breech at presentation

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

• Key Points |

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

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

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

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

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

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

Abnormal fetal lie, presentation, or position may occur with

Fetopelvic disproportion (fetus too large for the pelvic inlet)

Fetal congenital anomalies

Uterine structural abnormalities (eg, fibroids, synechiae)

Multiple gestation

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

Transverse lie

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

Breech presentation

There are several types of breech presentation.

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

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

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

Types of breech presentations

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

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

Predisposing factors for breech presentation include

Preterm labor

Uterine abnormalities

Fetal anomalies

If delivery is vaginal, breech presentation may increase risk of

Umbilical cord prolapse

Birth trauma

Perinatal death

Face or brow presentation

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

Brow presentation usually converts spontaneously to vertex or face presentation.

Occiput posterior position

The most common abnormal position is occiput posterior.

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

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

Position and Presentation of the Fetus

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

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

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

Copyright © 2024 Merck & Co., Inc., Rahway, NJ, USA and its affiliates. All rights reserved.

• Cookie Preferences

• Type 2 Diabetes
• Heart Disease
• Digestive Health
• Multiple Sclerosis
• Diet & Nutrition
• Health Insurance
• Public Health
• Patient Rights
• Caregivers & Loved Ones
• End of Life Concerns
• Health News
• Thyroid Test Analyzer
• Doctor Discussion Guides
• Hemoglobin A1c Test Analyzer
• Lipid Test Analyzer
• Complete Blood Count (CBC) Analyzer
• What to Buy
• Editorial Process
• Meet Our Medical Expert Board

What Is Breech?

When a fetus is delivered buttocks or feet first

• Types of Presentation

Risk Factors

Complications.

Breech concerns the position of the fetus before labor . Typically, the fetus comes out headfirst, but in a breech delivery, the buttocks or feet come out first. This type of delivery is risky for both the pregnant person and the fetus.

This article discusses the different types of breech presentations, risk factors that might make a breech presentation more likely, treatment options, and complications associated with a breech delivery.

Verywell / Jessica Olah

Types of Breech Presentation

During the last few weeks of pregnancy, a fetus usually rotates so that the head is positioned downward to come out of the vagina first. This is called the vertex position.

In a breech presentation, the fetus does not turn to lie in the correct position. Instead, the fetus’s buttocks or feet are positioned to come out of the vagina first.

At 28 weeks of gestation, approximately 20% of fetuses are in a breech position. However, the majority of these rotate to the proper vertex position. At full term, around 3%–4% of births are breech.

The different types of breech presentations include:

• Complete : The fetus’s knees are bent, and the buttocks are presenting first.
• Frank : The fetus’s legs are stretched upward toward the head, and the buttocks are presenting first.
• Footling : The fetus’s foot is showing first.

Signs of Breech

There are no specific symptoms associated with a breech presentation.

Diagnosing breech before the last few weeks of pregnancy is not helpful, since the fetus is likely to turn to the proper vertex position before 35 weeks gestation.

A healthcare provider may be able to tell which direction the fetus is facing by touching a pregnant person’s abdomen. However, an ultrasound examination is the best way to determine how the fetus is lying in the uterus.

Most breech presentations are not related to any specific risk factor. However, certain circumstances can increase the risk for breech presentation.

These can include:

• Previous pregnancies
• Multiple fetuses in the uterus
• An abnormally shaped uterus
• Uterine fibroids , which are noncancerous growths of the uterus that usually appear during the childbearing years
• Placenta previa, a condition in which the placenta covers the opening to the uterus
• Preterm labor or prematurity of the fetus
• Too much or too little amniotic fluid (the liquid that surrounds the fetus during pregnancy)
• Fetal congenital abnormalities

Most fetuses that are breech are born by cesarean delivery (cesarean section or C-section), a surgical procedure in which the baby is born through an incision in the pregnant person’s abdomen.

In rare instances, a healthcare provider may plan a vaginal birth of a breech fetus. However, there are more risks associated with this type of delivery than there are with cesarean delivery. 

Before cesarean delivery, a healthcare provider might utilize the external cephalic version (ECV) procedure to turn the fetus so that the head is down and in the vertex position. This procedure involves pushing on the pregnant person’s belly to turn the fetus while viewing the maneuvers on an ultrasound. This can be an uncomfortable procedure, and it is usually done around 37 weeks gestation.

ECV reduces the risks associated with having a cesarean delivery. It is successful approximately 40%–60% of the time. The procedure cannot be done once a pregnant person is in active labor.

Complications related to ECV are low and include the placenta tearing away from the uterine lining, changes in the fetus’s heart rate, and preterm labor.

ECV is usually not recommended if the:

• Pregnant person is carrying more than one fetus
• Placenta is in the wrong place
• Healthcare provider has concerns about the health of the fetus
• Pregnant person has specific abnormalities of the reproductive system

Recommendations for Previous C-Sections

The American College of Obstetricians and Gynecologists (ACOG) says that ECV can be considered if a person has had a previous cesarean delivery.

During a breech delivery, the umbilical cord might come out first and be pinched by the exiting fetus. This is called cord prolapse and puts the fetus at risk for decreased oxygen and blood flow. There’s also a risk that the fetus’s head or shoulders will get stuck inside the mother’s pelvis, leading to suffocation.

Complications associated with cesarean delivery include infection, bleeding, injury to other internal organs, and problems with future pregnancies.

A healthcare provider needs to weigh the risks and benefits of ECV, delivering a breech fetus vaginally, and cesarean delivery.

In a breech delivery, the fetus comes out buttocks or feet first rather than headfirst (vertex), the preferred and usual method. This type of delivery can be more dangerous than a vertex delivery and lead to complications. If your baby is in breech, your healthcare provider will likely recommend a C-section.

A Word From Verywell

Knowing that your baby is in the wrong position and that you may be facing a breech delivery can be extremely stressful. However, most fetuses turn to have their head down before a person goes into labor. It is not a cause for concern if your fetus is breech before 36 weeks. It is common for the fetus to move around in many different positions before that time.

At the end of your pregnancy, if your fetus is in a breech position, your healthcare provider can perform maneuvers to turn the fetus around. If these maneuvers are unsuccessful or not appropriate for your situation, cesarean delivery is most often recommended. Discussing all of these options in advance can help you feel prepared should you be faced with a breech delivery.

American College of Obstetricians and Gynecologists. If your baby is breech .

TeachMeObGyn. Breech presentation .

MedlinePlus. Breech birth .

Hofmeyr GJ, Kulier R, West HM. External cephalic version for breech presentation at term . Cochrane Database Syst Rev . 2015 Apr 1;2015(4):CD000083. doi:10.1002/14651858.CD000083.pub3

By Christine Zink, MD Dr. Zink is a board-certified emergency medicine physician with expertise in the wilderness and global medicine.

• Screening & Prevention
• Sexual Health & Relationships
• Birth Control
• Preparing for Surgery Checklist
• Healthy Teens
• Getting Pregnant
• During Pregnancy
• Labor and Delivery
• After Pregnancy
• Pregnancy Book
• Mental Health
• Prenatal Testing
• Menstrual Health
• Heart Health
• Special Procedures
• Diseases and Conditions
• Browse All Topics
• View All Frequently Asked Questions

Read common questions on the coronavirus and ACOG’s evidence-based answers.

If Your Baby Is Breech

URL has been copied to the clipboard

Frequently Asked Questions Expand All

In the last weeks of pregnancy, a fetus 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 fetus’s buttocks, feet, or both are in place to come out first during birth. This happens in 3–4% of full-term births.

It is not always known why a fetus is breech. Some factors that may contribute to a fetus being in a breech presentation include the following:

You have been pregnant before.

There is more than one fetus in the uterus (twins or more).

There is too much or too little amniotic fluid .

The uterus is not normal in shape or has abnormal growths such as fibroids .

The placenta covers all or part of the opening of the uterus ( placenta previa )

The fetus is preterm .

Occasionally fetuses with certain birth defects will not turn into the head-down position before birth. However, most fetuses in a breech presentation are otherwise normal.

Your health care professional may be able to tell which way your fetus is facing by placing his or her hands at certain points on your abdomen. By feeling where the fetus's head, back, and buttocks are, it may be possible to find out what part of the fetus is presenting first. An ultrasound exam or pelvic exam may be used to confirm it.

External cephalic version (ECV) is an attempt to turn the fetus so that he or she is head down. ECV can improve your chance of having a vaginal birth. If the fetus is breech and your pregnancy is greater than 36 weeks your health care professional may suggest ECV.

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 )

ECV can be considered if you have had a previous cesarean delivery .

The health care professional performs ECV by placing his or her hands on your abdomen. Firm pressure is applied to the abdomen so that the fetus rolls into a head-down position. Two people may be needed to perform ECV. Ultrasound also may be used to help guide the turning.

The fetus's heart rate is checked with fetal monitoring before and after ECV. If any problems arise with you or the fetus, ECV will be stopped right away. ECV usually is done near a delivery room. If a problem occurs, a cesarean delivery can be performed quickly, if necessary.

Complications may include the following:

Prelabor rupture of membranes

Changes in the fetus's heart rate

Placental abruption

Preterm labor

More than one half of attempts at ECV succeed. However, some fetuses who are successfully turned with ECV move back into a breech presentation. If this happens, ECV may be tried again. ECV tends to be harder to do as the time for birth gets closer. As the fetus grows bigger, there is less room for him or her to move.

Most fetuses that are breech are born by planned cesarean delivery. A planned vaginal birth of a single breech fetus may be considered in some situations. Both vaginal birth and cesarean birth carry certain risks when a fetus is breech. However, the risk of complications is higher with a planned vaginal delivery than with a planned cesarean delivery.

In a breech presentation, the body comes out first, leaving the baby’s head to be delivered last. The baby’s body may not stretch the cervix enough to allow room for the baby’s head to come out easily. There is a risk that the baby’s head or shoulders may become wedged against the bones of the mother’s pelvis. Another problem that can happen during a vaginal breech birth is a prolapsed umbilical cord . It can slip into the vagina before the baby is delivered. If there is pressure put on the cord or it becomes pinched, it can decrease the flow of blood and oxygen through the cord to the baby.

Although a planned cesarean birth is the most common way that breech fetuses are born, there may be reasons to try to avoid a cesarean birth.

A cesarean delivery is major surgery. Complications may include infection, bleeding, or injury to internal organs.

The type of anesthesia used sometimes causes problems.

Having a cesarean delivery also can lead to serious problems in future pregnancies, such as rupture of the uterus and complications with the placenta.

With each cesarean delivery, these risks increase.

If you are thinking about having a vaginal birth and your fetus is breech, your health care professional will review the risks and benefits of vaginal birth and cesarean birth in detail. You usually need to meet certain guidelines specific to your hospital. The experience of your health care professional in delivering breech babies vaginally also is an important factor.

Amniotic Fluid : Fluid in the sac that holds the fetus.

Anesthesia : Relief of pain by loss of sensation.

Breech Presentation : A position in which the feet or buttocks of the fetus would appear first during birth.

Cervix : The lower, narrow end of the uterus at the top of the vagina.

Cesarean Delivery : Delivery of a fetus from the uterus through an incision made in the woman’s abdomen.

External Cephalic Version (ECV) : A technique, performed late in pregnancy, in which the doctor attempts to manually move a breech baby into the head-down position.

Fetus : The stage of human development beyond 8 completed weeks after fertilization.

Fibroids : Growths that form in the muscle of the uterus. Fibroids usually are noncancerous.

Oxygen : An element that we breathe in to sustain life.

Pelvic Exam : A physical examination of a woman’s pelvic organs.

Placenta : Tissue that provides nourishment to and takes waste away from the fetus.

Placenta Previa : A condition in which the placenta covers the opening of the uterus.

Placental Abruption : A condition in which the placenta has begun to separate from the uterus before the fetus is born.

Prelabor Rupture of Membranes : Rupture of the amniotic membranes that happens before labor begins. Also called premature rupture of membranes (PROM).

Preterm : Less than 37 weeks of pregnancy.

Ultrasound Exam : A test in which sound waves are used to examine inner parts of the body. During pregnancy, ultrasound can be used to check the fetus.

Umbilical Cord : A cord-like structure containing blood vessels. It connects the fetus to the placenta.

Uterus : A muscular organ in the female pelvis. During pregnancy, this organ holds and nourishes the fetus.

Vagina : A tube-like structure surrounded by muscles. The vagina leads from the uterus to the outside of the body.

Vertex Presentation : A presentation of the fetus where the head is positioned down.

Article continues below

Advertisement

If you have further questions, contact your ob-gyn.

Don't have an ob-gyn? Learn how to find a doctor near you .

Published: January 2019

Last reviewed: August 2022

Copyright 2024 by the American College of Obstetricians and Gynecologists. All rights reserved. Read copyright and permissions information . This information is designed as an educational aid for the public. It offers current information and opinions related to women's health. It is not intended as a statement of the standard of care. It does not explain all of the proper treatments or methods of care. It is not a substitute for the advice of a physician. Read ACOG’s complete disclaimer .

Clinicians: Subscribe to Digital Pamphlets

Explore ACOG's library of patient education pamphlets.

A Guide to Pregnancy from Ob-Gyns

For trusted, in-depth advice from ob-gyns, turn to Your Pregnancy and Childbirth: Month to Month.

ACOG Explains

A quick and easy way to learn more about your health.

What to Read Next

Cesarean Birth

Fetal Heart Rate Monitoring During Labor

What is back labor?

What is delayed cord clamping?

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

• Variations in Fetal Position and Presentation |

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

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

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

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

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

Head first (called vertex or cephalic presentation)

Facing backward (occiput anterior position)

Spine parallel to mother's spine (longitudinal lie)

Neck bent forward with chin tucked

Arms folded across the chest

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

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

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

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

The fetus has a birth defect .

There is more than one fetus (multiple gestation).

Position and Presentation of the Fetus

Variations in Fetal Position and Presentation

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

Occiput posterior position

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

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

Breech presentation

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

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

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

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

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

Labor starts too soon (preterm labor).

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

Other presentations

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

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

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

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

Copyright © 2024 Merck & Co., Inc., Rahway, NJ, USA and its affiliates. All rights reserved.

• Cookie Preferences

• Search Please fill out this field.
• Newsletters
• Sweepstakes
• Pregnancy Complications

What Does It Mean to Have a Frank Breech Baby?

Frank breech is the most common type of breech position. Learn what this position means for you and your baby.

• Types of Breech Positions

How To Tell If Your Baby Is Breech

Causes of breech presentations, treatment for breech presentations, complications of a breech birth, what happens if my baby is breech.

If your baby is in a frank breech position, that means that their bottom is facing down towards the birth canal instead of their head. The part of the baby that is nearest to the cervix is called the presenting part. The presenting part, which is the part of the baby's body that is born first in a vaginal delivery , is usually the baby's head (known as vertex presentation).

In a small number of deliveries, however, a baby’s bottom or feet are in a position to be born first. This is called a breech presentation, and frank breech (bottom first, with feet up near the head) is the most common type.

Learn about the types of breech presentation including frank breech, what causes a baby to be breech, how it's treated, and what to expect with a breech delivery.

Jamie Grill / Getty Images 

Frank Breech and Other Types of Breech Positions

Babies can be in all sorts of positions during pregnancy, but most babies eventually turn head down in late pregnancy. As pregnancy progresses, the more likely it is that the baby will turn and the head will be down near the cervix when it's time for delivery.

Breech Presentation Statistics

• Before the 28th week of pregnancy, about 20% to 25% of babies are breech.
• By the 34th week of pregnancy, most babies will turn and approximately 5% to 7% will be breech.
• By full term, only 3% to 4% of babies (3 or 4 out of every 100 births) are breech.

Sometimes, however, babies are in a breech (bottom or leg down) position when labor begins. There are several types of breech positions.

Frank breech

A frank breech position is when the baby’s bottom is down, but their legs are straight up with their feet near their head. The presenting part is the buttocks.

A frank breech is the most common breech presentation, especially when a baby is born at full term. Of the 3% to 4% of term breech births, babies are in the frank breech position 50% to 70% of the time.

Complete breech

In this position, the bottom is down, but the baby's knees are also bent, so the feet are also down near the buttocks. The presenting part is not only the bottom but both feet as well. At delivery, about 10% of breech babies are in a complete breech position.

Incomplete (footling) breech

A footling breech position is when the baby’s legs are extended and facing straight down. Instead of the bottom, the presenting part is one foot (a single footling) or both feet (a double footling). Approximately 25% of breech deliveries are incomplete.

As your pregnancy progresses, your prenatal health care provider will examine you and keep track of your baby’s position . You might even be able to figure out how your baby is positioned on your own.

Here are some of the techniques you and your health care provider can use to tell which way your baby is facing.

• Kicks : You can feel where your baby is kicking you and judge their general position. If you feel kicks in your lower pelvis, then the baby hasn’t turned head down yet. But if the kicks are up toward your ribs and the top of your uterus, then the baby’s head is most likely facing down.
• Palpation : At your prenatal visits, your doctor or midwife will check your baby's position by palpating or feeling your belly to find the baby’s head, back, and bottom.
• Heartbeat : Listening to the baby’s heartbeat is another way to tell where your baby is in the uterus. By finding the heartbeat's location, the doctor or midwife can get a better idea of the baby’s position.
• Ultrasound : An ultrasound provides the best position information. It shows you and your health care team a picture of the baby and their exact position in your uterus. If your baby is breech, the ultrasound can determine the type of breech position your baby is in, such as frank breech or complete breech.
• Pelvic exam : During labor, your health care provider can perform a pelvic examination . They will be able to feel whether the baby’s head or their bottom and feet are in the birth canal.

The size of the baby, amount of amniotic fluid , and amount of space inside the uterus are all factors that can contribute to a baby’s ability to move around.

The most common reason for a breech presentation is prematurity, but other factors could lead to a baby in a breech position:

• Premature delivery : A premature baby is smaller and has more room inside the uterus to move around, which increases the chances that they will be in a breech presentation if you go into preterm labor .
• Multiples : Twins or other multiples have less room in the uterus to move around and get into the head-down position for delivery.
• Uterine issues : Fibroids or a heart-shaped uterus can get in the way of the baby’s ability to turn.
• Shortened umbilical cord : If the umbilical cord is very short, the baby may not be able to move and turn.
• Too much or too little amniotic fluid : Too much amniotic fluid gives the baby the ability to move around freely in the uterus. As they grow, they may still be able to flip and turn rather than turning head down and staying head down. Too little amniotic fluid , on the other hand, may prevent a baby from moving into the head-down position as they get closer to full-term.
• Location of the placenta : When the placenta is low and covers all or part of the cervix, it’s called placenta previa . When the placenta is in this position, it takes up the room at the bottom of the uterus and can make it difficult for the baby to turn head down.
• Congenital abnormalities in the baby : Some congenital abnormalities can affect the baby’s ability to move into the head-down position. These conditions are usually not a surprise at delivery since they are typically seen during prenatal ultrasound examinations .

If your baby is breech, you will face four possible outcomes to your pregnancy:

• Your baby may turn on its own . Especially if it's early in your pregnancy, there is a chance your baby will turn from a breech position to a head-down position. Many prenatal health care providers will take a wait-and-see approach early on.
• Your doctor may attempt to manually turn your baby . If there are no complications in your pregnancy and the baby has not yet turned on its own by the 36th or 37th week, your doctor may attempt to turn the baby using a manual procedure called external cephalic version (ECV). ECV works approximately 60% of the time.
• Your doctor may schedule a C-section . For a baby that remains in a breech position in late pregnancy, most doctors will recommend a surgical birth via a C-section .
• Your doctor may agree to help you attempt a vaginal delivery . The majority of pregnancy care providers will not deliver a breech baby vaginally, but a small percentage of doctors may be willing to work with you having a vaginal delivery with a breech baby.

You can also do some things to encourage your baby to turn head down , such as acupuncture and exercises like pelvic tilts and even walking.

Most babies who are born breech are healthy. But when a baby is frank breech or in any other breech position, there is a higher chance of a complicated labor and delivery. Here are some of the complications associated with breech birth.

Umbilical cord prolapse

During a vaginal breech delivery, there is a chance that the umbilical cord will come down through the cervix before the baby is born. As the baby comes through the birth canal, their body and head can press on the cord and cut off the supply of blood and oxygen that the cord is carrying.

This can affect the baby’s heart rate and the flow of oxygen and blood to the baby’s brain. The danger of a prolapsed cord is greater with a footling breech and a complete breech.

The risk of cord prolapse is less when the baby is in the frank breech position.

Head entrapment

The baby’s head can get stuck during the delivery if the baby’s body is born before the cervix fully dilates. This situation is dangerous since the head can press against the umbilical cord and cause asphyxia or a lack of oxygen.

Head entrapment is more common in premature deliveries because the baby’s head is typically bigger than their body.

Physical injuries to the baby

The risk of injury to the baby during delivery is higher when the baby is breech compared to when the baby is not breech. Preemies are more likely to injure their head and skull. Bruising, broken bones, and dislocated joints can also occur depending on the baby's position during birth.

