breech pregnancy presentation

TYPES OF BREECH PRESENTATION

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

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

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

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What Causes Breech Presentation?

Learn more about the types, causes, and risks of breech presentation, along with how breech babies are typically delivered.

What Is Breech Presentation?

Types of breech presentation, what causes a breech baby, can you turn a breech baby, how are breech babies delivered.

FatCamera/Getty Images

Toward the end of pregnancy, your baby will start to get into position for delivery, with their head pointed down toward the vagina. This is otherwise known as vertex presentation. However, some babies turn inside the womb so that their feet or buttocks are poised to be delivered first, which is commonly referred to as breech presentation, or a breech baby.

As you near the end of your pregnancy journey, an OB-GYN or health care provider will check your baby's positioning. You might find yourself wondering: What causes breech presentation? Are there risks involved? And how are breech babies delivered? We turned to experts and research to answer some of the most common questions surrounding breech presentation, along with what causes this positioning in the first place.

During your pregnancy, your baby constantly moves around the uterus. Indeed, most babies do somersaults up until the 36th week of pregnancy , when they pick their final position in the womb, says Laura Riley , MD, an OB-GYN in New York City. Approximately 3-4% of babies end up “upside-down” in breech presentation, with their feet or buttocks near the cervix.

Breech presentation is typically diagnosed during a visit to an OB-GYN, midwife, or health care provider. Your physician can feel the position of your baby's head through your abdominal wall—or they can conduct a vaginal exam if your cervix is open. A suspected breech presentation should ultimately be confirmed via an ultrasound, after which you and your provider would have a discussion about delivery options, potential issues, and risks.

There are three types of breech babies: frank, footling, and complete. Learn about the differences between these breech presentations.

Frank Breech

With frank breech presentation, your baby’s bottom faces the cervix and their legs are straight up. This is the most common type of breech presentation.

Footling Breech

Like its name suggests, a footling breech is when one (single footling) or both (double footling) of the baby's feet are in the birth canal, where they’re positioned to be delivered first .

Complete Breech

In a complete breech presentation, baby’s bottom faces the cervix. Their legs are bent at the knees, and their feet are near their bottom. A complete breech is the least common type of breech presentation.

Other Types of Mal Presentations

The baby can also be in a transverse position, meaning that they're sideways in the uterus. Another type is called oblique presentation, which means they're pointing toward one of the pregnant person’s hips.

Typically, your baby's positioning is determined by the fetus itself and the shape of your uterus. Because you can't can’t control either of these factors, breech presentation typically isn’t considered preventable. And while the cause often isn't known, there are certain risk factors that may increase your risk of a breech baby, including the following:

• The fetus may have abnormalities involving the muscular or central nervous system
• The uterus may have abnormal growths or fibroids
• There might be insufficient amniotic fluid in the uterus (too much or too little)
• This isn’t your first pregnancy
• You have a history of premature delivery
• You have placenta previa (the placenta partially or fully covers the cervix)
• You’re pregnant with multiples
• You’ve had a previous breech baby

In some cases, your health care provider may attempt to help turn a baby in breech presentation through a procedure known as external cephalic version (ECV). This is when a health care professional applies gentle pressure on your lower abdomen to try and coax your baby into a head-down position. During the entire procedure, the fetus's health will be monitored, and an ECV is often performed near a delivery room, in the event of any potential issues or complications.

However, it's important to note that ECVs aren't for everyone. If you're carrying multiples, there's health concerns about you or the baby, or you've experienced certain complications with your placenta or based on placental location, a health care provider will not attempt an ECV.

The majority of breech babies are born through C-sections . These are usually scheduled between 38 and 39 weeks of pregnancy, before labor can begin naturally. However, with a health care provider experienced in delivering breech babies vaginally, a natural delivery might be a safe option for some people. In fact, a 2017 study showed similar complication and success rates with vaginal and C-section deliveries of breech babies.

That said, there are certain known risks and complications that can arise with an attempt to deliver a breech baby vaginally, many of which relate to problems with the umbilical cord. If you and your medical team decide on a vaginal delivery, your baby will be monitored closely for any potential signs of distress.

Ultimately, it's important to know that most breech babies are born healthy. Your provider will consider your specific medical condition and the position of your baby to determine which type of delivery will be the safest option for a healthy and successful birth.

ACOG. If Your Baby Is Breech .

American Pregnancy Association. Breech Presentation .

Gray CJ, Shanahan MM. Breech Presentation . [Updated 2022 Nov 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.

Mount Sinai. Breech Babies .

Takeda J, Ishikawa G, Takeda S. Clinical Tips of Cesarean Section in Case of Breech, Transverse Presentation, and Incarcerated Uterus . Surg J (N Y). 2020 Mar 18;6(Suppl 2):S81-S91. doi: 10.1055/s-0040-1702985. PMID: 32760790; PMCID: PMC7396468.

Shanahan MM, Gray CJ. External Cephalic Version . [Updated 2022 Nov 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. 

Fonseca A, Silva R, Rato I, Neves AR, Peixoto C, Ferraz Z, Ramalho I, Carocha A, Félix N, Valdoleiros S, Galvão A, Gonçalves D, Curado J, Palma MJ, Antunes IL, Clode N, Graça LM. Breech Presentation: Vaginal Versus Cesarean Delivery, Which Intervention Leads to the Best Outcomes? Acta Med Port. 2017 Jun 30;30(6):479-484. doi: 10.20344/amp.7920. Epub 2017 Jun 30. PMID: 28898615.

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• Fetal presentation before birth

The way a baby is positioned in the uterus just before birth can have a big effect on labor and delivery. This positioning is called fetal presentation.

Babies twist, stretch and tumble quite a bit during pregnancy. Before labor starts, however, they usually come to rest in a way that allows them to be delivered through the birth canal headfirst. This position is called cephalic presentation. But there are other ways a baby may settle just before labor begins.

Following are some of the possible ways a baby may be positioned at the end of pregnancy.

Head down, face down

When a baby is head down, face down, the medical term for it is the cephalic occiput anterior position. This the most common position for a baby to be born in. With the face down and turned slightly to the side, the smallest part of the baby's head leads the way through the birth canal. It is the easiest way for a baby to be born.

Head down, face up

When a baby is head down, face up, the medical term for it is the cephalic occiput posterior position. In this position, it might be harder for a baby's head to go under the pubic bone during delivery. That can make labor take longer.

Most babies who begin labor in this position eventually turn to be face down. If that doesn't happen, and the second stage of labor is taking a long time, a member of the health care team may reach through the vagina to help the baby turn. This is called manual rotation.

In some cases, a baby can be born in the head-down, face-up position. Use of forceps or a vacuum device to help with delivery is more common when a baby is in this position than in the head-down, face-down position. In some cases, a C-section delivery may be needed.

Frank breech

When a baby's feet or buttocks are in place to come out first during birth, it's called a breech presentation. This happens in about 3% to 4% of babies close to the time of birth. The baby shown below is in a frank breech presentation. That's when the knees aren't bent, and the feet are close to the baby's head. This is the most common type of breech presentation.

If you are more than 36 weeks into your pregnancy and your baby is in a frank breech presentation, your health care professional may try to move the baby into a head-down position. This is done using a procedure called external cephalic version. It involves one or two members of the health care team putting pressure on your belly with their hands to get the baby to roll into a head-down position.

If the procedure isn't successful, or if the baby moves back into a breech position, talk with a member of your health care team about the choices you have for delivery. Most babies in a frank breech position are born by planned C-section.

Complete and incomplete breech

A complete breech presentation, as shown below, is when the baby has both knees bent and both legs pulled close to the body. In an incomplete breech, one or both of the legs are not pulled close to the body, and one or both of the feet or knees are below the baby's buttocks. If a baby is in either of these positions, you might feel kicking in the lower part of your belly.

