History

Factors that increase likelihood of breech delivery include the following:

Preterm delivery^[10]
Increased parity
Multiple gestations
Previous breech delivery
Pelvic tumors
Uterine anomalies (eg, septate uterus)
Older maternal age^[8]
Polyhydramnios
Fetal anomalies (eg, hydrocephalus with macrocrania)

Physical Examination

Physical findings may include the following:

Leopold maneuvers: With the first maneuver, the hard fetal head can be palpated at the uterine fundus.
Auscultation: Heart sounds can be heard above the umbilicus.
Vaginal examination
- In frank breech presentations, the ischial tuberosities, sacrum, anus, and/or genitals may be palpated. In addition, meconium staining of the examiner's digit may occur.
- In complete breech presentations, the feet or buttocks of the fetus can be palpated.
- In incomplete breech presentations, one or both of the feet/knees may be palpated.
During frank breech delivery, the following conditions make vaginal delivery less risky:
- Favorable pelvis - Gynecoid (ie, round) or anthropoid (ie, elliptical)
- Fetal weight less than 3600 g - The larger the fetus, the larger the head, as well as other noncompressible body parts, thereby leading to an increased risk of fetal hypoxia and birth trauma
- Complete dilation and effacement of the cervix - Provides the head a better chance to pass through the pelvis
- Availability of skilled obstetrician, neonatal resuscitation equipment, and anesthesia
The following conditions are unfavorable for delivery:
- Fetal weight more than 3600 g
- Unfavorable pelvis - Breech delivery does not allow sufficient time for molding of the fetal head; thus, a platypelloid (ie, anteroposterior flat) or android (ie, heart-shaped) pelvis decreases the fetal head's ability to navigate the maternal pelvis.
- Hyperextension of the head - Increases risk of cervical spine injury
- Footlings - Incidence of umbilical cord prolapse increases with coiling of the umbilical cord around the legs of the fetus

