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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.

When viewing this topic in a different language, you may notice some differences in the way the content is structured, but it still reflects the latest evidence-based guidance.

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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Breech Presentation

Introduction.

Breech presentation refers to the fetus in the longitudinal lie with the buttocks or lower extremity entering the pelvis first. The three types of breech presentation include frank breech, complete breech, and incomplete breech. In a frank breech, the fetus has flexion of both hips, and the legs are straight with the feet near the fetal face, in a pike position. The complete breech has the fetus sitting with flexion of both hips and both legs in a tuck position. Finally, the incomplete breech can have any combination of one or both hips extended, also known as footling (one leg extended) breech, or double footling breech (both legs extended). [1] [2] [3]

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Clinical conditions associated with breech presentation include those that may increase or decrease fetal motility, or affect the vertical polarity of the uterine cavity. Prematurity, multiple gestations, aneuploidies, congenital anomalies, Mullerian anomalies, uterine leiomyoma, and placental polarity as in placenta previa are most commonly associated with a breech presentation.  Also, a previous history of breech presentation at term increases the risk of repeat breech presentation at term in subsequent pregnancies. [4] [5] These are discussed in more detail in the pathophysiology section.

Epidemiology

Breech presentation occurs in 3% to 4% of all term pregnancies. A higher percentage of breech presentations occurs with less advanced gestational age. At 32 weeks, 7% of fetuses are breech, and 28 weeks or less, 25% are breech.

Specifically, following one breech delivery, the recurrence rate for the second pregnancy was nearly 10%, and for a subsequent third pregnancy, it was 27%. Prior cesarean delivery has also been described by some to increase the incidence of breech presentation two-fold.

Pathophysiology

As mentioned previously, the most common clinical conditions or disease processes that result in the breech presentation are those that affect fetal motility or the vertical polarity of the uterine cavity. [6] [7]

Conditions that change the vertical polarity or the uterine cavity, or affect the ease or ability of the fetus to turn into the vertex presentation in the third trimester include:

• Mullerian anomalies: Septate uterus, bicornuate uterus, and didelphys uterus 
• Placentation: Placenta previa as the placenta is occupying the inferior portion of the uterine cavity. Therefore, the presenting part cannot engage
• Uterine leiomyoma: Mainly larger myomas located in the lower uterine segment, often intramural or submucosal, that prevent engagement of the presenting part.
• Prematurity
• Aneuploidies and fetal neuromuscular disorders commonly cause hypotonia of the fetus, inability to move effectively
• Congenital anomalies:  Fetal sacrococcygeal teratoma, fetal thyroid goiter
• Polyhydramnios: Fetus is often in unstable lie, unable to engage
• Oligohydramnios: Fetus is unable to turn to vertex due to lack of fluid
• Laxity of the maternal abdominal wall: Uterus falls forward, the fetus is unable to engage in the pelvis.

The risk of cord prolapse varies depending on the type of breech. Incomplete or footling breech carries the highest risk of cord prolapse at 15% to 18%, while complete breech is lower at 4% to 6%, and frank breech is uncommon at 0.5%.

History and Physical

During the physical exam, using the Leopold maneuvers, palpation of a hard, round, mobile structure at the fundus and the inability to palpate a presenting part in the lower abdomen superior to the pubic bone or the engaged breech in the same area, should raise suspicion of a breech presentation.

During a cervical exam, findings may include the lack of a palpable presenting part, palpation of a lower extremity, usually a foot, or for the engaged breech, palpation of the soft tissue of the fetal buttocks may be noted. If the patient has been laboring, caution is warranted as the soft tissue of the fetal buttocks may be interpreted as caput of the fetal vertex.

Any of these findings should raise suspicion and ultrasound should be performed.

Diagnosis of a breech presentation can be accomplished through abdominal exam using the Leopold maneuvers in combination with the cervical exam. Ultrasound should confirm the diagnosis.

On ultrasound, the fetal lie and presenting part should be visualized and documented. If breech presentation is diagnosed, specific information including the specific type of breech, the degree of flexion of the fetal head, estimated fetal weight, amniotic fluid volume, placental location, and fetal anatomy review (if not already done previously) should be documented.

Treatment / Management

Expertise in the delivery of the vaginal breech baby is becoming less common due to fewer vaginal breech deliveries being offered throughout the United States and in most industrialized countries. The Term Breech Trial (TBT), a well-designed, multicenter, international, randomized controlled trial published in 2000 compared planned vaginal delivery to planned cesarean delivery for the term breech infant. The investigators reported that delivery by planned cesarean resulted in significantly lower perinatal mortality, neonatal mortality, and serious neonatal morbidity. Also, there was no significant difference in maternal morbidity or mortality between the two groups. Since that time, the rate of term breech infants delivered by planned cesarean has increased dramatically. Follow-up studies to the TBT have been published looking at maternal morbidity and outcomes of the children at two years. Although these reports did not show any significant difference in the risk of death and neurodevelopmental, these studies were felt to be underpowered. [8] [9] [10] [11] (B2)

Since the TBT, many authors since have argued that there are still some specific situations that vaginal breech delivery is a potential, safe alternative to planned cesarean. Many smaller retrospective studies have reported no difference in neonatal morbidity or mortality using these specific criteria.

The initial criteria used in these reports were similar: gestational age greater than 37 weeks, frank or complete breech presentation, no fetal anomalies on ultrasound examination, adequate maternal pelvis, and estimated fetal weight between 2500 g and 4000 g. In addition, the protocol presented by one report required documentation of fetal head flexion and adequate amniotic fluid volume, defined as a 3-cm vertical pocket. Oxytocin induction or augmentation was not offered, and strict criteria were established for normal labor progress. CT pelvimetry did determine an adequate maternal pelvis.

Despite debate on both sides, the current recommendation for the breech presentation at term includes offering external cephalic version (ECV) to those patients that meet criteria, and for those whom are not candidates or decline external cephalic version, a planned cesarean section for delivery sometime after 39 weeks.

Regarding the premature breech, gestational age will determine the mode of delivery. Before 26 weeks, there is a lack of quality clinical evidence to guide mode of delivery. One large retrospective cohort study recently concluded that from 28 to 31 6/7 weeks, there is a significant decrease in perinatal morbidity and mortality in a planned cesarean delivery versus intended vaginal delivery, while there is no difference in perinatal morbidity and mortality in gestational age 32 to 36 weeks. Of note, due to lack of recruitment, no prospective clinical trials are examining this issue.

Differential Diagnosis

• Face and brow presentation
• Fetal anomalies
• Fetal death
• Grand multiparity
• Multiple pregnancies
• Oligohydramnios
• Pelvis Anatomy
• Preterm labor
• Primigravida
• Uterine anomalies

Pearls and Other Issues

In light of the decrease in planned vaginal breech deliveries, thus the decrease in expertise in managing this clinical scenario, it is prudent that policies requiring simulation and instruction in the delivery technique for vaginal breech birth are established to care for the emergency breech vaginal delivery.

Enhancing Healthcare Team Outcomes

A breech delivery is usually managed by an obstetrician, labor and delivery nurse, anesthesiologist and a neonatologist. The ultimate decison rests on the obstetrician. To prevent complications, today cesarean sections are performed and experienced with vaginal deliveries of breech presentation is limited. For healthcare workers including the midwife who has no experience with a breech delivery, it is vital to communicate with an obstetrician, otherwise one risks litigation if complications arise during delivery. [12] [13] [14]

Hinnenberg P, Toijonen A, Gissler M, Heinonen S, Macharey G. Outcome of small for gestational age-fetuses in breech presentation at term according to mode of delivery: a nationwide, population-based record linkage study. Archives of gynecology and obstetrics. 2019 Apr:299(4):969-974. doi: 10.1007/s00404-019-05091-2. Epub 2019 Feb 8     [PubMed PMID: 30734863]

Schlaeger JM, Stoffel CL, Bussell JL, Cai HY, Takayama M, Yajima H, Takakura N. Moxibustion for Cephalic Version of Breech Presentation. Journal of midwifery & women's health. 2018 May:63(3):309-322. doi: 10.1111/jmwh.12752. Epub 2018 May 18     [PubMed PMID: 29775226]

Niles KM, Barrett JFR, Ladhani NNN. Comparison of cesarean versus vaginal delivery of extremely preterm gestations in breech presentation: retrospective cohort study. The journal of maternal-fetal & neonatal medicine : the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians. 2019 Apr:32(7):1142-1147. doi: 10.1080/14767058.2017.1401997. Epub 2017 Nov 20     [PubMed PMID: 29157039]

Grabovac M, Karim JN, Isayama T, Liyanage SK, McDonald SD. What is the safest mode of birth for extremely preterm breech singleton infants who are actively resuscitated? A systematic review and meta-analyses. BJOG : an international journal of obstetrics and gynaecology. 2018 May:125(6):652-663. doi: 10.1111/1471-0528.14938. Epub 2017 Nov 2     [PubMed PMID: 28921813]

Andrews S, Leeman L, Yonke N. Finding the breech: Influence of breech presentation on mode of delivery based on timing of diagnosis, attempt at external cephalic version, and provider success with version. Birth (Berkeley, Calif.). 2017 Sep:44(3):222-229. doi: 10.1111/birt.12290. Epub 2017 May 8     [PubMed PMID: 28481464]

Walker S, Breslin E, Scamell M, Parker P. Effectiveness of vaginal breech birth training strategies: An integrative review of the literature. Birth (Berkeley, Calif.). 2017 Jun:44(2):101-109. doi: 10.1111/birt.12280. Epub 2017 Feb 17     [PubMed PMID: 28211102]

Hofmeyr GJ, Barrett JF, Crowther CA. Planned caesarean section for women with a twin pregnancy. The Cochrane database of systematic reviews. 2015 Dec 19:2015(12):CD006553. doi: 10.1002/14651858.CD006553.pub3. Epub 2015 Dec 19     [PubMed PMID: 26684389]

Ainsworth A, Sviggum HP, Tolcher MC, Weaver AL, Holman MA, Arendt KW. Lessons learned from a single institution's retrospective analysis of emergent cesarean delivery following external cephalic version with and without neuraxial anesthesia. International journal of obstetric anesthesia. 2017 May:31():57-62. doi: 10.1016/j.ijoa.2017.03.012. Epub 2017 Apr 2     [PubMed PMID: 28499551]

Hutton EK, Simioni JC, Thabane L. Predictors of success of external cephalic version and cephalic presentation at birth among 1253 women with non-cephalic presentation using logistic regression and classification tree analyses. Acta obstetricia et gynecologica Scandinavica. 2017 Aug:96(8):1012-1020. doi: 10.1111/aogs.13161. Epub 2017 May 27     [PubMed PMID: 28449212]

Adjaoud S, Demailly R, Michel-Semail S, Rakza T, Storme L, Deruelle P, Garabedian C, Subtil D. Is trial of labor harmful in breech delivery? A cohort comparison for breech and vertex presentations. Journal of gynecology obstetrics and human reproduction. 2017 May:46(5):445-448. doi: 10.1016/j.jogoh.2017.04.003. Epub 2017 Apr 13     [PubMed PMID: 28412313]

Poole KL, McDonald SD, Griffith LE, Hutton EK, Early ECV Pilot and ECV2 Trial Collaborative Group. Association of external cephalic version before term with late preterm birth. Acta obstetricia et gynecologica Scandinavica. 2017 Aug:96(8):998-1005. doi: 10.1111/aogs.13153. Epub 2017 May 16     [PubMed PMID: 28414857]

Domingues AP, Belo A, Moura P, Vieira DN. Medico-legal litigation in Obstetrics: a characterization analysis of a decade in Portugal. Revista brasileira de ginecologia e obstetricia : revista da Federacao Brasileira das Sociedades de Ginecologia e Obstetricia. 2015 May:37(5):241-6. doi: 10.1590/SO100-720320150005304. Epub     [PubMed PMID: 26107576]

Delotte J, Oliver A, Boukaidi S, Mialon O, Breaud J, Benchimol D, Bongain A. [Who limit vaginal birth for breech presentation: medical practice or Law? Discussion between a medical doctor, a lawyer and the head chief of an university hospital]. Journal de gynecologie, obstetrique et biologie de la reproduction. 2011 Oct:40(6):587-9. doi: 10.1016/j.jgyn.2011.05.011. Epub 2011 Jul 16     [PubMed PMID: 21763083]

Burke G. The end of vaginal breech delivery. BJOG : an international journal of obstetrics and gynaecology. 2006 Aug:113(8):969-72     [PubMed PMID: 16827824]

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Management of Breech Presentation (Green-top Guideline No. 20b)

Summary: The aim of this guideline is to aid decision making regarding the route of delivery and choice of various techniques used during delivery. It does not include antenatal or postnatal care. Information regarding external cephalic version is the topic of the separate Royal College of Obstetricians and Gynaecologists Green-top Guideline No. 20a,  External Cephalic Version and Reducing the Incidence of Term Breech Presentation .

