overview of breech presentation

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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

• A 28-year-old G1P0 woman at 37 weeks of gestation presents to her obstetrician for a prenatal care appointment. She describes feeling some soreness under her ribs in the past few weeks and feels her baby kicking in her lower abdomen. An ultrasound is performed and is seen in the image. The obstetrician describes management approaches, including an external cephalic version before labor.
• flexion of the hips and knees
• some deflexion of one hip and knee
• flexion of both hips with extension of both knees
• 3-4% of all deliveries
• 22-25% of births before 28 weeks of gestation
• 7-15% of births at 32 weeks of gestation
• 3-4% of births at term
• prematurity
• uterine malformations
• uterine fibroids
• polyhydramnios
• placenta previa
• multiple gestations
• subcostal discomfort (due to fetal head in the uterine fundus)
• feeling of kicking in the lower abdomen
• presence of soft mass (buttocks) and absence of hard fetal skull on transabdominal examination of the lower uterine segment
• when cervix is dilated
• detection of breech presentation prior to 37 weeks does not warrant intervention
• fetal head in the uterine fundus
• buttocks in the lower uterine segment
• extension angle > 90 degrees
• at 37 weeks gestation or later
• perform trial of vaginal delivery if the version is successful
• may be planned for breech presentation, without a trial of external cephalic version
• may be performed if trial of vaginal delivery is unsuccessful after external cephalic labor
• ↑ up to 4-fold with breech presetnation
• associated with malformations, prematurity, and intrauterine fetal demise
• 17% of preterm breech deliveries
• 9% of term breech deliveries
• abnormalities include CNS malformations, neck masses, and aneuploidy
• - Breech Presentation

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Breech Presentation and Delivery

• First Online: 06 August 2021

Cite this chapter

• Uche A. Menakaya 5 , 6  

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Breech presentation refers to the presence of the fetal buttocks, knees or feet at the lower pole of the gravid uterus during pregnancy. At term, up to 4% of pregnancies are breech. The term breech foetus faces peculiar challenges in resource restricted countries with its lack of consensus on management and limited investments in health care systems and training of health care providers. This chapter describes the different types of breech presentation, the risk factors for term breech presentation and the antenatal management options including external cephalic version available to women presenting with a term breech foetus. The chapter also describes the techniques for performing external cephalic version and the maneuvers critical for a successful vaginal breech delivery and highlights the limitations of the evidence for and against vaginal breech delivery in the sub-Saharan continent.

• Term breech
• Caesarean section
• External cephalic version
• Vaginal breech delivery

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Menakaya, U.A. (2021). Breech Presentation and Delivery. In: Okonofua, F., Balogun, J.A., Odunsi, K., Chilaka, V.N. (eds) Contemporary Obstetrics and Gynecology for Developing Countries . Springer, Cham. https://doi.org/10.1007/978-3-030-75385-6_17

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• Pregnancy Classes

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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Breech Delivery

• Author: Philippe H Girerd, MD; Chief Editor: Ronald M Ramus, MD  more...
• Sections Breech Delivery
• Pathophysiology
• Epidemiology
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• Emergency Department Care
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Breech presentation occurs when the fetus presents to the birth canal with buttocks or feet first. This presentation creates a mechanical problem in delivery of the fetus.

The buttocks and feet of the fetus do not provide an effective wedge to dilate the cervix. The umbilical cord may prolapse, and/or the aftercoming head may get trapped during delivery.

The 3 types of breech presentation are as follows:

Frank (65%): Hips of the fetus are flexed, and knees are extended.

Complete (10%): The hips and knees of the fetus are flexed.

Incomplete (25%): The feet or knees of the fetus are the lowermost presenting part.

Single footling: One of the lower extremities is lowermost.

Double footling: Both of the lower extremities are lowermost.

United States

Incidence is correlated to gestational age (see the Table below). However, the overall frequency is 3-4% at delivery. [ 1 ]

Table. Gestational age and frequency of breech birth (Open Table in a new window)

International

The international incidence has been reported at 3-4%. [ 2 ]

Mortality/Morbidity

See the list below:

Many complications are associated with a breech presentation in labor. This may be due to the underlying etiology of the breech presentation, such as fetal anomalies or polyhydramnios. In addition, complications can occur as a result of umbilical cord compression due to the unusual presentation to the maternal pelvis.

Increased birth trauma: The inexperienced provider is more likely to pull on the fetus prematurely, and to perform the maneuvers to faciliate delivery incorrectly, increasing the risk of traumatic injury. In addition, as the duration of umbilical cord compression increases, the practitioner may try to deliver the infant more rapidly than advisable, thus increasing the incidence of birth trauma .

Incidence of prolapsed umbilical cord depends on type of breech presentation.

Footling, 17% incidence

Complete, 5% incidence

Frank, 0.5% incidence

Umbilical cord abnormalities : Cord length may be reduced, and, in footling breeches, there is an increased risk of the cord coiling around a leg of the fetus.

Older maternal age is a consideration. [ 3 ]

Tunde-Byass MO, Hannah ME. Breech vaginal delivery at or near term. Semin Perinatol . 2003 Feb. 27(1):34-45. [QxMD MEDLINE Link] .

Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group. Lancet . 2000 Oct 21. 356(9239):1375-83. [QxMD MEDLINE Link] .

Rayl J, Gibson PJ, Hickok DE. A population-based case-control study of risk factors for breech presentation. Am J Obstet Gynecol . 1996 Jan. 174(1 Pt 1):28-32. [QxMD MEDLINE Link] .

Bergenhenegouwen LA, Meertens LJ, Schaaf J, Nijhuis JG, Mol BW, Kok M, et al. Vaginal delivery versus caesarean section in preterm breech delivery: a systematic review. Eur J Obstet Gynecol Reprod Biol . 2013 Oct 16. [QxMD MEDLINE Link] .

Roecker CB. Breech repositioning unresponsive to Webster technique: coexistence of oligohydramnios. J Chiropr Med . 2013 Jun. 12(2):74-8. [QxMD MEDLINE Link] . [Full Text] .

Miwa I, Sase M, Nakamura Y, Hasegawa K, Kawasaki M, Ueda K. Congenital high airway obstruction syndrome in the breech presentation managed by ex utero intrapartum treatment procedure after intraoperative external cephalic version. J Obstet Gynaecol Res . 2012 Mar 22. [QxMD MEDLINE Link] .