Additionally, after a baby is born, breech newborns have a higher incidence of neonatal hip instability, also called developmental dysplasia of the hip (DDH). This complication occurs in between 12% to 24% of breech babies.

Physical injury to the gestational parent

The vaginal delivery of a breech baby can require an episiotomy and the use of forceps, which can cause injury to the birthing person's genital area.

Many babies will turn to the head-down position before labor begins. However, if your baby is still breech when labor begins, you and your doctor will have to decide between having a C-section or trying a vaginal birth.

Whenever possible, the standard choice is to deliver any breech baby who is premature or in distress via cesarean section. Since vaginal deliveries, even when all the above criteria are met, come with a higher risk of a difficult birth and birth injuries, most doctors prefer to deliver all breech presentations by C-section.

However, when there are no other complications, a baby in the frank breech position may be delivered vaginally if the doctor agrees to it and certain conditions are met:

• Emergency resources are available
• The baby is at least 36 weeks
• The baby is not too big or too small
• The baby’s head is in the right position (flexed)
• The health care team has experience with breech deliveries
• The size of your pelvis is large enough
• There is continuous monitoring of the baby
• You have delivered vaginally before

If any complications arise during the delivery, you may still need an emergency C-section .

If Your Baby Is Breech . American College of Obstetricians and Gynecologists . 2024.

A comparison of risk factors for breech presentation in preterm and term labor: A nationwide, population-based case-control study . Arch Gynecol Obstet . 2020.

Breech presentation: Vaginal versus cesarean delivery, which intervention leads to the best outcomes? . Acta Med Port. 2017.

Breech presentation . Medscape . 2022.

Breech presentation: CNGOF Guidelines for Clinical Practice - Information and management . Gynecol Obstet Fertil Senol. 2020.

Mode of Term Singleton Breech Delivery . American College of Obstetricians and Gynecologists . 2023.

Umbilical Cord Prolapse . StatPearls . 2023.

Incidence of acetabular dysplasia in breech infants following initially normal ultrasound: the effect of variable diagnostic criteria . J Child Orthop . 2017.

Related Articles

Warning: The NCBI web site requires JavaScript to function. more...

An official website of the United States government

The .gov means it's official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings
• Browse Titles

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

• Management of breech presentation

Evidence review M

NICE Guideline, No. 201

National Guideline Alliance (UK) .

• Copyright and Permissions

Review question

What is the most effective way of managing a longitudinal lie fetal malpresentation (breech presentation) in late pregnancy?

Introduction

Breech presentation of the fetus in late pregnancy may result in prolonged or obstructed labour with resulting risks to both woman and fetus. Interventions to correct breech presentation (to cephalic) before labour and birth are important for the woman’s and the baby’s health. The aim of this review is to determine the most effective way of managing a breech presentation in late pregnancy.

Summary of the protocol

Please see Table 1 for a summary of the Population, Intervention, Comparison and Outcome (PICO) characteristics of this review.

Summary of the protocol (PICO table).

For further details see the review protocol in appendix A .

Methods and process

This evidence review was developed using the methods and process described in Developing NICE guidelines: the manual 2014 . Methods specific to this review question are described in the review protocol in appendix A .

Declarations of interest were recorded according to NICE’s conflicts of interest policy .

Clinical evidence

Included studies.

Thirty-six randomised controlled trials (RCTs) were identified for this review.

The included studies are summarised in Table 2 .

Three studies reported on external cephalic version (ECV) versus no intervention ( Dafallah 2004 , Hofmeyr 1983 , Rita 2011 ). One study reported on a 4-arm trial comparing acupuncture, sweeping of fetal membranes, acupuncture plus sweeping, and no intervention ( Andersen 2013 ). Two studies reported on postural management versus no intervention ( Chenia 1987 , Smith 1999 ).

Seven studies reported on ECV plus anaesthesia ( Chalifoux 2017 , Dugoff 1999 , Khaw 2015 , Mancuso 2000 , Schorr 1997 , Sullivan 2009 , Weiniger 2010 ). Of these studies, 1 study compared ECV plus anaesthesia to ECV plus other dosages of the same anaesthetic ( Chalifoux 2017 ); 4 studies compared ECV plus anaesthesia to ECV only ( Dugoff 1999 , Mancuso 2000 , Schorr 1997 , Weiniger 2010 ); and 2 studies compared ECV plus anaesthesia to ECV plus a different anaesthetic ( Khaw 2015 , Sullivan 2009 ).

Ten studies reported ECV plus a β2 receptor agonist ( Brocks 1984 , Fernandez 1997 , Hindawi 2005 , Impey 2005 , Mahomed 1991 , Marquette 1996 , Nor Azlin 2005 , Robertson 1987 , Van Dorsten 1981 , Vani 2009 ). Of these studies, 5 studies compared ECV plus a β2 receptor agonist to ECV plus placebo ( Fernandez 1997 , Impey 2005 , Marquette 1996 , Nor Azlin 2005 , Vani 2009 ); 1 study compared ECV plus a β2 receptor agonist to ECV alone ( Robertson 1987 ); and 4 studies compared ECV plus a β2 receptor agonist to no intervention ( Brocks 1984 , Hindawi 2005 , Mahomed 1991 , Van Dorsten 1981 ).

One study reported on ECV plus Ca 2+ channel blocker versus ECV plus placebo ( Kok 2008 ). Two studies reported on ECV plus β2 receptor agonist versus ECV plus Ca 2+ channel blocker ( Collaris 2009 , Mohamed Ismail 2008 ). Four studies reported on ECV plus a µ-receptor agonist ( Burgos 2016 , Liu 2016 , Munoz 2014 , Wang 2017 ), of which 3 compared against ECV plus placebo ( Liu 2016 , Munoz 2014 , Wang 2017 ) and 1 compared to ECV plus nitrous oxide ( Burgos 2016 ).

Four studies reported on ECV plus nitroglycerin ( Bujold 2003a , Bujold 2003b , El-Sayed 2004 , Hilton 2009 ), of which 2 compared it to ECV plus β2 receptor agonist ( Bujold 2003b , El-Sayed 2004 ) and compared it to ECV plus placebo ( Bujold 2003a , Hilton 2009 ). One study compared ECV plus amnioinfusion versus ECV alone ( Diguisto 2018 ) and 1 study compared ECV plus talcum powder to ECV plus gel ( Vallikkannu 2014 ).

One study was conducted in Australia ( Smith 1999 ); 4 studies in Canada ( Bujold 2003a , Bujold 2003b , Hilton 2009 , Marquette 1996 ); 2 studies in China ( Liu 2016 , Wang 2017 ); 2 studies in Denmark ( Andersen 2013 , Brocks 1984 ); 1 study in France ( Diguisto 2018 ); 1 study in Hong Kong ( Khaw 2015 ); 1 study in India ( Rita 2011 ); 1 study in Israel ( Weiniger 2010 ); 1 study in Jordan ( Hindawi 2005 ); 5 studies in Malaysia ( Collaris 2009 , Mohamed Ismail 2008 , Nor Azlin 2005 , Vallikkannu 2014 , Vani 2009 ); 1 study in South Africa ( Hofmeyr 1983 ); 2 studies in Spain ( Burgos 2016 , Munoz 2014 ); 1 study in Sudan ( Dafallah 2004 ); 1 study in The Netherlands ( Kok 2008 ); 2 studies in the UK ( Impey 2005 , Chenia 1987 ); 9 studies in US ( Chalifoux 2017 , Dugoff 1999 , El-Sayed 2004 , Fernandez 1997 , Mancuso 2000 , Robertson 1987 , Schorr 1997 , Sullivan 2009 , Van Dorsten 1981 ); and 1 study in Zimbabwe ( Mahomed 1991 ).

The majority of studies were 2-arm trials, but there was one 3-arm trial ( Khaw 2015 ) and two 4-arm trials ( Andersen 2013 , Chalifoux 2017 ). All studies were conducted in a hospital or an outpatient ward connected to a hospital.

See the literature search strategy in appendix B and study selection flow chart in appendix C .

Excluded studies

Studies not included in this review with reasons for their exclusions are provided in appendix K .

Summary of clinical studies included in the evidence review

Summaries of the studies that were included in this review are presented in Table 2 .

Summary of included studies.

See the full evidence tables in appendix D and the forest plots in appendix E .

Quality assessment of clinical outcomes included in the evidence review

See the evidence profiles in appendix F .

Economic evidence

A systematic review of the economic literature was conducted but no economic studies were identified which were applicable to this review question.

A single economic search was undertaken for all topics included in the scope of this guideline. See supplementary material 2 for details.

Economic studies not included in this review are listed, and reasons for their exclusion are provided in appendix K .

Summary of studies included in the economic evidence review

No economic studies were identified which were applicable to this review question.

Economic model

No economic modelling was undertaken for this review because the committee agreed that other topics were higher priorities for economic evaluation.

Evidence statements

Clinical evidence statements, comparison 1. complementary therapy versus control (no intervention), critical outcomes, cephalic presentation in labour.

No evidence was identified to inform this outcome.

Method of birth

Caesarean section.

• Very low quality evidence from 1 RCT (N=204) showed that there is no clinically important difference between acupuncture and control (no intervention) on the number of caesarean sections in pregnant women with breech presentation: RR 0.74 (95% CI 0.38 to 1.43).
• Very low quality evidence from 1 RCT (N=200) showed that there is no clinically important difference between acupuncture plus membrane sweeping and control (no intervention) on the number of caesarean sections in pregnant women with breech presentation: RR 1.29 (95% CI 0.73 to 2.29).

Admission to SCBU/NICU

• Very low quality evidence from 1 RCT (N=204) showed that there is no clinically important difference between acupuncture and control (no intervention) on admission to SCBU/NICU in pregnant women with breech presentation: RR 0.19 (95% CI 0.02 to 1.62).
• Very low quality evidence from 1 RCT (N=200) showed that there is no clinically important difference between acupuncture plus membrane sweeping and control (no intervention) on admission to SCBU/NICU in pregnant women with breech presentation: RR 0.40 (0.08 to 2.01).

Fetal death after 36 +0 weeks gestation

Infant death up to 4 weeks chronological age, important outcomes, apgar score <7 at 5 minutes.

• Very low quality evidence from 1 RCT (N=204) showed that there is no clinically important difference between acupuncture and control (no intervention) on Apgar score <7 at 5 minutes in pregnant women with breech presentation: RR 0.32 (95% CI 0.01 to 7.78).
• Very low quality evidence from 1 RCT (N=200) showed that there is no clinically important difference between acupuncture plus membrane sweeping and control (no intervention) on Apgar score <7 at 5 minutes in pregnant women with breech presentation: RR 0.33 (0.01 to 8.09).

Birth before 39 +0 weeks of gestation

Comparison 2. complementary therapy versus other treatment.

• Low quality evidence from 1 RCT (N=207) showed that there is no clinically important difference between acupuncture and membrane sweeping on the number of caesarean sections in pregnant women with breech presentation: RR 0.64 (95% CI 0.34 to 1.22).
• Low quality evidence from 1 RCT (N=204) showed that there is no clinically important difference between acupuncture and acupuncture plus membrane sweeping on the number of caesarean sections in pregnant women with breech presentation: RR 0.57 (95% CI 0.30 to 1.07).
• Very low quality evidence from 1 RCT (N=203) showed that there is no clinically important difference between acupuncture plus membrane sweeping and membrane sweeping on the number of caesarean sections in pregnant women with breech presentation: RR 1.13 (95% CI 0.66 to 1.94).
• Very low quality evidence from 1 RCT (N=207) showed that there is no clinically important difference between acupuncture and membrane sweeping on admission to SCBU/NICU in pregnant women with breech presentation: RR 0.33 (95% CI 0.03 to 3.12).
• Very low quality evidence from 1 RCT (N=204) showed that there is no clinically important difference between acupuncture and acupuncture plus membrane sweeping on admission to SCBU/NICU in pregnant women with breech presentation: RR 0.48 (95% CI 0.04 to 5.22).
• Very low quality evidence from 1 RCT (N=203) showed that there is no clinically important difference between acupuncture plus membrane sweeping and membrane sweeping on admission to SCBU/NICU in pregnant women with breech presentation: RR 0.69 (95% CI 0.12 to 4.02).
• Low quality evidence from 1 RCT (N=207) showed that there is no clinically important difference between acupuncture and membrane sweeping on Apgar score <7 at 5 minutes in pregnant women with breech presentation: RD 0.00 (95% CI −0.02 to 0.02).
• Low quality evidence from 1 RCT (N=204) showed that there is no clinically important difference between acupuncture and acupuncture plus membrane sweeping on Apgar score <7 at 5 minutes in pregnant women with breech presentation: RD 0.00 (95% CI −0.02 to 0.02).
• Low quality evidence from 1 RCT (N=203) showed that there is no clinically important difference between acupuncture plus membrane sweeping and membrane sweeping on Apgar score <7 at 5 minutes in pregnant women with breech presentation: RD 0.00 (95% CI −0.02 to 0.02).

Comparison 3. ECV versus no ECV

• Moderate quality evidence from 2 RCTs (N=680) showed that there is clinically important difference favouring ECV over no ECV on cephalic presentation in labour in pregnant women with breech presentation: RR 1.83 (95% CI 1.53 to 2.18).

Cephalic vaginal birth

• Very low quality evidence from 3 RCTs (N=740) showed that there is a clinically important difference favouring ECV over no ECV on cephalic vaginal birth in pregnant women with breech presentation: RR 1.67 (95% CI 1.20 to 2.31).

Breech vaginal birth

• Very low quality evidence from 2 RCTs (N=680) showed that there is no clinically important difference between ECV and no ECV on breech vaginal birth in pregnant women with breech presentation: RR 0.29 (95% CI 0.03 to 2.84).
• Very low quality evidence from 3 RCTs (N=740) showed that there is no clinically important difference between ECV and no ECV on the number of caesarean sections in pregnant women with breech presentation: RR 0.52 (95% CI 0.23 to 1.20).
• Very low quality evidence from 1 RCT (N=60) showed that there is no clinically important difference between ECV and no ECV on admission to SCBU//NICU in pregnant women with breech presentation: RR 0.50 (95% CI 0.14 to 1.82).
• Very low evidence from 3 RCTs (N=740) showed that there is no statistically significant difference between ECV and no ECV on fetal death after 36 +0 weeks gestation in pregnant women with breech presentation: Peto OR 0.29 (95% CI 0.05 to 1.73) p=0.18.
• Very low quality evidence from 2 RCTs (N=120) showed that there is no clinically important difference between ECV and no ECV on Apgar score <7 at 5 minutes in pregnant women with breech presentation: Peto OR 0.28 (95% CI 0.04 to 1.70).

Comparison 4. ECV + Amnioinfusion versus ECV only

• Very low quality evidence from 1 RCT (N=109) showed that there is no clinically important difference between ECV plus amnioinfusion and ECV alone on cephalic presentation in labour in pregnant women with breech presentation: RR 1.74 (95% CI 0.74 to 4.12).
• Low quality evidence from 1 RCT (N=109) showed that there is no clinically important difference between ECV plus amnioinfusion and ECV alone on the number of caesarean sections in pregnant women with breech presentation: RR 0.95 (95% CI 0.75 to 1.19).

Comparison 5. ECV + Anaesthesia versus ECV only

• Very low quality evidence from 2 RCTs (N=210) showed that there is no clinically important difference between ECV plus anaesthesia and ECV alone on cephalic presentation in labour in pregnant women with breech presentation: RR 1.16 (95% CI 0.56 to 2.41).
• Very low quality evidence from 5 RCTs (N=435) showed that there is no clinically important difference between ECV plus anaesthesia and ECV alone on cephalic vaginal birth in pregnant women with breech presentation: RR 1.16 (95% CI 0.77 to 1.74).
• Very low quality evidence from 1 RCT (N=108) showed that there is no clinically important difference between ECV plus anaesthesia and ECV alone on breech vaginal birth in pregnant women with breech presentation: RR 0.33 (95% CI 0.04 to 3.10).
• Very low quality evidence from 3 RCTs (N=263) showed that there is no clinically important difference between ECV plus anaesthesia and ECV alone on the number of caesarean sections in pregnant women with breech presentation: RR 0.76 (95% CI 0.42 to 1.38).
• Moderate quality evidence from 1 RCT (N=69) showed that there is a clinically important difference favouring ECV plus anaesthesia over ECV alone on admission to SCBU/NICU in pregnant women with breech presentation: MD −1.80 (95% CI −2.53 to −1.07).
• Low quality evidence from 1 RCT (N=126) showed that there is no clinically important difference between ECV plus anaesthesia and ECV alone on Apgar score <7 at 5 minutes in pregnant women with breech presentation: RD 0.00 (95% CI −0.03 to 0.03).

Comparison 6. ECV + Anaesthesia versus ECV + Anaesthesia

• Very low quality evidence from 1 RCT (N=120) showed that there is no clinically important difference between ECV plus 2.5mg Bupivacaine plus 0.015mg Fentanyl and ECV plus 5mg Bupivacaine plus 0.015mg Fentanyl on cephalic vaginal birth in pregnant women with breech presentation: RR 1.13 (95% CI 0.73 to 1.74).
• Low quality evidence from 1 RCT (N=119) showed that there is no clinically important difference between ECV plus 2.5mg Bupivacaine plus 0.015mg Fentanyl and ECV plus 7.5mg Bupivacaine plus 0.015mg Fentanyl on cephalic vaginal birth in pregnant women with breech presentation: RR 0.81 (95% CI 0.53 to 1.23).
• Very low quality evidence from 1 RCT (N=120) showed that there is no clinically important difference between ECV plus 2.5mg Bupivacaine plus 0.015mg Fentanyl and ECV plus 10mg Bupivacaine plus 0.015mg Fentanyl on cephalic vaginal birth in pregnant women with breech presentation: RR 0.96 (95% CI 0.61 to 1.50).
• Very low quality evidence from 1 RCT (N=95) showed that there is no clinically important difference between ECV plus 2.5mg Bupivacaine plus 0.015mg Fentanyl and ECV plus 0.05mg Fentanyl on cephalic vaginal birth in pregnant women with breech presentation: RR 0.69 (95% CI 0.37 to 1.28).
• Low quality evidence from 1 RCT (N=119) showed that there is no clinically important difference between ECV plus 5mg Bupivacaine plus 0.015mg Fentanyl and ECV plus 7.5mg Bupivacaine plus 0.015mg Fentanyl on cephalic vaginal birth in pregnant women with breech presentation: RR 0.81 (95% CI 0.53 to 1.23).
• Very low quality evidence from 1 RCT (N=120) showed that there is no clinically important difference between ECV plus 5mg Bupivacaine plus 0.015mg Fentanyl and ECV plus 10mg Bupivacaine plus 0.015mg Fentanyl on cephalic vaginal birth in pregnant women with breech presentation: RR 0.96 (95% CI 0.61 to 1.50).
• Very low evidence from 1 RCT (N=119) showed that there is no clinically important difference between ECV plus 7.5mg Bupivacaine plus 0.015mg Fentanyl and ECV plus 10mg Bupivacaine plus 0.015mg Fentanyl on cephalic vaginal birth in pregnant women with breech presentation: RR 1.19 (95% CI 0.79 to 1.79).
• Low quality evidence from 1 RCT (N=120) showed that there is no clinically important difference between ECV plus 2.5mg Bupivacaine plus 0.015mg Fentanyl and ECV plus 5mg Bupivacaine plus 0.015mg Fentanyl on the number of caesarean sections in pregnant women with breech presentation: RR 0.92 (95% CI 0.68 to 1.24).
• Very low evidence from 1 RCT (N=119) showed that there is no clinically important difference between ECV plus 2.5mg Bupivacaine plus 0.015mg Fentanyl and ECV plus 7.5mg Bupivacaine plus 0.015mg Fentanyl on the number of caesarean sections in pregnant women with breech presentation: RR 1.08 (95% CI 0.78 to 1.50).
• Very low evidence from 1 RCT (N=120) showed that there is no clinically important difference between ECV plus 2.5mg Bupivacaine plus 0.015mg Fentanyl and ECV plus 10mg Bupivacaine plus 0.015mg Fentanyl on the number of caesarean sections in pregnant women with breech presentation: RR 0.94 (95% CI 0.70 to 1.28).
• Low quality evidence from 1 RCT (N=119) showed that there is no clinically important difference between ECV plus 5mg Bupivacaine plus 0.015mg Fentanyl and ECV plus 7.5mg Bupivacaine plus 0.015mg Fentanyl on the number of caesarean sections in pregnant women with breech presentation: RR 1.17 (95% CI 0.86 to 1.61).
• Very low quality evidence from 1 RCT (N=120) showed that there is no clinically important difference between ECV plus 5mg Bupivacaine plus 0.015mg Fentanyl and ECV plus 10mg Bupivacaine plus 0.015mg Fentanyl on the number of caesarean sections in pregnant women with breech presentation: RR 1.03 (95% CI 0.77 to 1.37).
• Low quality evidence from 1 RCT (N=119) showed that there is no clinically important difference between ECV plus 7.5mg Bupivacaine plus 0.015mg Fentanyl and ECV plus 10mg Bupivacaine plus 0.015mg Fentanyl on the number of caesarean sections in pregnant women with breech presentation: RR 0.88 (95% CI 0.64 to 1.20).