Breech presentation occurs in 3–4% of term deliveries and is more common in preterm deliveries and nulliparous women. Breech presentation is associated with uterine and congenital abnormalities, and has a significant recurrence risk. Term babies presenting by the breech have worse outcomes than cephalic presenting babies, irrespective of the mode of delivery.

A large reduction in the incidence of planned vaginal breech birth followed publication of the Term Breech Trial. Nevertheless, due to various circumstances vaginal breech births will continue. Lack of experience has led to a loss of skills essential for these deliveries. Conversely, caesarean section can has serious long-term consequences.

COVID disclaimer: This guideline was developed as part of the regular updates to programme of Green-top Guidelines, as outlined in our document  Developing a Green-top Guideline: Guidance for developers , and prior to the emergence of COVID-19.

Version history: This is the fourth edition of this guideline.

Please note that the RCOG Guidelines Committee regularly assesses the need to update the information provided in this publication. Further information on this review is available on request.

Developer declaration of interests:

Mr M Griffiths  is a member of Doctors for a Woman's right to Choose on Abortion. He is an unpaid member of a Quality Standards Advisory Committee at NICE, for which he does receive expenses for related travel, accommodation and meals.

Mr LWM Impey  is Director of Oxford Fetal Medicine Ltd. and a member of the International Society of Ultrasound in Obstetrics and Gynecology. He also holds patents related to ultrasound processing, which are of no relevance to the Breech guidelines.

Professor DJ Murphy  provides medicolegal expert opinions in Scotland and Ireland for which she is remunerated.

Dr LK Penna:  None declared.

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

• Key Points |

Abnormal fetal lie or presentation may occur due to fetal size, fetal anomalies, uterine structural abnormalities, multiple gestation, or other factors. Diagnosis is by examination or ultrasonography. Management is with physical maneuvers to reposition the fetus, operative vaginal delivery , or cesarean delivery .

Terms that describe the fetus in relation to the uterus, cervix, and maternal pelvis are

Fetal presentation: Fetal part that overlies the maternal pelvic inlet; vertex (cephalic), face, brow, breech, shoulder, funic (umbilical cord), or compound (more than one part, eg, shoulder and hand)

Fetal position: Relation of the presenting part to an anatomic axis; for transverse presentation, occiput anterior, occiput posterior, occiput transverse

Fetal lie: Relation of the fetus to the long axis of the uterus; longitudinal, oblique, or transverse

Normal fetal lie is longitudinal, normal presentation is vertex, and occiput anterior is the most common position.

Abnormal fetal lie, presentation, or position may occur with

Fetopelvic disproportion (fetus too large for the pelvic inlet)

Fetal congenital anomalies

Uterine structural abnormalities (eg, fibroids, synechiae)

Multiple gestation

Several common types of abnormal lie or presentation are discussed here.

Transverse lie

Fetal position is transverse, with the fetal long axis oblique or perpendicular rather than parallel to the maternal long axis. Transverse lie is often accompanied by shoulder presentation, which requires cesarean delivery.

Breech presentation

There are several types of breech presentation.

Frank breech: The fetal hips are flexed, and the knees extended (pike position).

Complete breech: The fetus seems to be sitting with hips and knees flexed.

Single or double footling presentation: One or both legs are completely extended and present before the buttocks.

Types of breech presentations

Breech presentation makes delivery difficult ,primarily because the presenting part is a poor dilating wedge. Having a poor dilating wedge can lead to incomplete cervical dilation, because the presenting part is narrower than the head that follows. The head, which is the part with the largest diameter, can then be trapped during delivery.

Additionally, the trapped fetal head can compress the umbilical cord if the fetal umbilicus is visible at the introitus, particularly in primiparas whose pelvic tissues have not been dilated by previous deliveries. Umbilical cord compression may cause fetal hypoxemia.

Predisposing factors for breech presentation include

Preterm labor

Uterine abnormalities

Fetal anomalies

If delivery is vaginal, breech presentation may increase risk of

Umbilical cord prolapse

Birth trauma

Perinatal death

Face or brow presentation

In face presentation, the head is hyperextended, and position is designated by the position of the chin (mentum). When the chin is posterior, the head is less likely to rotate and less likely to deliver vaginally, necessitating cesarean delivery.

Brow presentation usually converts spontaneously to vertex or face presentation.

Occiput posterior position

The most common abnormal position is occiput posterior.

The fetal neck is usually somewhat deflexed; thus, a larger diameter of the head must pass through the pelvis.

Progress may arrest in the second phase of labor. Operative vaginal delivery or cesarean delivery is often required.

Position and Presentation of the Fetus

If a fetus is in the occiput posterior position, operative vaginal delivery or cesarean delivery is often required.

In breech presentation, the presenting part is a poor dilating wedge, which can cause the head to be trapped during delivery, often compressing the umbilical cord.

For breech presentation, usually do cesarean delivery at 39 weeks or during labor, but external cephalic version is sometimes successful before labor, usually at 37 or 38 weeks.

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Breech Births

In the last weeks of pregnancy, a baby usually moves so his or her head is positioned to come out of the vagina first during birth. This is called a vertex presentation. A breech presentation occurs when the baby’s buttocks, feet, or both are positioned to come out first during birth. This happens in 3–4% of full-term births.

What are the different types of breech birth presentations?

• Complete breech: Here, the buttocks are pointing downward with the legs folded at the knees and feet near the buttocks.
• Frank breech: In this position, the baby’s buttocks are aimed at the birth canal with its legs sticking straight up in front of his or her body and the feet near the head.
• Footling breech: In this position, one or both of the baby’s feet point downward and will deliver before the rest of the body.

What causes a breech presentation?

The causes of breech presentations are not fully understood. However, the data show that breech birth is more common when:

• You have been pregnant before
• In pregnancies of multiples
• When there is a history of premature delivery
• When the uterus has too much or too little amniotic fluid
• When there is an abnormally shaped uterus or a uterus with abnormal growths, such as fibroids
• The placenta covers all or part of the opening of the uterus placenta previa

How is a breech presentation diagnosed?

A few weeks prior to the due date, the health care provider will place her hands on the mother’s lower abdomen to locate the baby’s head, back, and buttocks. If it appears that the baby might be in a breech position, they can use ultrasound or pelvic exam to confirm the position. Special x-rays can also be used to determine the baby’s position and the size of the pelvis to determine if a vaginal delivery of a breech baby can be safely attempted.

Can a breech presentation mean something is wrong?

Even though most breech babies are born healthy, there is a slightly elevated risk for certain problems. Birth defects are slightly more common in breech babies and the defect might be the reason that the baby failed to move into the right position prior to delivery.

Can a breech presentation be changed?

It is preferable to try to turn a breech baby between the 32nd and 37th weeks of pregnancy . The methods of turning a baby will vary and the success rate for each method can also vary. It is best to discuss the options with the health care provider to see which method she recommends.

Medical Techniques

External Cephalic Version (EVC)  is a non-surgical technique to move the baby in the uterus. In this procedure, a medication is given to help relax the uterus. There might also be the use of an ultrasound to determine the position of the baby, the location of the placenta and the amount of amniotic fluid in the uterus.

Gentle pushing on the lower abdomen can turn the baby into the head-down position. Throughout the external version the baby’s heartbeat will be closely monitored so that if a problem develops, the health care provider will immediately stop the procedure. ECV usually is done near a delivery room so if a problem occurs, a cesarean delivery can be performed quickly. The external version has a high success rate and can be considered if you have had a previous cesarean delivery.

ECV will not be tried if:

• You are carrying more than one fetus
• There are concerns about the health of the fetus
• You have certain abnormalities of the reproductive system
• The placenta is in the wrong place
• The placenta has come away from the wall of the uterus ( placental abruption )

Complications of EVC include:

• Prelabor rupture of membranes
• Changes in the fetus’s heart rate
• Placental abruption
• Preterm labor

Vaginal delivery versus cesarean for breech birth?

Most health care providers do not believe in attempting a vaginal delivery for a breech position. However, some will delay making a final decision until the woman is in labor. The following conditions are considered necessary in order to attempt a vaginal birth:

• The baby is full-term and in the frank breech presentation
• The baby does not show signs of distress while its heart rate is closely monitored.
• The process of labor is smooth and steady with the cervix widening as the baby descends.
• The health care provider estimates that the baby is not too big or the mother’s pelvis too narrow for the baby to pass safely through the birth canal.
• Anesthesia is available and a cesarean delivery possible on short notice

What are the risks and complications of a vaginal delivery?

In a breech birth, the baby’s head is the last part of its body to emerge making it more difficult to ease it through the birth canal. Sometimes forceps are used to guide the baby’s head out of the birth canal. Another potential problem is cord prolapse . In this situation the umbilical cord is squeezed as the baby moves toward the birth canal, thus slowing the baby’s supply of oxygen and blood. In a vaginal breech delivery, electronic fetal monitoring will be used to monitor the baby’s heartbeat throughout the course of labor. Cesarean delivery may be an option if signs develop that the baby may be in distress.

When is a cesarean delivery used with a breech presentation?

Most health care providers recommend a cesarean delivery for all babies in a breech position, especially babies that are premature. Since premature babies are small and more fragile, and because the head of a premature baby is relatively larger in proportion to its body, the baby is unlikely to stretch the cervix as much as a full-term baby. This means that there might be less room for the head to emerge.

Want to Know More?

• Creating Your Birth Plan
• Labor & Birth Terms to Know
• Cesarean Birth After Care

Compiled using information from the following sources:

• ACOG: If Your Baby is Breech
• William’s Obstetrics Twenty-Second Ed. Cunningham, F. Gary, et al, Ch. 24.
• Danforth’s Obstetrics and Gynecology Ninth Ed. Scott, James R., et al, Ch. 21.

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Clinical exam

Palpation of the abdomen to determine the position of the baby's head

Palpation of the abdomen to confirm the position of the fetal spine on one side and fetal extremities on the other

Palpation of the area above the symphysis pubis to locate the fetal presenting part

Palpation of the presenting part to confirm presentation, to determine how far the fetus has descended and whether the fetus is engaged.

Ultrasound examination

Premature fetus.

Prematurity is consistently associated with breech presentation. [ 6 ] [ 9 ] This may be due to the smaller size of preterm infants, who are more likely to change their in utero position.

Increasing duration of pregnancy may allow breech-presenting fetuses time to grow, turn spontaneously or by external cephalic version, and remain cephalic-presenting.

