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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. Zink is a board-certified emergency medicine physician with expertise in the wilderness and global medicine.

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INTRODUCTION

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

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

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

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

• Key Points |

Abnormal fetal lie or presentation may occur due to fetal size, fetal anomalies, uterine structural abnormalities, multiple gestation, or other factors. Diagnosis is by examination or ultrasonography. Management is with physical maneuvers to reposition the fetus, operative vaginal delivery , or cesarean delivery .

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

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

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

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

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

Abnormal fetal lie, presentation, or position may occur with

Fetopelvic disproportion (fetus too large for the pelvic inlet)

Fetal congenital anomalies

Uterine structural abnormalities (eg, fibroids, synechiae)

Multiple gestation

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

Transverse lie

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

Breech presentation

There are several types of breech presentation.

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

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

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

Types of breech presentations

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

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

Predisposing factors for breech presentation include

Preterm labor

Uterine abnormalities

Fetal anomalies

If delivery is vaginal, breech presentation may increase risk of

Umbilical cord prolapse

Birth trauma

Perinatal death

Face or brow presentation

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

Brow presentation usually converts spontaneously to vertex or face presentation.

Occiput posterior position

The most common abnormal position is occiput posterior.

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

Progress may arrest in the second phase of labor. Operative vaginal delivery or cesarean delivery is often required.

Position and Presentation of the Fetus

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

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

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

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Breech presentation

• Overview  
• Theory  
• Diagnosis  
• Management  
• Follow up  
• Resources  

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

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

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

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

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

Breech presentation in pregnancy occurs when a baby presents with the buttocks or feet rather than the head first (cephalic presentation) and is associated with increased morbidity and mortality for both the mother and the baby. [1] Cunningham F, Gant N, Leveno K, et al. Williams obstetrics. 21st ed. New York: McGraw-Hill; 1997. [2] Kish K, Collea JV. Malpresentation and cord prolapse. In: DeCherney AH, Nathan L, eds. Current obstetric and gynecologic diagnosis and treatment. New York: McGraw-Hill Professional; 2002. There is good current evidence regarding effective management of breech presentation in late pregnancy using external cephalic version and/or planned cesarean section.

History and exam

Key diagnostic factors.

• buttocks or feet as the presenting part
• fetal head under costal margin
• fetal heartbeat above the maternal umbilicus

Other diagnostic factors

• subcostal tenderness
• pelvic or bladder pain

Risk factors

• premature fetus
• small for gestational age fetus
• nulliparity
• fetal congenital anomalies
• previous breech delivery
• uterine abnormalities
• abnormal amniotic fluid volume
• placental abnormalities
• female fetus

Diagnostic investigations

1st investigations to order.

• transabdominal/transvaginal ultrasound

Treatment algorithm

<37 weeks' gestation and in labor, ≥37 weeks' gestation not in labor, ≥37 weeks' gestation in labor: no imminent delivery, ≥37 weeks' gestation in labor: imminent delivery, contributors, natasha nassar, phd.

Associate Professor

Menzies Centre for Health Policy

Sydney School of Public Health

University of Sydney

Disclosures

NN has received salary support from Australian National Health and a Medical Research Council Career Development Fellowship; she is an author of a number of references cited in this topic.

Christine L. Roberts, MBBS, FAFPHM, DrPH

Research Director

Clinical and Population Health Division

Perinatal Medicine Group

Kolling Institute of Medical Research

CLR declares that she has no competing interests.

Jonathan Morris, MBChB, FRANZCOG, PhD

Professor of Obstetrics and Gynaecology and Head of Department

JM declares that he has no competing interests.

Peer reviewers

John w. bachman, md.

Consultant in Family Medicine

Department of Family Medicine

Mayo Clinic

JWB declares that he has no competing interests.

Rhona Hughes, MBChB

Lead Obstetrician

Lothian Simpson Centre for Reproductive Health

The Royal Infirmary

RH declares that she has no competing interests.

Brian Peat, MD

Director of Obstetrics

Women's and Children's Hospital

North Adelaide

South Australia

BP declares that he has no competing interests.

Lelia Duley, MBChB

Professor of Obstetric Epidemiology

University of Leeds

Bradford Institute of Health Research

Temple Bank House

Bradford Royal Infirmary

LD declares that she has no competing interests.

Justus Hofmeyr, MD

Head of the Department of Obstetrics and Gynaecology

East London Private Hospital

East London

South Africa

JH is an author of a number of references cited in this topic.

Differentials

• Transverse lie
• Caesarean birth
• Mode of term singleton breech delivery

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Breech presentation: diagnosis and management

Key messages.

• All women with a breech presentation should be offered an external cephalic version (ECV) from 37 weeks, if there are no contraindications.
• Elective caesarean section (ELCS) for a singleton breech at term has been shown to reduce perinatal and neonatal mortality rates.
• Planning for vaginal breech birth requires careful assessment of suitability criteria, contraindications and the ability of the service to provide experienced personnel.

In June 2023, we commenced a project to review and update the Maternity and Neonatal eHandbook guidelines, with a view to targeting completion in 2024. Please be aware that pending this review, some of the current guidelines may be out of date. In the meantime, we recommend that you also refer to more contemporaneous evidence.

Breech and external cephalic version

Breech presentation is when the fetus is lying longitudinally and its buttocks, foot or feet are presenting instead of its head.

Figure 1. Breech presentations

• Breech presentation occurs in three to four per cent of term deliveries and is more common in nulliparous women.
• External cephalic version (ECV) from 37 weeks has been shown to decrease the incidence of breech presentation at term and the subsequent elective caesarean section (ELCS) rate.
• Vaginal breech birth increases the risk of low Apgar scores and more serious short-term complications, but evidence has not shown an increase in long-term morbidity.
• Emergency caesarean section (EMCS) is needed in approximately 40 per cent of women planning a vaginal breech birth.
• 0.5/1000 with ELCS for breech >39 weeks gestation
• 2.0/1000 planned vaginal breech birth >39/40
• 1.0/1000 with planned cephalic birth.
• A reduction in planned vaginal breech birth followed publication of the Term Breech Trial (TBT) in 2001.
• Acquisition of skills necessary to manage breech presentation (for example, ECV) is important to optimise outcomes.

Clinical suspicion of breech presentation

• Abdominal palpation: if the presenting part is irregular and not ballotable or if the fetal head is ballotable at the fundus
• Pelvic examination: head not felt in the pelvis
• Cord prolapse
• Very thick meconium after rupture of membranes
• Fetal heart heard higher in the abdomen

In cases of extended breech, the breech may not be ballotable and the fetal heart may be heard in the same location as expected for a cephalic presentation.

If breech presentation is suspected, an ultrasound examination will confirm diagnosis.

Cord prolapse is an obstetric emergency. Urgent delivery is indicated after confirming gestation and fetal viability.