Alarab M, Regan C, O'Connell MP, Keane DP, O'Herlihy C, Foley ME. Singleton vaginal breech delivery at term: still a safe option. Obstet Gynecol . 2004 Mar. 103(3):407-12. [QxMD MEDLINE Link] .

Carbillon L. Vaginal versus cesarean delivery for breech presentation in California: a population-based study. Obstet Gynecol . 2004 May. 103(5 Pt 1):1003-4. [QxMD MEDLINE Link] .

Cunningham FG, Gant FG, Leveno KJ. Breech Presentation and Delivery (Chapter 22). Williams Obstetrics . 21st ed. 2001.

Ghosh MK. Breech presentation: evolution of management. J Reprod Med . 2005 Feb. 50(2):108-16. [QxMD MEDLINE Link] .

Gilbert WM, Hicks SM, Boe NM, Danielsen B. Vaginal versus cesarean delivery for breech presentation in California: a population-based study. Obstet Gynecol . 2003 Nov. 102(5 Pt 1):911-7. [QxMD MEDLINE Link] .

Roberts JR, Hedges JR. Emergency childbirth. Clinical Procedures in Emergency Medicine . 3rd ed. 1997. chap75, 1000-1003.

Scorza WE. Intrapartum management of breech presentation. Clin Perinatol . 1996 Mar. 23(1):31-49. [QxMD MEDLINE Link] .

Stitely ML, Gherman RB. Labor with abnormal presentation and position. Obstet Gynecol Clin North Am . 2005 Jun. 32(2):165-79. [QxMD MEDLINE Link] .

Warke HS, Saraogi RM, Sanjanwalla SM. Should a preterm breech go for vaginal delivery or caesarean section. J Postgrad Med . 1999 Jan-Mar. 45(1):1-4. [QxMD MEDLINE Link] .

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

Contributor Information and Disclosures

Philippe H Girerd, MD Associate Professor, Department of Obstetrics and Gynecology, Virginia Commonwealth University, Medical College of Virginia Philippe H Girerd, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists , Association of Professors of Gynecology and Obstetrics , Medical Society of Virginia , AAGL Disclosure: Nothing to disclose.

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

John G Pierce, Jr, MD Associate Professor, Departments of Obstetrics/Gynecology and Internal Medicine, Medical College of Virginia at Virginia Commonwealth University John G Pierce, Jr, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists , Association of Professors of Gynecology and Obstetrics , Christian Medical and Dental Associations , Medical Society of Virginia , Society of Laparoendoscopic Surgeons Disclosure: Nothing to disclose.

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

Assaad J Sayah, MD, FACEP Chief, Department of Emergency Medicine; Senior Vice President, Primary and Emergency Care, Cambridge Health Alliance Assaad J Sayah, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians , Massachusetts Medical Society , National Association of EMS Physicians Disclosure: Nothing to disclose.

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

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

Disclosure: Nothing to disclose.

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• Identification of breech presentation

Evidence review L

NICE Guideline, No. 201

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Review question

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

Introduction

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

Summary of the protocol

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

Summary of the protocol (PICO table).

For further details see the review protocol in appendix A .

Methods and process

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

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

Clinical evidence

Included studies.

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

The included study is summarised in Table 2 .

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

Excluded studies

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

Summary of clinical studies included in the evidence review

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

Summary of included studies.

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

Quality assessment of clinical outcomes included in the evidence review

See the evidence profiles in appendix F .

Economic evidence

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

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

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

Summary of studies included in the economic evidence review

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

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

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

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

Economic model

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

Evidence statements

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

No evidence was identified to inform this outcome.

Mode of birth

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

Important outcomes

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

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

Admission to neonatal unit

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

Economic evidence statements

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

The committee’s discussion of the evidence

Interpreting the evidence, the outcomes that matter most.

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

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

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

The quality of the evidence

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

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

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

Benefits and harms

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

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

Cost effectiveness and resource use

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

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

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

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

McKenna 2003

Wastlund 2019

Appendix A. Review protocols

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

Appendix B. Literature search strategies

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

Appendix C. Clinical evidence study selection

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

Appendix D. Clinical evidence tables

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

Appendix E. Forest plots

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

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

Appendix F. GRADE tables

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

Appendix G. Economic evidence study selection

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

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

Appendix H. Economic evidence tables

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

Appendix I. Economic evidence profiles

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

Appendix J. Economic analysis

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

No economic analysis was conducted for this review question.

Appendix K. Excluded studies

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

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Economic studies

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

Appendix L. Research recommendations

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

Evidence reviews underpinning recommendations 1.2.36 to 1.2.37

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

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

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

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

• Cite this Page National Guideline Alliance (UK). Identification of breech presentation: Antenatal care: Evidence review L. London: National Institute for Health and Care Excellence (NICE); 2021 Aug. (NICE Guideline, No. 201.)
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• Review Management of breech presentation: Antenatal care: Evidence review M [ 2021] Review Management of breech presentation: Antenatal care: Evidence review M National Guideline Alliance (UK). 2021 Aug
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• [The effect of the woman's age on the course of pregnancy and labor in breech presentation]. [Akush Ginekol (Sofiia). 1996] [The effect of the woman's age on the course of pregnancy and labor in breech presentation]. Dimitrov A, Borisov S, Nalbanski B, Kovacheva M, Chintolova G, Dzherov L. Akush Ginekol (Sofiia). 1996; 35(1-2):7-9.
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Breech - series—Types of breech presentation

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There are three types of breech presentation: complete, incomplete, and frank.

Complete breech is when both of the baby's knees are bent and his feet and bottom are closest to the birth canal.

Incomplete breech is when one of the baby's knees is bent and his foot and bottom are closest to the birth canal.

Frank breech is when the baby's legs are folded flat up against his head and his bottom is closest to the birth canal.

There is also footling breech where one or both feet are presenting.

Review Date 11/21/2022

Updated by: LaQuita Martinez, MD, Department of Obstetrics and Gynecology, Emory Johns Creek Hospital, Alpharetta, GA. Also reviewed by David C. Dugdale, MD, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.

Related MedlinePlus Health Topics

• Childbirth Problems

Breech Presentation

Affiliations.

• 1 Creighton University School of Medicine
• 2 Creighton University
• PMID: 28846227
• Bookshelf ID: NBK448063

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

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Overview of breech presentation.