Comparison 7. ECV + β2 agonist versus Control (no intervention)

• Moderate quality evidence from 2 RCTs (N=256) showed that there is a clinically important difference favouring ECV plus β2 agonist over control (no intervention) on cephalic presentation in labour in pregnant women with breech presentation: RR 4.83 (95% CI 3.27 to 7.11).
• Very low quality evidence from 3 RCTs (N=265) showed that there no clinically important difference between ECV plus β2 agonist and control (no intervention) on cephalic vaginal birth in pregnant women with breech presentation: RR 2.03 (95% CI 0.22 to 19.01).
• Very low quality evidence from 4 RCTs (N=513) showed that there is a clinically important difference favouring ECV plus β2 agonist over control (no intervention) on breech vaginal birth in pregnant women with breech presentation: RR 0.38 (95% CI 0.20 to 0.69).
• Low quality evidence from 4 RCTs (N=513) showed that there is a clinically important difference favouring ECV plus β2 agonist over control (no intervention) on the number of caesarean sections in pregnant women with breech presentation: RR 0.53 (95% CI 0.41 to 0.67).
• Very low quality evidence from 1 RCT (N=48) showed that there is no clinically important difference between ECV plus β2 agonist and control (no intervention) on admission to SCBU/NICU in pregnant women with breech presentation: RD 0.00 (95% CI −0.08 to 0.08).
• Very low quality evidence from 3 RCTs (N=208) showed that there is no statistically significant difference between ECV plus β2 agonist and control (no intervention) on fetal death after 36 +0 weeks gestation in pregnant women with breech presentation: RD −0.01 (95% CI −0.03 to 0.01) p=0.66.
• Very low quality evidence from 2 RCTs (N=208) showed that there is no clinically important difference between ECV plus β2 agonist and control (no intervention) on Apgar score <7 at 5 minutes in pregnant women with breech presentation: Peto OR 0.80 (95% CI 0.31 to 2.10).

Comparison 8. ECV + β2 agonist versus ECV only

• Very low quality evidence from 2 RCTs (N=172) showed that there is no clinically important difference between ECV plus β2 agonist and ECV only on cephalic vaginal birth in pregnant women with breech presentation: RR 1.32 (95% CI 0.67 to 2.62).
• Very low quality evidence from 1 RCT (N=58) showed that there is no clinically important difference between ECV plus β2 agonist and ECV only on breech vaginal birth in pregnant women with breech presentation: RR 0.75 (95% CI 0.22 to 2.50).
• Very low quality evidence from 2 RCTs (N=172) showed that there is no clinically important difference between ECV plus β2 agonist and ECV only on the number of caesarean sections in pregnant women with breech presentation: RR 0.79 (95% CI 0.27 to 2.28).
• Very low quality evidence from 1 RCT (N=114) showed that there is no clinically important difference between ECV plus β2 agonist and ECV only on admission to SCBU/NICU in pregnant women with breech presentation: RR 1.00 (95% CI 0.21 to 4.75).

Comparison 9. ECV + β2 agonist versus ECV + Placebo

• Very low quality evidence from 2 RCTs (N=146) showed that there is no clinically important difference between ECV plus β2 agonist and ECV plus placebo on cephalic presentation in labour in pregnant women with breech presentation: RR 1.54 (95% CI 0.24 to 9.76).
• Very low quality evidence from 2 RCTs (N=125) showed that there is no clinically important difference between ECV plus β2 agonist and ECV plus placebo on cephalic vaginal birth in pregnant women with breech presentation: RR 1.27 (95% CI 0.41 to 3.89).
• Very low quality evidence from 2 RCTs (N=227) showed that there is no clinically important difference between ECV plus β2 agonist and ECV plus placebo on breech vaginal birth in pregnant women with breech presentation: RR 1.00 (95% CI 0.33 to 2.97).
• Low quality evidence from 4 RCTs (N=532) showed that there is no clinically important difference between ECV plus β2 agonist and ECV plus placebo on the number of caesarean sections in pregnant women with breech presentation: RR 0.81 (95% CI 0.72 to 0.92)
• Very low quality evidence from 2 RCTs (N=146) showed that there is no clinically important difference between ECV plus β2 agonist and ECV plus placebo on admission to SCBU/NICU in pregnant women with breech presentation: RR 0.78 (95% CI 0.17 to 3.63).
• Very low quality evidence from 1 RCT (N=124) showed that there is no clinically important difference between ECV plus β2 agonist and ECV plus placebo on Apgar score <7 at 5 minutes in pregnant women with breech presentation: RD 0.00 (95% CI −0.03 to 0.03).

Comparison 10. ECV + Ca 2+ channel blocker versus ECV + Placebo

• Moderate quality evidence from 1 RCT (N=310) showed that there is no clinically important difference between ECV plus Ca 2+ channel blocker and ECV plus placebo on cephalic presentation in labour in pregnant women with breech presentation: RR 1.13 (95% CI 0.87 to 1.48).
• Moderate quality evidence from 1 RCT (N=310) showed that there is no clinically important difference between ECV plus Ca 2+ channel blocker and ECV plus placebo on cephalic vaginal birth in pregnant women with breech presentation: RR 0.90 (95% CI 0.73 to 1.12).
• Moderate quality evidence from 1 RCT (N=310) showed that there is no clinically important difference between ECV plus Ca 2+ channel blocker and ECV plus placebo on the number of caesarean sections in pregnant women with breech presentation: RR 1.11 (95% CI 0.88 to 1.40).
• High quality evidence from 1 RCT (N=310) showed that there is no clinically important difference between ECV plus Ca 2+ channel blocker and ECV plus placebo on admission to SCBU/NICU in pregnant women with breech presentation: MD −0.20 (95% CI −0.70 to 0.30).
• Moderate quality evidence from 1 RCT (N=310) showed that there is no statistically significant difference between ECV plus Ca 2+ channel blocker and ECV plus placebo on fetal death after 36 +0 weeks gestation in pregnant women with breech presentation: RD 0.00 (95% CI −0.01 to 0.01) p=1.00.
• Low quality evidence from 1 RCT (N=310) showed that there is no clinically important difference between ECV plus Ca 2+ channel blocker and ECV plus placebo on Apgar score <7 at 5 minutes in pregnant women with breech presentation: Peto OR 0.52 (95% 0.05 to 5.02).

Comparison 11. ECV + Ca2+ channel blocker versus ECV + β2 agonist

• Low quality evidence from 1 RCT (N=90) showed that there is a clinically important difference favouring ECV plus β2 agonist over ECV plus Ca 2+ channel blocker on cephalic presentation in labour in pregnant women with breech presentation: RR 0.62 (95% CI 0.39 to 0.98).
• Very low quality evidence from 2 RCTs (N=126) showed that there is no clinically important difference between ECV plus Ca 2+ channel blocker and ECV plus β2 agonist on cephalic vaginal birth in pregnant women with breech presentation: RR 1.26 (95% CI 0.55 to 2.89).
• Very low quality evidence from 2 RCTs (N=132) showed that there is a clinically important difference favouring ECV plus β2 agonist over ECV plus Ca 2+ channel blocker on the number of caesarean sections in pregnant women with breech presentation: RR 1.42 (95% CI 1.06 to 1.91).
• Very low quality evidence from 2 RCTs (N=176) showed that there is no clinically important difference between ECV plus Ca 2+ channel blocker and ECV plus β2 agonist on admission to SCBU/NICU in pregnant women with breech presentation: Peto OR 0.53 (95% CI 0.05 to 5.22).
• Very low quality evidence from 2 RCTs (N=176) showed that there is no clinically important difference between ECV plus Ca 2+ channel blocker and ECV plus β2 agonist on Apgar score <7 at 5 minutes in pregnant women with breech presentation: RD 0.00 (95% CI −0.03 to 0.03).

Comparison 12. ECV + µ-receptor agonist versus ECV only

• High quality evidence from 1 RCT (N=80) showed that there is no clinically important difference between ECV plus µ-receptor agonist and ECV alone on cephalic vaginal birth in pregnant women with breech presentation: RR 1.00 (95% CI 0.80 to 1.24).
• Low quality evidence from 1 RCT (N=80) showed that there is no clinically important difference between ECV plus µ-receptor agonist and ECV alone on the number of caesarean sections in pregnant women with breech presentation: RR 1.00 (95% CI 0.42 to 2.40).
• Low quality evidence from 1 RCT (N=126) showed that there is no clinically important difference between ECV plus µ-receptor agonist and ECV alone on Apgar score <7 at 5 minutes in pregnant women with breech presentation: RD 0.00 (95% CI −0.03 to 0.03).

Comparison 13. ECV + µ-receptor agonist versus ECV + Placebo

Cephalic vaginal birth after successful ecv.

• High quality evidence from 2 RCTs (N=98) showed that there is no clinically important difference between ECV plus µ-receptor agonist and ECV plus placebo on cephalic vaginal birth after successful ECV in pregnant women with breech presentation: RR 1.00 (95% CI 0.86 to 1.17).

Caesarean section after successful ECV

• Low quality evidence from 2 RCTs (N=98) showed that there is no clinically important difference between ECV plus µ-receptor agonist and ECV plus placebo on caesarean section after successful ECV in pregnant women with breech presentation: RR 0.97 (95% CI 0.33 to 2.84).

Breech vaginal birth after unsuccessful ECV

• High quality evidence from 3 RCTs (N=186) showed that there is a clinically important difference favouring ECV plus µ-receptor agonist over ECV plus placebo on breech vaginal birth after unsuccessful ECV in pregnant women with breech presentation: RR 0.10 (95% CI 0.02 to 0.53).

Caesarean section after unsuccessful ECV

• Moderate quality evidence from 3 RCTs (N=186) showed that there is no clinically important difference between ECV plus µ-receptor agonist and ECV plus placebo on caesarean section after unsuccessful ECV in pregnant women with breech presentation: RR 1.19 (95% CI 1.09 to 1.31).
• Low quality evidence from 1 RCT (N=137) showed that there is no statistically significant difference between ECV plus µ-receptor agonist and ECV plus placebo on fetal death after 36 +0 weeks gestation in pregnant women with breech presentation: RD 0.00 (95% CI −0.03 to 0.03) p=1.00.

Comparison 14. ECV + µ-receptor agonist versus ECV + Anaesthesia

• Moderate quality evidence from 1 RCT (N=92) showed that there is no clinically important difference between ECV plus µ-receptor agonist and ECV plus anaesthesia on cephalic vaginal birth in pregnant women with breech presentation: RR 1.04 (95% CI 0.84 to 1.29).
• Very low quality evidence from 2 RCTs (N=212) showed that there is no clinically important difference between ECV plus µ-receptor agonist and ECV plus anaesthesia on the number of caesarean sections in pregnant women with breech presentation: RR 0.90 (95% CI 0.61 to 1.34).
• Very low quality evidence from 1 RCT (N=129) showed that there is no clinically important difference between ECV plus µ-receptor agonist and ECV plus anaesthesia on admission to SCBU/NICU in pregnant women with breech presentation: RR 2.30 (95% CI 0.21 to 24.74).
• Low quality evidence from 2 RCTs (N=255) showed that there is no clinically important difference between ECV plus µ-receptor agonist and ECV plus anaesthesia on Apgar score <7 at 5 minutes in pregnant women with breech presentation: RD 0.00 (95% CI −0.02 to 0.02).

Comparison 15. ECV + Nitric oxide donor versus ECV + Placebo

• Very low quality evidence from 3 RCTs (N=224) showed that there is no clinically important difference between ECV plus nitric oxide donor and ECV plus placebo on cephalic presentation in labour in pregnant women with breech presentation: RR 1.13 (95% CI 0.59 to 2.16).
• Low quality evidence from 1 RCT (N=99) showed that there is no clinically important difference between ECV plus nitric oxide donor and ECV plus placebo on cephalic vaginal birth in pregnant women with breech presentation: RR 0.78 (95% CI 0.49 to 1.22).
• Low quality evidence from 2 RCTs (N=125) showed that there is no clinically important difference between ECV plus nitric oxide donor and ECV plus placebo on the number of caesarean sections in pregnant women with breech presentation: RR 0.83 (95% CI 0.68 to 1.01).

Comparison 16. ECV + Nitric oxide donor versus ECV + β2 agonist

• Low quality evidence from 1 RCT (N=74) showed that there is no clinically important difference between ECV plus β2 agonist and ECV plus nitric oxide donor on cephalic presentation in labour in pregnant women with breech presentation: RR 0.56 (95% CI 0.29 to 1.09).
• Very low quality evidence from 2 RCTs (N=97) showed that there is no clinically important difference between ECV plus nitric oxide donor and ECV plus β2 agonist on cephalic vaginal birth in pregnant women with breech presentation: RR 0.98 (95% CI 0.47 to 2.05).
• Very low quality evidence from 1 RCT (N=59) showed that there is no clinically important difference between ECV plus nitric oxide donor and ECV plus β2 agonist on the number of caesarean sections in pregnant women with breech presentation: RR 1.07 (95% CI 0.73 to 1.57).

Comparison 17. ECV + Talcum powder versus ECV + Gel

• Low quality evidence from 1 RCT (N=95) showed that there is no clinically important difference between ECV plus talcum powder and ECV plus gel on cephalic presentation in labour in pregnant women with breech presentation: RR 1.02 (95% CI 0.68 to 1.53).
• Low quality evidence from 1 RCT (N=95) showed that there is no clinically important difference between ECV plus talcum powder and ECV plus gel on cephalic vaginal birth in pregnant women with breech presentation: RR 1.08 (95% CI 0.67 to 1.74).
• Low quality evidence from 1 RCT (N=95) showed that there is no clinically important difference between ECV plus talcum powder and ECV plus gel on the number of caesarean sections in pregnant women with breech presentation: RR 0.94 (95% CI 0.67 to 1.33).
• Low quality evidence from 1 RCT (N=95) showed that there is no clinically important difference between ECV plus talcum powder and ECV plus gel on admission to SCBU/NICU in pregnant women with breech presentation: RR 1.96 (95% CI 0.38 to 10.19).

Comparison 18. Postural management versus No postural management

• Low quality evidence from 1 RCT (N=76) showed that there is no clinically important difference between postural management and no postural management on cephalic presentation in labour in pregnant women with breech presentation: RR 1.26 (95% CI 0.70 to 2.30).
• Low quality evidence from 1 RCT (N=76) showed that there is no clinically important difference between postural management and no postural management on cephalic vaginal birth in pregnant women with breech presentation: RR 1.11 (95% CI 0.59 to 2.07).

Breech vaginal delivery

• Low quality evidence from 1 RCT (N=76) showed that there is no clinically important difference between postural management and no postural management on breech vaginal delivery in pregnant women with breech presentation: RR 1.15 (95% CI 0.67 to 1.99).
• Low quality evidence from 1 RCT (N=76) showed that there is no clinically important difference between postural management and no postural management on the number of caesarean sections in pregnant women with breech presentation: RR 0.69 (95% CI 0.31 to 1.52).
• Low quality evidence from 1 RCT (N=76) showed that there is no clinically important difference between postural management and no postural management on Apgar score <7 at 5 minutes in pregnant women with breech presentation: RR 0.24 (95% CI 0.03 to 2.03).

Comparison 19. Postural management + ECV versus ECV only

• Moderate quality evidence from 1 RCT (N=100) showed that there is no clinically important difference between postural management plus ECV and ECV only on the number of caesarean sections in pregnant women with breech presentation: RR 1.05 (95% CI 0.80 to 1.38).
• Low quality evidence from 1 RCT (N=100) showed that there is no clinically important difference between postural management plus ECV and ECV only on Apgar score <7 at 5 minutes in pregnant women with breech presentation: Peto OR 0.13 (95% CI 0.00 to 6.55).

Economic evidence statements

No economic evidence was identified which was applicable to this review question.

The committee’s discussion of the evidence

Interpreting the evidence, the outcomes that matter most.

Provision of antenatal care is important for the health and wellbeing of both mother and baby with the aim of avoiding adverse pregnancy outcomes and enhancing maternal satisfaction and wellbeing. Breech presentation in labour may be associated with adverse outcomes for the fetus, which has contributed to an increased likelihood of caesarean birth. The committee therefore agreed that cephalic presentation in labour and method of birth were critical outcomes for the woman, and admission to SCBU/NICU, fetal death after 36 +0 weeks gestation, and infant death up to 4 weeks chronological age were critical outcomes for the baby. Apgar score <7 at 5 minutes and birth before 39 +0 weeks of gestation were important outcomes for the baby.

The quality of the evidence

The quality of the evidence for interventions for managing a longitudinal lie fetal malpresentation (that is breech presentation) in late pregnancy ranged from very low to high, with most of the evidence being of a very low or low quality.

This was predominately due to serious overall risk of bias in some outcomes; imprecision around the effect estimate in some outcomes; indirect population in some outcomes; and the presence of serious heterogeneity in some outcomes, which was unresolved by subgroup analysis. The majority of included studies had a small sample size, which contributed to imprecision around the effect estimate.

No evidence was identified to inform the outcomes of infant death up to 4 weeks chronological age and birth before 39 +0 weeks of gestation.

There was no publication bias identified in the evidence. However, the committee noted the influence pharmacological developers may have in these trials as funders, and took this into account in their decision making.

Benefits and harms

The committee discussed that in the case of breech presentation, a discussion with the woman about the different options and their potential benefits, harms and implications is needed to ensure an informed decision. The committee discussed that some women may prefer a breech vaginal birth or choose an elective caesarean birth, and that her preferences should be supported, in line with shared decision making.

The committee discussed that external cephalic version is standard practice for managing breech presentation in uncomplicated singleton pregnancies at or after 36+0 weeks. The committee discussed that there could be variation in the success rates of ECV based on the experience of the healthcare professional providing the ECV. There was some evidence supporting the use of ECV for managing a breech presentation in late pregnancy. The evidence showed ECV had a clinically important benefit in terms of cephalic presentations in labour and cephalic vaginal deliveries, when compared to no intervention. The committee noted that the evidence suggested that ECV was not harmful to the baby, although the effect estimate was imprecise relating to the relative rarity of the fetal death as an outcome.

Cephalic (head-down) vaginal birth is preferred by many women and the evidence suggests that external cephalic version is an effective way to achieve this. The evidence suggested ECV increased the chance for a cephalic vaginal birth and the committee agreed that it was important to explain this to the woman during her consultation.

The committee discussed the optimum timing for ECV. Timing of ECV must take into account the likelihood of the baby turning naturally before a woman commences labour and the possibility of the baby turning back to a breech presentation after ECV if it is done too early. The committee noted that in their experience, current practice was to perform ECV at 37 gestational weeks. The majority of the evidence demonstrating a benefit of ECV in this review involved ECV performed around 37 gestational weeks, although the review did not look for studies directly comparing different timings of ECV and their relative success rates.

The evidence in this review excluded women with previous complicated pregnancies, such as those with previous caesarean section or uterine surgery. The committee discussed that a previous caesarean section indicates a complicated pregnancy and that this population of women are not the focus of this guideline, which concentrates on women with uncomplicated pregnancies.

The committee’s recommendations align with other NICE guidance and cross references to the NICE guideline on caesarean birth and the section on breech presenting in labour in the NICE guideline on intrapartum care for women with existing medical conditions or obstetric complications and their babies were made.

ECV combined with pharmacological agents

There were some small studies comparing a variety of pharmacological agents (including β2 agonists, Ca 2+ channel blockers, µ-receptor agonists and nitric oxide donors) given alongside ECV. Overall the evidence typically showed no clinically important benefit of adding any pharmacological agent to ECV except in comparisons with a control arm with no ECV where it was not possible to isolate the effect of the ECV versus the pharmacological agent. The evidence tended toward benefit most for β2 agonists and µ-receptor agonists however there was no consistent or high quality evidence of benefit even for these agents. The committee agreed that although these pharmacological agents are used in practice, there was insufficient evidence to make a recommendation supporting or refuting their use or on which pharmacological agent should be used.

The committee discussed that the evidence suggesting µ-receptor agonist, remifentanil, had a clinically important benefit in terms reducing breech vaginal births after unsuccessful ECV was biologically implausible. The committee noted that this pharmacological agent has strong sedative effects, depending on the dosage, and therefore studies comparing it to a placebo had possible design flaws as it would be obvious to all parties whether placebo or active drug had been received. The committee discussed that the risks associated with using remifentanil such as respiratory depression, likely outweigh any potential added benefit it may have on managing breech presentation.

There was some evidence comparing different anaesthetics together with ECV. Although there was little consistent evidence of benefit overall, one small study of low quality showed a combination of 2% lidocaine and epinephrine via epidural catheter (anaesthesia) with ECV showed a clinically important benefit in terms of cephalic presentations in labour and the method of birth. The committee discussed the evidence and agreed the use of anaesthesia via epidural catheter during ECV was uncommon practice in the UK and could be expensive, overall they agreed the strength of the evidence available was insufficient to support a change in practice.

