Clinical overview
Breech presentation — the fetus lying longitudinally with the buttocks or feet as the presenting part — is the commonest malpresentation at term, complicating roughly 3–4% of singleton pregnancies at 37 weeks (standard teaching). It is far commoner earlier in gestation (around a quarter of pregnancies before 28 weeks) because the relatively large fetal head naturally seeks the roomier uterine fundus until the fetus grows and spontaneously turns cephalic. Most breeches therefore correct themselves; the clinical problem is the minority that persist to term, and the decision about how that baby should be born.
The registrar must hold two parallel tasks in mind. Antenatally, the aim is to detect breech reliably (clinically and by ultrasound), exclude or define the reasons it is breech (placenta praevia, fibroids, fetal anomaly, oligohydramnios, multiple pregnancy), and offer the interventions that change the outcome — chiefly external cephalic version (ECV), which converts a breech into a cephalic presentation and so removes the risk altogether. Intrapartum, the task is to counsel honestly about mode of delivery, recognise that the evidence (the Term Breech Trial) shifted practice strongly towards planned caesarean, and yet retain the skills and judgement to conduct a safe vaginal breech birth when one is chosen or forced — the unbooked woman in advanced labour, the second twin, or the woman who declines surgery. In the South African context, where many women present late, undiagnosed breech in labour is common, and the ability to deliver a breech safely is not optional. This chapter sits alongside complicated-labour, instrumental-delivery and multiple-pregnancy.
Core knowledge
Types of breech
- Frank (extended) breech — hips flexed, knees extended, legs splinted up against the trunk. The commonest type at term (classically ~60–70%). The presenting part is well-applied to the cervix and the buttocks dilate the cervix effectively — the most favourable type for vaginal birth.
- Complete (flexed) breech — hips and knees both flexed; the fetus is "sitting cross-legged". Presenting part is buttocks and feet together.
- Footling (incomplete) breech — one or both hips extended so a foot is the presenting part. Carries the highest risk of cord prolapse (a small irregular presenting part poorly applied to the cervix) and is generally regarded as a contraindication to vaginal breech birth.
Why a breech is dangerous to deliver vaginally
The hazard of vaginal breech birth is mechanical and is concentrated in the after-coming head. In a cephalic birth the head — the largest, least compressible part — moulds and descends first, so by the time the body is born the pelvis has proven adequate. In a breech the soft, compressible buttocks and trunk deliver first through a cervix and pelvis that have not been tested by the head. The head then arrives last and rapidly, with no time to mould, and may become entrapped at an incompletely dilated cervix (especially if the baby is preterm, where the head is disproportionately large) or behind the symphysis. Once the cord is in the vagina alongside the trunk it is compressed, so there is a hard time limit on delivering the head before hypoxic injury. Other mechanisms of harm include cord prolapse (especially footling), nuchal arms (arms extended above the head, obstructing delivery), head extension/deflexion, and birth trauma to the brachial plexus, spine, abdominal viscera and genitalia from incorrect handling.
Figure J6.1 — Breech type and after-coming-head mechanics linking frank, complete and footling presentations to cord prolapse, head entrapment, nuchal arms, head extension and vaginal-birth selection criteria.
Causes and associations
A persistent breech is sometimes simply chance, but it should prompt a search for a reason that may itself change management:
- Reduced/abnormal fetal mobility or room to turn — oligohydramnios, fetal growth restriction (see intrauterine-growth-restriction), fetal neuromuscular anomaly.
- Polyhydramnios — excessive mobility, late or unstable lie.
- Uterine/pelvic factors — uterine anomaly (septate, bicornuate), fibroids, previous breech.
- Placental — placenta praevia (a cause of malpresentation and an absolute contraindication to ECV and to vaginal birth — see antepartum-haemorrhage) or cornual placenta.
- Multiple pregnancy — restricted space; the breech second twin is a distinct scenario.
- Fetal — anomalies (notably hydrocephalus, anencephaly), and prematurity (the single commonest "association", since most preterm fetuses are breech).