Diagnosis: preterm ≤36+6 weeks

• Breech presentation is a normal finding in preterm pregnancy.
• If diagnosed at the 35-36 week antenatal visit, refer the woman for ultrasound scan to enable assessment prior to ECV.
• Mode of birth in a breech preterm delivery depends on the clinical circumstances.

Diagnosis: ≥37+0 weeks

• determine type of breech presentation
• determine extension/flexion of fetal head
• locate position of placenta and exclude placenta praevia
• exclude fetal congenital abnormality
• calculate amniotic fluid index
• estimate fetal weight.

Practice points

• Offer ECV if there are no contraindications.
• If ECV is declined or unsuccessful, provide counselling on risks and benefits of a planned vaginal birth versus an ELCS.
• Inform the woman that there are fewer maternal complications with a successful vaginal birth, however the risk to the woman increases significantly if there is a need for an EMCS.
• Inform the woman that caesarean section increases the risk of complication in future pregnancies, including the risk of a repeat caesarean section and the risk of invasive placentation.
• If the woman chooses an ELCS, document consent and organise booking for 39 weeks gestation.

Information and decision making

Women with a breech presentation should have the opportunity to make informed decisions about their care and treatment, in partnership with the clinicians providing care.

Planning for birth requires careful assessment for risk of poor outcomes relating to planned vaginal breech birth. If any risk factors are identified, inform the woman that an ELCS is recommended due to increased perinatal risk.

Good communication between clinicians and women is essential. Treatment, care and information provided should:

• take into account women's individual needs and preferences
• be supported by evidence-based, written information tailored to the needs of the individual woman
• be culturally appropriate
• be accessible to women, their partners, support people and families
• take into account any specific needs, such as physical or cognitive disabilities or limitations to their ability to understand spoken or written English.

Documentation

The following should be documented in the woman's hospital medical record and (where applicable) in her hand-held medical record:

• discussion of risks and benefits of vaginal breech birth and ELCS
• discussion of the woman's questions about planned vaginal breech birth and ELCS
• discussion of ECV, if applicable
• consultation, referral and escalation

External cephalic version (ECV)

• ECV can be offered from 37 weeks gestation
• The woman must provide written consent prior to the procedure
• The success rate of ECV is 40-60 per cent
• Approximately one in 200 ECV attempts will lead to EMCS
• ECV should only be performed by a suitably trained, experienced clinician
• continuous electronic fetal monitoring (EFM)
• capability to perform an EMCS.

Contraindications

Table 1. Contraindications to ECV

Precautions

• Hypertension
• Oligohydramnios
• Nuchal cord

Escalate care to a consultant obstetrician if considering ECV in these circumstances.

• Perform a CTG prior to the procedure - continue until  RANZCOG criteria  for a normal antenatal CTG are met.
• 250 microg s/c, 30 minutes prior to the procedure.
• Administer Anti-D immunoglobulin if the woman is rhesus negative.
• Do not make more than four attempts at ECV, for a suggested maximum time of ten minutes in total.
• Undertake CTG monitoring post-procedure until  RANZCOG criteria  for a normal antenatal CTG are met.

Emergency management

Urgent delivery is indicated in the event of the following complications:

• abnormal CTG
• vaginal bleeding
• unexplained pain.

Initiate emergency response as per local guidelines.

Alternatives to ECV

There is a lack of evidence to support the use of moxibustion, acupuncture or postural techniques to achieve a vertex presentation after 35 weeks gestation.

Criteria for a planned vaginal breech birth

• Documented evidence of counselling regarding mode of birth
• Documentation of informed consent, including written consent from the woman
• Estimated fetal weight of 2500-4000g
• Flexed fetal head
• Emergency theatre facilities available on site
• Availability of suitably skilled healthcare professional
• Frank or complete breech presentation
• No previous caesarean section.
• Cord presentation
• Fetal growth restriction or macrosomia
• Any presentation other than a frank or complete breech
• Extension of the fetal head
• Fetal anomaly incompatible with vaginal delivery
• Clinically inadequate maternal pelvis
• Previous caesarean section
• Inability of the service to provide experienced personnel.

If an ELCS is booked

• Confirm presentation by ultrasound scan when a woman presents for ELCS.
• If fetal presentation is cephalic on admission for ELCS, plan ongoing management with the woman.

Intrapartum management

Fetal monitoring.

• Advise the woman that continuous EFM may lead to improved neonatal outcomes.
• Where continuous EFM is declined, perform intermittent EFM or intermittent auscultation, with conversion to EFM if an abnormality is detected.
• A fetal scalp electrode can be applied to the breech.

Position of the woman

• The optimal maternal position for birth is upright.
• Lithotomy may be appropriate, depending on the accoucheur's training and experience.

Pain relief

• Epidural analgesia may increase the risk of intervention with a vaginal breech birth.
• Epidural analgesia may impact on the woman's ability to push spontaneously in the second stage of labour.

Induction of labour (IOL)

See the  IOL eHandbook page  for more detail.

• IOL may be offered if clinical circumstances are favourable and the woman wishes to have a vaginal birth.
• Augmentation (in the absence of an epidural) should be avoided as adequate progress in the absence of augmentation may be the best indicator of feto-pelvic proportions.

The capacity to offer IOL will depend on clinician experience and availability and service capability.

First stage

• Manage with the same principles as a cephalic presentation.
• Labour should be expected to progress as for a cephalic presentation.
• If progress in the first stage is slow, consider a caesarean section.
• If an epidural is in situ and contractions are less than 4:10, consult with a senior obstetrician.
• Avoid routine amniotomy to avoid the risk of cord prolapse or cord compression.

Second stage

• Allow passive descent of the breech to the perineum prior to active pushing.
• If breech is not visible within one hour of passive descent, a caesarean section is normally recommended.
• Active second stage should be ½ hour for a multigravida and one hour for a primipara.
• All midwives and obstetricians should be familiar with the techniques and manoeuvres required to assist a vaginal breech birth.
• Ensure a consultant obstetrician is present for birth.
• Ensure a senior paediatric clinician is present for birth.

VIDEO:  Maternity Training International - Vaginal Breech Birth

• Encouragement of maternal pushing (if at all) should not begin until the presenting part is visible.
• A hands-off approach is recommended.
• Significant cord compression is common once buttocks have passed the perineum.
• Timely intervention is recommended if there is slow progress once the umbilicus has delivered.
• Allow spontaneous birth of the trunk and limbs by maternal effort as breech extraction can cause extension of the arms and head.
• Grasp the fetus around the bony pelvic girdle, not soft tissue, to avoid trauma.
• Assist birth if there is a delay of more than five minutes from delivery of the buttocks to the head, or of more than three minutes from the umbilicus to the head.
• Signs that delivery should be expedited also include lack of tone or colour or sign of poor fetal condition.
• Ensure fetal back remains in the anterior position.
• Routine episiotomy not recommended.
• Lovset's manoeuvre for extended arms.
• Reverse Lovset's manoeuvre may be used to reduce nuchal arms.
• Supra-pubic pressure may aide flexion of the fetal head.
• Maricueau-Smellie-Veit manoeuvre or forceps may be used to deliver the after coming head.