Postural management

There was limited evidence on postural management as an intervention for managing breech presentation in late pregnancy, which showed no difference in effectiveness. Postural management was defined as ‘knee-chest position for 15 minutes, 3 times a day’. The committee agreed that in their experience women valued trying interventions at home first which might make postural management an attractive option for some women, however, there was no evidence that postural management was beneficial. The committee also noted that in their experience postural management can cause notable discomfort so it is not an intervention without disadvantages.

Cost effectiveness and resource use

A systematic review of the economic literature was conducted but no relevant studies were identified which were applicable to this review question.

The committee’s recommendations to offer external cephalic version reinforces current practice. The committee noted that, compared to no intervention, external cephalic version results in clinically important benefits and that there would also be overall downstream cost savings from lower adverse events. It was therefore the committee’s view that offering external cephalic version is cost effective and would not entail any resource impact.

Andersen 2013

Brocks 1984

Bujold 2003

Burgos 2016

Chalifoux 2017

Chenia 1987

Collaris 2009

Dafallah 2004

Diguisto 2018

Dugoff 1999

El-Sayed 2004

Fernandez 1997

Hindawi 2005

Hilton 2009

Hofmeyr 1983

Mahomed 1991

Mancuso 2000

Marquette 1996

Mohamed Ismail 2008

NorAzlin 2005

Robertson 1987

Schorr 1997

Sullivan 2009

VanDorsten 1981

Vallikkannu 2014

Weiniger 2010

Appendix A. Review protocols

Review protocol for review question: What is the most effective way of managing a longitudinal lie fetal malpresentation (breech presentation) in late pregnancy? (PDF, 260K)

Appendix B. Literature search strategies

Literature search strategies for review question: What is the most effective way of managing a longitudinal lie fetal malpresentation (breech presentation) in late pregnancy? (PDF, 281K)

Appendix C. Clinical evidence study selection

Clinical study selection for: What is the most effective way of managing a longitudinal lie fetal malpresentation (breech presentation) in late pregnancy? (PDF, 113K)

Appendix D. Clinical evidence tables

Clinical evidence tables for review question: What is the most effective way of managing a longitudinal lie fetal malpresentation (breech presentation) in late pregnancy? (PDF, 1.2M)

Appendix E. Forest plots

Forest plots for review question: What is the most effective way of managing a longitudinal lie fetal malpresentation (breech presentation) in late pregnancy? (PDF, 678K)

Appendix F. GRADE tables

GRADE tables for review question: What is the most effective way of managing a longitudinal lie fetal malpresentation (breech presentation) in late pregnancy? (PDF, 1.0M)

Appendix G. Economic evidence study selection

Economic evidence study selection for review question: what is the most effective way of managing a longitudinal lie fetal malpresentation (breech presentation) in late pregnancy, appendix h. economic evidence tables, economic evidence tables for review question: what is the most effective way of managing a longitudinal lie fetal malpresentation (breech presentation) in late pregnancy, appendix i. economic evidence profiles, economic evidence profiles for review question: what is the most effective way of managing a longitudinal lie fetal malpresentation (breech presentation) in late pregnancy, appendix j. economic analysis, economic evidence analysis for review question: what is the most effective way of managing a longitudinal lie fetal malpresentation (breech presentation) in late pregnancy.

No economic analysis was conducted for this review question.

Appendix K. Excluded studies

Excluded clinical and economic studies for review question: what is the most effective way of managing a longitudinal lie fetal malpresentation (breech presentation) in late pregnancy, clinical studies, table 24 excluded studies.

View in own window

Economic studies

No economic evidence was identified for this review.

Appendix L. Research recommendations

Research recommendations for review question: what is the most effective way of managing a longitudinal lie fetal malpresentation (breech presentation) in late pregnancy.

No research recommendations were made for this review question.

Evidence reviews underpinning recommendation 1.2.38

These evidence reviews were developed by the National Guideline Alliance, which is a part of the Royal College of Obstetricians and Gynaecologists

Disclaimer : The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.

Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.

NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government , Scottish Government , and Northern Ireland Executive . All NICE guidance is subject to regular review and may be updated or withdrawn.

• Cite this Page National Guideline Alliance (UK). Management of breech presentation: Antenatal care: Evidence review M. London: National Institute for Health and Care Excellence (NICE); 2021 Aug. (NICE Guideline, No. 201.)
• PDF version of this title (2.2M)

In this Page

Other titles in this collection.

• NICE Evidence Reviews Collection

Related NICE guidance and evidence

• NICE Guideline 201: Antenatal care

Supplemental NICE documents

• Supplement 1: Methods (PDF)
• Supplement 2: Health economics (PDF)

Related information

• PMC PubMed Central citations
• PubMed Links to PubMed

Similar articles in PubMed

• Review Identification of breech presentation: Antenatal care: Evidence review L [ 2021] Review Identification of breech presentation: Antenatal care: Evidence review L National Guideline Alliance (UK). 2021 Aug
• Vaginal delivery of breech presentation. [J Obstet Gynaecol Can. 2009] Vaginal delivery of breech presentation. Kotaska A, Menticoglou S, Gagnon R, MATERNAL FETAL MEDICINE COMMITTEE. J Obstet Gynaecol Can. 2009 Jun; 31(6):557-566.
• Review Cephalic version by moxibustion for breech presentation. [Cochrane Database Syst Rev. 2005] Review Cephalic version by moxibustion for breech presentation. Coyle ME, Smith CA, Peat B. Cochrane Database Syst Rev. 2005 Apr 18; (2):CD003928. Epub 2005 Apr 18.
• [Fetal expulsion: Which interventions for perineal prevention? CNGOF Perineal Prevention and Protection in Obstetrics Guidelines]. [Gynecol Obstet Fertil Senol. 2...] [Fetal expulsion: Which interventions for perineal prevention? CNGOF Perineal Prevention and Protection in Obstetrics Guidelines]. Riethmuller D, Ramanah R, Mottet N. Gynecol Obstet Fertil Senol. 2018 Dec; 46(12):937-947. Epub 2018 Oct 28.
• Foetal weight, presentaion and the progress of labour. II. Breech and occipito-posterior presentation related to the baby's weight and the length of the first stage of labour. [J Obstet Gynaecol Br Emp. 1961] Foetal weight, presentaion and the progress of labour. II. Breech and occipito-posterior presentation related to the baby's weight and the length of the first stage of labour. BAINBRIDGE MN, NIXON WC, SMYTH CN. J Obstet Gynaecol Br Emp. 1961 Oct; 68:748-54.

Recent Activity

• Management of breech presentation Management of breech presentation

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

Connect with NLM

National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894

Web Policies FOIA HHS Vulnerability Disclosure

Help Accessibility Careers

• Pregnancy Classes

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.

BLOG CATEGORIES

• Pregnancy Symptoms 5
• Can I get pregnant if… ? 3
• Paternity Tests 2
• The Bumpy Truth Blog 7
• Multiple Births 10
• Pregnancy Complications 68
• Pregnancy Concerns 62
• Cord Blood 4
• Pregnancy Supplements & Medications 14
• Pregnancy Products & Tests 8
• Changes In Your Body 5
• Health & Nutrition 2
• Labor and Birth 65
• Planning and Preparing 24
• Breastfeeding 29
• Week by Week Newsletter 40
• Is it Safe While Pregnant 55
• The First Year 41
• Genetic Disorders & Birth Defects 17
• Pregnancy Health and Wellness 149
• Your Developing Baby 16
• Options for Unplanned Pregnancy 18
• Child Adoption 19
• Fertility 54
• Pregnancy Loss 11
• Uncategorized 4
• Women's Health 34
• Prenatal Testing 16
• Abstinence 3
• Birth Control Pills, Patches & Devices 21
• Thank You for Your Donation
• Unplanned Pregnancy
• Getting Pregnant
• Healthy Pregnancy
• Privacy Policy
• Pregnancy Questions Center

Share this post:

Similar post.

Episiotomy: Advantages & Complications

Retained Placenta

What is Dilation in Pregnancy?

Track your baby’s development, subscribe to our week-by-week pregnancy newsletter.

• The Bumpy Truth Blog
• Fertility Products Resource Guide

Pregnancy Tools

• Ovulation Calendar
• Baby Names Directory
• Pregnancy Due Date Calculator
• Pregnancy Quiz

Pregnancy Journeys

• Partner With Us
• Corporate Sponsors

Head down, face up

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

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

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

Frank breech

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

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

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

Complete and incomplete breech

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Products and Services

• A Book: Mayo Clinic Guide to a Healthy Pregnancy
• 3rd trimester pregnancy
• Fetal development: The 3rd trimester
• Overdue pregnancy
• Pregnancy due date calculator
• Prenatal care: Third trimester

Mayo Clinic does not endorse companies or products. Advertising revenue supports our not-for-profit mission.

• Opportunities

Mayo Clinic Press

Check out these best-sellers and special offers on books and newsletters from Mayo Clinic Press .

• Mayo Clinic on Incontinence - Mayo Clinic Press Mayo Clinic on Incontinence
• The Essential Diabetes Book - Mayo Clinic Press The Essential Diabetes Book
• Mayo Clinic on Hearing and Balance - Mayo Clinic Press Mayo Clinic on Hearing and Balance
• FREE Mayo Clinic Diet Assessment - Mayo Clinic Press FREE Mayo Clinic Diet Assessment
• Mayo Clinic Health Letter - FREE book - Mayo Clinic Press Mayo Clinic Health Letter - FREE book
• Healthy Lifestyle

5X Challenge

Thanks to generous benefactors, your gift today can have 5X the impact to advance AI innovation at Mayo Clinic.

What happens if your baby is breech?

Babies often twist and turn during pregnancy, but most will have moved into the head-down (also known as head-first) position by the time labour begins. However, that does not always happen, and a baby may be:

• bottom first or feet first (breech position)
• lying sideways (transverse position)

Bottom first or feet first (breech baby)

If your baby is lying bottom or feet first, they are in the breech position. If they're still breech at around 36 weeks' gestation, the obstetrician and midwife will discuss your options for a safe delivery.

Turning a breech baby

If your baby is in a breech position at 36 weeks, you'll usually be offered an external cephalic version (ECV). This is when a healthcare professional, such as an obstetrician, tries to turn the baby into a head-down position by applying pressure on your abdomen. It's a safe procedure, although it can be a bit uncomfortable.

Giving birth to a breech baby

If an ECV does not work, you'll need to discuss your options for a vaginal birth or  caesarean section  with your midwife and obstetrician.

If you plan a caesarean and then go into labour before the operation, your obstetrician will assess whether it's safe to proceed with the caesarean delivery. If the baby is close to being born, it may be safer for you to have a vaginal breech birth.

The Royal College of Obstetricians and Gynaecologists (RCOG) website has more information on what to expect if your baby is still breech at the end of pregnancy .

The RCOG advises against a vaginal breech delivery if:

• your baby's feet are below its bottom – known as a "footling breech"
• your baby is larger or smaller than average – your healthcare team will discuss this with you
• your baby is in a certain position – for example, their neck is very tilted back, which can make delivery of the head more difficult
• you have a low-lying placenta (placenta praevia)
• you have  pre-eclampsia

Lying sideways (transverse baby)

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

Giving birth to a transverse baby

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

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

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

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

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

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

Breech Presentation

• Author: Richard Fischer, MD; Chief Editor: Ronald M Ramus, MD  more...
• Sections Breech Presentation
• Vaginal Breech Delivery
• Cesarean Delivery
• Comparative Studies
• External Cephalic Version
• Conclusions
• Media Gallery

Breech presentation is defined as a fetus in a longitudinal lie with the buttocks or feet closest to the cervix. This occurs in 3-4% of all deliveries. The percentage of breech deliveries decreases with advancing gestational age from 22-25% of births prior to 28 weeks' gestation to 7-15% of births at 32 weeks' gestation to 3-4% of births at term. [ 1 ]

Predisposing factors for breech presentation include prematurity , uterine malformations or fibroids, polyhydramnios , placenta previa , fetal abnormalities (eg, CNS malformations, neck masses, aneuploidy), and multiple gestations . Fetal abnormalities are observed in 17% of preterm breech deliveries and in 9% of term breech deliveries.

Perinatal mortality is increased 2- to 4-fold with breech presentation, regardless of the mode of delivery. Deaths are most often associated with malformations, prematurity, and intrauterine fetal demise .

Types of breeches

The types of breeches are as follows:

Frank breech (50-70%) - Hips flexed, knees extended (pike position)

Complete breech (5-10%) - Hips flexed, knees flexed (cannonball position)

Footling or incomplete (10-30%) - One or both hips extended, foot presenting

Historical considerations

Vaginal breech deliveries were previously the norm until 1959 when it was proposed that all breech presentations should be delivered abdominally to reduce perinatal morbidity and mortality. [ 2 ]

Vaginal breech delivery

Three types of vaginal breech deliveries are described, as follows:

Spontaneous breech delivery: No traction or manipulation of the infant is used. This occurs predominantly in very preterm, often previable, deliveries.

Assisted breech delivery: This is the most common type of vaginal breech delivery. The infant is allowed to spontaneously deliver up to the umbilicus, and then maneuvers are initiated to assist in the delivery of the remainder of the body, arms, and head.

Total breech extraction: The fetal feet are grasped, and the entire fetus is extracted. Total breech extraction should be used only for a noncephalic second twin; it should not be used for a singleton fetus because the cervix may not be adequately dilated to allow passage of the fetal head. Total breech extraction for the singleton breech is associated with a birth injury rate of 25% and a mortality rate of approximately 10%. Total breech extractions are sometimes performed by less experienced accoucheurs when a foot unexpectedly prolapses through the vagina. As long as the fetal heart rate is stable in this situation, it is permissible to manage expectantly to allow the cervix to completely dilate around the breech (see the image below).

Technique and tips for assisted vaginal breech delivery

The fetal membranes should be left intact as long as possible to act as a dilating wedge and to prevent overt cord prolapse .

Oxytocin induction and augmentation are controversial. In many previous studies, oxytocin was used for induction and augmentation, especially for hypotonic uterine dysfunction. However, others are concerned that nonphysiologic forceful contractions could result in an incompletely dilated cervix and an entrapped head.

An anesthesiologist and a pediatrician should be immediately available for all vaginal breech deliveries. A pediatrician is needed because of the higher prevalence of neonatal depression and the increased risk for unrecognized fetal anomalies. An anesthesiologist may be needed if intrapartum complications develop and the patient requires general anesthesia .

Some clinicians perform an episiotomy when the breech delivery is imminent, even in multiparas, as it may help prevent soft tissue dystocia for the aftercoming head (see the images below).

The Pinard maneuver may be needed with a frank breech to facilitate delivery of the legs but only after the fetal umbilicus has been reached. Pressure is exerted in the popliteal space of the knee. Flexion of the knee follows, and the lower leg is swept medially and out of the vagina.

No traction should be exerted on the infant until the fetal umbilicus is past the perineum, after which time maternal expulsive efforts should be used along with gentle downward and outward traction of the infant until the scapula and axilla are visible (see the image below).

Use a dry towel to wrap around the hips (not the abdomen) to help with gentle traction of the infant (see the image below).

An assistant should exert transfundal pressure from above to keep the fetal head flexed.

Once the scapula is visible, rotate the infant 90° and gently sweep the anterior arm out of the vagina by pressing on the inner aspect of the arm or elbow (see the image below).

Rotate the infant 180° in the reverse direction, and sweep the other arm out of the vagina. Once the arms are delivered, rotate the infant back 90° so that the back is anterior (see the image below).

The fetal head should be maintained in a flexed position during delivery to allow passage of the smallest diameter of the head. The flexed position can be accomplished by using the Mauriceau Smellie Veit maneuver, in which the operator's index and middle fingers lift up on the fetal maxillary prominences, while the assistant applies suprapubic pressure (see the image below).

Alternatively, Piper forceps can be used to maintain the head in a flexed position (see the image below).

In many early studies, routine use of Piper forceps was recommended to protect the head and to minimize traction on the fetal neck. Piper forceps are specialized forceps that are placed from below the infant and, unlike conventional forceps, are not tailored to the position of the fetal head (ie, it is a pelvic, not cephalic, application). The forceps are applied while the assistant supports the fetal body in a horizontal plane.

During delivery of the head, avoid extreme elevation of the body, which may result in hyperextension of the cervical spine and potential neurologic injury (see the images below).

Lower Apgar scores, especially at 1 minute, are more common with vaginal breech deliveries. Many advocate obtaining an umbilical cord artery and venous pH for all vaginal breech deliveries to document that neonatal depression is not due to perinatal acidosis.

Fetal head entrapment may result from an incompletely dilated cervix and a head that lacks time to mold to the maternal pelvis. This occurs in 0-8.5% of vaginal breech deliveries. [ 3 ] This percentage is higher with preterm fetuses (< 32 wk), when the head is larger than the body. Dührssen incisions (ie, 1-3 cervical incisions made to facilitate delivery of the head) may be necessary to relieve cervical entrapment. However, extension of the incision can occur into the lower segment of the uterus, and the operator must be equipped to deal with this complication. The Zavanelli maneuver has been described, which involves replacement of the fetus into the abdominal cavity followed by cesarean delivery. While success has been reported with this maneuver, fetal injury and even fetal death have occurred.

Nuchal arms, in which one or both arms are wrapped around the back of the neck, are present in 0-5% of vaginal breech deliveries and in 9% of breech extractions. [ 3 ] Nuchal arms may result in neonatal trauma (including brachial plexus injuries) in 25% of cases. Risks may be reduced by avoiding rapid extraction of the infant during delivery of the body. To relieve nuchal arms when it is encountered, rotate the infant so that the fetal face turns toward the maternal symphysis pubis (in the direction of the impacted arm); this reduces the tension holding the arm around the back of the fetal head, allowing for delivery of the arm.

Cervical spine injury is predominantly observed when the fetus has a hyperextended head prior to delivery. Ballas and Toaff (1976) reported 20 cases of hyperextended necks, defined as an angle of extension greater than 90° ("star-gazing"), discovered on antepartum radiographs. [ 4 ] Of the 11 fetuses delivered vaginally, 8 (73%) sustained complete cervical spinal cord lesions, defined as either transection or nonfunction.

Cord prolapse may occur in 7.4% of all breech labors. This incidence varies with the type of breech: 0-2% with frank breech, 5-10% with complete breech, and 10-25% with footling breech. [ 3 ] Cord prolapse occurs twice as often in multiparas (6%) than in primigravidas (3%). Cord prolapse may not always result in severe fetal heart rate decelerations because of the lack of presenting parts to compress the umbilical cord (ie, that which predisposes also protects).

Prior to the 2001 recommendations by the American College of Obstetricians and Gynecologists (ACOG), approximately 50% of breech presentations were considered candidates for vaginal delivery. Of these candidates, 60-82% were successfully delivered vaginally.

Candidates can be classified based on gestational age. For pregnancies prior to 26 weeks' gestation, prematurity, not mode of delivery, is the greatest risk factor. Unfortunately, no randomized clinical trials to help guide clinical management have been reported. Vaginal delivery can be considered, but a detailed discussion of the risks from prematurity and the lack of data regarding the ideal mode of delivery should take place with the parent(s). For example, intraventricular hemorrhage, which can occur in an infant of extremely low birth weight, should not be misinterpreted as proof of a traumatic vaginal breech delivery.

For pregnancies between 26 and 32 weeks, retrospective studies suggest an improved outcome with cesarean delivery, although these reports are subject to selection bias. In contrast, between 32 and 36 weeks' gestation, vaginal breech delivery may be considered after a discussion of risks and benefits with the parent(s).

After 37 weeks' gestation, parents should be informed of the results of a multicenter randomized clinical trial that demonstrated significantly increased perinatal mortality and short-term neonatal morbidity associated with vaginal breech delivery (see Comparative Studies). For those attempting vaginal delivery, if estimated fetal weight (EFW) is more than 4000 g, some recommend cesarean delivery because of concern for entrapment of the unmolded head in the maternal pelvis, although data to support this practice are limited.

A frank breech presentation is preferred when vaginal delivery is attempted. Complete breeches and footling breeches are still candidates, as long as the presenting part is well applied to the cervix and both obstetrical and anesthesia services are readily available in the event of a cord prolapse.

The fetus should show no neck hyperextension on antepartum ultrasound imaging (see the image below). Flexed or military position is acceptable.

Regarding prior cesarean delivery, a retrospective study by Ophir et al of 71 women with one prior low transverse cesarean delivery who subsequently delivered a breech fetus found that 24 women had an elective repeat cesarean and 47 women had a trial of labor. [ 5 ] In the 47 women with a trial of labor, 37 (78.7%) resulted in a vaginal delivery. Two infants in the trial of labor group had nuchal arms (1 with a transient brachial plexus injury) and 1 woman required a hysterectomy for hemorrhage due to a uterine dehiscence discovered after vaginal delivery. Vaginal breech delivery after one prior cesarean delivery is not contraindicated, though larger studies are needed.