Larger fetuses may be forced into a cephalic presentation in late pregnancy due to space or alignment constraints within the uterus.

small for gestational age fetus

Low birth-weight is a risk factor for breech presentation. [ 9 ] [ 11 ] [ 12 ] [ 13 ] [ 14 ] Term breech births are associated with a smaller fetal size for gestational age, highlighting the association with low birth-weight rather than prematurity. [ 6 ]

nulliparity

Women having a first birth have increased rates of breech presentation, probably due to the increased likelihood of smaller fetal size. [ 6 ] [ 9 ]

Relaxation of the uterine wall in multiparous women may reduce the odds of breech birth and contribute to a higher spontaneous or external cephalic version rate. [ 10 ]

fetal congenital anomalies

Congenital anomalies in the fetus may result in a small fetal size or inappropriate fetal growth. [ 9 ] [ 12 ] [ 14 ] [ 15 ]

Anencephaly, hydrocephaly, Down syndrome, and fetal neuromuscular dysfunction are associated with breech presentation, the latter due to its effect on the quality of fetal movements. [ 9 ] [ 14 ]

previous breech delivery

The risk of recurrent breech delivery is 8%, the risk increasing from 4% after one breech delivery to 28% after three. [ 16 ]

The effects of recurrence may be due to recurring specific causal factors, either genetic or environmental in origin.

uterine abnormalities

Women with uterine abnormalities have a high incidence of breech presentation. [ 14 ] [ 17 ] [ 18 ] [ 19 ]

female fetus

Fifty-four percent of breech-presenting fetuses are female. [ 14 ]

abnormal amniotic fluid volume

Both oligohydramnios and polyhydramnios are associated with breech presentation. [ 1 ] [ 12 ] [ 14 ]

Low amniotic fluid volume decreases the likelihood of a fetus turning to a cephalic position; an increased amniotic fluid volume may facilitate frequent change in position.

placental abnormalities

An association between placental implantation in the cornual-fundal region and breech presentation has been reported, although some studies have not found it a risk factor. [ 8 ] [ 20 ] [ 21 ] [ 22 ] [ 10 ] [ 14 ]

The association with placenta previa is also inconsistent. [ 8 ] [ 9 ] [ 22 ] Placenta previa is associated with preterm birth and may be an indirect risk factor.

Pelvic or vaginal examination reveals the buttocks and/or feet, felt as a yielding, irregular mass, as the presenting part. [ 26 ] In cephalic presentation, a hard, round, regular fetal head can be palpated. [ 26 ]

The Leopold maneuver on examination suggests breech position by palpation of the fetal head under the costal margin. [ 26 ]

The baby's heartbeat should be auscultated using a Pinard stethoscope or a hand-held Doppler to indicate the position of the fetus. The fetal heartbeat lies above the maternal umbilicus in breech presentation. [ 1 ]

Tenderness under one or other costal margin as a result of pressure by the harder fetal head.

Pain due to fetal kicks in the maternal pelvis or bladder.

breech position

Visualizes the fetus and reveals its position.

Used to confirm a clinically suspected breech presentation. [ 28 ]

Should be performed by practitioners with appropriate skills in obstetric ultrasound.

Establishes the type of breech presentation by imaging the fetal femurs and their relationship to the distal bones.

Transverse lie

Differentiating Signs/Symptoms

Fetus lies horizontally across the uterus with the shoulder as the presenting part.

Similar predisposing factors such as placenta previa, abnormal amniotic fluid volume, and uterine anomalies, although more common in multiparity. [ 1 ] [ 2 ] [ 29 ]

Differentiating Tests

Clinical examination and fetal auscultation may be indicative.

Ultrasound confirms presentation.

Treatment Approach

Breech presentation <37 weeks' gestation.

The UK Royal College of Obstetricians and Gynaecologists (RCOG) recommends that corticosteroids should be offered to women between 24 and 34+6 weeks' gestation, in whom imminent preterm birth is anticipated. Corticosteroids should only be considered after discussion of risks/benefits at 35 to 36+6 weeks. Given within 7 days of preterm birth, corticosteroids may reduce perinatal and neonatal death and respiratory distress syndrome. [ 32 ] The American College of Obstetricians and Gynecologists (ACOG) recommends a single course of corticosteroids for pregnant women between 24 and 33+6 weeks' gestation who are at risk of preterm delivery within 7 days, including those with ruptured membranes and multiple gestations. It may also be considered for pregnant women starting at 23 weeks' gestation who are at risk of preterm delivery within 7 days. A single course of betamethasone is recommended for pregnant women between 34 and 36+6 weeks' gestation at risk of preterm birth within 7 days, and who have not received a previous course of prenatal corticosteroids. Regularly scheduled repeat courses or serial courses (more than two) are not currently recommended. A single repeat course of prenatal corticosteroids should be considered in women who are less than 34 weeks' gestation, who are at risk of preterm delivery within 7 days, and whose prior course of prenatal corticosteroids was administered more than 14 days previously. Rescue course corticosteroids could be provided as early as 7 days from the prior dose, if indicated by the clinical scenario. [ 33 ]

Magnesium sulfate given before anticipated early preterm birth reduces the risk of cerebral palsy in surviving infants. Physicians electing to use magnesium sulfate for fetal neuroprotection should develop specific guidelines regarding inclusion criteria, treatment regimens, and concurrent tocolysis. [ 34 ]

Breech presentation from 37 weeks' gestation, before labor

ECV is the initial treatment for a breech presentation at term when the patient is not in labor. It involves turning a fetus presenting by the breech to a cephalic (head-down) presentation to increase the likelihood of vaginal birth. [ 35 ] [ 36 ] Where available, it should be offered to all women in late pregnancy, by an experienced clinician, in hospitals with facilities for emergency delivery, and no contraindications to the procedure. [ 35 ] There is no upper time limit on the appropriate gestation for ECV, with success reported at 42 weeks.

There is no general consensus on contraindications to ECV. Contraindications include multiple pregnancy (except after delivery of a first twin), ruptured membranes, current or recent (<1 week) vaginal bleeding, rhesus isoimmunization, other indications for cesarean section (e.g., placenta previa or uterine malformation), or abnormal electronic fetal monitoring. [ 35 ] One systematic review of relative contraindications for ECV highlighted that most contraindications do not have clear empirical evidence. Exceptions include placental abruption, severe preeclampsia/HELLP syndrome, or signs of fetal distress (abnormal cardiotocography and/or Doppler flow). [ 36 ]

The procedure involves applying external pressure and firmly pushing or palpating the mother's abdomen to coerce the fetus to somersault (either forward or backward) into a cephalic position. [ 37 ]

The overall ECV success rate varies but, in a large series, 47% of women following an ECV attempt had a cephalic presentation at birth. [ 35 ] [ 38 ]  Various factors influence the success rate. One systematic review found ECV success rates to be 68% overall, with the rate significantly higher for women from African countries (89%) compared with women from non-African countries (62%), and higher among multiparous (78%) than nulliparous women (48%). [ 39 ] Overall, the ECV success rates for nulliparous and multiparous non-African women were 43% and 73%, respectively, while for nulliparous and multiparous African women rates were 79% and 91%, respectively. Another study reported no difference in success rate or rate of cesarean section among women with previous cesarean section undergoing ECV compared with women with previous vaginal birth. However, numbers were small and further studies in this regard are required. [ 40 ]

Women's preference for vaginal delivery is a major contributing factor in their decision for ECV. However, studies suggest women with a breech presentation at term may not receive complete and/or evidence-based information about the benefits and risks of ECV. [ 41 ] [ 42 ] Although up to 60% of women reported ECV to be painful, the majority highlighted the benefits outweigh the risks (71%) and would recommend ECV to their friends or be willing to repeat for themselves (84%). [ 41 ] [ 42 ]

Cardiotocography and ultrasound should be performed before and after the procedure. Tocolysis should be used to facilitate the maneuver, and Rho(D) immune globulin should be administered to women who are Rhesus negative. [ 35 ] Tocolytic agents include adrenergic beta-2 receptor stimulants such as albuterol, terbutaline, or ritodrine (widely used with ECV in some countries, but not yet available in the US). One Cochrane review of tocolytic beta stimulants demonstrates that these are less likely to be associated with failed ECV, and are effective in increasing cephalic presentation and reducing cesarean section. [ 43 ] There is no current evidence to recommend one beta-2 adrenergic receptor agonist over another. Until these data are available, adherence to a local protocol for tocolysis is recommended. The Food and Drug Administration has issued a warning against using injectable terbutaline beyond 48 to 72 hours, or acute or prolonged treatment with oral terbutaline, in pregnant women for the prevention or prolonged treatment of preterm labor, due to potential serious maternal cardiac adverse effects and death. [ 44 ] Whether this warning applies to the subcutaneous administration of terbutaline in ECV is still unclear; however, studies currently support this use. The European Medicines Agency (EMA) recommends that injectable beta agonists should be used for up to 48 hours between the 22nd and 37th week of pregnancy only. They should be used under specialist supervision with continuous monitoring of the mother and unborn baby owing to the risk of adverse cardiovascular effects in both the mother and baby. The EMA no longer recommends oral or rectal formulations for obstetric indications. [ 45 ]

If ECV is successful, pregnancy care should continue as usual for any cephalic presentation. One systematic review assessing the mode of delivery after a successful ECV found that these women were at increased risk for cesarean section and instrumental vaginal delivery compared with women with spontaneous cephalic pregnancies. However, they still had a lower rate of cesarean section following ECV (i.e., 47%) compared with the cesarean section rate for those with a persisting breech (i.e., 85%). With a number needed to treat of three, ECV is still considered to be an effective means of preventing the need for cesarean section. [ 46 ]

Planned cesarean section should be offered as the safest mode of delivery for the baby, even though it carries a small increase in serious immediate maternal complications compared with vaginal birth. [ 24 ] [ 25 ] [ 31 ] In the US, most unsuccessful ECV with persistent breech will be delivered via cesarean section.

A vaginal mode of delivery may be considered by some clinicians as an option, particularly when maternal request is provided, senior and experienced staff are available, there is no absolute contraindication to vaginal birth (e.g., placenta previa, compromised fetal condition), and with optimal fetal growth (estimated weight above the tenth centile and up to 3800 g). Other factors that make planned vaginal birth higher risk include hyperextended neck on ultrasound and footling presentation. [ 24 ]

Breech presentation from 37 weeks' gestation, during labor

The first option should be a planned cesarean section.

There is a small increase in the risk of serious immediate maternal complications compared with vaginal birth (RR 1.29, 95% CI 1.03 to 1.61), including pulmonary embolism, infection, bleeding, damage to the bladder and bowel, slower recovery from the delivery, longer hospitalization, and delayed bonding and breast-feeding. [ 23 ] [ 31 ] [ 47 ] [ 48 ] [ 49 ] [ 50 ] [ 51 ] [ 52 ] [ 53 ] [ 54 ] [ 55 ] [ 56 ] [ 57 ] [ 58 ] Consider using antimicrobial triclosan-coated sutures for wound closure to reduce the risk of surgical site infection. [ 59 ]

The long-term risks include potential compromise of future obstetric performance, increased risk of repeat cesarean section, infertility, uterine rupture, placenta accreta, placental abruption, and emergency hysterectomy. [ 60 ] [ 61 ] [ 62 ] [ 63 ]

Planned cesarean section is safer for babies, but is associated with increased neonatal respiratory distress. The risk is reduced when the section is performed at 39 weeks' gestation. [ 64 ] [ 65 ] [ 66 ] For women undergoing a planned cesarean section, RCOG recommends an informed discussion about the potential risks and benefits of a course of prenatal corticosteroids between 37 and 38+6 weeks' gestation. Although prenatal corticosteroids may reduce admission to the neonatal unit for respiratory morbidity, it is uncertain if there is any reduction in respiratory distress syndrome, transient tachypnea of the newborn, or neonatal unit admission overall. In addition, prenatal corticosteroids may result in harm to the neonate, including hypoglycemia and potential developmental delay. [ 32 ] ACOG does not recommend corticosteroids in women >37 weeks' gestation. [ 33 ]

Undiagnosed breech in labor generally results in cesarean section after the onset of labor, higher rates of emergency cesarean section associated with the least favorable maternal outcomes, a greater likelihood of cord prolapse, and other poor infant outcomes. [ 23 ] [ 67 ] [ 49 ] [ 68 ] [ 69 ] [ 70 ] [ 71 ]

This mode of delivery may be considered by some clinicians as an option for women who are in labor, particularly when delivery is imminent. Vaginal breech delivery may also be considered, where suitable, when delivery is not imminent, maternal request is provided, senior and experienced staff are available, there is no absolute contraindication to vaginal birth (e.g., placenta previa, compromised fetal condition), and with optimal fetal growth (estimated weight above the tenth centile and up to 3800 g). Other factors that make planned vaginal birth higher risk include hyperextended neck on ultrasound and footling presentation. [ 24 ]

Findings from one systematic review of 27 observational studies revealed that the absolute risks of perinatal mortality, fetal neurologic morbidity, birth trauma, 5-minute Apgar score <7, and neonatal asphyxia in the planned vaginal delivery group were low at 0.3%, 0.7%, 0.7%, 2.4%, and 3.3%, respectively. However, the relative risks of perinatal mortality and morbidity were 2- to 5-fold higher in the planned vaginal than in the planned cesarean delivery group. Authors recommend ongoing judicious decision-making for vaginal breech delivery for selected singleton, term breech babies. [ 72 ]

ECV may also be considered an option for women with breech presentation in early labor, when delivery is not imminent, provided that the membranes are intact.

