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

, MD, Children's Hospital of Philadelphia

Variations in Fetal Position and Presentation

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Presentation refers to the part of the fetus’s body that leads the way out through the birth canal (called the presenting part). Usually, the head leads the way, but sometimes the buttocks (breech presentation), shoulder, or face leads the way.

Position refers to whether the fetus is facing backward (occiput anterior) or forward (occiput posterior). The occiput is a bone at the back of the baby's head. Therefore, facing backward is called occiput anterior (facing the mother’s back and facing down when the mother lies on her back). Facing forward is called occiput posterior (facing toward the mother's pubic bone and facing up when the mother lies on her back).

Lie refers to the angle of the fetus in relation to the mother and the uterus. Up-and-down (with the baby's spine parallel to mother's spine, called longitudinal) is normal, but sometimes the lie is sideways (transverse) or at an angle (oblique).

For these aspects of fetal positioning, the combination that is the most common, safest, and easiest for the mother to deliver is the following:

Head first (called vertex or cephalic presentation)

Facing backward (occiput anterior position)

Spine parallel to mother's spine (longitudinal lie)

Neck bent forward with chin tucked

Arms folded across the chest

If the fetus is in a different position, lie, or presentation, labor may be more difficult, and a normal vaginal delivery may not be possible.

Variations in fetal presentation, position, or lie may occur when

The fetus is too large for the mother's pelvis (fetopelvic disproportion).

The fetus has a birth defect Overview of Birth Defects Birth defects, also called congenital anomalies, are physical abnormalities that occur before a baby is born. They are usually obvious within the first year of life. The cause of many birth... read more .

There is more than one fetus (multiple gestation).

Position and Presentation of the Fetus

Some variations in position and presentation that make delivery difficult occur frequently.

Occiput posterior position

In occiput posterior position (sometimes called sunny-side up), the fetus is head first (vertex presentation) but is facing forward (toward the mother's pubic bone—that is, facing up when the mother lies on her back). This is a very common position that is not abnormal, but it makes delivery more difficult than when the fetus is in the occiput anterior position (facing toward the mother's spine—that is facing down when the mother lies on her back).

Breech presentation

In breech presentation, the baby's buttocks or sometimes the feet are positioned to deliver first (before the head).

When delivered vaginally, babies that present buttocks first are more at risk of injury or even death than those that present head first.

The reason for the risks to babies in breech presentation is that the baby's hips and buttocks are not as wide as the head. Therefore, when the hips and buttocks pass through the cervix first, the passageway may not be wide enough for the head to pass through. In addition, when the head follows the buttocks, the neck may be bent slightly backwards. The neck being bent backward increases the width required for delivery as compared to when the head is angled forward with the chin tucked, which is the position that is easiest for delivery. Thus, the baby’s body may be delivered and then the head may get caught and not be able to pass through the birth canal. When the baby’s head is caught, this puts pressure on the umbilical cord in the birth canal, so that very little oxygen can reach the baby. Brain damage due to lack of oxygen is more common among breech babies than among those presenting head first.

Breech presentation is more likely to occur in the following circumstances:

Labor starts too soon (preterm labor).

Sometimes the doctor can turn the fetus to be head first before labor begins by doing a procedure that involves pressing on the pregnant woman’s abdomen and trying to turn the baby around. Trying to turn the baby is called an external cephalic version and is usually done at 37 or 38 weeks of pregnancy. Sometimes women are given a medication (such as terbutaline ) during the procedure to prevent contractions.

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Breech presentation

Learning objectives.

Types of breech presentation
Management of breech presentation

Definition and mechanisms

Breech presentation refers to the fetus in the longitudinal lie with the buttocks or lower extremity entering the pelvis first
Frank breech: fetus has flexion of both hips, and the legs are straight with the feet near the fetal face, in a pike position
Complete breech: fetus sits with flexion of both hips and both legs in a tuck position
Incomplete breech: can have any combination of one or both hips extended, also known as footling (one leg extended) breech, or double footling breech (both legs extended)
A higher percentage of breech presentations occurs with less advanced gestational age
At 32 weeks, 7% of fetuses are breech
At 28 weeks or less, 25% are breech
Clinical conditions associated with a breech presentation include those that may increase or decrease fetal motility, or affect the vertical polarity of the uterine cavity
It is unsafe for a breech baby to be born vaginally due to the risk of injury (dislocated or broken bones) or umbilical cord problems (flattening or twisting)
Turning the baby into the head-first position and/or a planned C-section are the safest option
Prematurity
Multiple gestations
Aneuploidies
Congenital anomalies: fetal sacrococcygeal teratoma, fetal thyroid goiter
Mullerian anomalies
Uterine leiomyoma
Placental polarity as in placenta previa
Polyhydramnios
Oligohydramnios
Previous history of breech presentation (recurrence rate is 10% for the second pregnancy and 27% in the third pregnancy)
Physical exam: palpation of a hard, round, mobile structure at the fundus and the inability to palpate a presenting part in the lower abdomen superior to the pubic bone or the engaged breach in the same area, should raise suspicion of a breech presentation
Cervical exam: the lack of a palpable presenting part, palpation of a lower extremity, usually a foot, or for the engaged breech, palpation of the soft tissue of the fetal buttocks may be noted
Note that the soft tissue of the fetal buttocks may be interpreted as caput of the fetal vertex if the patient has been laboring
Ultrasound confirms the diagnosis

Breech presentation, CTG, external cephalic version (ECV), vaginal breech, ceasarean delivery

Breech Births

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

What are the different types of breech birth presentations?

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

What causes a breech presentation?

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

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

How is a breech presentation diagnosed?

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

Can a breech presentation mean something is wrong?

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

Can a breech presentation be changed?

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

Medical Techniques

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

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

ECV will not be tried if:

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

Complications of EVC include:

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

Vaginal delivery versus cesarean for breech birth?

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

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

What are the risks and complications of a vaginal delivery?

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

When is a cesarean delivery used with a breech presentation?

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

Want to Know More?

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

Compiled using information from the following sources:

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

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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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Breech presentation

Highlights & basics, diagnostic approach, risk factors, history & exam, differential diagnosis.

Tx Approach

Emerging Tx

Complications.

PATIENT RESOURCES

Patient Instructions

Breech presentation refers to the baby presenting for delivery with the buttocks or feet first rather than head.

Associated with increased morbidity and mortality for the mother in terms of emergency cesarean section and placenta previa; and for the baby in terms of preterm birth, small fetal size, congenital anomalies, and perinatal mortality.

Incidence decreases as pregnancy progresses and by term occurs in 3% to 4% of singleton term pregnancies.

Treatment options include external cephalic version to increase the likelihood of vaginal birth or a planned cesarean section, the optimal gestation being 37 and 39 weeks, respectively.

Planned cesarean section is considered the safest form of delivery for infants with a persisting breech presentation at term.

Quick Reference

Key Factors

buttocks or feet as the presenting part

Fetal head under costal margin, fetal heartbeat above the maternal umbilicus.

Other Factors

subcostal tenderness

Pelvic or bladder pain.

Diagnostics Tests

1st Tests to Order

transabdominal/transvaginal ultrasound

Treatment options.

presumptive

<37 weeks' gestation

specialist evaluation

corticosteroid

magnesium sulfate

≥37 weeks' gestation not in labor

unsuccessful ECV with persistent breech

Classifications

Types of breech presentation

Baby's buttocks lead the way into the birth canal

Hips are flexed, knees are extended, and the feet are in close proximity to the head

65% to 70% of breech babies are in this position.

Baby presents with buttocks first

Both the hips and the knees are flexed; the baby may be sitting cross-legged.

One or both of the baby's feet lie below the breech so that the foot or knee is lowermost in the birth canal

This is rare at term but relatively common with premature fetuses.

Common Vignette

Epidemiology

33% of births less than 28 weeks' gestation

14% of births at 29 to 32 weeks' gestation

9% of births at 33 to 36 weeks' gestation

6% of births at 37 to 40 weeks' gestation.

Pathophysiology

Natasha Nassar, PhD
Christine L. Roberts, MBBS, FAFPHM, DrPH
Jonathan Morris, MBChB, FRANZCOG, PhD
John W. Bachman, MD
Rhona Hughes, MBChB
Brian Peat, MD
Lelia Duley, MBChB
Justus Hofmeyr, MD

Clinical exam

Palpation of the abdomen to determine the position of the baby's head

Palpation of the abdomen to confirm the position of the fetal spine on one side and fetal extremities on the other

Palpation of the area above the symphysis pubis to locate the fetal presenting part

Palpation of the presenting part to confirm presentation, to determine how far the fetus has descended and whether the fetus is engaged.

Ultrasound examination

Premature fetus.

Prematurity is consistently associated with breech presentation. [ 6 ] [ 9 ] This may be due to the smaller size of preterm infants, who are more likely to change their in utero position.

Increasing duration of pregnancy may allow breech-presenting fetuses time to grow, turn spontaneously or by external cephalic version, and remain cephalic-presenting.

Larger fetuses may be forced into a cephalic presentation in late pregnancy due to space or alignment constraints within the uterus.

small for gestational age fetus

Low birth-weight is a risk factor for breech presentation. [ 9 ] [ 11 ] [ 12 ] [ 13 ] [ 14 ] Term breech births are associated with a smaller fetal size for gestational age, highlighting the association with low birth-weight rather than prematurity. [ 6 ]

nulliparity

Women having a first birth have increased rates of breech presentation, probably due to the increased likelihood of smaller fetal size. [ 6 ] [ 9 ]

Relaxation of the uterine wall in multiparous women may reduce the odds of breech birth and contribute to a higher spontaneous or external cephalic version rate. [ 10 ]

fetal congenital anomalies

Congenital anomalies in the fetus may result in a small fetal size or inappropriate fetal growth. [ 9 ] [ 12 ] [ 14 ] [ 15 ]

Anencephaly, hydrocephaly, Down syndrome, and fetal neuromuscular dysfunction are associated with breech presentation, the latter due to its effect on the quality of fetal movements. [ 9 ] [ 14 ]

previous breech delivery

The risk of recurrent breech delivery is 8%, the risk increasing from 4% after one breech delivery to 28% after three. [ 16 ]

The effects of recurrence may be due to recurring specific causal factors, either genetic or environmental in origin.

uterine abnormalities

Women with uterine abnormalities have a high incidence of breech presentation. [ 14 ] [ 17 ] [ 18 ] [ 19 ]

female fetus

Fifty-four percent of breech-presenting fetuses are female. [ 14 ]

abnormal amniotic fluid volume

Both oligohydramnios and polyhydramnios are associated with breech presentation. [ 1 ] [ 12 ] [ 14 ]

Low amniotic fluid volume decreases the likelihood of a fetus turning to a cephalic position; an increased amniotic fluid volume may facilitate frequent change in position.

placental abnormalities

An association between placental implantation in the cornual-fundal region and breech presentation has been reported, although some studies have not found it a risk factor. [ 8 ] [ 20 ] [ 21 ] [ 22 ] [ 10 ] [ 14 ]

The association with placenta previa is also inconsistent. [ 8 ] [ 9 ] [ 22 ] Placenta previa is associated with preterm birth and may be an indirect risk factor.