Primigravida versus multiparous

It had been commonly believed that primigravidas with a breech presentation should have a cesarean delivery, although no data (prospective or retrospective) support this view. The only documented risk related to parity is cord prolapse, which is 2-fold higher in parous women than in primigravid women.

Radiographic and CT pelvimetry

Historically, radiograph pelvimetry was believed to be useful to quantitatively assess the inlet and mid pelvis. Recommended pelvimetry criteria included a transverse inlet diameter larger than 11.5 cm, anteroposterior inlet diameter larger than 10.5 cm, transverse midpelvic diameter (between the ischial spines) larger than 10 cm, and anteroposterior midpelvic diameter larger than 11.5 cm. However, radiographic pelvimetry is rarely, if ever, used in the United States.

CT pelvimetry , which is associated with less fetal radiation exposure than conventional radiographic pelvimetry, was more recently advocated by some investigators. It, too, is rarely used today.

Ultimately, if the obstetrical operator is not experienced or comfortable with vaginal breech deliveries, cesarean delivery may be the best choice. Unfortunately, with the dwindling number of experienced obstetricians who still perform vaginal breech deliveries and who can teach future generations of obstetricians, this technique may soon be lost due to attrition.

In 1970, approximately 14% of breeches were delivered by cesarean delivery. By 1986, that rate had increased to 86%. In 2003, based on data from the National Center for Health Statistics, the rate of cesarean delivery for all breech presentations was 87.2%. Most of the remaining breeches delivered vaginally were likely second twins, fetal demises, and precipitous deliveries. However, the rise in cesarean deliveries for breeches has not necessarily equated with an improvement in perinatal outcome. Green et al compared the outcome for term breeches prior to 1975 (595 infants, 22% cesarean delivery rate for breeches) with those from 1978-1979 (164 infants, 94% cesarean delivery rate for breeches). [ 6 ] Despite the increase in rates of cesarean delivery, the differences in rates of asphyxia, birth injury, and perinatal deaths were not significant.

Maneuvers for cesarean delivery are similar to those for vaginal breech delivery, including the Pinard maneuver, wrapping the hips with a towel for traction, head flexion during traction, rotation and sweeping out of the fetal arms, and the Mauriceau Smellie Veit maneuver.

An entrapped head can still occur during cesarean delivery as the uterus contracts after delivery of the body, even with a lower uterine segment that misleadingly appears adequate prior to uterine incision. Entrapped heads occur more commonly with preterm breeches, especially with a low transverse uterine incision. As a result, some practitioners opt to perform low vertical uterine incisions for preterm breeches prior to 32 weeks' gestation to avoid head entrapment and the kind of difficult delivery that cesarean delivery was meant to avoid. Low vertical incisions usually require extension into the corpus, resulting in cesarean delivery for all future deliveries.

If a low transverse incision is performed, the physician should move quickly once the breech is extracted in order to deliver the head before the uterus begins to contract. If any difficulty is encountered with delivery of the fetal head, the transverse incision can be extended vertically upward (T incision). Alternatively, the transverse incision can be extended laterally and upward, taking great care to avoid trauma to the uterine arteries. A third option is the use of a short-acting uterine relaxant (eg, nitroglycerin) in an attempt to facilitate delivery.

Only 3 randomized studies have evaluated the mode of delivery of the term breech. All other studies were nonrandomized or retrospective, which may be subject to selection bias.

In 1980, Collea et al randomized 208 women in labor with term frank breech presentations to either elective cesarean delivery or attempted vaginal delivery after radiographic pelvimetry. [ 7 ] Oxytocin was allowed for dysfunctional labor. Of the 60 women with adequate pelves, 49 delivered vaginally. Two neonates had transient brachial plexus injuries. Women randomized to elective cesarean delivery had higher postpartum morbidity rates (49.3% vs 6.7%).

In 1983, Gimovsky et al randomized 105 women in labor with term nonfrank breech presentations to a trial of labor versus elective cesarean delivery. [ 8 ] In this group of women, 47 had complete breech presentations, 16 had incomplete breech presentations (hips flexed, 1 knee extended/1 knee flexed), 32 had double-footling presentations, and 10 had single-footling presentations. Oxytocin was allowed for dysfunctional labor. Of the labor group, 44% had successful vaginal delivery. Most cesarean deliveries were performed for inadequate pelvic dimensions on radiographic pelvimetry. The rate of neonatal morbidity did not differ between neonates delivered vaginally and those delivered by cesarean delivery, although a higher maternal morbidity rate was noted in the cesarean delivery group.

In 2000, Hannah and colleagues completed a large, multicenter, randomized clinical trial involving 2088 term singleton fetuses in frank or complete breech presentations at 121 institutions in 26 countries. [ 9 ] In this study, popularly known as the Term Breech Trial, subjects were randomized into a planned cesarean delivery group or a planned vaginal birth group. Exclusion criteria were estimated fetal weight (EFW) more than 4000 g, hyperextension of the fetal head, lethal fetal anomaly or anomaly that might result in difficulty with delivery, or contraindication to labor or vaginal delivery (eg, placenta previa ).

Subjects randomized to cesarean delivery were scheduled to deliver after 38 weeks' gestation unless conversion to cephalic presentation had occurred. Subjects randomized to vaginal delivery were treated expectantly until labor ensued. Electronic fetal monitoring was either continuous or intermittent. Inductions were allowed for standard obstetrical indications, such as postterm gestations. Augmentation with oxytocin was allowed in the absence of apparent fetopelvic disproportion, and epidural analgesia was permitted.

Adequate labor was defined as a cervical dilation rate of 0.5 cm/h in the active phase of labor and the descent of the breech fetus to the pelvic floor within 2 hours of achieving full dilation. Vaginal delivery was spontaneous or assisted and was attended by an experienced obstetrician. Cesarean deliveries were performed for inadequate progress of labor, nonreassuring fetal heart rate, or conversion to footling breech. Results were analyzed by intent-to-treat (ie, subjects were analyzed by randomization group, not by ultimate mode of delivery).

Of 1041 subjects in the planned cesarean delivery group, 941 (90.4%) had cesarean deliveries. Of 1042 subjects in the planned vaginal delivery group, 591 (56.7%) had vaginal deliveries. Indications for cesarean delivery included: fetopelvic disproportion or failure to progress in labor (226), nonreassuring fetal heart rate tracing (129), footling breech (69), request for cesarean delivery (61), obstetrical or medical indications (45), or cord prolapse (12).

The composite measurement of either perinatal mortality or serious neonatal morbidity by 6 weeks of life was significantly lower in the planned cesarean group than in the planned vaginal group (5% vs 1.6%, P < .0001). Six of 16 neonatal deaths were associated with difficult vaginal deliveries, and 4 deaths were associated with fetal heart rate abnormalities. The reduction in risk in the cesarean group was even greater in participating countries with overall low perinatal mortality rates as reported by the World Health Organization. The difference in perinatal outcome held after controlling for the experience level of the obstetrician. No significant difference was noted in maternal mortality or serious maternal morbidity between the 2 groups within the first 6 weeks of delivery (3.9% vs 3.2%, P = .35).

A separate analysis showed no difference in breastfeeding, sexual relations, or depression at 3 months postpartum, though the reported rate of urinary incontinence was higher in the planned vaginal group (7.3% vs 4.5%).

Based on the multicenter trial, the ACOG published a Committee Opinion in 2001 that stated "planned vaginal delivery of a singleton term breech may no longer be appropriate." This did not apply to those gravidas presenting in advanced labor with a term breech and imminent delivery or to a nonvertex second twin.

A follow-up study by Whyte et al was conducted in 2004 on 923 children who were part of the initial multicenter study. [ 10 ] The authors found no differences between the planned cesarean delivery and planned vaginal breech delivery groups with regards to infant death rates or neurodevelopmental delay by age 2 years. Similarly, among 917 participating mothers from the original trial, no substantive differences were apparent in maternal outcome between the 2 groups. [ 11 ] No longer-term maternal effects, such as the impact of a uterine scar on future pregnancies, have yet been reported.

A meta-analysis of the 3 above mentioned randomized trials was published in 2015. The findings included a reduction in perinatal/neonatal death, reduced composite short-term outcome of perinatal/neonatal death or serious neonatal morbidity with planned cesarean delivery versus planned vaginal delivery. [ 12 ] However, at 2 years of age, there was no significant difference in death or neurodevelopmental delay between the two groups.  Maternal outcomes assessed at 2 years after delivery were not significantly different.

With regard to preterm breech deliveries, only one prospective randomized study has been performed, which included only 38 subjects (28-36 wk) with preterm labor and breech presentation. [ 13 ] Of these subjects, 20 were randomized to attempted vaginal delivery and 18 were randomized to immediate cesarean delivery. Of the attempted vaginal delivery group, 25% underwent cesarean delivery for nonreassuring fetal heart rate tracings. Five neonatal deaths occurred in the vaginal delivery group, and 1 neonatal death occurred in the cesarean delivery group. Two neonates died from fetal anomalies, 3 from respiratory distress, and 1 from sepsis.

Nonanomalous infants who died were not acidotic at delivery and did not have birth trauma. Differences in Apgar scores were not significant, although the vaginal delivery group had lower scores. The small number of enrolled subjects precluded any definitive conclusions regarding the safety of vaginal breech delivery for a preterm breech.

Retrospective analyses showed a higher mortality rate in vaginal breech neonates weighing 750-1500 g (26-32 wk), but less certain benefit was shown with cesarean delivery if the fetal weight was more than 1500 g (approximately 32 wk). Therefore, this subgroup of very preterm infants (26-32 wk) may benefit from cesarean delivery, although this recommendation is based on potentially biased retrospective data.

A large cohort study was published in 2015 from the Netherlands Perinatal Registry, which included 8356 women with a preterm (26-36 6/7 weeks) breech from 2000 to 2011, over three quarters of whom intended to deliver vaginally. In this overall cohort, there was no significant difference in perinatal mortality between the planned vaginal delivery and planned cesarean delivery groups (adjusted odds ratio 0.97, 95% confidence interval 0.60 – 1.57).  However, the subgroup delivering at 28 to 32 weeks had a lower perinatal mortality with planned cesarean section (aOR 0.27, 95% CI 0.10 – 0.77).  After adding a composite of perinatal morbidity, planned cesarean delivery was associated with a better outcome than a planned vaginal delivery (aOR 0.77, 95% CI 0.63 – 0.93. [ 14 ]

A Danish study found that nulliparous women with a singleton breech presentation who had a planned vaginal delivery were at significantly higher risk for postoperative complications, such as infection, compared with women who had a planned cesarean delivery. This increased risk was due to the likelihood of conversion to an emergency cesarean section, which occurred in over 69% of the planned vaginal deliveries in the study. [ 15 ]

The Maternal-Fetal Medicine Units Network of the US National Institute of Child Health and Human Development considered a multicenter randomized clinical trial of attempted vaginal delivery versus elective cesarean delivery for 24- to 28-week breech fetuses. [ 16 ] However, it was not initiated because of anticipated difficulty with recruitment, inadequate numbers to show statistically significant differences, and medicolegal concerns. Therefore, this study is not likely to be performed.

External cephalic version (ECV) is the transabdominal manual rotation of the fetus into a cephalic presentation.

Initially popular in the 1960s and 1970s, ECV virtually disappeared after reports of fetal deaths following the procedure. Reintroduced to the United States in the 1980s, it became increasingly popular in the 1990s.

Improved outcome may be related to the use of nonstress tests both before and after ECV, improved selection of low-risk fetuses, and Rh immune globulin to prevent isoimmunization.

Prepare for the possibility of cesarean delivery. Obtain a type and screen as well as an anesthesia consult. The patient should have nothing by mouth for at least 8 hours prior to the procedure. Recent ultrasonography should have been performed for fetal position, to check growth and amniotic fluid volume, to rule out a placenta previa, and to rule out anomalies associated with breech. Another sonogram should be performed on the day of the procedure to confirm that the fetus is still breech.

A nonstress test (biophysical profile as backup) should be performed prior to ECV to confirm fetal well-being.

Perform ECV in or near a delivery suite in the unlikely event of fetal compromise during or following the procedure, which may require emergent delivery.

ECV can be performed with 1 or 2 operators. Some prefer to have an assistant to help turn the fetus, elevate the breech out of the pelvis, or to monitor the position of the baby with ultrasonography. Others prefer a single operator approach, as there may be better coordination between the forces that are raising the breech and moving the head.

ECV is accomplished by judicious manipulation of the fetal head toward the pelvis while the breech is brought up toward the fundus. Attempt a forward roll first and then a backward roll if the initial attempts are unsuccessful. No consensus has been reached regarding how many ECV attempts are appropriate at one time. Excessive force should not be used at any time, as this may increase the risk of fetal trauma.

Following an ECV attempt, whether successful or not, repeat the nonstress test (biophysical profile if needed) prior to discharge. Also, administer Rh immune globulin to women who are Rh negative. Some physicians traditionally induce labor following successful ECV. However, as virtually all of these recently converted fetuses are unengaged, many practitioners will discharge the patient and wait for spontaneous labor to ensue, thereby avoiding the risk of a failed induction of labor. Additionally, as most ECV’s are attempted prior to 39 weeks, as long as there are no obstetrical or medical indications for induction, discharging the patient to await spontaneous labor would seem most prudent.

In those with an unsuccessful ECV, the practitioner has the option of sending the patient home or proceeding with a cesarean delivery. Expectant management allows for the possibility of spontaneous version. Alternatively, cesarean delivery may be performed at the time of the failed ECV, especially if regional anesthesia is used and the patient is already in the delivery room (see Regional anesthesia). This would minimize the risk of a second regional analgesia.

In those with an unsuccessful ECV, the practitioner may send the patient home, if less than 39 weeks, with plans for either a vaginal breech delivery or scheduled cesarean after 39 weeks. Expectant management allows for the possibility of a spontaneous version. Alternatively, if ECV is attempted after 39 weeks, cesarean delivery may be performed at the time of the failed ECV, especially if regional anesthesia is used and the patient is already in the delivery room (see Regional anesthesia). This would minimize the risk of a second regional analgesia.

Success rate

Success rates vary widely but range from 35% to 86% (average success rate in the 2004 National Vital Statistics was 58%). Improved success rates occur with multiparity, earlier gestational age, frank (versus complete or footling) breech presentation, transverse lie, and in African American patients.

Opinions differ regarding the influence of maternal weight, placental position, and amniotic fluid volume. Some practitioners find that thinner patients, posterior placentas, and adequate fluid volumes facilitate successful ECV. However, both patients and physicians need to be prepared for an unsuccessful ECV; version failure is not necessarily a reflection of the skill of the practitioner.

Zhang et al reviewed 25 studies of ECV in the United States, Europe, Africa, and Israel. [ 17 ] The average success rate in the United States was 65%. Of successful ECVs, 2.5% reverted back to breech presentation (other estimates range from 3% to 5%), while 2% of unsuccessful ECVs had spontaneous version to cephalic presentation prior to labor (other estimates range from 12% to 26%). Spontaneous version rates depend on the gestational age when the breech is discovered, with earlier breeches more likely to undergo spontaneous version.

A prospective study conducted in Germany by Zielbauer et al demonstrated an overall success rate of 22.4% for ECV among 353 patients with a singleton fetus in breech presentation. ECV was performed at 38 weeks of gestation. Factors found to increase the likelihood of success were a later week of gestation, abundant amniotic fluid, fundal and anterior placental location, and an oblique lie. [ 18 ]

A systematic review in 2015 looked at the effectiveness of ECV with eight randomized trials of ECV at term. Compared to women with no attempt at ECV, ECV reduced non-cephalic presentation at birth by 60% and reduced cesarean sections by 40% in the same group. [ 19 ] Although the rate of cesarean section is lower when ECV is performed than if not, the overall rate of cesarean section remains nearly twice as high after successful ECV due to both dystocia and non-reassuring fetal heart rate patterns. [ 20 ]  Nulliparity was the only factor shown in follow-up to increase the risk of instrumental delivery following successful ECV. [ 21 ]

While most studies of ECV have been performed in university hospitals, Cook showed that ECV has also been effective in the private practice setting. [ 22 ] Of 65 patients with term breeches, 60 were offered ECV. ECV was successful in 32 (53%) of the 60 patients, with vaginal delivery in 23 (72%) of the 32 patients. Of the remaining breech fetuses believed to be candidates for vaginal delivery, 8 (80%) had successful vaginal delivery. The overall vaginal delivery rate was 48% (31 of 65 patients), with no significant morbidity.

Cost analysis

In 1995, Gifford et al performed a cost analysis of 4 options for breech presentations at term: (1) ECV attempt on all breeches, with attempted vaginal breech delivery for selected persistent breeches; (2) ECV on all breeches, with cesarean delivery for persistent breeches; (3) trial of labor for selected breeches, with scheduled cesarean delivery for all others; and (4) scheduled cesarean delivery for all breeches prior to labor. [ 23 ]

ECV attempt on all breeches with attempted vaginal breech delivery on selected persistent breeches was associated with the lowest cesarean delivery rate and was the most cost-effective approach. The second most cost-effective approach was ECV attempt on all breeches, with cesarean delivery for persistent breeches.

Uncommon risks of ECV include fractured fetal bones, precipitation of labor or premature rupture of membranes , abruptio placentae , fetomaternal hemorrhage (0-5%), and cord entanglement (< 1.5%). A more common risk of ECV is transient slowing of the fetal heart rate (in as many as 40% of cases). This risk is believed to be a vagal response to head compression with ECV. It usually resolves within a few minutes after cessation of the ECV attempt and is not usually associated with adverse sequelae for the fetus.

Trials have not been large enough to determine whether the overall risk of perinatal mortality is increased with ECV. The Cochrane review from 2015 reported perinatal death in 2 of 644 in ECV and 6 of 661 in the group that did not attempt ECV. [ 19 ]

A 2016 Practice Bulletin by ACOG recommended that all women who are near term with breech presentations should be offered an ECV attempt if there are no contraindications (see Contraindications below). [ 24 ]  ACOG guidelines issued in 2020 recommend that ECV should be performed starting at 37+0 weeks, in order to reduce the likelihood of reversion and to increase the rate of spontaneous version. [ 25 ]

ACOG recommends that ECV be offered as an alternative to a planned cesarean section for a patient who has a term singleton breech fetus, wishes to have a planned vaginal delivery of a vertex-presenting fetus, and has no contraindications. ACOG also advises that ECV be attempted only in settings where cesarean delivery services are available. [ 26 ]

ECV is usually not performed on preterm breeches because they are more likely to undergo spontaneous version to cephalic presentation and are more likely to revert to breech after successful ECV (approximately 50%). Earlier studies of preterm ECV did not show a difference in the rates of breech presentations at term or overall rates of cesarean delivery. Additionally, if complications of ECV were to arise that warranted emergent delivery, it would result in a preterm neonate with its inherent risks. The Early External Cephalic Version (ECV) 2 trial was an international, multicentered, randomized clinical trial that compared ECV performed at 34-35 weeks’ gestation compared with 37 weeks’ gestation or more. [ 27 ] Early ECV increased the chance of cephalic presentation at birth; however, no difference in cesarean delivery rates was noted, along with a nonstatistical increase in preterm births.

A systematic review looked at 5 studies of ECV completed prior to 37 weeks and concluded that compared with no ECV attempt, ECV commenced before term reduces the non-cephalic presentation at birth, however early ECV may increase the risk of late preterm birth. [ 28 ]

Given the increasing awareness of the risks of late preterm birth and early term deliveries, the higher success of earlier ECV should be weighed against the risks of iatrogenic prematurity should a complication arise necessitating delivery.

Contraindications

Absolute contraindications for ECV include multiple gestations with a breech presenting fetus, contraindications to vaginal delivery (eg, herpes simplex virus infection, placenta previa), and nonreassuring fetal heart rate tracing.

Relative contraindications include polyhydramnios or oligohydramnios , fetal growth restriction , uterine malformation , and major fetal anomaly.

Controversial candidates

Women with prior uterine incisions may be candidates for ECV, but data are scant. In 1991, Flamm et al attempted ECV on 56 women with one or more prior low transverse cesarean deliveries. [ 29 ] The success rate of ECV was 82%, with successful vaginal births in 65% of patients with successful ECVs. No uterine ruptures occurred during attempted ECV or subsequent labor, and no significant fetal complications occurred.

In 2010 ACOG acknowledged that although there is limited data in both the above study and one more recently, [ 30 ] no serious adverse events occurred in these series. A larger prospective cohort study that was published in 2014 reported similar success rates of ECV among women with and without prior cesarean section, although lower vaginal birth rates. There were, however, no cases of uterine rupture or other adverse outcomes. [ 31 ]

Another controversial area is performing ECV on a woman in active labor. In 1985, Ferguson and Dyson reported on 15 women in labor with term breeches and intact membranes. [ 32 ] Four patients were dilated greater than 5 cm (2 women were dilated 8 cm). Tocolysis was administered, and intrapartum ECV was attempted. ECV was successful in 11 of 15 patients, with successful vaginal births in 10 patients. No adverse effects were noted. Further studies are needed to evaluate the safety and efficacy of intrapartum ECV.

