breech presentation in 33 weeks pregnant

Breech Position: What It Means if Your Baby Is Breech

Medical review policy, latest update:.

Medically reviewed for accuracy.

What does it mean if a baby is breech?

What are the different types of breech positions, what causes a baby to be breech, recommended reading, how can you tell if your baby is in a breech position, what does it mean to turn a breech baby, how can you turn a breech baby, how does labor usually start with a breech baby.

If your cervix dilates too slowly, if your baby doesn’t move down the birth canal steadily or if other problems arise, you’ll likely have a C-section. Talk your options over with your practitioner now to be prepared. Remember that though you may feel disappointed things didn’t turn out exactly as you envisioned, these feelings will melt away once your bundle of joy safely enters the world.

Updates history

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When is Breech an Issue?

The later in pregnancy a baby is breech , the more difficult it is for the baby to flip head down. The baby’s size grows in relation to the uterus and there is a smaller percentage of amniotic fluid for the baby to move freely. The more complicated past births were due to fetal position, the earlier I suggest starting to get your muscles unwound and your pelvis aligned. If a previous baby remained either breech or posterior until birth, I suggest bodywork throughout the pregnancy.

In time, the breech baby’s head becomes heavy enough (between 5-7 months) for gravity to bring the head down in a symmetrical womb. The baby will move head down if there is room or if there is tone in the support to the uterus to direct the baby head down.

Common issues with breech:

Health of the baby overall
Safety of the birth
Safety for the mother facing surgical birth
Emotions of the birthing parent(s)
Belly Mapping® Breech
Flip a Breech
When Baby Flips Head Down
Breech & Bicornuate Uterus
Breech for Providers
What if My Breech Baby Doesn't Turn?
Belly Mapping ®️ Method

After Baby Turns

Head Down is Not Enough
Sideways/Transverse
Asynclitism
Oblique Lie
Left Occiput Transverse
Right Occiput Anterior
Right Occiput Posterior
Right Occiput Transverse
Face Presentation
Left Occiput Anterior
OP Truths & Myths
Anterior Placenta
Body Balancing

When should I be concerned about a breech position?

During the month before 30 weeks, about 15% of babies are breech. Since breech baby’s spine is vertical, the womb is “stretched” upwards. We expect babies to turn head down by 28-32 weeks.

Breech may not be an issue until 32-34 weeks. If you know your womb has an unusual limitation in shape or size, such as a bicornate uterus then begin body balancing before pregnancy and once 15 weeks in pregnancy. In this case, the baby needs to be head down much earlier so that the uterus still has the room for baby to turn. Every unique womb is unique so these dates are theoretical, not absolute.

The timeline for breech

This is a timeline of what to do and when to do it in order to help a breech baby move head down:

Before 24-26 weeks, most babies lie diagonally or sideways in the Transverse Lie position .
Between 24-29 weeks, most babies turn vertical and some will be breech.
By 30-32 weeks, most babies flip head down and bottom-up.
By 34 weeks pregnant, the provider expects the baby to be head down.
Between 36-37 weeks, a provider may suggest an external cephalic version .
Full term is from 37-42 weeks gestation, and about 3-4% of term babies are breech.

The medical model of care addresses the breech position between 36-37 weeks, when baby’s survival outside the womb won’t include special nursery care to breathe or suck. Physicians Oxorn and Foote, however, recommend helping babies turn head down at 34 weeks. Some home birth midwives suggest interacting with a baby at 30-34 weeks to encourage a head-down position (vertex).

Women who have had difficult previous births due to posterior, asynclitism , or a labor that didn’t progress, may want to begin bodywork and the Forward-leaning Inversion as soon as the second trimester of pregnancy (after morning sickness is gone and extra things like fetal positioning activities can be thought about).

Here is a general guideline for the average pregnancy:

10-24 weeks gestation

This is the time when fetal position is generally determined, even though the baby’s final position isn’t typically set before 34 weeks gestation. How can this be? The body has a habit, so to speak, of how the soft tissues, ligaments, muscles, and alignment of the pelvis and whole body is set. The baby simply follows this basic pattern. By adding body balancing now, the baby has an increased chance of ideal positioning for labor at 34 weeks and beyond.

24-30 weeks

Routine good posture with walking and exercise will help most babies be head down as the third trimester gets underway. A 30-second inversion is good practice for everyone. Unless you have a medical reason not to, please consider the Forward-leaning Inversion. If you have a history of car accidents, falls, uncomfortable pregnancies, hormonal imbalance, or a previous breech or posterior baby, then begin the inversion and body work before or during early pregnancy.

30-34 weeks

After 30 weeks, you can start following our 6-day program for Helping Your Breech Baby Turn . By 32-34 weeks, chiropractic adjustments are suggested. We recommend consulting with one of our Spinning Babies ® Aware Practitioners . The best time to flip a breech is now.

Oxorn and Foote recommend external version at 34 weeks, but most doctors want to wait for the baby’s lungs and suck reflex to be more developed in case the maneuver goes wrong and starts labor or pulls the placenta off the uterine wall. There is often enough amniotic fluid for an easy flip before 35 weeks.

Dad's the hero in this "over the top" support to help his mate do a Breech Tilt in the comfort of bed!

Dad’s the hero in this “over the top” support to help his mate do a Breech Tilt in the comfort of a bed!

Breech Tilt: Follow the FLI with the Breech Tilt for 10-20 minutes. This allows you to tuck your chin while upside down on a similar slanted surface. Use an ironing board against the couch, for instance.
Open-knee Chest: Open-knee Chest has been studied and shown to help breeches flip. I like inversion positions that allow the mother to tuck her own chin. Myofascial workers tell me this relaxes her pelvis, whereas extending the chin tightens the pelvis.
Professional bodywork: Acupuncture and Moxibustion both have good statistics for flipping breeches. Find out if there’s a Spinning Babies ® Aware Practitioner in your area.
Therapeutic massage: There are muscle/fascia attachments at the base of the skull, respiratory diaphragm, inguinal ligament, and even the hip sockets! We are whole organisms, not machines with reproductive parts.
Chiropractic or Osteopathic: Spinal adjustmentsof the neck do improve pelvic alignment, especially if accompanied by fascial release. Not all chiropractors are trained in soft tissue body work, however. And not all soft tissue work is equal. This is why we promote our Aware Practitioner Workshops for bodyworkers.

Should manual external cephalic version be done earlier?

A few midwives recommend version (manually turning the breech baby to head down) at 30 –31 weeks. Anne Frye, author of Holistic Midwifery, reported a very low incidence of breech at term when her midwifery group manually rotated babies during this gestational age.

Attempting to turn the baby now is over a month before the medical model of turning breeches. Utmost gentleness must be the protective factor. If forcing a baby to turn harms the baby or placenta, the baby is too young to be cared for outside of the Neonatal Intensive Care Unit.

Midwives who turn babies now believe there is less chance of hurting a baby and proceed very carefully, stopping at once if there is resistance. Typically, there is less resistance from the uterus because there is more fluid and the baby is still very small.

Body work is suggested before attempting this, especially for first-time moms or women who had a difficult time with their first birth. There are risks to a manual version, so the baby should be monitored closely in between each 10-30 degrees of rotation.

35-36 weeks

If your baby is breech during this time your doctor or midwife will begin to talk about how to help the baby flip head down, and possibly about scheduling a manual version for 36-37 weeks. Getting body work and having acupuncture or homeopathy may help soften the ligaments and a tense uterus to either help the baby flip spontaneously or to allow more success in an attempt at a version.

Moxibustion has its highest success rate this week.

36-37 weeks.

During this time, you can continue with the suggestions in the “Professional Help” page. Also, an obstetrician may suggest manually flipping the baby to a head down position at this time. A few midwives will also offer this, perhaps even earlier, at 30-34 weeks.

NOTE: Don’t let someone manually flip your baby without using careful monitoring of the baby’s heartbeat. Accidents can occur, even when there is good intention. The baby must be listened to and the version stopped immediately if the heart rate drops.

External cephalic version near the end of pregnancy

You may also agree to go through with a cephalic version at this time. The baby is in the womb with the cord and placenta and there is a small risk in turning the baby manually. This maneuver should be done with monitoring by experienced professionals, in a setting ready for a cesarean if needed.

There is about a 40-50% chance this will be successful. Sometimes the baby moves easily and sometimes the procedure is painful. I believe it’s important who performs it, and that ligament tightness would make this more uncomfortable. I suggest getting chiropractic, myofascial, acupuncture, homeopathy, or moxibustion (or all of these) before and after the version.

Doing the Three Sisters of Balance SM (or following the Turning Your Breech Baby guidelines) daily beforehand and just before the procedure would be relaxing and helpful. More birth professionals are using our approach in the hours or the week before the procedure and report that fewer procedures are necessary and those that are seem to be easier than average to do when the baby is able to be turned.

38-40 weeks

Sometimes a woman and her caregiver don’t know the baby is breech until this point or until labor. Rarely does a baby flip to breech this late in pregnancy but they can. Parents and providers may learn that baby is breech during a routine bio-physical ultrasound exam during this time or later in pregnancy.

An external cephalic version may yet be successful, depending on the fluid level and the flexibility of the uterus, the baby’s head position and location, a uterine septum, where the placenta is, etc.

It is still possible that the baby flips doing body balancing activities or even labor itself (contractions might be the very action that turns baby in about 1% of breeches). You may find turning easier if you keep doing the activities listed above.

40-41 weeks

Though many breeches are born about 37-39 weeks gestation, some will happily go to 41 or 42 weeks. For a head down baby, 41 weeks and 1 to 3 days is a common time for labor to begin on its own. SStarting labor at this gestation can certainly be normal for a healthy breechling, too.

If the pregnant person has a tendency to be somewhat overweight or lower energy, which can indicate low thyroid function, a longer pregnancy may be more likely. This tendency deserves looking after. Well-nourished and peppy women may also go a full pregnancy length, of course.

Going into labor and then having a planned cesarean is recommend by Dr. Michel Odent in his book, Cesarean. Going into labor spontaneously is safer for the breech vaginal birth, as well. Women who are trying to flip their baby often find it necessary to slow down the efforts and come to terms with a breech birth.

When facing a cesarean, it can be nurturing to you and your baby to plan a cesarean with skin-to-skin, delayed cord clamping, and breastfeeding on the operating room table or in the recovery room. Give yourself some time and compassion to feel your feelings and explore your options to adapt to the options you have available to you.

Postdates (after your due date) with a breech

With a breech, going all the way to 42 weeks may or may not be more of an issue. Some providers will have to end any plans for a vaginal birth by now. Midwifery statutes often limit midwifery care out of the hospital to 37-42 weeks (or 36-43, depending on where you live).

After 42 weeks, the baby’s skull bones are setting up more firmly and a vaginal birth is less favorable. I’ve been to a few breech births after 42 weeks gestation and everything went very well. But, I do sometimes wonder why labor isn’t starting and if metabolism is a reason, especially when there’s been regular bodywork for weeks.

For a person carrying a breech baby who does show signs of low thyroid function or otherwise a “sloshy” metabolism, I am inclined to transfer care to a kind hospital provider at 41.5 weeks. Intelligent and experienced monitoring may rule out issues that arise post dates that may complicate labor. With slow metabolism postdates issues with breech position may need extra attention before 42 weeks.

Continue body balancing and daily stretching but stop inversions for three days. Walk with a stride. See more at https://www.spinningbabies.com/pregnancy-birth/baby-position/breech/when-baby-flips-head-down/

If Baby Does Not Turn

Not every breech baby will turn on their own. Not every attempt at an External Cephalic Version works (It’s often 50-50). Adding body balancing has abundant anecdotal reporting to show success. But this balancing should be individualized if the pregnant person has followed general guidelines closely for 1-2 weeks without success.

Be compassionate to you and your baby. You are both doing the best you can with the resources you have.

Choose your path. Sometimes it may feel like you don’t have a choice. Consider why it feels that way. Perhaps your choice is safety over manner of birth? That’s totally valid. Just because a vaginal birth might be available to some doesn’t mean it is your first choice, too.

Sometimes babies choose, too. The labor goes too fast to do surgery for the birth. Or, the baby doesn’t come into the pelvis and surgical birth is necessary. (Remember reaching in and pulling out the baby is not reasonable if a cesarean is available in the region unless this is a second twin (subsequent triplet) or travel is impossible due to weather, war, or whatever reason. Life is real. Babies don’t follow a script. Be real with your own experience.

Inducing a breech

Inducing a breech is not recommended in out of hospital settings. Even in the hospital, the risk rises. In some areas where breech is common, Pitocin/Syntocin inductions are done with outcomes that are good enough to keep the options open. Induction by herbs is also considered out of scope for breech.

We need to respect the breech and not stress the baby, especially in settings where we don’t have the rescue setup to solve any potential problems. Try body balancing and see if labor begins on its own. That would be a non-invasive, non-manipulating approach.

The Breech Turned During Labor

It is a rare possibility that the baby flips to head down during labor. I once assisted a midwife who’s laboring mother’s water had released. Her labor was mild and not picking up, so after 24 hours we transferred and found that the baby had flipped. The doctor thought we’d misdiagnosed, but the mother’s abdomen was so thin we could feel the baby’s knuckles and elbow and found the baby in the opposite direction after entering the hospital!

Another mother had Dynamic Body Balancing in early labor with one of Dr. Carol Phillips students who was also a midwife. Her breech baby turned head down during transition phase of labor!

