eMedicine Specialties > Emergency Medicine > Obstetrics & Gynecology

Pregnancy, Breech Delivery

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

Updated: Oct 26, 2009

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.¹

Table 1. Gestational age and frequency of breech birth

Mortality/Morbidity

• Many complications can result from breech presentation. They are generally related to complications of the fetal abnormalities that may be the primary reason for the breech presentation and those related to umbilical cord compression resultant from abnormal progression through the maternal pelvis.
• Increased birth trauma: As the duration of umbilical cord compression increases, the practitioner tries 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 footlings, there is an increased risk of the cord coiling around the legs of the fetus.

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 the uterine fundus.
• Auscultation: Heart sounds can be heard above the umbilicus.
• Vaginal examination
  • In frank breech 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 breech presentations, the feet of the fetus may be palpated with the buttocks.
  • In incomplete breech presentations, one or both of the feet/knees may be palpated.
• During frank breech delivery, the following conditions make vaginal delivery less risky:
  • Favorable pelvis - Gynecoid (ie, round) or anthropoid (ie, elliptical)
  • Fetal weight less than 3600 g - The larger the fetus, the larger the head, as well as other noncompressible body parts, thereby leading to increased chance for 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:
  • Fetal 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 the fetal head's ability to navigate the 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:
  • Premature gestational age: 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 shifted position.
  • Increased maternal parity may cause stretch or laxity of the uterus, predisposing the fetus to breech deliveries.
  • Multiple fetuses: As a result of limited space in the uterus, fetuses may position themselves head to foot.
  • Hydramnios, ie, too much amniotic fluid, may allow the fetus too much movement.
  • Oligohydramnios, ie, too little amniotic fluid, may impede final shift of the fetus to cephalic presentation.
  • Placenta previa, ie, placental implantation over the cervical os, allows the fetus too much space for movement within the uterus.
  • Hydrocephalus, ie, 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 another one secondary to an anatomical anomaly.
    • Uterine anomalies include uterine scarring from previous cesarean section, bicornuate uterus, and septate uterus.
    • Pelvic tumors may impede fetal movement and trap the fetus in breech presentation position.
  • Placental cornual-fundal implantation increases risk of breech presentation.

Differential Diagnoses

Abortion, Incomplete
Pregnancy, Delivery
Pregnancy, Ectopic

Workup

• Portable radiographs inform the practitioner if the fetal head is hyperextended and indicates the shape of the maternal pelvis and type of breech presentation.
• Limited bedside pelvic ultrasonography: The mainstay for fetal assessment, if breech presentation is suspected, obtain a sonogram to confirm or refute suspicions. In addition to fetal presentation, a sonogram may reveal other fetal and/or uterine abnormalities.

Treatment

Prehospital Care

• Secondary to 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.
• Consult an obstetrician and neonatologist.
• Alert labor & delivery.
• 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 further extracted.
  • 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. Note: The presence of the feet at the vulva is not an indication to the physician to proceed with active extraction.
• Technique for footling extraction

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.

• 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.

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.

• Wrap the legs with a towel to aid in grasping the fetus.

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.

• 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:

Assisted vaginal breech delivery. After the scapula is reached, the fetus should be rotated 90° in order to deliver the anterior arm.

• 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:

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.

• 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 its possibility. Their presence at the bedside is imperative.
• As most infants delivered breech are premature, notify a neonatologist or a pediatric intensivist.
• Premature infants do not have great pulmonary reserve. Thus, airway support and intubation may be necessary.

Follow-up

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, the lungs may be 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.

Inpatient & Outpatient Medications

• 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.
• In decreasing order of frequency, the spinal cord, liver, adrenals, and spleen also are injured.

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:¹
    • 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

Medicolegal 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 an unstable condition, or both (See the eMedicine article, COBRA Laws and EMTALA.)

Multimedia

Media file 1: 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.

Media file 2: 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.

Media file 3: 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.

Media file 4: Assisted vaginal breech delivery. No downward or outward traction is applied to the fetus until the umbilicus has been reached.

Media file 5: 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.

Media file 6: Assisted vaginal breech delivery. After the scapula is reached, the fetus should be rotated 90° in order to deliver the anterior arm.

Media file 7: Assisted vaginal breech delivery. The anterior arm is followed to the elbow, and the arm is swept out of the vagina.

Media file 8: 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.

Media file 9: 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.

Media file 10: 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.

Media file 11: 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.

Media file 12: Assisted vaginal breech delivery. The neonate after birth.

Media file 13: Ultrasound demonstrating a fetus in breech presentation with a hyperextended head (ie, "star gazing").

References

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

2. 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].

3. 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].

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

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

6. 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].

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

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

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

10. 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].

Keywords

breech presentation, breech pregnancy, breech birth, 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

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.

Medical Editor

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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Mark Zwanger, MD, MBA, Assistant Professor, Department of Emergency Medicine, 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: Medicines Company Consulting fee Consulting; Pfizer Salary Employment

CME Editor

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

Pamela L Dyne, MD, Professor of Clinical Medicine/Emergency Medicine, David Geffen School of Medicine at UCLA; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center
Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

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