Data regarding the benefit of intravenous or subcutaneous beta-mimetics in improving ECV rates are conflicting.

In 1996, Marquette et al performed a prospective, randomized, double-blinded study on 283 subjects with breech presentations between 36 and 41 weeks' gestation. [ 33 ] Subjects received either intravenous ritodrine or placebo. The success rate of ECV was 52% in the ritodrine group versus 42% in the placebo group ( P = .35). When only nulliparous subjects were analyzed, significant differences were observed in the success of ECV (43% vs 25%, P < .03). ECV success rates were significantly higher in parous versus nulliparous subjects (61% vs 34%, P < .0001), with no additional improvement with ritodrine.

A systematic review published in 2015 of six randomized controlled trials of ECV that compared the use of parenteral beta-mimetic tocolysis during ECV concluded that tocolysis was effective in increasing the rate of cephalic presentation in labor and reducing the cesarean delivery rate by almost 25% in both nulliparous and multiparous women. [ 34 ] Data on adverse effects and other tocolytics was insufficient. A review published in 2011 on Nifedipine did not show an improvement in ECV success. [ 35 ]

Regional anesthesia

Regional analgesia, either epidural or spinal, may be used to facilitate external cephalic version (ECV) success. When analgesia levels similar to that for cesarean delivery are given, it allows relaxation of the anterior abdominal wall, making palpation and manipulation of the fetal head easier. Epidural or spinal analgesia also eliminates maternal pain that may cause bearing down and tensing of the abdominal muscles. If ECV is successful, the epidural can be removed and the patient sent home to await spontaneous labor. If ECV is unsuccessful, a patient can proceed to cesarean delivery under her current anesthesia, if the gestational age is more than 39 weeks.

The main disadvantage is the inherent risk of regional analgesia, which is considered small. Additionally, lack of maternal pain could potentially result in excessive force being applied to the fetus without the knowledge of the operator.

In 1994, Carlan et al retrospectively analyzed 61 women who were at more than 36 weeks' gestation and had ECV with or without epidural. [ 36 ] The success rate of ECV was 59% in the epidural group and 24% in the nonepidural group ( P < .05). In 7 of 8 women with unsuccessful ECV without epidural, a repeat ECV attempt after epidural was successful. No adverse effects on maternal or perinatal morbidity or mortality occurred.

In 1997, Schorr et al randomized 69 subjects who were at least 37 weeks' gestation to either epidural or control groups prior to attempted ECV. [ 37 ] Those in whom ECV failed underwent cesarean delivery. The success rate of ECV was 69% in the epidural group and 32% in the control group (RR, 2.12; 95% CI, 1.24-3.62). The cesarean delivery rate was 79% in the control group and 34% in the epidural group ( P = .001). No complications of epidural anesthesia and no adverse fetal effects occurred.

In 1999, Dugoff et al randomized 102 subjects who were at more than 36 weeks' gestation with breech presentations to either spinal anesthesia or a control group. [ 38 ] All subjects received 0.25 mg terbutaline subcutaneously. The success rate of ECV was 44% in the spinal group and 42% in the nonspinal group, which was not statistically significant.

In contrast, a 2007 randomized clinical trial of spinal analgesia versus no analgesia in 74 women showed a significant improvement in ECV success (66.7% vs 32.4%, p = .004), with a significantly lower pain score by the patient. [ 39 ]

The 2015 systematic review asserted that regional analgesia in combination with a tocolytic was more effective than the tocolytic alone for increasing ECV success; however there was no difference in cephalic presentation in labor. Data from the same review was insufficient to assess regional analgesia without tocolysis [ 34 ]

Acoustic stimulation

Johnson and Elliott performed a randomized, blinded trial on 23 subjects to compare acoustic stimulation prior to ECV with a control group when the fetal spine was in the midline (directly back up or back down). [ 40 ] Of those who received acoustic stimulation, 12 of 12 fetuses shifted to a spine-lateral position after acoustic stimulation, and 11 (91%) underwent successful ECV. In the control group, 0 of 11 shifts and 1 (9%) successful ECV ( P < .0001) occurred. Additional studies are needed.

Amnioinfusion

Although an earlier study reported on the utility of amnioinfusion to successfully turn 6 fetuses who initially failed ECV, [ 41 ] a subsequent study was published of 7 women with failed ECV who underwent amniocentesis and amnioinfusion of up to 1 liter of crystalloid. [ 42 ] Repeat attempts of ECV were unsuccessful in all 7 cases. Amnioinfusion to facilitate ECV cannot be recommended at this time.

Vaginal delivery rates after successful version

The rate of cesarean delivery ranges from 0-31% after successful external cephalic version (ECV). Controversy has existed on whether there is a higher rate of cesarean delivery for labor dystocia following ECV. In 1994, a retrospective study by Egge et al of 76 successful ECVs matched with cephalic controls by delivery date, parity, and gestational age failed to note any significant difference in the cesarean delivery rate (8% in ECV group, 6% in control group). [ 43 ]

However, in 1997, Lau et al compared 154 successful ECVs to 308 spontaneously occurring cephalic controls (matched for age, parity, and type of labor onset) with regard to the cesarean delivery rate. [ 44 ] Cesarean delivery rates were higher after ECV (16.9% vs 7.5%, P < .005) because of higher rates of cephalopelvic disproportion and nonreassuring fetal heart rate tracings. This may be related to an increased frequency of compound presentations after ECV. Immediate induction of labor after successful ECV may also contribute to an increase in the cesarean delivery rate due to failed induction in women with unripe cervices and unengaged fetal heads.

Further, in another cohort study from 2015, factors were described which decreased the vaginal delivery rate after successful ECV including labor induction, less than 2 weeks between ECV and delivery, high body mass index, and previous cesarean. [ 45 ] The overall caesarean delivery rate in this cohort was 15%.

Vaginal breech delivery requires an experienced obstetrician and careful counseling of the parents. Although studies on the delivery of the preterm breech are limited, the multicenter Term Breech Trial found an increased rate of perinatal mortality and serious immediate perinatal morbidity, though no differences were seen in infant outcome at 2 years of age.

Parents must be informed about potential risks and benefits to the mother and neonate for both vaginal breech delivery and cesarean delivery. Discussion of risks should not be limited only to the current pregnancy. The risks of a cesarean on subsequent pregnancies, including uterine rupture and placental attachment abnormalities ( placenta previa , abruption , accreta), as well as maternal and perinatal sequelae from these complications, should be reviewed as well.

It remains concerning that the dearth of experienced physicians to teach younger practitioners will lead to the abandonment of vaginal breeches altogether. For those wishing to learn the art of vaginal breech deliveries, simulation training with pelvic models has been advocated to familiarize trainees with the procedure in a nonthreatening environment. [ 46 ] Once comfortable with the appropriate maneuvers, vaginal delivery of the second, noncephalic twin, may be attempted under close supervision by an experienced physician. The cervix will already be fully dilated, and, assuming the second twin is not significantly larger, the successful vaginal delivery rate has been quoted to be as high as 96%.

External cephalic version (ECV) is a safe alternative to vaginal breech delivery or cesarean delivery, reducing the cesarean delivery rate for breech by 50%. ACOG recommends offering ECV to all women with a breech fetus near term. [ 24 ] Adjuncts such as tocolysis, regional anesthesia, and acoustic stimulation when appropriate may improve ECV success rates.

Hickok DE, Gordon DC, Milberg JA, Williams MA, Daling JR. The frequency of breech presentation by gestational age at birth: a large population-based study. Am J Obstet Gynecol . 1992 Mar. 166(3):851-2. [QxMD MEDLINE Link] .

Wright RC. Reduction of perinatal mortality and morbidity in breech delivery through routine use of cesarean section. Obstet Gynecol . 1959. 14:758-63.

Cheng M, Hannah M. Breech delivery at term: a critical review of the literature. Obstet Gynecol . 1993 Oct. 82(4 Pt 1):605-18. [QxMD MEDLINE Link] .

Ballas S, Toaff R. Hyperextension of the fetal head in breech presentation: radiological evaluation and significance. Br J Obstet Gynaecol . 1976 Mar. 83(3):201-4. [QxMD MEDLINE Link] .

Ophir E, Oettinger M, Yagoda A, Markovits Y, Rojansky N, Shapiro H. Breech presentation after cesarean section: always a section?. Am J Obstet Gynecol . 1989 Jul. 161(1):25-8. [QxMD MEDLINE Link] .

Green JE, McLean F, Smith LP, Usher R. Has an increased cesarean section rate for term breech delivery reduced in incidence of birth asphyxia, trauma, and death?. Am J Obstet Gynecol . 1982 Mar 15. 142(6 Pt 1):643-8. [QxMD MEDLINE Link] .

Collea JV, Chein C, Quilligan EJ. The randomized management of term frank breech presentation: a study of 208 cases. Am J Obstet Gynecol . 1980 May 15. 137(2):235-44. [QxMD MEDLINE Link] .

Gimovsky ML, Wallace RL, Schifrin BS, Paul RH. Randomized management of the nonfrank breech presentation at term: a preliminary report. Am J Obstet Gynecol . 1983 May 1. 146(1):34-40. [QxMD MEDLINE Link] .

Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group. Lancet . 2000 Oct 21. 356(9239):1375-83. [QxMD MEDLINE Link] .

Whyte H, Hannah ME, Saigal S, et al. Outcomes of children at 2 years after planned cesarean birth versus planned vaginal birth for breech presentation at term: the International Randomized Term Breech Trial. Am J Obstet Gynecol . 2004 Sep. 191(3):864-71. [QxMD MEDLINE Link] .

Hannah ME, Whyte H, Hannah WJ, Hewson S, Amankwah K, Cheng M. Maternal outcomes at 2 years after planned cesarean section versus planned vaginal birth for breech presentation at term: the international randomized Term Breech Trial. Am J Obstet Gynecol . 2004 Sep. 191(3):917-27. [QxMD MEDLINE Link] .

Hofmeyr GJ, Hannah M, Lawrie TA. Planned caesarean section for term breech delivery. Cochrane Database Syst Rev . 2015 Jul 21. 7:CD000166. [QxMD MEDLINE Link] .

Zlatnik FJ. The Iowa premature breech trial. Am J Perinatol . 1993 Jan. 10(1):60-3. [QxMD MEDLINE Link] .

Bergenhenegouwen L, Vlemmix F, Ensing S, Schaaf J, van der Post J, Abu-Hanna A, et al. Preterm Breech Presentation: A Comparison of Intended Vaginal and Intended Cesarean Delivery. Obstet Gynecol . 2015 Dec. 126 (6):1223-30. [QxMD MEDLINE Link] .

Caning MM, Rasmussen SC, Krebs L. Maternal outcomes of planned mode of delivery for term breech in nulliparous women. PLoS One . 2024. 19 (4):e0297971. [QxMD MEDLINE Link] . [Full Text] .

Eller DP, VanDorsten JP. Route of delivery for the breech presentation: a conundrum. Am J Obstet Gynecol . 1995 Aug. 173(2):393-6; discussion 396-8. [QxMD MEDLINE Link] .

Zhang J, Bowes WA Jr, Fortney JA. Efficacy of external cephalic version: a review. Obstet Gynecol . 1993 Aug. 82(2):306-12. [QxMD MEDLINE Link] .

Zielbauer AS, Louwen F, Jennewein L. External cephalic version at 38 weeks' gestation at a specialized German single center. PLoS One . 2021. 16 (8):e0252702. [QxMD MEDLINE Link] . [Full Text] .

Hofmeyr GJ, Kulier R, West HM. External cephalic version for breech presentation at term. Cochrane Database Syst Rev . 2015 Apr 1. 4:CD000083. [QxMD MEDLINE Link] .

de Hundt M, Velzel J, de Groot CJ, Mol BW, Kok M. Mode of delivery after successful external cephalic version: a systematic review and meta-analysis. Obstet Gynecol . 2014 Jun. 123 (6):1327-34. [QxMD MEDLINE Link] .

de Hundt M, Vlemmix F, Bais JM, de Groot CJ, Mol BW, Kok M. Risk factors for cesarean section and instrumental vaginal delivery after successful external cephalic version. J Matern Fetal Neonatal Med . 2016 Jun. 29 (12):2005-7. [QxMD MEDLINE Link] .

Cook HA. Experience with external cephalic version and selective vaginal breech delivery in private practice. Am J Obstet Gynecol . 1993 Jun. 168(6 Pt 1):1886-9; discussion 1889-90. [QxMD MEDLINE Link] .

Gifford DS, Keeler E, Kahn KL. Reductions in cost and cesarean rate by routine use of external cephalic version: a decision analysis. Obstet Gynecol . 1995 Jun. 85(6):930-6. [QxMD MEDLINE Link] .

Practice Bulletin No. 161 Summary: External Cephalic Version. Obstet Gynecol . 2016 Feb. 127 (2):412-3. [QxMD MEDLINE Link] .

[Guideline] External Cephalic Version: ACOG Practice Bulletin, Number 221. Obstet Gynecol . 2020 May. 135 (5):e203-e212. [QxMD MEDLINE Link] .

[Guideline] ACOG Committee Opinion No. 745: Mode of Term Singleton Breech Delivery. Obstet Gynecol . 2018 Aug; reaffirmed 2023. 132 (2):e60-e63. [QxMD MEDLINE Link] . [Full Text] .

Hutton E, Hannah M, Ross S, Delisle MF, Carson G, Windrim R, et al. The Early External Cephalic Version (ECV) 2 Trial: an international multicentre randomised controlled trial of timing of ECV for breech pregnancies. BJOG . 2011 Apr. 118(5):564-577. [QxMD MEDLINE Link] .

Hutton EK, Hofmeyr GJ, Dowswell T. External cephalic version for breech presentation before term. Cochrane Database Syst Rev . 2015 Jul 29. 7:CD000084. [QxMD MEDLINE Link] .

Flamm BL, Fried MW, Lonky NM, Giles WS. External cephalic version after previous cesarean section. Am J Obstet Gynecol . 1991 Aug. 165(2):370-2. [QxMD MEDLINE Link] .

de Meeus JB, Ellia F, Magnin G. External cephalic version after previous cesarean section: a series of 38 cases. Eur J Obstet Gynecol Reprod Biol . 1998 Oct. 81 (1):65-8. [QxMD MEDLINE Link] .

Burgos J, Cobos P, Rodríguez L, Osuna C, Centeno MM, Martínez-Astorquiza T, et al. Is external cephalic version at term contraindicated in previous caesarean section? A prospective comparative cohort study. BJOG . 2014 Jan. 121 (2):230-5; discussion 235. [QxMD MEDLINE Link] .

Ferguson JE 2nd, Dyson DC. Intrapartum external cephalic version. Am J Obstet Gynecol . 1985 Jun 1. 152(3):297-8. [QxMD MEDLINE Link] .

Marquette GP, Boucher M, Theriault D, Rinfret D. Does the use of a tocolytic agent affect the success rate of external cephalic version?. Am J Obstet Gynecol . 1996 Oct. 175(4 Pt 1):859-61. [QxMD MEDLINE Link] .

Cluver C, Gyte GM, Sinclair M, Dowswell T, Hofmeyr GJ. 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. [QxMD MEDLINE Link] .

Wilcox CB, Nassar N, Roberts CL. Effectiveness of nifedipine tocolysis to facilitate external cephalic version: a systematic review. BJOG . 2011 Mar. 118 (4):423-8. [QxMD MEDLINE Link] .

Carlan SJ, Dent JM, Huckaby T, Whittington EC, Shaefer D. The effect of epidural anesthesia on safety and success of external cephalic version at term. Anesth Analg . 1994 Sep. 79(3):525-8. [QxMD MEDLINE Link] .

Schorr SJ, Speights SE, Ross EL, et al. A randomized trial of epidural anesthesia to improve external cephalic version success. Am J Obstet Gynecol . 1997 Nov. 177(5):1133-7. [QxMD MEDLINE Link] .

Dugoff L, Stamm CA, Jones OW 3rd, Mohling SI, Hawkins JL. The effect of spinal anesthesia on the success rate of external cephalic version: a randomized trial. Obstet Gynecol . 1999 Mar. 93(3):345-9. [QxMD MEDLINE Link] .

Weiniger CF, Ginosar Y, Elchalal U, Sharon E, Nokrian M, Ezra Y. External cephalic version for breech presentation with or without spinal analgesia in nulliparous women at term: a randomized controlled trial. Obstet Gynecol . 2007 Dec. 110(6):1343-50. [QxMD MEDLINE Link] .

Johnson RL, Elliott JP. Fetal acoustic stimulation, an adjunct to external cephalic version: a blinded, randomized crossover study. Am J Obstet Gynecol . 1995 Nov. 173(5):1369-72. [QxMD MEDLINE Link] .

Benifla JL, Goffinet F, Darai E, Madelenat P. Antepartum transabdominal amnioinfusion to facilitate external cephalic version after initial failure. Obstet Gynecol . 1994 Dec. 84(6):1041-2. [QxMD MEDLINE Link] .

Adama van Scheltema PN, Feitsma AH, Middeldorp JM, Vandenbussche FP, Oepkes D. Amnioinfusion to facilitate external cephalic version after initial failure. Obstet Gynecol . 2006 Sep. 108(3 Pt 1):591-2. [QxMD MEDLINE Link] .

Egge T, Schauberger C, Schaper A. Dysfunctional labor after external cephalic version. Obstet Gynecol . 1994 May. 83(5 Pt 1):771-3. [QxMD MEDLINE Link] .

Lau TK, Lo KW, Rogers M. Pregnancy outcome after successful external cephalic version for breech presentation at term. Am J Obstet Gynecol . 1997 Jan. 176(1 Pt 1):218-23. [QxMD MEDLINE Link] .

Burgos J, Iglesias M, Pijoan JI, Rodriguez L, Fernández-Llebrez L, Martínez-Astorquiza T. Probability of cesarean delivery after successful external cephalic version. Int J Gynaecol Obstet . 2015 Nov. 131 (2):192-5. [QxMD MEDLINE Link] .

Deering S, Brown J, Hodor J, Satin AJ. Simulation training and resident performance of singleton vaginal breech delivery. Obstet Gynecol . 2006 Jan. 107(1):86-9. [QxMD MEDLINE Link] .

• Footling breech presentation. Once the feet have delivered, one may be tempted to pull on the feet. However, a singleton gestation should not be pulled by the feet because this action may precipitate head entrapment in an incompletely dilated cervix or may precipitate nuchal arms. As long as the fetal heart rate is stable and no physical evidence of a prolapsed cord is evident, management may be expectant while awaiting full cervical dilation.
• Assisted vaginal breech delivery. Thick meconium passage is common as the breech is squeezed through the birth canal. This is usually not associated with meconium aspiration because the meconium passes out of the vagina and does not mix with the amniotic fluid.
• Assisted vaginal breech delivery. The Ritgen maneuver is applied to take pressure off the perineum during vaginal delivery. Episiotomies are often performed for assisted vaginal breech deliveries, even in multiparous women, to prevent soft tissue dystocia.
• Assisted vaginal breech delivery. No downward or outward traction is applied to the fetus until the umbilicus has been reached.
• Assisted vaginal breech delivery. With a towel wrapped around the fetal hips, gentle downward and outward traction is applied in conjunction with maternal expulsive efforts until the scapula is reached. An assistant should be applying gentle fundal pressure to keep the fetal head flexed.
• Assisted vaginal breech delivery. After the scapula is reached, the fetus should be rotated 90° in order to deliver the anterior arm.
• Assisted vaginal breech delivery. The anterior arm is followed to the elbow, and the arm is swept out of the vagina.
• Assisted vaginal breech delivery. The fetus is rotated 180°, and the contralateral arm is delivered in a similar manner as the first. The infant is then rotated 90° to the backup position in preparation for delivery of the head.
• Assisted vaginal breech delivery. The fetal head is maintained in a flexed position by using the Mauriceau maneuver, which is performed by placing the index and middle fingers over the maxillary prominence on either side of the nose. The fetal body is supported in a neutral position, with care to not overextend the neck.
• Piper forceps application. Piper forceps are specialized forceps used only for the after-coming head of a breech presentation. They are used to keep the fetal head flexed during extraction of the head. An assistant is needed to hold the infant while the operator gets on one knee to apply the forceps from below.
• Assisted vaginal breech delivery. Low 1-minute Apgar scores are not uncommon after a vaginal breech delivery. A pediatrician should be present for the delivery in the event that neonatal resuscitation is needed.
• Assisted vaginal breech delivery. The neonate after birth.
• Ultrasound demonstrating a fetus in breech presentation with a hyperextended head (ie, "star gazing").

Contributor Information and Disclosures

Richard Fischer, MD Professor, Division Head, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Cooper University Hospital Richard Fischer, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists , American Institute of Ultrasound in Medicine , Association of Professors of Gynecology and Obstetrics , Society for Maternal-Fetal Medicine Disclosure: Stock ownership for: Pfizer Pharmaceuticals (< 5% of portfolio); Johnson & Johnson (< 5% of portfolio).