Undiagnosed breech in labour

• This occurs in approximately 25 per cent of breech presentations.
• Management depends on the stage of labour when presenting.
• Assessment is required around increased complications, informed consent and suitability of skilled expertise.
• Do not routinely offer caesarean section to women in active second stage.
• If there is no senior obstetrician skilled in breech delivery, an EMCS is the preferred option.
• If time permits, a detailed ultrasound scan to estimate position of fetal neck and legs and estimated fetal weight should be made and the woman counselled.

Entrapment of the fetal head

This is an extreme emergency

This complication is often due to poor selection for vaginal breech birth.

• A vaginal examination (VE) should be performed to ensure that the cervix is fully dilated.
• If a lip of cervix is still evident try to push the cervix over the fetal head.
• If the fetal head has entered the pelvis, perform the Mauriceau-Smellie-Veit manoeuvre combined with suprapubic pressure from a second attendant in a direction that maintains flexion and descent of the fetal head.
• Rotate fetal body to a lateral position and apply suprapubic pressure to flex the fetal head; if unsuccessful consider alternative manoeuvres.
• Reassess cervical dilatation; if not fully dilated consider Duhrssen incision at 2, 10 and 6 o'clock.
• A caesarean section may be performed if the baby is still alive.

Neonatal management

• Paediatric review.
• Routine observations as per your local guidelines, recorded on a track and trigger chart.
• Observe for signs of jaundice.
• Observe for signs of tissue or nerve damage.
• Hip ultrasound scan to be performed at 6-12 weeks post birth to monitor for developmental dysplasia of the hip (DDH). See Neonatal eHandbook -  Developmental dysplasia of the hip .

More information

Audit and performance improvement.

All maternity services should have processes in place for:

• auditing clinical practice and outcomes
• providing feedback to clinicians on audit results
• addressing risks, if identified
• implementing change, if indicated.

Potential auditable standards are:

• number of women with a breech presentation offered ECV
• success rate of ECV
• ECV complications
• rate of planned vaginal breech birth
• breech birth outcomes for vaginal and caesarean birth.

For more information or assistance with auditing, please contact us via  [email protected]

• Bue and Lauszus 2016, Moxibustion did not have an effect in a randomised clinical trial for version of breech position.  Danish Medical Journal  63(2), A599
• Coulon et.al. 2014,  Version of breech fetuses by moxibustion with acupuncture.  Obstetrics and Gynecology  124(1), 32-39. DOI: 10.1097/AOG.0000000000000303
• Coyle ME, Smith CA, Peat B 2012, Cephalic version by moxibustion for breech presentation.  Cochrane Database of Systematic Reviews  2012, Issue 5. Art. No.: CD003928. DOI: 10.1002/14651858.CD003928.pub3
• Evans J 2012,  Essentially MIDIRS Understanding Physiological Breech Birth  Volume 3. Number 2. February 2012
• Hoffmann J, Thomassen K, Stumpp P, Grothoff M, Engel C, Kahn T, et al. 2016, New MRI Criteria for Successful Vaginal Breech Delivery in Primiparae.  PLoS ONE  11(8): e0161028. doi:10.1371/journal.pone.0161028
• Hofmeyr GJ, Kulier R 2012, Cephalic version by postural management for breech presentation.  Cochrane Database of Systematic Reviews  2012, Issue 10. Art. No.: CD000051. DOI: 10.1002/14651858.CD000051.pub2
• New South Wales Department of Health 2013,  Maternity: Management of Breech Presentation  HNELHD CG 13_01, NSW Government; 2013
• Royal College of Obstetricians and Gynaecologists 2017, External Cephalic Version and Reducing the Incidence of Term Breech Presentation.  Green-top Guideline No. 20a . London: RCOG; 2017
• The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) 2016,  Management of breech presentation at term , July 2016 C-Obs-11:
• The Royal Women's Hospital 2015,  Management of Breech - Clinical Guideline
• Women's and Newborn Health Service, King Edward Memorial Hospital 2015, Complications of Pregnancy Breech Presentation

Abbreviations

Get in touch, version history.

First published:  November 2018 Due for review:  November 2021

Uncontrolled when downloaded

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Maternal and fetal risks of planned vaginal breech delivery vs planned caesarean section for term breech birth: A systematic review and meta-analysis

Francisco j fernández-carrasco.

1 Department of Gynaecology and Obstetrics, Punta de Europa Hospital, Cádiz, Spain

2 Nursing and Physiotherapy Department, Faculty of Nursing, University of Cádiz, Algeciras, Spain

Delia Cristóbal-Cañadas

3 Neonatal and Paediatric Intensive Care Unit, Torrecárdenas University Hospital, Almeria, Spain

Juan Gómez-Salgado

4 Department of Gynaecology and Obstetrics, Ceuta University Hospital, Midwifery Teaching Unit of Ceuta, University of Granada, Ceuta, Spain

5 Safety and Health Postgraduate Programme, Espíritu Santo University, Guyaquil, Ecuador

Juana M Vázquez-Lara

6 Department of Gynaecology and Obbstetrics, Ceuta University Hospital, Midwifery Teaching Unit of Ceuta, University of Granada, Ceuta, Spain

Luciano Rodríguez-Díaz

Tesifón parrón-carreño.

7 School of Health Sciences, University of Almeria, Almeria, Spain

8 Territorial Delegation of Equality, Health and Social Policies, Health Delegation of Almeria, Almeria, Spain

Associated Data

Breech presentation delivery approach is a controversial issue in obstetrics. How to cope with breech delivery (vaginal or C-section) has been discussed to find the safest in terms of morbidity. The aim of this study was to assess the risks of foetal and maternal mortality and perinatal morbidity associated with vaginal delivery against elective caesarean in breech presentations, as reported in observational studies.

Studies assessing perinatal morbidity and mortality associated with breech presentations births. Cochrane, Medline, Scopus, Embase, Web of Science, and Cuiden databases were consulted. This protocol was registered in PROSPERO CRD42020197598. Selection criteria were: years between 2010 and 2020, in English language, and full-term gestation (37-42 weeks). The methodological quality of the eligible articles was assessed according to the Newcastle-Ottawa scale. Meta-analyses were performed to study each parameter related to neonatal mortality and maternal morbidity.

The meta-analysis included 94 285 births with breech presentation. The relative risk of perinatal mortality was 5.48 (95% confidence interval (CI) = 2.61-11.51) times higher in the vaginal delivery group, 4.12 (95% CI = 2.46-6.89) for birth trauma and 3.33 (95% CI = 1.95-5.67) for Apgar results. Maternal morbidity showed a relative risk 0.30 (95% CI = 0.13-0.67) times higher in the planned caesarean group.

Conclusions

An increment in the risk of perinatal mortality, birth trauma, and Apgar lower than 7 was identified in planned vaginal delivery. However, the risk of severe maternal morbidity because of complications of a planned caesarean was slightly higher.

