breech presentation in the pregnancy

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.

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

• Variations in Fetal Position and Presentation |

During pregnancy, the fetus can be positioned in many different ways inside the mother's uterus. The fetus may be head up or down or facing the mother's back or front. At first, the fetus can move around easily or shift position as the mother moves. Toward the end of the pregnancy the fetus is larger, has less room to move, and stays in one position. How the fetus is positioned has an important effect on delivery and, for certain positions, a cesarean delivery is necessary. There are medical terms that describe precisely how the fetus is positioned, and identifying the fetal position helps doctors to anticipate potential difficulties during labor and delivery.

Presentation refers to the part of the fetus’s body that leads the way out through the birth canal (called the presenting part). Usually, the head leads the way, but sometimes the buttocks (breech presentation), shoulder, or face leads the way.

Position refers to whether the fetus is facing backward (occiput anterior) or forward (occiput posterior). The occiput is a bone at the back of the baby's head. Therefore, facing backward is called occiput anterior (facing the mother’s back and facing down when the mother lies on her back). Facing forward is called occiput posterior (facing toward the mother's pubic bone and facing up when the mother lies on her back).

Lie refers to the angle of the fetus in relation to the mother and the uterus. Up-and-down (with the baby's spine parallel to mother's spine, called longitudinal) is normal, but sometimes the lie is sideways (transverse) or at an angle (oblique).

For these aspects of fetal positioning, the combination that is the most common, safest, and easiest for the mother to deliver is the following:

Head first (called vertex or cephalic presentation)

Facing backward (occiput anterior position)

Spine parallel to mother's spine (longitudinal lie)

Neck bent forward with chin tucked

Arms folded across the chest

If the fetus is in a different position, lie, or presentation, labor may be more difficult, and a normal vaginal delivery may not be possible.

Variations in fetal presentation, position, or lie may occur when

The fetus is too large for the mother's pelvis (fetopelvic disproportion).

The uterus is abnormally shaped or contains growths such as fibroids .

The fetus has a birth defect .

There is more than one fetus (multiple gestation).

Position and Presentation of the Fetus

Variations in fetal position and presentation.

Some variations in position and presentation that make delivery difficult occur frequently.

Occiput posterior position

In occiput posterior position (sometimes called sunny-side up), the fetus is head first (vertex presentation) but is facing forward (toward the mother's pubic bone—that is, facing up when the mother lies on her back). This is a very common position that is not abnormal, but it makes delivery more difficult than when the fetus is in the occiput anterior position (facing toward the mother's spine—that is facing down when the mother lies on her back).

When a fetus faces up, the neck is often straightened rather than bent,which requires more room for the head to pass through the birth canal. Delivery assisted by a vacuum device or forceps or cesarean delivery may be necessary.

Breech presentation

In breech presentation, the baby's buttocks or sometimes the feet are positioned to deliver first (before the head).

When delivered vaginally, babies that present buttocks first are more at risk of injury or even death than those that present head first.

The reason for the risks to babies in breech presentation is that the baby's hips and buttocks are not as wide as the head. Therefore, when the hips and buttocks pass through the cervix first, the passageway may not be wide enough for the head to pass through. In addition, when the head follows the buttocks, the neck may be bent slightly backwards. The neck being bent backward increases the width required for delivery as compared to when the head is angled forward with the chin tucked, which is the position that is easiest for delivery. Thus, the baby’s body may be delivered and then the head may get caught and not be able to pass through the birth canal. When the baby’s head is caught, this puts pressure on the umbilical cord in the birth canal, so that very little oxygen can reach the baby. Brain damage due to lack of oxygen is more common among breech babies than among those presenting head first.

In a first delivery, these problems may occur more frequently because a woman’s tissues have not been stretched by previous deliveries. Because of risk of injury or even death to the baby, cesarean delivery is preferred when the fetus is in breech presentation, unless the doctor is very experienced with and skilled at delivering breech babies or there is not an adequate facility or equipment to safely perform a cesarean delivery.

Breech presentation is more likely to occur in the following circumstances:

Labor starts too soon (preterm labor).

The uterus is abnormally shaped or contains abnormal growths such as fibroids .

Other presentations

In face presentation, the baby's neck arches back so that the face presents first rather than the top of the head.

In brow presentation, the neck is moderately arched so that the brow presents first.

Usually, fetuses do not stay in a face or brow presentation. These presentations often change to a vertex (top of the head) presentation before or during labor. If they do not, a cesarean delivery is usually recommended.

In transverse lie, the fetus lies horizontally across the birth canal and presents shoulder first. A cesarean delivery is done, unless the fetus is the second in a set of twins. In such a case, the fetus may be turned to be delivered through the vagina.

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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, ≥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
• Antenatal corticosteroids to reduce neonatal morbidity and mortality
• Caesarean birth

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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.

FatCamera/Getty Images

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.

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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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• Pregnancy week by week
• Fetal presentation before birth

The way a baby is positioned in the uterus just before birth can have a big effect on labor and delivery. This positioning is called fetal presentation.

Babies twist, stretch and tumble quite a bit during pregnancy. Before labor starts, however, they usually come to rest in a way that allows them to be delivered through the birth canal headfirst. This position is called cephalic presentation. But there are other ways a baby may settle just before labor begins.

Following are some of the possible ways a baby may be positioned at the end of pregnancy.

Head down, face down

When a baby is head down, face down, the medical term for it is the cephalic occiput anterior position. This the most common position for a baby to be born in. With the face down and turned slightly to the side, the smallest part of the baby's head leads the way through the birth canal. It is the easiest way for a baby to be born.

Head down, face up

When a baby is head down, face up, the medical term for it is the cephalic occiput posterior position. In this position, it might be harder for a baby's head to go under the pubic bone during delivery. That can make labor take longer.

Most babies who begin labor in this position eventually turn to be face down. If that doesn't happen, and the second stage of labor is taking a long time, a member of the health care team may reach through the vagina to help the baby turn. This is called manual rotation.

In some cases, a baby can be born in the head-down, face-up position. Use of forceps or a vacuum device to help with delivery is more common when a baby is in this position than in the head-down, face-down position. In some cases, a C-section delivery may be needed.

Frank breech

When a baby's feet or buttocks are in place to come out first during birth, it's called a breech presentation. This happens in about 3% to 4% of babies close to the time of birth. The baby shown below is in a frank breech presentation. That's when the knees aren't bent, and the feet are close to the baby's head. This is the most common type of breech presentation.

If you are more than 36 weeks into your pregnancy and your baby is in a frank breech presentation, your health care professional may try to move the baby into a head-down position. This is done using a procedure called external cephalic version. It involves one or two members of the health care team putting pressure on your belly with their hands to get the baby to roll into a head-down position.

If the procedure isn't successful, or if the baby moves back into a breech position, talk with a member of your health care team about the choices you have for delivery. Most babies in a frank breech position are born by planned C-section.

Complete and incomplete breech

A complete breech presentation, as shown below, is when the baby has both knees bent and both legs pulled close to the body. In an incomplete breech, one or both of the legs are not pulled close to the body, and one or both of the feet or knees are below the baby's buttocks. If a baby is in either of these positions, you might feel kicking in the lower part of your belly.

If you are more than 36 weeks into your pregnancy and your baby is in a complete or incomplete breech presentation, your health care professional may try to move the baby into a head-down position. This is done using a procedure called external cephalic version. It involves one or two members of the health care team putting pressure on your belly with their hands to get the baby to roll into a head-down position.

If the procedure isn't successful, or if the baby moves back into a breech position, talk with a member of your health care team about the choices you have for delivery. Many babies in a complete or incomplete breech position are born by planned C-section.