If you are more than 36 weeks into your pregnancy and your baby is in a complete or incomplete breech presentation, your health care professional may try to move the baby into a head-down position. This is done using a procedure called external cephalic version. It involves one or two members of the health care team putting pressure on your belly with their hands to get the baby to roll into a head-down position.

If the procedure isn't successful, or if the baby moves back into a breech position, talk with a member of your health care team about the choices you have for delivery. Many babies in a complete or incomplete breech position are born by planned C-section.

When a baby is sideways — lying horizontal across the uterus, rather than vertical — it's called a transverse lie. In this position, the baby's back might be:

• Down, with the back facing the birth canal.
• Sideways, with one shoulder pointing toward the birth canal.
• Up, with the hands and feet facing the birth canal.

Although many babies are sideways early in pregnancy, few stay this way when labor begins.

If your baby is in a transverse lie during week 37 of your pregnancy, your health care professional may try to move the baby into a head-down position. This is done using a procedure called external cephalic version. External cephalic version involves one or two members of your health care team putting pressure on your belly with their hands to get the baby to roll into a head-down position.

If the procedure isn't successful, or if the baby moves back into a transverse lie, talk with a member of your health care team about the choices you have for delivery. Many babies who are in a transverse lie are born by C-section.

If you're pregnant with twins and only the twin that's lower in the uterus is head down, as shown below, your health care provider may first deliver that baby vaginally.

Then, in some cases, your health care team may suggest delivering the second twin in the breech position. Or they may try to move the second twin into a head-down position. This is done using a procedure called external cephalic version. External cephalic version involves one or two members of the health care team putting pressure on your belly with their hands to get the baby to roll into a head-down position.

Your health care team may suggest delivery by C-section for the second twin if:

• An attempt to deliver the baby in the breech position is not successful.
• You do not want to try to have the baby delivered vaginally in the breech position.
• An attempt to move the baby into a head-down position is not successful.
• You do not want to try to move the baby to a head-down position.

In some cases, your health care team may advise that you have both twins delivered by C-section. That might happen if the lower twin is not head down, the second twin has low or high birth weight as compared to the first twin, or if preterm labor starts.

• Landon MB, et al., eds. Normal labor and delivery. In: Gabbe's Obstetrics: Normal and Problem Pregnancies. 8th ed. Elsevier; 2021. https://www.clinicalkey.com. Accessed May 19, 2023.
• Holcroft Argani C, et al. Occiput posterior position. https://www.updtodate.com/contents/search. Accessed May 19, 2023.
• Frequently asked questions: If your baby is breech. American College of Obstetricians and Gynecologists https://www.acog.org/womens-health/faqs/if-your-baby-is-breech. Accessed May 22, 2023.
• Hofmeyr GJ. Overview of breech presentation. https://www.updtodate.com/contents/search. Accessed May 22, 2023.
• Strauss RA, et al. Transverse fetal lie. https://www.updtodate.com/contents/search. Accessed May 22, 2023.
• Chasen ST, et al. Twin pregnancy: Labor and delivery. https://www.updtodate.com/contents/search. Accessed May 22, 2023.
• Cohen R, et al. Is vaginal delivery of a breech second twin safe? A comparison between delivery of vertex and non-vertex second twins. The Journal of Maternal-Fetal & Neonatal Medicine. 2021; doi:10.1080/14767058.2021.2005569.
• Marnach ML (expert opinion). Mayo Clinic. May 31, 2023.

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What to know if your baby is breech

Find out what breech position means, how to turn a breech baby, and what having a breech baby means for your labor and delivery.

What does it mean when a baby is breech?

Signs of a breech baby, why are some babies breech, how to turn a breech baby: is it possible, will i need a c-section if my baby is breech, how to turn a breech baby naturally.

Breech is a term used to describe your baby's position in the womb. Breech position means your baby is bottom-down instead of head-down.

Babies are often active in early pregnancy, moving into different positions. But by around 8 months, there's not much room in the uterus. Most babies maximize their cramped quarters by settling in head down, in what's known as a cephalic or vertex presentation. But if you have a breech baby, it means they're poised to come out buttocks and/or feet first. At 28 weeks or less, about a quarter of babies are breech, and at 32 weeks, 7 percent are breech. By the end of pregnancy, only 3 to 4 percent of babies are in breech position. At term, a baby in breech position is unlikely to turn on their own.

There are several types of breech presentations:

• Frank breech (bottom first with feet up near the head)
• Complete breech (bottom first with legs crossed)
• Incomplete or footling breech (one or both feet are poised to come out first)

(In rare cases, a baby will be sideways in the uterus with their shoulder, back, or arm presenting first – this is called a transverse lie.)

See what these breech presentations look like .

If your baby is in breech position, you may feel them kicking in your lower belly. Or you may feel pressure under your ribcage, from their head.

By the beginning of your third trimester , your practitioner may be able to tell what position your baby is in by feeling your abdomen and locating the baby's head, back, and bottom.

If your baby's position isn't clear during an abdominal exam at 36 weeks, your caregiver may do an internal exam to try to feel what part of the baby is in your pelvis. In some cases, they may use ultrasound to confirm the baby's position.

We don't usually know why some babies are breech – in most cases it seems to be chance. While sometimes a baby with certain birth defects may not turn to a head-down position, most babies in breech position are perfectly fine. Here are some things that might increase the risk of a breech presentation:

• You're carrying multiples
• You've been pregnant before
• You've had a breech presentation before
• There's too much amniotic fluid or not enough amniotic fluid
• You have placenta previa (the placenta is covering all of part of the opening of the uterus)
• Your baby is preterm
• Your uterus is shaped abnormally or has growths, such as fibroids
• The umbilical cord is short
• You were a breech delivery, or your sibling or parent was a breech delivery
• Advanced maternal age (especially age 45 and older)
• Your baby is a low weight at delivery
• You're having a girl

There is a procedure for turning a breech baby. It's called an external cephalic version (ECV). An ob/gyn turns your baby by applying pressure to your abdomen and manually manipulating the baby into a head-down position. Some women find it very uncomfortable or even painful.

An EVC has about a 58 percent success rate, and it's more likely to work if this isn't your first baby. It's not for everyone – you can't have the procedure if you're carrying multiples or if you have too little amniotic fluid or placental abruption , for example. Your provider also won't attempt to turn your breech baby if your baby has any health problems.

The procedure is done after 36 weeks and in the hospital, where your baby can be monitored and where you'll be near a delivery room should any complications arise.

It depends, and it's something you'll want to talk with your caregiver about ahead of time. Discuss your preferences, the advantages and risks of each option ( vaginal and cesarean delivery of a breech presentation), and their experience. The biggest risk of a breech delivery is when the body delivers but the head stays entrapped within the cervix.

In the United States, most breech babies are delivered via cesarean. You may wind up having a vaginal breech delivery if your labor is so rapid that you arrive at the hospital just about to deliver. Another scenario is if you have a twin pregnancy where the first baby is in the head-first position and the second baby is not. A baby who delivers head-first will make room for the breech baby.

However, the vast majority of babies who remain breech arrive by c-section. If a c-section is planned, it will usually be scheduled at 39 weeks. To make sure your baby hasn't changed position in the meantime, you'll have an ultrasound at the hospital to confirm their position just before the surgery.

If you go into labor or your water will break s before your planned c-section, be sure to call your provider right away and head for the hospital.

In rare circumstances, if you're at low risk of complications and your caregiver is experienced delivering breech babies vaginally, you may choose to have what is called a "trial of vaginal birth." This means that you can attempt to deliver vaginally but should be prepared to have a cesarean delivery if labor isn't progressing well. You and your baby will be closely monitored during labor.

In addition to ECV, there are some alternative, natural ways to try to turn your baby. There's no proof that any of them work – or that all of them are safe. Consult your practitioner before trying them.

There's no conclusive proof that the mother's position has any effect on the baby's position, but the idea is to employ gravity to help your baby somersault into a head-down position. A few tips:

• Get into one of the following positions twice a day, starting at around 32 weeks.
• Be sure to do these moves on an empty stomach, lest your lunch comes back up.
• Make sure there's someone around to help you get up if you start feeling lightheaded.
• If you find these positions uncomfortable, stop doing them.