INTRODUCTION  —  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 dysplasia of the hip. Pregnant people with fetuses in breech presentation at or near term are usually offered external cephalic version (ECV) because a persistent breech presentation is often delivered by planned cesarean, which is associated with a clinically significant decrease in perinatal/neonatal mortality and neonatal morbidity compared with vaginal birth.

This topic will provide an overview of major issues related to breech presentation, including choosing the best route for delivery. Techniques for breech delivery, with a focus on the technique for vaginal breech delivery, are discussed separately. (See "Delivery of the singleton fetus in breech presentation" .)

TYPES OF BREECH PRESENTATION  —  The main types of breech presentation are:

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

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

● Incomplete breech – One or both hips are not completely flexed ( figure 3 ); accounts for 10 to 40 percent of breech fetuses at term.

In the two nonfrank breech presentations, one or both feet (or rarely one or both knees) may present before the buttocks in the birth canal.

Significance  —  Because the hips are flexed and the knees are extended or flexed in the frank and complete breech presentations, the thighs and trunk pass through the birth canal simultaneously. If this large fetal diameter passes through the birth canal easily, then the aftercoming shoulders and head are likely to pass through easily as well, though a difficult delivery is still possible.

By contrast, in an incomplete breech presentation, one or both hips are not flexed; therefore, the thighs and trunk do not pass through the birth canal simultaneously. This smaller fetal diameter may easily pass through an incompletely dilated cervix (or an inadequate pelvis) followed by entrapment of the shoulders or head, which have larger diameters and require a fully dilated cervix and normal pelvic dimensions unless the fetus is small. Entrapment increases the risks for hypoxic injury and delivery-related trauma. Even before entrapment, the smaller fetal diameter provides space for umbilical cord prolapse, which can also result in hypoxic injury. In a series of planned vaginal breech deliveries (284 complete or incomplete breech, 884 frank breech), umbilical cord prolapse was more common in nonfrank breech presentations and was the reason for cesarean birth in 5/63 (7.9 percent) complete or incomplete breech presentations versus 3/222 (1.4 percent) frank breech presentations [ 1 ]. The overall cesarean birth rate was similar for both groups (nonfrank breech 22.2 percent, frank breech 25.1 percent). (See "Umbilical cord prolapse" .)

PREVALENCE  —  The prevalence of breech presentation at <28 weeks, 32 weeks, and term is approximately 20 to 25, 7 to 16, and 3 to 4 percent, respectively [ 2,3 ]. Breech presentation is more common earlier in pregnancy because the fetus can be highly mobile within the relatively large volume of amniotic fluid.

PATHOGENESIS  —  Breech presentation appears to be a chance occurrence in most pregnancies. In up to 15 percent of cases, however, it may be due to fetal, maternal, or placental abnormalities. It is hypothesized that a fetus with normal anatomy, activity, amniotic fluid volume, and placental location adopts the cephalic presentation near term because this position is the best fit for the intrauterine space, but if any of these variables is abnormal, then breech presentation is more likely.

RISK FACTORS  —  Multiple factors have been associated with an increased risk for breech presentation, including:

● Preterm gestation

● A previous sibling or either parent who was in breech presentation (see 'Risk of recurrence' below)

● Uterine abnormality (eg, bicornuate or septate uterus, fibroid) [ 4,5 ]

● Placental location (eg, placenta previa, cornual placenta) [ 6,7 ]

● Extremes of amniotic fluid volume (polyhydramnios, oligohydramnios)

● Nulliparity [ 8-10 ]

● Contracted maternal pelvis [ 11 ]

● Fetal anomaly (eg, anencephaly, hydrocephaly, sacrococcygeal teratoma, neck mass) [ 12 ]

● Extended fetal legs [ 13 ]

● Crowding from multiple gestation

● Fetal neurologic impairment

● Maternal hypothyroidism [ 8 ]

● Short umbilical cord [ 14 ]

● Fetal growth restriction [ 9 ]

● Fetal asphyxia [ 15 ]

● Female sex [ 9,16 ]

● Maternal anticonvulsant therapy [ 17 ]

● Older maternal age [ 9 ]

Risk of recurrence  —  Population-based registries indicate an increased risk of recurrent breech presentation [ 18,19 ]:

● After one pregnancy with breech presentation, the frequency of recurrence in the next pregnancy is approximately 9 percent

● After two consecutive pregnancies with breech presentation, the frequency of recurrence in the next pregnancy is approximately 25 percent

● After three consecutive pregnancies with breech presentation, the frequency of recurrence in the next pregnancy is almost 40 percent

By comparison, if the first pregnancy is not a breech presentation, the frequency of breech presentation in the next pregnancy is approximately 2 percent.  

Recurrence is usually attributed to recurrent fetal, maternal, or placental abnormalities. However, the possibility of a heritable component to fetal presentation that can be transmitted from either parent was suggested by the observation that parents who themselves were delivered at term from breech presentation were twice as likely to have firstborn offspring in breech presentation compared with parents who were born as a cephalic presentation [ 20 ].

CLINICAL FINDINGS AND COURSE  —  Clinical assessment of fetal presentation should be a routine part of prenatal examination in late pregnancy since breech presentation affects antepartum and intrapartum management. (See 'Approach to management at or near term' below.)

Symptoms  —  Symptoms of breech presentation are most common in the third trimester. Patients often report subcostal discomfort because the fetal head is in the fundus [ 21 ]. They may also perceive kicking in the lower abdomen when the breech is complete or incomplete.

Physical examination  —  Breech presentation is most readily appreciated in the third trimester. However, abdominal palpation, even by an experienced clinician, may misdiagnose the presentation.

● On transabdominal examination of the lower uterine segment, breech presentation is characterized by the presence of a soft mass (ie, buttocks) and the absence of a hard fetal skull. In addition, a hollow (fetal neck) next to the presenting part is absent in a breech presentation and palpable in a cephalic presentation.

● On examination of the fundus, the fetal head can be readily balloted since it pivots on the neck and moves independently from the trunk. In comparison, in cephalic presentation, ballottement of the breech in the upper part of the uterus is typically sluggish because it is accompanied by movement of the entire trunk.

● On transvaginal examination, the soft buttocks, anal orifice, or feet may be identified when the cervix is dilated but can be difficult to palpate when the cervix is closed. A foot is differentiated from a hand by the presence of the heel, while palpating a fist or a grasp may identify a hand.

