AUTHOR AND EDITOR INFORMATION

Section 1 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• References

Background

Breech presentation occurs when the fetus presents to the birth canal with buttocks or feet first. This presentation creates a mechanical problem in delivery of the fetus.

Pathophysiology

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

The 3 types of breech presentation are as follows:

• Frank (65%): Hips of the fetus are flexed, and knees are extended.
• Complete (10%): The hips and knees of the fetus are flexed.
• Incomplete (25%): The feet or knees of the fetus are the lowermost presenting part.
  • Single footling: One of the lower extremities is lowermost.
  • Double footling: Both of the lower extremities are lowermost.

Frequency

United States

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

Table 1. Gestational age and frequency of breech birth

Mortality/Morbidity

• Increased birth trauma: As duration of umbilical cord compression increases, the practitioner tries to deliver the infant more rapidly, increasing incidence of birth trauma.
• Decreased birth weight may result from preterm delivery/growth retardation.
• Incidence of prolapsed umbilical cord depends on type of breech presentation.
  • Footling, 17% incidence
  • Complete, 5% incidence
  • Frank, 0.5% incidence
• Umbilical cord abnormalities: Cord length may be reduced, and, in footlings, there is an increased risk of the cord's coiling around the legs of the fetus.
• Placenta previa
• Fetal/neonatal/infant anomalies
• Uterine anomalies/tumors
• Multiple fetuses
• Surgical intervention (eg, cesarean delivery)

CLINICAL

Section 3 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• References

History

• Factors that increase likelihood of breech delivery include the following:
• • Preterm delivery
  • Increased parity
  • Multiple gestations
  • Previous breech delivery
  • Pelvic tumors

Physical

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

Causes

• Risk factors for breech presentation include the following:
• • Gestational age of fetus less than term. Prior to onset of labor, the fetus turns into cephalic presentation. If labor occurs abruptly or unexpectedly (eg, following trauma), the fetus may not have had the chance to shift position.
  • Increased maternal parity may cause stretch or laxity of the uterus, predisposing the patient to breech deliveries.
  • Multiple fetuses: As a result of limited space in the uterus, fetuses in cases of multiple births may position themselves head to foot.
  • Hydramnios, or too much amniotic fluid, may allow the fetus too much movement.
  • Oligohydramnios, or too little amniotic fluid, may impede final shift of the fetus to cephalic presentation.
  • Placenta previa, or placental implantation over the cervical os, allows the fetus too much space for movement within the uterus.
  • Hydrocephalus, or enlarged head in the fetus, makes it more difficult for the fetus to make final shift to cephalic presentation prior to onset of labor.
  • Previous breech deliveries may increase likelihood of breech presentation, as the uterus may have an anomaly, predisposing it to breech presentations.
  • Uterine anomalies that predispose to breech presentation include bicornuate uterus and septate uterus.
  • Pelvic tumors may impede fetal movement and trap the fetus in breech presentation position.
  • Placental cornual-fundal implantation also increases risk of breech presentation.

DIFFERENTIALS

Section 4 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• References

WORKUP

Section 5 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• References

• Portable radiographs inform the practitioner if the fetal head is hyperextended and indicates the shape of the maternal pelvis and type of breech presentation.
• Ultrasound: If breech presentation is suspected, obtain an ultrasound of the fetus to confirm or refute suspicions. In addition to fetal presentation, ultrasound may reveal other fetal and/or uterine abnormalities.

TREATMENT

Section 6 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• References

Prehospital Care

• As a result of the high risk of fetal and maternal morbidity and mortality, transport the mother to the nearest facility with neonatal intensive care.
• If the mother is in second-stage labor, or if amniotic membranes have ruptured, take the mother to the nearest hospital or urgent care center for emergency delivery.
• Administer supportive oxygen and IV fluids.
• Transport the mother in a comfortable position or in the left lateral decubitus position.
• Inform the hospital of an impending arrival and of the clinical situation.

Emergency Department Care

• Provide supportive care, including IV, oxygen, monitor, complete blood count (CBC), and blood type and screen.
• Three types of vaginal breech delivery exist.
• • Spontaneous breech (rare): No manipulation of the infant is necessary, other than supporting the infant.
  • Partial breech extraction: Fetus descends spontaneously to where umbilicus is at the vaginal introitus; then, the fetus is extracted completely.
  • Total breech extraction: The entire body is extracted. This is indicated only if there is evidence of fetal distress unresponsive to routine maneuvers and a cesarean delivery is not possible. As mentioned earlier, it is imperative that the cervix be fully dilated and effaced before the infant is delivered past its umbilicus. The presence of the feet at the vulva is not an indication to the physician to proceed with active extraction.
• Technique for footling extraction
• • Advance the hand into the vagina and grasp the feet. Place a finger between the legs and apply gentle traction.
  • After the feet are pulled through the vulva, make a wide episiotomy.
  • Wrap the legs with a towel to aid in grasping the fetus.
  • Perform gentle downward traction to deliver the hips, and, then, the buttocks. At this point, the fetus's back should rotate anteriorly.
  • Adjust grip so that the thumbs overlay the sacrum. With the fingers over the hips, continue gentle downward traction.
  • As the scapulae are delivered, the fetus's back rotates laterally. If this does not occur spontaneously, gently rotate the fetus.
  • Once the lower halves of the scapula have passed the vulva and the axillae are identified, deliver the shoulders by 1 of 2 maneuvers:
    • In the first method, rotate the trunk posteriorly until the anterior arm and shoulder are delivered; then, rotate the body in the reverse direction to deliver the other shoulder and arm beneath the symphysis pubis.
    • If the rotation and counter-rotation method is unsuccessful, deliver the posterior shoulder first. Grasp the feet of the fetus in one hand and, with upward traction, pull the fetus over the mother's groin. The posterior shoulder and extremity slide out above the perineum. Afterward, deliver the anterior shoulder and upper extremity with downward traction.
    • If the arm does not pass with the shoulder, deliver the upper extremity manually. Slide two fingers along the humerus until the elbow is reached. Use fingers to splint the humerus, and sweep the forearm of the fetus across the chest and out of the vagina.
  • The last part to pass is the head. Typically, the fetal chin is posterior. The head is extracted using the Mauriceau maneuver, as follows:
    • With the fetus resting on your hand and forearm, insert index and middle fingers into the vagina to rest upon the fetal maxilla.
    • This maneuver accomplishes flexion of the head. Use caution to avoid placing fingers into the mouth or pushing hard on the neck, as tears may occur.
    • Hook 2 fingers from the other hand on either side of the fetus's neck. Grasp the shoulders and apply downward traction until the fetal subocciput appears beneath the symphysis pubis.
    • The fetus subsequently is elevated toward the maternal abdomen with delivery of the mouth, nose, brow, and occiput beyond the perineum.
    • An assistant may apply suprapubic pressure during the Mauriceau maneuver to aid in delivery of the head.
• Technique for frank delivery
• • After episiotomy, allow breech birth to proceed spontaneously as far as possible. Then apply posterior traction with a finger from each hand placed around the hips of the fetus and into each inguinal region.
  • Once the knees appear, flex the legs gently to assist in delivery.