When a baby is sideways — lying horizontal across the uterus, rather than vertical — it's called a transverse lie. In this position, the baby's back might be:

• Down, with the back facing the birth canal.
• Sideways, with one shoulder pointing toward the birth canal.
• Up, with the hands and feet facing the birth canal.

Although many babies are sideways early in pregnancy, few stay this way when labor begins.

If your baby is in a transverse lie during week 37 of your pregnancy, your health care professional may try to move the baby into a head-down position. This is done using a procedure called external cephalic version. External cephalic version involves one or two members of your health care team putting pressure on your belly with their hands to get the baby to roll into a head-down position.

If the procedure isn't successful, or if the baby moves back into a transverse lie, talk with a member of your health care team about the choices you have for delivery. Many babies who are in a transverse lie are born by C-section.

If you're pregnant with twins and only the twin that's lower in the uterus is head down, as shown below, your health care provider may first deliver that baby vaginally.

Then, in some cases, your health care team may suggest delivering the second twin in the breech position. Or they may try to move the second twin into a head-down position. This is done using a procedure called external cephalic version. External cephalic version involves one or two members of the health care team putting pressure on your belly with their hands to get the baby to roll into a head-down position.

Your health care team may suggest delivery by C-section for the second twin if:

• An attempt to deliver the baby in the breech position is not successful.
• You do not want to try to have the baby delivered vaginally in the breech position.
• An attempt to move the baby into a head-down position is not successful.
• You do not want to try to move the baby to a head-down position.

In some cases, your health care team may advise that you have both twins delivered by C-section. That might happen if the lower twin is not head down, the second twin has low or high birth weight as compared to the first twin, or if preterm labor starts.

• Landon MB, et al., eds. Normal labor and delivery. In: Gabbe's Obstetrics: Normal and Problem Pregnancies. 8th ed. Elsevier; 2021. https://www.clinicalkey.com. Accessed May 19, 2023.
• Holcroft Argani C, et al. Occiput posterior position. https://www.updtodate.com/contents/search. Accessed May 19, 2023.
• Frequently asked questions: If your baby is breech. American College of Obstetricians and Gynecologists https://www.acog.org/womens-health/faqs/if-your-baby-is-breech. Accessed May 22, 2023.
• Hofmeyr GJ. Overview of breech presentation. https://www.updtodate.com/contents/search. Accessed May 22, 2023.
• Strauss RA, et al. Transverse fetal lie. https://www.updtodate.com/contents/search. Accessed May 22, 2023.
• Chasen ST, et al. Twin pregnancy: Labor and delivery. https://www.updtodate.com/contents/search. Accessed May 22, 2023.
• Cohen R, et al. Is vaginal delivery of a breech second twin safe? A comparison between delivery of vertex and non-vertex second twins. The Journal of Maternal-Fetal & Neonatal Medicine. 2021; doi:10.1080/14767058.2021.2005569.
• Marnach ML (expert opinion). Mayo Clinic. May 31, 2023.

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Breech, posterior, transverse lie: What position is my baby in?

Fetal presentation, or how your baby is situated in your womb at birth, is determined by the body part that's positioned to come out first, and it can affect the way you deliver. At the time of delivery, 97 percent of babies are head-down (cephalic presentation). But there are several other possibilities, including feet or bottom first (breech) as well as sideways (transverse lie) and diagonal (oblique lie).

Fetal presentation and position

During the last trimester of your pregnancy, your provider will check your baby's presentation by feeling your belly to locate the head, bottom, and back. If it's unclear, your provider may do an ultrasound or an internal exam to feel what part of the baby is in your pelvis.

Fetal position refers to whether the baby is facing your spine (anterior position) or facing your belly (posterior position). Fetal position can change often: Your baby may be face up at the beginning of labor and face down at delivery.

Here are the many possibilities for fetal presentation and position in the womb.

Medical illustrations by Jonathan Dimes

Head down, facing down (anterior position)

A baby who is head down and facing your spine is in the anterior position. This is the most common fetal presentation and the easiest position for a vaginal delivery.

This position is also known as "occiput anterior" because the back of your baby's skull (occipital bone) is in the front (anterior) of your pelvis.

Head down, facing up (posterior position)

In the posterior position , your baby is head down and facing your belly. You may also hear it called "sunny-side up" because babies who stay in this position are born facing up. But many babies who are facing up during labor rotate to the easier face down (anterior) position before birth.

Posterior position is formally known as "occiput posterior" because the back of your baby's skull (occipital bone) is in the back (posterior) of your pelvis.

Frank breech

In the frank breech presentation, both the baby's legs are extended so that the feet are up near the face. This is the most common type of breech presentation. Breech babies are difficult to deliver vaginally, so most arrive by c-section .

Some providers will attempt to turn your baby manually to the head down position by applying pressure to your belly. This is called an external cephalic version , and it has a 58 percent success rate for turning breech babies. For more information, see our article on breech birth .

Complete breech

A complete breech is when your baby is bottom down with hips and knees bent in a tuck or cross-legged position. If your baby is in a complete breech, you may feel kicking in your lower abdomen.

Incomplete breech

In an incomplete breech, one of the baby's knees is bent so that the foot is tucked next to the bottom with the other leg extended, positioning that foot closer to the face.

Single footling breech

In the single footling breech presentation, one of the baby's feet is pointed toward your cervix.

Double footling breech

In the double footling breech presentation, both of the baby's feet are pointed toward your cervix.

Transverse lie

In a transverse lie, the baby is lying horizontally in your uterus and may be facing up toward your head or down toward your feet. Babies settle this way less than 1 percent of the time, but it happens more commonly if you're carrying multiples or deliver before your due date.

If your baby stays in a transverse lie until the end of your pregnancy, it can be dangerous for delivery. Your provider will likely schedule a c-section or attempt an external cephalic version , which is highly successful for turning babies in this position.

Oblique lie

In rare cases, your baby may lie diagonally in your uterus, with his rump facing the side of your body at an angle.

Like the transverse lie, this position is more common earlier in pregnancy, and it's likely your provider will intervene if your baby is still in the oblique lie at the end of your third trimester.

Was this article helpful?

What to know if your baby is breech

What's a sunny-side up baby?

What happens to your baby right after birth

How your twins’ fetal positions affect labor and delivery

BabyCenter's editorial team is committed to providing the most helpful and trustworthy pregnancy and parenting information in the world. When creating and updating content, we rely on credible sources: respected health organizations, professional groups of doctors and other experts, and published studies in peer-reviewed journals. We believe you should always know the source of the information you're seeing. Learn more about our editorial and medical review policies .

Ahmad A et al. 2014. Association of fetal position at onset of labor and mode of delivery: A prospective cohort study. Ultrasound in obstetrics & gynecology 43(2):176-182. https://www.ncbi.nlm.nih.gov/pubmed/23929533 Opens a new window [Accessed September 2021]

Gray CJ and Shanahan MM. 2019. Breech presentation. StatPearls.  https://www.ncbi.nlm.nih.gov/books/NBK448063/ Opens a new window [Accessed September 2021]

Hankins GD. 1990. Transverse lie. American Journal of Perinatology 7(1):66-70.  https://www.ncbi.nlm.nih.gov/pubmed/2131781 Opens a new window [Accessed September 2021]

Medline Plus. 2020. Your baby in the birth canal. U.S. National Library of Medicine. https://medlineplus.gov/ency/article/002060.htm Opens a new window [Accessed September 2021]

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Breech Presentation: What It Is and How It Can Affect Your Baby's Delivery

As you get close to your due date, your baby might sense she’s approaching her grand entrance and move into a head-down position in your uterus, ready to be born. However, in some cases, she might choose another position instead, such as bottom or feet down. When this happens, it’s called a breech presentation. Read on to learn how your healthcare provider checks the position of your baby, what delivery options you may have if your baby is breech, and what can cause a breech presentation.