Position 1: Lie flat on your back and raise your pelvis so that it's 9 to 12 inches off the floor. Support your hips with a pillow and stay in this position for five to 15 minutes. Position 2: Kneel down, with your forearms on the floor in front of you, so that your bottom sticks up in the air. Stay in this position for five to 15 minutes. Sleeping position

Many women wonder if there are sleeping positions to turn a breech baby. But the positions you use to try to coax your baby head down for a short time shouldn't be used while you're sleeping. (It's not safe to sleep flat on your back in late pregnancy, for example, because the weight of your baby may compress the blood vessels that provide oxygen and nutrients to them.)

The best position for sleeping during pregnancy is on your side. Placing a pillow between your legs in this position may help open your pelvis, giving your baby room to move more easily. Support your back with plenty of pillows, too. Again, there's no proof that this works, but since it's the best sleeping position for you and your baby, you may as well give it a try.

Moxibustion

This ancient Chinese technique burns herbs to stimulate key acupressure points. To help turn a breech baby, an acupuncturist or other practitioner burns mugwort near the acupressure point of your pinky toes. According to Chinese medicine, this should stimulate your baby's activity enough that they may change position on their own. Some studies show that moxibustion in combination with acupuncture and/or positioning methods may be of some benefit. Others show moxibustion to provide no help in coaxing a baby into cephalic position. If you've discussed it with your caregiver and want to give it a try, contact your state acupuncture or Chinese medicine association and ask for the names of licensed practitioners.

One small study found that women who are regularly hypnotized into a state of deep relaxation at 37 to 40 weeks are more likely to have their baby turn than other women. If you're willing to try this technique, look for a licensed hypnotherapist with experience working with pregnant women.

Chiropractic care

There's a technique – called The Webster Breech Technique – that aims to reduce stress on the pelvis by relaxing the uterus and surrounding ligaments. The idea is that a breech baby can turn more naturally in a relaxed uterus, but research is limited as to the risks and benefits of this technique. If you're interested, talk with your provider about working with a chiropractor who's experienced with the technique.

This is a safe – and again, unproven – method based on the fact that your baby can hear sounds outside the womb. Simply play music close to the lower part of your abdomen (some women use headphones) to encourage your baby to move in the direction of the sound.

Learn more:

• C-section recovery
• Third trimester pregnancy guide and checklist
• Hospital bag checklist

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ACOG. 2019. If your baby is breech. FAQ. The American College of Obstetricians and Gynecologists. https://www.acog.org/womens-health/faqs/if-your-baby-is-breech Opens a new window [Accessed November 2021]

ACOG. 2018. Mode of term singleton breech delivery. Committee opinion number 745. The American College of Obstetricians and Gynecologists. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/08/mode-of-term-singleton-breech-delivery Opens a new window [Accessed November 2021]

Brici P et al. 2019. Turning foetal breech presentation at 32-35 weeks of gestational age by acupuncture and moxibustion. Evidence-based Complementary and Alternative Medicine https://www.hindawi.com/journals/ecam/2019/8950924/ Opens a new window [Accessed November 2021]

Ekeus C et al. 2019. Vaginal breech delivery at term and neonatal morbidity and mortality — a population-based cohort study in Sweden. Journal of Maternal Fetal Neonatal Medicine 32(2):265. https://pubmed.ncbi.nlm.nih.gov/28889774/ Opens a new window [Accessed November 2021]

Fruscalzo A et al 2014. New and old predictive factors for breech presentation: our experience in 14433 singleton pregnancies and a literature review. Journal of Maternal Fetal Neonatal Medicine 27(2): 167-72. https://pubmed.ncbi.nlm.nih.gov/23688372/ Opens a new window [Accessed November 2021]

Garcia MM et al. 2019 Effectiveness and safety of acupuncture and moxibustion in pregnant women with noncephalic presentation: An overview of systematic reviews. Evidence Based Complementary Alternative Medicine 7036914. https://pubmed.ncbi.nlm.nih.gov/31885661/ Opens a new window [Accessed November 2021]

Gray C. 2021. Breech presentation. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK448063/ Opens a new window [Accessed November 2021]

Meaghan M et al. 2021. External cephalic version. NCBI StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK482475/ Opens a new window [Accessed November 2021]

MedlinePlus. 2020. Breech - series - Types of breech presentation. https://medlineplus.gov/ency/presentations/100193_3.htm Opens a new window [Accessed November 2020]

Noli SA et al. 2019. Preterm birth, low gestational age, low birth weight, parity, and other determinants of breech presentation: Results from a large retrospective population-based study. Biomed Research International https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6766171/ Opens a new window [Accessed November 2021]

Pistolese RA. 2002. The Webster Technique: A chiropractic technique with obstetric implications. Journal of Manipulative and Physiological Therapeutics 25(6): E1-9. https://pubmed.ncbi.nlm.nih.gov/12183701/ Opens a new window [Accessed November 2021]

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Evidence review L

NICE Guideline, No. 201

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Review question

What is the effectiveness of routine scanning between 36+0 and 38+6 weeks of pregnancy compared to standard care regarding breech presentation?

Introduction

Breech presentation in late pregnancy may result in prolonged or obstructed labour for the woman. There are interventions that can correct or assist breech presentation which are important for the woman’s and the baby’s health. This review aims to determine the most effective way of identifying a breech presentation in late pregnancy.

Summary of the protocol

Please see Table 1 for a summary of the Population, Intervention, Comparison and Outcome (PICO) characteristics of this review.

Summary of the protocol (PICO table).

For further details see the review protocol in appendix A .

Methods and process

This evidence review was developed using the methods and process described in Developing NICE guidelines: the manual 2014 . Methods specific to this review question are described in the review protocol in appendix A .

Declarations of interest were recorded according to NICE’s conflicts of interest policy .

Clinical evidence

Included studies.

One single centre randomised controlled trial (RCT) was included in this review ( McKenna 2003 ). The study was carried out in Northern Ireland, UK. The study compared ultrasound examination at 30-32 and 36-37 weeks with maternal abdomen palpation during the same gestation period. The intervention group in the study had the ultrasound scans in addition to the abdomen palpation, while the control group had only the abdomen palpation. Clinical management options reported in the study based on the ultrasound scan or the abdomen palpation include referral for full biophysical assessment which included umbilical artery Doppler ultrasound, early antenatal review, admission to antenatal ward, and induction of labour.

The included study is summarised in Table 2 .

See the literature search strategy in appendix B and study selection flow chart in appendix C .

Excluded studies

Studies not included in this review are listed, and reasons for their exclusion are provided in appendix K .

Summary of clinical studies included in the evidence review

Summaries of the studies that were included in this review are presented in Table 2 .

Summary of included studies.

See the full evidence tables in appendix D . No meta-analysis was conducted (and so there are no forest plots in appendix E ).

Quality assessment of clinical outcomes included in the evidence review

See the evidence profiles in appendix F .

Economic evidence

One study, a cost utility analysis was included ( Wastlund 2019 ).

See the literature search strategy in appendix B and economic study selection flow chart in appendix G .

Studies not included in this review with reasons for their exclusions are provided in appendix K .

Summary of studies included in the economic evidence review

For full details of the economic evidence, see the economic evidence tables in appendix H and economic evidence profiles in appendix I .

Wastlund (2019) assessed the cost effectiveness of universal ultrasound scanning for breech presentation at 36 weeks’ gestational age in nulliparous woman (N=3879). The comparator was selective ultrasound scanning which was reported as current practice. In this instance, fetal presentation was assessed by palpation of the abdomen by a midwife, obstetrician or general practitioner. The sensitivity of this method ranges between 57%-70% whereas ultrasound scanning is detected with 100% sensitivity and 100% specificity. Women in the selective ultrasound scan arm only received an ultrasound scan after detection of a breech presentation by abdominal palpation. Where a breech was detected, a woman was offered external cephalic version (ECV). The structure of the model undertook a decision tree, with end states being the mode of birth; either vaginal, elective or emergency caesarean section. Long term health outcomes were modelled based on the mortality risk associated with each mode of birth. Average lifetime quality-adjusted life years (QALYs) were estimated from Euroqol general UK population values.