Laboring With a Breech Before The Cesarean

If the plan is to have a cesarean once labor begins, call the hospital and alert them of labor immediately. Go to the hospital right away. Breech births can go quite quickly and you want to be where people are ready to help you. If you plan to have a vaginal birth, don’t delay in getting to your birth location or getting your birth team to you.

While it can be totally normal to have a 24-hour or longer breech birth, many breech labors are quite short. Because the softer bottom is first, it may take you by surprise that you are progressing with such little pain (though some breech births are as painful as head down births). Just don’t base your decision to get to the hospital on your pain level!

A cesarean can be more complicated if the baby is wedged low in the pelvis. That is why there is a recommendation to have the cesarean in early labor. But cesareans are done everyday with head down babies low in the pelvis. Sometimes it’s how it is.

Starting labor in and of itself doesn’t make the surgery more dangerous. Rushing around and doing things in a hurry might. Alert your hospital before labor and again once you start labor. Be firm that you know what you are about and that they need to get the Operating Room ready while you are on your way.

Mostly, a leisurely transition into the hospital can be sustained with a sense of humor and practicality. There can be a sense of calm while you and the staff take the steps to welcome your baby. This is your birth. Be present with how your experience unfolds.

After the birth

While the concern about breech position is during the birthing, when the baby is breech for most of the third trimester, their skull bones become shaped by the inside of the upper womb (the fundus). This isn’t typically an issue but can be noticed.

Craniosacral therapy can gently (and without using force) reshape the baby’s head, ideally during the month or two after birth. Surgery on baby’s skull is seldom necessary after 3-6 sessions with a Craniosacral therapist. For most breech babies, this issue is not present. I list is here because I have heard some assumptions that can be dispelled.

A question about breech

Email from Wed, Feb 11, 2009:

…I’m 30 weeks and the baby is what I’d describe as oblique breech – his head is on my right side next to my belly button, his hips/butt are in my pelvis on the lower left side (my left) and his feet are in front of his face. I think he’s facing forward – towards my belly button. I’ve known this for weeks just because his big head is so hard I always bump that spot on accident. …. my first son was 9 lbs and born posterior, so I’m really hoping this baby is in the ideal position for delivery… so both of these things make me nervous that he won’t move. He has been in this position for a few weeks now. … Anyway, just wondering if I should worry and what, if anything, I can do to help him move now. My Midwife suggested a Chiropractor that can do some adjustments. I’d like to do the couch inversion too. Would it help for me to walk more? Also, should I sleep more on one side than the other? Thanks for your help! Great site!

Gail’s reply:

Hi…. now is a good time to take action, not so much that your baby is breech, but because your first baby was OP . You see, a pelvic misalignment and/or round ligament spasms (they often go together) can result in either a breech or a posterior fetal position . So, a breech will often flip to a posterior position and may stay that way unless you resolve the underlying issue. Maternal positioning is often not enough by itself to correct a posterior fetal position when there is a history of previous posterior or breech babies. While certainly most breech babies flip head down, it’s beneficial to help correct the symmetry of your uterine ligaments now, while the baby is still small enough to have plenty of room to flip head down once the reason for the previous posterior position is remedied. See some things a Chiropractor can do for breech and posterior by reading Professional Help .

breech presentation in 33 weeks pregnant

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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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your baby is larger or smaller than average – your healthcare team will discuss this with you

your baby is in a certain position – for example, their neck is very tilted back, which can make delivery of the head more difficult

you have a low-lying placenta (placenta praevia)

you have pre-eclampsia

Lying sideways (transverse baby)

If your baby is lying sideways across the womb, they are in the transverse position. Although many babies lie sideways early on in pregnancy, most turn themselves into the head-down position by the final trimester.

Giving birth to a transverse baby

Depending on how many weeks pregnant you are when your baby is in a transverse position, you may be admitted to hospital. This is because of the very small risk of the umbilical cord coming out of your womb before your baby is born (cord prolapse). If this happens, it's a medical emergency and the baby must be delivered very quickly.

Sometimes, it's possible to manually turn the baby to a head-down position, and you may be offered this.

But, if your baby is still in the transverse position when you approach your due date or by the time labour begins, you'll most likely be advised to have a caesarean section.

Video: My baby is breech. What help will I get?

In this video, a midwife describes what a breech position is and what can be done if your baby is breech.

Page last reviewed: 1 November 2023 Next review due: 1 November 2026

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

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

Fetal presentation and position

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

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

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

Medical illustrations by Jonathan Dimes

Head down, facing down (anterior position)

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

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

Head down, facing up (posterior position)

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

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

Frank breech

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

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

Complete breech

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

Incomplete breech

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

Single footling breech

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

Double footling breech

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

Transverse lie

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

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

Oblique lie

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

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

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What to know if your baby is breech

What's a sunny-side up baby?

What happens to your baby right after birth

A newborn baby wrapped in a receiving blanket in the hospital.

How your twins’ fetal positions affect labor and delivery

illustration of twin babies head down in utero

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

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

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

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

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

Where to go next

Breech baby at the end of pregnancy

Published: July 2017

Please note that this information will be reviewed every 3 years after publication.

This patient information page provides advice if your baby is breech towards the end of pregnancy and the options available to you.

It may also be helpful if you are a partner, relative or friend of someone who is in this situation.

The information here aims to help you better understand your health and your options for treatment and care. Your healthcare team is there to support you in making decisions that are right for you. They can help by discussing your situation with you and answering your questions.

This information is for you if your baby remains in the breech position after 36 weeks of pregnancy. Babies lying bottom first or feet first in the uterus (womb) instead of in the usual head-first position are called breech babies.

This information includes:

What breech is and why your baby may be breech
The different types of breech
The options if your baby is breech towards the end of your pregnancy
What turning a breech baby in the uterus involves (external cephalic version or ECV)
How safe ECV is for you and your baby
Options for birth if your baby remains breech
Other information and support available

Within this information, we may use the terms ‘woman’ and ‘women’. However, it is not only people who identify as women who may want to access this information. Your care should be personalised, inclusive and sensitive to your needs, whatever your gender identity.

A glossary of medical terms is available at A-Z of medical terms .

Breech is very common in early pregnancy, and by 36–37 weeks of pregnancy most babies will turn into the head-first position. If your baby remains breech, it does not usually mean that you or your baby have any problems.
Turning your baby into the head-first position so that you can have a vaginal delivery is a safe option.
The alternative to turning your baby into the head-first position is to have a planned caesarean section or a planned vaginal breech birth.

Babies lying bottom first or feet first in the uterus (womb) instead of in the usual head-first position are called breech babies. Breech is very common in early pregnancy, and by 36-37 weeks of pregnancy, most babies turn naturally into the head-first position.

Towards the end of pregnancy, only 3-4 in every 100 (3-4%) babies are in the breech position.

A breech baby may be lying in one of the following positions:

It may just be a matter of chance that your baby has not turned into the head-first position. However, there are certain factors that make it more difficult for your baby to turn during pregnancy and therefore more likely to stay in the breech position. These include:

if this is your first pregnancy
if your placenta is in a low-lying position (also known as placenta praevia); see the RCOG patient information Placenta praevia, placenta accreta and vasa praevia
if you have too much or too little fluid ( amniotic fluid ) around your baby
if you are having more than one baby.

Very rarely, breech may be a sign of a problem with the baby. If this is the case, such problems may be picked up during the scan you are offered at around 20 weeks of pregnancy.

If your baby is breech at 36 weeks of pregnancy, your healthcare professional will discuss the following options with you:

trying to turn your baby in the uterus into the head-first position by external cephalic version (ECV)
planned caesarean section
planned vaginal breech birth.

What does ECV involve?

ECV involves applying gentle but firm pressure on your abdomen to help your baby turn in the uterus to lie head-first.

Relaxing the muscle of your uterus with medication has been shown to improve the chances of turning your baby. This medication is given by injection before the ECV and is safe for both you and your baby. It may make you feel flushed and you may become aware of your heart beating faster than usual but this will only be for a short time.

Before the ECV you will have an ultrasound scan to confirm your baby is breech, and your pulse and blood pressure will be checked. After the ECV, the ultrasound scan will be repeated to see whether your baby has turned. Your baby’s heart rate will also be monitored before and after the procedure. You will be advised to contact the hospital if you have any bleeding, abdominal pain, contractions or reduced fetal movements after ECV.

ECV is usually performed after 36 or 37 weeks of pregnancy. However, it can be performed right up until the early stages of labour. You do not need to make any preparations for your ECV.

ECV can be uncomfortable and occasionally painful but your healthcare professional will stop if you are experiencing pain and the procedure will only last for a few minutes. If your healthcare professional is unsuccessful at their first attempt in turning your baby then, with your consent, they may try again on another day.

If your blood type is rhesus D negative, you will be advised to have an anti-D injection after the ECV and to have a blood test. See the NICE patient information Routine antenatal anti-D prophylaxis for women who are rhesus D negative , which is available at: www.nice.org.uk/guidance/ta156/informationforpublic .

Why turn my baby head-first?

If your ECV is successful and your baby is turned into the head-first position you are more likely to have a vaginal birth. Successful ECV lowers your chances of requiring a caesarean section and its associated risks.

Is ECV safe for me and my baby?

ECV is generally safe with a very low complication rate. Overall, there does not appear to be an increased risk to your baby from having ECV. After ECV has been performed, you will normally be able to go home on the same day.

When you do go into labour, your chances of needing an emergency caesarean section, forceps or vacuum (suction cup) birth is slightly higher than if your baby had always been in a head-down position.

Immediately after ECV, there is a 1 in 200 chance of you needing an emergency caesarean section because of bleeding from the placenta and/or changes in your baby’s heartbeat.

ECV should be carried out by a doctor or a midwife trained in ECV. It should be carried out in a hospital where you can have an emergency caesarean section if needed.

ECV can be carried out on most women, even if they have had one caesarean section before.

ECV should not be carried out if:

you need a caesarean section for other reasons, such as placenta praevia; see the RCOG patient information Placenta praevia, placenta accreta and vasa praevia
you have had recent vaginal bleeding
your baby’s heart rate tracing (also known as CTG) is abnormal
your waters have broken
you are pregnant with more than one baby; see the RCOG patient information Multiple pregnancy: having more than one baby .

Is ECV always successful?

ECV is successful for about 50% of women. It is more likely to work if you have had a vaginal birth before. Your healthcare team should give you information about the chances of your baby turning based on their assessment of your pregnancy.

If your baby does not turn then your healthcare professional will discuss your options for birth (see below). It is possible to have another attempt at ECV on a different day.

If ECV is successful, there is still a small chance that your baby will turn back to the breech position. However, this happens to less than 5 in 100 (5%) women who have had a successful ECV.

There is no scientific evidence that lying down or sitting in a particular position can help your baby to turn. There is some evidence that the use of moxibustion (burning a Chinese herb called mugwort) at 33–35 weeks of pregnancy may help your baby to turn into the head-first position, possibly by encouraging your baby’s movements. This should be performed under the direction of a registered healthcare practitioner.

Depending on your situation, your choices are:

There are benefits and risks associated with both caesarean section and vaginal breech birth, and these should be discussed with you so that you can choose what is best for you and your baby.

Caesarean section

If your baby remains breech towards the end of pregnancy, you should be given the option of a caesarean section. Research has shown that planned caesarean section is safer for your baby than a vaginal breech birth. Caesarean section carries slightly more risk for you than a vaginal birth.

Caesarean section can increase your chances of problems in future pregnancies. These may include placental problems, difficulty with repeat caesarean section surgery and a small increase in stillbirth in subsequent pregnancies. See the RCOG patient information Choosing to have a caesarean section .

If you choose to have a caesarean section but then go into labour before your planned operation, your healthcare professional will examine you to assess whether it is safe to go ahead. If the baby is close to being born, it may be safer for you to have a vaginal breech birth.

Vaginal breech birth

After discussion with your healthcare professional about you and your baby’s suitability for a breech delivery, you may choose to have a vaginal breech birth. If you choose this option, you will need to be cared for by a team trained in helping women to have breech babies vaginally. You should plan a hospital birth where you can have an emergency caesarean section if needed, as 4 in 10 (40%) women planning a vaginal breech birth do need a caesarean section. Induction of labour is not usually recommended.

While a successful vaginal birth carries the least risks for you, it carries a small increased risk of your baby dying around the time of delivery. A vaginal breech birth may also cause serious short-term complications for your baby. However, these complications do not seem to have any long-term effects on your baby. Your individual risks should be discussed with you by your healthcare team.

Before choosing a vaginal breech birth, it is advised that you and your baby are assessed by your healthcare professional. They may advise against a vaginal birth if:

your baby is a footling breech (one or both of the baby’s feet are below its bottom)
your baby is larger or smaller than average (your healthcare team will discuss this with you)
your baby is in a certain position, for example, if its neck is very tilted back (hyper extended)
you have a low-lying placenta (placenta praevia); see the RCOG patient information Placenta Praevia, placenta accreta and vasa praevia
you have pre-eclampsia or any other pregnancy problems; see the RCOG patient information Pre-eclampsia .

With a breech baby you have the same choices for pain relief as with a baby who is in the head-first position. If you choose to have an epidural, there is an increased chance of a caesarean section. However, whatever you choose, a calm atmosphere with continuous support should be provided.

If you have a vaginal breech birth, your baby’s heart rate will usually be monitored continuously as this has been shown to improve your baby’s chance of a good outcome.

In some circumstances, for example, if there are concerns about your baby’s heart rate or if your labour is not progressing, you may need an emergency caesarean section during labour. A paediatrician (a doctor who specialises in the care of babies, children and teenagers) will attend the birth to check your baby is doing well.