What Is Breech?

During your pregnancy, your baby has likely taken every opportunity to let you know she means business by kicking up a storm and doing countless somersaults. It's natural for your baby to move and shift positions within the uterus. Then, usually between 32 and 36 weeks of pregnancy, your baby will likely get into a head-down position in preparation for being born.

There is a small chance — just 3 to 4 percent — that your baby may not move into this head-down position by the time your pregnancy is full term. This is called a breech presentation. The chance of a breech presentation is higher if your pregnancy is not yet full term or if you go into preterm labor .

Types of Birth Positions

There are many different types of positions, including a number of breech presentations, that your baby may take on before birth:

Frank breech presentation. Your baby's bottom is positioned downward. This is the most common type of breech presentation.

Complete breech presentation. Your baby's feet are positioned downward with her hips and knees flexed, almost cross-legged.

Incomplete breech presentation. Your baby's feet are positioned downward with only one hip or one knee flexed.

Shoulder presentation or transverse lie. This is a form of breech in which your baby is positioned horizontally in the uterus. Few babies remain this way at the time of delivery.

Footling breech. One or both of your baby's feet are pointed downward.

Cephalic or vertex presentation (occiput). Your baby is in the normal position for delivery. Her head is down and she’s facing toward your back.

Cephalic or vertex presentation (occiput posterior). In some cases, your baby may be in a downward position but with her face toward your front. If this happens in early labor, your baby may naturally turn to face your back on her own, or, later in labor, your provider may decide to manually assist the baby in getting into this position. If this doesn't work, your baby can still be delivered vaginally, but delivery may be prolonged and more painful.

The causes of your baby being in breech position aren't always clear, but it can be more common if any of the following apply to you:

You've been pregnant before

You are pregnant with twins (read on to learn more about twin breech)

The uterus has more or less amniotic fluid than usual

The uterus has an abnormal shape or has abnormal growths, such as fibroids.

You have a condition called placenta previa , which is when the placenta covers the cervix.

Your healthcare provider likely already knows whether any of these factors affect your situation, but you might want to mention it just to be sure.

Diagnosis of a Breech Presentation

At one of your prenatal visits in the lead up to your due date, your provider will check that everything is progressing as planned , and will examine your abdomen to try to find out whether your baby is in the correct head-down position. If your provider thinks there may be a breech presentation, she or he may recommend an ultrasound exam to confirm it.

Can a Breech Baby Be Turned?

If your baby is breech, your provider may consider turning your baby so that a vaginal delivery can proceed, if that’s in the cards for you anyway. Alternatively, your provider may recommend that a cesarean delivery is the safer option.

Keep in mind, your baby's position might change at some point before delivery day, so your provider may recommend waiting and seeing.

If you are 37 weeks pregnant or more, your provider may recommend turning your baby through a process called external cephalic version or ECV.

ECV involves your provider placing hands on your abdomen and applying firm pressure in order to turn the baby. This procedure will most likely be done near a delivery room. Your provider may offer an epidural block to help with any pain this procedure causes.

An ECV is about 50 percent effective and there is a small risk of complications. You and your baby will be monitored closely before, during, and after the procedure to ensure that both of you are doing well.

If the ECV procedure is successful, your baby can be delivered vaginally , if there’s no other impediment.

Delivery Options for a Breech Baby

If your baby is in a breech position, the risks associated with a vaginal delivery are much higher than with a cesarean section. Risks include the umbilical cord cutting off his blood supply or his head or shoulders becoming stuck. That’s why, in some cases, your provider may recommend a cesarean delivery .

It could be that your provider’s level of experience in delivering breech babies might also inform the discussion you have with your provider about what’s right for your situation. Ultimately, your provider will recommend the best course of action for you and your baby based on your personal situation.

Twins and Breech Presentation

It's possible for twins to be delivered vaginally if the first baby — the lower-positioned twin — is correctly positioned with the head facing down. Of course, that's if the twin pregnancy is otherwise progressing well and there are no complications. If the second twin is in a breech position, the provider may do an ECV procedure to get this baby in the correct head-down position for a vaginal delivery, too.

If the first twin baby (the one lower down) is in a breech position, the provider may recommend a cesarean section. Triplets or more will most likely require a cesarean section.

Although you might feel like the added stress of a breech baby is the last thing you need as you approach your due date, remember that your healthcare provider has seen this situation before and will know what to do to ensure your baby is delivered safely. Next thing you know, you'll be bringing your brand-new baby home , stocking up on diapers, waking up for late-night feedings, and reveling in your baby's growth .

See all sources

• Cleveland clinic: Cesarean Birth (C-Section)
• Cleveland Clinic: Fetal Positions for Birth
• Mayo Clinic: Fetal presentation before birth
• Mayo Clinic: Prenatal care: 3rd trimester visits
• Mayo Clinic: Third Trimester
• Book: Your Pregnancy and Childbirth: Month to Month, Sixth Edition Paperback – January 1, 2016 by American College of Obstetricians and Gynecologists (Author)

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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

Management of Breech Presentation Green-top Guideline

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

Related links.

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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A comparison of risk factors for breech presentation in preterm and term labor: a nationwide, population-based case–control study

Anna e. toijonen.

1 Department of Obstetrics and Gynecology, University Hospital (HUS), University of Helsinki, Haartmaninkatu 2, 00290 Helsinki, Finland

3 School of Medicine, University of Helsinki, Helsinki, Finland

Seppo T. Heinonen

Mika v. m. gissler.

2 National Institute for Health and Welfare (THL), Helsinki, Finland

Georg Macharey

To determine if the common risks for breech presentation at term labor are also eligible in preterm labor.

A Finnish cross-sectional study included 737,788 singleton births (24–42 gestational weeks) during 2004–2014. A multivariable logistic regression analysis was used to calculate the risks of breech presentation.

The incidence of breech presentation at delivery decreased from 23.5% in pregnancy weeks 24–27 to 2.5% in term pregnancies. In gestational weeks 24–27, preterm premature rupture of membranes was associated with breech presentation. In 28–31 gestational weeks, breech presentation was associated with maternal pre-eclampsia/hypertension, preterm premature rupture of membranes, and fetal birth weight below the tenth percentile. In gestational weeks 32–36, the risks were advanced maternal age, nulliparity, previous cesarean section, preterm premature rupture of membranes, oligohydramnios, birth weight below the tenth percentile, female sex, and congenital anomaly. In term pregnancies, breech presentation was associated with advanced maternal age, nulliparity, maternal hypothyroidism, pre-gestational diabetes, placenta praevia, premature rupture of membranes, oligohydramnios, congenital anomaly, female sex, and birth weight below the tenth percentile.

Breech presentation in preterm labor is associated with obstetric risk factors compared to cephalic presentation. These risks decrease linearly with the gestational age. In moderate to late preterm delivery, breech presentation is a high-risk state and some obstetric risk factors are yet visible in early preterm delivery. Breech presentation in extremely preterm deliveries has, with the exception of preterm premature rupture of membranes, similar clinical risk profiles as in cephalic presentation.

Introduction

The prevalence of breech presentation at delivery decreases with increasing gestational age. At 28 pregnancy weeks, every fifth fetus lies in the breech presentation and in term pregnancies, less than 4% of all singleton fetuses are in breech presentation at delivery [ 1 , 2 ]. Most likely this is due to a lack of fetal movements [ 3 ] or an incomplete fetal rotation, since the possibility of a spontaneous rotation declines with increasing gestational age. Consequently, preterm labor itself is often associated with breech presentation at delivery, since the fetus was not yet able to rotate [ 4 – 9 ]. This fact makes preterm labor as one of the strongest risk factors for breech presentation.