Only the probabilistic results (n=100000 simulations) were reported which showed that on average, universal ultrasound resulted in an absolute decrease in breech deliveries by 0.39% compared with selective ultrasound scanning. The expected cost per person with breech presentation of universal ultrasound was £2957 (95% Credibility Interval [CrI]: £2922 to £2991), compared to £2,949 (95%CrI: £2915 to £2984) from selective ultrasound. The expected QALYs per person was 24.27615 in the universal ultrasound cohort and 24.27582 in the selective ultrasound cohort. The incremental cost effectiveness ratio (ICER) from the probabilistic analysis was £23611 (95%CrI: £8184 to £44851).

A series of one-way sensitivity analysis were conducted which showed that the most important cost parameter was the unit cost of a universal ultrasound scan. This parameter is particularly noteworthy as the study costed this scan at a much lower value than the ‘standard antenatal ultrasound’ scan in NHS reference costs on the basis that such a scan can be performed by a midwife during a routine antenatal care visit in primary care. According to the NICE guideline manual economic evaluation checklist this model was assessed as being directly applicable with potentially severe limitations. The limitations were mostly attributable to the limitations of the clinical inputs.

Economic model

No economic modelling was undertaken for this review because the committee agreed that other topics were higher priorities for economic evaluation.

Evidence statements

Clinical evidence statements, comparison 1. routine ultrasound scan versus selective ultrasound scan, critical outcomes, unexpected breech presentation in labour.

No evidence was identified to inform this outcome.

Mode of birth

• Moderate quality evidence from 1 RCT (N=1993) showed that there is no clinically important difference between routine ultrasound scan at 36-37 weeks and selective ultrasound scan on the number of women who had elective caesarean section: RR 1.22 (95% CI 0.91 to 1.63).
• Moderate quality evidence from 1 RCT (N=1993) showed that there is no clinically important difference between routine ultrasound scan at 36-37 weeks and selective ultrasound scan on number of women who had emergency caesarean section: RR 1.20 (95% CI 0.90 to 1.60).
• High quality evidence from 1 RCT (N=1993) showed that there is no clinically important difference between routine ultrasound scan at 36-37 weeks and selective ultrasound scan on number of women who had vaginal birth: RR 0.95 (95% CI 0.89 to 1.01).

Important outcomes

Maternal anxiety, women’s experience and satisfaction of care, gestational age at birth.

• High quality evidence from 1 RCT (N=1993) showed that there is no clinically important difference between routine ultrasound scan at 36-37 weeks and selective ultrasound scan on the number of babies’ born between 39-42 gestational weeks: RR 0.98 (95% CI 0.94 to 1.02).

Admission to neonatal unit

• Low quality evidence from 1 RCT (N=1993) showed that there is no clinically important difference between routine ultrasound scan at 36-37 weeks and selective ultrasound scan on the number of babies admitted into the neonatal unit: RR 0.83 (95% CI 0.51 to 1.35).

Economic evidence statements

One directly applicable cost-utility analysis from the UK with potentially serious limitations compared universal ultrasound scanning for breech presentation at 36 weeks’ gestational age with selective ultrasound scanning, stated as current practice. Universal ultrasound scanning was found to be borderline cost effective; the incremental cost-effectiveness ratio was £23611 per QALY gained. The cost of the scan was seen to be a key driver in the cost effectiveness result.

The committee’s discussion of the evidence

Interpreting the evidence, the outcomes that matter most.

Unexpected breech presentation in labour and mode of birth were prioritised as critical outcomes by the committee. This reflects the different options available to women with a known breech presentation in pregnancy and the different choices that women make. There are some women and/or clinicians who may feel uncomfortable with the risks of aiming for vaginal breech birth, and for these women and/or clinicians avoiding an unexpected breech presentation in labour would be the preferred option.

As existing evidence suggests that aiming for vaginal breech birth carries greater risk to the fetus than planned caesarean birth, it is important to consider whether earlier detection of the breech presentation would reduce the risk of these outcomes.

The committee agreed that maternal anxiety and women’s experience and satisfaction of care were important outcomes to consider as the introduction of an additional routine scan during pregnancy could have a treatment burden for women. Gestational age at birth and admission to neonatal unit were also chosen as important outcomes as the committee wanted to find out whether earlier detection of breech presentation would have an impact on whether the baby was born preterm, and as a consequence admitted to the neonatal unit. These outcomes were agreed to be important rather than critical as they are indirect outcomes of earlier detection of breech presentation.

The quality of the evidence

The quality of the evidence ranged from low to high. Most of the evidence was rated high or moderate, with only 1 outcome rated as low. The quality of the evidence was downgraded due to imprecision around the effect estimates for emergency caesarean section, elective caesarean section and admissions to neonatal unit.

No evidence was identified for the following outcomes: unexpected breech presentation in labour, maternal anxiety, women’s experiences and satisfaction of care.

The committee had hoped to find evidence that would inform whether early identification of breech presentation had an impact on preterm births, and although the review reported evidence for gestational age as birth, the available evidence was for births 39-42 weeks of gestation.

Benefits and harms

The available evidence compared routine ultrasound scanning with selective ultrasound scanning, and found no clinically important differences for mode of birth, gestational age at birth, or admissions to the neonatal unit. However, the committee discussed that it was important to note that the study did not focus on identifying breech presentation. The committee discussed the differences between the intervention in the study, which was an ultrasound scan to assess placental maturity, liquor volume, and fetal weight, to an ultrasound scan used to detect breech presentation. Whilst the ultrasound scan in the study has the ability to determine breech presentation, there are additional and costlier training required for the assessment of the other criteria. As such, it is important to separate the interventions. The committee also highlighted that the study did not look at whether an identification of breech presentation had an impact on the outcomes which were selected for this review.

In light of this, the committee felt that they were unable to reach a conclusion as to whether routine scanning to identify breech presentation, was associated with any benefits or harms. The committee agreed that while this review suggests routine ultrasound scanning to be no more effective than selective scanning, it does not definitively establish equivalence. Therefore, the committee agreed to recommend a continuation of the current practice with selective scanning and make a research recommendation to compare the clinical and cost effectiveness of routine ultrasound scanning versus selective ultrasound scanning from 36 weeks to identify fetal breech presentation.

Cost effectiveness and resource use

The committee acknowledged that there was included economic evidence on the effectiveness of routine scanning between 36+0 and 38+6 weeks of pregnancy compared to standard care regarding breech presentation.

The 1 included study suggested that offering a routine scan for breech is borderline cost effective. A key driver of cost effectiveness was the cost of the scan, which was substantially lower in the economic model than the figure quoted in NHS reference costs for routine ultrasound scanning. The committee noted that a scan for breech presentation only is a simpler technique and uses a cheaper machine. The committee agreed that the other costing assumptions presented in the study seemed appropriate.

However, the committee expressed concerns about the cohort study which underpinned the economic analysis which had a high risk of bias. The committee noted that a number of assumptions in the model which were key drivers of cost effectiveness, including the palpation diagnosis rates and prevalence of breech position, were from this 1 cohort study. This increased the uncertainty around the cost effectiveness of the routine scan. The committee also noted that, whilst the cost of the scan was fairly inexpensive, the resource impact would be substantial if a routine scan for breech presentation was offered to all pregnant women.

Overall, the committee felt that the clinical and cost effectiveness evidence presented was not strong enough to recommend offering a routine ultrasound scan given the potential for a significant resource impact. The recommendation to offer abdominal palpation to all pregnant women, and to offer an ultrasound scan where breech is suspected reflects current practice and so no substantial resource impact is anticipated.

