what are the types of cord presentation

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• Funic presentation
• Cord (funic) presentation

A cord presentation (also known as a funic presentation or obligate cord presentation ) is a variation in the fetal presentation  where the umbilical cord points towards the internal cervical os or lower uterine segment.

It may be a transient phenomenon and is usually considered insignificant until ~32 weeks. It is concerning if it persists past that date, after which it is recommended that an underlying cause be sought and precautionary management implemented.

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Epidemiology, radiographic features, treatment and prognosis, differential diagnosis.

• Cases and figures

The estimated incidence is at ~4% of pregnancies.

Associations

Recognized associations include:

marginal cord insertion from the caudal end of a low-lying placenta

uterine fibroids

uterine adhesions

congenital uterine anomalies that may prevent the fetus from engaging well into the lower uterine segment

cephalopelvic disproportion

polyhydramnios

multifetal pregnancy

long umbilical cord

Color Doppler interrogation is extremely useful and shows cord between the fetal presenting part and the internal cervical os. However, unlike a vasa previa , the placental insertion is usually normal.

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As the complicating umbilical cord prolapse can lead to catastrophic consequences, most advocate an elective cesarean section delivery for persistent cord presentation in the third trimester 3 .

Complications

It can result in a higher rate of umbilical cord prolapse .

For the presence of umbilical cord vessels between the fetal presenting part and the internal cervical os on ultrasound consider:

vasa previa

• 1. Ezra Y, Strasberg SR, Farine D. Does cord presentation on ultrasound predict cord prolapse? Gynecol. Obstet. Invest. 2003;56 (1): 6-9. doi:10.1159/000072323 - Pubmed citation
• 2. Kinugasa M, Sato T, Tamura M et-al. Antepartum detection of cord presentation by transvaginal ultrasonography for term breech presentation: potential prediction and prevention of cord prolapse. J. Obstet. Gynaecol. Res. 2007;33 (5): 612-8. doi:10.1111/j.1447-0756.2007.00620.x - Pubmed citation
• 3. Raga F, Osborne N, Ballester MJ et-al. Color flow Doppler: a useful instrument in the diagnosis of funic presentation. J Natl Med Assoc. 1996;88 (2): 94-6. - Free text at pubmed - Pubmed citation
• 4. Bluth EI. Ultrasound, a practical approach to clinical problems. Thieme Publishing Group. (2008) ISBN:3131168323. Read it at Google Books - Find it at Amazon

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INTRODUCTION

Funic or cord presentation is defined as one or more loops of umbilical cord floating between the fetal presenting part and the internal cervical os, typically with the membranes are intact. With normal amniotic fluid volume, funic presentation is often a dynamic process that can appear and disappear with fetal movement, especially earlier in gestation. The clinical significance of funic presentation is that as gestational age advances and the fetal head becomes engaged, the cord can become wedged between the uterine wall and fetal presenting part, creating an occult or overt prolapse upon membrane rupture.

Of note, an alternative nomenclature has been proposed whereby classification is based on the positional relationship among the cord, the fetal presenting part, and the cervix [ 1 ]. In this system, "cord prolapse" refers to an umbilical cord that has prolapsed past the fetal presenting part and beyond the internal cervical os, "cord presentation" refers to an umbilical cord ahead of the fetal presenting part but above the internal cervical os, and "compound cord presentation" refers to both the cord and fetus presenting above the internal cervical os. Any of the three clinical scenarios can occur with either intact or ruptured membranes.

This topic will discuss the frequency, pathogenesis, risk factors, clinical findings, diagnosis, management, potential prevention, and outcome of umbilical cord prolapse.