Pelvic or vaginal examination reveals the buttocks and/or feet, felt as a yielding, irregular mass, as the presenting part. [ 26 ] In cephalic presentation, a hard, round, regular fetal head can be palpated. [ 26 ]

The Leopold maneuver on examination suggests breech position by palpation of the fetal head under the costal margin. [ 26 ]

The baby's heartbeat should be auscultated using a Pinard stethoscope or a hand-held Doppler to indicate the position of the fetus. The fetal heartbeat lies above the maternal umbilicus in breech presentation. [ 1 ]

Tenderness under one or other costal margin as a result of pressure by the harder fetal head.

Pain due to fetal kicks in the maternal pelvis or bladder.

breech position

Visualizes the fetus and reveals its position.

Used to confirm a clinically suspected breech presentation. [ 28 ]

Should be performed by practitioners with appropriate skills in obstetric ultrasound.

Establishes the type of breech presentation by imaging the fetal femurs and their relationship to the distal bones.

Transverse lie

Differentiating Signs/Symptoms

Fetus lies horizontally across the uterus with the shoulder as the presenting part.

Similar predisposing factors such as placenta previa, abnormal amniotic fluid volume, and uterine anomalies, although more common in multiparity. [ 1 ] [ 2 ] [ 29 ]

Differentiating Tests

Clinical examination and fetal auscultation may be indicative.

Ultrasound confirms presentation.

Treatment Approach

Breech presentation <37 weeks' gestation.

The UK Royal College of Obstetricians and Gynaecologists (RCOG) recommends that corticosteroids should be offered to women between 24 and 34+6 weeks' gestation, in whom imminent preterm birth is anticipated. Corticosteroids should only be considered after discussion of risks/benefits at 35 to 36+6 weeks. Given within 7 days of preterm birth, corticosteroids may reduce perinatal and neonatal death and respiratory distress syndrome. [ 32 ] The American College of Obstetricians and Gynecologists (ACOG) recommends a single course of corticosteroids for pregnant women between 24 and 33+6 weeks' gestation who are at risk of preterm delivery within 7 days, including those with ruptured membranes and multiple gestations. It may also be considered for pregnant women starting at 23 weeks' gestation who are at risk of preterm delivery within 7 days. A single course of betamethasone is recommended for pregnant women between 34 and 36+6 weeks' gestation at risk of preterm birth within 7 days, and who have not received a previous course of prenatal corticosteroids. Regularly scheduled repeat courses or serial courses (more than two) are not currently recommended. A single repeat course of prenatal corticosteroids should be considered in women who are less than 34 weeks' gestation, who are at risk of preterm delivery within 7 days, and whose prior course of prenatal corticosteroids was administered more than 14 days previously. Rescue course corticosteroids could be provided as early as 7 days from the prior dose, if indicated by the clinical scenario. [ 33 ]

Magnesium sulfate given before anticipated early preterm birth reduces the risk of cerebral palsy in surviving infants. Physicians electing to use magnesium sulfate for fetal neuroprotection should develop specific guidelines regarding inclusion criteria, treatment regimens, and concurrent tocolysis. [ 34 ]

Breech presentation from 37 weeks' gestation, before labor

ECV is the initial treatment for a breech presentation at term when the patient is not in labor. It involves turning a fetus presenting by the breech to a cephalic (head-down) presentation to increase the likelihood of vaginal birth. [ 35 ] [ 36 ] Where available, it should be offered to all women in late pregnancy, by an experienced clinician, in hospitals with facilities for emergency delivery, and no contraindications to the procedure. [ 35 ] There is no upper time limit on the appropriate gestation for ECV, with success reported at 42 weeks.

There is no general consensus on contraindications to ECV. Contraindications include multiple pregnancy (except after delivery of a first twin), ruptured membranes, current or recent (<1 week) vaginal bleeding, rhesus isoimmunization, other indications for cesarean section (e.g., placenta previa or uterine malformation), or abnormal electronic fetal monitoring. [ 35 ] One systematic review of relative contraindications for ECV highlighted that most contraindications do not have clear empirical evidence. Exceptions include placental abruption, severe preeclampsia/HELLP syndrome, or signs of fetal distress (abnormal cardiotocography and/or Doppler flow). [ 36 ]

The procedure involves applying external pressure and firmly pushing or palpating the mother's abdomen to coerce the fetus to somersault (either forward or backward) into a cephalic position. [ 37 ]

The overall ECV success rate varies but, in a large series, 47% of women following an ECV attempt had a cephalic presentation at birth. [ 35 ] [ 38 ] Various factors influence the success rate. One systematic review found ECV success rates to be 68% overall, with the rate significantly higher for women from African countries (89%) compared with women from non-African countries (62%), and higher among multiparous (78%) than nulliparous women (48%). [ 39 ] Overall, the ECV success rates for nulliparous and multiparous non-African women were 43% and 73%, respectively, while for nulliparous and multiparous African women rates were 79% and 91%, respectively. Another study reported no difference in success rate or rate of cesarean section among women with previous cesarean section undergoing ECV compared with women with previous vaginal birth. However, numbers were small and further studies in this regard are required. [ 40 ]

Women's preference for vaginal delivery is a major contributing factor in their decision for ECV. However, studies suggest women with a breech presentation at term may not receive complete and/or evidence-based information about the benefits and risks of ECV. [ 41 ] [ 42 ] Although up to 60% of women reported ECV to be painful, the majority highlighted the benefits outweigh the risks (71%) and would recommend ECV to their friends or be willing to repeat for themselves (84%). [ 41 ] [ 42 ]

Cardiotocography and ultrasound should be performed before and after the procedure. Tocolysis should be used to facilitate the maneuver, and Rho(D) immune globulin should be administered to women who are Rhesus negative. [ 35 ] Tocolytic agents include adrenergic beta-2 receptor stimulants such as albuterol, terbutaline, or ritodrine (widely used with ECV in some countries, but not yet available in the US). One Cochrane review of tocolytic beta stimulants demonstrates that these are less likely to be associated with failed ECV, and are effective in increasing cephalic presentation and reducing cesarean section. [ 43 ] There is no current evidence to recommend one beta-2 adrenergic receptor agonist over another. Until these data are available, adherence to a local protocol for tocolysis is recommended. The Food and Drug Administration has issued a warning against using injectable terbutaline beyond 48 to 72 hours, or acute or prolonged treatment with oral terbutaline, in pregnant women for the prevention or prolonged treatment of preterm labor, due to potential serious maternal cardiac adverse effects and death. [ 44 ] Whether this warning applies to the subcutaneous administration of terbutaline in ECV is still unclear; however, studies currently support this use. The European Medicines Agency (EMA) recommends that injectable beta agonists should be used for up to 48 hours between the 22nd and 37th week of pregnancy only. They should be used under specialist supervision with continuous monitoring of the mother and unborn baby owing to the risk of adverse cardiovascular effects in both the mother and baby. The EMA no longer recommends oral or rectal formulations for obstetric indications. [ 45 ]

If ECV is successful, pregnancy care should continue as usual for any cephalic presentation. One systematic review assessing the mode of delivery after a successful ECV found that these women were at increased risk for cesarean section and instrumental vaginal delivery compared with women with spontaneous cephalic pregnancies. However, they still had a lower rate of cesarean section following ECV (i.e., 47%) compared with the cesarean section rate for those with a persisting breech (i.e., 85%). With a number needed to treat of three, ECV is still considered to be an effective means of preventing the need for cesarean section. [ 46 ]

Planned cesarean section should be offered as the safest mode of delivery for the baby, even though it carries a small increase in serious immediate maternal complications compared with vaginal birth. [ 24 ] [ 25 ] [ 31 ] In the US, most unsuccessful ECV with persistent breech will be delivered via cesarean section.

A vaginal mode of delivery may be considered by some clinicians as an option, particularly when maternal request is provided, senior and experienced staff are available, there is no absolute contraindication to vaginal birth (e.g., placenta previa, compromised fetal condition), and with optimal fetal growth (estimated weight above the tenth centile and up to 3800 g). Other factors that make planned vaginal birth higher risk include hyperextended neck on ultrasound and footling presentation. [ 24 ]

Breech presentation from 37 weeks' gestation, during labor

The first option should be a planned cesarean section.

There is a small increase in the risk of serious immediate maternal complications compared with vaginal birth (RR 1.29, 95% CI 1.03 to 1.61), including pulmonary embolism, infection, bleeding, damage to the bladder and bowel, slower recovery from the delivery, longer hospitalization, and delayed bonding and breast-feeding. [ 23 ] [ 31 ] [ 47 ] [ 48 ] [ 49 ] [ 50 ] [ 51 ] [ 52 ] [ 53 ] [ 54 ] [ 55 ] [ 56 ] [ 57 ] [ 58 ] Consider using antimicrobial triclosan-coated sutures for wound closure to reduce the risk of surgical site infection. [ 59 ]

Planned cesarean section is safer for babies, but is associated with increased neonatal respiratory distress. The risk is reduced when the section is performed at 39 weeks' gestation. [ 64 ] [ 65 ] [ 66 ] For women undergoing a planned cesarean section, RCOG recommends an informed discussion about the potential risks and benefits of a course of prenatal corticosteroids between 37 and 38+6 weeks' gestation. Although prenatal corticosteroids may reduce admission to the neonatal unit for respiratory morbidity, it is uncertain if there is any reduction in respiratory distress syndrome, transient tachypnea of the newborn, or neonatal unit admission overall. In addition, prenatal corticosteroids may result in harm to the neonate, including hypoglycemia and potential developmental delay. [ 32 ] ACOG does not recommend corticosteroids in women >37 weeks' gestation. [ 33 ]

Undiagnosed breech in labor generally results in cesarean section after the onset of labor, higher rates of emergency cesarean section associated with the least favorable maternal outcomes, a greater likelihood of cord prolapse, and other poor infant outcomes. [ 23 ] [ 67 ] [ 49 ] [ 68 ] [ 69 ] [ 70 ] [ 71 ]

This mode of delivery may be considered by some clinicians as an option for women who are in labor, particularly when delivery is imminent. Vaginal breech delivery may also be considered, where suitable, when delivery is not imminent, maternal request is provided, senior and experienced staff are available, there is no absolute contraindication to vaginal birth (e.g., placenta previa, compromised fetal condition), and with optimal fetal growth (estimated weight above the tenth centile and up to 3800 g). Other factors that make planned vaginal birth higher risk include hyperextended neck on ultrasound and footling presentation. [ 24 ]

Findings from one systematic review of 27 observational studies revealed that the absolute risks of perinatal mortality, fetal neurologic morbidity, birth trauma, 5-minute Apgar score <7, and neonatal asphyxia in the planned vaginal delivery group were low at 0.3%, 0.7%, 0.7%, 2.4%, and 3.3%, respectively. However, the relative risks of perinatal mortality and morbidity were 2- to 5-fold higher in the planned vaginal than in the planned cesarean delivery group. Authors recommend ongoing judicious decision-making for vaginal breech delivery for selected singleton, term breech babies. [ 72 ]

ECV may also be considered an option for women with breech presentation in early labor, when delivery is not imminent, provided that the membranes are intact.