McKenna 2003

Wastlund 2019

Appendix A. Review protocols

Review protocol for review question: What is the effectiveness of routine scanning between 36+0 and 38+6 weeks of pregnancy compared to standard care regarding breech presentation? (PDF, 244K)

Appendix B. Literature search strategies

Literature search strategies for review question: What is the effectiveness of routine scanning between 36+0 and 38+6 weeks of pregnancy compared to standard care regarding breech presentation? (PDF, 370K)

Appendix C. Clinical evidence study selection

Clinical study selection for review question: What is the effectiveness of routine scanning between 36+0 and 38+6 weeks of pregnancy compared to standard care regarding breech presentation? (PDF, 117K)

Appendix D. Clinical evidence tables

Clinical evidence tables for review question: What is the effectiveness of routine scanning between 36+0 and 38+6 weeks of pregnancy compared to standard care regarding breech presentation? (PDF, 213K)

Appendix E. Forest plots

Forest plots for review question: what is the effectiveness of routine scanning between 36+0 and 38+6 weeks of pregnancy compared to standard care regarding breech presentation.

This section includes forest plots only for outcomes that are meta-analysed. Outcomes from single studies are not presented here, but the quality assessment for these outcomes is provided in the GRADE profiles in appendix F .

Appendix F. GRADE tables

GRADE tables for review question: What is the effectiveness of routine scanning between 36+0 and 38+6 weeks of pregnancy compared to standard care regarding breech presentation? (PDF, 196K)

Appendix G. Economic evidence study selection

Economic evidence study selection for review question: what is the effectiveness of routine scanning between 36+0 and 38+6 weeks of pregnancy compared to standard care regarding breech presentation.

A single economic search was undertaken for all topics included in the scope of this guideline. One economic study was identified which was applicable to this review question. See supplementary material 2 for details.

Appendix H. Economic evidence tables

Economic evidence tables for review question: What is the effectiveness of routine scanning between 36+0 and 38+6 weeks of pregnancy compared to standard care regarding breech presentation? (PDF, 143K)

Appendix I. Economic evidence profiles

Economic evidence profiles for review question: What is the effectiveness of routine scanning between 36+0 and 38+6 weeks of pregnancy compared to standard care regarding breech presentation? (PDF, 129K)

Appendix J. Economic analysis

Economic evidence analysis for review question: what is the effectiveness of routine scanning between 36+0 and 38+6 weeks of pregnancy compared to standard care regarding breech presentation.

No economic analysis was conducted for this review question.

Appendix K. Excluded studies

Excluded clinical and economic studies for review question: what is the effectiveness of routine scanning between 36+0 and 38+6 weeks of pregnancy compared to standard care regarding breech presentation, clinical studies, table 8 excluded studies and reasons for their exclusion.

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Economic studies

A single economic search was undertaken for all topics included in the scope of this guideline. No economic studies were identified which were applicable to this review question. See supplementary material 2 for details.

Appendix L. Research recommendations

Research recommendations for review question: What is the effectiveness of routine scanning between 36+0 and 38+6 weeks of pregnancy compared to standard care regarding breech presentation? (PDF, 164K)

Evidence reviews underpinning recommendations 1.2.36 to 1.2.37

These evidence reviews were developed by the National Guideline Alliance, which is a part of the Royal College of Obstetricians and Gynaecologists

Disclaimer : The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.

Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.

NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government , Scottish Government , and Northern Ireland Executive . All NICE guidance is subject to regular review and may be updated or withdrawn.

• Cite this Page National Guideline Alliance (UK). Identification of breech presentation: Antenatal care: Evidence review L. London: National Institute for Health and Care Excellence (NICE); 2021 Aug. (NICE Guideline, No. 201.)
• PDF version of this title (518K)

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Related NICE guidance and evidence

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Related information

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Similar articles in PubMed

• Review Management of breech presentation: Antenatal care: Evidence review M [ 2021] Review Management of breech presentation: Antenatal care: Evidence review M National Guideline Alliance (UK). 2021 Aug
• Vaginal delivery of breech presentation. [J Obstet Gynaecol Can. 2009] Vaginal delivery of breech presentation. Kotaska A, Menticoglou S, Gagnon R, MATERNAL FETAL MEDICINE COMMITTEE. J Obstet Gynaecol Can. 2009 Jun; 31(6):557-566.
• [The effect of the woman's age on the course of pregnancy and labor in breech presentation]. [Akush Ginekol (Sofiia). 1996] [The effect of the woman's age on the course of pregnancy and labor in breech presentation]. Dimitrov A, Borisov S, Nalbanski B, Kovacheva M, Chintolova G, Dzherov L. Akush Ginekol (Sofiia). 1996; 35(1-2):7-9.
• Review Cephalic version by moxibustion for breech presentation. [Cochrane Database Syst Rev. 2005] Review Cephalic version by moxibustion for breech presentation. Coyle ME, Smith CA, Peat B. Cochrane Database Syst Rev. 2005 Apr 18; (2):CD003928. Epub 2005 Apr 18.
• Review Hands and knees posture in late pregnancy or labour for fetal malposition (lateral or posterior). [Cochrane Database Syst Rev. 2005] Review Hands and knees posture in late pregnancy or labour for fetal malposition (lateral or posterior). Hofmeyr GJ, Kulier R. Cochrane Database Syst Rev. 2005 Apr 18; (2):CD001063. Epub 2005 Apr 18.

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Breech Presentation: What It Is and How It Can Affect Your Baby's Delivery

As you get close to your due date, your baby might sense she’s approaching her grand entrance and move into a head-down position in your uterus, ready to be born. However, in some cases, she might choose another position instead, such as bottom or feet down. When this happens, it’s called a breech presentation. Read on to learn how your healthcare provider checks the position of your baby, what delivery options you may have if your baby is breech, and what can cause a breech presentation.

What Is Breech?

During your pregnancy, your baby has likely taken every opportunity to let you know she means business by kicking up a storm and doing countless somersaults. It's natural for your baby to move and shift positions within the uterus. Then, usually between 32 and 36 weeks of pregnancy, your baby will likely get into a head-down position in preparation for being born.

There is a small chance — just 3 to 4 percent — that your baby may not move into this head-down position by the time your pregnancy is full term. This is called a breech presentation. The chance of a breech presentation is higher if your pregnancy is not yet full term or if you go into preterm labor .

Types of Birth Positions

There are many different types of positions, including a number of breech presentations, that your baby may take on before birth:

Frank breech presentation. Your baby's bottom is positioned downward. This is the most common type of breech presentation.

Complete breech presentation. Your baby's feet are positioned downward with her hips and knees flexed, almost cross-legged.

Incomplete breech presentation. Your baby's feet are positioned downward with only one hip or one knee flexed.

Shoulder presentation or transverse lie. This is a form of breech in which your baby is positioned horizontally in the uterus. Few babies remain this way at the time of delivery.

Footling breech. One or both of your baby's feet are pointed downward.

Cephalic or vertex presentation (occiput). Your baby is in the normal position for delivery. Her head is down and she’s facing toward your back.

Cephalic or vertex presentation (occiput posterior). In some cases, your baby may be in a downward position but with her face toward your front. If this happens in early labor, your baby may naturally turn to face your back on her own, or, later in labor, your provider may decide to manually assist the baby in getting into this position. If this doesn't work, your baby can still be delivered vaginally, but delivery may be prolonged and more painful.

The causes of your baby being in breech position aren't always clear, but it can be more common if any of the following apply to you:

You've been pregnant before

You are pregnant with twins (read on to learn more about twin breech)

The uterus has more or less amniotic fluid than usual

The uterus has an abnormal shape or has abnormal growths, such as fibroids.

You have a condition called placenta previa , which is when the placenta covers the cervix.

Your healthcare provider likely already knows whether any of these factors affect your situation, but you might want to mention it just to be sure.

