessation of the ECV attempt and is not usually associated with adverse sequelae for the fetus.

Trials have not been large enough to determine whether the overall risk of perinatal mortality is increased with ECV. The Cochrane review from 2015 reported perinatal death in 2 of 644 in ECV and 6 of 661 in the group that did not attempt ECV. [ 18 ]

A 2016 Practice Bulletin by ACOG recommended that all women who are near term with breech presentations should be offered an ECV attempt if there are no contraindications (see Contraindications below). [ 23 ]  ACOG guidelines issued in 2020 recommend that ECV should be performed starting at 37+0 weeks, in order to reduce the likelihood of reversion and to increase the rate of spontaneous version. [ 24 ]

ECV is usually not performed on preterm breeches because they are more likely to undergo spontaneous version to cephalic presentation and are more likely to revert to breech after successful ECV (approximately 50%). Earlier studies of preterm ECV did not show a difference in the rates of breech presentations at term or overall rates of cesarean delivery. Additionally, if complications of ECV were to arise that warranted emergent delivery, it would result in a preterm neonate with its inherent risks. The Early External Cephalic Version (ECV) 2 trial was an international, multicentered, randomized clinical trial that compared ECV performed at 34-35 weeks’ gestation compared with 37 weeks’ gestation or more. [ 25 ] Early ECV increased the chance of cephalic presentation at birth; however, no difference in cesarean delivery rates was noted, along with a nonstatistical increase in preterm births.

A systematic review from 2015 looked at 5 studies of ECV completed prior to 37 weeks and concluded that compared with no ECV attempt, ECV commenced before term reduces the non-cephalic presentation at birth, however early ECV may increase the risk of late preterm birth. [ 26 ]

Given the increasing awareness of the risks of late preterm birth and early term deliveries, the higher success of earlier ECV should be weighed against the risks of iatrogenic prematurity should a complication arise necessitating delivery.

Contraindications

Absolute contraindications for ECV include multiple gestations with a breech presenting fetus, contraindications to vaginal delivery (eg, herpes simplex virus infection, placenta previa), and nonreassuring fetal heart rate tracing.

Relative contraindications include polyhydramnios or oligohydramnios , fetal growth restriction , uterine malformation , and major fetal anomaly.

Controversial candidates

Women with prior uterine incisions may be candidates for ECV, but data are scant. In 1991, Flamm et al attempted ECV on 56 women with one or more prior low transverse cesarean deliveries. [ 27 ] The success rate of ECV was 82%, with successful vaginal births in 65% of patients with successful ECVs. No uterine ruptures occurred during attempted ECV or subsequent labor, and no significant fetal complications occurred.

In 2010 ACOG acknowledged that although there is limited data in both the above study and one more recently, [ 28 ] no serious adverse events occurred in these series. A larger prospective cohort study that was published in 2014 reported similar success rates of ECV among women with and without prior cesarean section, although lower vaginal birth rates. There were, however, no cases of uterine rupture or other adverse outcomes. [ 29 ]

Another controversial area is performing ECV on a woman in active labor. In 1985, Ferguson and Dyson reported on 15 women in labor with term breeches and intact membranes. [ 30 ] Four patients were dilated greater than 5 cm (2 women were dilated 8 cm). Tocolysis was administered, and intrapartum ECV was attempted. ECV was successful in 11 of 15 patients, with successful vaginal births in 10 patients. No adverse effects were noted. Further studies are needed to evaluate the safety and efficacy of intrapartum ECV.

Data regarding the benefit of intravenous or subcutaneous beta-mimetics in improving ECV rates are conflicting.

In 1996, Marquette et al performed a prospective, randomized, double-blinded study on 283 subjects with breech presentations between 36 and 41 weeks' gestation. [ 31 ] Subjects received either intravenous ritodrine or placebo. The success rate of ECV was 52% in the ritodrine group versus 42% in the placebo group ( P = .35). When only nulliparous subjects were analyzed, significant differences were observed in the success of ECV (43% vs 25%, P < .03). ECV success rates were significantly higher in parous versus nulliparous subjects (61% vs 34%, P < .0001), with no additional improvement with ritodrine.