One of the most controversial topics in obstetrics in recent years has been the discussion about how to deal with breech delivery, whether vaginal or caesarean. Although caesarean is considered a safe way of treating breech delivery, it contributes to high rates of postpartum maternal morbidity in developed countries and it is known to cause significant complications such as anaemia, urinary tract infections, superficial or complete dehiscence of the operative wound, endometritis, inflammatory complications [ 1 ], muscle pain, headache, lack of sexual satisfaction after delivery, digestive problems, fever and infection, abnormal bleeding, and stress urinary incontinence [ 2 ].

However, in 2000, the authors of the Term Breech Trial Collaborative Group (TBT) [ 3 ] published a randomised multicentre collaborative study about how to deal with term breech delivery. They concluded that elective caesareans offered better results than vaginal deliveries in full-term foetuses with breech presentation, while maternal complications were similar between the two groups. So, according to this evidence, the practice of elective caesarean was fostered in such presentations [ 3 ]. Following this trend, the TBT recommendation was adopted by important organisations in many countries, opting for a scheduled caesarean before the end of gestation and this way preventing spontaneous breech vaginal delivery, and the attributed risks, from being triggered [ 4 ].

Subsequently, in 2006 the PREMODA multicentre study was published [ 5 ]. Based on this study, The American College of Obstetricians and Gynecologists changed their protocols that same year and concluded that vaginal delivery in breech presentation and single-term gestation was a reasonable option in properly selected pregnant women and experienced health workers [ 6 ].

Therefore, the TBT study [ 3 ] was called into question and some national associations [ 7 ] included the option of having a vaginal breech delivery in their childbirth care protocol for full-term breech presentation, allowing the free evolution of the delivery process, provided that there is specifically trained staff in the affected centre. This procedure is currently accepted [ 6 ].

Analysing the original TBT data [ 3 ], serious concerns were raised regarding the design of the study, methods, and conclusions. In a considerable number of cases, there was a lack of adherence to the inclusion criteria and there was great interinstitutional variation regarding the standards of care. Also, inadequate methods of foetal antepartum and intrapartum evaluation were used, and a large proportion of women were recruited during active delivery, in many cases, without assistance from a doctor with adequate experience [ 8 ].

Primary caesarean in the first pregnancy has been associated with neonatal and maternal adverse outcomes in subsequent delivery [ 9 ]. In this way, abandoning vaginal delivery with breech presentation and opting indiscriminately for a caesarean would mean denying women access to health care options [ 10 ].

The Cochrane review conducted by Hofmeyr et al., which focused on planned caesarean section for term breech delivery, concluded that it reduced perinatal and neonatal death as well as serious neonatal morbidity, at the expense of somewhat increased maternal morbidity compared with planned vaginal delivery. Authors suggested to consider mother's preference for vaginal birth and risks such as future pregnancy complications, and the option of external cephalic version [ 11 ].

The meta-analysis conducted by Berhan et al. [ 12 ] (1993-2014) aimed at assessing the risk of morbidity and perinatal mortality in breech, full-term and single-foetus deliveries. Results showed a higher relative risk in vaginal delivery for perinatal mortality, trauma at birth, and Apgar at the fifth minute of life.

The present meta-analysis sought to update scientific evidence with the latest studies published in the last 10 years (2010-2020), so the results would be a complementary update. The objective of this meta-analysis was to compare the risks of vaginal delivery with elective caesarean in breech presentations, in terms of neonatal mortality, perinatal trauma, Apgar, neonatal intensive care unit (ICU) admittance, and maternal morbidity, according to evidence published during the last 10 years.

Study design

A systematic review of observational studies and meta-analysis was conducted. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed [ 13 , 14 ].

A systematic bibliographic search was carried out using the Cochrane, Medline, Scopus, Embase, Web of Science, and Cuiden databases. Extensive searches were performed on the reference lists of selected articles. Our search terms included: “breech”, “breech presentation”, “breech birth”, “breech delivery”. During the process, search terms were alternately combined using Boolean logic. The search was based on a clinically answerable question in PICO format, Population (pregnant women with single, full-term foetus, and breech presentation); Intervention (vaginal delivery risks); Comparison (caesarean delivery risks) and Outcomes (risk of neonatal mortality, perinatal trauma, Apgar test with low score, neonatal ICU admittance, and maternal morbidity). Following this structure, the different search strategies were designed. The detailed search strategies employed in each database are summarised in Table S1 in the Online Supplementary Document .

This revision protocol was registered in PROSPERO.

Inclusion and selection criteria

For this study, the default inclusion criteria were:

• Observational studies of cohorts were included; reviews, brief reports, guidelines, and comments were excluded.
• Studies that assessed perinatal mortality and morbidity in relation to the type of delivery with breech presentation.
• Studies published in any language, between January 2010 and September 2020.
• Studies in which the samples were characterised by full-term gestations (between 37 and 42 weeks of gestation), with a single foetus, and breech presentation.

The authors decided to establish observational studies as an inclusion criterion as a review restricted to randomised controlled trials would have given an incomplete summary of the effects of a treatment, due to potential harms. Therefore, ClinicalTrials.gov was not consulted. The studies published before 2010 were excluded because recent scientific publications have turned other previously published ones into outdated evidence, and the aimed was to gather the latest reliable results. In addition, studies where foetuses had lethal congenital abnormalities and caesareans made by other obstetric indications such as multiple pregnancy or intrauterine foetal deaths were also excluded.

The selection of studies was carried out in three stages. First, after reviewing the titles, all relevant literature was retrieved from the respective databases. Second, summaries of all recovered articles were reviewed and then grouped as “eligible for inclusion” or “Not eligible for inclusion”. Third, articles that were grouped as “eligible for inclusion” were revised in detail for the final decision.

The entire process of selection, the quality assessment and also data extraction were carried out by two investigators independently. Each study was individually evaluated by one of the researchers and results were shared. In case of discrepancies, both researchers discussed their arguments and agreement was reached by consensus; occasionally, a third researcher’s assessment was required.

Methodological quality of the included studies

The methodological quality of the eligible articles was assessed according to the Newcastle-Ottawa scale. This scale was designed for assessing the quality of non-randomised studies included in a systematic review and/or meta-analyses. It contains eight items organised in three dimensions: the selection of the study groups (four items); the comparability of the groups (one item); and the ascertainment of the outcome (three items). Studies were evaluated following a star system such that each item can be awarded a maximum of one star, excepting the item related to comparability, which allows the assignment of two stars. The total score ranges between zero and nine stars [ 15 , 16 ].

Data extraction

To structure the collected data, all results compatible with perinatal mortality and morbidity in relation to the type of delivery with breech presentation in full-term gestations (between 37 and 42 weeks of gestation) with a single foetus were searched internationally. The results of the different items were compared on the basis of the primary outcomes, which were neonatal mortality, perinatal trauma, Apgar, neonatal ICU admittance, and maternal morbidity.

