In one line
Term breech is a decision problem, not a delivery technique: offer external cephalic version (ECV) first to convert the problem away, then counsel honestly that planned caesarean lowers the small absolute neonatal risk while planned vaginal breech — safe only with strict selection and an experienced accoucheur — spares the mother a caesarean and the next pregnancy a scar.
This chapter assumes the mechanics and manoeuvres covered in breech basics; it spends its words on defending a plan from the trial data — the appraisal, the thresholds, and the judgement calls a consultant owns, rather than a recital of how to perform Løvset's.
Why this matters in South Africa
The breech consultation in a South African public hospital is rarely a clean elective choice between two equivalent routes — it is a systems decision constrained by skill, theatre access and referral geography. Three SA-specific realities shape the plan. First, the skills-loss spiral: as caesarean became the default after the Term Breech Trial, registrars stopped accruing supervised vaginal-breech numbers, so fewer clinicians can safely offer or supervise it — which sections even good candidates, which loses more skill. Second, caesarean is not free in this setting: it carries real anaesthetic and sepsis morbidity in a high-HIV, often under-resourced theatre environment, and — because grand-multiparity and limited access to safe future operative delivery are common — every first scar genuinely constrains the next pregnancy's options (Uterine rupture, Multiple pregnancy for the compounding cases). Third, the woman often meets the system late and undiagnosed: the breech is first found in advanced labour at a district hospital with no on-site experienced accoucheur and no immediate theatre. The defensible SA stance flows from this: maximise ECV (the one high-value, low-risk intervention that reduces caesarean without the neonatal trade-off), refer breech antenatally from district to regional level before labour rather than improvising in second stage, and concentrate planned vaginal breech in the few units that maintain the skill.
Aetiology / pathophysiology — the advanced layer
The Intermediate groundwork (the mechanics of breech, the four types) is assumed. What matters at this level is why the subtype matters mechanically and what each one predicts, because the type is not a label — it changes both the probability of a safe vaginal birth and the specific catastrophe you are guarding against.
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Persistent breech as a marker, not a coincidence. Most fetuses are breech in mid-pregnancy and turn spontaneously; persistence to term means something has prevented version. The clinically useful corollary is that a term breech is a screening signal: actively exclude the conditions that hold a fetus breech because several of them independently contraindicate vaginal birth or even ECV — fetal anomaly (hydrocephalus, anencephaly, neuromuscular conditions that abolish the fetal tone needed to flex and turn), uterine factors (bicornuate/septate uterus, a low or fundo-cornual fibroid, a short or contracted cavity), placental factors (praevia/low-lying placenta restricting the lower pole), and liquor extremes (oligohydramnios fixes the fetus; polyhydramnios allows it to revert after version). A term breech without a deliberate ultrasound look for these has been under-assessed.
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Frank (extended-leg) breech — the safest vaginal candidate. Flexed hips with extended knees splint the legs against the trunk, so the breech is bulky and well-applied to the cervix. Mechanistically this gives the best fit and the lowest cord-prolapse risk because there is no irregular presenting part for the cord to slip past — the reason frank breech is the type that may be selected for vaginal birth. It is also the type most likely to revert after ECV (the splinted attitude resists the turning forces).
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Complete (flexed) breech. Flexed hips and knees, so feet sit alongside the buttocks. The presenting part is more irregular and less perfectly applied, raising cord-prolapse risk above frank breech — the clinical consequence is closer intrapartum surveillance and a lower threshold to abandon.
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Footling / kneeling (incomplete) breech — the dangerous mechanism. One or both feet (or knees) present below a non-engaged breech. The presenting part is small and irregular, the cervix is not snugly filled, and the feet can deliver through an incompletely dilated cervix — so this is the type with the highest cord-prolapse risk and the highest risk of head entrapment behind an undilated cervix. This mechanism, not dogma, is why footling presentation contraindicates planned vaginal birth: the body delivers through a cervix that has not opened enough for the aftercoming head.
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The two attitudes that kill regardless of type. A hyperextended ("stargazing") fetal neck converts the aftercoming head from a flexed, smallest-diameter passage into an extended one that can hinge on the symphysis and cause cervical-spinal-cord injury — an absolute contraindication to vaginal birth and a finding you must specifically seek on the version-day or pre-labour scan. A nuchal arm (an arm trailing up beside or behind the head) enlarges the diameter that must pass and is a leading cause of birth trauma at vaginal breech — its mechanism (traction-induced extension of the arm during a hurried or mistimed delivery) is exactly why the "hands-off until the scapulae" discipline exists.
The mechanism→consequence links that drive the route decision: footling → cord prolapse + head entrapment → abdominal delivery; hyperextended neck → cord injury → caesarean; traction before the scapulae → nuchal arm / extended head → trauma; large or growth-restricted fetus → disproportion or fragility → caesarean.
Assessment
The diagnosis is the easy part; stratifying the candidate for vaginal birth is the consultant task. The basic clinical picture is assumed from Intermediate; the selection judgement builds on it.
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Confirm presentation and type by ultrasound — clinical examination is unreliable. A hard ballottable mass at the fundus and FHR above the umbilicus are suggestive at best; ultrasound is mandatory before any plan. The scan is not just "is it breech" — it must define type, fetal neck attitude, estimated fetal weight (EFW), placental site, liquor volume and any anomaly, because each shifts the route decision.
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Severity-stratify the vaginal-breech candidate. The defensible "safe to offer vaginal birth" phenotype is narrow: frank or complete breech, EFW appropriate for gestation (not below the 10th centile and not above 3.8 kg), a flexed or neutral neck, no fetal compromise, normal liquor, and a skilled accoucheur available (RCOG GTG 20b). Each of these failing pushes toward caesarean. The subtle calls are at the edges — an EFW of 3.7 kg in a multipara with a proven pelvis is different from 3.7 kg in a primigravida; a marginally small-for-gestational-age fetus is more fragile and tolerates the mechanical stress of breech birth less well, so growth restriction shifts you toward caesarean even within the "acceptable weight" band.
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Pelvimetry does not predict outcome and is not recommended. Routine clinical or radiological pelvimetry does not improve selection; the labour itself, with normal progress, is the functional test of the pelvis. Quoting pelvimetry as a selection tool is a dated answer.
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Screen ECV eligibility deliberately. The absolute contraindications to ECV — the situations in which it must not be attempted — are: recent antepartum haemorrhage, an abnormal CTG, major uterine anomaly, ruptured membranes, any independent indication for caesarean, and multiple pregnancy (except for version of a second twin). Check rhesus status — ECV can provoke feto-maternal haemorrhage, so Rh-negative women need anti-D (and a Kleihauer to size the bleed). Relative factors that lower success — but do not forbid the attempt — are nulliparity, an anterior placenta, low liquor, an engaged breech and a tense abdominal wall.