A systematic review published in 2015 of six randomized controlled trials of ECV that compared the use of parenteral beta-mimetic tocolysis during ECV concluded that tocolysis was effective in increasing the rate of cephalic presentation in labor and reducing the cesarean delivery rate by almost 25% in both nulliparous and multiparous women. [ 32 ] Data on adverse effects and other tocolytics was insufficient. A review published in 2011 on Nifedipine did not show an improvement in ECV success. [ 33 ]

Regional anesthesia

Regional analgesia, either epidural or spinal, may be used to facilitate external cephalic version (ECV) success. When analgesia levels similar to that for cesarean delivery are given, it allows relaxation of the anterior abdominal wall, making palpation and manipulation of the fetal head easier. Epidural or spinal analgesia also eliminates maternal pain that may cause bearing down and tensing of the abdominal muscles. If ECV is successful, the epidural can be removed and the patient sent home to await spontaneous labor. If ECV is unsuccessful, a patient can proceed to cesarean delivery under her current anesthesia, if the gestational age is more than 39 weeks.

The main disadvantage is the inherent risk of regional analgesia, which is considered small. Additionally, lack of maternal pain could potentially result in excessive force being applied to the fetus without the knowledge of the operator.

In 1994, Carlan et al retrospectively analyzed 61 women who were at more than 36 weeks' gestation and had ECV with or without epidural. [ 34 ] The success rate of ECV was 59% in the epidural group and 24% in the nonepidural group ( P < .05). In 7 of 8 women with unsuccessful ECV without epidural, a repeat ECV attempt after epidural was successful. No adverse effects on maternal or perinatal morbidity or mortality occurred.

In 1997, Schorr et al randomized 69 subjects who were at least 37 weeks' gestation to either epidural or control groups prior to attempted ECV. [ 35 ] Those in whom ECV failed underwent cesarean delivery. The success rate of ECV was 69% in the epidural group and 32% in the control group (RR, 2.12; 95% CI, 1.24-3.62). The cesarean delivery rate was 79% in the control group and 34% in the epidural group ( P = .001). No complications of epidural anesthesia and no adverse fetal effects occurred.

In 1999, Dugoff et al randomized 102 subjects who were at more than 36 weeks' gestation with breech presentations to either spinal anesthesia or a control group. [ 36 ] All subjects received 0.25 mg terbutaline subcutaneously. The success rate of ECV was 44% in the spinal group and 42% in the nonspinal group, which was not statistically significant.

In contrast, a 2007 randomized clinical trial of spinal analgesia versus no analgesia in 74 women showed a significant improvement in ECV success (66.7% vs 32.4%, p = .004), with a significantly lower pain score by the patient. [ 37 ]

The 2015 systematic review asserted that regional analgesia in combination with a tocolytic was more effective than the tocolytic alone for increasing ECV success; however there was no difference in cephalic presentation in labor. Data from the same review was insufficient to assess regional analgesia without tocolysis [ 32 ]

Acoustic stimulation

Johnson and Elliott performed a randomized, blinded trial on 23 subjects to compare acoustic stimulation prior to ECV with a control group when the fetal spine was in the midline (directly back up or back down). [ 38 ] Of those who received acoustic stimulation, 12 of 12 fetuses shifted to a spine-lateral position after acoustic stimulation, and 11 (91%) underwent successful ECV. In the control group, 0 of 11 shifts and 1 (9%) successful ECV ( P < .0001) occurred. Additional studies are needed.

Amnioinfusion

Although an earlier study reported on the utility of amnioinfusion to successfully turn 6 fetuses who initially failed ECV, [ 39 ] a subsequent study was published of 7 women with failed ECV who underwent amniocentesis and amnioinfusion of up to 1 liter of crystalloid. [ 40 ] Repeat attempts of ECV were unsuccessful in all 7 cases. Amnioinfusion to facilitate ECV cannot be recommended at this time.

Vaginal delivery rates after successful version

The rate of cesarean delivery ranges from 0-31% after successful external cephalic version (ECV). Controversy has existed on whether there is a higher rate of cesarean delivery for labor dystocia following ECV. In 1994, a retrospective study by Egge et al of 76 successful ECVs matched with cephalic controls by delivery date, parity, and gestational age failed to note any significant difference in the cesarean delivery rate (8% in ECV group, 6% in control group). [ 41 ]

However, in 1997, Lau et al compared 154 successful ECVs to 308 spontaneously occurring cephalic controls (matched for age, parity, and type of labor onset) with regard to the cesarean delivery rate. [ 42 ] Cesarean delivery rates were higher after ECV (16.9% vs 7.5%, P < .005) because of higher rates of cephalopelvic disproportion and nonreassuring fetal heart rate tracings. This may be related to an increased frequency of compound presentations after ECV. Immediate induction of labor after successful ECV may also contribute to an increase in the cesarean delivery rate due to failed induction in women with unripe cervices and unengaged fetal heads.