Assessment
History and examination
The diagnosis is often first suspected on abdominal palpation at the antenatal visit: a firm, ballottable, round mass (the head) felt in the fundus; a softer, less defined presenting part in the pelvis; and the fetal heart auscultated higher than expected (at or above the umbilicus). Leopold's manoeuvres should be performed at every late antenatal contact; relying on the woman to report "feeling kicks low down" is unreliable. A high presenting part, an apparently small or oddly shaped abdomen, or difficulty identifying the lie should all trigger imaging.
Clinical detection is imperfect — a substantial proportion of breeches are missed on palpation, which is why a fetus whose presentation is uncertain near term warrants a scan. Ultrasound is the confirmatory test and does far more than confirm presentation: it should establish the type of breech (degree of hip/knee flexion, footling), head attitude (flexed vs deflexed/extended — a hyperextended "star-gazing" head is a contraindication to vaginal birth), estimated fetal weight, liquor volume, placental site (excluding praevia), and gross anomaly. Use it also to confirm a single fetus and assess growth (see obstetric-ultrasound and gestational-age-assessment).
Decisions the assessment must feed
The assessment exists to answer three questions in sequence:
- Is this a breech, and why? (palpation → ultrasound, with the checklist above.)
- Should we attempt to turn it (ECV)? — i.e. is the woman at/near term with no contraindication.
- If it stays breech, how should it be born? — planned caesarean vs planned vaginal breech birth, informed by selection criteria.
Selection criteria for considering vaginal breech birth
When vaginal breech birth is being considered, the assessment looks for features that make it favourable; the presence of unfavourable features steers towards caesarean. Standard teaching and RCOG guidance favour:
- Frank or complete breech (footling is unfavourable/contraindicated).
- Flexed fetal head (not hyperextended).
- Estimated fetal weight within a reasonable range — classically ~2000–3800 g (avoid the very small and the macrosomic — see macrosomia); thresholds vary, so verify against the local protocol.
- No fetopelvic disproportion on clinical/imaging assessment; adequate pelvis.
- No other indication for caesarean (e.g. placenta praevia, previous classical caesarean).
- Availability of a clinician skilled in vaginal breech birth and immediate access to theatre and neonatal resuscitation.
Management
Antenatal management
External cephalic version (ECV) is the single most effective antenatal intervention because a successful version removes the breech problem entirely and roughly halves the chance of a non-cephalic presentation at birth and of caesarean for malpresentation. ECV should be offered to every woman with an uncomplicated breech at term in whom there is no contraindication.
- Timing: classically offered from ~36 weeks in nulliparous women and ~37 weeks in multiparous women (RCOG GTG 20a). Earlier than term risks spontaneous reversion and a procedure-triggered preterm delivery; at term, if version succeeds or labour follows, the baby is mature.
- Success: roughly 40–60% overall (higher in multiparas, with relaxed/ample liquor, a non-engaged breech and a palpable head; lower with nulliparity, oligohydramnios, an engaged breech, and an anterior placenta) — figures are approximate, confirm locally.
- Technique: performed where immediate caesarean is available, with the woman fasted, CTG confirming fetal wellbeing before and after, and a forward- or back-flip disimpaction-then-rotation manoeuvre. Tocolysis (a beta-agonist such as salbutamol/terbutaline, or another agent per local protocol — verify dose against the EML/local guideline) improves success, particularly in nulliparas.
- Anti-D: give anti-D immunoglobulin to Rh-negative, non-sensitised women after ECV (a potentially sensitising event) — see rh-isoimmunisation.
- Risks: low but real — transient abnormal CTG, placental abruption, cord accident, and rarely emergency delivery. Quote a small (<0.5%) risk of an immediate emergency caesarean; the procedure is otherwise safe.
- Contraindications: placenta praevia, recent antepartum haemorrhage, abnormal CTG, ruptured membranes, multiple pregnancy (except delivery of a second twin), major uterine anomaly, and any other standing indication for caesarean. A previous caesarean is a relative contraindication — discuss individually.