If you go into labour before 37 weeks of pregnancy, the balance of the benefits and risks of having a caesarean section or vaginal birth changes and will be discussed with you.

If you are having twins and the first baby is breech, your healthcare professional will usually recommend a planned caesarean section.

If, however, the first baby is head-first, the position of the second baby is less important. This is because, after the birth of the first baby, the second baby has lots more room to move. It may turn naturally into a head-first position or a doctor may be able to help the baby to turn. See the RCOG patient information Multiple pregnancy: having more than one baby .

If you would like further information on breech babies and breech birth, you should speak with your healthcare professional.

Further information

NHS information on breech babies
NCT information on breech babies

If you are asked to make a choice, you may have lots of questions that you want to ask. You may also want to talk over your options with your family or friends. It can help to write a list of the questions you want answered and take it to your appointment.

Ask 3 Questions

To begin with, try to make sure you get the answers to 3 key questions , if you are asked to make a choice about your healthcare:

What are my options?
What are the pros and cons of each option for me?
How do I get support to help me make a decision that is right for me?

*Ask 3 Questions is based on Shepherd et al. Three questions that patients can ask to improve the quality of information physicians give about treatment options: A cross-over trial. Patient Education and Counselling, 2011;84:379-85

https://aqua.nhs.uk/resources/shared-decision-making-case-studies/

Sources and acknowledgements

This information has been developed by the RCOG Patient Information Committee. It is based on the RCOG Green-top Clinical Guidelines No. 20a External Cephalic Version and Reducing Incidence of Term Breech Presentation and No. 20b Management of Breech Presentation . The guidelines contain a full list of the sources of evidence we have used.

This information was reviewed before publication by women attending clinics in Nottingham, Essex, Inverness, Manchester, London, Sussex, Bristol, Basildon and Oxford, by the RCOG Women’s Network and by the RCOG Women’s Voices Involvement Panel.

Please give us feedback by completing our feedback survey:

Members of the public – patient information feedback
Healthcare professionals – patient information feedback

External Cephalic Version and Reducing the Incidence of Term Breech Presentation Green-top Guideline

Management of Breech Presentation Green-top Guideline

Breech presentation: diagnosis and management

Key messages.

All women with a breech presentation should be offered an external cephalic version (ECV) from 37 weeks, if there are no contraindications.
Elective caesarean section (ELCS) for a singleton breech at term has been shown to reduce perinatal and neonatal mortality rates.
Planning for vaginal breech birth requires careful assessment of suitability criteria, contraindications and the ability of the service to provide experienced personnel.

In June 2023, we commenced a project to review and update the Maternity and Neonatal eHandbook guidelines, with a view to targeting completion in 2024. Please be aware that pending this review, some of the current guidelines may be out of date. In the meantime, we recommend that you also refer to more contemporaneous evidence.

Breech and external cephalic version

Breech presentation is when the fetus is lying longitudinally and its buttocks, foot or feet are presenting instead of its head.

Figure 1. Breech presentations

Breech presentation occurs in three to four per cent of term deliveries and is more common in nulliparous women.
External cephalic version (ECV) from 37 weeks has been shown to decrease the incidence of breech presentation at term and the subsequent elective caesarean section (ELCS) rate.
Vaginal breech birth increases the risk of low Apgar scores and more serious short-term complications, but evidence has not shown an increase in long-term morbidity.
Emergency caesarean section (EMCS) is needed in approximately 40 per cent of women planning a vaginal breech birth.
0.5/1000 with ELCS for breech >39 weeks gestation
2.0/1000 planned vaginal breech birth >39/40
1.0/1000 with planned cephalic birth.
A reduction in planned vaginal breech birth followed publication of the Term Breech Trial (TBT) in 2001.
Acquisition of skills necessary to manage breech presentation (for example, ECV) is important to optimise outcomes.

Clinical suspicion of breech presentation

Abdominal palpation: if the presenting part is irregular and not ballotable or if the fetal head is ballotable at the fundus
Pelvic examination: head not felt in the pelvis
Cord prolapse
Very thick meconium after rupture of membranes
Fetal heart heard higher in the abdomen

In cases of extended breech, the breech may not be ballotable and the fetal heart may be heard in the same location as expected for a cephalic presentation.

If breech presentation is suspected, an ultrasound examination will confirm diagnosis.

Cord prolapse is an obstetric emergency. Urgent delivery is indicated after confirming gestation and fetal viability.

Diagnosis: preterm ≤36+6 weeks

Breech presentation is a normal finding in preterm pregnancy.
If diagnosed at the 35-36 week antenatal visit, refer the woman for ultrasound scan to enable assessment prior to ECV.
Mode of birth in a breech preterm delivery depends on the clinical circumstances.

Diagnosis: ≥37+0 weeks

determine type of breech presentation
determine extension/flexion of fetal head
locate position of placenta and exclude placenta praevia
exclude fetal congenital abnormality
calculate amniotic fluid index
estimate fetal weight.

Practice points

Offer ECV if there are no contraindications.
If ECV is declined or unsuccessful, provide counselling on risks and benefits of a planned vaginal birth versus an ELCS.
Inform the woman that there are fewer maternal complications with a successful vaginal birth, however the risk to the woman increases significantly if there is a need for an EMCS.
Inform the woman that caesarean section increases the risk of complication in future pregnancies, including the risk of a repeat caesarean section and the risk of invasive placentation.
If the woman chooses an ELCS, document consent and organise booking for 39 weeks gestation.

Information and decision making

Women with a breech presentation should have the opportunity to make informed decisions about their care and treatment, in partnership with the clinicians providing care.

Planning for birth requires careful assessment for risk of poor outcomes relating to planned vaginal breech birth. If any risk factors are identified, inform the woman that an ELCS is recommended due to increased perinatal risk.

Good communication between clinicians and women is essential. Treatment, care and information provided should:

take into account women's individual needs and preferences
be supported by evidence-based, written information tailored to the needs of the individual woman
be culturally appropriate
be accessible to women, their partners, support people and families
take into account any specific needs, such as physical or cognitive disabilities or limitations to their ability to understand spoken or written English.

Documentation

The following should be documented in the woman's hospital medical record and (where applicable) in her hand-held medical record:

discussion of risks and benefits of vaginal breech birth and ELCS
discussion of the woman's questions about planned vaginal breech birth and ELCS
discussion of ECV, if applicable
consultation, referral and escalation

External cephalic version (ECV)

ECV can be offered from 37 weeks gestation
The woman must provide written consent prior to the procedure
The success rate of ECV is 40-60 per cent
Approximately one in 200 ECV attempts will lead to EMCS
ECV should only be performed by a suitably trained, experienced clinician
continuous electronic fetal monitoring (EFM)
capability to perform an EMCS.

Contraindications

Table 1. Contraindications to ECV

Precautions

Hypertension
Oligohydramnios
Nuchal cord

Escalate care to a consultant obstetrician if considering ECV in these circumstances.

Perform a CTG prior to the procedure - continue until RANZCOG criteria for a normal antenatal CTG are met.
250 microg s/c, 30 minutes prior to the procedure.
Administer Anti-D immunoglobulin if the woman is rhesus negative.
Do not make more than four attempts at ECV, for a suggested maximum time of ten minutes in total.
Undertake CTG monitoring post-procedure until RANZCOG criteria for a normal antenatal CTG are met.

Emergency management

Urgent delivery is indicated in the event of the following complications:

abnormal CTG
vaginal bleeding
unexplained pain.

Initiate emergency response as per local guidelines.

Alternatives to ECV

There is a lack of evidence to support the use of moxibustion, acupuncture or postural techniques to achieve a vertex presentation after 35 weeks gestation.

Criteria for a planned vaginal breech birth

Documented evidence of counselling regarding mode of birth
Documentation of informed consent, including written consent from the woman
Estimated fetal weight of 2500-4000g
Flexed fetal head
Emergency theatre facilities available on site
Availability of suitably skilled healthcare professional
Frank or complete breech presentation
No previous caesarean section.
Cord presentation
Fetal growth restriction or macrosomia
Any presentation other than a frank or complete breech
Extension of the fetal head
Fetal anomaly incompatible with vaginal delivery
Clinically inadequate maternal pelvis
Previous caesarean section
Inability of the service to provide experienced personnel.

If an ELCS is booked

Confirm presentation by ultrasound scan when a woman presents for ELCS.
If fetal presentation is cephalic on admission for ELCS, plan ongoing management with the woman.

Intrapartum management

Fetal monitoring.

Advise the woman that continuous EFM may lead to improved neonatal outcomes.
Where continuous EFM is declined, perform intermittent EFM or intermittent auscultation, with conversion to EFM if an abnormality is detected.
A fetal scalp electrode can be applied to the breech.

Position of the woman

The optimal maternal position for birth is upright.
Lithotomy may be appropriate, depending on the accoucheur's training and experience.

Pain relief

Epidural analgesia may increase the risk of intervention with a vaginal breech birth.
Epidural analgesia may impact on the woman's ability to push spontaneously in the second stage of labour.

Induction of labour (IOL)

See the IOL eHandbook page for more detail.

IOL may be offered if clinical circumstances are favourable and the woman wishes to have a vaginal birth.
Augmentation (in the absence of an epidural) should be avoided as adequate progress in the absence of augmentation may be the best indicator of feto-pelvic proportions.

The capacity to offer IOL will depend on clinician experience and availability and service capability.

First stage

Manage with the same principles as a cephalic presentation.
Labour should be expected to progress as for a cephalic presentation.
If progress in the first stage is slow, consider a caesarean section.
If an epidural is in situ and contractions are less than 4:10, consult with a senior obstetrician.
Avoid routine amniotomy to avoid the risk of cord prolapse or cord compression.

Second stage

Allow passive descent of the breech to the perineum prior to active pushing.
If breech is not visible within one hour of passive descent, a caesarean section is normally recommended.
Active second stage should be ½ hour for a multigravida and one hour for a primipara.
All midwives and obstetricians should be familiar with the techniques and manoeuvres required to assist a vaginal breech birth.
Ensure a consultant obstetrician is present for birth.
Ensure a senior paediatric clinician is present for birth.

VIDEO: Maternity Training International - Vaginal Breech Birth

Encouragement of maternal pushing (if at all) should not begin until the presenting part is visible.
A hands-off approach is recommended.
Significant cord compression is common once buttocks have passed the perineum.
Timely intervention is recommended if there is slow progress once the umbilicus has delivered.
Allow spontaneous birth of the trunk and limbs by maternal effort as breech extraction can cause extension of the arms and head.
Grasp the fetus around the bony pelvic girdle, not soft tissue, to avoid trauma.
Assist birth if there is a delay of more than five minutes from delivery of the buttocks to the head, or of more than three minutes from the umbilicus to the head.
Signs that delivery should be expedited also include lack of tone or colour or sign of poor fetal condition.
Ensure fetal back remains in the anterior position.
Routine episiotomy not recommended.
Lovset's manoeuvre for extended arms.
Reverse Lovset's manoeuvre may be used to reduce nuchal arms.
Supra-pubic pressure may aide flexion of the fetal head.
Maricueau-Smellie-Veit manoeuvre or forceps may be used to deliver the after coming head.

Undiagnosed breech in labour

This occurs in approximately 25 per cent of breech presentations.
Management depends on the stage of labour when presenting.
Assessment is required around increased complications, informed consent and suitability of skilled expertise.
Do not routinely offer caesarean section to women in active second stage.
If there is no senior obstetrician skilled in breech delivery, an EMCS is the preferred option.
If time permits, a detailed ultrasound scan to estimate position of fetal neck and legs and estimated fetal weight should be made and the woman counselled.

Entrapment of the fetal head

This is an extreme emergency

This complication is often due to poor selection for vaginal breech birth.

A vaginal examination (VE) should be performed to ensure that the cervix is fully dilated.
If a lip of cervix is still evident try to push the cervix over the fetal head.
If the fetal head has entered the pelvis, perform the Mauriceau-Smellie-Veit manoeuvre combined with suprapubic pressure from a second attendant in a direction that maintains flexion and descent of the fetal head.
Rotate fetal body to a lateral position and apply suprapubic pressure to flex the fetal head; if unsuccessful consider alternative manoeuvres.
Reassess cervical dilatation; if not fully dilated consider Duhrssen incision at 2, 10 and 6 o'clock.
A caesarean section may be performed if the baby is still alive.

Neonatal management

Paediatric review.
Routine observations as per your local guidelines, recorded on a track and trigger chart.
Observe for signs of jaundice.
Observe for signs of tissue or nerve damage.
Hip ultrasound scan to be performed at 6-12 weeks post birth to monitor for developmental dysplasia of the hip (DDH). See Neonatal eHandbook - Developmental dysplasia of the hip .

More information

Audit and performance improvement.

All maternity services should have processes in place for:

auditing clinical practice and outcomes
providing feedback to clinicians on audit results
addressing risks, if identified
implementing change, if indicated.

Potential auditable standards are:

number of women with a breech presentation offered ECV
success rate of ECV
ECV complications
rate of planned vaginal breech birth
breech birth outcomes for vaginal and caesarean birth.