A woman presenting with a breech presentation <37 weeks is an area of clinical controversy. Optimal mode of delivery for preterm breech has not been fully evaluated in clinical trials, and the relative risks for the preterm infant and mother remain unclear. In the absence of good evidence, if diagnosis of breech presentation prior to 37 weeks' gestation is made, prematurity and clinical circumstances should determine management and mode of delivery.

Primary Options

12 mg intramuscularly every 24 hours for 2 doses

6 mg intramuscularly every 12 hours for 4 doses

The UK Royal College of Obstetricians and Gynaecologists recommends that corticosteroids should be offered to women between 24 and 34+6 weeks' gestation, in whom imminent preterm birth is anticipated. Corticosteroids should only be considered after discussion of risks/benefits at 35 to 36+6 weeks. Given within 7 days of preterm birth, corticosteroids may reduce perinatal and neonatal death and respiratory distress syndrome. [ 32 ]

The American College of Obstetricians and Gynecologists recommends a single course of corticosteroids for pregnant women between 24 and 33+6 weeks' gestation who are at risk of preterm delivery within 7 days, including those with ruptured membranes and multiple gestations. It may also be considered for pregnant women starting at 23 weeks' gestation who are at risk of preterm delivery within 7 days. A single course of betamethasone is recommended for pregnant women between 34 and 36+6 weeks' gestation at risk of preterm birth within 7 days, and who have not received a previous course of prenatal corticosteroids. Regularly scheduled repeat courses or serial courses (more than two) are not currently recommended. A single repeat course of prenatal corticosteroids should be considered in women who are less than 34 weeks' gestation, who are at risk of preterm delivery within 7 days, and whose prior course of prenatal corticosteroids was administered more than 14 days previously. Rescue course corticosteroids could be provided as early as 7 days from the prior dose, if indicated by the clinical scenario. [ 33 ]

consult specialist for guidance on dose

external cephalic version (ECV)

There is no upper time limit on the appropriate gestation for ECV; it should be offered to all women in late pregnancy by an experienced clinician in hospitals with facilities for emergency delivery and no contraindications to the procedure. [ 35 ] [ 36 ]

ECV involves applying external pressure and firmly pushing or palpating the mother's abdomen to coerce the fetus to somersault (either forward or backward) into a cephalic position. [ 37 ]

There is no general consensus on contraindications to ECV. Contraindications include multiple pregnancy (except after delivery of a first twin), ruptured membranes, current or recent (<1 week) vaginal bleeding, rhesus isoimmunization, other indications for cesarean section (e.g., placenta previa or uterine malformation), or abnormal electronic fetal monitoring. [ 35 ]  One systematic review of relative contraindications for ECV highlighted that most contraindications do not have clear empirical evidence. Exceptions include placental abruption, severe preeclampsia/HELLP syndrome, or signs of fetal distress (abnormal cardiotocography and/or Doppler flow). [ 36 ]

Cardiotocography and ultrasound should be performed before and after the procedure.

If ECV is successful, pregnancy care should continue as usual for any cephalic presentation. A systematic review assessing the mode of delivery after a successful ECV found that these women were at increased risk for cesarean section and instrumental vaginal delivery compared with women with spontaneous cephalic pregnancies. However, they still had a lower rate of cesarean section following ECV (i.e., 47%) compared with the cesarean section rate for those with a persisting breech (i.e., 85%). With a number needed to treat of 3, ECV is still considered to be an effective means of preventing the need for cesarean section. [ 46 ]

tocolytic agents

see local specialist protocol for dosing guidelines

Tocolytic agents include adrenergic beta-2 receptor stimulants such as albuterol, terbutaline, or ritodrine (widely used with external cephalic version [ECV] in some countries, but not yet available in the US). They are used to delay or inhibit labor and increase the success rate of ECV. There is no current evidence to recommend one beta-2 adrenergic receptor agonist over another. Until these data are available, adherence to a local protocol for tocolysis is recommended.

The Food and Drug Administration has issued a warning against using injectable terbutaline beyond 48-72 hours, or acute or prolonged treatment with oral terbutaline, in pregnant women for the prevention or prolonged treatment of preterm labor, due to potential serious maternal cardiac adverse effects and death. [ 44 ] Whether this warning applies to the subcutaneous administration of terbutaline in ECV is still unclear; however, studies currently support this use. The European Medicines Agency (EMA) recommends that injectable beta agonists should be used for up to 48 hours between the 22nd and 37th week of pregnancy only. They should be used under specialist supervision with continuous monitoring of the mother and unborn baby owing to the risk of adverse cardiovascular effects in both the mother and baby. The EMA no longer recommends oral or rectal formulations for obstetric indications. [ 45 ]

A systematic review found there was no evidence to support the use of nifedipine for tocolysis. [ 73 ]

There is insufficient evidence to evaluate other interventions to help ECV, such as fetal acoustic stimulation in midline fetal spine positions, or epidural or spinal analgesia. [ 43 ]

Rho(D) immune globulin

300 micrograms intramuscularly as a single dose

Nonsensitized Rh-negative women should receive Rho(D) immune globulin. [ 35 ]

The indication for its administration is to prevent rhesus isoimmunization, which may affect subsequent pregnancy outcomes.

Rho(D) immune globulin needs to be given at the time of external cephalic version and should be given again postpartum to those women who give birth to an Rh-positive baby. [ 74 ]

It is best administered as soon as possible after the procedure, usually within 72 hours.

Dose depends on brand used. Dose given below pertains to most commonly used brands. Consult specialist for further guidance on dose.

elective cesarean section/vaginal breech delivery

Mode of delivery (cesarean section or vaginal breech delivery) should be based on the experience of the attending clinician, hospital policies, maternal request, and the presence or absence of complicating factors. In the US, most unsuccessful external cephalic version (ECV) with persistent breech will be delivered via cesarean section.

Cesarean section, at 39 weeks or greater, has been shown to significantly reduce perinatal mortality and neonatal morbidity compared with vaginal breech delivery (RR 0.33, 95% CI 0.19 to 0.56). [ 31 ] Although safer for these babies, there is a small increase in serious immediate maternal complications compared with vaginal birth (RR 1.29, 95% CI 1.03 to 1.61), as well as long-term risks for future pregnancies, including pulmonary embolism, bleeding, infection, damage to the bladder and bowel, slower recovery from the delivery, longer hospitalization, and delayed bonding and breast-feeding. [ 23 ] [ 31 ] [ 47 ] [ 48 ] [ 49 ] [ 50 ] [ 51 ] [ 52 ] [ 53 ] [ 54 ] [ 55 ] [ 56 ] [ 57 ] [ 58 ] Consider using antimicrobial triclosan-coated sutures for wound closure to reduce the risk of surgical site infection. [ 59 ]

Vaginal delivery may be considered by some clinicians as an option, particularly when maternal request is provided, when senior and experienced staff are available, when there is no absolute contraindication to vaginal birth (e.g., placenta previa, compromised fetal condition), and with optimal fetal growth (estimated weight above the tenth centile and up to 3800 g). Other factors that make planned vaginal birth higher risk include hyperextended neck on ultrasound and footling presentation. [ 24 ]

For women undergoing a planned cesarean section, the UK Royal College of Obstetricians and Gynaecologists recommends an informed discussion about the potential risks and benefits of a course of prenatal corticosteroids between 37 and 38+6 weeks' gestation. Although prenatal corticosteroids may reduce admission to the neonatal unit for respiratory morbidity, it is uncertain if there is any reduction in respiratory distress syndrome, transient tachypnea of the newborn, or neonatal unit admission overall. In addition, prenatal corticosteroids may result in harm to the neonate, including hypoglycemia and potential developmental delay. [ 32 ] The American College of Obstetricians and Gynecologists does not recommend corticosteroids in women >37 weeks' gestation. [ 33 ]

It is best administered as soon as possible after delivery, usually within 72 hours.

Administration of postpartum Rho (D) immune globulin should not be affected by previous routine prenatal prophylaxis or previous administration for a potentially sensitizing event. [ 74 ]

≥37 weeks' gestation in labor: no imminent delivery

planned cesarean section

For women with breech presentation in labor, planned cesarean section at 39 weeks or greater has been shown to significantly reduce perinatal mortality and neonatal morbidity compared with vaginal breech delivery (RR 0.33, 95% CI 0.19 to 0.56). [ 31 ]

Although safer for these babies, there is a small increase in serious immediate maternal complications compared with vaginal birth (RR 1.29, 95% CI 1.03 to 1.61), as well as long-term risks for future pregnancies, including pulmonary embolism, infection, bleeding, damage to the bladder and bowel, slower recovery from the delivery, longer hospitalization, and delayed bonding and breast-feeding. [ 23 ] [ 31 ] [ 47 ] [ 48 ] [ 49 ] [ 50 ] [ 51 ] [ 52 ] [ 53 ] [ 54 ] [ 55 ] [ 56 ] [ 57 ] [ 58 ]  Consider using antimicrobial triclosan-coated sutures for wound closure to reduce the risk of surgical site infection. [ 59 ]

Continuous cardiotocography monitoring should continue until delivery. [ 24 ] [ 25 ]

vaginal breech delivery

Mode of delivery (cesarean section or vaginal breech delivery) should be based on the experience of the attending clinician, hospital policies, maternal request, and the presence or absence of complicating factors.

This mode of delivery may be considered by some clinicians as an option, particularly when maternal request is provided, when senior and experienced staff are available, when there is no absolute contraindication to vaginal birth (e.g., placenta previa, compromised fetal condition), and with optimal fetal growth (estimated weight above the tenth centile and up to 3800 g). Other factors that make planned vaginal birth higher risk include hyperextended neck on ultrasound and footling presentation. [ 24 ]

For women with persisting breech presentation, planned cesarean section has, however, been shown to significantly reduce perinatal mortality and neonatal morbidity compared with vaginal breech delivery (RR 0.33, 95% CI 0.19 to 0.56). [ 31 ]

ECV may also be considered an option for women with breech presentation in early labor, provided that the membranes are intact.

There is no upper time limit on the appropriate gestation for ECV. [ 35 ]

Involves applying external pressure and firmly pushing or palpating the mother's abdomen to coerce the fetus to somersault (either forward or backward) into a cephalic position. [ 37 ]

Relative contraindications include placental abruption, severe preeclampsia/HELLP syndrome, and signs of fetal distress (abnormal cardiotocography and/or abnormal Doppler flow). [ 35 ] [ 36 ]

Rho(D) immune globulin needs to be given at the time of ECV and should be given again postpartum to those women who give birth to an Rh-positive baby. [ 74 ]

≥37 weeks' gestation in labor: imminent delivery

cesarean section

For women with persistent breech presentation, planned cesarean section has been shown to significantly reduce perinatal mortality and neonatal morbidity compared with vaginal breech delivery (RR 0.33, 95% CI 0.19 to 0.56). [ 31 ] Although safer for these babies, there is a small increase in serious immediate maternal complications compared with vaginal birth (RR 1.29, 95% CI 1.03 to 1.61), as well as long-term risks for future pregnancies, including pulmonary embolism, infection, bleeding, damage to the bladder and bowel, slower recovery from the delivery, longer hospitalization, and delayed bonding and breast-feeding. [ 23 ] [ 31 ] [ 47 ] [ 48 ] [ 49 ] [ 50 ] [ 51 ] [ 52 ] [ 53 ] [ 54 ] [ 55 ] [ 56 ] [ 57 ] [ 58 ]  Consider using antimicrobial triclosan-coated sutures for wound closure to reduce the risk of surgical site infection. [ 59 ]

This mode of delivery may be considered by some clinicians as an option, particularly when delivery is imminent, maternal request is provided, when senior and experienced staff are available, when there is no absolute contraindication to vaginal birth (e.g., placenta previa, compromised fetal condition), and with optimal fetal growth (estimated weight above the tenth centile and up to 3800 g). Other factors that make planned vaginal birth higher risk include hyperextended neck on ultrasound and footling presentation. [ 24 ]

It is best administered as soon as possible after the delivery, usually within 72 hours.