Diagnosis of a Breech Presentation

At one of your prenatal visits in the lead up to your due date, your provider will check that everything is progressing as planned , and will examine your abdomen to try to find out whether your baby is in the correct head-down position. If your provider thinks there may be a breech presentation, she or he may recommend an ultrasound exam to confirm it.

Can a Breech Baby Be Turned?

If your baby is breech, your provider may consider turning your baby so that a vaginal delivery can proceed, if that’s in the cards for you anyway. Alternatively, your provider may recommend that a cesarean delivery is the safer option.

Keep in mind, your baby's position might change at some point before delivery day, so your provider may recommend waiting and seeing.

If you are 37 weeks pregnant or more, your provider may recommend turning your baby through a process called external cephalic version or ECV.

ECV involves your provider placing hands on your abdomen and applying firm pressure in order to turn the baby. This procedure will most likely be done near a delivery room. Your provider may offer an epidural block to help with any pain this procedure causes.

An ECV is about 50 percent effective and there is a small risk of complications. You and your baby will be monitored closely before, during, and after the procedure to ensure that both of you are doing well.

If the ECV procedure is successful, your baby can be delivered vaginally , if there’s no other impediment.

Delivery Options for a Breech Baby

If your baby is in a breech position, the risks associated with a vaginal delivery are much higher than with a cesarean section. Risks include the umbilical cord cutting off his blood supply or his head or shoulders becoming stuck. That’s why, in some cases, your provider may recommend a cesarean delivery .

It could be that your provider’s level of experience in delivering breech babies might also inform the discussion you have with your provider about what’s right for your situation. Ultimately, your provider will recommend the best course of action for you and your baby based on your personal situation.

Twins and Breech Presentation

It's possible for twins to be delivered vaginally if the first baby — the lower-positioned twin — is correctly positioned with the head facing down. Of course, that's if the twin pregnancy is otherwise progressing well and there are no complications. If the second twin is in a breech position, the provider may do an ECV procedure to get this baby in the correct head-down position for a vaginal delivery, too.

If the first twin baby (the one lower down) is in a breech position, the provider may recommend a cesarean section. Triplets or more will most likely require a cesarean section.

Although you might feel like the added stress of a breech baby is the last thing you need as you approach your due date, remember that your healthcare provider has seen this situation before and will know what to do to ensure your baby is delivered safely. Next thing you know, you'll be bringing your brand-new baby home , stocking up on diapers, waking up for late-night feedings, and reveling in your baby's growth .

See all sources

• Cleveland clinic: Cesarean Birth (C-Section)
• Cleveland Clinic: Fetal Positions for Birth
• Mayo Clinic: Fetal presentation before birth
• Mayo Clinic: Prenatal care: 3rd trimester visits
• Mayo Clinic: Third Trimester
• Book: Your Pregnancy and Childbirth: Month to Month, Sixth Edition Paperback – January 1, 2016 by American College of Obstetricians and Gynecologists (Author)

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Breech baby at the end of pregnancy

Published: July 2017

Please note that this information will be reviewed every 3 years after publication.

This patient information page provides advice if your baby is breech towards the end of pregnancy and the options available to you.

It may also be helpful if you are a partner, relative or friend of someone who is in this situation.

The information here aims to help you better understand your health and your options for treatment and care. Your healthcare team is there to support you in making decisions that are right for you. They can help by discussing your situation with you and answering your questions. 

This information is for you if your baby remains in the breech position after 36 weeks of pregnancy. Babies lying bottom first or feet first in the uterus (womb) instead of in the usual head-first position are called breech babies. 

This information includes:

• What breech is and why your baby may be breech
• The different types of breech
• The options if your baby is breech towards the end of your pregnancy
• What turning a breech baby in the uterus involves (external cephalic version or ECV)
• How safe ECV is for you and your baby
• Options for birth if your baby remains breech
• Other information and support available

Within this information, we may use the terms ‘woman’ and ‘women’. However, it is not only people who identify as women who may want to access this information. Your care should be personalised, inclusive and sensitive to your needs, whatever your gender identity.

A glossary of medical terms is available at  A-Z of medical terms .

• Breech is very common in early pregnancy, and by 36–37 weeks of pregnancy most babies will turn into the head-first position. If your baby remains breech, it does not usually mean that you or your baby have any problems.
• Turning your baby into the head-first position so that you can have a vaginal delivery is a safe option.
• The alternative to turning your baby into the head-first position is to have a planned caesarean section or a planned vaginal breech birth.

Babies lying bottom first or feet first in the uterus (womb) instead of in the usual head-first position are called breech babies. Breech is very common in early pregnancy, and by 36-37 weeks of pregnancy, most babies turn naturally into the head-first position.

Towards the end of pregnancy, only 3-4 in every 100 (3-4%) babies are in the breech position.

A breech baby may be lying in one of the following positions:

It may just be a matter of chance that your baby has not turned into the head-first position. However, there are certain factors that make it more difficult for your baby to turn during pregnancy and therefore more likely to stay in the breech position. These include:

• if this is your first pregnancy
• if your placenta is in a low-lying position (also known as placenta praevia); see the RCOG patient information  Placenta praevia, placenta accreta and vasa praevia
• if you have too much or too little fluid ( amniotic fluid ) around your baby
• if you are having more than one baby.

Very rarely, breech may be a sign of a problem with the baby. If this is the case, such problems may be picked up during the scan you are offered at around 20 weeks of pregnancy.

If your baby is breech at 36 weeks of pregnancy, your healthcare professional will discuss the following options with you:

• trying to turn your baby in the uterus into the head-first position by external cephalic version (ECV)
• planned caesarean section
• planned vaginal breech birth.

What does ECV involve?

ECV involves applying gentle but firm pressure on your abdomen to help your baby turn in the uterus to lie head-first.

Relaxing the muscle of your uterus with medication has been shown to improve the chances of turning your baby. This medication is given by injection before the ECV and is safe for both you and your baby. It may make you feel flushed and you may become aware of your heart beating faster than usual but this will only be for a short time.

Before the ECV you will have an ultrasound scan to confirm your baby is breech, and your pulse and blood pressure will be checked. After the ECV, the ultrasound scan will be repeated to see whether your baby has turned. Your baby’s heart rate will also be monitored before and after the procedure. You will be advised to contact the hospital if you have any bleeding, abdominal pain, contractions or reduced fetal movements after ECV.

ECV is usually performed after 36 or 37 weeks of pregnancy. However, it can be performed right up until the early stages of labour. You do not need to make any preparations for your ECV.

ECV can be uncomfortable and occasionally painful but your healthcare professional will stop if you are experiencing pain and the procedure will only last for a few minutes. If your healthcare professional is unsuccessful at their first attempt in turning your baby then, with your consent, they may try again on another day.

If your blood type is rhesus D negative, you will be advised to have an anti-D injection after the ECV and to have a blood test. See the NICE patient information  Routine antenatal anti-D prophylaxis for women who are rhesus D negative , which is available at:  www.nice.org.uk/guidance/ta156/informationforpublic .

Why turn my baby head-first?

If your ECV is successful and your baby is turned into the head-first position you are more likely to have a vaginal birth. Successful ECV lowers your chances of requiring a caesarean section and its associated risks.

Is ECV safe for me and my baby?

ECV is generally safe with a very low complication rate. Overall, there does not appear to be an increased risk to your baby from having ECV. After ECV has been performed, you will normally be able to go home on the same day.

When you do go into labour, your chances of needing an emergency caesarean section, forceps or vacuum (suction cup) birth is slightly higher than if your baby had always been in a head-down position.

Immediately after ECV, there is a 1 in 200 chance of you needing an emergency caesarean section because of bleeding from the placenta and/or changes in your baby’s heartbeat.

ECV should be carried out by a doctor or a midwife trained in ECV. It should be carried out in a hospital where you can have an emergency caesarean section if needed.

ECV can be carried out on most women, even if they have had one caesarean section before.