A woman presenting with a breech presentation <37 weeks is an area of clinical controversy. Optimal mode of delivery for preterm breech has not been fully evaluated in clinical trials, and the relative risks for the preterm infant and mother remain unclear. In the absence of good evidence, if diagnosis of breech presentation prior to 37 weeks' gestation is made, prematurity and clinical circumstances should determine management and mode of delivery.

Primary Options

12 mg intramuscularly every 24 hours for 2 doses

6 mg intramuscularly every 12 hours for 4 doses

The UK Royal College of Obstetricians and Gynaecologists recommends that corticosteroids should be offered to women between 24 and 34+6 weeks' gestation, in whom imminent preterm birth is anticipated. Corticosteroids should only be considered after discussion of risks/benefits at 35 to 36+6 weeks. Given within 7 days of preterm birth, corticosteroids may reduce perinatal and neonatal death and respiratory distress syndrome. [ 32 ]

The American College of Obstetricians and Gynecologists recommends a single course of corticosteroids for pregnant women between 24 and 33+6 weeks' gestation who are at risk of preterm delivery within 7 days, including those with ruptured membranes and multiple gestations. It may also be considered for pregnant women starting at 23 weeks' gestation who are at risk of preterm delivery within 7 days. A single course of betamethasone is recommended for pregnant women between 34 and 36+6 weeks' gestation at risk of preterm birth within 7 days, and who have not received a previous course of prenatal corticosteroids. Regularly scheduled repeat courses or serial courses (more than two) are not currently recommended. A single repeat course of prenatal corticosteroids should be considered in women who are less than 34 weeks' gestation, who are at risk of preterm delivery within 7 days, and whose prior course of prenatal corticosteroids was administered more than 14 days previously. Rescue course corticosteroids could be provided as early as 7 days from the prior dose, if indicated by the clinical scenario. [ 33 ]

consult specialist for guidance on dose

external cephalic version (ECV)

There is no upper time limit on the appropriate gestation for ECV; it should be offered to all women in late pregnancy by an experienced clinician in hospitals with facilities for emergency delivery and no contraindications to the procedure. [ 35 ] [ 36 ]

ECV involves applying external pressure and firmly pushing or palpating the mother's abdomen to coerce the fetus to somersault (either forward or backward) into a cephalic position. [ 37 ]

Cardiotocography and ultrasound should be performed before and after the procedure.

If ECV is successful, pregnancy care should continue as usual for any cephalic presentation. A systematic review assessing the mode of delivery after a successful ECV found that these women were at increased risk for cesarean section and instrumental vaginal delivery compared with women with spontaneous cephalic pregnancies. However, they still had a lower rate of cesarean section following ECV (i.e., 47%) compared with the cesarean section rate for those with a persisting breech (i.e., 85%). With a number needed to treat of 3, ECV is still considered to be an effective means of preventing the need for cesarean section. [ 46 ]

tocolytic agents

see local specialist protocol for dosing guidelines

Tocolytic agents include adrenergic beta-2 receptor stimulants such as albuterol, terbutaline, or ritodrine (widely used with external cephalic version [ECV] in some countries, but not yet available in the US). They are used to delay or inhibit labor and increase the success rate of ECV. There is no current evidence to recommend one beta-2 adrenergic receptor agonist over another. Until these data are available, adherence to a local protocol for tocolysis is recommended.

The Food and Drug Administration has issued a warning against using injectable terbutaline beyond 48-72 hours, or acute or prolonged treatment with oral terbutaline, in pregnant women for the prevention or prolonged treatment of preterm labor, due to potential serious maternal cardiac adverse effects and death. [ 44 ] Whether this warning applies to the subcutaneous administration of terbutaline in ECV is still unclear; however, studies currently support this use. The European Medicines Agency (EMA) recommends that injectable beta agonists should be used for up to 48 hours between the 22nd and 37th week of pregnancy only. They should be used under specialist supervision with continuous monitoring of the mother and unborn baby owing to the risk of adverse cardiovascular effects in both the mother and baby. The EMA no longer recommends oral or rectal formulations for obstetric indications. [ 45 ]

A systematic review found there was no evidence to support the use of nifedipine for tocolysis. [ 73 ]

There is insufficient evidence to evaluate other interventions to help ECV, such as fetal acoustic stimulation in midline fetal spine positions, or epidural or spinal analgesia. [ 43 ]

Rho(D) immune globulin

300 micrograms intramuscularly as a single dose

Nonsensitized Rh-negative women should receive Rho(D) immune globulin. [ 35 ]

The indication for its administration is to prevent rhesus isoimmunization, which may affect subsequent pregnancy outcomes.

Rho(D) immune globulin needs to be given at the time of external cephalic version and should be given again postpartum to those women who give birth to an Rh-positive baby. [ 74 ]

It is best administered as soon as possible after the procedure, usually within 72 hours.

Dose depends on brand used. Dose given below pertains to most commonly used brands. Consult specialist for further guidance on dose.

elective cesarean section/vaginal breech delivery

Mode of delivery (cesarean section or vaginal breech delivery) should be based on the experience of the attending clinician, hospital policies, maternal request, and the presence or absence of complicating factors. In the US, most unsuccessful external cephalic version (ECV) with persistent breech will be delivered via cesarean section.

Cesarean section, at 39 weeks or greater, has been shown to significantly reduce perinatal mortality and neonatal morbidity compared with vaginal breech delivery (RR 0.33, 95% CI 0.19 to 0.56). [ 31 ] Although safer for these babies, there is a small increase in serious immediate maternal complications compared with vaginal birth (RR 1.29, 95% CI 1.03 to 1.61), as well as long-term risks for future pregnancies, including pulmonary embolism, bleeding, infection, damage to the bladder and bowel, slower recovery from the delivery, longer hospitalization, and delayed bonding and breast-feeding. [ 23 ] [ 31 ] [ 47 ] [ 48 ] [ 49 ] [ 50 ] [ 51 ] [ 52 ] [ 53 ] [ 54 ] [ 55 ] [ 56 ] [ 57 ] [ 58 ] Consider using antimicrobial triclosan-coated sutures for wound closure to reduce the risk of surgical site infection. [ 59 ]

Vaginal delivery may be considered by some clinicians as an option, particularly when maternal request is provided, when senior and experienced staff are available, when there is no absolute contraindication to vaginal birth (e.g., placenta previa, compromised fetal condition), and with optimal fetal growth (estimated weight above the tenth centile and up to 3800 g). Other factors that make planned vaginal birth higher risk include hyperextended neck on ultrasound and footling presentation. [ 24 ]

For women undergoing a planned cesarean section, the UK Royal College of Obstetricians and Gynaecologists recommends an informed discussion about the potential risks and benefits of a course of prenatal corticosteroids between 37 and 38+6 weeks' gestation. Although prenatal corticosteroids may reduce admission to the neonatal unit for respiratory morbidity, it is uncertain if there is any reduction in respiratory distress syndrome, transient tachypnea of the newborn, or neonatal unit admission overall. In addition, prenatal corticosteroids may result in harm to the neonate, including hypoglycemia and potential developmental delay. [ 32 ] The American College of Obstetricians and Gynecologists does not recommend corticosteroids in women >37 weeks' gestation. [ 33 ]

It is best administered as soon as possible after delivery, usually within 72 hours.

Administration of postpartum Rho (D) immune globulin should not be affected by previous routine prenatal prophylaxis or previous administration for a potentially sensitizing event. [ 74 ]

≥37 weeks' gestation in labor: no imminent delivery

planned cesarean section

For women with breech presentation in labor, planned cesarean section at 39 weeks or greater has been shown to significantly reduce perinatal mortality and neonatal morbidity compared with vaginal breech delivery (RR 0.33, 95% CI 0.19 to 0.56). [ 31 ]

Although safer for these babies, there is a small increase in serious immediate maternal complications compared with vaginal birth (RR 1.29, 95% CI 1.03 to 1.61), as well as long-term risks for future pregnancies, including pulmonary embolism, infection, bleeding, damage to the bladder and bowel, slower recovery from the delivery, longer hospitalization, and delayed bonding and breast-feeding. [ 23 ] [ 31 ] [ 47 ] [ 48 ] [ 49 ] [ 50 ] [ 51 ] [ 52 ] [ 53 ] [ 54 ] [ 55 ] [ 56 ] [ 57 ] [ 58 ] Consider using antimicrobial triclosan-coated sutures for wound closure to reduce the risk of surgical site infection. [ 59 ]

Continuous cardiotocography monitoring should continue until delivery. [ 24 ] [ 25 ]

vaginal breech delivery

This mode of delivery may be considered by some clinicians as an option, particularly when maternal request is provided, when senior and experienced staff are available, when there is no absolute contraindication to vaginal birth (e.g., placenta previa, compromised fetal condition), and with optimal fetal growth (estimated weight above the tenth centile and up to 3800 g). Other factors that make planned vaginal birth higher risk include hyperextended neck on ultrasound and footling presentation. [ 24 ]

For women with persisting breech presentation, planned cesarean section has, however, been shown to significantly reduce perinatal mortality and neonatal morbidity compared with vaginal breech delivery (RR 0.33, 95% CI 0.19 to 0.56). [ 31 ]

ECV may also be considered an option for women with breech presentation in early labor, provided that the membranes are intact.