External cephalic version before term

Moxibustion, postural management, follow-up overview, perinatal complications.

Compared with cephalic presentation, persistent breech presentation has increased frequency of cord prolapse, abruptio placentae, prelabor rupture of membranes, perinatal mortality, fetal distress (heart rate <100 bpm), preterm delivery, lower fetal weight. [ 10 ] [ 11 ] [ 67 ]

complications of cesarean section

There is a small increase in the risk of serious immediate maternal complications compared with vaginal birth (RR 1.29, 95% CI 1.03 to 1.61), including pulmonary embolism, infection, bleeding, damage to the bladder and bowel, slower recovery from the delivery, longer hospitalization, and delayed bonding and breast-feeding. [ 23 ] [ 31 ] [ 47 ] [ 48 ] [ 49 ] [ 50 ] [ 51 ] [ 52 ] [ 53 ] [ 54 ] [ 55 ] [ 56 ] [ 57 ] [ 58 ]

The long-term risks include potential compromise of future obstetric performance, increased risk of repeat cesarean section, infertility, uterine rupture, placenta accreta, placental abruption, and emergency hysterectomy. [ 60 ] [ 61 ] [ 62 ] [ 63 ] The evidence suggests that using sutures, rather than staples, for wound closure after cesarean section reduces the incidence of wound dehiscence. [ 59 ]

Emergency cesarean section, compared with planned cesarean section, has demonstrated a higher risk of severe obstetric morbidity, intra-operative complications, postoperative complications, infection, blood loss >1500 mL, fever, pain, tiredness, and breast-feeding problems. [ 23 ] [ 48 ] [ 50 ] [ 70 ] [ 81 ]

Key Articles

Impey LWM, Murphy DJ, Griffiths M, et al; Royal College of Obstetricians and Gynaecologists. Management of breech presentation: green-top guideline no. 20b. BJOG. 2017 Jun;124(7):e151-77. [Full Text]

Hofmeyr GJ, Hannah M, Lawrie TA. Planned caesarean section for term breech delivery. Cochrane Database Syst Rev. 2015 Jul 21;(7):CD000166. [Abstract] [Full Text]

Royal College of Obstetricians and Gynaecologists. External cephalic version and reducing the incidence of term breech presentation. March 2017 [internet publication]. [Full Text]

Cluver C, Gyte GM, Sinclair M, et al. Interventions for helping to turn term breech babies to head first presentation when using external cephalic version. Cochrane Database Syst Rev. 2015 Feb 9;(2):CD000184. [Abstract] [Full Text]

de Hundt M, Velzel J, de Groot CJ, et al. Mode of delivery after successful external cephalic version: a systematic review and meta-analysis. Obstet Gynecol. 2014 Jun;123(6):1327-34. [Abstract]

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30. Hofmeyr GJ, Kulier R, West HM. External cephalic version for breech presentation at term. Cochrane Database Syst Rev. 2012 Oct 17;(10):CD000083. [Abstract] [Full Text]

31. Hofmeyr GJ, Hannah M, Lawrie TA. Planned caesarean section for term breech delivery. Cochrane Database Syst Rev. 2015 Jul 21;(7):CD000166. [Abstract] [Full Text]

32. Stock SJ, Thomson AJ, Papworth S, et al. Antenatal corticosteroids to reduce neonatal morbidity and mortality: Green-top Guideline No. 74. BJOG. 2022 Jul;129(8):e35-60. [Abstract] [Full Text]

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47. Lydon-Rochelle M, Holt VL, Martin DP, et al. Association between method of delivery and maternal rehospitalisation. JAMA. 2000 May 10;283(18):2411-6. [Abstract]

48. Yokoe DS, Christiansen CL, Johnson R, et al. Epidemiology of and surveillance for postpartum infections. Emerg Infect Dis. 2001 Sep-Oct;7(5):837-41. [Abstract]

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51. Lydon-Rochelle MT, Holt VL, Martin DP. Delivery method and self-reported postpartum general health status among primiparous women. Paediatr Perinat Epidemiol. 2001 Jul;15(3):232-40. [Abstract]

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54. MacLennan AH, Taylor AW, Wilson DH, et al. The prevalence of pelvic disorders and their relationship to gender, age, parity and mode of delivery. BJOG. 2000 Dec;107(12):1460-70. [Abstract]

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Published by

American College of Obstetricians and Gynecologists

2016 (reaffirmed 2022)

Royal College of Obstetricians and Gynaecologists (UK)

National Institute for Health and Care Excellence (UK)

Topic last updated: 2024-03-05

Natasha Nassar , PhD

Associate Professor

Menzies Centre for Health Policy

Sydney School of Public Health

University of Sydney

Christine L. Roberts , MBBS, FAFPHM, DrPH

Research Director

Clinical and Population Health Division

Perinatal Medicine Group

Kolling Institute of Medical Research

Jonathan Morris , MBChB, FRANZCOG, PhD

Professor of Obstetrics and Gynaecology and Head of Department

Peer Reviewers

John W. Bachman , MD

Consultant in Family Medicine

Department of Family Medicine

Mayo Clinic

Rhona Hughes , MBChB

Lead Obstetrician

Lothian Simpson Centre for Reproductive Health

The Royal Infirmary

Brian Peat , MD

Director of Obstetrics

Women's and Children's Hospital

North Adelaide

South Australia

Lelia Duley , MBChB

Professor of Obstetric Epidemiology

University of Leeds

Bradford Institute of Health Research

Temple Bank House

Bradford Royal Infirmary

Justus Hofmeyr , MD

Head of the Department of Obstetrics and Gynaecology

East London Private Hospital

East London

South Africa

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INTRODUCTION

For patients who present in labor with a breech fetus, cesarean birth is the preferred approach in many hospitals in the United States and elsewhere. Cesarean is performed for over 90 percent of breech presentations, and this rate has increased worldwide [ 1,2 ]. However, even in institutions with a policy of routine cesarean birth for breech presentation, vaginal breech births occur because of situations such as patient preference, precipitous birth, out-of-hospital birth, and lethal fetal anomaly or fetal death. Therefore, it is essential for clinicians to maintain familiarity with the techniques required to assist in a vaginal breech birth.

In addition, some clinicians and patients consider vaginal breech birth preferable to cesarean birth. Recent trends, particularly in central Europe, support vaginal breech birth [ 3-5 ]. In selected cases, as described below and depicted in the algorithm ( algorithm 1 ), it is associated with a low risk of complications. The American College of Obstetricians and Gynecologists has opined that "Planned vaginal delivery of a term singleton breech fetus may be reasonable under hospital-specific protocol guidelines for eligibility and labor management" [ 6 ].

This topic will focus on vaginal birth of breech singletons, with a brief discussion of breech delivery at cesarean. Choosing the best route of birth for the fetus in breech presentation and delivery of the breech first or second twin are reviewed separately.

● (See "Overview of breech presentation", section on 'Approach to management at or near term' .)

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.

Breech presentation management: A critical review of leading clinical practice guidelines

Affiliations.

• 1 Edith Cowan University; King Edward Memorial Hopsital. Electronic address: [email protected].
• 2 Edith Cowan University.
• PMID: 34253466
• DOI: 10.1016/j.wombi.2021.06.011

Problem: Clinical practice guidelines are designed to guide clinicians and consumers of maternity services in clinical decision making, but recommendations are often consensus based and differ greatly between leading organisations.

Background: Breech birth is a divisive clinical issue, however vaginal breech births continue to occur despite a globally high caesarean section rate for breech presenting fetuses. Inconsistencies are known to exist between clinical practice guidelines relating to the management of breech presentation.

Aim: The aim of this review was to critically evaluate and compare leading obstetric clinical practice guidelines related to the management of breech presenting fetuses.

Methods: Leading obstetric guidelines were purposively obtained for review. Analysis was conducted using the International Centre for Allied Health Evidence (iCAHE) Guideline Quality Checklist and reviewing the content of each guideline.

Findings: Antenatal care recommendations and indications for Caesarean Section were relatively consistent between clinical guidelines. However, several inconsistencies were found among the other recommendations in terms of birth mode counselling, intrapartum management and the basis for recommendations.

Discussion: Inconsistencies noted in the clinical practice guidelines have the potential to cause issues related to valid consent and create confusion among clinicians and maternity consumers.

Conclusion: Clinical practice guidelines, which focus on the risks of a Vaginal Breech Birth without also discussing the risks of a Caesarean Section when a breech presentation is diagnosed, has the potential to sway clinician attitudes and impact birth mode decision-making in maternity consumers. To respect pregnant women's autonomy and fulfil the legal requirements of consent, clinicians should provide balanced counselling.

Keywords: Breech presentation; Clinical practice guidelines; Review.

Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.

Publication types

• Breech Presentation* / therapy
• Cesarean Section
• Delivery, Obstetric / methods
• Parturition
• Practice Guidelines as Topic

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Smoke or smokeless moxibustion treatment for breech presentation: A three‐arm pilot trial

Akiko higashihara.

1 Department of Nursing, Saitama Prefectural University, Saitama Japan

Shigeko Horiuchi

2 Graduate School of Nursing Science, St. Luke's International University, Tokyo Japan

Associated Data

We conducted a pilot trial to compare the effects of smoke and smokeless moxibustion with a control as a possible supplement to external cephalic version (ECV) for converting breech to cephalic presentation and increasing adherence to cephalic position, and to assess their effects on the well‐being of the mother and child.

We used a quasi‐experimental design with 3 arms: a smoke moxibustion (SM) ( n  = 20) and smokeless moxibustion (SLM) ( n  = 20) groups (20‐min acupoint BL67 stimulation once or twice daily for 10–14 days), and a control group ( n  = 20). The participants had singleton breech presentations between 33 and 35 gestation weeks. The primary outcome was cephalic presentation at the conclusion of intervention. The secondary outcomes were cephalic presentation at birth and effects on mother and child well‐being.

At the conclusion of intervention, cephalic presentation was higher in the SLM (60.0%) than the control groups (25.0%), Relative Risk 2.40, 95% Confidence Interval [1.04–5.56]; there was no significant difference for SM. At birth, there were no significant differences in cephalic presentation or well‐being.

SLM treatment showed an increasing trend towards cephalic presentation at the conclusion of intervention. Although significant differences were not observed at birth possibly due to the small samples and non‐randomization, moxibustion was safe, and not associated with perinatal morbidity and mortality. A randomized controlled trial with a larger sample is warranted to ascertain SLM treatment as a possible ECV supplement for converting and increasing adherence to cephalic position.

1. INTRODUCTION

The breech presentation is a major condition for performing elective cesarean section. Singh et al. ( 2020 ) previously described the various indications for cesarean section. They reported that the primary, secondary, and tertiary indications for elective cesarean section were previous cesarean section (33%), fetal distress (19%), and malpresentations (13%), respectively. Breech presentation is reportedly the main indication for elective cesarean section. Thus, to increase spontaneous fetal movement towards cephalic presentation, the development of methods for correcting breech presentation in pregnant women who desire to have a vaginal cephalic birth is needed. Methods of effective care based on evidence for converting breech presentation to cephalic presentation must also be carefully examined.

The proportion of breech presentation is usually approximately 20% at 28 weeks of gestation (Cunningham et al.,  2014 , pp. 558–573; Westgren et al.,  1985 ). However, the majority subsequently convert into cephalic presentation, decreasing the proportion to 3–4% of the fetuses at full term (Cunningham et al.,  2014 , pp. 558–573; Hickok et al.,  1992 ). Some of the methods for converting to cephalic presentation include posture management, moxibustion alone or together with acupuncture, and external cephalic version (ECV). When planning to correct the fetal position, the timing of physical manipulative intervention is highly crucial. For example, the critical timing for physical manipulative interventions such as ECV is before or after 37 weeks of gestation, which is the border between preterm birth and full‐term birth. However, this is not an issue for non‐manipulative interventions such as moxibustion even before 37 weeks of gestation. The effects of posture management (e.g., the knee‐to‐chest position) for correcting fetal presentation still need further clarification (Hofmeyr & Kulier,  2012 ). ECV at term is reported to decrease non‐cephalic presentation at delivery, Relative Risk (RR) 0.42, 95% Confidence Interval (CI) [0.29, 0.61], and cesarean section, RR 0.57, 95% CI [0.40, 0.82] (Hofmeyr et al.,  2015 ). However, Hutton et al. ( 2015 ) showed evidence that the risk of preterm labor was increased with early ECV compared with ECV after 37 weeks, RR 1.51, 95% CI [1.03, 2.21]. Therefore, the timing of the implementation of ECV should be carefully considered.