ECV should not be carried out if:

• you need a caesarean section for other reasons, such as placenta praevia; see the RCOG patient information  Placenta praevia, placenta accreta and vasa praevia
• you have had recent vaginal bleeding
• your baby’s heart rate tracing (also known as CTG) is abnormal
• your waters have broken
• you are pregnant with more than one baby; see the RCOG patient information  Multiple pregnancy: having more than one baby .

Is ECV always successful?

ECV is successful for about 50% of women. It is more likely to work if you have had a vaginal birth before. Your healthcare team should give you information about the chances of your baby turning based on their assessment of your pregnancy.

If your baby does not turn then your healthcare professional will discuss your options for birth (see below). It is possible to have another attempt at ECV on a different day.

If ECV is successful, there is still a small chance that your baby will turn back to the breech position. However, this happens to less than 5 in 100 (5%) women who have had a successful ECV.

There is no scientific evidence that lying down or sitting in a particular position can help your baby to turn. There is some evidence that the use of moxibustion (burning a Chinese herb called mugwort) at 33–35 weeks of pregnancy may help your baby to turn into the head-first position, possibly by encouraging your baby’s movements. This should be performed under the direction of a registered healthcare practitioner.

Depending on your situation, your choices are:

There are benefits and risks associated with both caesarean section and vaginal breech birth, and these should be discussed with you so that you can choose what is best for you and your baby.

Caesarean section

If your baby remains breech towards the end of pregnancy, you should be given the option of a caesarean section. Research has shown that planned caesarean section is safer for your baby than a vaginal breech birth. Caesarean section carries slightly more risk for you than a vaginal birth.

Caesarean section can increase your chances of problems in future pregnancies. These may include placental problems, difficulty with repeat caesarean section surgery and a small increase in stillbirth in subsequent pregnancies. See the RCOG patient information  Choosing to have a caesarean section .

If you choose to have a caesarean section but then go into labour before your planned operation, your healthcare professional will examine you to assess whether it is safe to go ahead. If the baby is close to being born, it may be safer for you to have a vaginal breech birth.

Vaginal breech birth

After discussion with your healthcare professional about you and your baby’s suitability for a breech delivery, you may choose to have a vaginal breech birth. If you choose this option, you will need to be cared for by a team trained in helping women to have breech babies vaginally. You should plan a hospital birth where you can have an emergency caesarean section if needed, as 4 in 10 (40%) women planning a vaginal breech birth do need a caesarean section. Induction of labour is not usually recommended.

While a successful vaginal birth carries the least risks for you, it carries a small increased risk of your baby dying around the time of delivery. A vaginal breech birth may also cause serious short-term complications for your baby. However, these complications do not seem to have any long-term effects on your baby. Your individual risks should be discussed with you by your healthcare team.

Before choosing a vaginal breech birth, it is advised that you and your baby are assessed by your healthcare professional. They may advise against a vaginal birth if:

• your baby is a footling breech (one or both of the baby’s feet are below its bottom)
• your baby is larger or smaller than average (your healthcare team will discuss this with you)
• your baby is in a certain position, for example, if its neck is very tilted back (hyper extended)
• you have a low-lying placenta (placenta praevia); see the RCOG patient information  Placenta Praevia, placenta accreta and vasa praevia
• you have pre-eclampsia or any other pregnancy problems; see the RCOG patient information  Pre-eclampsia .

With a breech baby you have the same choices for pain relief as with a baby who is in the head-first position. If you choose to have an epidural, there is an increased chance of a caesarean section. However, whatever you choose, a calm atmosphere with continuous support should be provided.

If you have a vaginal breech birth, your baby’s heart rate will usually be monitored continuously as this has been shown to improve your baby’s chance of a good outcome.

In some circumstances, for example, if there are concerns about your baby’s heart rate or if your labour is not progressing, you may need an emergency caesarean section during labour. A  paediatrician  (a doctor who specialises in the care of babies, children and teenagers) will attend the birth to check your baby is doing well.

If you go into labour before 37 weeks of pregnancy, the balance of the benefits and risks of having a caesarean section or vaginal birth changes and will be discussed with you.

If you are having twins and the first baby is breech, your healthcare professional will usually recommend a planned caesarean section.

If, however, the first baby is head-first, the position of the second baby is less important. This is because, after the birth of the first baby, the second baby has lots more room to move. It may turn naturally into a head-first position or a doctor may be able to help the baby to turn. See the RCOG patient information  Multiple pregnancy: having more than one baby .

If you would like further information on breech babies and breech birth, you should speak with your healthcare professional. 

Further information

• NHS information on breech babies  
• NCT information on breech babies

If you are asked to make a choice, you may have lots of questions that you want to ask. You may also want to talk over your options with your family or friends. It can help to write a list of the questions you want answered and take it to your appointment.

Ask 3 Questions

To begin with, try to make sure you get the answers to  3 key questions , if you are asked to make a choice about your healthcare:

• What are my options?
• What are the pros and cons of each option for me?
• How do I get support to help me make a decision that is right for me?

*Ask 3 Questions is based on Shepherd et al. Three questions that patients can ask to improve the quality of information physicians give about treatment options: A cross-over trial. Patient Education and Counselling, 2011;84:379-85  

• https://aqua.nhs.uk/resources/shared-decision-making-case-studies/

Sources and acknowledgements

This information has been developed by the RCOG Patient Information Committee. It is based on the RCOG Green-top Clinical Guidelines No. 20a  External Cephalic Version and Reducing Incidence of Term Breech Presentation  and No. 20b  Management of Breech Presentation . The guidelines contain a full list of the sources of evidence we have used.

This information was reviewed before publication by women attending clinics in Nottingham, Essex, Inverness, Manchester, London, Sussex, Bristol, Basildon and Oxford, by the RCOG Women’s Network and by the RCOG Women’s Voices Involvement Panel.

Please give us feedback by completing our feedback survey:

• Members of the public – patient information feedback
• Healthcare professionals – patient information feedback

External Cephalic Version and Reducing the Incidence of Term Breech Presentation Green-top Guideline

Management of Breech Presentation Green-top Guideline

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First, recognize breech presentation when the buttocks appear in the birth canal before the head does. Experienced providers can deliver some babies in frank or complete breech presentations. Have a cloth or surgical towel available as well as other instruments used for routine deliveries and prepare for what to do if vaginal delivery is unsuccessful.

This position is a frank breech.

This position is a complete breech.

And this position is an incomplete complete breech.

Allow delivery to the level of the umbilicus with maternal effort. If possible, do this without touching the infant. Anticipate umbilical cord compression and possibly fetal decelerations.

To deliver a leg, splint the medial thigh parallel to the femur and sweep the thigh laterally. Repeat this procedure to deliver the other leg.

Wrap a towel around the infant, putting your fingers on the anterior superior iliac spines and your thumbs on the sacrum.

Assist the mother’s efforts during contractions by applying gentle traction to help deliver the body to the level of the scapulas.

Rotate the body in either direction to make one shoulder anterior. Deliver the anterior arm by sweeping it across the chest. Rotate the infant 180 degrees in either direction. Deliver the arm that is now anterior the same way the other arm was delivered. Move the towel up to cover the arms and rotate the body to make the back anterior.

To deliver the head, place your index and middle fingers of one hand over the fetal maxilla to flex the head, while the body rests on your palm and forearm, as shown here. With your other hand, hook 2 fingers over the neck, grasp the shoulder, and apply gentle downward traction. Have an assistant apply suprapubic pressure to help maintain head flexion and deliver the head.

Procedure by Will Stone, MD, and Kate Leonard, MD, Walter Reed National Military Medical Center Residency in Obstetrics and Gynecology; and Shad Deering, COL, MD, Chair, Department of Obstetrics and Gynecology, Uniformed Services University. Assisted by Elizabeth N. Weissbrod, MA, CMI, Eric Wilson, 2LT, and Jamie Bradshaw at the Val G. Hemming Simulation Center at the Uniformed Services University.