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• Volume 14, Issue 5
• Cord presentation in labour: imminent risk of cord prolapse
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• Tiago Aguiar 1 , 2 ,
• João Cavaco Gomes 1 and
• Teresa Rodrigues 2
• 1 Gynaecology Department , Centro Hospitalar Universitário São João , Porto , Portugal
• 2 Obstetrics Department , Centro Hospitalar Universitário São João , Porto , Portugal
• Correspondence to Dr Tiago Aguiar; tiagomdiasaguiar{at}gmail.com

https://doi.org/10.1136/bcr-2021-243320

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Description

A 37-year-old pregnant woman at 39 weeks of gestation, gravida 3, para 2, with a history of uncomplicated spontaneous vaginal deliveries at term, presented to the emergency department with lower abdominal cramps and watery vaginal discharge that started 2 hours before. Vaginal examination confirmed ruptured membranes, 3 cm cervical dilation, 30% effacement, and a mass of umbilical cord loops was presenting. Transvaginal ultrasound demonstrated an agglomerate of umbilical cord loops lying between the internal os and the fetal head ( figures 1 and 2 ). Due to the imminent possibility of overt cord prolapse, an emergent caesarean section was performed, with the delivery of a newborn weighing 3640 g, Apgar score 9 at 1 min and 10 at 5 min.

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Transvaginal ultrasound showing the umbilical cord between the fetal head and the cervix.

Transvaginal ultrasound showing loops of cord presenting above the internal cervical os. Flow confirmed with colour Doppler.

Suspicion may arise during vaginal examination but the diagnosis may not clear. Ultrasound can confirm the diagnosis by showing the presence of umbilical cord between the fetal presenting part and the cervix.

Spontaneous resolution by time of delivery can occur when the diagnosis is established during third trimester scan. However, the combination of ruptured membranes and cord presentation during labour precedes an inevitable cord prolapse, as cervical dilation progress. Therefore, we agree with the majority of authors recommending caesarean section when funic presentation is found during labour. 4

Learning points

Cord presentation is a rare condition during labour, associated with imminent risk of cord prolapse.

Diagnosis may be suspected during vaginal examination and is confirmed by ultrasound.

Caesarean section is recommended when diagnosis is established during labour.

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• Strasberg SR ,
• Royal College of Obstetricians and Gynaecologists (RCOG)
• Matsuzaki S , et al
• Grenier S ,

Contributors All authors were responsible for the diagnosis and management of the case reported. Dr TA was responsible for writing of the report. Dr JCG and Professor TR were responsible for the corrections before submission of the document.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

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Cord Prolapse and Transverse Lie

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Kumar, A., George, N. (2020). Cord Prolapse and Transverse Lie. In: Sharma, A. (eds) Labour Room Emergencies. Springer, Singapore. https://doi.org/10.1007/978-981-10-4953-8_33

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Umbilical cord constriction can be due to intrinsic or extrinsic mechanisms. Constriction may lead to different degrees of flow limitation in the cord"s vessels, which can be demonstrated by pulsed Doppler flow studies. Intrinsic constriction is characterized by localized absence of Wharton"s jelly, leading to narrowing of the cord, thickening of the vascular walls and narrowing of the vascular lumens. In this setting, fetal death might occur due to acute vasospasm, acute oligohydramnios and uterine contraction, or an obliterating thrombus (10). Extrinsic constriction can be caused by:

Occasionally loops of cord may lie between the lower uterine segment and the presenting part (cord or funic presentation). This is important to recognize as it predisposes to cord prolapse and possible fetal death when the membranes rupture. Funic presentation is more common with malpresentations (especially breech and transverse lie).

