Near term or during labor, the fetus normally assumes a vertical orientation (lie) and cephalic presentation.¹ Breech presentation occurs when fetal longitudinal axis is such that the cephalic pole occupies the uterine fundus (Fig. E1). Three types exist: Frank (flexed hips, extended knees or pike position), complete (flexed hips and knees tuck position), and footling (hips extended).¹

• Diagnosis can be made by abdominal palpation, vaginal examination, or ultrasound¹
• Lack of presenting part on vaginal examination
• Fetal heart tones heard above the umbilicus
• Leopold maneuvers revealing mobile fetal part in the uterine fundus

• Abnormal placentation (fundal), uterine anomalies (fibroids, septa), pelvic or adnexal masses, alterations in fetal muscular tone, or fetal malformations
• Associated conditions: Trisomy 13, 18, 21; Potter syndrome; myotonic dystrophy; prematurity

Vertex, oblique, or transverse lie

• Determine if any etiology for breech presentation exists that may affect mode of delivery selection: Presence of uterine anomalies (fibroids, septum, Mullerian anomaly), placentation issues, estimated gestational age of fetus, fetal congenital anomalies, fetal aneuploidy.
• If the fetus is viable and it is clinically indicated, assess fetal status by continuous fetal heart rate (FHR) monitoring.
• Perform ultrasound to confirm position and presenting part (see “Imaging Studies”).
• Assess pelvis to determine feasibility of vaginal delivery.
• Assess other comorbidities with regard to safety of vaginal versus abdominal delivery.

Ultrasound to evaluate for:

• Fetal anomalies
• Placental location
• Position of fetal head relative to spine (check for hyperextension)
• Estimated fetal weight (2500 to 3800 g for attempt of vaginal delivery)³
• Type of breech (frank, complete, footling)
• Gestational age⁴

• Vaginal delivery in breech position.
  1. Vaginal delivery in selected patients (see “Comments” section): Continuous electronic FHR monitoring and noninterference until spontaneous delivery of the breech to the umbilicus.¹ Allow maternal expulsive forces to deliver fetus until scapula visible (avoiding traction); with flexion and/or Piper forceps, deliver fetal head
• Cesarean delivery.
  1. Perform cesarean section (see “Comments”).
• External cephalic version followed by induction of labor and attempt at vaginal delivery in vertex position.⁵
  1. Improved success if >37 wk. Success rates range from 16% to 100%. Adequate uterine relaxation is essential. Use of terbutaline and/or epidural anesthesia improves success rates. Data are not adequate to establish absolute or relative contraindications; must individualize. Contraindicated if vaginal delivery is not appropriate. In general, contraindicated with active placental abruption, placenta previa, certain fetal anomalies, version of a first breech presenting multiple gestation, or nonreassuring fetal status. Other relative contraindications: Perform with caution with low-lying placenta, prior uterine incision, and preterm gestation. Informed consent includes risks of abruption, cord prolapse, rupture of membranes, stillbirth, and hemorrhage (<1%).

• Head entrapment: Leading cause of death (with the exception of anomalous fetuses). Can be avoided by maintaining flexion of fetal head (Mauriceau Smellie Veit maneuver), use of Piper forceps, or Dührssen incisions. Avoid hyperextension of head during delivery.
• Cord prolapse: Usually occurs late in labor, more common with footling breech.
• Nuchal arm: Arm extended above fetal head; occurs when there is undue traction before delivery of fetal scapulas. Treatment: Bring trapped arm across infant’s face (Lovset maneuver).

If confounding variables are corrected for route of delivery plays less important role in fetal outcome than previously believed if the obstetrician performing the delivery is experienced in breech delivery.¹ Since the publication of the Term Breech Trial in 2000, planned cesarean is becoming the preferred mode of birth for women with a breech fetus. In addition, as seasoned obstetricians retire, and fewer new physicians are taught the technique of breech delivery, despite relative safety, this modality as an option for delivery has decreased over time.³

An obstetrician trained in vaginal breech delivery is prerequisite for attempt; explain to the patient that with cesarean section, certain risks (i.e., hyperextension of the fetal head with resultant spinal cord injury) may be minimized but not eliminated. Cesarean section also comes with its own risks and requires informed consent as well.

Since the publication of the Term Breech Trial in 2000, little evidence has proven conclusively that cesarean birth is safer than vaginal birth of a term fetus in a breech presentation when certain criteria are met. For a planned vaginal delivery of the term breech presentation, mortality rate increased thirteenfold and morbidity sevenfold, mainly because of an increase in congenital anomalies, perinatal hypoxia, birth injury, and prematurity. Based on the 2015 Cochrane Review, planned cesarean section compared with planned vaginal birth reduced perinatal or neonatal death at term as well as the composite outcome death or serious neonatal morbidity, at the expense of increased maternal morbidity.⁶ In a subset with 2-yr follow-up, infant medical problems were increased following planned C-section, and no difference in long-term neurodevelopmental delay was found. There is no contraindication to induction of labor in breech presentation or planned breech delivery in primigravidas. Many obstetric organizations support the option of a planned vaginal birth for women with a term breech presentation. The benefits need to be weighed against factors such as mother’s preference for vaginal birth and risks such as future pregnancy complications. Planned vaginal delivery of term singleton breech fetus is reasonable under a hospital-specific, strict prelabor selection criteria with intrapartum management guidelines/protocols, and with an experienced provider and informed consent of the patient.

• Gestational age >37 wk (proceed with caution in preterm delivery of the breech fetus; consider Maternal-Fetal Medicine consultation in these situations)
• Estimated fetal weight, 2500 to 4000 g-recognizing inherent error in estimated fetal weight approximations; actual fetal weight may be substantially smaller or larger (proceed with caution in fetuses weighing 1500 to 2500 g; consider Maternal-Fetal Medicine consultation in these situations)
• Adequate pelvis
• Flexed fetal head
• Frank or complete breech preferred if planning induction, although in active spontaneous unplanned labor, footling breech can be delivered safely if no cord prolapse
• No known fetal anomalies
• Normal amniotic fluid index (consider at minimum presence of mean vertical pocket >2 cm)
• Bedside availability of anesthesia and capability for immediate cesarean section (consider epidural placement; consider delivery in operating room in the event of need for emergent cesarean section)
• Informed consent
• Obstetrician trained in vaginal breech delivery

• Estimated fetal weight <1500 g (gestational age also impacts counseling/decision making)
• Estimated fetal weight >4000 g
• Footling presentation (20% risk of cord prolapse, usually late in course of labor)
• Inadequate pelvis
• Hyperextended fetal head (21% risk of spinal cord injury)
• Nonreassuring fetal status
• Abnormal progress of labor
• Lack of trained obstetrician

Breech Birth (Patient Information)

Preterm Labor (Related Key Topic)