Differential Diagnoses

ACOG Committee on Obstetric Practice. ACOG Committee Opinion No. 745: Mode of Term Singleton Breech Delivery. Obstet Gynecol. 2018 Aug. 132 (2):e60-e63. [QxMD MEDLINE Link].
Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group. Lancet. 2000 Oct 21. 356(9239):1375-83. [QxMD MEDLINE Link].
Committee on Obstetric Practice. ACOG committee opinion. Mode of term singleton breech delivery. Number 265, December 2001. American College of Obstetricians and Gynecologists. Int J Gynaecol Obstet. 2002 Apr. 77 (1):65-6. [QxMD MEDLINE Link].
Whyte H, Hannah ME, Saigal S, Hannah WJ, Hewson S, Amankwah K, et al. Outcomes of children at 2 years after planned cesarean birth versus planned vaginal birth for breech presentation at term: the International Randomized Term Breech Trial. Am J Obstet Gynecol. 2004 Sep. 191 (3):864-71. [QxMD MEDLINE Link].
Hofmeyr GJ, Barrett JF, Crowther CA. Planned caesarean section for women with a twin pregnancy. Cochrane Database Syst Rev. 2015 Dec 19. 12:CD006553. [QxMD MEDLINE Link].
Roecker CB. Breech repositioning unresponsive to Webster technique: coexistence of oligohydramnios. J Chiropr Med. 2013 Jun. 12(2):74-8. [QxMD MEDLINE Link]. [Full Text].
Tunde-Byass MO, Hannah ME. Breech vaginal delivery at or near term. Semin Perinatol. 2003 Feb. 27(1):34-45. [QxMD MEDLINE Link].
Rayl J, Gibson PJ, Hickok DE. A population-based case-control study of risk factors for breech presentation. Am J Obstet Gynecol. 1996 Jan. 174(1 Pt 1):28-32. [QxMD MEDLINE Link].
Toijonen AE, Heinonen ST, Gissler MVM, Macharey G. A comparison of risk factors for breech presentation in preterm and term labor: a nationwide, population-based case-control study. Arch Gynecol Obstet. 2020 Feb. 301 (2):393-403. [QxMD MEDLINE Link].
Bergenhenegouwen LA, Meertens LJ, Schaaf J, Nijhuis JG, Mol BW, Kok M, et al. Vaginal delivery versus caesarean section in preterm breech delivery: a systematic review. Eur J Obstet Gynecol Reprod Biol. 2013 Oct 16. [QxMD MEDLINE Link].
Miwa I, Sase M, Nakamura Y, Hasegawa K, Kawasaki M, Ueda K. Congenital high airway obstruction syndrome in the breech presentation managed by ex utero intrapartum treatment procedure after intraoperative external cephalic version. J Obstet Gynaecol Res. 2012 Mar 22. [QxMD MEDLINE Link].
Alarab M, Regan C, O'Connell MP, Keane DP, O'Herlihy C, Foley ME. Singleton vaginal breech delivery at term: still a safe option. Obstet Gynecol. 2004 Mar. 103(3):407-12. [QxMD MEDLINE Link].
Carbillon L. Vaginal versus cesarean delivery for breech presentation in California: a population-based study. Obstet Gynecol. 2004 May. 103(5 Pt 1):1003-4. [QxMD MEDLINE Link].
Cunningham FG, Gant FG, Leveno KJ. Breech Presentation and Delivery (Chapter 22). Williams Obstetrics. 21st ed. 2001.
Ghosh MK. Breech presentation: evolution of management. J Reprod Med. 2005 Feb. 50(2):108-16. [QxMD MEDLINE Link].
Gilbert WM, Hicks SM, Boe NM, Danielsen B. Vaginal versus cesarean delivery for breech presentation in California: a population-based study. Obstet Gynecol. 2003 Nov. 102(5 Pt 1):911-7. [QxMD MEDLINE Link].
Roberts JR, Hedges JR. Emergency childbirth. Clinical Procedures in Emergency Medicine. 3rd ed. 1997. chap75, 1000-1003.
Scorza WE. Intrapartum management of breech presentation. Clin Perinatol. 1996 Mar. 23(1):31-49. [QxMD MEDLINE Link].
Stitely ML, Gherman RB. Labor with abnormal presentation and position. Obstet Gynecol Clin North Am. 2005 Jun. 32(2):165-79. [QxMD MEDLINE Link].
Warke HS, Saraogi RM, Sanjanwalla SM. Should a preterm breech go for vaginal delivery or caesarean section. J Postgrad Med. 1999 Jan-Mar. 45(1):1-4. [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. 2015 Sep 3. 1-3. [QxMD MEDLINE Link].
Macharey G, Ulander VM, Heinonen S, Kostev K, Nuutila M, Vaisanen-Tommiska M. Induction of labor in breech presentations at term: a retrospective observational study. Arch Gynecol Obstet. 2015 Aug 28. [QxMD MEDLINE Link].

Media Gallery

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").

of 13

Author

Philippe H Girerd, MD Associate Professor, Department of Obstetrics and Gynecology, Virginia Commonwealth University, Medical College of Virginia

Philippe H Girerd, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, Association of Professors of Gynecology and Obstetrics, Medical Society of Virginia, AAGL

Disclosure: Nothing to disclose.

Specialty Editor Board

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.

John G Pierce, Jr, MD Chairman of Women’s Health and Medical Specialties, Liberty University College of Osteopathic Medicine; Obstetrician/Gynecologist, Women’s Health of Central Virginia

John G Pierce, Jr, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, Association of Professors of Gynecology and Obstetrics, Christian Medical and Dental Associations, Medical Society of Virginia, Society of Laparoscopic and Robotic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

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.

Additional Contributors

Assaad J Sayah, MD, FACEP President and Chief Executive Officer, Cambridge Health Alliance

Assaad J Sayah, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, Massachusetts Medical Society

Disclosure: Nothing to disclose.

Acknowledgements

Andrew D Jenis, MD Chair, Department of Emergency Medicine, Memorial Hospital, York, PA

Andrew D Jenis, MD is a member of the following medical societies: American College of Emergency Physicians and Medical Society of the State of New York

Disclosure: Nothing to disclose.