Vaginal breech delivery in term pregnancies is not only associated with poorer perinatal outcomes compared to vaginal delivery with a fetus in cephalic presentation [ 6 , 10 , 11 ], but also it is debated whether the cause of breech presentation itself is a risk for adverse peri- and neonatal outcomes [ 3 , 12 , 13 ]. Several fetal and maternal features, such as fetal growth restriction, congenital anomaly, oligohydramnios, gestational diabetes, and previous cesarean section, are linked to a higher risk of breech presentation at term, and, furthermore, are associated with an increased risk for adverse perinatal outcomes [ 3 – 5 , 8 , 9 , 14 – 17 ].

The literature lacks studies on the risk factors of breech presentation in preterm pregnancies. It remains unclear whether breech presentation at preterm labor is only caused by the incomplete fetal rotation, or whether breech presentation in preterm labor is also associated with other obstetric risk factors. Most of the studies reviewing risk factors for breech presentation focus on term pregnancies. Our hypothesis is that breech presentation in preterm deliveries is, besides preterm pregnancy itself, associated with other risk factors similar to breech presentation at term. We aim to compare the risks of preterm breech presentation to those in cephalic presentation by gestational age. Such information would be valuable in the risk stratification of breech deliveries by gestational age.

Materials and methods

We conducted a retrospective population-based cross-sectional study. The population included all the singleton preterm and term births, from January 2004 to December 2014 in Finland. The data were collected from the national medical birth register and the hospital discharge register, maintained by the National Institute for Health and Welfare. All Finnish maternity hospitals are obligated to contribute clinical data on births from 22 weeks or birth weight of 500 g to the register. All newborn infants are examined by a pediatrician and given a personal identification number that can be traced in the case of perinatal mortality or morbidity. The hospital discharge register contains information on all surgical procedures and diagnoses (International Statistical Classification of Diseases and Related Health Problems 10th Revision, ICD-10) in all inpatient care and outpatient care in public hospitals.

Authorization to use the data was obtained from the National Institute for Health and Welfare as required by the national data protection law in Finland (reference number THL/652/5.05.00/2017).

The study population included all the women with a singleton fetus in breech presentation at the time of delivery. The control group included all the women with a singleton fetus in cephalic presentation at delivery. Other presentations were excluded from the study ( N  = 1671) (Fig.  1 ). Gestational age was determined according to early ultrasonographic measurement which is routinely performed in Finland and it encompasses over 95% of the mothers, or if not available, to the last menstrual period. We excluded neonates delivered before 24 weeks of gestation and birth weight of less than 500 g, because the lower viability may have influenced the mode of the delivery or the outcome. The study population was divided into four categories according to the World Health Organization (WHO) definitions of preterm and term deliveries. WHO defines preterm birth as a fetus born alive before 37 completed weeks of pregnancy. WHO recommends sub-categories of preterm birth, based on gestational age, as extremely preterm (less than 28 pregnancy weeks), very preterm (28–32 pregnancy weeks), and moderate to late preterm (32–37 pregnancy weeks).

Breech presentation for singleton pregnancies during the period of 2004–2014 in Finland

In our study, we assessed four factors that may be associated with breech presentation based on prior reports [ 3 – 5 , 14 , 17 – 20 ]. These factors were: maternal age below 25 and 35 years or more, smoking, pre-pregnancy body mass index (BMI) over 30, and in vitro fertilization. The following factors were also analyzed: nulliparity, more than three previous deliveries, and history of cesarean section. The obstetric risk factors including maternal hypo- or hyperthyroidism (ICD-10 E03, E05), gestational diabetes (ICD-10 O24.4) and other diabetes treated with insulin (ICD-10 O24.0), arterial hypertension or pre-eclampsia (ICD-10 O13, O14), and maternal care for (suspected) damage to fetus by alcohol or drugs (ICD-10 O35.4, O35.5) were assessed in the analysis. The variables that were also included in the analysis were: oligohydramnios (ICD-10 O41.0), placenta praevia (ICD-10 O44), placental abruption (ICD-10 O45), preterm premature rupture of membranes (PPROM) (ICD-10 O42), infant sex, fetal birth weight below the tenth percentile, fetuses with birth weight above the 97th percentile, and fetal congenital anomalies as defined in the register of congenital malformations.

The babies born in breech presentation from the four study groups were compared with the babies born in cephalic presentation with the equal gestational age, according to WHO classification. The calculations were performed using SPSS 19. Statistical differences in categorical variables were evaluated with the Chi-squared test or Fisher’s exact test when appropriate. We calculated odds ratios (ORs) with corresponding 95% confidence intervals (CIs) using binary logistic regression. Each study group was separately adjusted, according to gestational age at delivery, defined by WHO. The adjustment for the risk factors was done by multivariable logistic regression model for all variables. Differences were deemed to be statistically significant with P value < 0.05.

This analysis includes 737,788 singleton births, from these 20,086 were in breech presentation at the time of delivery. Out of all deliveries, 33,489 infants were born preterm. The prevalence of breech presentation at delivery decreased with the increase of the gestational age: 23.5% in extremely preterm delivery, 15.4% very preterm deliveries, and 6.7% in moderate to late preterm deliveries. At term, the prevalence of breech presentation at delivery was 2.5% (Fig.  1 ).

From all deliveries, 2056 fetuses were born extremely preterm (24 + 0 to 27 + 6 gestational weeks). The differences in the possible risk factors for breech presentation at delivery were higher odds of PPROM (aOR 1.39, 95% CI 1.08–1.79, P  = 0.010) and a lower risk of placental abruption (aOR 0.59, 95% CI 0.36–0.98, P  = 0.040). No statistically significant differences were observed for the other factors (Table ​ (Table1, 1 , Figs.  1 , ​ ,2, 2 , ​ ,3, 3 , ​ ,4 4 ).

Unadjusted and adjusted odds ratios for risk factors in singleton extremely preterm 24 + 0 to 27 + 6 weeks of gestational age fetuses in breech and in cephalic presentations during 2004–2014 in Finland

BMI body mass index, IVF in vitro fertilization, maternal intoxication, PPROM preterm premature rupture of membranes

Prevalence of obstetric risk factors for breech presentation compared to cephalic by gestational age. PPROM preterm premature rupture of membranes, PROM premature rupture of membranes

Obstetric risk factors for breech presentation with adjusted odds ratios by gestational age. PPROM preterm premature rupture of membranes, PROM premature rupture of membranes, aOR adjusted odds ratio

The determinants of breech presentation by gestational age. PPROM preterm premature rupture of membranes, PROM premature rupture of membranes

The group of very preterm deliveries (28 + 0 to 31 + 6 gestational weeks) included 4582 singleton newborns. Breech presentation at delivery was associated with PPROM (aOR 1.61, 95% CI 1.32–1.96, P  < 0.001), oligohydramnios (aOR 1.65, 95% CI 1.03–2.64, P  = 0.038), fetal birth weight below the tenth percentile (aOR 1.57, 95% CI 1.19–2.08, P  = 0.002), and maternal pre-eclampsia and arterial hypertension (aOR 1.31, 95% CI 1.04–1.66, P  = 0.023). Details of risk factors in very preterm breech deliveries are described in Table ​ Table2. 2 . The risk of placenta praevia as well as having a birth weight above the 97th percentile was lower in pregnancies with fetuses in breech rather than in cephalic presentation (Table ​ (Table2, 2 , Figs. ​ Figs.2, 2 , ​ ,3, 3 , ​ ,4 4 ).