• Transient and usually insignificant prior to 32 weeks. If this is persistent one must look for a cause.
• Marginal cord insertion from the caudal end of a low-lying placenta.
• Uterine fibroids / Uterine adhesions.
• Congenital uterine anomalies that may prevent the fetus from engaging well into the lower uterine segment.
• Cephalopelvic disproportion.
• Polyhydramnios.
• Multiple gestations.
• Increased umbilical cord length.
• Prolapse of the cord occurs in 0.5% of cases.
• High perinatal mortality rate due to cord compression (1).
• Selbing A. Umbilical cord compression diagnosed by means of ultrasound. Acta Obstet Gynecol Scand 1988;67:565-567.
• Hales ED, Westney LS. Sonography of occult cord prolapse. JCU 1984;12:283-285.
• Dudiak CM, Salomon CG, Posniak HV et.al. Sonography of the umbilical cord. Radiographics 1995;15:1035-1050.
• Johnson RL, Anderson JC, Irsik RD et.al. Duplex ultrasound diagnosis of umbilical cord prolapse. J Clin Ultrasound 1987;15:282-284.
• Kanayama MD, Gaffey TA, Ogburn PL Jr. Constriction of the umbilical cord by an amniotic band, with fetal compromise illustrated by reverse diastolic flow in the umbilical artery. A case report. J Reprod Med 1995 Jan;40(1):71-73.
• Boughizane S, Zhioua F, Jedoui A, Kattech R, Gargoubi N, Srasra M, Ben Romdhane K, Meriah S. Swallowing of an amniotic string by a fetus at term. J Gynecol Obstet Biol Reprod (Paris) 1993;22(4):409-410.
• Heifetz SA. Strangulation of the umbilical cord by amniotic bands: report of 6 cases and literature review. Pediatr Pathol 1984;2(3):285-304.
• Reles A, Friedmann W, Vogel M, Dudenhausen JW. Intrauterine fetal death after strangulation of the umbilical cord by amniotic bands. Geburtshilfe Frauenheilkd 1991 Dec;51(12):1006-1008.
• Sherer DM, Anyaegbunam A. Prenatal ultrasonographic morphologic assessment of the umbilical cord: a review. Part I. Obstet Gynecol Surv 1997 Aug;52(8):506-514
• Hallak M, Pryde PG, Qureshi F, Johnson MP, Jacques SM, Evans MI. Constriction of the umbilical cord leading to fetal death. A report of three cases. J Reprod Med 1994 Jul;39(7):561-565.

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Chapter 19. Malpresentation & Cord Prolapse

Karen Kish, MD

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Essentials of Diagnosis

• Breech presentation occurs when the fetal pelvis or lower extremities engage the maternal pelvic inlet.
• Breech presentation may be suspected based on clinical examination, either by palpating fetal parts over the maternal abdomen or by pelvic examination.
• The diagnosis can be confirmed via ultrasound.

Breech presentation , which complicates 3–4% of all pregnancies, occurs when the fetal pelvis or lower extremities engage the maternal pelvic inlet. Three types of breech are distinguished, according to fetal attitude ( Fig. 19–1 ). In frank breech , the hips are flexed with extended knees bilaterally. In complete breech , both hips and knees are flexed. In footling breech , 1 (single footling breech) or both (double footling breech) legs are extended below the level of the buttocks.

Figure 19–1.

Types of breech presentations. (Reproduced, with permission, from Pernoll ML. Benson and Pernoll's Handbook of Obstetrics and Gynecology . 10th ed. New York, NY: McGraw-Hill; 2001.)

In singleton breech presentations in which the infant weighs less than 2500 g, 40% are frank breech, 10% complete breech, and 50% footling breech. With birth weights of more than 2500 g, 65% are frank breech, 10% complete breech, and 25% footling breech. The incidences of singleton breech presentations by birth weight and gestational age are listed in Table 19–1 .

Fetal position in breech presentation is determined by using the fetal sacrum as the point of reference to the maternal pelvis. This is true for frank, complete, and footling breeches. Eight possible positions are recognized: sacrum anterior (SA), sacrum posterior (SP), left sacrum transverse (LST), right sacrum transverse (RST), left sacrum anterior (LSA), left sacrum posterior (LSP), right sacrum anterior (RSA), and right sacrum posterior (RSP). The station of the breech presenting part is the location of the fetal sacrum with regard to the maternal ischial spines.

Pathogenesis

Before 28 weeks, the fetus is small enough in relation to intrauterine volume to rotate from cephalic to breech presentation and back again with relative ease. As gestational age and fetal weight increase, the relative decrease in intrauterine volume makes such changes more difficult. In most cases, the fetus spontaneously assumes the cephalic presentation to better accommodate the bulkier breech pole in the roomier fundal portion of the uterus.