Imaging  —  Ultrasound clearly identifies the fetal head in the fundus, buttocks in the lower uterine segment, extension or flexion of each hip and knee, and location of each foot.

Hyperextension of the fetal head (defined by an extension angle greater than 90 degrees) is an important finding as it is a contraindication to vaginal birth. (See "Delivery of the singleton fetus in breech presentation", section on 'Criteria for minimizing risk in patients who opt for vaginal breech birth' .)

Natural history  —  Spontaneous version may occur at any time before labor, even after 40 weeks of gestation. In a prospective longitudinal study using serial ultrasound examinations, spontaneous version from breech to cephalic presentation after 36 weeks occurred in 25 percent of cases [ 13 ]. In the Term Breech Trial in which patients with breech presentation at ≥37 weeks of gestation were randomized to planned cesarean or vaginal birth, cephalic birth occurred in approximately 2 percent of those allocated to planned cesarean and 4 percent of the planned vaginal birth group, suggesting that additional spontaneous cephalic versions occurred during expectant management until the onset of spontaneous labor [ 22 ].

Characteristics that reduce the likelihood of spontaneous version include extended fetal legs, oligohydramnios, short umbilical cord, fetal/uterine abnormalities, and nulliparity.

DIAGNOSIS  —  The diagnosis of breech presentation should be suspected in patients who describe subcostal discomfort or kicking in the lower abdomen in late pregnancy. The diagnosis is confirmed by identifying the buttocks and/or feet as the presenting part on physical examination (transabdominal and/or transvaginal) or ultrasound examination (ultrasound is more reliable).

Our approach  —  Antepartum, our practice is to routinely perform a careful abdominal examination in late pregnancy to determine fetal presentation, with the addition of ultrasound examination if the presentation is not identifiable with certainty, as the diagnosis informs decision making around external cephalic version (ECV) and route of delivery. However, physical examination is not infallible [ 23,24 ]. In a study in which an experienced clinician examined 138 patients at 30 to 41 weeks of gestation immediately before an ultrasound examination, the examiner identified only three of eight breech presentations and falsely diagnosed six breeches [ 23 ]. Physical examination is fallible because characteristic findings of breech presentation on transabdominal examination may be obscured or distorted in patients with obesity, full bladder, leiomyoma, polyhydramnios, anterior placenta, or multiple gestation. Because ultrasound detects 100 percent of breech presentations at the time of the examination, performing ultrasound for fetal presentation in late pregnancy in conjunction with offering external cephalic version may be cost-effective [ 25,26 ].

We also routinely perform an ultrasound examination in laboring patients to confirm suspected breech presentation and the type of breech when physical findings are uncertain since sonographic confirmation of a previously unsuspected breech presentation should prompt a discussion about cesarean versus vaginal birth.

Intrapartum differential diagnosis

● Face presentation – On intrapartum transvaginal examination through a dilated cervix a frank breech presentation can feel like an edematous face presentation. A useful distinguishing characteristic is that the fetal greater trochanters and anal orifice form a straight line across the buttocks, whereas the malar bones and mouth form a triangle in the face. (See "Face and brow presentations in labor", section on 'Face presentation' .)

● Compound cephalic presentation – On intrapartum transvaginal examination through a dilated cervix, a foot suggests breech presentation but can also occur with a compound cephalic presentation, which often has one or both hands but may have one or both feet or a hand and a foot presenting alongside or in front of the head. A foot can be distinguished from a hand by its three bony protuberances (calcaneous, lateral and medial malleolus), the angle at the level of the calcaneous, and the toes, which are short and lie in the same line with no opposing thumb. On abdominal examination, the diagnosis of breech presentation is supported by palpation of the head in the fundus. Ultrasound confirms the diagnosis. (See "Compound fetal presentation", section on 'Differential diagnosis' .)

APPROACH TO MANAGEMENT AT OR NEAR TERM

Overview  —  There is general agreement that the breech fetus is at higher risk for asphyxia and traumatic injury during vaginal birth than the cephalic fetus (see 'Significance' above). To minimize the risk of these complications, the choice of delivery route for the term breech fetus is guided by patient values and preferences and provider experience, values, and preferences, taking into account the risks and benefits of the various approaches [ 27 ]. The pregnant person's choice of birth route should be informed by unbiased, noncoercive counseling [ 28 ]. The choice should be made with due consideration of specific health care environments, individual values and preferences [ 29 ], and the limitations inherent in the data described in the following sections of this topic [ 30-35 ]. Clinicians should be aware that people with breech presentation may experience a sense of loss of power and autonomy during this process [ 36 ].

Four strategies have evolved:

● External cephalic version (ECV) before labor, with a trial of labor if the version is successful and cesarean birth if unsuccessful. This is the most common approach in the United States and many other countries.

● ECV before labor, with a trial of labor if the version is successful. However, if the version is unsuccessful, a trial of labor and vaginal breech birth are offered to patients who have characteristics that are believed to place them at a low risk of labor and delivery-related complications. Cesarean birth is offered to higher risk patients and any patient who declines to attempt a vaginal breech birth. This is the author's approach. (See "Delivery of the singleton fetus in breech presentation", section on 'Criteria for minimizing risk in patients who opt for vaginal breech birth' .)

● Planned cesarean birth for breech presentation, without an attempt at ECV.

● A trial of labor and vaginal breech birth for patients who have characteristics that are believed to place them at a low risk of labor and delivery-related complications, without an attempt at ECV. (See "Delivery of the singleton fetus in breech presentation", section on 'Criteria for minimizing risk in patients who opt for vaginal breech birth' .)

Antepartum maternal postural changes, moxibustion, and acupuncture do not improve the chances of spontaneous version compared with expectant care alone. This evidence is reviewed separately. (See "External cephalic version", section on 'Postural maneuvers to facilitate spontaneous version' and "External cephalic version", section on 'Moxibustion and acupuncture' .)