Alisa B Modena, MD, FACOG Assistant Professor, Cooper Medical School of Rowan University; Attending Physician, Division of Maternal-Fetal Medicine, Cooper University Hospital Alisa B Modena, MD, FACOG is a member of the following medical societies: American College of Obstetricians and Gynecologists , American Institute of Ultrasound in Medicine , Philadelphia Perinatal Society, Society for Maternal-Fetal Medicine Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Received salary from Medscape for employment. for: Medscape.

Richard S Legro, MD Professor, Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology, Pennsylvania State University College of Medicine; Consulting Staff, Milton S Hershey Medical Center Richard S Legro, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists , Society of Reproductive Surgeons , American Society for Reproductive Medicine , Endocrine Society , Phi Beta Kappa Disclosure: Received honoraria from Korea National Institute of Health and National Institute of Health (Bethesda, MD) for speaking and teaching; Received honoraria from Greater Toronto Area Reproductive Medicine Society (Toronto, ON, CA) for speaking and teaching; Received honoraria from American College of Obstetrics and Gynecologists (Washington, DC) for speaking and teaching; Received honoraria from National Institute of Child Health and Human Development Pediatric and Adolescent Gynecology Research Thi.

Ronald M Ramus, MD Professor of Obstetrics and Gynecology, Director, Division of Maternal-Fetal Medicine, Virginia Commonwealth University School of Medicine Ronald M Ramus, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists , American Institute of Ultrasound in Medicine , Medical Society of Virginia , Society for Maternal-Fetal Medicine Disclosure: Nothing to disclose.

What would you like to print?

• Print this section
• Print the entire contents of
• Print the entire contents of article

• HIV in Pregnancy
• Pulmonary Disease and Pregnancy
• Kidney Disease and Pregnancy
• Vaccinations/Immunizations During Pregnancy
• Common Pregnancy Complaints and Questions
• Shock and Pregnancy
• Anemia and Thrombocytopenia in Pregnancy
• Is immunotherapy for cancer safe in pregnancy?
• The Pregnancy Challenges of Women With Chronic Conditions
• Labetalol, Nifedipine: Outcome on Pregnancy Hypertension

• Drug Interaction Checker
• Pill Identifier
• Calculators

• 2020/viewarticle/immunotherapy-cancer-safe-pregnancy-2024a100083dnews news Is immunotherapy for cancer safe in pregnancy?

• 2002261369-overviewDiseases & Conditions Diseases & Conditions Postterm Pregnancy

Breech Presentation

• 📖 Geeky Medics OSCE Book
• ⚡ Geeky Medics Bundles
• ✨ 1300+ OSCE Stations
• ✅ OSCE Checklist PDF Booklet
• 🧠 UKMLA AKT Question Bank
• 💊 PSA Question Bank
• 💉 Clinical Skills App
• 🗂️ Flashcard Collections | OSCE , Medicine , Surgery , Anatomy
• 💬 SCA Cases for MRCGP

To be the first to know about our latest videos subscribe to our YouTube channel 🙌

Table of Contents

Suggest an improvement

• Hidden Post Title
• Hidden Post URL
• Hidden Post ID
• Type of issue * N/A Fix spelling/grammar issue Add or fix a link Add or fix an image Add more detail Improve the quality of the writing Fix a factual error
• Please provide as much detail as possible * You don't need to tell us which article this feedback relates to, as we automatically capture that information for you.
• Your Email (optional) This allows us to get in touch for more details if required.
• Which organ is responsible for pumping blood around the body? * Enter a five letter word in lowercase
• Email This field is for validation purposes and should be left unchanged.

Introduction

Breech presentation is a type of malpresentation and occurs when the fetal head lies over the uterine fundus and fetal buttocks or feet present over the maternal pelvis (instead of cephalic/head presentation).

The incidence in the United Kingdom of breech presentation is 3-4% of all fetuses. 1

Breech presentation is most commonly idiopathic .

Types of breech presentation

The three types of breech presentation are:

• Complete (flexed) breech : one or both knees are flexed (Figure 1)
• Footling (incomplete) breech : one or both feet present below the fetal buttocks, with hips and knees extended (Figure 2)
• Frank (extended) breech : both hips flexed and both knees extended. Babies born in frank breech are more likely to have developmental dysplasia of the hip (Figure 3)

Risk factors

Risk factors for breech presentation can be divided into maternal , fetal and placental risk factors:

• Maternal : multiparity, fibroids, previous breech presentation, Mullerian duct abnormalities
• Fetal : preterm, macrosomia, fetal abnormalities (anencephaly, hydrocephalus, cystic hygroma), multiple pregnancy
• Placental : placenta praevia , polyhydramnios, oligohydramnios , amniotic bands

Clinical features

Before 36 weeks , breech presentation is not significant, as the fetus is likely to revert to a cephalic presentation. The mother will often be asymptomatic with the diagnosis being incidental.

The incidence of breech presentation is approximately 20% at 28 weeks gestation, 16% at 32 weeks gestation and 3-4% at term . Therefore, breech presentation is more common in preterm labour . Most fetuses with breech presentation in the early third trimester will turn spontaneously and be cephalic at term.

However, spontaneous version rates for nulliparous women with breech presentation at 36 weeks of gestation are less than 10% .

Clinical examination

Typical clinical findings of a breech presentation include:

• Longitudinal lie
• Head palpated at the fundus
• Irregular mass over pelvis (feet, legs and buttocks)
• Fetal heart auscultated higher on the maternal abdomen
• Palpation of feet or sacrum at the cervical os during vaginal examination

For more information, see the Geeky Medics guide to obstetric abdominal examination .

Positions in breech presentation

There are multiple fetal positions in breech presentation which are described according to the relation of the fetal sacrum to the maternal pelvis .

These are: direct sacroanterior, left sacroanterior, right sacroanterior, direct sacroposterior, right sacroposterior, left sacroposterior, left sacrotransverse and right sacrotranverse. 5

Investigations

An ultrasound scan is diagnostic for breech presentation. Growth, amniotic fluid volume and anatomy should be assessed to check for abnormalities.

There are three management options for breech presentation at term, with consideration of maternal choice: external cephalic version , vaginal delivery and Caesarean section .

External cephalic version

External cephalic version (ECV) involves manual rotation of the fetus into a cephalic presentation by applying pressure to the maternal abdomen under ultrasound guidance. Entonox and subcutaneous terbutaline are used to relax the uterus.

ECV has a 40% success rate in primiparous women and 60% in multiparous women . It should be offered to nulliparous women at 36 weeks and multiparous women at 37 weeks gestation. 

If ECV is unsuccessful, then delivery options include elective caesarean section or vaginal delivery. 

Contraindications for undertaking external cephalic version include:

• Antepartum haemorrhage
• Ruptured membranes
• Previous caesarean section
• Major uterine abnormality  
• Multiple pregnancy 
• Abnormal cardiotocography (CTG) 

Vaginal delivery

Vaginal delivery is an option but carries risks including head entrapment, birth asphyxia, intracranial haemorrhage, perinatal mortality, cord prolapse and fetal and/or maternal trauma.

The preference is to deliver the baby without traction and with an anterior sacrum during delivery to decrease the risk of fetal head entrapment .

The mother may be offered an epidural , as vaginal breech delivery can be very painful. 6

Contraindications for vaginal delivery in a breech presentation include:

• Footling breech: the baby’s head and trunk are more likely to be trapped if the feet pass through the dilated cervix too soon
• Macrosomia: usually defined as larger than 3800g
• Growth restricted baby: usually defined as smaller than 2000g
• Other complications of vaginal birth: for example, placenta praevia and fetal compromise
• Lack of clinical staff trained in vaginal breech delivery

Caesarean section

A caesarian section booked as an elective procedure at term is the most common management for breech presentation.

Caesarean section is preferred for preterm babies (due to an increased head to abdominal circumference ratio in preterm babies) and is used if the external cephalic version is unsuccessful or as a maternal preference. This option has fewer risks than a vaginal delivery. 

Complications

Fetal complications of breech presentation include:

• Developmental dysplasia of the hip (DDH)
• Cord prolapse
• Fetal head entrapment
• Birth asphyxia
• Intracranial haemorrhage
• Perinatal mortality

Complications of external cephalic version include:

• Transient fetal heart abnormalities (common)
• Fetomaternal haemorrhage
• Placental abruption (rare)
• There are three types of breech presentation: complete, incomplete and frank breech
• The most common clinical findings include: longitudinal lie, smooth fetal head-shape at the fundus, irregular masses over the pelvis and abnormal placement being required for fetal hear auscultation
• The diagnostic investigation is an ultrasound scan
• Breech presentation can be managed in three ways: external cephalic version , vaginal delivery or elective caesarean section
• Complications are more common in vaginal delivery , such as cord prolapse, fetal head entrapment, intracranial haemorrhage and birth asphyxia

Miss Saba Al Juboori

Consultant in Obstetrics and Gynaecology

Miss Neeraja Kuruba

Dr chris jefferies.

• Oxford Handbook of Obstetrics and Gynaecology. Breech Presentation: Overview. Published in 2011.
• Jemimah Thomas. Image: Complete breech.
• Bonnie Urquhart Gruenberg. Footling breech. Licence: [ CC BY-SA ]
• Bonnie Urquhart Gruenberg. Frank breech . Licence: [ CC BY-SA ]
• A Comprehensive Textbook of Obstetrics and Gynaecology. Chapter 50: Malpresentation and Malposition: Breech Presentation. Published in 2011.
• Diana Hamilton Fairley. Lecture Notes: Obstetrics and Gynaecology, Malpresentation, Breech Presentation. Published in 2009.

Other pages

• Product Bundles 🎉
• Join the Team 🙌
• Institutional Licence 📚
• OSCE Station Creator Tool 🩺
• Create and Share Flashcards 🗂️
• OSCE Group Chat 💬
• Newsletter 📰
• Advertise With Us

Join the community

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

See More About

Select your interests.

Customize your JAMA Network experience by selecting one or more topics from the list below.

• Academic Medicine
• Acid Base, Electrolytes, Fluids
• Allergy and Clinical Immunology
• American Indian or Alaska Natives
• Anesthesiology
• Anticoagulation
• Art and Images in Psychiatry
• Artificial Intelligence
• Assisted Reproduction
• Bleeding and Transfusion
• Caring for the Critically Ill Patient
• Challenges in Clinical Electrocardiography
• Climate and Health
• Climate Change
• Clinical Challenge
• Clinical Decision Support
• Clinical Implications of Basic Neuroscience
• Clinical Pharmacy and Pharmacology
• Complementary and Alternative Medicine
• Consensus Statements
• Coronavirus (COVID-19)
• Critical Care Medicine
• Cultural Competency
• Dental Medicine
• Dermatology
• Diabetes and Endocrinology
• Diagnostic Test Interpretation
• Drug Development
• Electronic Health Records
• Emergency Medicine
• End of Life, Hospice, Palliative Care
• Environmental Health
• Equity, Diversity, and Inclusion
• Facial Plastic Surgery
• Gastroenterology and Hepatology
• Genetics and Genomics
• Genomics and Precision Health
• Global Health
• Guide to Statistics and Methods
• Hair Disorders
• Health Care Delivery Models
• Health Care Economics, Insurance, Payment
• Health Care Quality
• Health Care Reform
• Health Care Safety
• Health Care Workforce
• Health Disparities
• Health Inequities
• Health Policy
• Health Systems Science
• History of Medicine
• Hypertension
• Images in Neurology
• Implementation Science
• Infectious Diseases
• Innovations in Health Care Delivery
• JAMA Infographic
• Law and Medicine
• Leading Change
• Less is More
• LGBTQIA Medicine
• Lifestyle Behaviors
• Medical Coding
• Medical Devices and Equipment
• Medical Education
• Medical Education and Training
• Medical Journals and Publishing
• Mobile Health and Telemedicine
• Narrative Medicine
• Neuroscience and Psychiatry
• Notable Notes
• Nutrition, Obesity, Exercise
• Obstetrics and Gynecology
• Occupational Health
• Ophthalmology
• Orthopedics
• Otolaryngology
• Pain Medicine
• Palliative Care
• Pathology and Laboratory Medicine
• Patient Care
• Patient Information
• Performance Improvement
• Performance Measures
• Perioperative Care and Consultation
• Pharmacoeconomics
• Pharmacoepidemiology
• Pharmacogenetics
• Pharmacy and Clinical Pharmacology
• Physical Medicine and Rehabilitation
• Physical Therapy
• Physician Leadership
• Population Health
• Primary Care
• Professional Well-being
• Professionalism
• Psychiatry and Behavioral Health
• Public Health
• Pulmonary Medicine
• Regulatory Agencies
• Reproductive Health
• Research, Methods, Statistics
• Resuscitation
• Rheumatology
• Risk Management
• Scientific Discovery and the Future of Medicine
• Shared Decision Making and Communication
• Sleep Medicine
• Sports Medicine
• Stem Cell Transplantation
• Substance Use and Addiction Medicine
• Surgical Innovation
• Surgical Pearls
• Teachable Moment
• Technology and Finance
• The Art of JAMA
• The Arts and Medicine
• The Rational Clinical Examination
• Tobacco and e-Cigarettes
• Translational Medicine
• Trauma and Injury
• Treatment Adherence
• Ultrasonography
• Users' Guide to the Medical Literature
• Vaccination
• Venous Thromboembolism
• Veterans Health
• Women's Health
• Workflow and Process
• Wound Care, Infection, Healing

Others Also Liked

• Download PDF
• X Facebook More LinkedIn

Cardini F , Weixin H. Moxibustion for Correction of Breech Presentation : A Randomized Controlled Trial . JAMA. 1998;280(18):1580–1584. doi:10.1001/jama.280.18.1580

Manage citations:

© 2024

• Permissions

Moxibustion for Correction of Breech Presentation : A Randomized Controlled Trial

From the Jiangxi Women's Hospital, Nanchang, People's Republic of China (Dr Weixin). Dr Cardini is in private practice in Verona, Italy.

Context.—  Traditional Chinese medicine uses moxibustion (burning herbs to stimulate acupuncture points) of acupoint BL 67 (Zhiyin, located beside the outer corner of the fifth toenail), to promote version of fetuses in breech presentation. Its effect may be through increasing fetal activity. However, no randomized controlled trial has evaluated the efficacy of this therapy.

Objective.—  To evaluate the efficacy and safety of moxibustion on acupoint BL 67 to increase fetal activity and correct breech presentation.

Design.—  Randomized, controlled, open clinical trial.

Setting.—  Outpatient departments of the Women's Hospital of Jiangxi Province, Nanchang, and Jiujiang Women's and Children's Hospital in the People's Republic of China.

Patients.—  Primigravidas in the 33rd week of gestation with normal pregnancy and an ultrasound diagnosis of breech presentation.

Interventions.—  The 130 subjects randomized to the intervention group received stimulation of acupoint BL 67 by moxa (Japanese term for Artemisia vulgaris ) rolls for 7 days, with treatment for an additional 7 days if the fetus persisted in the breech presentation. The 130 subjects randomized to the control group received routine care but no interventions for breech presentation. Subjects with persistent breech presentation after 2 weeks of treatment could undergo external cephalic version anytime between 35 weeks' gestation and delivery.

Main Outcome Measures.—  Fetal movements counted by the mother during 1 hour each day for 1 week; number of cephalic presentations during the 35th week and at delivery.

Results.—  The intervention group experienced a mean of 48.45 fetal movements vs 35.35 in the control group ( P <.001; 95% confidence interval [CI] for difference, 10.56-15.60). During the 35th week of gestation, 98 (75.4%) of 130 fetuses in the intervention group were cephalic vs 62 (47.7%) of 130 fetuses in the control group ( P <.001; relative risk [RR], 1.58; 95% CI, 1.29-1.94). Despite the fact that 24 subjects in the control group and 1 subject in the intervention group underwent external cephalic version, 98 (75.4%) of the 130 fetuses in the intervention group were cephalic at birth vs 81 (62.3%) of the 130 fetuses in the control group ( P =.02; RR, 1.21; 95% CI, 1.02-1.43).

Conclusion.—  Among primigravidas with breech presentation during the 33rd week of gestation, moxibustion for 1 to 2 weeks increased fetal activity during the treatment period and cephalic presentation after the treatment period and at delivery.

IN CASES OF BREECH presentation at the onset of labor, delivery is associated with additional risks: for the mother, cesarean delivery and for the neonate, physical injury. Breech presentation is common in the midtrimester pregnancy and the incidence decreases as the pregnancy approaches term because of spontaneous version. 1 - 4 It is reasonable to assume (although not firmly established) that fetal activity plays an important role in spontaneous version. 5 - 9 The incidence of breech presentation at delivery can be reduced, but not eliminated, by the use of external cephalic version (ECV). 10

Since ancient times, traditional Chinese medicine has proposed moxibustion of acupoint BL 67 (Zhiyin) to promote version of fetuses in breech presentation. Moxibustion is a traditional Chinese method that uses the heat generated by burning herbal preparations containing Artemisia vulgaris (mugwort) (the Japanese name is moxa ) to stimulate acupuncture points. Acupoint BL 67 is beside the outer corner of the fifth toenail.

At present, there are no randomized, controlled clinical trials to evaluate the efficacy of this therapy. The 2 published Chinese studies 11 , 12 are not randomized and are based on a mixed population of primipara and multipara subjects stimulated at varying times between the 28th and 38th weeks of pregnancy. Although both studies give encouraging results and stimulate reflection regarding possible mechanisms of action, they do not allow definitive conclusions regarding efficacy because they are not randomized, little information is provided about the population sample, and the times at which stimulation is applied are wide ranging.

Cardini et al 13 identified the stage of pregnancy at which stimulation should commence and the parity status of the groups studied as primary factors to ensure the reliability of a clinical trial concerning spontaneous or induced correction of breech presentation.

Data in the literature concerning the probability of spontaneous correction indicate that correcting breech presentation before the 32nd week is useless. 14 - 16 There is also a sharp differentiation between multigravidas (high likelihood of spontaneous correction of breech presentation, even between the 32nd and 35th weeks) and primigravidas or multigravidas with a previous breech presentation at term (low probability of spontaneous version after the 32nd week). 15 - 17

Gottlicher and Madjaric, 15 , 16 by ultrasound examination of 4066 pregnant women, defined the likelihood of spontaneous correction of breech presentation from the 33rd week of pregnancy as 15.5% (95% confidence interval [CI], 2.8%-28.2%) for primigravidas and 57.5% (95% CI, 36.3%-78.7%) for multigravidas.

Westgren et al, 17 by ultrasound screening of 4600 women in the 32nd week of pregnancy, identified 310 cases (6.7%) of breech presentation, which were prospectively studied until birth. Rates of spontaneous cephalic version varied, according to whether subjects were primigravida (46%), multigravida with a previous breech presentation (32%), or multigravida with no previous breech presentation (78%). All the studies available report data relating to Western populations and we have been unable to retrieve any information regarding the spontaneous version rate from the 33rd week to term among Chinese pregnant women.

Given this background, Cardini and Marcolongo, 18 in a retrospectively controlled clinical trial, compared 23 primigravidas treated for breech presentation by moxibustion in the 32nd and 33rd week with a retrospective, untreated group at the same stage of pregnancy. The difference in prevalence of breech presentation showed borderline statistical significance ( P =.05). Thus, the subgroup of primigravidas with breech presentation at the 33rd week of pregnancy seemed to be the ideal population for a randomized, controlled clinical trial.

We undertook this study to evaluate the efficacy and safety of moxibustion on acupoint BL 67 in correcting breech presentation in a population of primigravidas treated since the 33rd week of pregnancy and to evaluate the efficacy of this technique in increasing active fetal movements (AFMs).

These 2 main objectives are consistent with the hypothesis that the use of moxibustion in women whose fetuses are breech in the 33rd week of pregnancy will (1) increase fetal activity; (2) reduce the proportion of fetuses that remain in a nonvertex presentation and, hence, decrease the need for ECV; and (3) decrease the incidence of breech presentation at birth. A secondary aim of the study was to assess the efficacy of 2 different dosages of moxibustion.

This was a randomized, controlled, open clinical trial of subjects treated by moxibustion since the 33rd week of pregnancy (intervention group) vs untreated subjects (control group). Subjects with persistent breech presentation after 2 weeks' treatment (intervention group) or observation (control group) could undergo ECV. Moxibustion in the early third trimester and ECV in late pregnancy are the standard care for breech presentation in both the centers involved in the trial. Thus (and also for ethical reasons), the availability of ECV was maintained for all subjects recruited.