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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

StatPearls [Internet].

Umbilical cord prolapse.

Marina Boushra ; Alicia Stone ; Kimberly M. Rathbun .

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Last Update: May 8, 2023 .

• Continuing Education Activity

Umbilical cord prolapse is when the umbilical cord exits the cervical os before the fetal presenting part. Compression of the cord results in vasoconstriction and resultant fetal hypoxia, which can lead to fetal death or disability if not rapidly diagnosed and managed. This activity reviews the diagnosis and management of patients with umbilical cord prolapse in the emergency department and highlights the role of early recognition and interprofessional involvement in improving patient outcomes.

• Describe the clinical presentation of umbilical cord prolapse.
• Outline the key steps in the acute management of umbilical cord prolapse.
• Review alternative management strategies that can be utilized after initial attempts at funic decompression have failed or in cases where obstetric care is not immediately available.
• Explain strategies to improve care coordination between the interprofessional teams caring for patients with umbilical cord prolapse to improve outcomes.
• Introduction

Umbilical cord prolapse (UCP) occurs when the umbilical cord exits the cervical opening before the fetal presenting part. It is a rare obstetric emergency that carries a high rate of potential fetal morbidity and mortality. Resultant compression of the cord by the descending fetus during delivery leads to fetal hypoxia and bradycardia, which can result in fetal death or permanent disability. Early recognition and intervention are paramount to the reduction of adverse outcomes in the fetus.

Certain features of pregnancy increase the risk for the development of umbilical cord prolapse by preventing appropriate engagement of the presenting part with the pelvis. These include fetal malpresentation, multiple gestations, polyhydramnios, preterm rupture of membranes, intrauterine growth restriction, preterm delivery, and fetal and cord abnormalities. [1] Nearly half of the cases of umbilical cord prolapse can be attributable to iatrogenic causes. [2] Iatrogenic risk factors include amniotomy without an engaged fetal presenting part, attempted external cephalic version in the setting of ruptured membranes, amnioinfusion, placement of a fetal scalp electrode or intrauterine pressure catheter, or the use of a cervical ripening balloon. [1]

• Epidemiology

Estimates of the incidence of umbilical cord prolapse range from 1.4 to 6.2 per 1000. [3] The majority of cases of umbilical cord prolapse occur in single gestation pregnancies; in twin gestations, the incidence increases in the second twin. [2] Most prolapses occur shortly after rupture of membranes; one study estimates that 57% occur within five minutes of membrane rupture while 67% occur within one hour of rupture. [2] The incidence of umbilical cord prolapse is on a downward trend, which is thought to be secondary to the widespread use of cesarean sections for many of the risk factors of cord prolapse, such as fetal malpresentation. [4] [5] Decreasing rates of grand multiparity worldwide are also thought to contribute to the reduced incidence. [5]

• History and Physical

The occurrence of fetal bradycardia in the setting of ruptured membranes should prompt immediate evaluation for potential cord prolapse. There are two forms of umbilical cord prolapse. [1] The first, overt prolapse, occurs when the cord exits the cervix before the fetal presenting part; the second, occult prolapse, occurs when the cord exits the cervix with the fetal presenting part. [1] In overt prolapse, the cord is palpable as a pulsating structure in the vaginal vault. In occult prolapse, the cord is not visible or palpable ahead of the fetal presenting part. In overt prolapse, the diagnosis is clinical and made by palpation of a pulsating structure in the vaginal vault or visibly protruding from the vaginal introitus; this is typically accompanied by fetal bradycardia or severe variable decelerations, though fetal heart rate changes only present in approximately two-thirds of cases. [2] [6] In occult prolapse, only fetal heart rate abnormalities may appear, as the cord will not be palpable or visible on examination. The diagnosis should be a consideration in cases of unexplained fetal heart rate changes in the setting of recent membrane rupture or other maneuvers that increase the risk of prolapse (for example, placement of a fetal scalp electrode). [1]