For more information or assistance with auditing, please contact us via [email protected]

Bue and Lauszus 2016, Moxibustion did not have an effect in a randomised clinical trial for version of breech position. Danish Medical Journal 63(2), A599
Coulon et.al. 2014, Version of breech fetuses by moxibustion with acupuncture. Obstetrics and Gynecology 124(1), 32-39. DOI: 10.1097/AOG.0000000000000303
Coyle ME, Smith CA, Peat B 2012, Cephalic version by moxibustion for breech presentation. Cochrane Database of Systematic Reviews 2012, Issue 5. Art. No.: CD003928. DOI: 10.1002/14651858.CD003928.pub3
Evans J 2012, Essentially MIDIRS Understanding Physiological Breech Birth Volume 3. Number 2. February 2012
Hoffmann J, Thomassen K, Stumpp P, Grothoff M, Engel C, Kahn T, et al. 2016, New MRI Criteria for Successful Vaginal Breech Delivery in Primiparae. PLoS ONE 11(8): e0161028. doi:10.1371/journal.pone.0161028
Hofmeyr GJ, Kulier R 2012, Cephalic version by postural management for breech presentation. Cochrane Database of Systematic Reviews 2012, Issue 10. Art. No.: CD000051. DOI: 10.1002/14651858.CD000051.pub2
New South Wales Department of Health 2013, Maternity: Management of Breech Presentation HNELHD CG 13_01, NSW Government; 2013
Royal College of Obstetricians and Gynaecologists 2017, External Cephalic Version and Reducing the Incidence of Term Breech Presentation. Green-top Guideline No. 20a . London: RCOG; 2017
The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) 2016, Management of breech presentation at term , July 2016 C-Obs-11:
The Royal Women's Hospital 2015, Management of Breech - Clinical Guideline
Women's and Newborn Health Service, King Edward Memorial Hospital 2015, Complications of Pregnancy Breech Presentation

Abbreviations

Get in touch, version history.

First published: November 2018 Due for review: November 2021

Uncontrolled when downloaded

Breech presentation

Highlights & basics, diagnostic approach, risk factors, history & exam, differential diagnosis.

Tx Approach

Emerging Tx

Complications.

PATIENT RESOURCES

Patient Instructions

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.

Quick Reference

Key Factors

buttocks or feet as the presenting part

Fetal head under costal margin, fetal heartbeat above the maternal umbilicus.

Other Factors

subcostal tenderness

Pelvic or bladder pain.

Diagnostics Tests

1st Tests to Order

transabdominal/transvaginal ultrasound

Treatment options.

presumptive

<37 weeks' gestation

specialist evaluation

corticosteroid

magnesium sulfate

≥37 weeks' gestation not in labor

unsuccessful ECV with persistent breech

Classifications

Types of breech presentation

Baby's buttocks lead the way into the birth canal

Hips are flexed, knees are extended, and the feet are in close proximity to the head

65% to 70% of breech babies are in this position.

Baby presents with buttocks first

Both the hips and the knees are flexed; the baby may be sitting cross-legged.

One or both of the baby's feet lie below the breech so that the foot or knee is lowermost in the birth canal

This is rare at term but relatively common with premature fetuses.

Common Vignette

Epidemiology

33% of births less than 28 weeks' gestation

14% of births at 29 to 32 weeks' gestation

9% of births at 33 to 36 weeks' gestation

6% of births at 37 to 40 weeks' gestation.

Pathophysiology

Natasha Nassar, PhD
Christine L. Roberts, MBBS, FAFPHM, DrPH
Jonathan Morris, MBChB, FRANZCOG, PhD
John W. Bachman, MD
Rhona Hughes, MBChB
Brian Peat, MD
Lelia Duley, MBChB
Justus Hofmeyr, MD

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 ]

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 ]

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

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

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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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

Breech presentation in pregnancy

Published 13th September 2022 | Dr Ujwala Parashar

What is a breech presentation? Ideally for childbirth, a baby is positioned so that the head will deliver first during a vaginal birth. A breech presentation is when your baby’s bottom, feet or both are in position to come out first during birth. Most babies will turn to a headfirst position by 36 weeks, however if the baby hasn’t turned by 37 weeks, it will be a breech baby.

How common are breech babies?

Breech babies are not common and account for around 3-4% of childbirths each year.

What are the different types of breech presentation.

There are a number of types of breech presentation. These are:

· Frank breech – when baby’s buttocks or bottom is aimed at the vaginal canal and its legs are sticking straight in from of their body with the feet near to the head.

· Complete breech – when baby’s buttocks or bottom is pointing downward, and the hips and knees are flexed, or folded under them.

· Footling breech- when one or both of baby’s feet are pointing downward.

· Transverse lie – when the baby is positioned horizontally across the uterus. When in this position, the baby’s shoulder will enter the vagina first.

What causes a breech presentation?

It’s not always known what causes a breech presentation, but some factors that are believed to contribute are:

· Multiple birth pregnancy (twins or more). This makes it more difficult for each baby to get into the right position.

· There is either too much or not enough amniotic fluid.

· The mother’s uterus is not normal in a shape (an upside-down pear), or has abnormal growths such as fibroids. If it’s shaped differently or is obstructed by growths, there may not be enough room for a full-grown baby to change position.

· Placenta previa. This a condition where the placenta covers all or part of the cervix.

· You go into labour preterm (less than 37 weeks gestation) and baby may not yet have turned into a head-first position.

· The baby has a birth defect which causes them not to turn head-first.

Are breech babies’ high risk?

In general breech babies are not high-risk during pregnancy but do become dangerous at childbirth. This is because there is an increased risk for the baby to get stuck in the birth canal and for their oxygen supply to get cut off.

How is a breech baby diagnosed?

At your 36-week consultation, Dr Parashar will examine you by placing her hands at certain places on your abdomen and feeling where the baby’s head, back and buttocks are. This makes it possible for her to find out what part of the baby’s body is positioned to come out first during a normal vaginal birth. Sometimes it might be necessary for an ultrasound to be performed to confirm the baby’s position.

How is a breech baby delivered?

Due to the dangers involved in a normal vaginal delivery when a baby (or babies) is in a breech position, there will likely need to be changes made to your birth plan, as Dr Parashar will recommend a caesarean section delivery.

A caesarean section is a relatively safe surgical procedure where a surgical cut is made in the abdominal wall and uterus through which the baby is born.

If it is discovered that your baby is breech at your 36-week consultation, Dr Parashar will discuss the implications and the best delivery options available to keep both you and your baby safe.

Planning a pregnancy?

If you are pregnant or planning a pregnancy, Dr Parashar is a specialist trained obstetrician. She and her team will provide you with the individualised support and assistance you need throughout your pregnancy and when your baby is delivered.

Dr Ujwala Parashar, Obstetrician & Gynaecologist

Dr Ujwala Parashar is a highly trained female obstetrician and gynaecologist with over 15 years of professional experience and training, practicing in Sydney's North Shore and Barangaroo. If you would like more information on conception, or if you are seeking obstetric options and advice, please contact us or call 1300 811 827 to arrange a consultation with her.

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Open Access

Peer-reviewed

Research Article

Maternal outcomes of planned mode of delivery for term breech in nulliparous women

Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Visualization, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliations Department of Gynecology and Obstetrics, University of Copenhagen, Holbaek Hospital, Holbaek, Denmark, Department of Gynecology and Obstetrics, Herlev Hospital, Herlev, Denmark

Roles Data curation, Software

Affiliation Department of Gynecology and Obstetrics, University of Copenhagen, Amager Hvidovre Hospital, Hvidovre, Denmark

Roles Conceptualization, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Validation, Writing – original draft, Writing – review & editing

Affiliations Department of Gynecology and Obstetrics, University of Copenhagen, Amager Hvidovre Hospital, Hvidovre, Denmark, Department of Clinical Medicine, University of Copenhagen, Copenhagen N, Denmark

Malene Mie Caning,
Steen Christian Rasmussen,

Published: April 3, 2024
https://doi.org/10.1371/journal.pone.0297971
Reader Comments

To estimate short- and long-term maternal complications in relation to planned mode of term breech delivery in first pregnancy.

Nulliparous women with singleton breech delivery at term between 1991 and 2018 (n = 30,778).

We used data from the Danish national health registries to identify nulliparous women with singleton breech presentation at term and their subsequent pregnancies. We performed logistic regression to compare the risks of maternal complications by planned mode of delivery. All data were proceeded and statistical analyses were performed in SAS 9.4 (SAS Institute Inc. Cary, NC, USA).

Main outcome measures

Postpartum hemorrhage, operative complications, puerperal infections in first pregnancy and uterine rupture, placenta previa, post-partum hemorrhage, hysterectomy and stillbirth in the subsequent two pregnancies.

We identified 19,187 with planned cesarean and 9,681 with planned vaginal breech delivery of which 2,970 (30.7%) delivered vaginally. Planned cesarean significantly reduced the risk of postoperative infections (2.4% vs 3.9% adjusted odds ratio (aOR): 0.54 95% confidence interval (CI) 0.44–0.66) and surgical organ lesions (0.06% vs 0.1%; (aOR): 0.29 95% CI 0.11–0.76) compared to planned vaginal breech delivery. Planned cesarean delivery in the first pregnancy was associated with a significantly higher risk of uterine rupture in the subsequent pregnancies but not with risk of postpartum hemorrhage, placenta previa, hysterectomy, or stillbirth.

Compared to planned vaginal breech delivery at term, nulliparous women with planned cesarean breech delivery have a significantly reduced risk of postoperative complications but a higher risk of uterine rupture in their subsequent pregnancies.

Citation: Caning MM, Rasmussen SC, Krebs L (2024) Maternal outcomes of planned mode of delivery for term breech in nulliparous women. PLoS ONE 19(4): e0297971. https://doi.org/10.1371/journal.pone.0297971

Editor: Abera Mersha, Arba Minch University, ETHIOPIA

Received: June 28, 2023; Accepted: January 15, 2024; Published: April 3, 2024

Copyright: © 2024 Caning et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: Data used to calculate means and odds ratios are available in S1 Dataset . All data were obtained from the Danish Medical Birth Registry, and be accessed by applying for access to relevant data from the Danish Health Data Authority. All researchers can apply for access. The authors of this study did not have any special access privileges.

Funding: This study was supported by grants from the Health Research Foundation of Region Zealand and Carsten Lenstrup’s research foundation for Danish obstetrics. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Breech presentation at term occurs in 3–4% of all singleton pregnancies [ 1 , 2 ].

Up until the 1960´s women were expected to deliver vaginally regardless presentation. During the 1960´s and 1970´the rate of cesarean for breech increased and during the 1980´s and 1990´s the rate was about 80% in Denmark [ 3 ]. After the publication of the results of the Term Breech Trial in 2000 the rate of cesarean at term breech increased and has since been around 90% with small variations between birthplaces in Denmark [ 4 , 5 ]. Thus, at present, the majority of term breech deliveries are by planned cesarean delivery (CD); in Denmark, approximately 10% are vaginal deliveries (VD) [ 3 , 6 ].

Planned vaginal breech delivery is associated with a small increased risk of perinatal and neonatal morbidity and mortality. Several descriptive studies and a meta-analysis published after 2015 report a higher relative risk of low Apgar scores, neonatal birth trauma, admission to Neonatal Intensive Care Unit (NICU), and neonatal mortality [ 7 – 11 ] in association with planned vaginal delivery compared to planned cesarean delivery.

In some countries, obstetricians still point out that the neonatal risks can be reduced by following strict criteria regarding which women are suitable for an attempt at vaginal breech delivery as well as a strict awareness of normal progression during vaginal delivery [ 12 – 14 ].

The neonatal risks should be weighed against the risks of maternal complications associated with a cesarean delivery as well as the risk of complications in the woman’s future pregnancies. It is well documented that cesarean delivery increases the risk of maternal short-term complications including postpartum bleeding and wound infections [ 15 , 16 ]. However, these risks are increased when the cesarean is performed during labour, compared to a planned cesarean delivery [ 17 ]. Cesarean delivery entails a risk of uterine rupture, abnormal invasive placenta, placenta previa, and hysterectomy in subsequent pregnancies [ 15 , 18 , 19 ]. Some studies furthermore, indicate an increased risk of antepartum fetal death [ 20 ]. Also, a higher rate of subfertility, ectopic pregnancies, and miscarriages has been linked to a history of a previous cesarean [ 21 – 23 ].

However, the high risk of an emergency cesarean during an attempted vaginal breech delivery is important to bear in mind and include when discussing mode of delivery with the pregnant woman and her partner.

The aim of this study was to investigate short- and long-term maternal complications in present and future pregnancies in relation to planned mode of delivery of breech babies at term in the first pregnancy.

Materials and methods

We conducted a retrospective register-based cohort study using data from the Danish Medical Birth Registry (DMBR) and the Danish National Patient Registry (DNPR).

The DMBR is a population-based registry. It was established in 1968, computerized since 1973. The registry links together the personal ID number of mother, father, and child. The DNPR was established in 1977 and is the key Danish health register. It covers all inpatient, and since 1995 also all outpatient activity, in Danish public and private hospitals or clinics. Information in the DNPR is based on the codes according to the International Statistical Classification of Diseases (ICD-coding) and Related Health Problems Information regarding any procedure is based on the codes according to the Nordic Medico-statistical Committee classification of surgical procedures [ 24 ]. Since 2012, blood loss during delivery has been reported to the DMBR in millilitres (mL). All information regarding maternal characteristics and pregnancy and delivery outcomes was retrieved from the DMBR and the DNPR [ 6 ].

We retrieved data from all women with singleton pregnancies who delivered their first child in breech presentation at term in Denmark from 1991 to 2018, both years included. Additional inclusion criterion was pregnancies with no congenital malformations. All information regarding maternal characteristics and pregnancy and delivery outcomes was retrieved from the DMBR and the DNPR.

Women with stillbirth at first delivery or unknown planned mode of first delivery were excluded ( Fig 1 ). Women who fulfilled the inclusion criteria were identified in the registry, and information on their first and subsequent pregnancies and deliveries was obtained.