Further, in another cohort study from 2015, factors were described which decreased the vaginal delivery rate after successful ECV including labor induction, less than two weeks between ECV and delivery, high body mass index and previous cesarean. [ 43 ] The overall caesarean delivery rate in this cohort was 15%.

Vaginal breech delivery requires an experienced obstetrician and careful counseling of the parents. Although studies on the delivery of the preterm breech are limited, the multicenter Term Breech Trial found an increased rate of perinatal mortality and serious immediate perinatal morbidity, though no differences were seen in infant outcome at 2 years of age.

Parents must be informed about potential risks and benefits to the mother and neonate for both vaginal breech delivery and cesarean delivery. Discussion of risks should not be limited only to the current pregnancy. The risks of a cesarean on subsequent pregnancies, including uterine rupture and placental attachment abnormalities ( placenta previa , abruption , accreta), as well as maternal and perinatal sequelae from these complications, should be reviewed as well.

It remains concerning that the dearth of experienced physicians to teach younger practitioners will lead to the abandonment of vaginal breeches altogether. For those wishing to learn the art of vaginal breech deliveries, simulation training with pelvic models has been advocated to familiarize trainees with the procedure in a nonthreatening environment. [ 44 ] Once comfortable with the appropriate maneuvers, vaginal delivery of the second, noncephalic twin, may be attempted under close supervision by an experienced physician. The cervix will already be fully dilated, and, assuming the second twin is not significantly larger, the successful vaginal delivery rate has been quoted to be as high as 96%.

External cephalic version (ECV) is a safe alternative to vaginal breech delivery or cesarean delivery, reducing the cesarean delivery rate for breech by 50%. ACOG (2016) recommends offering ECV to all women with a breech fetus near term. [ 23 ] Adjuncts such as tocolysis, regional anesthesia, and acoustic stimulation when appropriate may improve ECV success rates.

Hickok DE, Gordon DC, Milberg JA, Williams MA, Daling JR. The frequency of breech presentation by gestational age at birth: a large population-based study. Am J Obstet Gynecol . 1992 Mar. 166(3):851-2. [QxMD MEDLINE Link] .

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de Hundt M, Velzel J, de Groot CJ, Mol BW, Kok M. Mode of delivery after successful external cephalic version: a systematic review and meta-analysis. Obstet Gynecol . 2014 Jun. 123 (6):1327-34. [QxMD MEDLINE Link] .

de Hundt M, Vlemmix F, Bais JM, de Groot CJ, Mol BW, Kok M. Risk factors for cesarean section and instrumental vaginal delivery after successful external cephalic version. J Matern Fetal Neonatal Med . 2016 Jun. 29 (12):2005-7. [QxMD MEDLINE Link] .

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Hutton E, Hannah M, Ross S, Delisle MF, Carson G, Windrim R, et al. The Early External Cephalic Version (ECV) 2 Trial: an international multicentre randomised controlled trial of timing of ECV for breech pregnancies. BJOG . 2011 Apr. 118(5):564-577. [QxMD MEDLINE Link] .

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de Meeus JB, Ellia F, Magnin G. External cephalic version after previous cesarean section: a series of 38 cases. Eur J Obstet Gynecol Reprod Biol . 1998 Oct. 81 (1):65-8. [QxMD MEDLINE Link] .

Burgos J, Cobos P, Rodríguez L, Osuna C, Centeno MM, Martínez-Astorquiza T, et al. Is external cephalic version at term contraindicated in previous caesarean section? A prospective comparative cohort study. BJOG . 2014 Jan. 121 (2):230-5; discussion 235. [QxMD MEDLINE Link] .

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Marquette GP, Boucher M, Theriault D, Rinfret D. Does the use of a tocolytic agent affect the success rate of external cephalic version?. Am J Obstet Gynecol . 1996 Oct. 175(4 Pt 1):859-61. [QxMD MEDLINE Link] .

Cluver C, Gyte GM, Sinclair M, Dowswell T, Hofmeyr GJ. 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. [QxMD MEDLINE Link] .