Umbilical cord prolapse is a clinical diagnosis and should be considered in the case of fetal bradycardia or recurrent variable decelerations, especially if they occur immediately after rupture of membranes. The diagnosis is confirmed by palpation of a pulsatile mass in the vaginal vault. No radiographic or laboratory confirmation is available, and funic decompression should be attempted as soon as the diagnosis is suspected. Antenatal ultrasound for cord presentation has been demonstrated to be a poor predictor of umbilical cord prolapse. [7]

• Treatment / Management

The definitive management of umbilical cord prolapse is expedient delivery; this is usually by cesarean section. In rare cases, vaginal delivery or operative vaginal delivery may be faster and, thus, preferable, but this should only occur under the presence and guidance of an experienced obstetrician. [1]

Until delivery is possible, the cornerstone of management of umbilical cord prolapse is funic decompression, relieving the pressure on the cord by elevation of the fetal presenting part. Studies suggest that the interval to funic decompression may be more important to outcomes than interval to delivery. [8] Decompression should be done manually by the medical provider through the placement of their finger or hand in the vaginal vault and gentle elevation of the presenting part off the umbilical cord. The provider should be conscientious not to place any additional pressure on the cord, as this can cause vasospasm and worsen outcomes. [9] Placement of the mother in a steep Trendelenburg or knee-chest position can also aid in cord decompression. In cases of a potentially prolonged interval to delivery (i.e., the need for transfer to a hospital with obstetric capabilities), saline infusion into the bladder may aid in funic decompression and remove the need for continuous manual elevation by the provider. [10] [11] If fetal decelerations persist and delivery is not imminent, the administration of a tocolytic can be attempted to relieve pressure on the umbilical vessels and to improve placental perfusion, thereby improving blood flow to the fetus. [12] [13] Reduction of the cord into the os, which was common before the widespread availability of cesarean sections, has been associated with increased fetal mortality and is not routinely recommended except in cases of an expected long interval to delivery where other maneuvers have failed. [1]

If the cord is visibly protruding from the introitus, it should remain warm and moist because the ambient temperature is significantly colder than the temperature in the uterus and can result in vasospasm of the umbilical arteries, contributing to fetal hypoxia. [1] One method described as preventing this is the replacement of the cord into the vaginal vault followed by insertion of a moist tampon to keep it in place. [14]

In very rare cases of umbilical cord prolapse in peri-viable pregnancies, case studies demonstrate that conservative management may allow the continuation of the pregnancy until reaching a more desirable gestational age. [9] [15]  However, a frank discussion should take place with the patient regarding the experimental nature of this treatment and its potential risks. 

Pre-viable gestational age, lethal fetal abnormalities, or fetal demise are not indications for expedient delivery, and instead, a dilation and evacuation or labor induction should be the therapeutic choice, dependent on gestational age or maternal preference. [5]

• Differential Diagnosis

Potential causes of a palpable mass in the vaginal vault include fetal malpresentation. [1] Possible causes of severe, prolonged fetal bradycardia include maternal hypotension, uterine rupture, vasa previa, and abruptio placentae. [1]

The rate of fetal mortality in umbilical cord prolapse is estimated to be less than 10%. [9] [2] [4] This reduction is a drastic decrease from earlier estimates of mortality, which ranged from 32 to 47%, which researchers hypothesize is due to the increased availability of cesarean sections and advances in neonatal resuscitation. [1] [9] Gestational age and location of prolapse (inside versus outside the hospital) are the two significant determinants of outcome in umbilical cord prolapse. [5]  Cord prolapse that occurs outside the hospital carries an 18-fold increased risk of mortality. [6] Premature infants and those with low birth weights have an increased risk of perinatal complications and twice the mortality. [9]  Death in these infants appears to be attributable to their underlying conditions and the preterm delivery necessitated by the prolapse rather than complications of the prolapse itself. 