If ECV fails or is declined or contraindicated, counsel on mode of delivery. The honest, balanced conversation — supported in writing — covers the Term Breech Trial finding that planned caesarean reduces perinatal mortality and serious short-term neonatal morbidity compared with planned vaginal breech birth, set against the maternal risks of caesarean and the implications for future pregnancies (see vbac). Document the discussion and the woman's informed choice (see informed-consent). Postural/knee-chest exercises and moxibustion are sometimes requested; evidence for effectiveness is weak — do not let them substitute for ECV.
Figure J6.2 — External cephalic version pathway from ultrasound confirmation through contraindication screening, timing, safe setup, version attempt and post-ECV mode-of-birth counselling.
Intrapartum management — planned vaginal breech birth
Vaginal breech birth is conducted on a "hands-off" principle: the safest breech is the one you do not touch until you must, because traction and inappropriate handling cause extension of the arms and head. The cardinal rule is never to pull; you assist descent that the woman's expulsive efforts and uterine forces are already achieving.
- Setting: delivery room with immediate theatre access, continuous CTG (see ctg-interpretation), an experienced accoucheur/attendant present, and a neonatal resuscitation team standing by (see neonatal-resuscitation). Ensure the bladder is empty.
- First stage: manage as normal labour with continuous fetal monitoring; augmentation of slow labour is controversial and generally avoided — poor progress in breech may signal disproportion. Confirm full dilatation before active pushing.
- Allow spontaneous descent to the buttocks; encourage maternal effort. Do not handle until the buttocks and lower scapulae are visible ("hands off the breech").
- Delivery of the legs/body: with a frank breech the legs often deliver spontaneously; for a flexed breech, flexion behind the knee (Pinard manoeuvre) frees an entrapped leg. Allow the body to hang to encourage flexion and descent of the head ("let the baby hang"); keep the fetal back anterior.
- Delivery of the arms: if the arms do not deliver spontaneously, use Løvset's manoeuvre — rotate the trunk to bring each posterior shoulder anteriorly under the symphysis so the arm can be swept down.
- Delivery of the after-coming head: use the Mauriceau–Smellie–Veit manoeuvre (the baby astride the forearm, fingers on the maxilla — not the mandible — to promote flexion, the other hand applying suprapubic flexion pressure) or apply forceps to the after-coming head for controlled flexion and delivery. Maintain flexion throughout.
EMERGENCY — head entrapment / undelivered after-coming head
This is a true obstetric emergency: the body is born, the cord is compressed, and the head is stuck. The clock is running. Call for help immediately and act:
- CALL FOR HELP — senior obstetrician, anaesthetist, paediatric/neonatal team, theatre alerted.
- Confirm full dilatation; if the cervix is trapping the head and the baby is preterm, Dührssen's incisions (cervical incisions) may be needed — senior decision.
- Flex the head: Mauriceau–Smellie–Veit manoeuvre + firm suprapubic pressure by an assistant to flex and push the head into the pelvis.
- Forceps to the after-coming head for controlled flexion if MSV alone fails.
- If the head remains entrapped, symphysiotomy or emergency caesarean (delivering the trunk back up and out, the "Zavanelli" type approach) are last-resort options requiring the most senior help available.
- Resuscitate the neonate the moment it is born — anticipate the need (see neonatal-resuscitation).
If a footling breech or cord prolapse occurs, manage cord prolapse drill in parallel — relieve cord compression, knee-chest/Trendelenburg, and expedite delivery (usually caesarean unless birth is imminent).
Figure J6.3 — Planned vaginal breech drill: selected-case criteria, hands-off sequence, Pinard, Løvset, MSV/forceps and escalation for an undelivered after-coming head.
Planned caesarean
For a persistent term breech that is not turned and where vaginal birth is not chosen or not safe, planned caesarean at ~39 weeks is the default in most settings, balancing perinatal benefit against neonatal respiratory morbidity from earlier delivery (see safe-caesarean-technique). A breech baby may still need skilled hands at caesarean — the same manoeuvres (Løvset, MSV) apply through the uterine incision.