Subjects were included if they were primigravidas, in the 33rd week of gestation (from 32 weeks + 1 day to 33 complete weeks, based on the last menstruation date and ultrasound data), with breech presentation diagnosed by ultrasound within 24 hours of randomization, and with normal fetal biometry (biparietal diameter and abdominal circumference between the 10th and 90th percentiles). Subjects were excluded if they had pelvic defects, previous uterine surgery, uterine malformation or fibromyoma of diameter greater than 4 cm, fetal malformation, twin gestation, tocolytic therapy during pregnancy, risk of premature birth (uterine hypercontractility and/or initial shortening or dilatation of the neck, with a Bishop score ≥4), or pathological pregnancy (eg, intrauterine growth retardation, gestosis, serious infections, placenta previa, polyhydramnios, oligohydramnios) judged by the investigator to contraindicate inclusion in the study. Subjects refusing to undergo treatment were also excluded.

The trial was conducted from April 1995 through August 1996 in the Women's Hospital of Jiangxi Province, Nanchang, People's Republic of China. A few subjects (23) were recruited in the nearby Jiujiang Women's and Children's Hospital, also in Jiangxi Province. The subjects were recruited during the routine management of normal pregnancies in the outpatient department. All procedures were executed by midwives (with the supervision of physicians) except ultrasound examinations and ECVs. The protocol followed the ethical standards of the Declaration of Helsinki.

Pregnant women fulfilling all criteria of the study were asked to participate. Interested subjects gave oral informed consent. Subjects had an ultrasound scan at the 33rd week. On the day of the ultrasound scan by which breech presentation was confirmed, the selected subject was randomly assigned to 1 of the 2 groups. The sample was randomly allocated by numbered envelopes (randomized in groups of 10 by the computer program PACT, Version 2.0 [Glaxo-Wellcome, London, England], in Italy). Once randomized, subjects and investigators were aware of group assignment. All subjects recruited were advised to avoid or, at least, to ask the investigators about other interventions or therapies that could contaminate the results of the trial.

All subjects were asked to return after 2 weeks for an ultrasound check on presentation. If breech presentation persisted at this time, the subject (after giving informed consent) could undergo ECV in the following weeks.

All subjects were also asked to complete 2 record forms for AFMs, 1 for each of the 2 weeks subsequent to recruitment. These 2 forms were returned at the time of the ultrasound examination. Each record form had to be completed once daily for 7 days, reporting the number of AFMs counted in 1 hour (if possible, between 5 and 8 PM) and times of starting and finishing the count.

Finally, each subject was asked to report all significant details of her pregnancy and delivery during a personal or telephone appointment after she had given birth. The following specific information was collected: date of birth, place of birth, name and address of the obstetrician normally consulted, and name and address of the obstetrician present at birth. In this way, it was possible to consult other sources of information (obstetrician normally consulted, obstetrician present at birth, patient record forms) if the subject provided incomplete or unreliable information. Because almost all the enrolled subjects gave birth in the same hospital where they had been studied, information about delivery was reliable and easy to check.

If the subject belonged to the intervention group, she was admitted to the hospital to attend an instruction session within 24 hours of randomization, alone or with her partner or the person who was actually going to help administer the treatment. Teaching the technique for applying moxibustion at home included presenting the moxibustion material (cigar-shaped rolls containing Artemisia ), locating of acupoint BL 67, and explaining the technique for stimulation of acupoint BL 67. During the therapy the subject relaxed in the sitting or semisupine position, with the partner sitting comfortably. The therapy was executed for 30 minutes (15 minutes per side) daily for 7 days in the first 87 subjects, and twice daily in the last 43 subjects. The subjects were allowed to choose the time, ensuring no interruptions in the therapy (if possible, between 5 and 8 PM). The intensity of moxibustion was just below the individual tolerability threshold, causing hyperemia from local vasodilatation but not burn blisters.

Reasons for discontinuing stimulation and consulting the investigator (abdominal pain, other suspected adverse effects, sensation that version had occurred before completion of 7 days' treatment) were explained to the subject, together with symptoms suggesting that version had occurred (decreased pressure in the epigastrium or hypochondrium, increased pressure in the hypogastrium, pollakiuria, a "different feeling" in the abdomen). The first stimulation session was executed in the hospital and the necessary materials for the following 6 days' stimulation were dispensed, together with the AFM record forms.

Last, an examination after 1 week's treatment (visit 2) was scheduled. Visit 2 included a check on presentation and collection of the AFM record form. The presentation check was by localization of fetal heartbeats and abdominal palpation (Leopold maneuvers). Ultrasound examination was performed only in the event that the techniques described herein failed or yielded uncertain findings. 19 This was to avoid an excess of ultrasound examinations, given that an ultrasound examination was scheduled for the 35th week in all subjects. If cephalic version had not occurred, another week's treatment was advised if there were no adverse effects and the subject agreed to continue. Further moxa rolls were therefore dispensed to the subject with a second AFM record form. The frequency of the treatment was the same as in the first week. Visit 3 was scheduled and executed after a further week; the procedure was the same for all treated and untreated subjects as described herein ( Figure 1 ).

The primary outcomes were number of cephalic presentations at the 35th week and at birth and fetal motor activity. Secondary outcomes were compliance with treatment, observation of possible adverse effects in the intervention group and adverse events in both groups, number of cephalic versions after 1 and 2 weeks of treatment (ie, 34th and 35th weeks' gestation), number of cephalic versions with 2 different dosages of moxibustion (once or twice daily), number and causes of cesarean deliveries, spontaneous and induced vaginal deliveries, and Apgar score at 5 minutes.

On the basis of the study by Cardini and Marcolongo, 18 for primigravidas it seemed possible to identify a 30% difference in the number of cephalic presentations at the 35th week and at term between the intervention and control groups, with an α significance level of .05 and greater than 90% power if 60 subjects per group completed the study. Given that the reliability of the preliminary study was limited because it was based on retrospective data and that we decided to assess the efficacy of 2 different dosages of moxibustion, the number of enrolled subjects was increased to 130 per group.

Even if not attributable to 1 of the causes specified in the research protocol, discontinuation of treatment did not entail the subject's exclusion from the study. Outcomes of all subjects recruited were analyzed on the basis of intention to treat. Every possible effort was made to ascertain the reason for withdrawal.

The statistical processing was performed using Epi Info, Version 6.04 (Centers for Disease Control and Prevention, Atlanta, Ga). The χ 2 test (supplemented, where necessary, by the Fisher exact test) and the t test were used for comparing qualitative and continuous variables, respectively. The measurement of effects was also described in terms of relative risk (RR) with 95% confidence intervals (CIs).

The total number of subjects was 260 (130 subjects per group), recruited, randomized, observed, or treated and followed up to delivery. No significant differences emerged between the intervention group and the control group ( Table 1 ). Neither the placental localization and grading nor the amount of amniotic fluid at the 33rd week showed significant differences between the 2 groups.

The main results of the trial are summarized in Table 2 . At the ultrasound check at the 35th week of gestation (2 weeks after the first visit), 98 (75.4%) of 130 fetuses in the intervention group were cephalic compared with 62 (47.7%) of 130 in the control group ( P <.001; RR, 1.58; 95% CI, 1.29-1.94).

After 35 weeks of pregnancy, only 1 subject in the intervention group agreed to undergo ECV, but version was not obtained. Twenty-four subjects in the control group agreed to undergo ECV and in 19 subjects cephalic version was obtained. Despite this, the number of cephalic presentations at birth was still significantly different in the 2 groups: 98 (75.4%) of 130 in the intervention group compared with 81 (62.3%) of 130 in the control group ( P =.02; RR, 1.21; 95% CI, 1.02-1.43). The results obtained excluding subjects treated with ECV are shown in Table 2 .

Of the 98 cephalic versions obtained in the intervention group, 82 occurred during the first week and 16 during the second week of treatment. The cephalic or breech presentations observed at the second visit (35th week of pregnancy) remained unchanged up to term in all subjects treated and observed, except for those successfully treated with ECV.

The only intervention allowed for the subjects in the control group was ECV during the last 5 weeks of pregnancy. They were specifically questioned at the 35th week and after delivery and none reported having been treated with moxibustion or other therapies.

Among the intervention group only 1 subject failed to comply with the treatment schedule prescribed and discontinued the therapy. At the end of the first week of treatment 8 subjects withdrew from therapy, 3 on the advice of the obstetrician (for Braxton Hicks contractions, breech engagement, and maternal tachycardia and atrial sinus arrhythmia, respectively) and 5 subjects for unspecified reasons. All 9 subjects maintained the breech presentations of their fetuses to term and none of them were excluded from the statistical analysis.

The form of discomfort most frequently reported by both groups was a sense of tenderness and pressure in the epigastric region or in one of the hypochondria (epigastric crushing) attributable to the head of the breech fetus pressing against the maternal organs.

No adverse events occurred in the intervention group during treatment. After treatment, 2 premature births occurred (both at 37 weeks), 1 of which was preceded by premature rupture of the membranes (PROM). There were 4 PROMs in the intervention group.

Adverse events occurring in the control group included 3 premature births at 34, 35, and 37 weeks (the third was preceded by placental detachment with fetal distress) and 1 intrauterine fetal death (intrauterine growth retardation and oligohydramnios, spontaneous delivery at 38 weeks; growth was within normal limits at ultrasound examination at 35 weeks). The total number of PROMs in the control group was 12.

Regarding the efficacy of the moxibustion treatment in producing an increase in fetal motility, comparison between the 2 groups proved possible for only the first week of treatment (or observation) because all the subjects in the intervention group who achieved cephalic version in the first week of treatment filled in only the first of the 2 record forms used for the weekly AFM counts. The mean value for fetal movements recorded during a 1-hour observation period for 7 days was 48.45 for the subjects in the intervention group and 35.35 for the subjects in the control group (difference, 13.08; 95% CI, 10.56-15.60; t test, 10.215; P <.001).

In the intervention group, the first 87 subjects received 1 stimulation per day, lasting 30 minutes, for 7 or 14 days (QD [ quaque die ] group). The last 47 subjects received 2 30-minute stimulations per day for 7 or 14 days (BID [ bis in die ] group). The 2 subgroups showed no significant differences in amount of amniotic fluid during the 33rd week, frequency of straight or bent leg position during the 33rd week, placental localization, neonatal sex, treatment compliance, or adverse effects attributable to the treatment.

At the end of the first week of treatment in the BID group, 34 (79.1%) of 43 cephalic versions were obtained compared with 48 (55.2%) of 87 in the QD group ( P =.007; RR, 1.43; 95% CI, 1.12-1.83).

During the second week of treatment, 15 additional cephalic versions were obtained in the QD group and only 1 additional version in the BID group. Thus, the following cephalic presentation results were observed on ultrasound examination at the end of the second week of treatment: 63 (72.4%) of 87 in the QD group and 35 (81.4%) of 43 in the BID group (nonsignificant difference). The same percentages were maintained to term.

No statistically significant differences were found in the number of cesarean deliveries performed. In the intervention group, 46 cesarean deliveries (35.4% of births) were performed, 20 of which were with cephalic presentations and 26 of which were with breech presentations. The 20 cesarean deliveries in the cephalic presentations were performed for fetopelvic disproportion (14 cases), postterm pregnancy (3 cases), or fetal distress (3 cases). The 26 cesarean deliveries in the breech presentations were performed for PROM after week 37 (10 cases), large fetus (2 cases), fetal distress (1 case), oligohydramnios (2 cases), and unspecified causes (11 cases).

In the control group, 47 cesarean deliveries (36.2%) were performed, 21 of which were with cephalic presentations and 26 of which were with breech presentations. Indications for cesarean delivery in the subjects with cephalic fetuses included fetopelvic disproportion (11 cases, 1 of which was with oligohydramnios), fetal distress (4 cases, 1 of which was in a subject with toxemia of pregnancy), sacral rotation of the occiput (2 cases), placental insufficiency (1 case), toxemia of pregnancy (1 case), PROM (1 case), and deep transverse arrest (1 case). Cesarean deliveries in the breech presentations were performed for PROM after 37 weeks (8 cases, 1 of which was with prolapse of the cord), oligohydramnios (3 cases), fetal distress (2 cases), large fetus (1 case), and unspecified causes (12 cases).

In both the intervention and control groups, cesarean delivery revealed 1 case of previously undiagnosed bicornuate uterus. In both cases, the presentation at birth was breech. Because they had been randomized, both cases were included in the statistical analysis of the data despite uterine malformations being exclusion criterion.

In regard to vaginal deliveries, the only significant difference between the 2 groups relates to the use of oxytocin, given to 7 (8.6%) of 81 subjects in the intervention group vs 25 (31.3%) of 80 in the control group (RR, 1.33 [95% CI, 1.13-1.56]; P <.001) before or during labor. In the intervention group, 2 vacuum-extractor and 1 forceps deliveries were performed and in the control group, 2 vacuum-extractor and 3 forceps deliveries were performed.

No neonates in the intervention group, but 7 in the control group, had Apgar scores of less than 7 at 5 minutes (Fisher exact test, P =.006). On grouping Apgar scores in the traditional manner, in the intervention group no neonates had Apgar scores less than 4 and 4 had scores 4 to 7; in the control group, 2 neonates had Apgar scores less than 4 and 12 had scores 4 to 7.

Moxibustion is a popular and much appreciated therapy for breech presentation in the People's Republic of China; thus, it would have been impossible to propose a "sham moxibustion" as a placebo for the control group.

Furthermore, moxibustion is a typical cheap, self-administered home therapy. This made blinding practically impossible. It was very difficult for investigators to persuade subjects to accept randomization and the consequent risk of having to do without the therapy. Consent was often obtained because of the availability of ECV later in pregnancy, but this is a much less popular and somewhat feared therapy; thus, only a few subjects, mostly belonging to the control group, opted for this solution.

Because the main results of the trial are of a qualitative type and were measured objectively (ultrasound), we believe that the lack of blinding and a placebo does not undermine the validity of the results. This is not entirely the case when considering fetal movement count, which was subjectively assessed.

The choice of sample (primigravidas at the 33rd week of gestation) appears to have been appropriate because the presentation did not change after the 35th week in any of the subjects (except for those undergoing ECV). This confirms the rarity of spontaneous fetal version (to either breech or cephalic presentation) among primigravidas after the 35th week. 16

Two half-hour stimulations per day proved more effective in producing cephalic version than a single stimulation. On prolonging the therapy by 1 week in those cases in which cephalic version was not achieved, this difference in efficacy was partly, although not entirely, annulled. Of the 2 dosages, then, twice-daily stimulation is recommended because it did not reduce treatment compliance and had no adverse effects. Compliance with the treatment was by and large good.

In 2 cases, disorders serious enough to prompt discontinuation were observed during treatment. It was not clear whether these were adverse effects of the treatment.

No severe adverse events attributable to the treatment were observed and, in particular, there were no cases of intrauterine death or placental detachment. No cases of severe fetal anemia attributable to fetomaternal transfusion 20 were reported. The number of PROMs was similar in both groups and the number of premature births was lower in the intervention group.

Moxibustion treatment did not reduce the rate of cesarean deliveries in a population in which elective cesarean delivery is not envisaged for breech presentations. On the other hand, it is possible that the significantly higher number of breech presentations at birth in the control group may have been a factor in bringing about worse Apgar scores.

The mechanism of action of moxibustion appears to be through increased AFMs, which proved significantly stronger in the treated subjects. Although a number of studies in China 11 , 12 , 21 have investigated the neurologic path of stimulation by moxibustion and have shown evidence of its effect on maternal plasma cortisol and prostaglandins, we think that the mechanism of action of moxibustion is not entirely clear and warrants further research.

Further studies 22 are needed to establish the efficacy and safety of moxibustion at more advanced gestational ages than those considered in this trial, as well as in second pregnancies or multigravidas and populations other than Chinese. Moreover, it is not clear whether moxibustion is more or less efficacious than ECV at term for obtaining cephalic presentation given the small number of subjects (nearly all belonging to the control group) who underwent ECV. Furthermore, since moxibustion and ECV must be performed at different gestational ages, we may regard them as complementary therapies to be used in succession. As we see it, if the results of this trial are confirmed, moxibustion should be extensively used on account of its noninvasiveness, low cost, and ease of execution. In fact, it is easy to train expectant mothers (either alone or with their partners) to administer the therapy at home. Further studies are also necessary to establish whether moxibustion treatment can reduce the rate of cesarean deliveries where these are used electively for breech presentation at birth.

Additional results regarding the effects of family history, fetal sex, cranial circumference, and leg position on the likelihood of cephalic version will be presented in a subsequent article.

On the basis of the results of the trial, moxibustion, when performed in primigravidas for 1 or 2 weeks starting in the 33rd week of pregnancy, has proved to be an effective therapy for inducing a significant increase in cephalic versions within 2 weeks of the start of therapy and in cephalic presentations at birth.

• Register for email alerts with links to free full-text articles
• Access PDFs of free articles
• Manage your interests
• Save searches and receive search alerts

Lazarus Group Targets Blockchain Pros with Fake Video Conferencing, Job Scam

Critical GeoServer Vulnerability Exploited in Global Malware Campaign

AI Firm’s Misconfigured Server Exposed 5.3 TB of Mental Health Records

RansomHub Claims Planned Parenthood Hack, Steals 93GB of Sensitive Data

• Zyklon B hacker
• Zues Malware
• Zoombombing
• Cyber Attacks

Nissan Confirms Data Breach Affected 100,000 Customers and Employees

Following a cyberattack in December 2023, Nissan confirms a data leak impacting customers, dealers, and employees. Information potentially compromised includes names, contact details, and even government-issued IDs for up to 10% of those affected. Nissan is notifying individuals and offering support services.

Nissan Motor Corporation’s Oceania region has confirmed a data breach impacting roughly 100,000 individuals. The breach, linked to a December 2023 cyberattack claimed by the Akira ransomware group, exposed the personal information of customers, dealers, and some current and former employees.

For your information, Nissan Motor Corporation and Nissan Financial Services in Australia and New Zealand were impacted by a cyberattack on December 5, 2023.

“On 5 December 2023, a malicious third party obtained unauthorised access to our local IT servers. We took immediate action to contain the breach, and promptly alerted the relevant government authorities, including the Australian and New Zealand national cyber security centres and privacy regulators” Nissan revealed in an update released on 13 March 2024.

Akira ransomware group claimed to have stolen 128 GB of information including corporate files and personal information. Other impacted businesses included Mitsubishi, Renault, Skyline, Infiniti, LDV, and RAM. Hackers then published files stolen from Nissan systems, indicating the company refused ransom demands.

Nissan detected the ‘disruptive incident’ the same month and notified customers but crucial details about data exfiltration weren’t confirmed until now. While the exact nature of the compromised data remains under investigation, Nissan acknowledges the possible leak of government-issued identification documents, names, and contact details. The company emphasizes that they are still validating contact information and removing duplicates, so the final number affected might be slightly lower.

Nissan Oceania has now started contacting the 100,000 affected individuals. The carmaker has reported that the type of information compromised in the breach might be different for each affected individual.

The company estimates that up to 10% of individuals may have had their government identification compromised, with the data set including 4,000 Medicare cards, 7,500 driver’s licenses, 220 passports, and 1,300 tax file numbers. The remaining 90% of the affectees Nissan is notifying have had other personal information impacted, including loan-related transaction statement copies, employment or salary information, and general information like dates of birth. 

The company is providing support services to affected individuals and enhancing cybersecurity measures to prevent future incidents, while also offering free identity theft and credit services.

Nissan advises customers to remain vigilant and be cautious of any suspicious emails, calls, or text messages. They recommend monitoring financial statements for unauthorized activity and considering placing a fraud alert on their credit reports.

Experts Comments

Commenting on the news and providing insight, Erfan Shadabi , a cybersecurity expert at comforte AG said, “This data breach on Nissan demonstrates just how important it is for every organization to rethink data security. Nissan must now assess just how much sensitive information has been released.”

“Hopefully, they can navigate this situation effectively with minimal damage. The distressing fact is that ordinary individuals and users invariably find themselves at the mercy of organizations failing to fortify their data against potential breaches. The fallout from such incidents can range from identity theft to financial losses, leaving users vulnerable to a myriad of cyber threats,” Shadabi warned.

“The ironic thing is that enterprises can avoid the threat of leaked hijacked data simply by taking a data-centric approach to protecting sensitive information. Using tokenization or format-preserving encryption, businesses can obfuscate any sensitive data within their data ecosystem, rendering it incomprehensible no matter who has access to it. These reports should all be treated as cautionary tales, as any enterprise might find itself in the same boat without the proper data-centric approach,” he stressed.

RELATED TOPICS

• Cybercriminals Exploit CAN Injection Hack to Steal Cars
• Nissan Leaf Maybe At Threat Because of Vulnerable APIs
• App Flaw Allowed Nissan Cars Hack by Knowing VIN number
• Nissan Canada cyber attack; millions of customer accounts stolen
• Nissan source code leaked, “admin” was its as username, password
• Cyber Attack
• Cybersecurity
• data breach

Related Posts

• Phishing Scam
• Scams and Fraud

Holiday and Christmas scams users should be aware of

This IoT Scanner Shows if Your Device is Vulnerable to be used in DDoS Attacks

• Hacking News

Cars with Vulnerable WIFI Dongle can be Hacked via Bluetooth

Supply Chain Attack: Abandoned S3 Buckets Used for Malicious Payloads