• Complications

Outcomes for umbilical cord prolapse have drastically improved in recent years. [4] Still, a diagnosis of umbilical cord prolapse carries a risk of fetal mortality. Though rare, surviving infants may develop complications secondary to asphyxia, including neonatal encephalopathy and cerebral palsy. [16] [17] [18]

• Consultations

Emergent obstetric consultation is necessary for umbilical cord prolapse occurring in the emergency department. The attending clinicians should attempt maneuvers for funic decompression until definitive management is available. 

• Deterrence and Patient Education

Many patients in resource-rich countries are opting for childbirth at home under the supervision of a non-physician attendant such as a midwife. Cases of umbilical cord prolapse that occur outside the hospital carry a nearly 20 times increased rate of mortality. As such, patients with increased risk of prolapses, such as those with fetal malpresentation or umbilical cord abnormalities, should be strongly discouraged from delivering outside of the hospital. Concentration on other portions of their birth plan, such as a silent birth or minimal pharmacologic intervention, may help these patients decide to deliver in the hospital. Since umbilical cord prolapse may happen in patients without risk factors, training for non-physician birth attendants in the early recognition and intervention in umbilical cord prolapse may lead to improved fetal outcomes in these cases. 

Patients themselves should also be counseled to recognize cord prolapse in the scenario of a gush of fluid followed by the feeling of vaginal pressure or something in the vagina. The patient should be instructed to call an ambulance and assume a knee-chest position while waiting for help to arrive.

Given the iatrogenic risk factors for umbilical cord prolapse, physician education also has a role to play in decreasing the frequency of this condition. The American College of Obstetricians and Gynecologists recommends against routine amniotomy in normally progressing labor unless needed for fetal monitoring. [19] If performing an amniotomy, engagement of the fetal head should be confirmed. In cases with risk of cord prolapse, for example, polyhydramnios or high fetal station, the amniotic sac may be ruptured with a needle rather than a hook to slow the flow of the amniotic fluid, though the efficacy of this technique has not been well-studied. [20]

• Enhancing Healthcare Team Outcomes

Knowledge of the risk factors for umbilical cord prolapse does not decrease its occurrence  [2] , but such knowledge can help both healthcare providers, including midwives, labor and delivery nurses, and the patient prepare for potential umbilical cord prolapse. In patients with risk factors for developing umbilical cord prolapses, such as breech presentation with desired vaginal delivery, frank discussion with the patient and her partner regarding the risk should be undertaken, and the recommendation is to plan the delivery at a healthcare center where emergent cesarean delivery is available. Patient counseling by the clinician and nurse regarding the expected course of events in the case of umbilical cord prolapse in delivery may help the patient better understand the urgent nature of management before occurrence. Simulation team training exercises have been shown to decrease the time from diagnosis to delivery and improve fetal outcomes. [21] [22] [23]

Umbilical cord prolapse cases require an interprofessional team approach to care. This team includes physicians and specialists, as well as specialty-trained neonatal nursing staff. Through collaborative team communication, optimal care can be the result, with the best possible patient outcomes for both the mother and the neonate. [Level 5]

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Umbilical Cord prolapse Contributed by Wikimedia Commons, W. Smellie, 1792 (Public Domain)

Disclosure: Marina Boushra declares no relevant financial relationships with ineligible companies.

Disclosure: Alicia Stone declares no relevant financial relationships with ineligible companies.

Disclosure: Kimberly Rathbun declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Boushra M, Stone A, Rathbun KM. Umbilical Cord Prolapse. [Updated 2023 May 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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• Fetal demise and associated factors following umbilical cord prolapse in Mulago hospital, Uganda: a retrospective study. [Reprod Health. 2014] Fetal demise and associated factors following umbilical cord prolapse in Mulago hospital, Uganda: a retrospective study. Wasswa EW, Nakubulwa S, Mutyaba T. Reprod Health. 2014 Feb 1; 11(1):12. Epub 2014 Feb 1.
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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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