Data were extracted using a standard Excel (Microsoft, Redmond, WA, USA) spreadsheet. The extracted data included: the name of the first author, year of publication, period of study, country where the study was conducted in, conclusion of the study, sample size, type of delivery, intrapartum and neonatal mortality, perinatal trauma, Apgar score at the first and fifth minute of life, neonatal ICU admissions, and severe maternal morbidity.

In this review, neonatal mortality was considered as deaths before 7 days of age after birth. The WHO establishes early neonatal mortality up to the seventh day of life. Complications at birth as a result of childbirth are manifested in the first 7 days [ 17 ]. In fact, all the observational studies included in the present meta-analysis took this same period of time as a reference. Perinatal trauma included collarbone fracture, humerus or femur, intracerebral bleeding, cephalic haematoma, facial paralysis, brachial plexus injury, and other trauma.

For this study, severe maternal morbidity was considered as unexpected labour and delivery outcomes that result in significant short-term or long-term consequences for the woman's health. Serious complications of the intervention, whether caesarean or delivery, severe postpartum haemorrhages, neurological problems, sepsis, lung, kidney, or cardiac problems were included [ 18 ].

Statistical analysis

A meta-analysis was performed to evaluate each of the indicators that could measure morbidity and mortality in planned vaginal delivery and scheduled caesarean for breech presentations for both the newborn and the mother.

The Mantel-Haenszel method was used to obtain typical RR estimates and 95% confidence intervals (CI). Heterogeneity was determined using the Cochran’s Q χ 2 test and the I 2 values for the following variables:

(1) Early and incipient neonatal death, (2) birth trauma, (3) Apgar test score at 5 minutes, (4) neonatal admission to ICU, (5) severe maternal morbidity.

Heterogeneity between studies was assessed by calculating values for I 2 and P values. Due to the high I 2 , an important statistic for assessing heterogeneity, the random effects method was used. The I 2 value was interpreted as without heterogeneity (0%), low heterogeneity (<40%), moderate heterogeneity (<60%), substantial heterogeneity (<75%) and considerable heterogeneity (≥75%) [ 19 ]. The stability of the overall RR in the withdrawal of any of the studies was performed by sensitivity analysis (treating one study at a time). All meta-analyses were performed using the Epidat Software 3.0 (Xunta de Galicia, Santiago de Compostela, Spain).

Description of the included studies

The initial electronic search yielded a total of 19 055 references, and after removing duplicate records, 6802 references were reviewed. Of these, after reading the title and abstract, 6644 references were deleted for not meeting the inclusion criteria, so 158 were selected for full text review. Following the research protocol, 142 were excluded because they were not related to the current revision, because some made comparisons between breech and vertex presentation, and others assessed long-term maternal and neonatal complications. Finally, 16 articles were selected for meta-analysis [ 10 , 20 - 34 ]. The selection process is shown in Figure 1 .

PRISMA flowchart.

Of the 16 studies, 10 had been conducted in Europe, 2 in Asia, 2 in Oceania, and 2 in Africa. Of these, 4 were in favour of elective caesarean to minimise neonatal morbidity but recognised that this increased long-term maternal morbidity by conditioning the type of birth for a future pregnancy [ 10 , 21 , 27 , 34 ]. Two of the reviewed studies found that caesarean reduced the risk of neonatal mortality [ 10 , 21 ]. However, 12 of the studies involved in the meta-analysis concluded that vaginal delivery could be an acceptable option in breech presentation provided that strict criteria for the selection of cases were established [ 20 , 22 - 26 , 28 - 33 ]. Sample sizes for the studies included ranged from 111 to 58 320 ( Table 1 ).

Characteristics of the studies included in the meta-analysis

Regarding methodological quality assessment, the included studies were scored from 5 to 9 stars according to de Newcastle-Ottawa scale ( Table 2 ). The publication bias was analysed, and results were summarised in Figure S1 and Figure S2 in the Online Supplementary Document .

Methodological quality assessment and quality of evidence*

*Selection: maximum score ****, Comparability: maximum score **, Outcome: maximum score ***. GRADE: 1 = high, 2 = moderate, 3 = low, 4 = very low.

Findings of the meta-analysis

Perinatal mortality analysis consisted of 16 studies and included 94 285 single foetus, full-term, breech presentation deliveries (38 787 planned vaginal deliveries and 55 498 scheduled caesareans). As shown in Figure 2 , perinatal mortality (intrapartum and early neonatal death) in the planned vaginal delivery group was 235 (0.6%), and in the elective caesarean group it was 76 (0.14%) (10,20-34). The grouped meta-analysis has shown that the risk of perinatal mortality was 5.48 (95% CI = 2.61 to 11.51) times higher in the vaginal delivery group than in the planned caesarean group. The overall heterogeneity of the tests showed substantial variability between studies (I 2  = 72%). Sensitivity analysis showed that the overall RR was 3.10; 95% CI = 1.8 - 5.2 (the detailed sensitivity analysis of each variable are summarised in Table S2 in the Online Supplementary Document ).

Meta-analysis of perinatal deaths in full-term singleton breech presentation (planned vaginal delivery vs planned caesarean section) (n = 94 285).

Perinatal trauma analysis included 70 143 single foetus, full-term, breech presentation deliveries (30 523 planned vaginal deliveries and 39 620 planned caesareans). As shown in Figure 3 , perinatal trauma in the planned vaginal delivery group was 285 (0.41%), and in the elective caesarean group it was 124 (0.18%) [ 10 , 20 , 22 - 25 , 27 , 29 , 30 , 32 - 34 ]. The grouped meta-analysis showed a 4.12 (95% CI = 2.46 to 6.89) times increased risk of birth trauma in the planned vaginal delivery group. The overall heterogeneity of the tests showed substantial variability between studies (I 2  = 70%). The sensitivity analysis showed that the overall RR was 3.6 95% CI = 2.17-6.09.

Meta-analysis of perinatal trauma in term singleton breech presentation (planned vaginal delivery vs planned caesarean section) (n = 70 143).

Regarding the Apgar score at minute 5, 13 studies were assessed including 92 135 deliveries with breech, single foetus, and term presentations (37 502 planned vaginal deliveries and 54 633 planned caesareans). 846 (0.92%) neonates of the planned vaginal delivery group had an Apgar below 7 points at the 5th minute of life. Also, in the planned caesarean group, there were 218 (0.24%) neonates whose test score was less than 7 points at 5 minutes of life [ 10 , 20 , 21 , 23 - 27 , 29 , 30 , 32 , 33 ] ( Figure 4 ). The grouped meta-analysis showed a nearly 3.33 (95% CI = 1.95-5.67) times higher risk of the Apgar test having a score of less than 7 points in the planned vaginal delivery group. The overall heterogeneity of the tests showed considerable variability between studies (I 2  = 86%). However, the sensitivity analysis showed that the overall RR was 3.8 95% CI = 2.07-7.25.