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https://doi.org/10.1371/journal.pone.0297971.g001

The women were categorized according to the planned mode of their first delivery. The definitions of planned mode of delivery were based on the Danish coding system. The four codes for cesarean delivery are (1) emergency CD prelabour, (2) planned (= elective) CD performed prelabour, (3) planned elective CD performed in labour, and (4) emergency CD performed in labour. Planned is in the coding system defined as scheduled >8 hours before the procedure, regardless of whether this was before or during labour. Planned vaginal delivery included all vaginal deliveries and emergency cesarean deliveries in labour (code 4). Planned cesarean delivery included both prelabour and in labour elective cesarean delivery (codes 2 and 3). Due to this design, we were not able to identify women with planned CD who delivered vaginally as they would hence be characterized as planned VD.

Outcome measures related to first delivery were postpartum hemorrhage (a blood loss of 1000 mL or more); infections; surgical organ lesions; re-laparotomy; and postoperative complications defined as a composite outcome including infection, surgical organ lesions (bladder or bowl injuries), or re-laparotomy. In relation to the subsequent pregnancies, the outcome measures included cesarean delivery, placenta previa, uterine rupture, postpartum hemorrhage, hysterectomy, and stillbirth. As data on postpartum hemorrhage before year 2012 are of poor quality, we only included this variable in cases where information on blood loss in mL was available (from 2012). Information on maternal body mass index (BMI) was introduced in the DMBR in 2004.

Supporting information S1 Table includes a detailed list describing codes and specifications for maternal and neonatal morbidity outcomes.

Statistical analyses

Clinical characteristics and demographic data were reported based on their distribution using counts (percentages) for categorical variables and means (range or standard deviation) for numerical variables.

Outcome measures were compared between cases and controls. Odds ratios (OR) with 95% confidence intervals (95% CI) were calculated by use of marginal two-by-two contingency tables.

Multiple logistic regression was used to adjust for the effect of possible confounding by maternal characteristics, including maternal age, BMI, and smoking. In the regression models any cases with missing values on one or more of the variables were eliminated. The results were expressed as adjusted odds ratios (aOR) with corresponding CIs. All analyses were performed in SAS 9.4 (SAS Institute Inc. Cary, NC, USA).

Ethical approval

The study was approved by the Danish Data Protection agency (PFI, Region Zealand); REG-209-2016. As a register-based study, no approval from the Danish Research Ethics Committee was obtained, as this was not required according to Danish legislation. For same reason informed consent was not required. All data were fully anonymized upon data analysis.

We identified a total of 30,778 nulliparous women with a singleton fetus in breech presentation at term during a period from 1991 to 2018. After exclusion of stillbirths (n = 189) and women with unknown planned mode of first delivery (n = 1,721), 28,868 women were included in the analysis and characterized by planned mode of first delivery ( Fig 1 ). A total of 9,681 (33.5%) women had planned vaginal delivery, 2,970 (30.7%) of which delivered vaginally and 6,711 (69.3%) delivered by intrapartum cesarean. Among 19,187 women with planned cesarean delivery, 17,078 (89.0%) delivered by elective cesarean and 2109 (11.0%) by an intrapartum cesarean prior to the planned cesarean delivery. Of the women with planned cesarean delivery in first pregnancy, 12,410 had a second and 2,907 a third pregnancy. In women with planned cesarean in first pregnancy, rates of cesarean in second and third delivery were 35.8% and 40.0%. In women with planned vaginal breech delivery, 6,709 had a second and 1,835 a third delivery. The corresponding cesarean rates were 20.5% and 26.1% ( Fig 1 ).

Maternal characteristics in the first pregnancy by planned mode of delivery are given in Table 1 . Compared with women with planned vaginal delivery, women with planned cesarean breech delivery more often had a Body Mass Index (BMI) of 35 or more, were non-smokers, or less than 160 cm in height. The gestational ages (GA) of children born to women with planned cesarean delivery were lower than in children born to women with planned vaginal delivery, and more children were born after 41 gestational weeks in women with planned vaginal delivery.

https://doi.org/10.1371/journal.pone.0297971.t001

Table 2 presents the risk of short-term complications in nulliparous with breech delivery at term by intended mode of delivery.

https://doi.org/10.1371/journal.pone.0297971.t002

Planned vaginal delivery was associated with a significantly higher risk of infection and surgical organ lesions compared to planned cesarean delivery. There was also a reduced risk of re-laparotomy, although this was not statistically significant. Using a composite outcome for postoperative complications (infection, surgical organ lesion and re-laparotomy), the risk of a postoperative complication was significantly reduced in women with planned cesarean delivery (373 (3.9%) versus 456 (2.4%); aOR of 0.54 [CI 0.44–0.66]). There was no statistical difference between planned mode of delivery regarding postpartum hemorrhage (>1000 ml).

Table 3 presents the risk of maternal complications in subsequent pregnancies. The women with planned cesarean breech delivery in the first pregnancy had a higher risk of repeated cesarean delivery in their subsequent pregnancies, 4,443 (35.8%) versus 1,375 (20.5%); aOR 5.3 (CI 4.1–7.1) in second pregnancy and 1,163 (40.0%) versus 479 (26.1%); aOR of 4.5 (CI 3.5–5.8) in third pregnancy. Women with planned cesarean breech delivery in first pregnancy had a significantly higher risk of uterine rupture compared to women with planned vaginal breech delivery, 195 (1.6%) versus 57 (0.9); aOR of 1.85 (CI: 1.37–2.50) in second pregnancy and 20 (0.69%) versus 4 (0.22%); aOR 3.15 (1.08–9.24) in third pregnancy.

https://doi.org/10.1371/journal.pone.0297971.t003

There was no significant association between planned mode of breech delivery and postpartum hemorrhage, placenta previa, and hysterectomy in second or third pregnancies.

Planned vaginal breech delivery was significantly related to stillbirth in third but not in second pregnancy.

Supporting information S2 Table presents a sub analysis for risk of complications based on actual mode of delivery.

Main findings

In this retrospective register-based cohort study among 28,868 nulliparous Danish women with breech delivery at term, we found that 66.5% intended to deliver by cesarean. Among the women who planned vaginal breech delivery, 69.3% delivered by emergency cesarean. Due to the high risk of secondary cesarean, women with planned vaginal breech delivery were at increased risk of postoperative complications in terms of infections, surgical organ lesions, and re-laparotomy, compared to women with planned cesarean delivery. Having a planned cesarean breech delivery in first pregnancy was associated with a significantly higher risk of uterine rupture in subsequent pregnancies but not to placenta previa, postpartum hemorrhage or hysterectomy. Women with planned vaginal delivery in first pregnancy had a significantly higher risk of stillbirth in their third pregnancy but not in their second. Planned cesarean breech delivery in first pregnancy was associated with a significantly higher risk of repeated cesarean in the two subsequent pregnancies.

Strength and limitations

This study has the major strength of including a large number of women with information on their complete obstetric history of both intended and actual mode of delivery as well as information on second and third pregnancies and deliveries.

The incidence of emergency cesarean among nulliparous was as high as 69% in the present study, which may be a result of misclassification of categories of cesarean delivery in the register, which of course should be considered as a limitation of the study. In the regression analyses we were able to adjust for some maternal characteristics including maternal age, BMI, and smoking. However, the results may have been affected by other unknown or unmeasured confounders.

Another weakness of the study is that the material is too small to truly evaluate risk of severe and rarely occurring long-term maternal complications such as abnormal invasive placenta and hysterectomies in subsequent pregnancies.

Interpretation

The present study confirms the findings of a previous study among Danish women showing a very low overall risk of maternal short- and long-term complications regardless of planned mode of breech delivery in first pregnancy [ 19 ]. Our data underline the importance of informing women with breech presentation at term about outcomes in relation not only to planned but also to actual mode of delivery and thus take the high risk of an intrapartum cesarean during an attempt of vaginal breech delivery into account. Furthermore, personal counselling should include an individualized assessment of the woman’s chance of having a successful attempt of vaginal breech delivery and include information on short- as well as long-term maternal complications.

What is the best mode of delivery for breech presentation at term has been debated since the 1950s [ 3 ]. The vast majority of the analyses are based on descriptive studies. Only a few prospective studies have been conducted. In the Term Breech Trial [ 4 ] in 2000, there were no significant differences in short-term maternal mortality or morbidity between groups with planned cesarean delivery and planned vaginal delivery. However, a relatively high percentage (56.7%) of the women randomized to the planned vaginal delivery group actually delivered vaginally and only 36.1% delivered by emergency cesarean.

A French/Belgian observational prospective study (PREMODA) [ 13 ] reported a high rate of vaginal deliveries (71%) among women with planned vaginal breech delivery. Unfortunately, this study did not evaluate any maternal outcomes. A secondary analysis of the data from the PREMODA study by Korb et al. [ 25 ] focused on short-term severe acute maternal morbidity (maternal death, maternal transfer to intensive care unit, severe postpartum hemorrhage involving blood transfusion, reoperation or pulmonary embolism), and found no differences between the groups with planned cesarean and planned vaginal breech delivery.

An Australian study [ 8 ] comparing 10,133 women with term breech presentation used strict criteria for selecting women eligible for vaginal delivery. Of 5,197 women found eligible for vaginal breech delivery, only 352 (6.8%) had planned vaginal delivery. Compared to the group with planned cesarean, the risk of postpartum hemorrhage was higher among the women with planned vaginal delivery (RR 1.69 CI: 1.07–2.68). No difference was found in severe maternal morbidity including cardiac arrest, cerebrovascular hemorrhage, hysterectomy, mechanical ventilation, or post-partum re-admission.

Mattila et al. [ 26 ] also compared term breech deliveries according to planned mode of delivery. Of 1,418 term breech deliveries, 406 (28.6%) planned vaginal birth following strict selection criteria. Of these, 338 (83.3%) delivered vaginally. In the group with planned cesarean delivery, 6.5% had postpartum hemorrhage >1000 mL compared to 3.8% in the group with planned vaginal delivery. This difference was not statistically significant. Women in the planned cesarean delivery group more often had puerperal infections including wound infections compared to the women with planned vaginal delivery.

In a Finnish observational study [ 27 ] from 2004, 2910 breech deliveries were compared to 133,680 deliveries in cephalic presentation. In the breech group, 56.4% delivered by elective cesarean versus 3.7% in the cephalic group, and 11.4% delivered by emergency cesarean versus 2.8% in the cephalic group. Maternal death occurred only in the cephalic presentation group (3 deaths versus none). Women in the cephalic vaginal delivery group had a higher risk of perineal tears compared to those in the vaginal breech delivery group (OR 0.38 [0.24–0.62]). There were no other differences in maternal morbidity between the groups.

In the secondary analysis of the PREMODA data, Korb et al. [ 25 ] also compared vaginal breech deliveries with a control group with cephalic presentation. Not surprisingly, the rate of cesarean was higher in the breech presentation group. The risk of severe acute maternal morbidity was significantly higher in the breech compared to the cephalic presentation group (RR 1.80 [1.02–3.17].

A recently published systematic review and meta-analysis [ 11 ] of 32 articles including only studies that focused on the intended mode of breech delivery reports a reduced risk of perinatal morbidity for intended cesarean delivery compared to intended vaginal delivery. The data were sparse on maternal short-term as well as long-term outcomes, hence no conclusions could be drawn.

The present study illustrates the importance of considering the high risk of secondary cesarean during a planned vaginal breech delivery.

Compared to previous studies, we find a high rate of planned vaginal deliveries, thus also a high rate of secondary cesarean. This could be due to an in Denmark cautious approach during attempted vaginal delivery of breech presentation where subacute cesarean is performed if the condition for a successful vaginal delivery is considered poor.

In Denmark, it is recommended that a trial of labour after cesarean be preferred if no other contraindications are present [ 28 ]. In this study, 64.2% of the women who gave birth by cesarean in first delivery had a vaginal delivery in their second pregnancy, while 35.8% had a repeated cesarean delivery in their second pregnancy and 40.0% in their third pregnancy. The risk of uterine rupture was twice as high in the second delivery in women with a prior cesarean.

Women with planned vaginal delivery in first pregnancy had a significantly higher risk of stillbirth in their third pregnancy but not in their second. We have no explanation for this finding but based on our results we find it very unlikely that caesarean for breech in first pregnancy is associated to stillbirth in subsequent pregnancies. No other statistical differences in risk of complications in the third pregnancy could be detected.

Women with breech presentation considering planned mode of delivery should be counselled regarding the risk of both neonatal and maternal complications. Overall, planned vaginal as well as planned cesarean breech delivery are safe procedures for the mother and there are only minor differences in maternal the outcomes in the subsequent pregnancies. Future research should evaluate the ability of machine learning models to predict successful vaginal breech delivery and thereby minimize the risk of secondary cesarean in women who wish a vaginal breech delivery.

Also, long-term health effects of planned mode of breech delivery on infant outcomes including auto-immune diseases such as diabetes type-1, asthma and allergies should be further investigated.

Compared to planned vaginal breech delivery at term, nulliparous women with planned cesarean breech delivery have a significantly reduced risk of postoperative complications in terms of infections and surgical organ lesions but a higher risk of uterine rupture in their subsequent pregnancies.

Supporting information

S1 table. detailed list describing codes and specifications for maternal and neonatal morbidity outcomes..

https://doi.org/10.1371/journal.pone.0297971.s001

S2 Table. Risk of complications in first, second and third pregnancy by actual mode of breech delivery in first pregnancy.

https://doi.org/10.1371/journal.pone.0297971.s002

S1 Dataset. Dataset Maternal Outcome Breech.

https://doi.org/10.1371/journal.pone.0297971.s003

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Article Contents

Introduction, case report, conflict of interest statement, successful management of prolonged abdominal pregnancy in low-resource setting: a case report.

