eMedicine Specialties > Emergency Medicine > Obstetrics & Gynecology
Pregnancy, Breech Delivery
Updated: May 10, 2006
Introduction
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
Open table in new window
Gestational age in weeks | % Breech |
21-24 | 33% |
25-28 | 28% |
29-32 | 14% |
33-36 | 9% |
37-40 | 7% |
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
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.
More on Pregnancy, Breech Delivery |
 Overview: Pregnancy, Breech Delivery |
| Differential Diagnoses & Workup: Pregnancy, Breech Delivery |
| Treatment & Medication: Pregnancy, Breech Delivery |
| Follow-up: Pregnancy, Breech Delivery |
| References |
| Next Page » |
References
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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].
Further Reading
Keywords
breech presentation, buttocks first, feet first, frank breech presentation, full breech presentation, complete breech presentation, incomplete breech presentation, single footling breech presentation, double footling breech presentation, breech delivery