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Open Access

Peer-reviewed

Research Article

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

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

* E-mail: [email protected]

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

Roles Data curation, Software

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

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

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

• Malene Mie Caning, 
• Steen Christian Rasmussen, 

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

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

Register-based cohort study

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

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

Main outcome measures

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

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

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

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

Editor: Abera Mersha, Arba Minch University, ETHIOPIA

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

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

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

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

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

Introduction

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

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

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

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

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

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

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

Materials and methods

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

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

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

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

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

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

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

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

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

Statistical analyses

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

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

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

Ethical approval

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

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

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

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

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

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

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

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

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

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

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

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

Main findings

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

Strength and limitations

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

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

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

Interpretation

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Supporting information

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

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

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

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

S1 Dataset. Dataset Maternal Outcome Breech.

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

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Introduction, case report, conflict of interest statement, successful management of prolonged abdominal pregnancy in low-resource setting: a case report.

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Cátia Samajo Zita, Gonzalo Gonzáles Villa, Eduardo Matediana, Pita Tomás, Damiano Pizzol, Lee Smith, Successful management of prolonged abdominal pregnancy in low-resource setting: a case report, Journal of Surgical Case Reports , Volume 2024, Issue 4, April 2024, rjae210, https://doi.org/10.1093/jscr/rjae210

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Ectopic pregnancy is a life-threatening complication of pregnancy and represents the leading cause of maternal mortality in the first trimester. In developing countries early diagnosis, necessary for favorable outcomes, is often unavailable and women are often not aware of possible conditions and associated complications. Moreover, access to sexual and reproductive health services and antenatal care are limited in such settings. Finally, management options are restricted and often performed in emergency with higher risk of complications and mortality. We report here a 33-year-old woman presenting a 41 weeks abdominal pregnancy successfully managed in a low-resource setting.

Ectopic pregnancy (EP) is a complication of pregnancy where the embryo implants outside the uterine cavity, mainly in the Fallopian tube but also in the cervix, ovaries, and abdomen [ 1 ]. EP is life-threatening for the mother especially due to the possible consequent internal hemorrhage and it represents the leading cause of maternal mortality in the first trimester, with an estimated incidence of 5–10% of all pregnancy-related deaths [ 1 ]. Reliable epidemiological data are available only in developed countries with well-established healthcare and it is estimated that EP accounts for ~2% of all pregnancies in Europe and North America [ 2 ]. On the contrary, in developing countries, due to poor medical and economic conditions, limited antenatal visits and prevention programs, not only it is difficult to find epidemiological data but there are important limitations in the understanding of the risk factors and management of EP [ 2 ]. The main risk factors for EP are the use of an intrauterine device at the time of conception, Chlamydia trachomatis and Neisseria gonorrhea infections, current or past history of pelvic inflammatory disease, previous EP, iron deficiency, and smoking cigarettes [ 3 ]. The gold standard for diagnosis is the serum concentrations of human β chorionic gonadotropin (hCG) and transvaginal ultrasound while clinical evaluation is not reliable as many women with EP report no pain nor adnexal tenderness and often it may be confused with miscarriage or induced abortion, a problem with the ovary or with a pelvic inflammatory disease [ 3 ]. In developing countries not only the gold standard is often unavailable, but women are often not aware of possible conditions and their complications and have no access to proper sexual and reproductive health services nor antenatal care [ 4 ]. Likewise, the EP management in developed countries is standardized both for stable patients, which can be treated medically with methotrexate injection, or surgically with the removal of the fallopian tube, both for unstable patients requiring emergency surgery to stop life-threatening hemorrhage [ 5 ]. In limited resources settings, instead, surgery, mostly performed by laparotomy, remains the main treatment and, due to late diagnosis, it is often performed in emergency with frequent tubal rupture and hemoperitoneum and, thus, higher risk of complications and mortality [ 3 ].

We reported a 33-year-old woman presenting a 41 weeks abdominal pregnancy successfully managed in a low-resource setting.

A 33-year-old woman presented with a prolonged (41 weeks) pregnancy without labor and history of fourth pregnancy with three births, one stillbirth and two live children.

At admission, the patient reported abdominal pain and discomfort due to fetal mobilization, with good baby movement, anorexia, and no other complaints. She presented a prenatal record of 10 consultations carried out in a rural context with no ultrasound availability and no complication. She was HIV positive on treatment with Tenofovir, Lamivudine, and Dolutegravir and tested negative for syphilis. At clinical examination, blood pressure levels were normal (115/83 mmHg), heart rate 106 bpm, respiratory rate 18 cpm, temperature 36.5°C, and cardiopulmonary auscultation unchanged. The abdomen was painful on superficial and deep palpation, the fetus was palpated in a longitudinal position, breech presentation, fundus height of 37 cm, auscultation of the fetal cardiac focus in the right hypochondrium at 130 bpm, without uterine dynamics. Upon vaginal examination, the posterior cervix was long and impervious. The ultrasound revealed a single intrauterine fetus, fetal heartbeat positive, breech presentation, biparietal diameter of 9.3 cm, femur length of 7.2 cm, and occlusive placenta previa and severe oligoamnios. Emergency cesarean section was performed. The abdominal cavity was accessed where the gestational sac was found, the empty uterus next to the gestational sac slightly increased in size. The amniotic membrane was opened and the newborn, a live male weight 2600 g was delivered with Apgar score of 6 at first minute and 8 at fifth minute ( Fig. 1A ). A small amount of clear amniotic fluid was observed, the placenta was inserted into the left interstitial region, with adhesions to the left annex of the uterus ( Fig. 1B ). Thus, the left adnexectomy was performed ( Fig. 1C ). Surgery was uneventful, postoperative course had no complication, and the mother and child were discharged 4 days after surgery. Importantly, 1 week follow up was regular for both.

Live newborn after prolonged abdominal pregnancy (A), placenta adhesions to the left annex of the uterus (B), and adnexectomy (C).

EP represents a potential highly preventable and treatable condition and, especially when early detected, the chances of successful treatment are high, leading to a low risk of complications and mortality. However, these optimal conditions are characteristics of high-income countries while in undeveloped and developing countries EP remains an underestimated and underdiagnosed condition leading to urgency and fatal outcomes. The main reasons are the lack of diagnostic tools as hCG and transvaginal ultrasound and limited access to proper health care system and service. However, the higher rate of morbidity and mortality seems also related to country or region’s combined educational, economic, and medical levels reflecting a strong role of social determinants of health [ 3 ].

The successful management of this case represents a rare and extraordinary case that reflects the poor social-economic context, limited resources but also the appropriateness of the care provided in this complex case.

Considering the limited scientific literature available especially in low-income countries, further research and investigation are necessary to better understand the underlying factors contributing to EP in low-resource settings. Moreover, considering the various factors such as ethnicity, economic status, and educational levels, it is mandatory to develop effective public health policies that address these disparities and provide enhanced protection for vulnerable women. Finally, it is crucial to promote early diagnosis and treatment of EP especially in low-resource settings to mitigate its impact on women and child health.

None declared.

Written informed consent was obtained from the patient for publication of this case report and any accompanying images.

Cátia Samajo Zita.

Mullany K , Minneci M , Monjazeb R , et al.    Overview of ectopic pregnancy diagnosis, management, and innovation . Womens Health (Lond)   2023 ; 19 : 174550572311603 .

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Zhang S , Liu J , Yang L , et al.    Global burden and trends of ectopic pregnancy: an observational trend study from 1990 to 2019 . PloS One   2023 ; 18 : e0291316 .

Goyaux N , Leke R , Keita N , et al.    Ectopic pregnancy in African developing countries . Acta Obstet Gynecol Scand   2003 ; 82 : 305 – 12 .

Brady PC . New evidence to guide ectopic pregnancy diagnosis and management . Obstet Gynecol Surv   2017 ; 72 : 618 – 25 .

Sonalkar S , Gilmore E . A fresh look at treatment for ectopic pregnancy . Lancet   2023 ; 401 : 619 – 20 .

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