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Cátia Samajo Zita, Gonzalo Gonzáles Villa, Eduardo Matediana, Pita Tomás, Damiano Pizzol, Lee Smith, Successful management of prolonged abdominal pregnancy in low-resource setting: a case report, Journal of Surgical Case Reports , Volume 2024, Issue 4, April 2024, rjae210, https://doi.org/10.1093/jscr/rjae210

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Ectopic pregnancy is a life-threatening complication of pregnancy and represents the leading cause of maternal mortality in the first trimester. In developing countries early diagnosis, necessary for favorable outcomes, is often unavailable and women are often not aware of possible conditions and associated complications. Moreover, access to sexual and reproductive health services and antenatal care are limited in such settings. Finally, management options are restricted and often performed in emergency with higher risk of complications and mortality. We report here a 33-year-old woman presenting a 41 weeks abdominal pregnancy successfully managed in a low-resource setting.

Ectopic pregnancy (EP) is a complication of pregnancy where the embryo implants outside the uterine cavity, mainly in the Fallopian tube but also in the cervix, ovaries, and abdomen [ 1 ]. EP is life-threatening for the mother especially due to the possible consequent internal hemorrhage and it represents the leading cause of maternal mortality in the first trimester, with an estimated incidence of 5–10% of all pregnancy-related deaths [ 1 ]. Reliable epidemiological data are available only in developed countries with well-established healthcare and it is estimated that EP accounts for ~2% of all pregnancies in Europe and North America [ 2 ]. On the contrary, in developing countries, due to poor medical and economic conditions, limited antenatal visits and prevention programs, not only it is difficult to find epidemiological data but there are important limitations in the understanding of the risk factors and management of EP [ 2 ]. The main risk factors for EP are the use of an intrauterine device at the time of conception, Chlamydia trachomatis and Neisseria gonorrhea infections, current or past history of pelvic inflammatory disease, previous EP, iron deficiency, and smoking cigarettes [ 3 ]. The gold standard for diagnosis is the serum concentrations of human β chorionic gonadotropin (hCG) and transvaginal ultrasound while clinical evaluation is not reliable as many women with EP report no pain nor adnexal tenderness and often it may be confused with miscarriage or induced abortion, a problem with the ovary or with a pelvic inflammatory disease [ 3 ]. In developing countries not only the gold standard is often unavailable, but women are often not aware of possible conditions and their complications and have no access to proper sexual and reproductive health services nor antenatal care [ 4 ]. Likewise, the EP management in developed countries is standardized both for stable patients, which can be treated medically with methotrexate injection, or surgically with the removal of the fallopian tube, both for unstable patients requiring emergency surgery to stop life-threatening hemorrhage [ 5 ]. In limited resources settings, instead, surgery, mostly performed by laparotomy, remains the main treatment and, due to late diagnosis, it is often performed in emergency with frequent tubal rupture and hemoperitoneum and, thus, higher risk of complications and mortality [ 3 ].

We reported a 33-year-old woman presenting a 41 weeks abdominal pregnancy successfully managed in a low-resource setting.

A 33-year-old woman presented with a prolonged (41 weeks) pregnancy without labor and history of fourth pregnancy with three births, one stillbirth and two live children.

At admission, the patient reported abdominal pain and discomfort due to fetal mobilization, with good baby movement, anorexia, and no other complaints. She presented a prenatal record of 10 consultations carried out in a rural context with no ultrasound availability and no complication. She was HIV positive on treatment with Tenofovir, Lamivudine, and Dolutegravir and tested negative for syphilis. At clinical examination, blood pressure levels were normal (115/83 mmHg), heart rate 106 bpm, respiratory rate 18 cpm, temperature 36.5°C, and cardiopulmonary auscultation unchanged. The abdomen was painful on superficial and deep palpation, the fetus was palpated in a longitudinal position, breech presentation, fundus height of 37 cm, auscultation of the fetal cardiac focus in the right hypochondrium at 130 bpm, without uterine dynamics. Upon vaginal examination, the posterior cervix was long and impervious. The ultrasound revealed a single intrauterine fetus, fetal heartbeat positive, breech presentation, biparietal diameter of 9.3 cm, femur length of 7.2 cm, and occlusive placenta previa and severe oligoamnios. Emergency cesarean section was performed. The abdominal cavity was accessed where the gestational sac was found, the empty uterus next to the gestational sac slightly increased in size. The amniotic membrane was opened and the newborn, a live male weight 2600 g was delivered with Apgar score of 6 at first minute and 8 at fifth minute ( Fig. 1A ). A small amount of clear amniotic fluid was observed, the placenta was inserted into the left interstitial region, with adhesions to the left annex of the uterus ( Fig. 1B ). Thus, the left adnexectomy was performed ( Fig. 1C ). Surgery was uneventful, postoperative course had no complication, and the mother and child were discharged 4 days after surgery. Importantly, 1 week follow up was regular for both.

Live newborn after prolonged abdominal pregnancy (A), placenta adhesions to the left annex of the uterus (B), and adnexectomy (C).

EP represents a potential highly preventable and treatable condition and, especially when early detected, the chances of successful treatment are high, leading to a low risk of complications and mortality. However, these optimal conditions are characteristics of high-income countries while in undeveloped and developing countries EP remains an underestimated and underdiagnosed condition leading to urgency and fatal outcomes. The main reasons are the lack of diagnostic tools as hCG and transvaginal ultrasound and limited access to proper health care system and service. However, the higher rate of morbidity and mortality seems also related to country or region’s combined educational, economic, and medical levels reflecting a strong role of social determinants of health [ 3 ].

The successful management of this case represents a rare and extraordinary case that reflects the poor social-economic context, limited resources but also the appropriateness of the care provided in this complex case.

Considering the limited scientific literature available especially in low-income countries, further research and investigation are necessary to better understand the underlying factors contributing to EP in low-resource settings. Moreover, considering the various factors such as ethnicity, economic status, and educational levels, it is mandatory to develop effective public health policies that address these disparities and provide enhanced protection for vulnerable women. Finally, it is crucial to promote early diagnosis and treatment of EP especially in low-resource settings to mitigate its impact on women and child health.

None declared.

Written informed consent was obtained from the patient for publication of this case report and any accompanying images.

Cátia Samajo Zita.

Mullany K , Minneci M , Monjazeb R , et al. Overview of ectopic pregnancy diagnosis, management, and innovation . Womens Health (Lond) 2023 ; 19 : 174550572311603 .

Google Scholar

Zhang S , Liu J , Yang L , et al. Global burden and trends of ectopic pregnancy: an observational trend study from 1990 to 2019 . PloS One 2023 ; 18 : e0291316 .

Goyaux N , Leke R , Keita N , et al. Ectopic pregnancy in African developing countries . Acta Obstet Gynecol Scand 2003 ; 82 : 305 – 12 .

Brady PC . New evidence to guide ectopic pregnancy diagnosis and management . Obstet Gynecol Surv 2017 ; 72 : 618 – 25 .

Sonalkar S , Gilmore E . A fresh look at treatment for ectopic pregnancy . Lancet 2023 ; 401 : 619 – 20 .

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v.16(4); 2019 Apr

Screening for breech presentation using universal late-pregnancy ultrasonography: A prospective cohort study and cost effectiveness analysis

David wastlund.

1 Cambridge Centre for Health Services Research, Cambridge Institute of Public Health, Cambridge, United Kingdom

2 The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom

Alexandros A. Moraitis

3 Department of Obstetrics and Gynaecology, University of Cambridge, NIHR Cambridge Comprehensive Biomedical Research Centre, Cambridge, United Kingdom

Alison Dacey

Edward c. f. wilson.

4 Health Economics Group, Norwich Medical School, University of East Anglia, Norwich, United Kingdom

Gordon C. S. Smith

Associated data.

The terms of the ethical permission for the POP study do not allow publication of individual patient level data. Requests for access to patient level data will usually require a Data Transfer Agreement, and should be made to Mrs Sheree Green-Molloy at the Department of Obstetrics and Gynaecology, Cambridge University, UK ( ku.ca.mac.lhcsdem@dohgdnaoap ).

Despite the relative ease with which breech presentation can be identified through ultrasound screening, the assessment of foetal presentation at term is often based on clinical examination only. Due to limitations in this approach, many women present in labour with an undiagnosed breech presentation, with increased risk of foetal morbidity and mortality. This study sought to determine the cost effectiveness of universal ultrasound scanning for breech presentation near term (36 weeks of gestational age [wkGA]) in nulliparous women.

Methods and findings

The Pregnancy Outcome Prediction (POP) study was a prospective cohort study between January 14, 2008 and July 31, 2012, including 3,879 nulliparous women who attended for a research screening ultrasound examination at 36 wkGA. Foetal presentation was assessed and compared for the groups with and without a clinically indicated ultrasound. Where breech presentation was detected, an external cephalic version (ECV) was routinely offered. If the ECV was unsuccessful or not performed, the women were offered either planned cesarean section at 39 weeks or attempted vaginal breech delivery. To compare the likelihood of different mode of deliveries and associated long-term health outcomes for universal ultrasound to current practice, a probabilistic economic simulation model was constructed. Parameter values were obtained from the POP study, and costs were mainly obtained from the English National Health Service (NHS). One hundred seventy-nine out of 3,879 women (4.6%) were diagnosed with breech presentation at 36 weeks. For most women (96), there had been no prior suspicion of noncephalic presentation. ECV was attempted for 84 (46.9%) women and was successful in 12 (success rate: 14.3%). Overall, 19 of the 179 women delivered vaginally (10.6%), 110 delivered by elective cesarean section (ELCS) (61.5%) and 50 delivered by emergency cesarean section (EMCS) (27.9%). There were no women with undiagnosed breech presentation in labour in the entire cohort. On average, 40 scans were needed per detection of a previously undiagnosed breech presentation. The economic analysis indicated that, compared to current practice, universal late-pregnancy ultrasound would identify around 14,826 otherwise undiagnosed breech presentations across England annually. It would also reduce EMCS and vaginal breech deliveries by 0.7 and 1.0 percentage points, respectively: around 4,196 and 6,061 deliveries across England annually. Universal ultrasound would also prevent 7.89 neonatal mortalities annually. The strategy would be cost effective if foetal presentation could be assessed for £19.80 or less per woman. Limitations to this study included that foetal presentation was revealed to all women and that the health economic analysis may be altered by parity.

Conclusions

According to our estimates, universal late pregnancy ultrasound in nulliparous women (1) would virtually eliminate undiagnosed breech presentation, (2) would be expected to reduce foetal mortality in breech presentation, and (3) would be cost effective if foetal presentation could be assessed for less than £19.80 per woman.

In their cohort study, David Wastlund and colleagues find that universal ultrasound scanning for breech presentation near term is associated with reduced undiagnosed breech presentation and improved pregnancy outcomes, and can be cost-effective.

Author summary

Why was this study done.

Risks of complications at delivery are higher for babies that are in a breech position, but sometimes breech presentation is not discovered until the time of birth.
Ultrasound screening could be used to detect breech presentation before birth and lower the risk of complications but would be associated with additional costs.
It is uncertain if offering ultrasound screening to every pregnancy is cost effective.

What did the researchers do and find?

This study recorded the birth outcomes of pregnancies that were all screened using ultrasound.
Economic modelling and simulation was used to compare these outcomes with those if ultrasound screening had not been used.
Modelling demonstrated that ultrasound screening would lower the risk of breech delivery and, as a result, reduce emergency cesarean sections and the baby’s risk of death.

What do these findings mean?

Offering ultrasound screening to every pregnancy would improve the health of mothers and babies nationwide.
Whether the health improvements are enough to justify the increased cost of ultrasound screening is still uncertain, mainly because the cost of ultrasound screening for presentation alone is unknown.
If ultrasound screening could be provided sufficiently inexpensively, for example, by being used during standard midwife appointments, routinely offering ultrasound screening would be worthwhile.

Introduction

Undiagnosed breech presentation in labour increases the risk of perinatal morbidity and mortality and represents a challenge for obstetric management. The incidence of breech presentation at term is around 3%–4% [ 1 – 3 ], and fewer than 10% of foetuses who are breech at term revert spontaneously to a vertex presentation [ 4 ]. Although breech presentation is easy to detect through ultrasound screening, many women go into labour with an undetected breech presentation [ 5 ]. The majority of these women will deliver through emergency cesarean section (EMCS), which has high costs and increased risk of morbidity and mortality for both mother and child.

In current practice, foetal presentation is routinely assessed by palpation of the maternal abdomen by a midwife, obstetrician, or general practitioner. The sensitivity of abdominal palpation varies between studies (range: 57%–70%) and depends on the skill and experience of the practitioner [ 6 , 7 ]. There is currently no guidance on what is considered an acceptable false negative rate when screening for breech presentation using abdominal palpation. In contrast, ultrasound examination provides a quick and safe method of accurately identifying foetal presentation.

