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What Is Breech?

When a fetus is delivered buttocks or feet first

  • Types of Presentation

Risk Factors

Complications.

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

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

Verywell / Jessica Olah

Types of Breech Presentation

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

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

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

The different types of breech presentations include:

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

Signs of Breech

There are no specific symptoms associated with a breech presentation.

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

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

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

These can include:

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

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

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

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

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

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

ECV is usually not recommended if the:

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

Recommendations for Previous C-Sections

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

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

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

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

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

A Word From Verywell

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

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

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

TeachMeObGyn. Breech presentation .

MedlinePlus. Breech birth .

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

By Christine Zink, MD Dr. Christine Zink, MD, is a board-certified emergency medicine with expertise in the wilderness and global medicine. She completed her medical training at Weill Cornell Medical College and residency in emergency medicine at New York-Presbyterian Hospital. She utilizes 15-years of clinical experience in her medical writing.

American Pregnancy Association

Breech Births

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

What are the different types of breech birth presentations?

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

What causes a breech presentation?

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

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

How is a breech presentation diagnosed?

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

Can a breech presentation mean something is wrong?

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

Can a breech presentation be changed?

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

Medical Techniques

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

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

ECV will not be tried if:

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

Complications of EVC include:

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

Vaginal delivery versus cesarean for breech birth?

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

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

What are the risks and complications of a vaginal delivery?

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

When is a cesarean delivery used with a breech presentation?

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

Want to Know More?

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

Compiled using information from the following sources:

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

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presentation at breech

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.

Illustration of the head-down, face-up position

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.

Illustration of the frank breech position

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.

Illustration of a complete breech presentation

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.

Illustration of baby lying sideways

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.

Illustration of twins before birth

  • 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.

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Breech presentation: diagnosis and management

Key messages.

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

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

Breech and external cephalic version

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

Figure 1. Breech presentations

Figure 1: Examples of breech

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

Clinical suspicion of breech presentation

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

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

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

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

Diagnosis: preterm ≤36+6 weeks

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

Diagnosis: ≥37+0 weeks

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

Practice points

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

Information and decision making

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

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

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

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

Documentation

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

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

External cephalic version (ECV)

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

Contraindications

Table 1. Contraindications to ECV

Precautions

  • Hypertension
  • Oligohydramnios
  • Nuchal cord

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

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

Emergency management

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

  • abnormal CTG
  • vaginal bleeding
  • unexplained pain.

Initiate emergency response as per local guidelines.

Alternatives to ECV

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

Criteria for a planned vaginal breech birth

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

If an ELCS is booked

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

Intrapartum management

Fetal monitoring.

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

Position of the woman

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

Pain relief

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

Induction of labour (IOL)

See the  IOL eHandbook page  for more detail.

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

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

First stage

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

Second stage

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

VIDEO:  Maternity Training International - Vaginal Breech Birth

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

Undiagnosed breech in labour

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

Entrapment of the fetal head

This is an extreme emergency

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

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

Neonatal management

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

More information

Audit and performance improvement.

All maternity services should have processes in place for:

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

Potential auditable standards are:

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

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

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

Abbreviations

Get in touch, version history.

First published:  November 2018 Due for review:  November 2021

Uncontrolled when downloaded

Related links.

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

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

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

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

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

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

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

Developer declaration of interests:

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

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

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

Dr LK Penna:  None declared.

  • Access the PDF version of this guideline on Wiley
  • Access the web version of this guideline on Wiley

This page was last reviewed 16 March 2017.

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  • v.2013; 2013

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Repetitive Breech Presentations at Term

Pavol zubor.

Department of Obstetrics and Gynecology, Jessenius Faculty of Medicine, Comenius University, Kollarova 2, 03601 Martin, Slovakia

Imrich Zigo

Jana sivakova, petra moricova, ivana kapustova, stefan krivus.

The authors present a case of 38-year-old laboring woman with four-time repetitive breech presentation of the fetus at term. This rare condition affects the mode of delivery and represents serious obstetrical problem as it is associated with increased perinatal morbidity or mortality. The authors give details on risk factors for breech presentation, its diagnosis, and the discussion points on possible causes leading to repetitive breeches in laboring women.

