Breech Delivery 

  • Author: Andrew D Jenis, MD; Chief Editor: Ronald M Ramus, MD   more...
 
Updated: Apr 4, 2012
 

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.

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Pathophysiology

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

The 3 types of breech presentation are as follows:

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

Frequency

United States

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

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

Gestational Age, WeeksBreech, %
21-2433
25-2828
29-3214
33-369
37-403-4

International

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

Mortality/Morbidity

  • Many complications are associated with a breech presentation in labor. This may be due to the underlying etiology of the breech presentation, such as fetal anomalies or polyhydramnios. In addition, complications can occur as a result of umbilical cord compression due to the unusual presentation to the maternal pelvis.
  • Increased birth trauma: The inexperienced provider is more likely to pull on the fetus prematurely, and to perform the maneuvers to faciliate delivery incorrectly, increasing the risk of traumatic injury. In addition, as the duration of umbilical cord compression increases, the practitioner may try to deliver the infant more rapidly than advisable, thus increasing the incidence of birth trauma.
  • Incidence of prolapsed umbilical cord depends on type of breech presentation.
    • Footling, 17% incidence
    • Complete, 5% incidence
    • Frank, 0.5% incidence
  • Umbilical cord abnormalities: Cord length may be reduced, and, in footling breeches, there is an increased risk of the cord coiling around a leg of the fetus.

Age

Older maternal age is a consideration.[3]

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Contributor Information and Disclosures
Author

Andrew D Jenis, MD  Chair, Department of Emergency Medicine, Cortland Regional Medical Center

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

Disclosure: Nothing to disclose.

Specialty Editor Board

Assaad J Sayah, MD  Chief, Department of Emergency Medicine, Cambridge Health Alliance

Assaad J Sayah, MD is a member of the following medical societies: National Association of EMS Physicians

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Mark Zwanger, MD, MBA  Assistant Professor, Department of Emergency Medicine, Jefferson Medical College of Thomas Jefferson University

Mark Zwanger, MD, MBA is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and American Medical Association

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Ronald M Ramus, MD  Practice of Maternal-Fetal Medicine, Director of Perinatal Services, Bon Secours Perinatal Center, Richmond Health System

Ronald M Ramus, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, Medical Society of Virginia, and Society for Maternal-Fetal Medicine

Disclosure: Nothing to disclose.

References

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

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

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

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

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

  6. 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].

  7. Cunningham FG, Gant FG, Leveno KJ. Breech Presentation and Delivery (Chapter 22). In: Williams Obstetrics. ed. 2001.

  8. Ghosh MK. Breech presentation: evolution of management. J Reprod Med. Feb 2005;50(2):108-16. [Medline].

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

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

  11. Scorza WE. Intrapartum management of breech presentation. Clin Perinatol. Mar 1996;23(1):31-49. [Medline].

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

  13. 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].

 
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Footling breech presentation. Once the feet have delivered, one may be tempted to pull on the feet. However, a singleton gestation should not be pulled by the feet because this action may precipitate head entrapment in an incompletely dilated cervix or may precipitate nuchal arms. As long as the fetal heart rate is stable and no physical evidence of a prolapsed cord is evident, management may be expectant while awaiting full cervical dilation.
Assisted vaginal breech delivery. Thick meconium passage is common as the breech is squeezed through the birth canal. This is usually not associated with meconium aspiration because the meconium passes out of the vagina and does not mix with the amniotic fluid.
Assisted vaginal breech delivery. The Ritgen maneuver is applied to take pressure off the perineum during vaginal delivery. Episiotomies are often performed for assisted vaginal breech deliveries, even in multiparous women, to prevent soft tissue dystocia.
Assisted vaginal breech delivery. No downward or outward traction is applied to the fetus until the umbilicus has been reached.
Assisted vaginal breech delivery. With a towel wrapped around the fetal hips, gentle downward and outward traction is applied in conjunction with maternal expulsive efforts until the scapula is reached. An assistant should be applying gentle fundal pressure to keep the fetal head flexed.
Assisted vaginal breech delivery. After the scapula is reached, the fetus should be rotated 90° in order to deliver the anterior arm.
Assisted vaginal breech delivery. The anterior arm is followed to the elbow, and the arm is swept out of the vagina.
Assisted vaginal breech delivery. The fetus is rotated 180°, and the contralateral arm is delivered in a similar manner as the first. The infant is then rotated 90° to the backup position in preparation for delivery of the head.
Assisted vaginal breech delivery. The fetal head is maintained in a flexed position by using the Mauriceau maneuver, which is performed by placing the index and middle fingers over the maxillary prominence on either side of the nose. The fetal body is supported in a neutral position, with care to not overextend the neck.
Piper forceps application. Piper forceps are specialized forceps used only for the after-coming head of a breech presentation. They are used to keep the fetal head flexed during extraction of the head. An assistant is needed to hold the infant while the operator gets on one knee to apply the forceps from below.
Assisted vaginal breech delivery. Low 1-minute Apgar scores are not uncommon after a vaginal breech delivery. A pediatrician should be present for the delivery in the event that neonatal resuscitation is needed.
Assisted vaginal breech delivery. The neonate after birth.
Ultrasound demonstrating a fetus in breech presentation with a hyperextended head (ie, "star gazing").
Table. Gestational age and frequency of breech birth
Gestational Age, WeeksBreech, %
21-2433
25-2828
29-3214
33-369
37-403-4
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