Wilcox CB, Nassar N, Roberts CL. Effectiveness of nifedipine tocolysis to facilitate external cephalic version: a systematic review. BJOG . 2011 Mar. 118 (4):423-8. [QxMD MEDLINE Link] .

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Schorr SJ, Speights SE, Ross EL, et al. A randomized trial of epidural anesthesia to improve external cephalic version success. Am J Obstet Gynecol . 1997 Nov. 177(5):1133-7. [QxMD MEDLINE Link] .

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Weiniger CF, Ginosar Y, Elchalal U, Sharon E, Nokrian M, Ezra Y. External cephalic version for breech presentation with or without spinal analgesia in nulliparous women at term: a randomized controlled trial. Obstet Gynecol . 2007 Dec. 110(6):1343-50. [QxMD MEDLINE Link] .

Johnson RL, Elliott JP. Fetal acoustic stimulation, an adjunct to external cephalic version: a blinded, randomized crossover study. Am J Obstet Gynecol . 1995 Nov. 173(5):1369-72. [QxMD MEDLINE Link] .

Benifla JL, Goffinet F, Darai E, Madelenat P. Antepartum transabdominal amnioinfusion to facilitate external cephalic version after initial failure. Obstet Gynecol . 1994 Dec. 84(6):1041-2. [QxMD MEDLINE Link] .

Adama van Scheltema PN, Feitsma AH, Middeldorp JM, Vandenbussche FP, Oepkes D. Amnioinfusion to facilitate external cephalic version after initial failure. Obstet Gynecol . 2006 Sep. 108(3 Pt 1):591-2. [QxMD MEDLINE Link] .

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Lau TK, Lo KW, Rogers M. Pregnancy outcome after successful external cephalic version for breech presentation at term. Am J Obstet Gynecol . 1997 Jan. 176(1 Pt 1):218-23. [QxMD MEDLINE Link] .

Burgos J, Iglesias M, Pijoan JI, Rodriguez L, Fernández-Llebrez L, Martínez-Astorquiza T. Probability of cesarean delivery after successful external cephalic version. Int J Gynaecol Obstet . 2015 Nov. 131 (2):192-5. [QxMD MEDLINE Link] .

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• Footling breech presentation. Once the feet have delivered, one may be tempted to pull on the feet. However, a singleton gestation should not be pulled by the feet because this action may precipitate head entrapment in an incompletely dilated cervix or may precipitate nuchal arms. As long as the fetal heart rate is stable and no physical evidence of a prolapsed cord is evident, management may be expectant while awaiting full cervical dilation.
• Assisted vaginal breech delivery. Thick meconium passage is common as the breech is squeezed through the birth canal. This is usually not associated with meconium aspiration because the meconium passes out of the vagina and does not mix with the amniotic fluid.
• Assisted vaginal breech delivery. The Ritgen maneuver is applied to take pressure off the perineum during vaginal delivery. Episiotomies are often performed for assisted vaginal breech deliveries, even in multiparous women, to prevent soft tissue dystocia.
• Assisted vaginal breech delivery. No downward or outward traction is applied to the fetus until the umbilicus has been reached.
• Assisted vaginal breech delivery. With a towel wrapped around the fetal hips, gentle downward and outward traction is applied in conjunction with maternal expulsive efforts until the scapula is reached. An assistant should be applying gentle fundal pressure to keep the fetal head flexed.
• Assisted vaginal breech delivery. After the scapula is reached, the fetus should be rotated 90° in order to deliver the anterior arm.
• Assisted vaginal breech delivery. The anterior arm is followed to the elbow, and the arm is swept out of the vagina.
• Assisted vaginal breech delivery. The fetus is rotated 180°, and the contralateral arm is delivered in a similar manner as the first. The infant is then rotated 90° to the backup position in preparation for delivery of the head.
• Assisted vaginal breech delivery. The fetal head is maintained in a flexed position by using the Mauriceau maneuver, which is performed by placing the index and middle fingers over the maxillary prominence on either side of the nose. The fetal body is supported in a neutral position, with care to not overextend the neck.
• Piper forceps application. Piper forceps are specialized forceps used only for the after-coming head of a breech presentation. They are used to keep the fetal head flexed during extraction of the head. An assistant is needed to hold the infant while the operator gets on one knee to apply the forceps from below.
• Assisted vaginal breech delivery. Low 1-minute Apgar scores are not uncommon after a vaginal breech delivery. A pediatrician should be present for the delivery in the event that neonatal resuscitation is needed.
• Assisted vaginal breech delivery. The neonate after birth.
• Ultrasound demonstrating a fetus in breech presentation with a hyperextended head (ie, "star gazing").