Strategy #1: ECV, cesarean birth if unsuccessful  —  ECV at or near term, followed by a trial of vaginal birth if the version is successful and planned cesarean birth if breech presentation persists is the preferred approach to delivery of the term breech fetus in the United States, and many other countries [ 27 ]. Patients are encouraged to undergo ECV to convert a breech presentation to cephalic presentation and thus increase the likelihood of vaginal cephalic birth. If ECV is unsuccessful or the fetus reverts to breech, one or two retrials of version can be attempted in one or more days. In a meta-analysis of randomized trials, ECV at term resulted in a 60 percent reduction in noncephalic presentation at birth (relative risk [RR] 0.42, 95% CI 0.29-0.61) and a 40 percent reduction in cesarean birth (RR 0.57, 95% CI 0.40-0.82) [ 37 ]. Performing the version at 34 to 35 weeks of gestation, using a tocolytic drug, and/or administering neuraxial anesthesia increase the likelihood of success, but overall benefits are uncertain. These data and the timing and procedure for ECV are discussed separately. (See "External cephalic version" .)

Planned cesarean birth for persistent term breech presentation is associated with a clinically significant decrease in perinatal/neonatal mortality and neonatal morbidity, with only a modest increase in short-term maternal morbidity, compared with a policy of planned vaginal birth. It should be performed at ≥39+0 weeks of gestation to allow optimal physiologic maturation (unless there are specific indications for earlier delivery). Delaying cesarean birth until at least 39+0 weeks is particularly important when the indication is breech presentation, as spontaneous version may occur at any gestational age.

However, a policy of planned cesarean birth may not be affordable or feasible in resource-limited settings. On an individual-case basis, there may be clinical situations in which the maternal risks of cesarean or the patient's desire to avoid cesarean birth outweigh the newborn's risks from vaginal birth. Both birth routes have similar long-term maternal outcomes and childhood outcomes in survivors, and some data suggest some long-term health benefits from being born vaginally, including reduced risk of childhood conditions such as asthma and arthritis [ 38-40 ]. In addition, cesarean birth has implications for patients planning future pregnancies, including repeat cesarean birth and increased risks for serious morbidity and mortality associated with placenta accreta spectrum [ 41 ] and uterine rupture [ 42 ]. Pregnancies following preterm breech cesarean birth versus preterm breech vaginal birth have been associated with increased neonatal acidosis and intensive care admission [ 43 ] and other adverse neonatal and maternal outcomes [ 44 ]. Lastly, the current policy is largely based on a single randomized multicenter international trial (see 'Evidence' below). Increasing the magnitude of planned cesarean births worldwide will increase the absolute number of patients who develop rare but life-threatening complications of this major operative procedure [ 45,46 ]. For example, in Africa, overall maternal mortality from cesarean birth is 0.5 percent [ 47 ].

Evidence  —  The evidence supporting planned cesarean birth was provided by a systematic review of randomized trials of planned cesarean versus planned vaginal birth for term breech presentation (three trials, 2396 participants) [ 48 ]. In two of the trials, which were from the same unit, patients with frank [ 49 ] or nonfrank [ 50 ] breech presentation were randomly assigned to undergo planned cesarean birth or a protocol allowing vaginal birth within prescribed limitations, including the absence of diminished pelvic dimensions on radiographic pelvimetry. The third trial, the Term Breech Trial, was a large (2088 participants) multicenter, international trial comparing planned cesarean with planned vaginal birth by an experienced clinician following agreed upon clinical guidelines [ 22 ]. The participating countries were classified as having low or high perinatal mortality rates (low ≤20 deaths per 1000 live births plus late fetal deaths, high >20 deaths per 1000 live births plus late fetal deaths). Cesarean birth was performed in 550 of 1227 patients (45 percent) allocated to the vaginal birth protocol.

The key findings were as follows:

Compared with planned vaginal birth of breech presentation, planned cesarean [ 48 ]:

● Reduced perinatal/neonatal death (RR 0.29, 95% CI 0.10-0.86). Risk ratios were similar for countries with low versus high national perinatal mortality rates, but absolute mortality rates were higher in the latter. Subsequently, others estimated that 338 cesareans for breech presentation need to be performed to prevent one perinatal death [ 51 ].

● Reduced composite short-term outcome of perinatal/neonatal death or serious neonatal morbidity (RR 0.33, 95% CI 0.19-0.56). This result was largely driven by data from countries with low national perinatal mortality rates, where the comparative risk of the composite outcome was RR 0.07 (95% CI 0.02-0.29; 4/1000 for planned cesarean versus 57/1000 for planned vaginal birth). In countries with high national perinatal mortality rates, the comparative risk of the composite outcome was RR 0.66 (95% CI 0.35-1.24; 29/1000 for planned cesarean versus 44/1000 for planned vaginal birth). The unexpectedly low absolute composite mortality/morbidity rate with planned vaginal birth in high perinatal mortality rate countries may have been due to less macrosomia, more experience with vaginal breech birth, and documentation issues.

The number of adverse events in the meta-analysis was small, thus reducing the chances of detecting statistically significant reductions in birth trauma and brachial plexus injury with planned cesarean birth.

In addition:

● Route of planned birth had no significant effect on long-term outcome in offspring, except that infant medical problems were significantly increased following planned cesarean birth. The combined risk of death/neurodevelopmental delay was similar for the planned vaginal and planned cesarean groups at two years of age. Since there were few serious adverse events despite the large number of study participants and 17 of 18 neonates with serious early morbidity were neurologically normal at two years of age, a small difference between groups in long-term composite mortality/morbidity cannot be excluded.

● Route of planned birth had no significant effect on long-term maternal outcome. In the short-term, planned cesarean resulted in a small increase in some maternal morbidities (eg, hemorrhage, transfusion, infection), but less urinary incontinence and incontinence of flatus. Complications in future pregnancies related to scarring of the uterus were not assessed.

A meta-analysis of 21 cohort studies including nearly 400,000 pregnancies support these findings [ 52 ].

The Term Breech Trial impacted clinical practice worldwide: The rate of planned vaginal breech birth fell substantially since publication of this trial [ 53-57 ]. In 2016, the cesarean birth rate for breech presentation in European countries was ≥70 percent and approximately 95 percent in the United States [ 58 ]. Limited observational data suggest that this fall in planned vaginal breech birth has been accompanied by a fall in the morbidity and mortality of breech birth [ 51,53 ], especially if performed before labor begins [ 59 ].