Meta-analysis of 5-minute Apgar <7 score in term singleton breech presentation (planned vaginal delivery vs planned caesarean section) (n = 92 135).

Admittance to neonatal ICU assessment included 9 studies, 32 438 single foetus, full-term, breech presentation deliveries (9053 planned vaginal deliveries and 23 385 elective caesareans) were included. In the planned vaginal delivery group, there were 435 (1.86%) admittances at the ICU of newborns, while in the planned caesarean group, the figure was 869 (3.72%) [ 20 , 21 , 23 - 25 , 27 , 29 , 30 ] ( Figure 5 ). The grouped meta-analysis showed a 1.90 (95% CI = 1.34-2.70) times increased risk of admittance to ICU in the planned vaginal delivery group. The overall heterogeneity of the tests showed substantial variability between studies (I 2  = 64%). However, the sensitivity analysis showed that the overall RR was 1.9 (95% CI = 1.36-2.76).

Meta-analysis of intensive care unit (ICU) admissions in term, singleton breech presentation (planned vaginal delivery vs planned caesarean section) (n = 32 438).

Regarding maternal morbidity, the analysis included 4 studies. 4007 single foetus, full-term, breech presentation deliveries were included (863 planned vaginal deliveries and 3144 planned caesareans) [ 23 , 27 , 30 , 34 ] ( Figure 6 ). Maternal morbidity was found in 6 cases (0.69%) for the planned vaginal delivery group, and in 83 cases (2.64%) for the planned caesarean group. The grouped meta-analysis showed a 0.30 (95% CI = 0.13-0.67) times reduced risk of severe maternal morbidity in the planned vaginal delivery group than in the planned caesarean group. The overall heterogeneity of the tests showed very low variability between studies (I 2  = 0%).

Meta-analysis of severe maternal morbidity in term singleton breech presentation (planned vaginal delivery vs planned caesarean section) (n = 4007).

Main findings

The meta-analysis has shown a decreased relative risk perinatal mortality and morbidity in a planned caesarean as compared with a vaginal delivery when breech presentation.

Interpretation

Regardless of whether childbirth is done vaginally or through caesarean delivery, morbidity and mortality rates have been represented higher at breech births than at cephalic births [ 35 ]. Since the publication of TBT [ 3 ], several studies have shown increased morbidity and perinatal mortality with breech presentations in planned vaginal delivery vs planned caesarean [ 9 , 21 , 36 , 37 ]. These results were consistent with TBT [ 3 ] and PREMODA results [ 5 ].

Although the potential biases associated with the observational design of the studies included in this meta-analysis must be recognised, with the consequent caution in comparing results with similar previous studies, our results were in line with previous meta-analyses. According to Berhan et al. [ 12 ], the relative risk of perinatal mortality, trauma at birth, and Apgar at the fifth minute of life were higher in the planned vaginal delivery than in planned caesarean for term singleton breech (3.4 vs 6.3; 3.1 vs 4.2; and 4.7 vs 2.99, respectively). Our study, despite having included only observational studies, agreed with these outcomes.

For the severe maternal morbidity indicator, the present meta-analysis showed a relative risk of 0.30 in favour of vaginal delivery. This means that vaginal delivery is a protective factor against severe maternal morbidity. Although the risk is low, maternal morbidity and mortality increase as a result of complications of a planned caesarean for breech presentations [ 21 , 36 ]. Several studies claimed that planned caesarean may increase the risks for the mother as a result of scarred uterus [ 9 , 21 , 34 ], so the relative safety of planned caesarean should be weighed [ 9 , 38 ].

In the absence of a contraindication for vaginal delivery, a woman with a breech presentation foetus must be truthfully informed, considering the scientific evidence so far, of the risks and benefits of vaginal breech delivery and elective caesarean, so that the woman can decide and consent to the desired type of delivery [ 29 , 39 ]. The woman's decision must be respected and, to do so, the staff attending births must be trained and updated in the assistance of breech vaginal deliveries [ 39 , 40 ]. Otherwise, the woman will be denied a medical treatment option to which she could have turned to [ 40 ].

Regardless of the way of planning the type of delivery, vaginal delivery in breech presentation will always exist, as a delivery may always become urgent and present with these characteristics. Therefore, it is essential that staff attending births do not lose this ability and master it in order to provide quality health care to women [ 39 ].

Strengths and limitations

The risks for neonatal mortality and maternal morbidity implies an ethical dilemma: assuming either the risk of neonatal mortality or the risk of severe maternal morbidity. The risk of neonatal mortality was higher; therefore, we would only consider exposing the mother and foetus to vaginal delivery in the case of good obstetric conditions and given that the health care professional is well trained and experienced in these procedures. Otherwise, we recommend delivery by caesarean section. Our study bases the practice of individualisation on decision-making when choosing the type of delivery in unique gestations with full-term foetuses and breech presentation. Each pregnancy should assess the risks individually, considering the woman's preferences and the context, and seeking a balance between neonatal mortality and maternal morbidity.

Some limitations have been found in conducting this research, starting with the great variability regarding the size of the samples. Studies with very small samples have had little weight when calculating RR in the grouped meta-analysis, while studies with a very large sample size had much more weight. For this reason, we have had to accept a relatively high (moderate) percentage of heterogeneity (I 2 ) in some meta-analyses as, if eliminated, the sample would be drastically reduced.

Vaginal, breech, full-term delivery with a single foetus had a higher risk of morbidity and perinatal mortality than caesarean delivery under the same conditions. Still, the results of this meta-analysis suggested that the risk of vaginal breech delivery is lower than in the results of other previously published studies [ 29 - 31 , 33 , 34 ].

Additionally, the potential bias accompanying observational studies should be acknowledged, given the Newcastle-Ottawa tool identified some items with lack of quality. Therefore, caution is suggested when comparing and generalising the results.

CONCLUSIONS

Term breech birth risks have been analysed according to two possibilities: Vaginal delivery and caesarean delivery risks. Caesarean had high rates of postpartum maternal morbidity. Also, there is no evidence of reduced child perinatal morbidity or mortality. Otherwise, there is no contraindication for vaginal delivery in breech presentation in selected pregnant women and in the presence of experienced health workers.

Our results could help in decision-making related to breech delivery, individualising the decision for each case by knowing the risks associated with each option. From an ethical perspective, the issue addressed in the review is highly sensitive, considering the risk of maternal morbidity and the risk of neonatal mortality. For this reason, further research is suggested that consolidates the available evidence for decision-making between the studied delivery methods.

Additional material

Funding : None.

Authors contributions : Conceptualization, FJFC, DCC, JMVL, TPC and LRD; Data curation, FJFC and DCC; Formal analysis, FJFC, DCC, JGS, JMVL, TPC and LRD; Investigation, FJFC, DCC, JGS, JMVL and TPC; Methodology, FJFC, JGS, JMVL, TPC and LRD; Project administration, TPC and LRD; Resources, DCC, JGS, JMVL and LRD; Software, FJFC, DCC, JGS and LRD; Supervision, JMVL, TPC and LRD; Validation, DCC, JGS, JMVL and TPC; Visualization, TPC; Writing – original draft, FJFC, DCC and JMVL; Writing – review & editing, JGS, JMVL, TPC and LRD.