Consultations

• Inform an obstetrician skilled in breech delivery of the possibility of breech delivery.
• As most infants delivered breech are premature, notify a specialist in fetal cardiopulmonary physiology.
• Premature infants do not have great pulmonary reserve. Thus, airway support and intubation may be necessary.

FOLLOW-UP

Section 7 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• Warm and dry the infant. Place him or her in an infant incubator.
• If the infant is younger than 37 weeks' gestation, consider the lungs premature. Consider endotracheal intubation with mechanical ventilation.
• Even in infants older than 37 weeks' gestation, the infant still should be placed in a hospital with a nursery.
• Inspect the maternal birth canal, and repair lacerations of the cervix and vagina, as required.

In/Out Patient Meds

• Administer 300 mcg RhoGAM IM if the mother is Rh negative.

Transfer

• When stable, transfer the infant to the nearest hospital with pediatric intensive care. Otherwise, transfer the infant and mother to a hospital with newborn facilities.

Complications

• Traumatic mortality to the fetus is 12 times more likely.
• Intracranial fetal hemorrhage is the most common injury in breech delivery.
• The spinal cord, liver, adrenals, and spleen also are injured, in decreasing order of frequency.

Prognosis

• Fetal and maternal morbidity and mortality increase with breech delivery.
• Maternal: A rise in the number of cesarean deliveries increases the maternal morbidity and mortality (eg, wound infection, aspiration, anesthesia risk), especially with emergency delivery.
• Fetus and infant
• • Mortality increases to 9%, compared with 3% in cephalic presentations.
  • Average Apgar score, especially at 1 minute, is lower.
  • Congenital abnormalities increase to 6%, compared with 2.4% in infants with cephalic presentations.
  • Factors for increased adverse fetal outcome include the following:
    • Older mothers
    • Footling presentation
    • Hyperextended fetal head
    • Birth weight less than 2500 g or greater than 4000 g
    • Prolonged labor
    • Nonexperienced clinician

Patient Education

• Early prenatal care can identify patients at risk for breech delivery.

MISCELLANEOUS

Section 8 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Beginning extraction of fetus prior to complete descent
• Failure to have neonatal and maternal resuscitation equipment ready prior to extraction
• Late consultation of obstetrics and neonatology personnel
• Transfer of mother in active labor, of mother or infant in unstable condition, or both. (See the eMedicine article, COBRA Laws.)

REFERENCES

Section 9 of 9

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• References

• Alarab M, Regan C, O'Connell MP. Singleton vaginal breech delivery at term: still a safe option. Obstet Gynecol. Mar 2004;103(3):407-12. [Medline].
• Carbillon L. Vaginal versus cesarean delivery for breech presentation in California: a population-based study. Obstet Gynecol. May 2004;103(5 Pt 1):1003-4. [Medline].
• Cunningham FG, Gant FG, Leveno KJ. Breech Presentation and Delivery (Chapter 22) In: Williams Obstetrics, 21st ed. 2001.
• Ghosh MK. Breech presentation: evolution of management. J Reprod Med. Feb 2005;50(2):108-16. [Medline].
• Gilbert WM, Hicks SM, Boe NM. Vaginal versus cesarean delivery for breech presentation in California: a population-based study. Obstet Gynecol. Nov 2003;102(5 Pt 1):911-7. [Medline].
• Roberts JR, Hedges JR. Emergency childbirth. In: Clinical Procedures in Emergency Medicine. 3rd ed. 1997:chap75, 1000-1003.
• Scorza WE. Intrapartum management of breech presentation. Clin Perinatol. Mar 1996;23(1):31-49. [Medline].
• Stitely ML, Gherman RB. Labor with abnormal presentation and position. Obstet Gynecol Clin North Am. Jun 2005;32(2):165-79. [Medline].
• Tunde-Byass MO, Hannah ME. Breech vaginal delivery at or near term. Semin Perinatol. Feb 2003;27(1):34-45. [Medline].
• Warke HS, Saraogi RM, Sanjanwalla SM. Should a preterm breech go for vaginal delivery or caesarean section. J Postgrad Med. Jan-Mar 1999;45(1):1-4. [Medline].

Article Last Updated: May 10, 2006