1. Introduction

The breech presentation is defined as the initial entrance of the gluteal region of the fetus into the maternal pelvis and is the most common abnormal fetal presentation. Breech delivery is a challenge in obstetric management and is associated with increased perinatal morbidity and mortality [ 1 – 3 ]. The prevalence of breeches ranges from 3% to 4% at term [ 4 ]. The predisposing factors for breech presentation are prematurity, multiple gestation, multiparity, fetal hydrocephalus, oligohydramnios, polar placentation, placenta previa, gestational diabetes, history of breech delivery, short umbilical cord, low birth weight, uterine anomalies, congenital anomaly, previous cesarean delivery, and pelvic tumors. As these factors explain only 15% of the variance of breech presentation [ 5 – 7 ], the etiology of breech delivery (causes of failure of spontaneous cephalic version) is not clear. Moreover, when fetal malposition in the form of breech presentation is repetitively presented in the same women. Thus, further research into the mechanism of breech presentation is needed.

The current study describes unusual case of repetitive (4 times) recurrence of breech delivery in the same women with hypothesis describing possible etiology of such rare case.

2. Case Report

A 38-years-old quadrugravida 168 cm tall Caucasian woman with singleton pregnancy at term (38 + 5 g.w.) was admitted to the delivery room due to regular uterine contractions every 5 minutes and sharp pain perception in scar after previous cesarean section. Gynecology examination revealed breech (Frank) presentation and vaginal findings showed 1 cm long cervix, dilated to 3 cm without signs of bleeding. A fetal predelivery ultrasonography was done with term corresponding biometry and EFW 3420 grams. The fetal monitor consisted of a baseline 140 bpm, accelerations, and good variability. Increased pain perception in lower uterine segment below the scar was the reason for pregnancy termination by uncomplicated cesarean section (Joel-Cohen incision with Misgav Ladach method) 3.5 hrs after admission. The intraoperative finding on the uterus was negative, without myoma, septum, or adhesions ( Figure 1 ). Her past history was uneventful except the obstetrical history of repetitive breech presentation of all previous deliveries (2 times spontaneously, once by low transverse cesarean section, Table 1 ). A 3500 g weighted male neonate with 9, 10, 10 Apgar score was delivered and discharged home with mother on 5th day after uncomplicated postpartum recovery.

An external file that holds a picture, illustration, etc.
Object name is CRIM.OBGYN2013-628572.001.jpg

The intraoperative findings on the uterus.

The clinical data of all deliveries.

3. Discussion

The breech delivery may represent the obstetrical problem that necessitates increased patience because of it possible complications. Thus many pregnancies with fetuses in breech lie are terminated for prevention by cesarean section. On the other side there exist obstetricians that can deliver breeches without fetal injury. However, despite their wide clinical practice, few of them faced the situation as described by our case: four-time repetitive breech presentation in one laboring woman giving the probability of such event at 0.045. In this section we will try to explain some possible reasons of this rare obstetric situation.

There are several maternal and fetal factors that predispose to a breech presentation, for example, uterine anomalies, myomas, pelvic tumors, fetal anomalies, changes of amniotic fluid, placental localization, or length of umbilical cord [ 8 ] that solely or in combination provoke fetal malpresentation. Moreover, some studies have found a relationship between placenta previa and polar fundal localization of the placenta and the breech presentation [ 9 , 10 ]. For example, cornu-fundal localization of the placenta occurred in 70% of breech presentations, but only in about 5% of cephalic presentations. In our case we have revealed 3-time fundal and one anterior wall placenta localizations on antepartum ultrasound what confirms the above-mentioned risk factors for breech presentations.

Adinma's study, in which 1000 cases were observed, found that breech fetuses had shorter umbilical cords than those of cephalic fetuses and that the average umbilical cord length is about 51 cm (range, 15–130) [ 11 ]. The lengths of umbilical cords in our case were as follows for subsequent pregnancies: 34 cm, 53 cm, 42 cm, and 57 cm, respectively. The relative short cords in pregnancies may explain the repetitive breeches in our case.