There is no upper time limit on the appropriate gestation for ECV. [ 35 ]

Involves applying external pressure and firmly pushing or palpating the mother's abdomen to coerce the fetus to somersault (either forward or backward) into a cephalic position. [ 37 ]

Relative contraindications include placental abruption, severe preeclampsia/HELLP syndrome, and signs of fetal distress (abnormal cardiotocography and/or abnormal Doppler flow). [ 35 ] [ 36 ]

Rho(D) immune globulin needs to be given at the time of ECV and should be given again postpartum to those women who give birth to an Rh-positive baby. [ 74 ]

≥37 weeks' gestation in labor: imminent delivery

cesarean section

For women with persistent breech presentation, planned cesarean section has been shown to significantly reduce perinatal mortality and neonatal morbidity compared with vaginal breech delivery (RR 0.33, 95% CI 0.19 to 0.56). [ 31 ] Although safer for these babies, there is a small increase in serious immediate maternal complications compared with vaginal birth (RR 1.29, 95% CI 1.03 to 1.61), as well as long-term risks for future pregnancies, including pulmonary embolism, infection, bleeding, damage to the bladder and bowel, slower recovery from the delivery, longer hospitalization, and delayed bonding and breast-feeding. [ 23 ] [ 31 ] [ 47 ] [ 48 ] [ 49 ] [ 50 ] [ 51 ] [ 52 ] [ 53 ] [ 54 ] [ 55 ] [ 56 ] [ 57 ] [ 58 ] Consider using antimicrobial triclosan-coated sutures for wound closure to reduce the risk of surgical site infection. [ 59 ]

This mode of delivery may be considered by some clinicians as an option, particularly when delivery is imminent, maternal request is provided, when senior and experienced staff are available, when there is no absolute contraindication to vaginal birth (e.g., placenta previa, compromised fetal condition), and with optimal fetal growth (estimated weight above the tenth centile and up to 3800 g). Other factors that make planned vaginal birth higher risk include hyperextended neck on ultrasound and footling presentation. [ 24 ]

It is best administered as soon as possible after the delivery, usually within 72 hours.

External cephalic version before term

Moxibustion, postural management, follow-up overview, perinatal complications.

Compared with cephalic presentation, persistent breech presentation has increased frequency of cord prolapse, abruptio placentae, prelabor rupture of membranes, perinatal mortality, fetal distress (heart rate <100 bpm), preterm delivery, lower fetal weight. [ 10 ] [ 11 ] [ 67 ]

complications of cesarean section

The long-term risks include potential compromise of future obstetric performance, increased risk of repeat cesarean section, infertility, uterine rupture, placenta accreta, placental abruption, and emergency hysterectomy. [ 60 ] [ 61 ] [ 62 ] [ 63 ] The evidence suggests that using sutures, rather than staples, for wound closure after cesarean section reduces the incidence of wound dehiscence. [ 59 ]

Emergency cesarean section, compared with planned cesarean section, has demonstrated a higher risk of severe obstetric morbidity, intra-operative complications, postoperative complications, infection, blood loss >1500 mL, fever, pain, tiredness, and breast-feeding problems. [ 23 ] [ 48 ] [ 50 ] [ 70 ] [ 81 ]

Key Articles

Impey LWM, Murphy DJ, Griffiths M, et al; Royal College of Obstetricians and Gynaecologists. Management of breech presentation: green-top guideline no. 20b. BJOG. 2017 Jun;124(7):e151-77. [Full Text]

Hofmeyr GJ, Hannah M, Lawrie TA. Planned caesarean section for term breech delivery. Cochrane Database Syst Rev. 2015 Jul 21;(7):CD000166. [Abstract] [Full Text]

Royal College of Obstetricians and Gynaecologists. External cephalic version and reducing the incidence of term breech presentation. March 2017 [internet publication]. [Full Text]

Cluver C, Gyte GM, Sinclair M, et al. Interventions for helping to turn term breech babies to head first presentation when using external cephalic version. Cochrane Database Syst Rev. 2015 Feb 9;(2):CD000184. [Abstract] [Full Text]

de Hundt M, Velzel J, de Groot CJ, et al. Mode of delivery after successful external cephalic version: a systematic review and meta-analysis. Obstet Gynecol. 2014 Jun;123(6):1327-34. [Abstract]

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73. Wilcox C, Nassar N, Roberts C. Effectiveness of nifedipine tocolysis to facilitate external cephalic version: a systematic review. BJOG. 2011 Mar;118(4):423-8. [Abstract]

74. Qureshi H, Massey E, Kirwan D, et al. BCSH guideline for the use of anti-D immunoglobulin for the prevention of haemolytic disease of the fetus and newborn. Transfus Med. 2014 Feb;24(1):8-20. [Abstract] [Full Text]

75. Hutton EK, Hofmeyr GJ, Dowswell T. External cephalic version for breech presentation before term. Cochrane Database Syst Rev. 2015 Jul 29;(7):CD000084. [Abstract] [Full Text]

76. Coyle ME, Smith CA, Peat B. Cephalic version by moxibustion for breech presentation. Cochrane Database Syst Rev. 2012 May 16;(5):CD003928. [Abstract] [Full Text]

77. Hofmeyr GJ, Kulier R. Cephalic version by postural management for breech presentation. Cochrane Database Syst Rev. 2012 Oct 17;(10):CD000051. [Abstract] [Full Text]

78. Hannah ME, Whyte H, Hannah WJ, et al. Maternal outcomes at 2 years after planned cesarean section versus planned vaginal birth for breech presentation at term: the International Randomized Term Breech Trial. Am J Obstet Gynecol. 2004 Sep;191(3):917-27. [Abstract]

79. Eide MG, Oyen N, Skjaerven R, et al. Breech delivery and Intelligence: a population-based study of 8,738 breech infants. Obstet Gynecol. 2005 Jan;105(1):4-11. [Abstract]

80. Whyte H, Hannah ME, Saigal S, et al. Outcomes of children at 2 years after planned cesarean birth versus planned vaginal birth for breech presentation at term: the International Randomized Term Breech Trial. Am J Obstet Gynecol. 2004 Sep;191(3):864-71. [Abstract]

81. Brown S, Lumley J. Maternal health after childbirth: results of an Australian population based survey. Br J Obstet Gynaecol. 1998 Feb;105(2):156-61. [Abstract]

Published by

American College of Obstetricians and Gynecologists

2016 (reaffirmed 2022)

Royal College of Obstetricians and Gynaecologists (UK)

National Institute for Health and Care Excellence (UK)

Topic last updated: 2024-03-05

Natasha Nassar , PhD

Associate Professor

Menzies Centre for Health Policy

Sydney School of Public Health

University of Sydney

Christine L. Roberts , MBBS, FAFPHM, DrPH

Research Director

Clinical and Population Health Division

Perinatal Medicine Group

Kolling Institute of Medical Research

Jonathan Morris , MBChB, FRANZCOG, PhD

Professor of Obstetrics and Gynaecology and Head of Department

Peer Reviewers

John W. Bachman , MD

Consultant in Family Medicine

Department of Family Medicine

Mayo Clinic

Rhona Hughes , MBChB

Lead Obstetrician

Lothian Simpson Centre for Reproductive Health

The Royal Infirmary

Brian Peat , MD

Director of Obstetrics

Women's and Children's Hospital

North Adelaide

South Australia

Lelia Duley , MBChB

Professor of Obstetric Epidemiology

University of Leeds

Bradford Institute of Health Research

Temple Bank House

Bradford Royal Infirmary

Justus Hofmeyr , MD

Head of the Department of Obstetrics and Gynaecology

East London Private Hospital

East London

South Africa

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

, MD, Children's Hospital of Philadelphia

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Abnormal fetal lie or presentation may occur due to fetal size, fetal anomalies, uterine structural abnormalities, multiple gestation, or other factors. Diagnosis is by examination or ultrasonography. Management is with physical maneuvers to reposition the fetus, operative vaginal delivery Operative Vaginal Delivery Operative vaginal delivery involves application of forceps or a vacuum extractor to the fetal head to assist during the second stage of labor and facilitate delivery. Indications for forceps... read more , or cesarean delivery Cesarean Delivery Cesarean delivery is surgical delivery by incision into the uterus. The rate of cesarean delivery was 32% in the United States in 2021 (see March of Dimes: Delivery Method). The rate has fluctuated... read more .

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

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

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

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

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

Abnormal fetal lie, presentation, or position may occur with

Fetopelvic disproportion (fetus too large for the pelvic inlet)

Fetal congenital anomalies

Uterine structural abnormalities (eg, fibroids, synechiae)

Multiple gestation

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

Transverse lie

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

Breech presentation

There are several types of breech presentation.

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

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

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

Types of breech presentations

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

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

Predisposing factors for breech presentation include

Preterm labor Preterm Labor Labor (regular uterine contractions resulting in cervical change) that begins before 37 weeks gestation is considered preterm. Risk factors include prelabor rupture of membranes, uterine abnormalities... read more

Multiple gestation Multifetal Pregnancy Multifetal pregnancy is presence of > 1 fetus in the uterus. Multifetal (multiple) pregnancy occurs in up to 1 of 30 deliveries. Risk factors for multiple pregnancy include Ovarian stimulation... read more

Uterine abnormalities

Fetal anomalies

If delivery is vaginal, breech presentation may increase risk of

Umbilical cord prolapse

Perinatal death

It is best to detect abnormal fetal lie or presentation before delivery. During routine prenatal care, clinicians assess fetal lie and presentation with physical examination in the late third trimester. Ultrasonography can also be done. If breech presentation is detected, external cephalic version can sometimes move the fetus to vertex presentation before labor, usually at 37 or 38 weeks. This technique involves gently pressing on the maternal abdomen to reposition the fetus. A dose of a short-acting tocolytic ( terbutaline 0.25 mg subcutaneously) may help. The success rate is about 50 to 75%. For persistent abnormal lie or presentation, cesarean delivery is usually done at 39 weeks or when the woman presents in labor.

Face or brow presentation

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

Brow presentation usually converts spontaneously to vertex or face presentation.

Occiput posterior position

The most common abnormal position is occiput posterior.

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

Progress may arrest in the second phase of labor. Operative vaginal delivery Operative Vaginal Delivery Operative vaginal delivery involves application of forceps or a vacuum extractor to the fetal head to assist during the second stage of labor and facilitate delivery. Indications for forceps... read more or cesarean delivery Cesarean Delivery Cesarean delivery is surgical delivery by incision into the uterus. The rate of cesarean delivery was 32% in the United States in 2021 (see March of Dimes: Delivery Method). The rate has fluctuated... read more is often required.

Position and Presentation of the Fetus

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

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

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

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IN THIS TOPIC

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

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

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

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

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

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

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

Developer declaration of interests:

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

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

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

Dr LK Penna: None declared.

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

This page was last reviewed 16 March 2017.