Effective interventions exist for the care of women who have breech presentation diagnosed near term. The Royal College of Obstetricians and Gynaecologists recommends ‘that all women with an uncomplicated breech presentation at term should be offered external cephalic version (ECV)’ [ 2 ]. The rationale for this is to reduce the incidence of breech presentation at term and avoid the risks of vaginal breech birth or cesarean section. The success rate of ECV is considered to be approximately 50% [ 2 , 8 , 9 ], but it differs greatly between nulliparous and parous women (34% and 66%, respectively) [ 9 ]. ECV is overall safe, with less than 1% risk to the foetus and even smaller risk to the mother [ 10 ]; despite this, a significant number of women decline ECV for various reasons [ 11 ]. Should ECV be declined or fail, generally women are offered delivery by planned (elective) cesarean section, as there is level 1 evidence of reduced risk of perinatal death and severe morbidity compared with attempting vaginal breech birth, and it is also associated with lower costs [ 3 , 12 , 13 ]. However, some women may still opt for an attempt at vaginal breech birth if they prioritise nonintervention over managing the relatively small absolute risks of a severe adverse event [ 1 , 14 ].

We sought to assess the cost effectiveness of universal late-pregnancy ultrasound presentation scans for nulliparous women. We used data from the Pregnancy Outcome Prediction (POP) study, a prospective cohort study of >4,000 nulliparous women, which included an ultrasound scan at 36 weeks of gestational age (wkGA) [ 15 ]. Here, we report the outcomes for pregnant nulliparous women with breech presentation in the study and use these data to perform a cost effectiveness analysis of universal ultrasound as a screening test for breech presentation.

Study design

The POP study was a prospective cohort study of nulliparous women conducted at the Rosie Hospital, Cambridge (United Kingdom) between January 14, 2008 and July 31, 2012, and the study has been described in detail elsewhere [ 15 – 17 ]. Ethical approval for the study was obtained from the Cambridgeshire 2 Research Ethics Committee (reference 07/H0308/163), and all participants provided informed consent in writing. Participation in the POP study involved serial phlebotomy and ultrasound at approximately 12 wkGA, 20 wkGA, 28 wkGA, and 36 wkGA [ 16 ]. The outcome of pregnancy was obtained by individual review of all case records by research midwives and by linkage to the hospital’s electronic databases of ultrasonography, biochemical testing, delivery data, and neonatal care data. The research ultrasound at 36 wkGA was performed by sonographers and included presentation, biometry, uteroplacental Doppler, and placental location. The ultrasound findings were blinded except in cases of breech presentation, low lying placenta, or foetal concerns such as newly diagnosed foetal anomaly and an amniotic fluid index (AFI) < 5 cm. This study was not prospectively defined in the POP study protocol paper [ 16 ] but required no further data collection.

If the foetus was in a breech presentation at 36 wkGA, women were counselled by a member of the medical team. In line with guidelines from the National Institute for Health and Care Excellence (NICE), ECV was routinely offered unless there was a clinical indication that contraindicated the procedure, e.g., reduced AFI (<5 cm) [ 18 ]. ECV was performed by 1 of 5 obstetric consultants in the unit between 36–38 wkGA, patients were scanned before the procedure to confirm presentation, and it was performed with ultrasound assessment; 0.25 mg terbutaline SC was given prior to the procedure at the discretion of the clinician. If women refused ECV or the procedure failed, the options of vaginal breech delivery and elective cesarean section (ELCS) were discussed and documented. The local guideline for management of breech presentation, including selection criteria for vaginal breech delivery, was based upon recommendations from the Royal College of Obstetricians and Gynaecologists (RCOG) [ 1 ]. We extracted information about ECV from case records that were individually reviewed by research midwives. Finally, we obtained delivery-related information from our hospital electronic database (Protos; iSoft, Banbury, UK).

Foetal outcomes included mode of delivery (MOD), birth weight, and gestational age at delivery. We used the UK population reference for birthweight, with the 10th and 90th percentile cut-offs for small and large for gestational age, respectively; the centiles were adjusted for sex and gestational age [ 19 ]. Maternal age was defined as age at recruitment. Smoking status, racial ancestry, alcohol consumption, and BMI were taken from data recorded at the booking assessment by the community midwife. Socioeconomic status was quantified using the Index of Multiple Deprivation (IMD) 2007, which is based on census data from the area in the mother’s postcode [ 20 ]. Ethical approval for the study was obtained from the Cambridgeshire 2 Research Ethics Committee (reference 07/H0308/163), and all participants provided informed consent in writing.

This study is reported as per the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guideline.

Statistical analysis

Data are presented as median (interquartile range) or n (%), as appropriate. P values are reported for the difference between groups calculated using the two-sample Wilcox rank-sum (Mann–Whitney) test for continuous variables and the Pearson Chi-square test for categorical variables, with trend tests when appropriate. Comparisons were performed using Stata (version 15.1). Missing values were included in the presentation of patient characteristics and outcomes but were excluded from the economic analysis and estimation of parameters.

Economic model and analysis

To evaluate the cost effectiveness of routinely offering late-pregnancy presentation scans, a decision-tree simulation model was constructed using R (version 3.4.1) [ 21 – 24 ]. The time horizon of the economic analysis was from the ultrasound scan (36 wkGA) to infant lifetime, and costs were from the perspective of the English National Health Service (NHS). Costs for modes of delivery were obtained from NHS reference costs [ 25 ]; since these do not list a separate cost for vaginal breech delivery, we assumed that the cost ratio between vaginal breech and ELCS deliveries was the same as in another study (see Supporting information , S1 Text ) [ 12 ].

The population of interest is unselected nulliparous women. The model compares the outcomes at birth for two strategies: ‘universal ultrasound’ and ‘selective ultrasound’ ( Fig 1 ). For universal ultrasound, we assumed that all breech presentations at the time of scanning would be detected (i.e., assumed 100% sensitivity and specificity for the test). For selective ultrasound, the breech presentation was diagnosed either clinically (by abdominal palpation followed by ultrasound for confirmation) or as an incidental finding during a scan for a different indication. These assumptions were based upon current practice and derived from the POP study.

An external file that holds a picture, illustration, etc.
Object name is pmed.1002778.g001.jpg

Structure of economic simulation model. ‘Universal ultrasound’ strategy starts in Model A, and patients with breech presentation enter Model C. ‘Selective ultrasound’, i.e., no routine ultrasound, starts in Model B, and only those with a detected breech presentation enter Model C. The letter–number codes for each node are equivalent to the codes in Table 1 . ELCS, elective cesarean section; EMCS, emergency cesarean section.

Compared to a standard antenatal ultrasound for which, typically, multiple measurements are made, an ultrasound scan for foetal presentation alone is technically simple. We theorised that such a scan could be provided by an attending midwife in conjunction with a standard antenatal visit in primary care, using basic ultrasound equipment. Since a specific unit cost for a scan for foetal presentation alone is not included in the national schedule of reference costs [ 25 ], we estimated the cost of ultrasound to include the midwife’s time, the cost of equipment, and room. More details are presented in the Supporting information, S1 Text . The cost of ECV was obtained from James and colleagues [ 26 ] and converted to the 2017 price level using the Hospital and Community Health Services (HCHS) index [ 27 ]. The probability of ECV uptake and success rate as well as MOD were obtained from the POP study. All model inputs are presented in Table 1 and S1 Table , and the calculation of cost inputs is shown in Supporting information, S1 Text .

Abbreviations: CV, cephalic vaginal; ELCS, elective cesarean section; EMCS, emergency cesarean section; MOD, mode of delivery; NHS, National Health Service; POP, Pregnancy Outcome Prediction; SRB, spontaneous reversion to breech; SRC, spontaneous reversion to cephalic; VB, vaginal breech.

Costs given per unit/episode. For probabilities, alpha represent case of event and beta case of no event. MOD shows input values for Dirichlet distribution. Node refers to the chance nodes in Fig 1 .

*Details on how this value was estimated is provided as Supporting information, S1 Text .

†Cost for ECV (high staff cost), converted to 2017 price level using the HCHS index [ 27 ].

‡Weighted average of all complication levels (Total HRGs).

§Due to the small sample size for these parameters in the POP study, the model used inputs for MOD for undetected breech instead.

The end state of the decision tree was the MOD, which was either vaginal, ELCS, or EMCS. Delivery could be either cephalic or breech. EMCS could be either due to previously undiagnosed breech presentation or for other reasons. All cases of breech could spontaneously revert to cephalic presentation. However, we assumed the probability of this to be lower if ECV had been attempted and failed [ 28 ]. If ECV was successful, a reversion back to breech presentation was possible. It is currently unclear whether the probability of MOD varies depending on whether cephalic presentation is the result of successful ECV or spontaneous reversion [ 2 , 10 , 29 – 31 ], but we assumed that the probabilities differed.

Long-term health outcomes were modelled based upon the mortality risk associated with each MOD. The risk of neonatal mortality was taken from the RCOG guidelines. For breech presentation, these risks were 0.05% for delivery through ELCS and 0.20% for vaginal delivery. The risk of neonatal mortality for cephalic presentation with vaginal delivery was 0.10% [ 1 ]. There were no randomised clinical trials that allowed us to compare the outcomes of ELCS versus vaginal delivery for uncomplicated pregnancies with cephalic presentation; however, most observational studies found no significant difference in neonatal mortality and serious morbidity between the two modes [ 32 – 34 ]. For this reason, we assumed the mortality risk for cephalic vaginal and ELCS deliveries to be identical. We also assumed that EMCS would have the same mortality rate as ELCS, both for cephalic and breech deliveries. Studies have found that the MOD for breech presentation affects the risk of serious neonatal morbidity in the short term but not in the long term [ 1 , 3 , 35 ]. For this reason, we focused the economic analysis on the effect from mortality only. The average lifetime quality-adjusted life-years (QALYs) per member of the UK population was estimated using data on quality of life from Euroqol, weighted by longevity indexes from the Office for National Statistics (ONS) [ 36 , 37 ]. Using the annual discount rate of 3.5%, as recommended by NICE, the net present value for the average lifetime QALYs at birth was 24.3 [ 38 ].

The model was probabilistic, capturing how uncertainty in the input parameters affected the outputs by allowing each parameter to vary according to its distribution. Binary and multivariable outcomes were modelled using the beta and the Dirichlet distributions, respectively [ 39 ]. Probabilities of events were calculated from the POP study and presented in Table 1 . On top of the probabilistic sensitivity analysis (PSA), the sensitivity of individual parameters was also explored through one-way sensitivity analyses modifying probabilities by +/− 1 percentage point and costs by +/− £10 to see which parameters had the greatest impact on cost effectiveness estimates.

Total costs depended on the distribution of MOD, the number of expected mortalities, and the cost of ultrasound scanning and ECV. Nationwide costs for each screening strategy were calculated for 585,489 deliveries, i.e., the number of births in England from 2016–2017, assuming 92% occur after 36 wkGA [ 15 , 40 ]. Model parameters were sampled from their respective distributions in a PSA of 100,000 simulations for each strategy. To determine cost effectiveness, we used two different willingness-to-pay thresholds: £20,000 and £30,000 [ 38 ]. A copy of the model code is available from the corresponding author (EW) upon request.

Recruitment to the POP study cohort is shown in Fig 2 and has been previously described [ 17 ]. Information about presentation at the 36-week scan was available for 3,879 women who delivered at the Rosie Hospital, Cambridge, UK; 179 of these had a breech presentation.

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Schedule of patient recruitment in the POP study shown by foetal presentation. POP, Pregnancy Outcome Prediction.

We compared maternal and foetal characteristics of the 179 women with breech presentation at 36 weeks to the women with a cephalic presentation ( Table 2 ). Women diagnosed with breech presentation were, on average, a year older than women with a cephalic presentation, but other maternal characteristics did not differ. The babies of women diagnosed breech were smaller and born earlier, but their birth weight centile and the proportions of small for gestational age (SGA) or large for gestational age (LGA) were not markedly different. There were no differences in maternal BMI between the groups. As expected, women with breech presentation were more likely to deliver by ELCS or EMCS.

Abbreviations: AGA, appropriate for gestational age; FTE, full-time education; LGA, large for gestational age; MOD, mode of delivery; POP, Pregnancy Outcome Prediction; SGA, small for gestational age.

Statistics are presented as n (%) for binary outcomes and median (interquartile range) for continuous variables. The "Missing" category was not included in statistical tests. For variables without a "Missing" category, data were 100% complete. P values are reported for the difference between groups using the two-sample Wilcox rank-sum test for continuous variables and the Pearson Chi-square test for categorical variables, with trend test as appropriate (i.e., for deprivation quartile and birth weight centile category).

Breech presentation was suspected before the 36-wkGA scan for 79 (44.1%) of the women with breech presentation through abdominal palpation by the midwife or doctor; out of these, 27 had a clinically indicated scan between 32–36 weeks in which the presentation was reported. For 96 women, the breech presentation was unsuspected before the 36-week scan. Information on suspected breech position was missing for 4 women. There were no differences in BMI between the 79 women with suspected breech and the 96 women misdiagnosed as cephalic prior to the scan (median BMI was 24 in both groups, Wilcoxon rank-sum test P = 0.31).

MOD by ECV status is shown in Table 3 . ECV was performed for 84 women, declined by 45 women, and unsuitable for 23; contraindications included low AFI at screening (18 women), uterine abnormalities (2), and other reasons (3). For 25 women, an ECV was never performed despite consent; 17 babies turned spontaneously, 6 had reduced AFI on the day of the ECV, and 2 went into labour before ECV. When performed, ECV was successful for 12 women; in one case, the baby later reverted to breech presentation before delivery. Information on ECV uptake was missing for 2 women. Foetal presentation and ECV status in the structure of the economic model is shown in Supporting information, S1 Fig .

Abbreviations: ECV, external cephalic version; ELCS, elective cesarean section; EMCS, emergency cesarean section; MOD, mode of delivery.