Contributor Information and Disclosures

Richard Fischer, MD Professor, Division Head, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Cooper University Hospital Richard Fischer, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists , American Institute of Ultrasound in Medicine , Association of Professors of Gynecology and Obstetrics , Society for Maternal-Fetal Medicine Disclosure: Stock ownership for: Pfizer Pharmaceuticals (< 5% of portfolio); Johnson & Johnson (< 5% of portfolio).

Alisa B Modena, MD, FACOG Assistant Professor, Cooper Medical School of Rowan University; Attending Physician, Division of Maternal-Fetal Medicine, Cooper University Hospital Alisa B Modena, MD, FACOG is a member of the following medical societies: American College of Obstetricians and Gynecologists , American Institute of Ultrasound in Medicine , Philadelphia Perinatal Society, Society for Maternal-Fetal Medicine Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Received salary from Medscape for employment. for: Medscape.

Richard S Legro, MD Professor, Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology, Pennsylvania State University College of Medicine; Consulting Staff, Milton S Hershey Medical Center Richard S Legro, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists , Society of Reproductive Surgeons , American Society for Reproductive Medicine , Endocrine Society , Phi Beta Kappa Disclosure: Received honoraria from Korea National Institute of Health and National Institute of Health (Bethesda, MD) for speaking and teaching; Received honoraria from Greater Toronto Area Reproductive Medicine Society (Toronto, ON, CA) for speaking and teaching; Received honoraria from American College of Obstetrics and Gynecologists (Washington, DC) for speaking and teaching; Received honoraria from National Institute of Child Health and Human Development Pediatric and Adolescent Gynecology Research Thi.

Ronald M Ramus, MD Professor of Obstetrics and Gynecology, Director, Division of Maternal-Fetal Medicine, Virginia Commonwealth University School of Medicine Ronald M Ramus, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists , American Institute of Ultrasound in Medicine , Medical Society of Virginia , Society for Maternal-Fetal Medicine Disclosure: Nothing to disclose.

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What Is Breech?

When a fetus is delivered buttocks or feet first

• Types of Presentation

Risk Factors

Complications.

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

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

Verywell / Jessica Olah

Types of Breech Presentation

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

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

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

The different types of breech presentations include:

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

Signs of Breech

There are no specific symptoms associated with a breech presentation.

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

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

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

These can include:

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

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

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

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

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

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

ECV is usually not recommended if the:

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

Recommendations for Previous C-Sections

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

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

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

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

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

A Word From Verywell

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

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

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

TeachMeObGyn. Breech presentation .

MedlinePlus. Breech birth .

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

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

Extended Breech, Flexed Breech and Footling Breech

• Download PDF Copy

The position of the baby inside the uterus keeps changing during pregnancy. At the time of delivery, the best position for the baby to be in is the head-down position. This position allows safer and easier passage of the baby via the birth canal and minimizes complications during child birth. However, this is not always the case and other fetal positions are common.

What is breech?

A fetus is said to be in a breech position if the baby is in a bottom-down position instead of head down. In breech presentation, the buttocks or foot / feet of the baby presents at the bottom of the uterus instead of the baby’s head.

During the last few weeks of pregnancy, health care providers check the position of the fetus with the help of a clinical examination and an ultrasound. In case breech presentation is confirmed, doctors discuss the matter with the woman and her partner and decide on options that will ensure a safe delivery.

Types of breech

Depending on which part is presenting as the lowest part of the fetus during a clinical examination, breech is classified into 3 types.

Extended breech – In this position, the hips of the baby are flexed and its legs are extended at the knee joint. The baby appears bottom first with its feet seen near its head.

Complete or flexed breech – Here, both the hips and knees of the fetus are flexed, the feet are stretched up and not seen below the level of the buttocks.

Footling breech – In this type of breech, one or both feet of the fetus extends downwards and lowers over the cervix, presenting as the lowest part of the fetus.