Open access
Published: 03 May 2020

Revisiting the management of term breech presentation: a proposal for overcoming some of the controversies

Lionel Carbillon ORCID: orcid.org/0000-0001-6367-4828 1 , 2 ,
Amelie Benbara 2 ,
Ahmed Tigaizin 2 ,
Rouba Murtada 2 ,
Marion Fermaut 2 ,
Fatma Belmaghni 2 ,
Alexandre Bricou 2 &
Jeremy Boujenah 2

BMC Pregnancy and Childbirth volume 20 , Article number: 263 ( 2020 ) Cite this article

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The debate surrounding the management of term breech presentation has excessively focused on the mode of delivery. Indeed, a steady decline in the rate of vaginal breech delivery has been observed over the last three decades, and the soundness of the vaginal route was seriously challenged at the beginning of the 2000s. However, associations between adverse perinatal outcomes and antenatal risk factors have been observed in foetuses that remain in the breech presentation in late gestation, confirming older data and raising the question of the role of these antenatal risk factors in adverse perinatal outcomes. Thus, aspects beyond the mode of delivery must be considered regarding the awareness and adequate management of such situations in term breech pregnancies.

In the context of the most recent meta-analysis and with the publication of large-scale epidemiologic studies from medical birth registries in countries that have not abruptly altered their criteria for individual decision-making regarding the breech delivery mode, the currently available data provide essential clues to understanding the underlying maternal-foetal conditions beyond the delivery mode that play a role in perinatal outcomes, such as foetal growth restriction and gestational diabetes mellitus. In view of such data, an accurate evaluation of these underlying conditions is necessary in cases of persistent term breech presentation. Timely breech detection, estimated foetal weight/growth curves and foetal/maternal well-being should be considered along with these possible antenatal risk factors; a thorough analysis of foetal presentation and an evaluation of the possible benefit of external cephalic version and pelvic adequacy in each specific situation of persistent breech presentation should be performed.

The adequate management of term breech pregnancies requires screening and the efficient identification of breech presentation at 36 weeks of gestation, followed by thorough evaluations of foetal weight, growth and mobility, while obstetric history, antenatal gestational disorders and pelvis size/conformation are considered. The management plan, including external cephalic version and follow-up based on the maternal/foetal condition and potentially associated disorders, should be organized on a case-by-case basis by a skilled team after the woman is informed and helped to make a reasoned decision regarding delivery route.

Peer Review reports

The ideal management of women with term breech presentation remains a matter of intense debate. The rate of vaginal delivery has steadily declined in the last decades of the last century [ 1 ]. In 2000, the Term Breech Trial (TBT) Collaborative Group concluded that a composite variable combining perinatal and neonatal mortality or serious neonatal morbidity was significantly lower in the planned caesarean section (CS) group than in the planned vaginal birth group [ 2 ], which marked an apparent turning point in this controversy. Based on the short-term outcomes presented in the TBT study, the Royal College of Obstetricians and Gynaecologists (RCOG) [ 3 ] and the American College of Obstetricians and Gynecologists (ACOG) [ 4 ] recommended over the next few years that all women with persistent singleton breech presentation at term should undergo a planned CS delivery. An important and almost immediate impact on the practice was also observed in some countries that previously had a high proportion of vaginal breech deliveries [ 5 ]. TBT was the largest randomized trial ever published on the term breech mode of delivery. However, despite its undeniable strengths, a number of weaknesses have been identified. Specifically, there was a lack of adherence to strict criteria for vaginal birth in an important proportion of the included patients and nonoptimal methods of labour management as recognized by the TBT group itself [ 6 , 7 , 8 ]. In addition, when the TBT Collaborative Group published the 2-year analysis of paediatric outcomes, despite a large (greater than 50%) post-randomization loss to follow-up [ 9 ], these researchers found no reduction in the risk of death or neurodevelopmental delay in children at 2 years of age, thus raising questions regarding the real lessons to be drawn from this trial. Using multiple logistic regression analyses, the TBT group also reported [ 10 ] that the risk of maternal morbidity was lowest following vaginal birth (odds ratio [OR] 1.0) and highest following CS after active labour (36.1% in the TBT) (OR 3.33; 95% CI 1.75–6.33, P < 0.001), particularly after a short second stage < 30 min (OR 0.25; 95% CI 0.11–0.57, P < 0.001) [ 9 ].

Later, population-based retrospective studies helped refine the consequences of applying recommendations of systematically planned CS for women with term breech presentation at the population level. Hartnack Tharin et al. [ 11 ] found that the rate of CS for term breech deliveries increased from 79.6 to 94.2% between 1997 and 2008 in Denmark, while intrapartum or early neonatal mortality decreased from 0.13 to 0.05% [relative risk (RR) 0.38 (95% CI 0.15–0.98)], which was a significant but lower reduction than the difference reported in the TBT. Using the Dutch National Perinatal Registry from 1999 to 2007, Vlemmix et al. [ 12 ] stated that after publication of the TBT, the elective CS rate increased from 24 to 60%, and overall perinatal mortality and short-term morbidity decreased. In contrast, these outcomes remained stable in the planned vaginal birth group. However, the authors estimated that 338 CS deliveries would need to be performed to prevent one perinatal death, and Schutte et al. [ 13 ] estimated the perinatal case fatality rate for elective CS for breech presentation in 2000–2002 at 0.47/1000 operations. At the same time, in the Netherlands the incidence of severe maternal morbidity (SMM) was estimated at 6.4/1000 during an elective CS compared with 3.9/1000 during an attempted vaginal delivery (OR 1.7; 95% CI 1.4–2.0), with an increased risk for SMM in the next pregnancy (OR 3.0; 95% CI 2.7–3.3) [ 14 ], despite the numerous facilities and adequate resources allocated to perinatal care in such a high-income country.

On the other hand, new guidelines were published in 2009 by the Society of Obstetricians and Gynaecologists of Canada (SOGC) stating that “planned vaginal delivery is reasonable in selected women with a term singleton breech foetus”. Afterwards, a study [ 15 ] including 52,671 breech deliveries in Canada (2003–2011) reported in 2011 that vaginal deliveries increased from 2.7% in 2003 to 3.9%. In this study, a concomitant increase in composite neonatal mortality and morbidity rates was observed with an adjusted rate ratio of 3.60 (95% CI 2.50–5.15), compared with CS without labour [ 15 ]. Moreover, CS with labour also increased from 8.7 to 9.8%, highlighting the particular difficulty in returning to previous practices after the clinical skills required to conduct a vaginal breech delivery have declined [ 15 , 16 ].

Some authors recently considered that “the TBT recommendations should be withdrawn” [ 6 ], while others still consider that the “results (of the TBT) are generalizable” [ 16 , 17 ]. Nevertheless, national guideline bodies have partially reversed their recommendations based on these discussions [ 18 , 19 , 20 ]. However, as rightly noted by Joseph et al. [ 16 ], the availability of clinical skills has declined in some of these countries, raising concerns from a pedagogic resident education and training standpoint [ 16 ]. In this regard, a meaningful role could be given to the possibility of training by simulation in building and maintaining specific skills and competencies for vaginal breech delivery.

A new meta-analysis [ 21 ] and several large-scale epidemiologic datasets from medical birth registries [ 22 , 23 , 24 ] recently evaluated risk factors associated with adverse perinatal outcomes in planned vaginal breech labours at term. These investigations were conducted in countries that have not abruptly modified their policies and that have continuously applied similar strict criteria over the last several decades for individual decision-making in cases of term breech presentation. We believe that the time has come to go beyond the sole question of delivery mode in the management of these situations.

Term breech presentation: are we asking the right questions?

It now appears time to expand our thinking and, considering recent important data that help elucidate the underlying significance of persistent breech presentation at term, to offer more dynamic and multidisciplinary insight into the management of these cases.

Indeed, similar to some older studies [ 25 , 26 , 27 ], several recent population-based studies [ 22 , 23 ] strongly suggest that the increased risk observed in foetuses that remain in the breech presentation at term is closely linked to antenatal or underlying disorders that may be associated with the breech presentation and is not solely due to the mode of delivery. Because adverse outcomes can be caused by underlying or gestational disorders, any discussion that is limited to delivery mode seems too restrictive and does not address the whole issue.

Most recent large-scale data

Deterministic or accidental breech presentation.

In a recent Finnish population-based case-control study including all singleton deliveries from 1 January 2005 to 31 December 2014 and excluding preterm deliveries, antepartum-diagnosed stillbirths, placenta previa and infants with congenital malformations (499,206 foetuses at term), Macharey et al. [ 22 ] evaluated the antenatal risk factors associated with adverse perinatal outcomes in planned vaginal breech labour at term. They found that the stillbirth rate was significantly higher in cases of planned vaginal breech labour than in cases of cephalic presentation (0.2 vs 0.1%, respectively), which was correlated with foetal growth restriction, oligohydramnios, gestational diabetes mellitus (GDM) and a history of CS. Furthermore, in another recent survey based on the same cohort of mother-neonate dyads that also excluded congenital malformations, placenta previa and prelabour stillbirths [ 23 ], this same group showed that breech presentation at term was significantly associated with antenatal stillbirth and a number of individual obstetric risk factors for adverse perinatal outcomes, including oligohydramnios, foetal growth restriction, gestational diabetes, history of CS section and congenital anomalies. Among all planned singleton vaginal deliveries with the foetus in the breech presentation at term, a composite adverse perinatal outcome defined as umbilical arterial pH < 7.00, 5-min Apgar score below 7 and/or neonatal mortality during the first 6 days of life (excluding stillbirth) was associated with foetal growth restriction (aOR 2.94 [1.30–6.67]), oligohydramnios (adjusted OR 2.94 [1.15–7.81]), gestational diabetes (aOR 2.89[1.54–5.40]), and a history of CS (aOR 2.94 [1.28–6.77]).