Strategy #2: ECV, trial of vaginal birth for selected patients if unsuccessful  —  The author's preference is to offer ECV followed by a trial of vaginal birth if successful. If unsuccessful, he offers planned cesarean birth, and, for patients who meet criteria, he also offers a trial of labor and vaginal breech birth [ 30-35,38-40,42,45,46 ]. There is a general consensus that patients who choose to undergo a trial of labor and vaginal breech birth should be at low risk of complications from vaginal breech birth and their labor and birth should be supervised by a clinician with experience in vaginal breech birth. Whether such pregnancies can be identified and how the fetal risks from vaginal birth compare with maternal risks from cesarean birth have been debated for decades. (See "Delivery of the singleton fetus in breech presentation", section on 'Criteria for minimizing risk in patients who opt for vaginal breech birth' .)

Closely monitoring the progress of labor is particularly important in patients who attempt a vaginal breech birth. The author has a low threshold for performing a cesarean birth if he believes that labor progress is inadequate. His criteria for abnormal labor progress are described in detail separately. (See "Delivery of the singleton fetus in breech presentation", section on 'Labor management' .)

Evidence  —  The PREsentation et MODe d'Accouchement (PREMODA) study is often cited as the best evidence to support vaginal breech birth in selected patients [ 60 ]. The results of this observational study are less robust than those of the Term Breech Trial discussed above but provide information illustrating the magnitude of morbidity/mortality of planned vaginal birth in patients managed using the authors' protocol. Subsequent smaller prospective observational studies have also reported low rates of adverse outcome from planned vaginal breech birth that followed strict protocols [ 61-65 ], including first pregnancies [ 66 ] and pregnancies beyond the estimated due date [ 67 ].

PREMODA was a prospective observational multicenter study conducted in 174 centers in France and Belgium and including 8105 singleton breech fetuses at term [ 60 ]. The study evaluated the safety of vaginal breech birth using strict criteria ( table 1 ) for selecting patients for a trial of labor. Major findings were [ 60,68 ]:

● The composite outcome of fetal/neonatal mortality or serious neonatal morbidity was not significantly different for planned vaginal versus planned cesarean birth (1.60 versus 1.45 percent, odds ratio 1.10, 95% CI 0.75-1.61) after adjustment for geographic origin, gestational age less than 39 weeks at birth, birth weight less than the 10 th percentile, and an annual number of maternity unit births of less than 1500.

● Approximately 70 percent of the 2502 patients in the planned vaginal birth group delivered vaginally, and 165 (6.6 percent) of these pregnancies had an adverse perinatal outcome, including but not limited to brachial plexus injury (five infants), skull fracture (one infant), genital injury (two infants), intraventricular hemorrhage (one infant), seizure (four infants), and death (two infants). Factors associated with adverse perinatal outcome were geographic origin, delivery at <39 weeks of gestation, birth weight <10 th percentile, and annual number of maternity unit births <1500.

Strategy #3: Cesarean birth without ECV  —  Some patients may choose to undergo a planned cesarean birth without an attempt at ECV. Patients with a low likelihood of successful version or at increased risk of fetal harm from the procedure may reasonably avoid an attempt at version and choose cesarean birth. (See "External cephalic version", section on 'Candidates' .)

Strategy #4: Vaginal birth without ECV  —  Some patients may choose to undergo a trial of labor and vaginal breech birth without an attempt at ECV. Those with a low likelihood of successful version or at increased risk of fetal harm from the procedure may reasonably avoid the procedure and choose to attempt vaginal birth (see "External cephalic version", section on 'Candidates' ). As discussed above, there is a general consensus that patients who choose to undergo a trial of labor and vaginal breech birth should be at low risk of complications from vaginal breech birth and their labor and birth should be supervised by a clinician with experience in vaginal breech birth. (See "Delivery of the singleton fetus in breech presentation", section on 'Criteria for minimizing risk in patients who opt for vaginal breech birth' .)

APPROACH TO MANAGEMENT OF PRETERM BREECH BIRTH  —  In most cases, cesarean is preferred for birth of the preterm breech fetus because the body of evidence from observational studies suggests that vaginal birth of the very preterm breech fetus is likely associated with a small but significant increase in adverse outcome that can be avoided by cesarean birth. The preterm fetal head circumference-to-abdominal circumference ratio is larger than that of a term fetus; thus, the preterm breech head is more likely to be entrapped in a partially dilated cervix, resulting in birth trauma and/or acute asphyxia from compression of the umbilical cord [ 69,70 ].

● In a 2014 systematic review of seven observational studies (3557 participants) that evaluated cesarean versus vaginal birth of the preterm breech, the weighted risk of neonatal mortality was lower in the cesarean group than in the vaginal birth group (3.8 versus 11.5 percent, pooled relative risk 0.63, 95% CI 0.48-0.81) [ 71 ]. In one of the included studies, a retrospective study of patients delivering breech infants at 26 to 29 weeks of gestation, the rate of head entrapment was twofold higher in the planned vaginal birth group than in the planned cesarean birth group (11/84 [13 percent] versus 5/85 [6 percent]) [ 70 ]. Four neonatal deaths were attributed to head entrapment; three of these infants were delivered vaginally and died within an hour of birth (neonatal death related to head entrapment 3/45 vaginal births versus 1/124 cesarean births). The single infant that died after cesarean birth complicated by head entrapment died five days later because of sepsis and grade 3 intraventricular hemorrhage. Of note, approximately 50 percent of planned vaginal births ended in cesarean birth, while 6 percent of planned cesareans ended in vaginal birth.

The authors of the systematic review subsequently published a cohort study including over 8300 patients with a singleton preterm fetus in breech presentation who delivered at 26+0 to 36+6 weeks of gestation in the Netherlands from 2000 to 2011 [ 72 ]. A strength of this study is the large number of participants who intended to deliver vaginally (6421), although 2995 of these individuals delivered by emergency cesarean during labor. Compared with intended vaginal birth, intended cesarean birth was not associated with a significant reduction in perinatal mortality (1.3 versus 1.5 percent, adjusted odds ratio [OR] 0.97, 95% CI 0.60-1.57) or the composite outcome of perinatal mortality/severe morbidity (3.2 versus 4.1 percent, adjusted OR 0.76, 95% CI 0.56-1.03); however, when minor morbidities such as five-minute Apgar score <7 were also considered, intended cesarean birth reduced the rate of the composite outcome of perinatal mortality/morbidity (8.7 versus 10.4 percent, OR 0.77, 95% CI 0.63-0.93). A subgroup analysis based on gestational age found that perinatal mortality, morbidity, and severe morbidity were significantly reduced by cesarean at 28 to 32 weeks of gestation.