*Eighteen women were contraindicated due to low AFI at screening, 2 for uterine abnormalities, and 3 for other reasons.

†Seventeen babies turned spontaneously, 6 had reduced AFI on the day of the ECV, and 2 went into labour before ECV.

The results from the economic analysis are presented in Table 4 . On average, universal ultrasound resulted in an absolute decrease in breech deliveries by 0.39%. It also led to fewer vaginal breech deliveries (absolute decrease by 1.04%) and overall EMCS deliveries (0.72%) than selective ultrasound but increased overall deliveries through ELCS (1.51%). Resulting from the more favourable distribution of MOD, the average risk of mortality fell by 0.0013%. On average, 40 women had to be scanned to identify one previously unsuspected breech presentation (95% Credibility Interval [CrI]: 33 to 49); across England, this would mean that 14,826 (95% CrI: 12,048–17,883) unidentified breech presentations could be avoided annually.

Abbreviations: ECV, external cephalic version; ELCS, elective cesarean section; EMCS, emergency cesarean section; MOD, mode of delivery; QALY, quality-adjusted life years; VB, vaginal breech.

Costs (£) are presented per patient, except in column for ‘total population’ ( n = 585,489).

The expected per person cost of universal ultrasound was £2,957 (95% CrI: £2,922–£2,991), compared to £2,949 (95% CrI: £2,915–£2,984) from selective ultrasound, a cost increase of £7.29 (95% CrI: 2.41–11.61). Across England, this means that universal ultrasound would cost £4.27 million more annually than current practice. The increase stems from higher costs of ultrasound scan (£20.3 per person) and ECV (£3.6 per person) but is partly offset by the lower delivery costs (−£16.5 per person). The distribution of differences in costs between the two strategies is shown as Supporting information, S2 Fig . The simulation shows that universal ultrasound would, on average, increase the number of total ELCS deliveries by 8,858 (95% CrI: 7,662–10,068) but decrease the number of EMCS and vaginal breech deliveries by 4,196 (95% CrI: 2,779–5,603) and 6,061 (95% CrI: 6,617–8,670) per year, respectively.

The long-term health outcomes are presented in Table 4 . Nationwide, universal ultrasound would be expected to lower mortality by 7.89 cases annually (95% CrI: 3.71, 12.7). After discounting, this means that universal ultrasound would be expected to yield 192 QALYs annually (95% CrI: 90,308). The cost effectiveness of universal ultrasound depends on the value assigned to these QALYs. The incremental cost effectiveness ratio (ICER) was £23,611 (95% CrI: 8,184, 44,851), which is of borderline cost effectiveness (given NICE’s willingness to pay of £20,000 to £30,000) [ 38 ]. The number needed to scan per prevented mortality was 74,204 (95% CrI: 46,124–157,642).

One-way sensitivity analysis showed that the probability parameter with the greatest impact upon the cost effectiveness of universal ultrasound was the prevalence of breech: increasing this parameter by 1 percentage point was associated with a relative reduction of costs for universal ultrasound by £3.07. The results were less sensitive to the ECV success rate; an increase by 1 percentage point led to a relative reduction in the cost of universal ultrasound by £0.12. The most important cost parameter was the unit cost of ultrasound scan; an increase in this parameter by £10 led to a relative increase for universal ultrasound by £9.79 (see Supporting information , S3 Fig ). Keeping all other parameters equal, universal ultrasound would be cost effective if ultrasound scanning could be provided for less than £19.80 or £23.10 per mother, for a willingness-to-pay threshold of £20,000 or £30,000, respectively. For universal ultrasound to be cost saving, scans would need to cost less than £12.90 per mother.

In a prospective cohort study of >3,800 women having first pregnancies, a presentation scan at approximately 36 wkGA identified the 4.6% of women who had a foetus presenting by the breech, and for more than half of these, breech presentation had not previously been clinically suspected. The majority of these women were ultimately delivered by planned cesarean section, some experienced labour before their scheduled date and were delivered by EMCS, and a small proportion had a cephalic vaginal delivery following either spontaneous cephalic version or ECV. No woman in the cohort had a vaginal breech delivery or experienced an intrapartum cesarean for undiagnosed breech. The low uptake of vaginal breech birth is likely to reflect the fact that this is a nulliparous population, and it is generally accepted that the risks associated with vaginal breech delivery are lower in women who have had a previous normal birth.

Our economic analysis suggests that a universal late-pregnancy presentation scan would decrease the number of foetal mortalities associated with breech presentation and that this is of borderline cost effectiveness, costing an estimated £23,611 per QALY gained. The key driver of cost effectiveness is the cost of the scan itself. In the absence of a specific national unit cost, we have identified the maximum cost at which it would be cost effective. This is £19.80 per scan to yield an ICER of £20,000 per QALY and £23.10 at £30,000. These unit costs may be possible if assessment of presentation could be performed as part of a routine antenatal visit. Portable ultrasound systems adequate for presentation scans are available at low cost, and a presentation scan is technically quite simple, so the required level of skill could be acquired by a large cadre of midwives. This would result in a small fraction of the costs associated with a trained ultrasonographer performing a scan in a dedicated space using a high-specification machine. If universal ultrasound could be provided for less than £12.90 per scan, the policy would also be cost saving.

Our sensitivity analysis shows that the unit cost of ultrasound scans and the prevalence of breech presentation were by far the biggest determinants of the cost and cost effectiveness of universal ultrasound. The detection rate with abdominal palpation (i.e., for selective ultrasound) is the most important parameter aside from these. By contrast, the costs, attempt, and success rates for ECV have modest impact upon the choice of scanning strategy. It appears that the main short-term cost benefit from late-pregnancy screening lies in the possibility of scheduling ELCSs when breech presentation is detected, rather than turning the baby into a cephalic position.

This analysis may have underestimated the health benefits of universal late-pregnancy ultrasound. In the absence of suitable data on long-term outcomes by MOD and foetal presentation, we made the simplifying assumption that mortality rates were equal for ELCSs and EMCSs. Relaxing this assumption would likely favour universal ultrasound, as this strategy would reduce EMCSs, and these are associated with higher risks of adverse outcomes than ELCSs [ 41 – 44 ]; on top of health benefits, this may also reduce long-term NHS costs. It is also possible that an EMCS for a known breech presentation is less expensive and has better health outcomes than one for which breech is detected intrapartum, although lack of separate data for these two scenarios prevented us from pursuing this analysis further.

Our analysis shows that universal late-pregnancy ultrasound screening would increase total number of cesarean sections. Evidence suggests that cesarean delivery may have long-term consequences on the health of the child (increased risk of asthma and obesity), the mother (reduced risk of pelvic organ prolapse and increased risk of subfertility), and future pregnancies (increased risk of placenta previa and stillbirth) [ 45 , 46 ]. There is no evidence that these are related to the type of the cesarean section (elective versus emergency) [ 45 , 46 ]. Our economic modelling has not been able to capture these complex effects due to the model’s endpoints and the focus on the current pregnancy only. However, accounting for these effects, it seems plausible that universal late-pregnancy ultrasound would be more favourable for mothers than children or future pregnancies.

Our results are also driven by vaginal delivery yielding worse long-term health outcomes than ELCS for breech presentation [ 1 ]. However, even though the rate of vaginal breech birth declined after the Term Breech Study, in many cases, the outcomes are not inferior to that of ELCS, and the RCOG guidelines state that vaginal breech delivery may be attempted following careful selection and counselling [ 1 , 3 , 47 ]. It is hard to assess how an increase in vaginal breech delivery would affect the cost effectiveness of universal ultrasound; while decreased mortality risk from vaginal breech delivery would decrease the importance of knowing the foetal presentation, universal screening would facilitate selection for attempted vaginal breech delivery.

One limitation of this study is that foetal presentation was revealed to all women in the POP study. Consequently, this study cannot say what would have happened without routine screening. However, we felt that it was appropriate to reveal the presentation at the time of the 36-wkGA scan, as there is level 1 evidence that planned cesarean delivery reduces the risk of perinatal morbidity and mortality in the context of breech presentation at term [ 44 ]. Another weakness was that the study was being undertaken in a single centre only and that the sample size was too small to avoid substantial parameter uncertainty for rare events. Moreover, less than half of all breech presentations in the POP study were detected by abdominal palpation. It is unclear whether the detection rates were affected by midwives knowing that the women were part of the POP study and, hence, would receive an ultrasound scan at 36 wkGA.

The prevalence of breech presentation in this study (4.6%) appears higher than the 3%–4% that is often reported in literature [ 1 ]. However, this study is unique in that it reports the prevalence at the time of ultrasound scanning, approximately 36 wkGA. Taking into account the number of spontaneous reversions to cephalic and that some cases of successful ECV may have turned spontaneously without intervention, our finding is consistent with the literature. The ECV success rate in the POP study was considerably lower than reported elsewhere in the literature; it was even lower than the 32% success rate that has been reported as the threshold level for when ECV is preferred over no intervention at all [ 48 ]. This might partly reflect the participants in the POP study; they were older and more likely to be obese than in many previous studies, and the cohort consisted of nulliparous women, who have higher rates of ECV failure than parous women [ 9 , 49 , 50 ]. It is also possible that the real-world ECV success rate is lower than in the literature due to publication bias. However, sensitivity analysis indicates that the impact from an increased ECV success rate would be modest (an increase in ECV success rate by 10 percentage points lowers the incremental cost of universal ultrasound by £0.91 per patient).

The findings from this study cannot easily be transferred to another health system due to the differences in healthcare costs and antenatal screening routines. Some countries, e.g., France and Germany, already offer a third-trimester routine ultrasound scan. However, these scans are offered prior to 36 wkGA, and as many preterm breech presentations revert spontaneously, it would have limited predictive value for breech at term [ 51 ]. Whether screening for breech presentation in lower-income settings is likely to be cost effective largely depends on the coverage of the healthcare system; while screening may be relatively more costly, the benefits from avoiding undiagnosed breech presentation may also be relatively larger.

Whether the findings of this study could be extrapolated beyond nulliparous women is hard to assess. The absence of comparable data on screening sensitivity without universal ultrasound for parous women is an important limitation. The risks associated with breech birth also differ between nulliparous and parous women [ 52 , 53 ]. Compared to nulliparous women, parous women have higher success rates for ECV but also higher risk of spontaneous reversion to breech after 36 wkGA [ 9 , 28 ]. Also, the risks associated with vaginal breech delivery are lower in women who have had a previous vaginal birth [ 30 ].

Breech presentation is not the only complication that could be detected through late-pregnancy ultrasound screening. The same ultrasound session could also be used to screen for other indicators of foetal health, such as biometry and signs of growth restriction. Whether also scanning for other complications could increase the benefits from universal ultrasound has been and currently is subject to research [ 54 , 55 ]. Exploring the consequences from such joint screening strategies goes beyond the scope of this paper but has important implications for policy-makers and should therefore be subject to further research.

This study shows that implementation of universal late-pregnancy ultrasound to assess foetal presentation would virtually eliminate undiagnosed intrapartum breech presentation in nulliparous women. If this procedure could be implemented into routine care, for example, by midwives conducting a routine 36-wkGA appointment and using a portable ultrasound system, it is likely to be cost effective. Such a programme would be expected to reduce the consequences to the child of undiagnosed breech presentation, including morbidity and mortality.

Supporting information

S1 strobe checklist.

ECV, external cephalic version; POPs, Pregnancy Outcome Prediction.

PSA, Probabilistic Sensitivity Analysis.

Abbreviations

Funding statement.

This study was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme, grant number 15/105/01. EW is part funded by the NIHR Cambridge Biomedical Research Centre. US is funded by the NIHR Cambridge Comprehensive Biomedical Research Centre. The views expressed here are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health ( https://www.nihr.ac.uk/ ). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Data Availability

COMMENTS

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Breech Position: What It Means if Your Baby Is Breech

What does it mean if a baby is breech?

Updates history

Common issues with breech:

After Baby Turns

When should I be concerned about a breech position?

The timeline for breech

10-24 weeks gestation

24-30 weeks

30-34 weeks

Should manual external cephalic version be done earlier?

35-36 weeks

Moxibustion has its highest success rate this week.

External cephalic version near the end of pregnancy

38-40 weeks

40-41 weeks

Postdates (after your due date) with a breech

If Baby Does Not Turn

Inducing a breech

The Breech Turned During Labor

Laboring With a Breech Before The Cesarean

After the birth

A question about breech

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Breech Births

What are the different types of breech birth presentations?

What causes a breech presentation?

How is a breech presentation diagnosed?

Can a breech presentation mean something is wrong?

Can a breech presentation be changed?

Medical Techniques

ECV will not be tried if:

Complications of EVC include:

Vaginal delivery versus cesarean for breech birth?

What are the risks and complications of a vaginal delivery?

When is a cesarean delivery used with a breech presentation?

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Compiled using information from the following sources:

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Fetal presentation and position

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Head down, facing up (posterior position)

Frank breech

Complete breech

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Double footling breech

Transverse lie

Oblique lie

What to know if your baby is breech

What's a sunny-side up baby?

What happens to your baby right after birth

How your twins’ fetal positions affect labor and delivery

Where to go next

Breech baby at the end of pregnancy

What does ECV involve?

Why turn my baby head-first?

Is ECV safe for me and my baby?

ECV should not be carried out if:

Is ECV always successful?

Caesarean section

Vaginal breech birth

Further information

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Sources and acknowledgements

Breech presentation: diagnosis and management

Breech and external cephalic version

Clinical suspicion of breech presentation

Diagnosis: preterm ≤36+6 weeks

Diagnosis: ≥37+0 weeks