Unadjusted and adjusted odds ratios for risk factors in singleton very preterm 28 + 0 to 31 + 6 weeks of gestational age fetuses in breech and in cephalic presentations during 2004–2014 in Finland

BMI body mass index, IVF in vitro fertilization, PPROM preterm premature rupture of membranes

The moderate to late preterm delivery group (32 + 0 to 36 + 6 gestational weeks) included 26,851 deliveries. Breech presentation in moderate to late preterm deliveries was associated with older maternal age (maternal age 35 years or more aOR 1.24, 95% CI 1.10–1.39, P  < 0.001), nullipara (aOR 1.43, 95% CI 1.27–1.60, P  < 0.001), maternal BMI less than 25 (maternal BMI ≥ 25 aOR 0.75, 95% CI 0.62–0.91, P  = 0.004), previous cesarean section (aOR 1.31, 95% CI 1.12–1.53, P  < 0.001), female sex (aOR 1.22, 95% CI 1.11–1.34, P  < 0.001), congenital anomaly (aOR 1.37, 95% CI 1.22–1.55, P  < 0.001), fetal birth weight below the tenth percentile (aOR 1.31, 95% CI 1.10–1.56, P  = 0.003), oligohydramnios (aOR 3.60, 95% CI 2.63–4.92, P  < 0.001), and PPROM (aOR 1.58, 95% CI 1.41–1.78, P  < 0.001). Breech presentation decreased the odds of having a fetus with birth weight above the 97th percentile (aOR 0.60, 95% CI 0.42–0.85, P  = 0.004) (Table ​ (Table3, 3 , Figs. ​ Figs.2, 2 , ​ ,3, 3 , ​ ,4 4 ).

Unadjusted and adjusted odds ratios for risk factors in singleton moderate to late preterm 32 + 0 to 36 + 6 weeks of gestational age fetuses in breech and in cephalic presentations during 2004–2014 in Finland

The term and post-term group included 704,299 deliveries, among them 17,044 fetuses in breech presentation. The factors associated with breech presentation amongst these were: maternal age of 35 years or more (aOR 1.24, 95% CI 1.19–1.29, P  < 0.001), nullipara (aOR 2.46, 95% CI 2.37–2.55, P  < 0.001), maternal BMI less than 25 (BMI ≥ 25 aOR 0.90, 95% CI 0.85–0.96, P  < 0.001), maternal hypothyroidism (aOR 1.53, 95% CI 1.28–1.82, P  < 0.001), pre-gestational diabetes treated with insulin (aOR 1.24, 95% CI 1.00–1.53, P  = 0.049), placenta praevia (aOR 1.45, 95% CI 1.11–1.91, P  = 0.007), premature rupture of membranes (PROM) (aOR 1.58, 95% CI 1.45–1.72, P  < 0.001), oligohydramnios (aOR 2.02, 95% CI 1.83–2.22, P  < 0.001), congenital anomaly (aOR 1.97, 95% CI 1.89–2.06, P  < 0.001), female sex (aOR 1.28, 95% CI 1.24–1.32, P  < 0.001), and birth weight below the tenth percentile (aOR 1.18, 95% CI 1.12–1.24, P  < 0.001) Table ​ Table4 4 includes details for risk factors of term and post-term group (Figs.  2 , ​ ,3, 3 , ​ ,4 4 ).

Unadjusted and adjusted odds ratios for risk factors in singleton term pregnancies in breech and in cephalic presentations during 2004–2014 in Finland

BMI body mass index, IVF in vitro fertilization, PROM premature rupture of membranes

The main novel finding of our study was that the risk associations increase with each gestational age group after 28 weeks of gestation. With the exception of PPROM, the extremely preterm breech deliveries have similar clinical risk profiles as in cephalic presentation when matched for gestational age. However, as gestation proceeds, the risks start to cluster. In moderate to late preterm pregnancies as in term pregnancies, the breech presentation is a high-risk state being associated with several risk factors: PPROM, oligohydramnios, advanced maternal age, nulliparity, previous cesarean section, fetal birth weight below the tenth percentile, female sex, and fetal congenital anomalies. These are in line with the findings of previous studies [ 3 , 5 , 7 , 8 ], that associated breech presentation at term with obstetric risk factors. The prevalence of breech presentation was negatively correlated with the gestational age with a decline from 23.5% in extremely preterm pregnancies to 2.5% at term. The prevalence of breech presentation in preterm pregnancies observed in our trial is similar to that of comparable studies [ 1 , 2 ].

In extremely preterm deliveries, PPROM was the only risk factor for breech presentation and it stayed as a risk for breech presentation through the gestational weeks. This finding is comparable to the previous literature suggesting that PPROM occurs more often at earlier gestational age in pregnancies with the fetus in breech presentation compared with cephalic [ 21 , 22 ]. PPROM might prevent the fetus to change into cephalic presentation. Furthermore, Goodman and colleagues (2013) reported that in pregnancies with a fetus in a presentation other than cephalic had more complications such as oligohydramnios, infections, placental abruption, and even stillbirths. In our study, surprisingly, placental abruption seemed to have a negative correlation with breech presentation among extremely preterm deliveries. This inconsistency between our results and the literature might be due to the small number of cases. Many of the obstetric complications, for example gestational diabetes, late pre-eclampsia, and late intrauterine growth restriction develop during the second or the third trimester of the pregnancy which explains partially why the risk factors for breech presentation are rarer in extremely preterm deliveries.

In very preterm delivery, breech presentation was associated with PPROM, pre-eclampsia, and fetal birth weight below the tenth percentile. Fetal growth restriction is a known risk factor for breech presentation at term, since it is associated with reduced fetal movements due to diminished resources [ 23 – 25 ]. Furthermore, fetal growth restriction is known to be the single largest factor for stillbirth and neonatal mortality [ 26 – 30 ]. Maternal arterial hypertension disturbs placental function which might cause low birth weight [ 31 , 32 ]. Arterial hypertension and pre-eclampsia increased the risk for breech presentation in very preterm births, but not in earlier or later preterm pregnancies. This finding may be due to the bias that pre-eclampsia is a well-described risk factor for PPROM, fetal growth restriction, and preterm deliveries which are also independent markers for breech presentation itself [ 4 , 5 , 31 , 33 , 34 ]. The severity of early pre-eclampsia might affect the fetal wellbeing, reduce fetal movements and growth, which might reduce the spontaneous fetal rotation to the cephalic position [ 35 ]. In addition, the most severe cases might not reach older gestational age before the delivery.

The risk factor for breech presentation in moderate to late preterm breech delivery was PPROM, oligohydramnios, advanced maternal age, nulliparity, previous cesarean section, fetal birth weight below the tenth percentile, female sex, and fetal congenital anomalies. Oligohydramnios is a known significant risk factor for term breech pregnancies [ 25 ] and it is linked to the reduced fetal movements partly due to a restricted intrauterine space [ 24 , 35 ] and nuchal cords [ 35 ]. Additionally, oligohydramnios is associated with placental dysfunction, which might reduce fetal resources and thus has a progressive effect on the fetal movements and prevent the fetus from turning into cephalic presentation [ 3 , 4 , 18 ]. Fetal female sex in moderate to late preterm breech pregnancies remained as a risk factor, as identified previously for term pregnancies [ 3 – 5 ]. It has been debated whether this risk is due to a smaller fetal size or that female fetuses tend to move less [ 9 , 20 ]. The mothers of infants born in breech presentation in moderate to late preterm and term and post-term pregnancies seemed to be older and had an increased risk of having a fetus with a congenital anomaly. The advanced maternal age is associated with negative effects on vascular health, which may have an influence on the developing fetus and increase the incidence of congenital anomalies [ 19 , 34 , 36 ]. Furthermore, congenital anomalies may have a negative influence on fetal movements [ 19 , 35 ]. Whereas, the low birth weight was found as a risk for breech presentation, a birth weight above the 97th percentile was, coherently a protective factor for breech presentation in very to term and post-term pregnancies.