● In a 2018 meta-analysis to determine the safest route of delivery of actively resuscitated extremely preterm (23+0 to 27+6 weeks) breech singletons, cesarean was associated with reductions in the odds of death by 41 percent (OR 0.59, 95% CI 0.36-0.95, number needed to treat [NNT] 8) and of severe intraventricular hemorrhage by 49 percent (OR 0.51, 95% CI 0.29-0.91, NNT 12) [ 73 ]. Infants at lower gestational ages experienced the greatest benefit. Data from one randomized trial, one prospective cohort study, and 13 retrospective cohort studies were combined for the analysis.

TECHNIQUE FOR BREECH DELIVERY  —  (See "Delivery of the singleton fetus in breech presentation" .)

NEONATAL OUTCOME  —  Newborns that were in breech presentation have increased morbidity and mortality; however, breech presentation itself probably is not an independent risk factor for adverse neonatal outcome [ 74,75 ]. Rather, adverse outcomes are related, in part, to underlying conditions associated with breech presentation (eg, congenital anomalies, fetal growth restriction, preterm birth) and, in part, to birth trauma, which is often related to vaginal breech birth.

Regardless of route of birth, neonates who are breech in utero are more likely to have congenital anomalies [ 76 ] (4.4 versus 2.4 percent in vertex presentation [ 77 ]) and mild deformations (eg, frontal bossing, prominent occiput, upward slant, and low-set ears), torticollis, and developmental dysplasia of the hip [ 78-80 ], which may present late despite normal initial ultrasound evaluation [ 81 ]. Ultrasonography at four to six weeks of age (adjusted for preterm birth) has been recommended for infants with an abnormal hip examination or a normal examination and breech position at ≥34 weeks of gestation. (See "Congenital muscular torticollis: Clinical features and diagnosis" and "Developmental dysplasia of the hip: Epidemiology and pathogenesis", section on 'Breech position' .)

SOCIETY GUIDELINE LINKS  —  Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Breech presentation and external cephalic version" .)

INFORMATION FOR PATIENTS  —  UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5 th to 6 th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10 th to 12 th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

● Basics topics (see "Patient education: Breech pregnancy (The Basics)" and "Patient education: External cephalic version (The Basics)" )

SUMMARY AND RECOMMENDATIONS

● Types – Breech presentation may be frank, complete, or incomplete ( figure 1 and figure 2 and figure 3 ). (See 'Types of breech presentation' above.)

● Prevalence – Breech presentation complicates 3 to 4 percent of pregnancies at term; the prevalence is inversely associated with gestational age. (See 'Prevalence' above.)

● Pathogenesis – In most pregnancies, breech presentation is a chance occurrence. In up to 15 percent of cases, it may be due to fetal, maternal, or placental abnormalities. (See 'Pathogenesis' above.)

● Symptoms – Symptoms of breech presentation include subcostal discomfort from the fetal head in the fundus and kicking in the lower abdomen when the breech is complete or incomplete. (See 'Symptoms' above.)

● Diagnosis – The diagnosis of breech presentation is based on identifying the buttocks and/or feet as the presenting part on physical examination (transabdominal or transvaginal) or ultrasound examination. (See 'Diagnosis' above and 'Physical examination' above and 'Imaging' above.)

● Management

• Overview – The management of breech presentation at term is guided by patient values and preferences and provider experience, values, and preferences after review of the evidence of the risks and benefits of available interventions. (See 'Approach to management at or near term' above.)

The choice of birth route should be made with due consideration of specific health care environments, individual patient values and preferences, and the limitations inherent in available evidence. A policy of planned cesarean birth may not be affordable or feasible in resource-limited settings. On an individual case basis, there may be clinical situations in which the risks of cesarean to the patient, or the patient's desire to avoid cesarean birth, may outweigh the newborn's short-term risks from vaginal birth. Both birth routes have similar long-term maternal and childhood outcomes, and some data suggest some long-term health benefits to being born vaginally. In addition, cesarean birth has implications for patients planning future pregnancies, including repeat cesarean birth and increased risks of placenta accreta spectrum and uterine rupture. (See 'Approach to management at or near term' above.)

• Role of external cephalic version – In the United States, clinician preference for pregnancies with breech presentation is to offer the patient external cephalic version (ECV) at or near term, followed by a trial of vaginal birth if the version is successful and planned cesarean if breech presentation persists because planned cesarean birth of the breech fetus reduces perinatal death or severe morbidity. (See 'Strategy #1: ECV, cesarean birth if unsuccessful' above.)

• Role of planned cesarean birth – Some patients may choose to undergo planned cesarean birth if the breech persists without an attempt at ECV. Patients with a low likelihood of successful version or at increased risk of fetal harm from the procedure may reasonably avoid the procedure. (See 'Strategy #3: Cesarean birth without ECV' above.)

• Role of vaginal breech birth – Some patients may choose to have a vaginal breech birth. There is a general consensus that these patients should be at low risk of complications from vaginal breech birth and their labor and delivery should be supervised by a clinician with experience in vaginal breech birth. (See 'Strategy #2: ECV, trial of vaginal birth for selected patients if unsuccessful' above.)

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• Thesis: Term breech delivery in The Netherlands. Congenital malformations among infants in breech position: a study of 1.4 million newborns . Rietberg CC, Anthony S, Schonbeck Y, Visser GH.
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1 : The influence of the fetal leg position on the outcome in vaginally intended deliveries out of breech presentation at term - A FRABAT prospective cohort study.

2 : Variation of fetal presentation with gestational age.

3 : The frequency of breech presentation by gestational age at birth: a large population-based study.

4 : Uterine anomalies. A retrospective, matched-control study.

5 : Outcome of pregnancy in women with uterine malformation: evaluation of 62 cases.

6 : The site of placental attachment as a factor in the aetiology of breech presentation.

7 : Breech presentation and the cornual-fundal location of the placenta.

8 : A comparison of risk factors for breech presentation in preterm and term labor: a nationwide, population-based case-control study.

9 : New and old predictive factors for breech presentation: our experience in 14 433 singleton pregnancies and a literature review.

10 : Spontaneous cephalic version and risk factors for persistent breech presentation: a longitudinal retrospective cohort study.

11 : The gentle art of external cephalic version.

12 : Breech presentation at delivery: a marker for congenital anomaly?

13 : Spontaneous cephalic version of breech presentation in the last trimester.