Specificity for higher breech presentation is body mass index (BMI) and maternal weight gain during pregnancy. It was revealed that higher BMI at term and increased body weight gain might be related to persistent breech presentation [ 12 ]. The last pregnancy of our case was associated with 13 kg body weight gain and 34 kg/m 2 BMI score. Another study revealed significantly higher incidence of breech deliveries in fetuses with increased placenta weight; however the reason was not revealed [ 13 ]. The weights of placentas in our case were in the range 430–560 g what represent the normal findings. Thus, did not confirm the above presented reasons associated with an increased risk for breech presentation.

Rayl et al. [ 14 ] highlighted smoking as a risk factor for breech presentation. In the current study we found no smoking history in any of the presented pregnancies. Similarly, Vendittelli et al. [ 15 ] reported that women with previous cesarean deliveries were at twice the risk of breech presentation at term than women with previous vaginal deliveries, which was in agreement with our data. Interestingly, Kuppens et al. [ 16 ] have provided data that women with higher TSH levels (>2.5 mIU/L) in pregnancy may exhibit higher rate of breech deliveries. This cannot be confirmed by our case as we did not make a hormonal profile in all of the pregnancies.

Nordtveit et al. [ 17 ] showed that breech delivery may exhibit partly inherited patterns as both men and women delivered in breech presentation at term contribute to increased risk of breech delivery in their offspring. Thus, this supports the theory that some genes on the specific environmental background passed on from the father or the mother seem to be closely related to breech delivery. Furthermore, the congenital pattern of breech delivery is supported by the findings from race-targeted studies, which have proved that white women have 69% higher risk for breech delivery than black women [ 18 ].

Finally, the congenital disorders in cerebellum cannot be omitted in the fetuses when describing the reason for breech delivery [ 19 ]. However, this theory has to be proved in the future. In general, there exists approximately 15% risk of repetitive breech delivery after the previous one, and this risk is higher for cesarean sections [ 20 ]. The relative risk of breech recurrence in a second pregnancy is 3.2 and in a third consecutive breech pregnancy 13.9 [ 21 ]. Any other breeches are extremely rare. Thus our case of four forthcoming breeches are worthy for presentation and for closer investigation of the causes.

In summary, we conclude that shorter umbilical cord, higher placental weight, increased maternal term BMI, cornu-fundal placenta localization, smoking, thyroid hormone disbalance, race, and genetics may be causative factors for repetitive breech presentations as described by our case and that it is the persistence of maternal risk factors rather than first pregnancy fetal or infant factors that play a role in repeating breech presentations at term. Thus, the consistently elevated recurrence rates highlight the need for women with a history of breech delivery to be closely monitored in the later stages of pregnancy (e.g., attempt for external cephalic version or prevention of cord prolapse after PROM).

Conflict of Interests

The authors declare that there is no conflict of interests.

Acknowledgments

This work was supported by the project centre of excellence for perinatal research (CEPV II, ITMS code: 26220120036) cofinanced by EU sources.

Abbreviations

Posted Feb 20, 2024

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IMAGES

  1. Breech presentation: diagnosis and management

    presentation at breech

  2. Breech Presentation: What It Is and How It Can Affect Your Baby's Deli

    presentation at breech

  3. types of breech presentation ultrasound

    presentation at breech

  4. Breech

    presentation at breech

  5. Breech Presentation and Turning a Breech Baby in the Womb (External

    presentation at breech

  6. Breech Presentation at the end of Pregnancy

    presentation at breech

VIDEO

  1. (BREECH PRESENTATION) by Ms Varnish Kumar (MTCN Kumhari)

  2. Lillie Excellence Center

  3. Breech presentation

  4. Breech baby presentation

  5. Breech presentation

  6. breech presentation

COMMENTS

  1. Breech: Types, Risk Factors, Treatment, Complications

    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

  2. Breech Presentation

    Breech presentation refers to the fetus in the longitudinal lie with the buttocks or lower extremity entering the pelvis first. The three types of breech presentation include frank breech, complete breech, and incomplete breech.

  3. Breech 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.

  4. Breech Baby: Causes, Complications, Turning & Delivery

    A breech baby, or breech birth, is when your baby's feet or buttocks are positioned to come out of your vagina first. Your baby's head is up closest to your chest and its bottom is closest to your vagina. Most babies will naturally move so their head is positioned to come out of the vagina first during birth.