Moxibustion is a traditional Chinese medicine that offers an alternative approach for inducing cephalic version of breech presentation. Moxibustion generates heat by burning a herbal preparation containing Artemisia vulgaris (mug‐wort) in the moxibustion stick, which is placed near the acupuncture point to induce a warming sensation (Turner & Low,  1987 ). To promote cephalic version, the acupuncture point bladder 67 (BL67; located on the outer corner of the fifth toenail) is stimulated using a moxibustion stick (Cardini et al.,  1991 ). Studies have shown that pregnant women have significantly more subjective fetal movements during moxibustion (Cardini & Weixin,  1998 ; Guittier et al.,  2009 ). This suggests that fetal movements may be increased and that fetal self‐rotation may be promoted. The specific mechanism of the action has yet to be determined.

Three systematic reviews have reported the effectiveness and safety of moxibustion for breech presentation (Coyle et al.,  2012 ; Vas et al.,  2009 ; Zhang et al.,  2013 ). Meta‐analyses have also been performed to compare moxibustion usage with no treatment. When moxibustion was combined with acupuncture and compared with no treatment, the moxibustion‐acupuncture combination resulted in fewer non‐cephalic presentations at birth, RR 0.73, 95% CI [0.57, 0.94], 1 trial, 226 women, and fewer births by cesarean section, RR 0.79, 95% CI [0.64, 0.98] (Coyle et al.,  2012 ). Moreover, a higher rate of cephalic version was found in the moxibustion group than in the control group, RR 1.36, 95% CI [1.17, 1.58] (Vas et al.,  2009 ). However, significant heterogeneity was evident among the systematic reviews. In these previous systematic reviews, there were trials for different moxibustion methods. Particularly for the types of moxibustion, the trials using smoke moxibustion and smokeless moxibustion were mixed. Thus, a unified study of moxibustion methods (i.e., homogenous methodology) is thought to be necessary.

To the best of our knowledge, there are presently no studies comparing and verifying smoke moxibustion, smokeless moxibustion, and control treatments for breech presentation as a three‐arm pilot trial. Moreover, regarding smoke moxibustion versus smokeless moxibustion, it remains unclear which is more effective, safe, and acceptable to pregnant women, and whether there is any difference in the amount of heat generated. Several studies have shown the effects of moxibustion smoke. Coulon et al. ( 2014 ) reported that out of 164 patients in the moxibustion group (with acupuncture), two patients complained of nausea or vomiting. In Cardini et al.'s ( 2005 ) randomized controlled trial (RCT) of Italians, 14 out of 65 patients in the intervention group had events such as nausea and throat problems due to smoke moxibustion. As the moxibustion used in the above two RCTs was smoke moxibustion, it is reported that its use may cause nausea and throat problems. Therefore, to successfully establish an effective moxibustion method for breech presentation, a pilot study is necessary to compare smoke moxibustion and smokeless moxibustion simultaneously. Thus, this research was conducted as a pilot study involving a non‐randomized controlled trial as a preliminary step towards a future randomized controlled trial.

The specific aims of this pilot study were (a) to compare the effects of smoke moxibustion and smokeless moxibustion treatments with the control group as a possible supplement to ECV for converting breech presentation to cephalic presentation and increasing adherence to the newly obtained cephalic position, and (b) to assess the effects of these treatments on the well‐being of the mother and child.

In line with these aims, we suggest and examine three hypotheses.

The smoke moxibustion stick group (SM group) and smokeless moxibustion stick group (SLM group) will have higher rates of cephalic presentation after treatment than the control group.

The SM group and SLM group will have higher rates of cephalic presentation at birth than the control group.

There will be no significant differences in the well‐being of the mother and child among the three groups in terms of the following outcomes: premature birth, premature rupture of membranes (PROM) at <37 weeks, Apgar score <7 at 5 min, umbilical cord blood pH <7.1, admission to neonatal intensive care unit (NICU), and intrauterine fetal death.

2.1. Study design

We used a quasi‐experimental design with three arms for this pilot trial.

2.2. Participants and setting

Eligible participants were allocated into the following groups: (a) SM group, (b) SLM group, and (c) control group. This study was conducted in two perinatal medical centers, a maternity hospital, and an obstetrics and gynecology clinic in Tokyo, Japan, between March 2016 and January 2017.

2.2.1. Inclusion criteria

The inclusion criteria were as follows:

• Pregnant women with singleton breech presentations between 33 and 35 gestation weeks diagnosed by physical examination and ultrasound.
• Japanese women aged 18 years and above, with normal fetal biometry, and with normal progression of pregnancy.

2.2.2. Exclusion criteria

The exclusion criteria were as follows:

• Non‐obstetric complications: Maternal heart or kidney disease.
• Obstetric complications: Pregnancy with multiples of twins and beyond, risk of preterm birth (preterm uterine contractions, initial dilatation, or shortening of the cervix with a score of 4 on the Bishop scale; tocolytic therapy), uterine fibroids >4 cm, placenta previa, hypertensive disorders of pregnancy, PROM.
• Contraindication to vaginal delivery: Previous uterine surgery, uterine malformations, bone pelvic defects.
• Fetal conditions: Intrauterine growth restriction, fetal malformation, or chromosomal disorder.
• Conditions to avoid in interventions: Pregnant woman or siblings of the fetus diagnosed with bronchial asthma or a pulmonary problem and are treated; allergies to Artemisia vulgaris ; pregnant woman or siblings of the fetus who have symptoms of coughing, respiratory discomfort from smoke, and prior moxibustion treatment to achieve fetal version.

2.2.3. Sample size

This three‐arm pilot study was conducted in preparation for a future RCT. The sample size was estimated based on a previous feasibility study which involved a sample of 30 women and reported on moxibustion for cephalic version (Do et al.,  2011 ). In this previous feasibility study which was a two‐arm trial, 20 women were eventually allocated and analyzed. In our present pilot study, we compared three groups and enrolled 60 women (i.e., 20 women in each group) with consideration of those lost to follow‐up.

2.2.4. Allocation of participants

First, participants were recruited for the SM group until the required number of 20 people was secured. Second, participants were recruited for the SLM group until the required number of 20 people was secured. Third, participants were recruited for the control group until the required number of 20 people was secured. At the end of the recruitment for the first group, posters in the facilities requesting participation were replaced with other posters designed to recruit the next group. The pilot trial was stopped when enrollment of the required number of women and performance of the intervention treatments were completed.

2.3. Interventions

2.3.1. smoke moxibustion stick method.

The SM method is a traditional moxibustion treatment which is presently the conventional smoke moxibustion stick method used. Participants in the SM group self‐administered the moxibustion treatment at home. The acupuncture point BL67 ( Zhiyin in Chinese), which is located close to the outer angle of the little toenail, was stimulated using a smoke moxibustion stick for 20 min once or twice daily for 10–14 days. The women performed the moxibustion treatment in relaxed clothes and posture. It was recommended that they sit down on a sofa or lean against a wall with cushions, and assume a comfortable posture. The heated moxibustion stick was placed on a stand especially made for the stick. The heated moxibustion stick was then applied for 10 min on each foot for a total of 20 min per treatment at BL67. The heated tip of the moxibustion stick was applied from a distance of 1.5–3 cm. The participants performed the treatment once or twice daily for 10–14 days, recording their self‐administered treatment in a moxibustion diary. The moxibustion diary and physical condition check sheet were provided to the participants. For the physical condition at pre‐treatment and post‐treatment, the participants checked for the presence or absence of uterine contraction, vaginal bleeding, and membrane rupture using the physical condition check sheet. The items in this check sheet, as well as the timeline and treatment protocol, were based on systematic reviews of possible adverse events and moxibustion for breech presentation (Coyle et al.,  2012 ; Vas et al.,  2009 ; Zhang et al.,  2013 ). The participants were given a moxibustion set that can be used for 14 days. Each set contained the following: moxibustion sticks, moxibustion stick stand, ashtray, lighter, fire extinguishing tool, trays, deodorizing spray, aluminum seats, and cap for safekeeping the moxibustion sticks. Follow‐up was made by phone on day 1 and after 7 days to confirm the application and safety of the moxibustion treatment, and check on whether there were any questions or concerns.

2.3.2. Smokeless moxibustion stick method

The SLM method uses a stick that is odorless and carbonized, and the smoke can be maximally controlled. Participants in the SLM group self‐administered the moxibustion treatment at home. BL67 was stimulated using a smokeless moxibustion stick for 20 min once or twice daily for 10–14 days. This procedure was identical to the smoke moxibustion technique except for the use of a stick that is carbonized with the smoke capable of being maximally controlled.

2.3.3. Control group

Participants in the control group received leaflets explaining about (a) adequate sleep, balanced diet, exercise, rest, and stress‐reduction that they need to pay attention to in their daily life, (b) important aspects of uterine contraction, and (c) lying down positions that they have to assume depending on the location of the fetal spine. In Japan, obstetricians perform an ultrasound almost every time during prenatal check‐ups. Particularly in the third trimester of pregnancy, when the baby is in the breech presentation, an ultrasound is performed every time to inform and educate the pregnant woman regarding the fetal position. Thus, the pregnant woman knows the position of the fetal spine. The participants were also instructed not to have any moxibustion treatment but to spend their time naturally until the next medical check‐up after 10–14 days.

2.4. Outcome measures

The primary outcome was the rate of cephalic presentation after 10–14 days from commencement of the intervention. Fetal presentation was determined by ultrasound. The secondary outcomes were the rate of cephalic presentation at birth, mode of birth, maternal outcomes (number of ECV), and well‐being of the mother and child (related to perinatal morbidity and mortality: premature birth, PROM at <37 weeks, Apgar score <7 at 5 min, umbilical cord blood pH < 7.1, admission to NICU, and intrauterine fetal death).

2.4.1. Independent measures

The following information was obtained at baseline: (a) demographic data: age, educational level, (b) obstetric‐gynecological variables: parity, gestational age at the start of treatment, height (centimeters [cm]), weight (kilograms), body mass index (BMI), employment status, sensitivity to cold (a risk factor that can precipitate premature birth, PROM, weak labor pains, prolonged labor, and atonic bleeding) (Nakamura & Horiuchi,  2013 ), and (c) factors related to breech presentation: gestational age at the start of breech presentation, placental location, estimated fetus weight at the start of treatment (grams), amniotic fluid depth (cm), type of presentation (breech or transverse), umbilical cord length at birth (cm), and coiling of the umbilical cord at the start of treatment. These data were collected using the clinical records and a self‐report questionnaire. The participants completed the self‐report questionnaire before and after the intervention.

2.5. Procedures

This study used a quasi‐experimental design. Three arms were allocated as follows: (a) SM group ( n  = 20), (b) SLM group ( n  = 20), and (c) control group ( n  = 20). For moxibustion administration, the participants self‐administered the moxibustion treatment at their home. We adopted this procedure based on the method of Cardini and Weixin ( 1998 ) who reported the effectiveness of self‐administered moxibustion for breech presentation by the participants at home. The treatment protocol was supervised by Dr. S.K., an acupuncture and moxibustion specialist for pregnant women with 35 years of clinical experience.

Regarding the recruitment setting, cooperation with research facilities was sought using a “request document to use a facility.” If approval of the sought cooperation was obtained, this was posted in the recruitment section of the bulletin board of the outpatient ward as a form of information disclosure of this research. Recruitment posters were put up on the bulletin boards for about 3 to 4 months per group, for a total of 11 months during the study period.