South African context
- NDoH National Integrated Maternal and Perinatal Care Guideline (NDoH, 2024) anchors local practice; ECV and breech delivery are conducted at facilities with theatre and neonatal resuscitation capability.
- Levels of care: undiagnosed breech in advanced labour at a district hospital/CHC is common given late presentation; midwives and medical officers must be competent in assisted vaginal breech birth and in safe transfer decisions to regional level. Do not start a planned vaginal breech in a unit without immediate theatre and neonatal support — refer antenatally.
- HIV: mode-of-delivery counselling integrates HIV status and viral load per the SA HIV/ART guidelines and hiv-in-pregnancy; a well-suppressed viral load does not by itself dictate caesarean, but the malpresentation decision proceeds on obstetric grounds.
- Saving Mothers/NCCEMD emphasises avoidable factors — missed antenatal diagnosis, delayed recognition of obstructed/entrapped delivery, and inadequate neonatal resuscitation — all directly relevant to breech.
Red flags / pitfalls
- Missed antenatal diagnosis. Failing to palpate at every late visit, or not scanning an uncertain lie, lands you with an undiagnosed breech in labour. Palpate, and scan when in doubt.
- Footling presentation treated as a "candidate for vaginal birth." It is not — high cord-prolapse risk and poor cervical application. Plan caesarean.
- Hyperextended (deflexed) fetal head on scan — a contraindication to vaginal breech birth (risk of spinal cord injury); deliver by caesarean.
- Pulling on the breech. Traction causes nuchal arms and head deflexion/entrapment — the commonest avoidable catastrophe. Hands off; never pull.
- Augmenting slow breech labour. Poor progress may be disproportion; oxytocin augmentation is generally avoided.
- ECV without the safety net. Never attempt ECV where caesarean is not immediately available, without pre/post CTG, or in a woman with praevia, APH, or ruptured membranes. Omitting anti-D in an Rh-negative woman is a recurring error.
- No neonatal team / no theatre. A planned vaginal breech without immediate resuscitation and surgical backup is unsafe.
- Inadequate counselling/documentation. The Term Breech Trial data and the maternal trade-offs must be discussed and recorded; mode of delivery is the woman's informed choice.
- Forgetting the second twin. A breech second twin is a distinct, often planned, vaginal breech scenario requiring the same skill set — see multiple-pregnancy.
Evidence anchors
- RCOG Green-top Guideline No. 20a — External Cephalic Version and No. 20b — Management of Breech Presentation — the core references for ECV technique/timing/success and for the conduct and selection of vaginal breech birth.
- Term Breech Trial (Hannah et al., Lancet 2000) — the landmark RCT showing reduced perinatal/neonatal mortality and serious morbidity with planned caesarean for term breech; the basis for current counselling. (Standard teaching; the longer-term follow-up and subsequent debate temper but do not overturn the short-term finding — flagged in notes.)
- NDoH National Integrated Maternal and Perinatal Care Guideline (NDoH, 2024) — South African source of truth for facility level, ECV provision, and intrapartum management.
- NICE NG235 — Intrapartum care (2023) and NICE NG229 — Fetal monitoring in labour (2022) — continuous CTG and intrapartum risk assessment in malpresentation.
- RCOG GTG 50 — Umbilical Cord Prolapse — the parallel drill for the footling/cord-prolapse complication.
- ILCOR 2025 / ERC 2025 Newborn Life Support / AAP NRP — neonatal resuscitation standards for the at-risk breech neonate.
- Saving Mothers (NCCEMD) report — avoidable-factor analysis relevant to missed diagnosis and intrapartum recognition in the SA setting.
- Anti-D after ECV in Rh-negative women aligns with NICE TA156 and current BSH/NHS anti-D prophylaxis guidance (see rh-isoimmunisation).