Risk factors contributing to breech presentation

Some risk factors at the maternal and fetal level can increase the chances of breech presentation. They are as follows:

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Maternal factors

• Previous breech birth
• First pregnancy
• Early labor
• Abnormal shape of the uterus
• Presence of fibroids in the uterus
• Excess or low levels of or amniotic fluid
• More than one baby in the womb
• Placental abnormalities such as placenta previa in which placenta is on the lower part of the uterine wall and blocks the cervix

Fetal factors

• Short umbilical cord
• Extended fetal legs
• Abnormal fetus
• Poor growth of the fetus

Clinical examination

In late pregnancy, a clinical examination is carried out to assess the presentation of the fetus.

Breech presentation is suspected in the following cases:

• During abdominal examination, the lowest part of the fetus or the presenting part feels irregular and a hard round part is found in the fundus, which is the upper part of the uterus.
• Heart sound of the fetus comes from the upper portion of the abdomen, typically above the navel or the umbilicus.
• During pelvic examination, the hard round head cannot be felt in the pelvis and instead the soft buttocks and / or the feet of the fetus are felt. Once the membrane breaks, thick, dark green feces called meconium may be present

When a breech presentation is suspected by 37 weeks of pregnancy, an ultrasound may be done to confirm the type of breech - extended, flexed, or footling breech - and exclude fetal head hyperextension and placenta previa.

In case of fetal head hyperextension beyond 90 degrees, there is a high risk of damage to the spinal cord during vaginal delivery and hence delivery via caesarean is recommended. The chance of a breech baby spontaneously turning into a cephalic position declines as pregnancy advances, but it is still possible in nearly 25% of women after 36 weeks.

• https://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000623.htm
• https://thewomens.r.worldssl.net/
• http://apps.who.int/iris/bitstream/10665/43972/1/9241545879_eng.pdf

Further Reading

• All Pregnancy Content
• Early Signs of Pregnancy
• Is it Safe to Exercise During Pregnancy?
• Pregnancy: 0-8 weeks
• Pregnancy: 9 - 12 weeks

Last Updated: Dec 29, 2022

Susha Cheriyedath

Susha is a scientific communication professional holding a Master's degree in Biochemistry, with expertise in Microbiology, Physiology, Biotechnology, and Nutrition. After a two-year tenure as a lecturer from 2000 to 2002, where she mentored undergraduates studying Biochemistry, she transitioned into editorial roles within scientific publishing. She has accumulated nearly two decades of experience in medical communication, assuming diverse roles in research, writing, editing, and editorial management.

Please use one of the following formats to cite this article in your essay, paper or report:

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

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

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

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

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

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

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

Developer declaration of interests:

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

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

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

Dr LK Penna:  None declared.

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

This page was last reviewed 16 March 2017.

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.

Footling presentation

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Citation, DOI, disclosures and article data

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

At the time the article was last revised Dennis Odhiambo Agolah had no financial relationships to ineligible companies to disclose.

• Footling fetal presentation
• Incomplete breech presentation

A footling presentation (sometimes termed an incomplete breech presentation ) is a variation in fetal presentation and is considered a form of breech presentation . It is uncommon and thought to account for around 10-30% of births. In this presentation the fetus has a longitudinal lie but has one of both hips extended with feet presenting towards the pelvis. This therefore can be subclassified as

single footling presentation : one leg extended

double footling presentation : both legs extended

Footling presentation has the highest rate of cord prolapse(15-18%) out of the other breech presentations. 3

• 1. Curet L. Management of Footling Breech Presentation. Wis Med J. 1982;81(3):32. - Pubmed
• 2. Caron J. Gray & Meaghan M. Shanahan. Breech Presentation. StatPearls Publishing. 2022. https://www.ncbi.nlm.nih.gov/books/NBK448063/ - Pubmed
• 3. Gray C & Shanahan M. Breech Presentation. 2022. - Pubmed
• 4. Kaneti H, Rosen D, Markov S, Beyth Y, Fejgin M. Intrapartum External Cephalic Version of Footling-Breech Presentation. Acta Obstet Gynecol Scand. 2000;79(12):1083-5. - Pubmed

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Breech, posterior, transverse lie: What position is my baby in?

Fetal presentation, or how your baby is situated in your womb at birth, is determined by the body part that's positioned to come out first, and it can affect the way you deliver. At the time of delivery, 97 percent of babies are head-down (cephalic presentation). But there are several other possibilities, including feet or bottom first (breech) as well as sideways (transverse lie) and diagonal (oblique lie).