The first author (A.H.) and research assistant (RA) midwives who acted as the intervention staff were directly involved in this research. The intervention staff previously underwent the same training on how to perform the moxibustion method. The intervention staff clearly explained the purpose of the research, adequately described the contents of the intervention and control groups, and efficiently administered the questionnaire. The intervention staff performed the same work, carried out recruitment, explained the research contents to pregnant women, and assisted in data collection. A video providing clear instructions on the moxibustion method was also created and provided to ensure that the same instructions and guidance would be given to all participants. After the 31–33 gestational weeks medical check‐up of pregnant women, those who met the eligibility criteria were identified from the reservation list for the next regular prenatal medical check‐up. At the 33–35 gestation weeks medical check‐up, women who were diagnosed with breech presentation by ultrasound were sampled conveniently by an obstetrician and gynecologist specialist, and were requested to participate in the present study, with the intervention staff explaining that it would take 30 min to introduce the research after the prenatal check‐up. For women who indicated interest, the intervention staff carefully explained the procedure in a private room, creating an atmosphere where it was easy to ask questions. Once consent to participate in the research was obtained, each participant received and completed a pre‐intervention self‐report questionnaire. The post‐intervention questionnaire was given to each participant at the next antenatal check‐up after the intervention. The intervention group participants were provided advice and training using instruction documents on the safe use the moxibustion stick including fire safety education, and the intervention procedure as demonstrated by the intervention staff. The pregnant women were checked by the intervention staff as to whether they were able to acquire the skills required to properly self‐administer moxibustion. In addition, the intervention group participants were provided access information for the video instructional website for the moxibustion method at home so that they could watch the video every time and check the precautions. The teaching materials were prepared under the supervision of a qualified practitioner of acupuncture and moxibustion. Some possible side effects in the intervention group were (a) burns, (b) feelings of unpleasantness, and (c) uterine contraction, PROM, or bleeding as induced by moxibustion. The possible adverse events and corresponding first aid were clearly explained and written in the explanation documents. The phone number of the researcher (A.H.) was also written in the explanation documents for any urgent requests for consultation regarding adverse events. For the control group, the intervention staff advised the participants not to undergo any acupuncture, moxibustion, or massage treatment to correct the breech presentation during the study period.

Ultrasound was performed to check the fetal position in all the participants of the three groups at 10 to 14 days after the intervention. If the fetus was still in breech presentation, the participants could choose the ECV treatment if needed.

2.6. Ethical considerations

The Institutional Review Board of St. Luke's International University, Tokyo, Japan approved this study (No. 15–086). This study was registered in the Clinical Trials Registry of University Hospital Medical Information Network in Japan after approval by the Ethics Screening Committee (UMIN000021377). All participants provided written informed consent.

2.7. Data analysis

Statistical analyses were conducted for all data. To evaluate the differences among the groups, continuous variables were analyzed using Student's t test and one‐way analysis of variance (ANOVA). Categorical variables were analyzed using the Fisher exact test or Chi‐square test. The relative risk (RR) and 95% CI were calculated for the SM versus the control groups and for the SLM versus the control groups. All analyses were performed using International Business Machines Corporation (IBM) Statistical Package for Social Science (SPSS version 22.0, IBM Japan, Tokyo, Japan). The level of statistical significance was set at p  < 0.05.

The participants were recruited and followed up from March 2016 to January 2017. A total of 63 women were registered in this trial. In the end, there were 20 participants in each group for analysis. The participant flow diagram is shown in Figure  1 .

Participant flow diagram

3.1. Characteristics of the study participants

There were no significant differences between groups in the sociodemographic characteristics, obstetric‐gynecological variables, and related factors of breech presentation as baseline characteristics of the study participants (Table  1 ).

Baseline characteristics of the study participants

Note: p ‐Value: One‐way analysis of variance or Fisher's exact test for comparisons between groups.

Abbreviations: BMI, body mass index; SD, standard deviation.

3.2. Primary outcome

3.2.1. cephalic presentation at intervention conclusion (after 10–14 days).

Nine fetuses in the SM group (45%), 12 fetuses in the SLM group (60%), and 5 fetuses in the control group (25%) converted to cephalic presentation at the conclusion of intervention. The proportion of cephalic version was higher in the SLM group (60%) than in the control group (25%), RR 2.40, 95% CI [1.04, 5.56]. There was no significant difference between the SM group and the control group, RR 1.80, 95% CI [0.73, 4.43] (Table  2 ).

Comparison of outcomes between moxibustion and control groups

Note : Data are expressed as n (%).

Abbreviations: CI, Confidence Interval; ECV, External Cephalic Version; RR, Relative Risk.

The protocol of this study was to perform moxibustion for 20 min once or twice daily for 10–14 days. The mean number of times of performing moxibustion was 17.65 times (SD 4.30, range 10–26 times) in the SM group and 19.95 times (SD 5.54, range 7–28 times) in the SLM group. The mean number of days of implementation was 12.65 days (SD 1.53, range 10–14 days) in the SM group and 12.65 days (SD 1.87, range 7–14 days) in the SLM group. There was no significant difference between the groups.

These results showed that the rate of cephalic presentation after 10–14 days of the intervention was higher in the SLM group than in the control group. This indicates that Hypothesis 1 is supported for the SLM group, but not for the SM group.

3.3. Secondary outcomes

3.3.1. cephalic presentation at birth.

In the calculation of the proportion of cephalic presentation at birth, the practice of ECV is considered a factor that affects the fetal position at birth. To examine the effects of moxibustion, we conducted analysis in ways which both included ECV practitioners, and also excluded ECV practitioners, in comparisons among the three groups.

First, numbers which included the women who underwent ECV were used for both the numerators and denominators in calculating the proportion of cephalic presentation. As a result, there was no significant difference between the intervention groups and the control group.

Next, only numbers which excluded women who underwent ECV were used for the numerators in making the same calculations. As a result, the gap increased between the proportion of cephalic version in the SLM group (60%) versus the control group (30%), RR 2.00, 95% CI [0.94, 4.27]. However, this difference between the two groups still did not reach a level of significance.

Third, numbers which excluded women who underwent ECV were used for both the numerators and denominator for the calculations. As a result, there were again no significant differences between either intervention group and the control group (Table  2 ).

Thus, Hypothesis 2 was not supported by the present results.

Regarding cesarean sections, we again analyzed two patterns: including those who underwent ECV and excluding those who underwent ECV. For calculations including those who underwent ECV, 10 women each in the SM and SLM groups had cesarean sections compared with 13 women in the control group, yielding the same values for each, RR 0.77, 95% CI [0.45, 1.33]. For calculations excluding those who underwent ECV, 7 of 17 women in the SM group, and 10 of 20 women in the SLM group had cesarean sections, compared with 9 of 15 women in the control group, yielding RR 0.69, 95% CI [0.34, 1.39] for the SM group, and RR 0.83, 95% CI [0.46, 1.52] for the SLM group. Overall, there were no significant differences in the proportions of cesarean section among the three groups.

3.4. Comparison of the effects of the intervention treatments on the well‐being of the mother and child among groups

There were no significant differences in the well‐being of the mother and child in all the outcomes (Table  3 ). Thus, Hypothesis 3 was supported by the present results.

Comparison of the effects of treatment intervention on the well‐being of the mother and child among groups

Abbreviations: NICU, neonatal intensive care unit; SD, standard deviation.

4. DISCUSSION

4.1. primary outcome.

Our results showed that at the conclusion of intervention, the proportion of cephalic version was significantly higher in the SLM group than in the control group. However, no significant difference was observed between the SM group and the control group. Two RCTs have shown different conclusions on the use of smokeless moxibustion sticks as reported by Do et al. ( 2011 ) and Guittier et al. ( 2009 ). Do et al. ( 2011 ) found a trend towards an increase in cephalic version at the conclusion of the intervention for women receiving moxibustion compared with the control. The treatment protocol involved 20 applications of heat stimulation using smokeless moxibustion (i.e., 20 min twice daily for 10 days). Guittier et al. ( 2009 ) found no difference in the proportion of versions among women treated with moxibustion and women in the control group. In the protocol of Guittier et al. ( 2009 ), the maximum number of moxibustion sessions was 14 times. In our present study protocol, the average number of moxibustion treatments was 19.95 times, which showed the effects of moxibustion. Therefore, we consider our protocol to be more effective. Based on these results, it is therefore important to identify the optimal number of times of rigorous moxibustion application. We found that heat stimulation using moxibustion is necessary for at least 20 times between 10 and 14 days, and this should to be incorporated into the protocol.

Some studies showed the effectiveness of smoke moxibustion for breech presentation, whereas other studies did not. In their study of 260 Chinese pregnant women, Cardini and Weixin ( 1998 ) showed a higher cephalic conversion ratio in the smoke moxibustion group than in the control group, RR 1.58, 95% CI [1.29, 1.94]. Cardini et al. ( 2005 ) found no significant difference, however, in the cephalic conversion ratio between the smoke moxibustion group and the control group in 123 Italian pregnant women, RR 0.95, 95% CI [0.59, 1.5]. Bue and Lauszus ( 2016 ) reported similar findings in 200 Danish women, RR 1.05, 95% CI [0.8, 1.38].

Overall, it appears that previous studies have significant differences and large sample sizes. Thus, in future studies, changes in temperature from the feet to the abdomen should be measured by thermography and included as data. Additionally, improvement of the intervention protocol using various strengths of moxibustion heat should be carefully considered and incorporated.

4.2. Secondary outcomes

Women who performed smoke and smokeless moxibustion stick treatments showed an increasing trend in cephalic version at birth compared with women in the control group. During birth, however, there were no significant differences among the three groups. As ECV was considered to be a factor that has an effect on the outcome, analysis was also conducted with women who underwent ECV excluded. The exclusion of ECV patients reduced the overall number of eligible women, therefore, the small sample size of the pilot study this did not result in any significant differences between the groups.

Notably, some previous studies have included women who underwent ECV in the analysis (Bue & Lauszus,  2016 ; Cardini et al.,  2005 ; Cardini & Weixin,  1998 ; Guittier et al.,  2009 ; Vas et al.,  2013 ). Some of these studies (Cardini & Weixin,  1998 ; Vas et al.,  2013 ) showed that moxibustion at BL67 is effective in correcting breech presentation whereas others revealed the opposite effect (Bue & Lauszus,  2016 ; Cardini et al.,  2005 ; Guittier et al.,  2009 ). These results imply that it is necessary to have a larger sample size that will have a sufficient effect even if the women who undergo ECV are included. Thus, it is necessary to calculate the sample size to be able to reliably verify the effects of moxibustion, and to increase the number of subjects in future trials.

4.3. Effects of the treatment intervention on the well‐being of the mother and child among groups

We found no significant difference in the well‐being of the mother and child (i.e., related to perinatal morbidity and mortality: premature birth, PROM at <37 weeks, Apgar score <7 at 5 min, umbilical cord blood pH < 7.1, admission to NICU, and intrauterine fetal death) among the three groups. Previous systematic reviews showed no significant difference in preterm birth between the moxibustion group, RR 0.95, 95% CI [0.23, 3.92] (Vas et al.,  2009 ) and the control group, RR 0.92, 95% CI [0.35, 2.47] (Zhang et al.,  2013 ). There was also no significant difference in PROM, RR 0.82, 95% CI [0.007, 9.31] (Coyle et al.,  2012 ); RR 0.54, 95% CI [0.10, 3.08] (Vas et al.,  2009 ); RR 1.55, 95% CI [0.17, 14.35] (Zhang et al.,  2013 ). The results of the present study are similar to the above‐mentioned results of the previous systematic reviews.

Overall, the results showed that moxibustion was not harmful to the pregnant woman and fetus in the third trimester of pregnancy, as well as to the newborn baby. We therefore consider moxibustion as one of the effective complementary alternative medicines for pregnant women.

4.4. Study limitations and future research

In the present study, selection bias may not have been completely excluded because of the lack of random allocation. Also, the sample size was small and the setting was limited to four tertiary obstetric hospitals in Tokyo.

In future studies, smokeless moxibustion will be used in the treatment protocol and moxibustion treatment will be performed 20 times between 10 and 14 days as in the protocol of this pilot study. RCT with a larger sample size will be needed to verify the effects of moxibustion even if women with ECV are included. It is also necessary to investigate whether moxibustion can be a secondary treatment to ECV, wherein moxibustion before ECV can promote conversion into a more cephalic version.