In another recent population-based study based on perinatal data of all (650,968) children born in Norway from 1999 to 2009 [ 24 ], the authors recognized the limitations of most registry-based studies, as the selection of women with breech presentation and planned vaginal delivery was based on criteria that might have identified pregnancies with a lower risk of adverse outcomes compared with those selected for CS delivery. Moreover, in this study [ 24 ], the intrapartum conversion of some of the planned vaginal deliveries to an emergency CS delivery may have increased the risk for adverse outcome in the CS group. However, Bjellmo et al. [ 24 ] conducted an innovative analysis comparing breech deliveries to vaginal cephalic births. Thus, they showed that singleton children born at term without congenital malformations had a higher risk for stillbirth and neonatal mortality if they were born in the breech presentation “regardless of whether they were born vaginally or by CS delivery” (0.9 per 1000 in those actually delivered vaginally and 0.8 per 1000 in those actually born by CS delivery) compared with those born by vaginal cephalic delivery (0.3 per 1000). Of note, among those children born in the breech rather than in the cephalic presentation, these authors [ 24 ] found that a higher proportion of infants were born small for gestational age (SGA). However, these authors [ 23 ] did not distinguish foetal growth restriction among SGA neonates. In their interpretation, Bjellmo et al. [ 23 ] considered that “the overall higher risk for stillbirth and the higher proportion of infants born SGA among children born in the breech than in the cephalic presentation may suggest that foetuses with antenatal acquired risk factors for adverse outcomes are more likely to present in the breech than in the cephalic presentation at birth.” According to these authors, the findings were most likely explained by a combination of antenatal acquired risk factors for neonatal death with increased vulnerability to the birth process. Of note, in the TBT group, birth weights of less than 2.8 kg were also associated with adverse perinatal outcomes ( P = 0.003) [ 10 ]. In fact, a limitation in the Norwegian study [ 24 ] was that, unlike Macharey et al., the authors did not distinguish foetal growth restriction among these SGA neonates. Indeed, in a large cohort study conducted with the National Health Service region in England through a multivariable analysis of 92,218 normally formed singletons delivered during 2009–2011 from 24 weeks of gestation, including 389 stillbirths, Gardosi et al. [ 25 ] showed that foetal growth restriction had the largest population attributable risk for stillbirth which was fivefold greater if it was not detected antenatally than when it was (32.0% v 6.2%). The above data suggest that some antenatal features associated with term breech presentation, notably foetal growth restriction, and some gestational disorders (such as uncontrolled gestational diabetes mellitus) could affect the prognosis in term breech cases. Previous data also support this conclusion; Luterkort M et al. [ 26 ] had previously reported in a prospective follow-up of 228 pregnancies with the foetus in the breech presentation in the 33rd gestational week that the 96 foetuses (42%) who remained in the breech presentation at delivery weighed 4.9% less than their vertex controls after adjustments were made for gestational age and had an increased frequency of oligohydramnios. Krebs et al. [ 27 ] later confirmed this association between breech presentation and foetal growth restriction from a register-based, case-control cohort of infants with cerebral palsy born between 1979 and 1986 in East Denmark.

In fact, as reported by Fox and Chapman [ 28 ], up to 21% of all foetuses adopt a noncephalic presentation at 28–29 weeks of gestation, and this proportion progressively decreases to 5% from 37 to 38 weeks [ 28 ]. Certain conditions, such as uterine malformation, can disturb both this continuous process of spontaneous cephalic version and normal foetal growth, thereby leading to increased term breech presentation rates in these cases [ 29 ]. This point highlights the importance of estimating foetal weight and well-being in cases of persistent breech presentation at term. Furthermore, even some cases of controlled GDM may be associated with excess foetal weight during the last weeks of pregnancy, leading to possible dystocia due to this overgrowth, or with other GDM-related complications, such as preeclampsia; thus, foetal weight estimates should be monitored closely beginning in the 37th week of gestation, with regular reassessment as long as the patient has not delivered.

The impact of strict criteria on the selection of vaginal delivery

From a broad perspective, in the most recent meta-analysis investigating the risks of planned vaginal breech delivery versus planned CS for term breech birth [ 21 ], the overall heterogeneity (I 2 = 36%) was informative. The variability of neonatal mortality among 14 studies accounting for 74,094 breech vaginal deliveries was low (ranging from 0.08 to 0.37%). On the other hand, neonatal mortality was markedly higher in only 2 studies authored by Singh et al. [ 30 ] and Hannah et al. [ 2 ] (the TBT). These two studies [ 2 , 30 ] accounted for 1099 breech vaginal deliveries (1.5% of births) and had perinatal mortality rates as high as 21 and 1.3%, respectively, for planned vaginal births (25.6% of perinatal deaths). The same was true for neurological morbidity, which was 3.4 and 1%, respectively, in the studies by Singh et al. [ 30 ] and TBT [ 2 ], while it ranged from 0.07 to 0.2% in the 14 other studies encompassing 74,094 breech vaginal deliveries conducted with the implementation of more stringent exclusion criteria for vaginal breech delivery.

In these 14 studies accounting for 74,094 breech vaginal deliveries, the retrospective observational cohort study from the Finnish Medical Birth Register [ 31 ] and the prospective observational study PREMODA [ 32 ] (as well as the more recent Norwegian Medical Birth Registry study) applied similar pre-established exclusion criteria for planned vaginal birth. In the PREMODA study, an increased absolute rate of perinatal death or serious neonatal morbidity was observed in both the planned vaginal group (1.60, 95% CI 1.14–2.17) and planned CS delivery group (1.45 [1.16–1.81]) with breech presentation among the total population of 264,105 births, but the planned vaginal group and the planned CS delivery group with breech presentation did not differ significantly for the combined outcome of foetal/neonatal mortality or serious morbidity (odds ratio [OR] = 1.10, 95% CI [0.75–1.61]). The Royal College of Obstetricians and Gynaecologists proposes comparable pre-established criteria for the management of term breech presentation, recommending that “women should be informed that a higher risk of planned vaginal breech birth is expected where there are independent indications for CS section and in circumstances such as a hyperextended neck on ultrasound, high estimated foetal weight (more than 3,800 g), low estimated weight (less than tenth centile), footling presentation, [and] evidence of antenatal foetal compromise” but considers that “the role of pelvimetry is unclear” [ 20 ]. Of note concerning this last point, Van Loon et al. showed in a randomized controlled trial [ 33 ] that the adequacy of pelvis size, as assessed by pelvimetry, improved the selection of delivery route. In line with them, two recent studies support this view [ 34 , 35 ]. Other authors also included criteria for the adequate management and continuous monitoring of foetal heart rate during labour (which is common in maternity wards of most high-income countries but could be monitored intermittently in the TBT). Indeed, decreased variability and late decelerations are more prevalent during breech deliveries than vertex deliveries [ 36 ], and good labour progress is a predictor of better neonatal outcomes [ 37 ]. In the Finnish Medical Birth Register [ 31 ], 1270 women (43.6%) were selected as candidates for vaginal breech delivery, and the selection quality was confirmed by the low conversion rate of vaginal to CS breech delivery (11.4%). This rate was higher (36.1%) in the TBT [ 30 ].

As noted by methodologists [ 38 ], real-world prenatal patient care is subject to decision-making based on the continuous evaluation of risk factors, medical history, comorbidities, behavioural aspects, and other factors that indeed cannot be strictly reproduced in randomized controlled trials. For example, in the TBT [ 2 ], an upper limit of 4000–4500 g was given for estimated foetal weight. However, as the duration between randomization and delivery inevitably lengthened in the planned vaginal delivery group, a significantly higher number of macrosomic neonates were born in the planned vaginal delivery group ( P = 0.002). In actuality, an informed woman who opts for vaginal delivery at 36 or 37 weeks of gestation usually changes her mind if she has not delivered several weeks later and if the clinician tells her that the birthweight will probably exceed 3800–4000 g, with an associated increased risk of adverse perinatal outcomes. Thus, in cases of even minor glycaemic disorder, special attention should be paid in the 37th week of gestation to foetal weight estimates and the possible occurrence of preeclampsia or associated gestational disorders; moreover, cases of SGA foetuses with possible foetal growth restriction should be closely followed, regardless of the delivery mode chosen by the patient [ 26 , 39 ].

How might we maximize patient benefit from a safe external cephalic version attempt?

With the restrictive practice of breech vaginal delivery in the last 15 years, national colleges of obstetricians (RCOG, ACOG, SOGC and RANZCOG) and FIGO updated their guidelines and recommended external cephalic version (ECV) at term to limit the increase in elective CS rate for cases of term breech presentation. However, recent data urge us to develop a broader perspective and an accurate assessment of the real impact of various ECV policies.

Indeed, the true impact of ECV may first be limited by the timely detection of breech presentation. In a retrospective cohort study of 394 consecutive cases of breech presentation at term, Hemelaar et al. [ 40 ] found that over two periods separated by 10 years (1998–1999 and 2008–2009), the proportion of breech presentations not diagnosed antenatally increased from 23.2 to 32.5% ( P = 0.04), causing 52.8% of women who were eligible for ECV to miss an attempt in 2008–2009. The authors also reported that the proportion of women who declined ECV during the same period decreased significantly from 19.1 to 9.0%.

Eligibility is a second limitation. In Australia, a large-scale survey [ 41 ] showed that 22.3% of 32,321 singleton breech pregnancies were considered ineligible (due to oligohydramnios, antepartum haemorrhage or abruption, previous CS or pelvic abnormality, placenta previa, placenta accreta, or an infant with major congenital anomalies). In this survey [ 41 ], only 10.5% of the singleton breech pregnancies had an ECV. In a systematic review, Rosman et al. [ 42 ] identified 60 studies that reported 39 different contraindications and five guidelines with 18 contraindications (varying from five to 13 contraindications per guideline), with oligohydramnios being the only contraindication that was consistently mentioned in all guidelines. Thus, there was no general consensus on the eligibility of patients for ECV, but contraindications generally include all conditions in which this procedure may be associated with a particular risk for the foetus or mother. These conditions include the following: severe intrauterine growth restriction, abnormal umbilical artery Doppler index and/or nonreassuring foetal heart rate, which may require an emergency CS birth; foetuses with a hyperextended head and significant foetal or uterine malformations, which may carry a particular foetal risk; rhesus alloimmunization, which might be reactivated by the procedure; and recent vaginal bleeding or ruptured membranes, which were associated with cord prolapse in 33% of reported cases after ECV attempt [ 43 ].

If CS or rapid delivery is indicated for another obstetric condition, ECV is also contraindicated, notably in cases of placenta previa, severe preeclampsia, and increased risk of placental abruption. Other situations, such as maternal obesity, nonsevere SGA foetuses, and nonsevere oligohydramnios, merely decrease the likelihood of ECV success. In contexts such as severe oligohydramnios or multiple gestations, ECV is simply impracticable, except for a second twin after delivery of the first. Furthermore, previous uterine surgery (CS delivery, myomectomy, or hysteroplasty) is considered a relative contraindication for ECV by some but not all authors [ 44 ]. On the other hand, in patients with gestational diabetes mellitus, incomplete or uncontrolled glucose levels are associated with an increased risk of foetal macrosomia in late pregnancy, and even if the estimated foetal weight seems compatible with a planned vaginal delivery when the mode of delivery is discussed, rapid foetal growth during the last weeks may lead to major difficulties during delivery. Therefore, in such a context, we believe there is potential for a particular benefit from successful ECV at 36 weeks.

Predictors of successful ECV

Pinard previously observed that unengaged breech presentation is an important predictor of successful ECV [ 45 ]; the same observation was made by Lau et al. [ 46 ], Aisenbrey et al. [ 47 ], and Hutton et al. [ 48 ]. In the large series of 1776 ECVs published by Hutton et al. [ 48 ], descent and impaction of the breech foetus were the most discriminating factors for predicting successful ECV, regardless of parity. Other predictors of success include parity [ 45 , 47 , 49 , 50 ], abundant amniotic fluid [ 49 , 50 , 51 ], nonfrank breech presentation [ 47 ], gestational age under 38 weeks [ 43 ], and posterior placenta [ 50 ]. In contrast, nulliparity and tense uterus are associated with a lower likelihood of success [ 44 , 48 , 52 ].