Fetal presentation and position

During the last trimester of your pregnancy, your provider will check your baby's presentation by feeling your belly to locate the head, bottom, and back. If it's unclear, your provider may do an ultrasound or an internal exam to feel what part of the baby is in your pelvis.

Fetal position refers to whether the baby is facing your spine (anterior position) or facing your belly (posterior position). Fetal position can change often: Your baby may be face up at the beginning of labor and face down at delivery.

Here are the many possibilities for fetal presentation and position in the womb.

Medical illustrations by Jonathan Dimes

Head down, facing down (anterior position)

A baby who is head down and facing your spine is in the anterior position. This is the most common fetal presentation and the easiest position for a vaginal delivery.

This position is also known as "occiput anterior" because the back of your baby's skull (occipital bone) is in the front (anterior) of your pelvis.

Head down, facing up (posterior position)

In the posterior position , your baby is head down and facing your belly. You may also hear it called "sunny-side up" because babies who stay in this position are born facing up. But many babies who are facing up during labor rotate to the easier face down (anterior) position before birth.

Posterior position is formally known as "occiput posterior" because the back of your baby's skull (occipital bone) is in the back (posterior) of your pelvis.

Frank breech

In the frank breech presentation, both the baby's legs are extended so that the feet are up near the face. This is the most common type of breech presentation. Breech babies are difficult to deliver vaginally, so most arrive by c-section .

Some providers will attempt to turn your baby manually to the head down position by applying pressure to your belly. This is called an external cephalic version , and it has a 58 percent success rate for turning breech babies. For more information, see our article on breech birth .

Complete breech

A complete breech is when your baby is bottom down with hips and knees bent in a tuck or cross-legged position. If your baby is in a complete breech, you may feel kicking in your lower abdomen.

Incomplete breech

In an incomplete breech, one of the baby's knees is bent so that the foot is tucked next to the bottom with the other leg extended, positioning that foot closer to the face.

Single footling breech

In the single footling breech presentation, one of the baby's feet is pointed toward your cervix.

Double footling breech

In the double footling breech presentation, both of the baby's feet are pointed toward your cervix.

Transverse lie

In a transverse lie, the baby is lying horizontally in your uterus and may be facing up toward your head or down toward your feet. Babies settle this way less than 1 percent of the time, but it happens more commonly if you're carrying multiples or deliver before your due date.

If your baby stays in a transverse lie until the end of your pregnancy, it can be dangerous for delivery. Your provider will likely schedule a c-section or attempt an external cephalic version , which is highly successful for turning babies in this position.

Oblique lie

In rare cases, your baby may lie diagonally in your uterus, with his rump facing the side of your body at an angle.

Like the transverse lie, this position is more common earlier in pregnancy, and it's likely your provider will intervene if your baby is still in the oblique lie at the end of your third trimester.

Was this article helpful?

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BabyCenter's editorial team is committed to providing the most helpful and trustworthy pregnancy and parenting information in the world. When creating and updating content, we rely on credible sources: respected health organizations, professional groups of doctors and other experts, and published studies in peer-reviewed journals. We believe you should always know the source of the information you're seeing. Learn more about our editorial and medical review policies .

Ahmad A et al. 2014. Association of fetal position at onset of labor and mode of delivery: A prospective cohort study. Ultrasound in obstetrics & gynecology 43(2):176-182. https://www.ncbi.nlm.nih.gov/pubmed/23929533 Opens a new window [Accessed September 2021]

Gray CJ and Shanahan MM. 2019. Breech presentation. StatPearls.  https://www.ncbi.nlm.nih.gov/books/NBK448063/ Opens a new window [Accessed September 2021]

Hankins GD. 1990. Transverse lie. American Journal of Perinatology 7(1):66-70.  https://www.ncbi.nlm.nih.gov/pubmed/2131781 Opens a new window [Accessed September 2021]

Medline Plus. 2020. Your baby in the birth canal. U.S. National Library of Medicine. https://medlineplus.gov/ency/article/002060.htm Opens a new window [Accessed September 2021]

Where to go next

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

Other Factors

Diagnostics Tests

Treatment Options

Epidemiology

Pathophysiology.

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. Mar 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

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41. 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]

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Breech - series—Types of breech presentation

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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