Disclosure of interest: The authors completed the ICMJE Disclosure of Interest Form (available upon request from the corresponding author) and declare no conflicts of interest.

Breech baby at the end of pregnancy

Published: July 2017

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

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

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

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

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

This information includes:

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

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

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

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

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

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

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

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

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

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

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

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

What does ECV involve?

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

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

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

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

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

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

Why turn my baby head-first?

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

Is ECV safe for me and my baby?

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

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

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

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

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

ECV should not be carried out if:

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

Is ECV always successful?

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

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

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

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

Depending on your situation, your choices are:

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

Caesarean section

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

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

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

Vaginal breech birth

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

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

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

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

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

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

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

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

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

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

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

Further information

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

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

Ask 3 Questions

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

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

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

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

Sources and acknowledgements

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

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

Please give us feedback by completing our feedback survey:

• Members of the public – patient information feedback
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External Cephalic Version and Reducing the Incidence of Term Breech Presentation Green-top Guideline

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What Causes Breech Presentation?

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

What Is Breech Presentation?

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

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

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

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

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

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

Frank Breech

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

Footling Breech

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

Complete Breech

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

Other Types of Mal Presentations

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

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

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

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

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

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

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

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

ACOG. If Your Baby Is Breech .

American Pregnancy Association. Breech Presentation .

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

Mount Sinai. Breech Babies .

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

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

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

Related Articles

What happens if your baby is breech?

Babies often twist and turn during pregnancy, but most will have moved into the head-down (also known as head-first) position by the time labour begins. However, that does not always happen, and a baby may be:

• bottom first or feet first (breech position)
• lying sideways (transverse position)

Bottom first or feet first (breech baby)

If your baby is lying bottom or feet first, they are in the breech position. If they're still breech at around 36 weeks' gestation, the obstetrician and midwife will discuss your options for a safe delivery.

Turning a breech baby

If your baby is in a breech position at 36 weeks, you'll usually be offered an external cephalic version (ECV). This is when a healthcare professional, such as an obstetrician, tries to turn the baby into a head-down position by applying pressure on your abdomen. It's a safe procedure, although it can be a bit uncomfortable.

Giving birth to a breech baby

If an ECV does not work, you'll need to discuss your options for a vaginal birth or  caesarean section  with your midwife and obstetrician.

If you plan a caesarean and then go into labour before the operation, your obstetrician will assess whether it's safe to proceed with the caesarean delivery. If the baby is close to being born, it may be safer for you to have a vaginal breech birth.

The Royal College of Obstetricians and Gynaecologists (RCOG) website has more information on what to expect if your baby is still breech at the end of pregnancy .

The RCOG advises against a vaginal breech delivery if:

• your baby's feet are below its bottom – known as a "footling breech"
• your baby is larger or smaller than average – your healthcare team will discuss this with you
• your baby is in a certain position – for example, their neck is very tilted back, which can make delivery of the head more difficult
• you have a low-lying placenta (placenta praevia)
• you have  pre-eclampsia

Lying sideways (transverse baby)

If your baby is lying sideways across the womb, they are in the transverse position. Although many babies lie sideways early on in pregnancy, most turn themselves into the head-down position by the final trimester.

Giving birth to a transverse baby

Depending on how many weeks pregnant you are when your baby is in a transverse position, you may be admitted to hospital. This is because of the very small risk of the umbilical cord coming out of your womb before your baby is born (cord prolapse). If this happens, it's a medical emergency and the baby must be delivered very quickly.

Sometimes, it's possible to manually turn the baby to a head-down position, and you may be offered this.

But, if your baby is still in the transverse position when you approach your due date or by the time labour begins, you'll most likely be advised to have a caesarean section.

Video: My baby is breech. What help will I get?

In this video, a midwife describes what a breech position is and what can be done if your baby is breech.

Page last reviewed: 1 November 2023 Next review due: 1 November 2026

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Home • Baby • Health

7 Common Breech Baby Birth Defects And Their Complications

Follow the course of action your doctor recommends for a safe delivery in this situation.

Dr. Supriya Mahajan is a pediatrician and pediatric hepatologist with 16 years of experience. She completed her MBBS from Shyam Shah Medical College and diploma from the National Board of Education, New Delhi. She went on to gain specializa... read full bio

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The breech presentation occurs during delivery when the baby’s buttocks, feet, or both emerge first from the birth canal. The birth position may increase the risk of birth defects or congenital malformations. Breech babies’ birth defects may vary from physical issues to genetic disorders.

Babies born breech do not move their heads down towards the birth canal as the due date approaches to be born with vertex presentation. About 3-4% of full-term infants are born with breech presentation (1) .

Despite the presence of a breech presentation, not all babies born with it may develop birth defects.

Types Of Breech Babies

There are three types of breech positions (2) .

• Frank breech: This is the most common breech position where buttocks are delivered first. Legs are positioned up in front of the body and feet near the head.
• Complete breech: The buttocks are presented near the birth canal. The knees are bent, and the feet are placed near the buttocks.
• Incomplete breech: Baby’s buttocks and a foot are presented in the birth canal. The other leg stays up towards the body like seen in the frank breech. If one foot and buttocks emerge first, it is called footling breech. If both feet appear first since both legs are extended, it is called double footling breech.

Besides these positions, a baby can be in a horizontal position across the uterus. In this position, the shoulder of the baby is positioned such that it will enter the birth canal first. It is called the transverse lie position ( 3 ).

What Causes A Baby To Be Breech?

Some common factors that might be responsible for a baby being in a breech position include ( 3 ) ( 4 ):

• The mother has been pregnant before.
• The amount of amniotic fluid present is either too much or too little.
• The mother is expecting twins or triplets.
• The uterus has abnormal growths, such as fibroids.
• The uterus has an irregular shape.
• The placenta covers most or a part of the uterus’s opening, a condition known as placenta previa.
• The fetus is preterm.
• The fetus has some type of congenital disability that prevents it from turning in the head-down position.

What Rate Of Breech Babies Have Birth Defects?

There may be a slight increase in the number of birth defects among breech babies. A study noted that 11.7% of infants born breech had at least one congenital anomaly . In comparison, only 5.1% of babies born with vertex presentation had any congenital anomaly (5) . This occurred regardless of the term of pregnancy.

The study established that breech presentation at birth may indicate congenital anomalies. Congenital defects could prevent the baby from moving to a cephalic position (head down) before delivery. Although the breech position may indicate a possible congenital anomaly, it may not be noted in all breech babies.

A study showed that the incidence of severe birth injury on breech presentation might differ with the gestational age. The graph below shows that most severe birth injuries due to breech vaginal delivery occurred at 32 weeks gestation. The incidence reduces with a stable occurrence between 37 and 39 weeks. The number of injuries spikes in the 41st week but does not reach a peak like it did at 32 weeks.