We found that in term pregnancies, breech presentation was associated with advanced maternal age, nulliparity, maternal hypothyroidism, pre-gestational diabetes, placenta praevia, PROM, oligohydramnios, fetal congenital anomaly, female sex of the fetus, and birth weight below the tenth percentile. A previous cesarean section is known to be positively related to the odds of having a fetus in breech presentation at term [ 5 , 14 ], and in our study, this risk factor started to show already in moderate to late preterm pregnancies. Instead of the scar being the cause of breech presentation, it is more likely that the women with a history of breech cesarean section have, during subsequent pregnancies, a fetus in breech presentation again or have a cesarean section for another reason [ 3 , 5 , 37 ]. Our data suggest that the advanced maternal age and nulliparity are the risks for breech presentation at term, but as well as in moderate to late preterm pregnancies. The tight wall of the abdomen and the uterus of nulliparous women might inhibit the fetus from rotating to cephalic presentation [ 9 ]. In a meta-analysis from 2017, older maternal age has been considered to increase the risk of placental dysfunction such as pre-eclampsia and preterm birth [ 36 ] that are also common risk factors for breech presentation [ 4 , 5 ]. Bearing the first child in older maternal age and giving birth by cesarean section may affect the decision not to have another child and might explain the higher rate of nulliparity among moderate to late preterm and term deliveries [ 1 ]. Our study found correlation between maternal hypothyroidism and breech presentation at term. Some studies have demonstrated an association between maternal thyroid hypofunction and adverse pregnancy outcomes such as pre-eclampsia and low birth weight which are, furthermore, risks for breech presentation and may explain partly the higher prevalence of maternal hypothyroidism in term breech deliveries [ 38 – 40 ]. However, the absence of screening of, for example, thyroid diseases may cause bias in the diagnoses.

Our study demonstrated that as gestation proceeds, more obstetric risk factors can be found associating with breech presentation. In the earlier gestation and excluding PPROM, breech deliveries did not differ in obstetric risk factors compared to cephalic. The risk factors in 32 weeks of gestational age are comparable to those in term pregnancy, and several of these factors, such as low birth weight, congenital anomalies and history of cesarean section, are associated with adverse fetal outcomes [ 1 , 4 , 5 , 8 , 14 , 17 ] and must be taken into account when treating breech pregnancies. Risk factors should be evaluated prior to offering a patient an external cephalic version, as the presence of some of these risks may increase the change of failed version or fetal intolerance of the procedure. This study had adequate power to show differences between the risk profiles of breech and cephalic presentations in different gestational phase. Further research, however, is needed for improving the identification of patients at risk for preterm breech labor and elucidating the optimal route for delivery in preterm breech pregnancies.

Our study is unique since it is the first study, to our knowledge, that compares the risks for breech presentation in preterm and term deliveries. The analysis is based on a large nationwide population, which is the major strength of our study. The study population included nearly 34,000 preterm births over 11 years in Finland and 737,788 deliveries overall. The medical treatment of pregnancies is homogenous, since there are no private hospitals treating deliveries. A further strength relates to the important information on the characteristics of the mother, for example smoking during pregnancy and pre-pregnancy body mass index. The retrospective approach is a limitation of the study, another one is the design as a record linkage study, due to which the variables were restricted to the data availability. Therefore, we were not able to assess, for example uterine anomalies or previous breech deliveries to the analysis.

Our results show that the factors associated with breech presentation in very late preterm breech deliveries resemble those in term pregnancies. However, breech presentation in extremely preterm breech birth has similar clinical risk profiles as in cephalic presentation.

Acknowledgements

Open access funding provided by University of Helsinki including Helsinki University Central Hospital.

Abbreviations

Author contribution.

AT: Project development, manuscript writing. SH: Project development. MG: Data collection and analysis, manuscript editing. GM: Project development, manuscript editing.

This study was supported by Helsinki University Hospital Research Grants. Authorization to use of the data was obtained from the National Institute for Health and Welfare as required by the national data protection legislation in Finland (reference number THL/652/5.05.00/2017).

Compliance with ethical standards

We declare that we have no conflict of interest.

For this type of study, formal consent is not required. The National Institute for Health and Welfare authorized to use the data (reference number THL/652/5.05.00/2017).

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Contributor Information

Anna E. Toijonen, Email: [email protected] .

Seppo T. Heinonen, Email: [email protected] .

Mika V. M. Gissler, Email: [email protected] .

Georg Macharey, Email: [email protected] .

The influence of epidural anesthesia in pregnancies with scheduled vaginal breech delivery at term: a hospital-based retrospective analysis

• Maternal-Fetal Medicine
• Open access
• Published: 20 November 2023

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• Roman Allert   ORCID: orcid.org/0000-0003-0051-4792 1 ,
• Dörthe Brüggmann 1 ,
• Florian J. Raimann 2 ,
• Nadja Zander 3 ,
• Frank Louwen 1 &
• Lukas Jennewein 1  

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Introduction

Epidural anesthesia is a well-established procedure in obstetrics for pain relief in labor and has been well researched as it comes to cephalic presentation. However, in vaginal intended breech delivery less research has addressed the influence of epidural anesthesia. The Greentop guideline on breech delivery states that there’s little evidence and recommends further evaluation.

The aim of this study was to compare maternal and neonatal outcomes in vaginally intended breech deliveries at term with and without an epidural anesthesia.

This study was a retrospective cohort study.

This study included 2122 women at term with a singleton breech pregnancy from 37 + 0 weeks of pregnancy on and a birth weight of at least 2500 g at the obstetric department of University hospital Frankfurt from January 2007 to December 2018.

Neonatal and maternal outcome was analyzed and compared between women receiving “walking” epidural anesthesia and women without an epidural anesthesia.

Fetal morbidity, measured with a modified PREMODA score, showed no significant difference between deliveries with (2.96%) or without (1.79%; p  = 0.168) an epidural anesthesia. Cesarean delivery rates were significantly higher in deliveries with an epidural (35 vs. 26.2%, p  = 0.0003), but after exclusion of multiparous women, cesarean delivery rates were not significantly different (40.2% cesarean deliveries with an epidural vs. 41.5%, p  = 0.717). As compared to no epidurals, epidural anesthesia in vaginal delivery was associated with a significantly higher rate of manual assistance (33.8 versus 52.1%) and a longer duration of birth (223.7 ± 194 versus 516.2 ± 310 min) (both p  < 0.0001)".

Epidural anesthesia can be offered as a safe option for pain relief without increasing neonatal or maternal morbidity and mortality. Nevertheless, it is associated with a longer birth duration and manually assisted delivery.

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Avoid common mistakes on your manuscript.

Regional anesthesia is a well-established procedure in obstetrics for pain relief in labor and is broadly recommended in guidelines [ 1 ]. A Cochrane review including data of 40 trials and over 11.000 women shows a higher chance of instrumental assisted delivery in trials before 2005, an effect that did not occur when trials before 2005 were excluded from the analysis. No difference was shown concerning neonatal outcome or the rate of cesarean delivery [ 2 ].