Velzel et al. [ 53 ] recently reviewed prediction models, most of which were developed without any external validation, and found that the most reliable predictors of successful ECV were nonimpacted breech presentation, parity and uterine softness (which usually go hand in hand), normal amniotic fluid index, posterior placental location, and, as noted by Pinard [ 45 ], foetal head in a palpable situation. These criteria might be used to support patient counselling and decision-making about ECV and to reduce the proportion of women declining ECV, particularly in the most favourable situations for ECV.

Obstetric outcomes after an ECV attempt

De Hundt et al. [ 54 ] conducted a systematic review and meta-analysis and showed that women who have had a successful ECV for breech presentation are at increased risk for CS delivery (OR 2.2; 95% CI 1.6–3.0) and instrumental vaginal delivery (OR 1.4; 95% CI 1.1–1.7) compared with women with spontaneous cephalic presentation. Interestingly, stratification by time delay between successful ECV and delivery revealed a trend for increased risk of CS during the first week after ECV [ 55 ]. Furthermore, in a cohort of 301 women with successful ECV, De Hundt et al. [ 56 ] found that nulliparity was the only of seven factors that predicted the risk of CS and instrumental vaginal delivery (OR 2.7; 95% CI 1.2–6.1). Based on a retrospective, population-based cohort study using the CDC’s birth data files from the US in 2006, Balayla et al. [ 57 ] also showed that relative to breech controls without an ECV attempt, cases of ECV failure with persistent breech presentation and labour attempts were associated with increased odds of CS delivery (adjusted OR 1.38; 95% CI 1.21–1.57), assisted ventilation at birth (aOR 1.50; 95% CI 1.27–1.78), 5-min Apgar score < 7 (aOR 1.35; 95% CI 1.20–1.51), and neonatal intensive care unit admission (aOR 1.48; 95% CI 1.20–1.82).

This information should also be considered in the dialog with women regarding the way in which late pregnancy and delivery should be managed based on existing data, their own situations and their wishes.

The true benefit of an active and systematic ECV policy is widely appreciated [ 58 , 59 ], and such evaluation may be subject to bias. Burgos et al. [ 58 ] found that their policy decreased the rate of breech presentation at delivery by 39.0% and decreased the CS rate for cases of breech presentation at term from 59 to 44%. On the other hand, Coppola et al. [ 59 ] reported that their CS rate was not significantly reduced in the planned ECV group, even after adjustments were made for age, parity and previous CS delivery. Thus, each perinatal centre should implement an appropriate and coherent policy in accordance with the prevalence of pathologies in the population.

Towards a consensus for a global shared vision and management of term breech presentation that could include the following

A policy of breech presentation screening at 36 weeks of gestation is efficient and cost effective [ 60 ].

Such screening should allow timely ECV and a careful evaluation of potential underlying antenatal risks, considering obstetric history, estimated foetal weight/growth and potential gestational disorders [ 23 , 24 , 25 , 26 , 27 , 29 ].

Foetal weight estimates based on clinical and ultrasound examinations are essential, despite the large confidence interval of all available algorithms for producing such estimates. Vaginal birth may be excluded when the estimated foetal weight approximates the upper limit used for selection in most national guidelines (3800 g) [ 18 , 19 , 20 ], particularly in the absence of previous successful vaginal delivery.

Before vaginal delivery is considered, clinical pelvic examination is universally recommended to rule out pathological pelvic contraction. Radiologic or magnetic resonance imaging (MRI) pelvimetry is not universally conducted [ 20 , 23 , 24 , 31 , 32 ]. However, Van Loon et al. [ 33 ] demonstrated in a randomized controlled trial that the use of MRI pelvimetry in breech presentation at term allowed better selection of delivery route, with a significantly lower emergency CS rate. More specifically, several recent studies [ 34 , 35 ] have evaluated the contribution of pelvimetry and found that MRI pelvimetry provided useful criteria for the preselection and counselling of women with breech presentation and the desire for vaginal delivery. Therefore, pelvimetry is diversely used in Europe for the preselection and counselling of women (particularly nulliparous women) with breech presentation and is specifically used in regions where vaginal delivery is still considered an option [ 35 ].

In cases of failed ECV with persistent breech presentation, this policy should allow customized care tailored to each situation in the last weeks of pregnancy.

A discussion with the informed patient is essential. One must thoroughly consider the experience of the health care team/the availability of clinical skills required for conducting a vaginal breech delivery and carefully select women who are eligible for planned vaginal delivery (considering obstetric history and the criteria described above for the choice between planned vaginal and CS deliveries) [ 20 , 23 , 24 , 26 , 28 ].

Regardless of the planned mode of delivery [ 22 ], adequate follow-up during the last weeks of pregnancy is mandatory, with particular consideration of possible associated underlying disorders (particularly foetal growth restriction or excessive foetal weight in cases of gestational diabetes mellitus) [ 24 , 25 , 26 ]. Thus, the foetal weight estimation should be carefully considered in the 37th week of gestation, even in cases of minor glycaemic disorder, with regular reassessments and a plan for CS delivery if the patient remains pregnant for many more weeks and if foetal weight estimates reach approximately 3600–3800 g.

If vaginal delivery is planned, careful labour management by a skilled team is needed, accompanied by continuous foetal heart rate monitoring [ 36 ] and a particular focus on the rate of progress in the second delivery stage [ 37 ]. When such conditions are not or cannot be fulfilled, a planned CS may be the best choice.

When a CS has been planned, adequate follow-up during the last weeks of pregnancy and careful calculation of the delivery date are needed, taking into account possible comorbidities and gestational disorders.

Term breech presentation is a condition for which personalized obstetrical care is particularly needed. The best way is likely to be as follows: first, efficiently screen for breech presentation at 36–37 weeks of gestation; second, thoroughly evaluate the maternal/foetal condition, foetal weight and growth potential, and the type (frank, complete, or footling) and mobility of breech presentation; and three, consider the obstetric history and pelvic size/conformation. The management plan, including ECV and follow-up during the last weeks, should then be organized taking into account antenatal risk factors on a case-by-case basis by a skilled team after informing the woman, discussing her personal situation and criteria and helping her make a rational decision. Foetal overgrowth or growth restriction and/or oligohydramnios may necessitate timely CS, and the mode of delivery should be re-evaluated as necessary according to obstetric conditions (e.g., estimated foetal weight and Bishop score).

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Not applicable.

Abbreviations

American College of Obstetricians and Gynecologists

Caesarean section

External cephalic version

International Federation of Gynecology and Obstetrics

Royal Australian and New Zealand College of Obstetricians and Gynaecologists

Royal College of Obstetricians and Gynaecologists

Severe maternal morbidity

Society of Obstetricians and Gynaecologists of Canada

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Study conception and design: LC, AB, JB, AT, FB, AB. Analysis and interpretation of data: LC, JB. Drafting of manuscript: LC. Critical revision: LC, JB, RM, MF. The authors read and approved the final manuscript.

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Carbillon, L., Benbara, A., Tigaizin, A. et al. Revisiting the management of term breech presentation: a proposal for overcoming some of the controversies. BMC Pregnancy Childbirth 20 , 263 (2020). https://doi.org/10.1186/s12884-020-2831-4

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Labor & Delivery

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.

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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.

Definition of breech presentation

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1801, in the meaning defined above

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Imrich Zigo

Jana sivakova, petra moricova, ivana kapustova, stefan krivus.

The authors present a case of 38-year-old laboring woman with four-time repetitive breech presentation of the fetus at term. This rare condition affects the mode of delivery and represents serious obstetrical problem as it is associated with increased perinatal morbidity or mortality. The authors give details on risk factors for breech presentation, its diagnosis, and the discussion points on possible causes leading to repetitive breeches in laboring women.

1. Introduction

The breech presentation is defined as the initial entrance of the gluteal region of the fetus into the maternal pelvis and is the most common abnormal fetal presentation. Breech delivery is a challenge in obstetric management and is associated with increased perinatal morbidity and mortality [ 1 – 3 ]. The prevalence of breeches ranges from 3% to 4% at term [ 4 ]. The predisposing factors for breech presentation are prematurity, multiple gestation, multiparity, fetal hydrocephalus, oligohydramnios, polar placentation, placenta previa, gestational diabetes, history of breech delivery, short umbilical cord, low birth weight, uterine anomalies, congenital anomaly, previous cesarean delivery, and pelvic tumors. As these factors explain only 15% of the variance of breech presentation [ 5 – 7 ], the etiology of breech delivery (causes of failure of spontaneous cephalic version) is not clear. Moreover, when fetal malposition in the form of breech presentation is repetitively presented in the same women. Thus, further research into the mechanism of breech presentation is needed.

The current study describes unusual case of repetitive (4 times) recurrence of breech delivery in the same women with hypothesis describing possible etiology of such rare case.

2. Case Report

A 38-years-old quadrugravida 168 cm tall Caucasian woman with singleton pregnancy at term (38 + 5 g.w.) was admitted to the delivery room due to regular uterine contractions every 5 minutes and sharp pain perception in scar after previous cesarean section. Gynecology examination revealed breech (Frank) presentation and vaginal findings showed 1 cm long cervix, dilated to 3 cm without signs of bleeding. A fetal predelivery ultrasonography was done with term corresponding biometry and EFW 3420 grams. The fetal monitor consisted of a baseline 140 bpm, accelerations, and good variability. Increased pain perception in lower uterine segment below the scar was the reason for pregnancy termination by uncomplicated cesarean section (Joel-Cohen incision with Misgav Ladach method) 3.5 hrs after admission. The intraoperative finding on the uterus was negative, without myoma, septum, or adhesions ( Figure 1 ). Her past history was uneventful except the obstetrical history of repetitive breech presentation of all previous deliveries (2 times spontaneously, once by low transverse cesarean section, Table 1 ). A 3500 g weighted male neonate with 9, 10, 10 Apgar score was delivered and discharged home with mother on 5th day after uncomplicated postpartum recovery.

An external file that holds a picture, illustration, etc.
Object name is CRIM.OBGYN2013-628572.001.jpg

The intraoperative findings on the uterus.

The clinical data of all deliveries.

3. Discussion

The breech delivery may represent the obstetrical problem that necessitates increased patience because of it possible complications. Thus many pregnancies with fetuses in breech lie are terminated for prevention by cesarean section. On the other side there exist obstetricians that can deliver breeches without fetal injury. However, despite their wide clinical practice, few of them faced the situation as described by our case: four-time repetitive breech presentation in one laboring woman giving the probability of such event at 0.045. In this section we will try to explain some possible reasons of this rare obstetric situation.