Incidence of severe birth injuries in breech delivery at different gestational weeks

What birth defects are associated with breech babies.

Studies have shown that the following birth defects are commonly seen in babies born breech (6) .

• Congenital hip deformity or hip dysplasia: Breech babies may have congenital hip problems, such as hip dysplasia , since their movements in the womb can be limited . It can be especially common in frank breech where knees are extended. Early detection and treatment of hip dysplasia are crucial for preventing developmental delays in walking and other motor skills.
• Nervous system and musculoskeletal system malformations: Breech babies may have a higher risk of neurological or musculoskeletal disorders due to reduced or lack of movements in the womb. These malformations can be the reason for the reduced ability to turn into the cephalic presentation (vertex) before delivery.
• Structural deformities of fetal ears, face, eyes, and neck: These conditions may affect the fetal rotation to a cephalic presentation near the due date.
• Cleft lip or cleft palate, respiratory and circulatory system problems: These conditions may increase breech presentation due to polyhydramnios (too much amniotic fluid).
• Genital and urinary malformations: These defects may contribute to breech position due to polyhydramnios (too much amniotic fluid) or oligohydramnios (too little amniotic fluid).
• Chromosomal anomalies: Intrauterine growth restrictions associated with chromosomal anomalies may cause breech presentation.
• Down syndrome: Babies with Down syndrome could be born breech due to their inability to turn to vertex position before birth.

Studies have shown that various malformations are associated with breech birth except for digestive system problems . Malformations may primarily cause the baby to fail to rotate to the cephalic presentation before birth.

Complications Of Breech Presentation

Umbilical cord prolapse and head entrapment are significant problems of breech delivery (7) . If the umbilical cord is compressed during breech birth, it could restrict the blood and oxygen flow to the fetus, leading to delivery complications, including premature birth and low birth weight.

Breech birth can be associated with fetal distress in many cases . Delay in delivery and meconium-stained amniotic fluid can be a reason for it. There is also an increased risk of hip dislocation during a breech delivery, which may require neonatal intensive care.

How To Prevent Problems Of Breech Births?

There is no way to prevent birth defects in breech babies. However, problems associated with breech birth could be prevented by changing the position of the fetus before the delivery. The following procedures or techniques may help to avoid breech birth.

1. External cephalic version

It is a procedure that turns the fetus from breech or side-lying (transverse) position to head-down or vertex position before the labor. This is usually done at 37 weeks of gestation before the labor begins but rarely done during the labor before the amniotic sac ruptures (3) .

Doctors may give tocolytic injections before the procedure to prevent uterine contractions and relax the uterus. After visualizing the baby’s position, placental location, and amniotic fluid volume, the doctor may gently push the abdomen to change the position. The fetus is closely monitored with fetal ultrasound and electronic fetal heart monitoring. If the first attempt fails, the second attempt may be made under epidural anesthesia.

Although complications are rare in the external cephalic version, there is always a possibility. Therefore, the procedure is always done in a hospital where women can have emergency C-sections. It is possible to have a vaginal birth after a successful external cephalic version. If there is no complication after an unsuccessful version, a scheduled cesarean section is done.

ECV may not be tried if there is more than one fetus, known fetal anomalies, abnormalities of the reproductive system, wrong placement of the placenta, or placental abruption (8) .

2. Chiropractic care

The Webster technique is a chiropractic method to move the fetus from breech position to normal position. This technique focuses on relaxing the uterus and ligaments, reducing stress on the pelvis. This technique is based on the theory that a more relaxed uterus lets the breech baby turn naturally.

Although it is attempted in chiropractic care, a few existing scientific studies backing the techniques are weak in conclusion (9) .

Frequently Asked Questions

1. Are breech babies less intelligent?

Some people believe that a baby’s presentation at birth is related to their intelligence. However, research shows that there’s no relationship between a baby’s position at birth and their intelligence later in life (10) .

2. Do breech babies have learning disabilities?

According to a study, the average frequency of hyperkinesia (state of excessive restlessness and hyperactivity) and learning disability in children born with breech presentation was 14%. On the other hand, it was found to be two percent in children born in vertex position (11) . It can be deduced that babies born in the breech position might have learning disabilities. However, it doesn’t happen in all the babies born in this position.

3. Does breech position mean the baby will have Down syndrome?

No clinical studies or research studies were found that could demonstrate that babies born in the breech position will have Down syndrome.

4. Do breech babies have leg problems?

No studies or clinical reports suggest that all babies born in the breech position will have leg problems. Some breech babies after birth may keep their legs in the air for the first few days. However, the legs usually return to their normal position gradually (12) .

Congenital disabilities are sometimes caused by fetal malpresentation, such as breech birth. However, it is impossible to generalize that all babies born in breech positions will have congenital disabilities or that babies born with vertex presentation will be healthy. In fact, various maternal and fetal factors, such as the amount of amniotic fluid in the uterus or intrauterine growth restrictions, can cause breech presentations. Therefore, doctors may recommend early hospitalization for interventions or cesarean section delivery if there is a risk of breech presentation or any possible risks for vaginal breech delivery.

Infographic: What Kinds Of Injuries Can Happen During Breech Birth?

Illustration: Momjunction Design Team

Key Pointers

• The breech position has three types – Frank, incomplete, and complete.
• The breech position may indicate a risk of congenital anomaly, but not all breech babies have them.
• Hip dysplasia, cleft lip or palate, and down syndrome are a few congenital anomalies associated with the breech position.
• Changing the fetal position before the delivery could avert issues linked with a breech birth.

Image: Dalle E/MomJunction Design Team

In this informative video, you can learn about breech babies, risks, natural vs cesarean birth, and more! Get the facts explained by an experienced midwife.

1. Management of Breech Presentation; Royal College of Obstetricians & Gynecologists 2. Breech Presentation; U.S. National Library of Medicine 3. If Your Baby Is Breech; The American College of Obstetricians and Gynecologists 4. Breech Baby; Cleveland Clinic 5. Breech presentation at delivery: a marker for congenital anomaly?; National Library of Medicine 6. Congenital anomalies in breech presentation: A nationwide record linkage study; Wiley Online Library 7. Breech position; Birth Injury Help Center 8. If Your Baby Is Breech; The American College of Obstetricians and Gynecologists 9. Breech repositioning unresponsive to Webster technique: coexistence of oligohydramnios; U.S. National Library of Medicine 10. Martha G Eide et al.; Breech delivery and intelligence: a population-based study of 8,738 breech infants ; NCBI (2005) 11. Stefan Fianu &Ingemar Joelsson; Minimal brain dysfunction in children born in breech presentation ; Taylor & Francis (1978) 12. Breech ; Brighton and Sussex University Hospitals NHS Trust 13. Breech Births ; American Pregnancy Association 14. Caesarean sections ; Australian Institute of Health and Welfare

• Fact-checker

Dr. Supriya Mahajan DNB, PDCC

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