14 : The length of the human umbilical cord in vertex and breech presentations.

15 : Umbilical cord length as an index of fetal activity: experimental study and clinical implications.

16 : Impact of sex ratio on onset and management of labour.

17 : Breech presentation associated with anticonvulsant drugs

18 : Reproductive career after breech presentation: subsequent pregnancy rates, interpregnancy interval, and recurrence.

19 : Recurrence of breech presentation in consecutive pregnancies.

20 : Maternal and paternal contribution to intergenerational recurrence of breech delivery: population based cohort study.

21 : Maternal and paternal contribution to intergenerational recurrence of breech delivery: population based cohort study.

22 : Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group.

23 : Utility of Leopold maneuvers in screening for malpresentation.

24 : Impact of point-of-care ultrasound and routine third trimester ultrasound on undiagnosed breech presentation and perinatal outcomes: An observational multicentre cohort study.

25 : Universal late pregnancy ultrasound screening to predict adverse outcomes in nulliparous women: a systematic review and cost-effectiveness analysis.

26 : The impact of a routine late third trimester growth scan on the incidence, diagnosis, and management of breech presentation in Oxfordshire, UK: A cohort study.

27 : ACOG Committee Opinion No. 745: Mode of Term Singleton Breech Delivery.

28 : Informed consent to breech birth in New Zealand.

29 : Women's Selection of Mode of Birth for their Breech Presentation.

30 : Five years to the term breech trial: the rise and fall of a randomized controlled trial.

31 : The term, singleton, vaginal breech delivery controversy.

32 : Inappropriate use of randomised trials to evaluate complex phenomena: case study of vaginal breech delivery.

33 : Vaginal breech delivery is still justified.

34 : There is still room for disagreement about vaginal delivery of breech infants at term.

35 : Why vaginal breech delivery should still be offered.

36 : Women's experiences of breech birth and disciplinary power.

37 : External cephalic version for breech presentation at term.

38 : 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.

39 : Mode of delivery and development of atopic disease during the first 2 years of life.

40 : Caesarean section and gastrointestinal symptoms, atopic dermatitis, and sensitisation during the first year of life.

41 : Trends, characteristics, and outcomes of placenta accreta spectrum: a national study in the United States.

42 : Multiple repeat cesareans and the threat of placenta accreta: incidence, diagnosis, management.

43 : Maternal and neonatal outcomes in the following delivery after previous preterm caesarean breech birth: a national cohort study.

44 : Term cesarean breech delivery in the first pregnancy is associated with an increased risk for maternal and neonatal morbidity in the subsequent delivery: a national cohort study.

45 : Maternal deaths after elective cesarean section for breech presentation in the Netherlands.

46 : Report of a breech cesarean section maternal death.

47 : Maternal and neonatal outcomes after caesarean delivery in the African Surgical Outcomes Study: a 7-day prospective observational cohort study.

48 : Planned caesarean section for term breech delivery.

49 : The randomized management of term frank breech presentation: a study of 208 cases.

50 : Randomized management of the nonfrank breech presentation at term: a preliminary report.

51 : Term breech deliveries in the Netherlands: did the increased cesarean rate affect neonatal outcome? A population-based cohort study.

52 : Term breech presentation-Intended cesarean section versus intended vaginal delivery-A systematic review and meta-analysis.

53 : Consequences of the Term Breech Trial in Denmark.

54 : Neonatal outcome of singleton term breech deliveries in Norway from 1991 to 2011.

55 : Time trend in the risk of delivery-related perinatal and neonatal death associated with breech presentation at term.

56 : How singleton breech babies at term are born in France: a survey of data from the AUDIPOG network.

57 : Trends in vaginal breech delivery.

58 : Maternal outcomes of term breech presentation delivery: impact of successful external cephalic version in a nationwide sample of delivery admissions in the United States.

59 : Delivery of breech presentation at term gestation in Canada, 2003-2011.

60 : Is planned vaginal delivery for breech presentation at term still an option? Results of an observational prospective survey in France and Belgium.

61 : Fetal outcome for infants in breech by method of delivery: experiences with a stand-by service system of senior obstetricians and women's choices of mode of delivery.

62 : Evaluation of a decision protocol for type of delivery of infants in breech presentation at term.

63 : Vaginal breech delivery: results of a prospective registration study.

64 : Breech Presentation: Vaginal Versus Cesarean Delivery, Which Intervention Leads to the Best Outcomes?

65 : Delivery in breech presentation: Perinatal outcome and neurodevelopmental evaluation at 18 months of life.

66 : Maternal and neonatal outcome after vaginal breech delivery of nulliparous versus multiparous women of singletons at term-A prospective evaluation of the Frankfurt breech at term cohort (FRABAT).

67 : Vaginal breech delivery of pregnancy before and after the estimated due date-A prospective cohort study.

68 : Factors associated with adverse perinatal outcomes for term breech fetuses with planned vaginal delivery.

69 : Vaginal vs. cesarean delivery for preterm breech presentation of singleton infants in California: a population-based study.

70 : Early preterm breech delivery: is a policy of planned vaginal delivery associated with increased risk of neonatal death?

71 : Vaginal delivery versus caesarean section in preterm breech delivery: a systematic review.

72 : Preterm Breech Presentation: A Comparison of Intended Vaginal and Intended Cesarean Delivery.

73 : What is the safest mode of birth for extremely preterm breech singleton infants who are actively resuscitated? A systematic review and meta-analyses.

74 : Neonatal Mortality and Long-Term Outcome of Infants Born between 27 and 32 Weeks of Gestational Age in Breech Presentation: The EPIPAGE Cohort Study.

75 : Breech presentation at term and associated obstetric risks factors-a nationwide population based cohort study.

76 : Congenital anomalies in breech presentation: A nationwide record linkage study.

77 : Congenital anomalies in breech presentation: A nationwide record linkage study.

78 : Breech deformation complex in neonates.

79 : The relationship between mode of delivery and developmental dysplasia of the hip in breech infants: a four-year prospective cohort study.

80 : Predictors of Hip Dysplasia at 4 Years in Children with Perinatal Risk Factors.

81 : Late Hip Dysplasia After Normal Ultrasound in Breech Babies: Implications on Surveillance Recommendations.

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

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

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

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

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

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

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

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

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

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

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

None declared.

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

Cátia Samajo Zita.

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

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

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