In deliveries with breech presentation evidence is scarce regarding the safety and effect of epidural anesthesia and recommendations are vague: the British Greentop guideline states that the effect of an epidural anesthesia on the success of vaginal breech birth is unclear and might increase the risk of intervention and recommends further research [ 3 ]. The French clinical practice guideline emphasizes the high level of evidence for epidural anesthesia in cephalic version, with no higher risk of cesarean or risk of vaginally assisted delivery and therefore encourages the use of epidural anesthesia in breech presentation [ 4 ]. The SOGC (Society of Obstetricians and Gynecologists of Canada) clinical practice guideline on breech delivery recommends avoiding dense epidural to maximize expulsive efforts, while neither ACOG (American College of Obstetricians and Gynecologists) nor RANZCOG (Royal Australian and New Zealand College of Obstetricians and Gynaecologists) addresses the issue of epidural anesthesia [ 5 , 6 , 7 ].

In the term Breech trial epidural anesthesia was not associated with adverse perinatal outcome [ 8 , 9 , 10 ]. The PREMODA (PREsentation et MODe d'Accouchement) trial does not report an impact of epidural anesthesia [ 11 ]. Even though safety of epidural anesthesia is established, there still are reports of associated increased adverse neonatal outcome, prolonged labor, or cesarean delivery rate [ 12 , 13 , 14 ].

In the FRABAT (FRAnkfurt Breech At Term Study Group) cohort, the demand for epidural analgesia was high, especially in primiparous women [ 15 ]. Thus, it can be assumed that the patients’ need for an epidural anesthesia during an intended vaginal breech birth is high and clinicians will be confronted with this topic frequently during clinical counseling.

Since every medical intervention with its possible complications should be discussed with patients before administration, it is mandatory to gain evidence in order to be able to give reliable information. The effect of epidural analgesia on vaginally intended birth out of breech presentation has not been elucidated properly because the respective recommendations are adopted from vertex presentations. We present a cohort study on the neonatal and maternal outcome in vaginally intended breech deliveries in light of the use of an epidural anesthesia. We hypothesize that an epidural anesthesia does not influence perinatal morbidity in vaginally intended breech deliveries provided the epidural keeps the motor function and patients are not immobilized.

Study design

We conducted a single center cohort study in all pregnant women at term (≥ 37 weeks of gestation) presenting with a breech presentation at the Goethe University Hospital Frankfurt, Germany, from January 2004 to December 2018. The analysis was performed in a retrospective manner through generating subgroups (deliveries with or without an epidural) within our study cohort.

The university hospital’s ethics committee gave consent (420/11). All data were assessed through the in-house patient data system as well as the Hessen Perinatalerhebung and were acquired after patient’s dismissal from the hospital. All patients received the standard clinical care. Because of the retrospective nature of data acquisition, the ethics committee waived an informed patient’s consent.

Exclusion criteria were fetal birth defect, uterine malformation, multiple pregnancies, contraindication for an epidural anesthesia, estimated birth weight less than 2500 g, and contraindications for vaginal approach.

Other studies with intersection cohorts have been published by different authors of the FRABAT group within previous publications. [ 15 , 16 , 17 , 18 , 19 ].

Clinical procedure and counseling

All pregnant women with a breech presentation are counseled between 34 and 36 weeks of gestation. External cephalic version, vaginal attempted birth, as well as cesarean delivery are discussed with each patient, depending on the individual patient history and examination. During vaginal delivery, which is performed predominantly in an upright maternal position, manual assistance to deliver the arms or the fetal head is performed by a trained physician if necessary. A maternal upright position applies when the mother stands or is on all fours (hands and knees). An epidural is offered to every woman by their own choice if no contraindications (e.g., thrombocytopenia) are present. Counseling specifics and details on manual assistance in the upright maternal position have been published [ 17 , 20 ]

Outcome parameters

Primary outcome was perinatal fetal morbidity, which was assessed using the modified PREMODA Score, potentially associated with the delivery mode. The PREMODA Score is adapted from the PREMODA study [ 11 ] implies NICU stay > 4 days, trauma at birth, neurological deficits, intubation > 24 h, or an APGAR score of less than 4 at 5 min [ 9 ]. Secondary outcome measures were duration of labor, rate of cesarean delivery, and rate of assisted vaginal delivery.

Method of epidural anesthesia

Epidural anesthesia was administered by an in-house anesthesiologist. It was initiated with a dose of Ropivacaine and Sufentanil. After the loading dose, a patient controlled pump with Ropivacaine / Sufentanil was connected to maintain persistent pain reduction. Patients were not immobilized and the rate could be reduced if necessary. If analgesia was not sufficient patients could receive up to three additional boli per hour.

Statistical analysis

Groups of variables were tested for normal distribution with Kolmogorov–Smirnov test [ 21 ]. Group differences were analyzed using Pearson’s χ2 testing. Student’s T-test was utilized to compare continuous variables [ 22 , 23 ]. A nominal logistic regression analysis with Wald testing was performed.[ 24 ] We used JMP 14.0 software (SAS Institute, Cary, NC, USA) for our analyses. A p-value of below 0.05 was considered as statistically significant.

Of the 2122 women presenting for counseling with breech presentation at our center, 1413 attempted vaginal delivery.

744/1413 (52.7%) women received an epidural anesthesia (EPI group), 669/1413 (47.3%) did not (NEPI group, Table 1 ). Patients in the NEPI group were significantly older than patients in the EPI group (NEPI 32.7 (± 4.5), EPI 31.9 (± 4.3) p  = 0.0009). BMI was equally distributed between both groups (Table 1 ). There were significantly more primiparous women in the EPI group (EPI 523, 70.3%; NEPI 316, 47.2%; p  < 0.0001; Table 1 ). Mean birth weight was significantly higher in the EPI group (3388 g; NEPI: 3323 g; p  = 0.002; Table 1 ). Duration of pregnancy was significantly longer in the EPI group (280 days) as compared to the NEPI group (278 days, p  > 0.0001; Table 1 ).

There were significantly more manually assisted vaginal deliveries when women received an epidural anesthesia: In the NEPI group 327/669 (48.9%) women delivered vaginally, while 167/669 (25.0%) delivered with manual assistance. In the EPI group 232/744 (31.2%) women delivered spontaneous and 252/744 (33.9%) with assistance ( p  < 0.0001). Cesarean delivery after onset of labor was performed in 175/669 (26.2%) in the NEPI group which is significantly less often than in the EPI group (260/744 (35.0%), p  = 0.0003, Table 1 and Fig.  1 ).

Flow chart of the study cohort

We investigated all vaginal deliveries in a sub-cohort analysis. There were significantly more primiparous women in the group of patients giving vaginal birth with an epidural anesthesia (vEPI group, n  = 313, 64.7%) as compared to primiparous women without an epidural anesthesia (vNEPI group, n  = 185, 37.5%; p  < 0.0001, Table 2 ). Birth weight was not significantly different between vNEPI group (3307 ± 340 g) and vEPI group (3325 ± 391 g; p  = 0.361; Table 2 ). Duration of labor was significantly longer in vaginal deliveries with an epidural anesthesia as compared to vaginal deliveries without epidural anesthesia (vEPI 516 ± 310 min; vNEPI 224 ± 194 min; p  < 0.0001, Table 2 ). Manual assistance was significantly more often necessary in vaginal deliveries with an epidural anesthesia (vEPI: n  = 252, 52.1%; vNEPI: n  = 167 33.8%; p  < 0.0001, Table 3 ). Fetal morbidity measured with the modified PREMODA score was not significantly different between both groups (vNEPI: 2.02%, vEPI: 3.31%; p  = 0.2373; Table 2 ). There was no significant difference in high grade perineal tears between groups (vNEPI: n  = 8; 1.6%, vEPI: n  = 10; 3.3%, p  = 0.642; Table 2 ), but perineal tears of all degrees were significantly more often in vaginal deliveries with an epidural anesthesia (vNEPI: n  = 224; 45.3%, vEPI: n  = 249; 51.4%, p  = 0.0056; Table 2 ).