5. CONCLUSION

Women who performed SLM treatment for 20 min once or twice daily for 10–14 days showed an increasing trend towards cephalic presentation at the conclusion of intervention compared with women in the control group. This was not evident for the SM treatment. Although significant differences in cephalic presentation at birth and effects on well‐being of the mother and child were not observed at birth, possibly due to the small sample size and non‐randomization, moxibustion was safe, and not associated with perinatal morbidity and mortality. With the potential of SLM treatment to increase cephalic position, a future RCT with a larger sample size should be explored to ascertain SLM treatment as a possible supplement to ECV for converting breech presentation to cephalic presentation and increasing adherence to the newly obtained cephalic position.

CONFLICT OF INTERESTS

The authors declare that they have no competing interests associated with this study. There are no conflicts of interests for this study.

AUTHORS' CONTRIBUTIONS

Akiko Higashihara designed the study, collected and analyzed the data, and drafted the initial manuscript. Shigeko Horiuchi co‐conceptualized the study, supervised the designing of the study protocol, provided guidance in the data analysis, reviewed the draft, and made important revisions to the manuscript. Both authors read and approved the final version of the manuscript for submission.

Supporting information

Appendix S1 Supporting Information.

ACKNOWLEDGMENTS

The authors gratefully acknowledge all the participants, the staff at the data collection settings, and Dr. Shuichi Katai (an acupuncture and moxibustion practitioner and an acupuncturist), for their professional assistance and advice. We thank Dr. Yukari Yaju for her helpful support on the statistical analysis.

The authors are especially indebted to Dr. Edward Barroga ( https://orcid.org/00000002-8920-2607 ), medical and nursing science editor and professor of academic writing at St. Luke's International University, for reviewing and editing the manuscript.

Higashihara A, Horiuchi S. Smoke or smokeless moxibustion treatment for breech presentation: A three‐arm pilot trial . Jpn J Nurs Sci . 2021; 18 :e12426. 10.1111/jjns.12426 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Funding information: This study was financially supported by (a) Yamaji Fumiko Nursing Research Fund, (b) Japan Society for the Promotion of Science (JSPS) KAKENHI Grant Numbers JP 16H05589 and 17H06985, and (c) the Japan Academy of Midwifery Grant‐in‐Aid for Encouragement of Scientists.

Parts of this study were presented in an oral presentation session at the 32nd Annual Meeting of the Japan Academy of Midwifery, March 2018, Yokohama, Japan. Our study closely adheres to the CONSORT guidelines.

Clinical Trial registration: UMIN Clinical Trials Registry (Registered: UMIN000021377).

Funding information Japan Society for the Promotion of Science (JSPS) KAKENHI, Grant/Award Numbers: 16H05589, 17H06985; The Japan Academy of Midwifery Grant‐in‐Aid for Encouragement of Scientists; Yamaji Fumiko Nursing Research Fund

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Acupuncture & Moxibustion for Breech Presentation BY SUSAN WALLMEYER, L.AC. & SARAH TEWHEY, L.AC.

Evidence summary:, acupuncture & moxibustion for breech presentation, strength of evidence.

INTRODUCTION

Breech (feet first) presentation of the foetus in the last month of pregnancy occurs in 3-4% of all pregnancies. 1 In the United States, 90% of all breech babies are born via cesarean section, 2 a major surgical procedure that carries risk but also impacts maternal outcomes, postpartum recovery, and adds to costs in the healthcare system. 3 Access to a variety of corrective options that may increase the chance of a baby turning from breech to cephalic (head down) will benefit both the healthcare system and people giving birth.

Acupuncture and Moxibustion for Breech Presentation PDF

Moxibustion treatment for breech presentation generally involves lighting a rolled cigar-like moxa stick of dried Chinese mugwort, also known as Ai Ye, or Artemisia argyi , and using the heat from it to warm and stimulate a point located on the outer edge of the 5th toe known as Zhi Yin or Urinary Bladder 67 (UB67). The moxa stick is held close to the point to warm it once or twice daily for 15-30 minutes, for 5-14 consecutive days. Optimal timing for moxibustion and acupuncture treatment for breech has not yet been definitively determined by research, but it is generally accepted within the acupuncture community that treatment is most effective at 33-35 weeks gestation. 4 Providing this intervention as an option to parents may help to reduce rates of breech presentation at term, 5, 6 thereby lowering rates of cesarean section and improving maternal outcomes, leading to improved satisfaction with birth experience.

CURRENT STANDARD OF CARE

Summary of research.

A 2023 Cochrane Systematic Review by Coyle et al. 5 looked at 13 trials (2181 participants) that assessed the use of moxibustion, acupuncture, postural techniques, and usual care for breech presentation in uncomplicated pregnancies. Of those 13 trials, 7 studies (1152 participants) compared moxibustion treatment plus usual care to usual care alone and found moderate certainty evidence that moxibustion before 37 weeks of pregnancy probably reduces the chance of breech presentation at birth and the need for oxytocin use during birth. Despite these findings, the overall rate of cesarean section was not decreased by using moxibustion to change foetal presentation. The authors noted that although a cesarean section can occur for many reasons unrelated to a baby’s position, none of the studies reported on the reasons for cesarean section in either group.

While contemporary East Asian Medicine practised in the West tends to emphasize moxibustion for turning breech babies, a survey of practitioners reported that 50% combine it with acupuncture as the standard of care in their practice. 4 At this time, only a small amount of research looks at the effect of this combination. A 2021 Systematic Review by Liao et al. 6 of 16 studies (2555 participants) found that each “acupuncture-type intervention” (whether moxibustion at UB67 alone, acupuncture alone or moxibustion at UB67 plus acupuncture) led to an increased rate of cephalic presentation at birth when compared to usual care. However, the 2023 Cochrane Review authors concluded that there is not enough data to determine if the “combination treatments” (moxibustion plus acupuncture) led to an increase in head down babies at birth over moxibustion alone. 5 More research is needed to determine the effects of this clinically relevant style of treatment.

Vas et al. 7 conducted a large (406 participants) and well-designed study to determine if the UB67 acupuncture point location was specifically helpful with turning breech babies. They compared three groups; those who had moxibustion at UB67, those who had moxibustion at an “inactive” point, and those who received usual care (no moxibustion). Fifty-eight percent of participants in the UB67 moxibustion group had babies who turned head down. The groups performing moxibustion on an inactive point or who had usual care had lower rates of cephalic version (43% and 45% respectively). This result shows a statistically significant difference between the groups. Although more studies are needed, this study suggests there may be something unique about the UB67 acupuncture point that is specifically useful in this context. The rates of cesarean section were not significantly different between the two groups in this study and the reasons for cesarean birth were not provided.

In 2017, the Royal College of Obstetricians and Gynecologists (RCOG) included moxibustion and acupuncture in their Green-top Guidelines for External Cephalic Version and Reducing the Incidence of Term Breech Presentation. 8 This document represents the first inclusion of moxibustion and acupuncture treatment in a clinical guideline by a major professional organization within the field of Obstetrics. The RCOG guidelines 8 recommend that pregnant people may wish to consider the use of moxibustion at 33-35 weeks gestation. The recommendation also emphasizes the importance of choosing a trained practitioner for individuals seeking out this type of treatment. 8

According to the 2023 Cochrane Review, 5 one hypothesized mechanism of action is that treatment at the acupuncture point UB67 may stimulate maternal hormones (placental oestrogens and prostaglandin). This hormonal change may prompt the lining of the uterus to gently contract, resulting in increased foetal activity. A 1998 study by Cardini and Weixin 9 measured foetal activity in a group receiving moxibustion treatment and a group receiving usual care. Foetal movements were counted by the pregnant participants for one hour each day for a week. An average of 48.45 movements per hour were reported in the moxibustion group versus 35.35 movements in the group receiving usual care. This result represents a statistically significant difference and indicates that an increase in foetal movement may play a role in the mechanism of UB67 to correct breech presentation. Since the exact mechanism by which moxibustion and/or acupuncture acts to correct breech position is unknown, more well-designed research is needed.

Using acupuncture and moxibustion to attempt to correct foetal position in uncomplicated pregnancies carries low risk. Serious adverse events, though not adequately reported in trials, appear to be rare. 5, 6

The 2023 Cochrane Review 5 reported the most common adverse events as the potential for burns, increased foetal movements, uterine contractions, nausea, and headaches. In many cases, adverse events were not reported by group allocation and causality was not well established, making definitive conclusions about safety difficult to determine. Moreover, current research on the safety and effectiveness of moxibustion for breech presentation has included uncomplicated pregnancies only. Therefore, providers performing these treatments must be well versed in potential risks and contraindications.

Moxibustion should be used in a well-ventilated room or outdoors due to the potential for respiratory irritation from the smoke it can produce. Additionally, the person performing the moxibustion should be attentive in order to avoid contact with skin and prevent burns.

The Maternal Acupuncture Mentoring and Peer Support (MAMPS) 12 advisory group provides a safety sheet for acupuncturists on their website that outlines a framework for safe practice by practitioners who are performing treatments for breech presentation. 13

Since treatment with acupuncture and moxibustion can be attempted several weeks prior to an ECV, it has potential to be an effective, safe, and well tolerated first-line option for breech presentation.

The authors wish to thank Debra Betts, PhD, LAc and Zena Kocher, LAc for their invaluable feedback in preparing this summary.

References:

1 . Hofmeyr, G. J., Kulier, R. & West, H. M. External cephalic version for breech presentation at term. Cochrane Database of Systematic Reviews 2019, (2015).

2 . Dekker, R. Evidence on: Breech Version. Evidence Based Birth® (2017) at https://evidencebasedbirth.com/what-is-the-evidence-for-using-an-external-cephalic- version-to-turn-a-breech-baby/

3 . Obstetric Care Consensus No. 1: Safe Prevention of the Primary Cesarean Delivery. Obstetrics & Gynecology 123, 693–711 (2014).

4 . Smith, C. A. & Betts, D. The practice of acupuncture and moxibustion to promote cephalic version for women with a breech presentation: Implications for clinical practice and research. Complementary Therapies in Medicine 22, 75–80 (2014).

5 . Coyle, M. E., Smith, C. A. & Peat, B. Cephalic version by moxibustion for breech presentation. Cochrane Database of Systematic Reviews (2023). doi:10.1002/14651858.CD003928. pub4

6 . Liao, J.-A., Shao, S.-C., Chang, C.-T., Chai, P. Y.-C., Owang, K.-L., Huang, T.-H., Yang, C.-H., Lee, T.-J. & Chen, Y.-C. Correction of Breech Presentation with Moxibustion and Acupuncture: A Systematic Review and Meta-Analysis. Healthcare 9, 619 (2021).

7 . Vas, J., Aranda-Regules, J. M., Modesto, M., Ramos-Monserrat, M., Barón, M., Aguilar, I., Benítez-Parejo, N., Ramírez-Carmona, C. & Rivas-Ruiz, F. Using Moxibustion in Primary Healthcare to Correct Non-Vertex Presentation: A Multicentre Randomised Controlled Trial. Acupunct Med 31, 31–38 (2013).

8 . External Cephalic Version and Reducing the Incidence of Term Breech Presentation: Green-top Guideline No. 20a. BJOG: Int J Obstet Gy 124, e178–e192 (2017).

9 . Cardini, F. & Weixin, H. Moxibustion for Correction of Breech Presentation: A Randomized Controlled Trial. JAMA 280, 1580 (1998).

10 . Cardini, F., Lombardo, P., Regalia, A. L., Regaldo, G., Zanini, A., Negri, M. G., Panepuccia, L. & Todros, T. A randomised controlled trial of moxibustion for breech presentation. BJOG: Int J O&G 112, 743–747 (2005).

11 . Neri, I., Airola, G., Contu, G., Allais, G., Facchinetti, F. & Benedetto, C. Acupuncture plus moxibustion to resolve breech presentation: a randomized controlled study. The Journal of Maternal-Fetal & Neonatal Medicine 15, 247–252 (2004).

12 . MAMPS. Maternity Acupuncture Mentoring & Peer Support. Maternity Acupuncture Mentoring & Peer Support at https://www.mamps.org

13 . MAMPS. MAMPS – Resources. Maternity Acupuncture Mentoring & Peer Support at https://www.mamps.org/resources