There are several maternal and fetal factors that predispose to a breech presentation, for example, uterine anomalies, myomas, pelvic tumors, fetal anomalies, changes of amniotic fluid, placental localization, or length of umbilical cord [ 8 ] that solely or in combination provoke fetal malpresentation. Moreover, some studies have found a relationship between placenta previa and polar fundal localization of the placenta and the breech presentation [ 9 , 10 ]. For example, cornu-fundal localization of the placenta occurred in 70% of breech presentations, but only in about 5% of cephalic presentations. In our case we have revealed 3-time fundal and one anterior wall placenta localizations on antepartum ultrasound what confirms the above-mentioned risk factors for breech presentations.

Adinma's study, in which 1000 cases were observed, found that breech fetuses had shorter umbilical cords than those of cephalic fetuses and that the average umbilical cord length is about 51 cm (range, 15–130) [ 11 ]. The lengths of umbilical cords in our case were as follows for subsequent pregnancies: 34 cm, 53 cm, 42 cm, and 57 cm, respectively. The relative short cords in pregnancies may explain the repetitive breeches in our case.

Specificity for higher breech presentation is body mass index (BMI) and maternal weight gain during pregnancy. It was revealed that higher BMI at term and increased body weight gain might be related to persistent breech presentation [ 12 ]. The last pregnancy of our case was associated with 13 kg body weight gain and 34 kg/m 2 BMI score. Another study revealed significantly higher incidence of breech deliveries in fetuses with increased placenta weight; however the reason was not revealed [ 13 ]. The weights of placentas in our case were in the range 430–560 g what represent the normal findings. Thus, did not confirm the above presented reasons associated with an increased risk for breech presentation.

Rayl et al. [ 14 ] highlighted smoking as a risk factor for breech presentation. In the current study we found no smoking history in any of the presented pregnancies. Similarly, Vendittelli et al. [ 15 ] reported that women with previous cesarean deliveries were at twice the risk of breech presentation at term than women with previous vaginal deliveries, which was in agreement with our data. Interestingly, Kuppens et al. [ 16 ] have provided data that women with higher TSH levels (>2.5 mIU/L) in pregnancy may exhibit higher rate of breech deliveries. This cannot be confirmed by our case as we did not make a hormonal profile in all of the pregnancies.

Nordtveit et al. [ 17 ] showed that breech delivery may exhibit partly inherited patterns as both men and women delivered in breech presentation at term contribute to increased risk of breech delivery in their offspring. Thus, this supports the theory that some genes on the specific environmental background passed on from the father or the mother seem to be closely related to breech delivery. Furthermore, the congenital pattern of breech delivery is supported by the findings from race-targeted studies, which have proved that white women have 69% higher risk for breech delivery than black women [ 18 ].

Finally, the congenital disorders in cerebellum cannot be omitted in the fetuses when describing the reason for breech delivery [ 19 ]. However, this theory has to be proved in the future. In general, there exists approximately 15% risk of repetitive breech delivery after the previous one, and this risk is higher for cesarean sections [ 20 ]. The relative risk of breech recurrence in a second pregnancy is 3.2 and in a third consecutive breech pregnancy 13.9 [ 21 ]. Any other breeches are extremely rare. Thus our case of four forthcoming breeches are worthy for presentation and for closer investigation of the causes.

In summary, we conclude that shorter umbilical cord, higher placental weight, increased maternal term BMI, cornu-fundal placenta localization, smoking, thyroid hormone disbalance, race, and genetics may be causative factors for repetitive breech presentations as described by our case and that it is the persistence of maternal risk factors rather than first pregnancy fetal or infant factors that play a role in repeating breech presentations at term. Thus, the consistently elevated recurrence rates highlight the need for women with a history of breech delivery to be closely monitored in the later stages of pregnancy (e.g., attempt for external cephalic version or prevention of cord prolapse after PROM).

Conflict of Interests

The authors declare that there is no conflict of interests.

Acknowledgments

This work was supported by the project centre of excellence for perinatal research (CEPV II, ITMS code: 26220120036) cofinanced by EU sources.

Abbreviations

IMAGES

Breech Baby
Breech Presentation Causes Mnemonic
caesarean section breech presentation
Breech
Breech Presentation and Turning a Breech Baby in the Womb (External
PPT

VIDEO

Breech Birth
(BREECH PRESENTATION) by Ms Varnish Kumar (MTCN Kumhari)
FNAF Security Breach
case presentation on breech presentation (BSC nursing and GNM)
Breech birth Meaning
Breech presentation (GTG guidline 20b)

COMMENTS

Breech Presentation
Breech presentation refers to the fetus in the longitudinal lie with the buttocks or lower extremity entering the pelvis first. The three types of breech presentation include frank breech, complete breech, and incomplete breech. In a frank breech, the fetus has flexion of both hips, and the legs are straight with the feet near the fetal face, in a pike position. The complete breech has the ...
Overview of breech presentation
Breech presentation, which occurs in approximately 3 percent of fetuses at term, describes the fetus whose presenting part is the buttocks and/or feet. Although most breech fetuses have normal anatomy, this presentation is associated with an increased risk for congenital malformations and mild deformations, torticollis, and developmental ...
Fetal Presentation, Position, and Lie (Including Breech Presentation
The reason for the risks to babies in breech presentation is that the baby's hips and buttocks are not as wide as the head. Therefore, when the hips and buttocks pass through the cervix first, the passageway may not be wide enough for the head to pass through. In addition, when the head follows the buttocks, the neck may be bent slightly backwards.
Breech presentation
Definition and mechanisms. Breech presentation refers to the fetus in the longitudinal lie with the buttocks or lower extremity entering the pelvis first. Three types: Frank breech: fetus has flexion of both hips, and the legs are straight with the feet near the fetal face, in a pike position. Complete breech: fetus sits with flexion of both ...
Breech Presentation
Breech Births. In the last weeks of pregnancy, a baby usually moves so his or her head is positioned to come out of the vagina first during birth. This is called a vertex presentation. A breech presentation occurs when the baby's buttocks, feet, or both are positioned to come out first during birth. This happens in 3-4% of full-term births.
Breech Presentation: Overview, Vaginal Breech Delivery ...
Overview. Breech presentation is defined as a fetus in a longitudinal lie with the buttocks or feet closest to the cervix. This occurs in 3-4% of all deliveries. The percentage of breech deliveries decreases with advancing gestational age from 22-25% of births prior to 28 weeks' gestation to 7-15% of births at 32 weeks' gestation to 3-4% of ...
Breech presentation
Summary. Breech presentation refers to the baby presenting for delivery with the buttocks or feet first rather than head. Associated with increased morbidity and mortality for the mother in terms of emergency cesarean section and placenta previa; and for the baby in terms of preterm birth, small fetal size, congenital anomalies, and perinatal ...
Breech: Types, Risk Factors, Treatment, Complications
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.
Breech presentation management: A critical review of leading clinical
Breech presentation: clinical practice guideline from the French College of Gynaecologists and Obstetricians [2020] ... Counselling should consist of short/long term risks and benefits of planned VBB versus planned C/S for mother and fetus in an unbiased way (5b). ... The lack of a standard definition of a footling breech is problematic because ...
Breech presentation
Incidence decreases as pregnancy progresses and by term occurs in 3% to 4% of singleton term pregnancies. Treatment options include external cephalic version to increase the likelihood of vaginal birth or a planned cesarean section, the optimal gestation being 37 and 39 weeks, respectively. Planned cesarean section is considered the safest form ...
Fetal Presentation, Position, and Lie (Including Breech Presentation
If breech presentation is detected, external cephalic version can sometimes move the fetus to vertex presentation before labor, usually at 37 or 38 weeks. This technique involves gently pressing on the maternal abdomen to reposition the fetus. A dose of a short-acting tocolytic (terbutaline 0.25 mg subcutaneously) may help. The success rate is ...
Management of Breech Presentation (Green-top Guideline No. 20b)
Breech presentation occurs in 3-4% of term deliveries and is more common in preterm deliveries and nulliparous women. Breech presentation is associated with uterine and congenital abnormalities, and has a significant recurrence risk. Term babies presenting by the breech have worse outcomes than cephalic presenting babies, irrespective of the ...
Management of Breech Presentation
Management of Breech Presentation. ... Women should be informed that planned vaginal breech birth increases the risk of low Apgar scores and serious short-term complications, but has not been shown to increase the risk of long-term morbidity. ... The strict criteria included 'normal' (definition unstated) radiological pelvimetry which was ...
Guideline for the Management of Breech Presentation
Definition Breech presentation is when the baby's buttocks, foot or feet present instead of its head. Breech presentation is sometimes associated with uterine, placental, or fetal abnormalities. ... score at 1 minute of age and short term complications but not an increased risk of long term morbidity for the infant. 4 ...
Revisiting the management of term breech presentation: a proposal for
Term breech presentation is a condition for which personalized obstetrical care is particularly needed. The best way is likely to be as follows: first, efficiently screen for breech presentation at 36-37 weeks of gestation; second, thoroughly evaluate the maternal/foetal condition, foetal weight and growth potential, and the type (frank, complete, or footling) and mobility of breech ...
Breech Presentation: Types, Causes, Risks
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 ...
Breech Baby: Causes, Complications, Turning & Delivery
A breech baby, or breech birth, is when your baby's feet or buttocks are positioned to come out of your vagina first. Your baby's head is up closest to your chest and its bottom is closest to your vagina. Most babies will naturally move so their head is positioned to come out of the vagina first during birth. Breech is common in early ...
Breech presentation Definition & Meaning
The meaning of BREECH PRESENTATION is presentation of the fetus in which the breech is the first part to appear at the uterine cervix. ... Share the Definition of breech presentation on Twitter Twitter. Medical Definition. breech presentation. noun: ...
Breech Presentation
Definition. The breech presentation refers to a longitudinal lie where the presenting part is the breech pole, which can be constituted by the fetal buttocks, the thighs and/or the feet. It must ...
Revisiting the management of term breech presentation: a proposal for
Based on the short-term outcomes presented in the TBT study, the Royal College of Obstetricians and Gynaecologists (RCOG) ... Term breech presentation is a condition for which personalized obstetrical care is particularly needed. The best way is likely to be as follows: first, efficiently screen for breech presentation at 36-37 weeks of ...
Repetitive Breech Presentations at Term
The breech presentation is defined as the initial entrance of the gluteal region of the fetus into the maternal pelvis and is the most common abnormal fetal presentation. ... oligohydramnios, polar placentation, placenta previa, gestational diabetes, history of breech delivery, short umbilical cord, low birth weight, uterine anomalies ...

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