We investigated a subgroup of primiparous women ( n  = 839). In the group of primiparous women with an epidural anesthesia (pEPI) birth weight was significantly higher as compared to deliveries of primiparous women without an epidural anesthesia (pNEPI: 3253 ± 411 g, pEPI: 3379 ± 416 g; p  < 0.0001, Table 3 ). Cesarean delivery rate was not significantly different between groups in this sub-analysis (pNEPI: n  = 131; 41.5%, pEPI: n  = 210; 40.2%; p  = 0.7174, Table 3 ). In primiparous women, there was no significant difference in the modified PREMODA score whether patients received an epidural or not (pNEPI: n  = 5; 1.58%, pEPI: n  = 20 3.82%; p  = 0.0917, Table 3 ).

Within a multiple nominal logistic regression analysis, maternal age, birth weight, neonatal morbidity, and cesarean delivery were not significantly associated with an epidural anesthesia (Table 4 ). In contrast, primiparity (OR 2.295; 95% CI: 1.781–2.956; p  < 0.0001) and pregnancy duration (OR 1.316; 95% CI: 1.182–1.465; p  < 0.0001) were significantly associated with an epidural anesthesia (Table 4 ).

In the subgroup of vaginal deliveries, only duration of birth (OR 1.0055; 95% CI: 1.0044–1.0066; p  < 0.0001) and manually assisted delivery (OR 2.23; 95% CI: 1.57–3.52; p  < 0.0001) were significantly increased, whereas perineal injuries were not affected (Table 4 ).

Evidence is scarce on the impact of an epidural anesthesia in vaginally intended breech deliveries since all recommendations are based on studies investigating epidural analgesia in cephalic deliveries. We have performed a cohort study on vaginally intended breech deliveries analyzing the effect of epidural anesthesia on perinatal outcome.

Perinatal morbidity was not significantly different between deliveries with and without epidural anesthesia (see Tables 1 , 2 , 3 , 4 ). Furthermore, Goffinet et al. [ 11 ] showed that increased short-term morbidity in breech deliveries did not translate into long-term morbidity. Primiparous women were analyzed separately because parity has an impact on delivery outcome measures. In our sub-cohort analyses of primiparous women (Table 3 ) and a nominal logistic regression model (Table 4 ), we were able to confirm the data seen in our whole cohort analyses concerning fetal morbidity. Here, PREMODA scores were consistently not different between deliveries with and without epidural anesthesia.

Patients receiving an epidural anesthesia had a higher probability for cesarean delivery after onset of labor in our main cohort (Table 1 ). But when only primiparous women were analyzed, cesarean delivery rates were not significantly different (Table 3 ). Also, a nominal logistic regression analysis found no association of cesarean delivery rate and epidural anesthesia (Table 4 ). The effect on cesarean delivery rates thus derives from the influence of parity. Primiparous women received an epidural anesthesia in 70.3% of cases, multiparous women only in 29.7% (Table 1 ). This finding contrasts the RCOG guideline; here authors stated that an epidural “might increase the risk of caesarean section” [ 3 ]. In vertex deliveries, a Cochrane analysis reports no effect on cesarean delivery rates linked to the use of epidurals [ 2 ].

New data suggest that not the epidural anesthesia but a prolonged labor and higher need for pain relief itself pose risk factors for an increased cesarean delivery likelihood; underlying problems are the actual cause rather than the analgesia itself [ 25 ].

In vaginal deliveries, the duration of the labor was significantly longer in deliveries with an epidural anesthesia. This effect has also been reported in vertex deliveries [ 26 , 27 ]. In these studies the immobilization though the application of an epidural is supposedly causative for a longer birth duration. In our center, patients are not immobilized after they receive pain relief by an epidural. This is important because women give birth predominantly in an upright position in order to reduce interventions and newborn morbidity [ 20 ]. This is both arguable in vertex and breech presentations. We believe that a “walking” epidural—keeping maternal motor function—is of important benefit for the course of labor: walking and an upright position reduce the duration of labor and the risk of cesarean [ 28 ].

Among the patients who delivered vaginally epidural anesthesia was associated with a higher chance of assisted vaginal delivery (see Tables 1 , 4 ). From vertex deliveries we have learned that operative vaginal deliveries are more often performed in deliveries with an epidural anesthesia [ 26 ].

When a vaginal operative delivery is indicated because of arrest of birth in active labor, women without an epidural anesthesia might prefer a cesarean section, while women with an epidural anesthesia might feel more equipped for a vaginal operative procedure.

In the cohort of women who experienced a successful vaginal breech delivery, maternal morbidity was not significantly increased in patients with an epidural anesthesia; in particular, we did not find a higher rate of third- and fourth-degree perineal tears or tear of all degrees (Tables 2 and 4 ). Our data imply that the use of an epidural for patients with a breech presentation undergoing labor is safe and not associated with a higher morbidity – neither for the fetus nor for the mother.

A strength of our study is a large cohort of patients, treated with a standardized protocol. This leads to homogeneity and comparability within our results.

A major limitation of our study is selection bias as all data derive from a single center. This is a retrospective analysis of an existing study cohort. Thus, only associations and not causative relationships can be concluded from our data. A prospective randomized controlled trial would be the gold standard to investigate a clinical intervention. Nevertheless, randomized controlled trials are hardly possible in women with breech delivery and an intention to deliver vaginally since only a few women would accept to stay without pain relief and to withhold an epidural due to a study design would be unethical.

In our data, only the application of an epidural analgesia was documented. The degree of actual pain relief and the time point of administration during labor were not recorded. Duration of pain relief of an epidural analgesia and patient satisfaction are important issues possibly influencing our outcome measures. In future studies, these items should be assessed in order to improve the quality of our results.

However, while the retrospective analysis has limitations, the absence of an influence on perinatal morbidity in our study adds value to the body of knowledge: our data show that mothers will not impact perinatal morbidity by requesting an epidural during labor, contrasting studies by Macharey or Toijonen. In these studies an epidural has been associated with adverse perinatal outcome in breech deliveries [ 12 , 14 ].

As in vertex presentations, an epidural anesthesia may be offered to ensure pain relief and is a safe gold standard for analgesia during labor. If manual assistance during birth is necessary, a sufficient pain relief might also be beneficial.

Further research in prospective settings would provide a more robust foundation for clinical decision-making and improve the understanding of the impact of epidural anesthesia on breech deliveries.

Data availability

The data that support the findings of this study are available from the corresponding author, [RA], upon reasonable request.

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Acknowledgements

The authors are in great gratitude toward all participants and the whole team staff of the obstetrics department at Frankfurt Goethe University hospital.

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Department of Obstetrics and Gynecology, University Hospital Frankfurt, Goethe University, 60590, Frankfurt, Germany

Roman Allert, Dörthe Brüggmann, Frank Louwen & Lukas Jennewein

Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, 60590, Frankfurt, Germany

Florian J. Raimann

Department of Midwifery Frankfurt, Goethe University, 60590, Frankfurt, Germany

Nadja Zander

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RA, DB, and FJR contributed to manuscript writing and editing, and data collection. NZ collected data. FL was responsible for protocol/project development. LJ performed protocol/project development, data analysis, and manuscript writing and editing.

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Allert, R., Brüggmann, D., Raimann, F.J. et al. The influence of epidural anesthesia in pregnancies with scheduled vaginal breech delivery at term: a hospital-based retrospective analysis. Arch Gynecol Obstet (2023). https://doi.org/10.1007/s00404-023-07244-w

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Received : 03 April 2023

Accepted : 20 September 2023

Published : 20 November 2023

DOI : https://doi.org/10.1007/s00404-023-07244-w

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