  5. Breech Presentation: Types, Causes, Risks

    What Is Breech Presentation? During your pregnancy, your baby constantly moves around the uterus. Indeed, most babies do somersaults up until the 36th week of pregnancy, when they pick their...

  6. Breech Presentation: Overview, Vaginal Breech Delivery ...

    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...

  7. If Your Baby Is Breech

    What factors are related to breech presentation? How can your health care professional tell if your fetus is breech? What is external cephalic version? When will external cephalic version not be attempted? How is external cephalic version performed? What complications can occur with external cephalic version?

  8. Fetal presentation before birth

    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.

  9. Management of breech presentation

    Management of breech presentation - NCBI Bookshelf Browse Titles Advanced Management of breech presentation Antenatal care Evidence review M NICE Guideline, No. 201 National Guideline Alliance (UK). London: National Institute for Health and Care Excellence (NICE); 2021 Aug. ISBN-13: 978-1-4731-4227-5 Copyright and Permissions Go to:

  10. Identification of breech presentation

    Identification of breech presentation Review question Introduction Summary of the protocol Please see for a summary of the Population, Intervention, Comparison and Outcome (PICO) characteristics of this review. Table 1 Summary of the protocol (PICO table). For further details see the review protocol in appendix A. Methods and process

  11. Management of Breech Presentation

    Observational, usually retrospective, series have consistently favoured elective caesarean birth over vaginal breech delivery. A meta-analysis of 27 studies examining term breech birth, 5 which included 258 953 births between 1993 and 2014, suggested that elective caesarean section was associated with a two- to five-fold reduction in perinatal mortality when compared with vaginal breech ...

  12. Breech presentation: diagnosis and management

    Breech presentations. Breech presentation occurs in three to four per cent of term deliveries and is more common in nulliparous women. External cephalic version (ECV) from 37 weeks has been shown to decrease the incidence of breech presentation at term and the subsequent elective caesarean section (ELCS) rate.

  13. What Is Breech Presentation?

    A breech presentation occurs when the fetus is lying longitudinally, and its buttocks or feet will be positioned to be delivered first. It happens in approximately 1 out of 25 full-term births. The probability of breech presentation decreases with the increase in gestational age (a measure of the age of a pregnancy taken from the beginning of a ...

  14. Term breech presentation—Intended cesarean section versus intended

    1 INTRODUCTION. Approximately 3% of all infants are born in breech presentation with bottom first, sometimes a foot or knee is leading. 1-3 The risk of breech presentation is sometimes increased, for example, in malformations of the child or the uterus; however, most of the infants and mothers among breech deliveries are totally healthy. 4 Vaginal delivery in breech compared with cephalic ...

  15. Breech presentation management: A critical review of leading clinical

    This pamphlet explains what a breech presentation is, the different types of breech presentation, discusses ECV and provides balanced information related to birth mode options along with visual representations of statistics comparing the perinatal mortality rate between cephalic vaginal birth, VBB and C/S. This pamphlet was also developed in ...

  16. Management of term breech presentation

    Undiagnosed term breech presentation can largely be prevented by routine third-trimester ultrasound. Research is needed to evaluate the efficacy of VBB simulation training in clinical practice. Learning objectives. To understand the evidence base around breech presentation at term, including ECV, VBB, caesarean section and adjunctive methods of ...

  17. No. 384-Management of Breech Presentation at Term

    For planned vaginal breech birth at term, care should be taken to rule out growth restriction. Estimated fetal weight should be between 2800 and 4000 g (strong; moderate). The maternal pelvis should be clinically assessed to be ade-quate. Radiologic pelvimetry is not necessary for planned vagi-nal breech birth.

  18. Breech Presentation

    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

  19. A comparison of risk factors for breech presentation in preterm and

    Introduction. The prevalence of breech presentation at delivery decreases with increasing gestational age. At 28 pregnancy weeks, every fifth fetus lies in the breech presentation and in term pregnancies, less than 4% of all singleton fetuses are in breech presentation at delivery [1, 2].Most likely this is due to a lack of fetal movements [] or an incomplete fetal rotation, since the ...

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

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

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    The 3-minute presentation will be available on YouTube with subtitles in your preferred language. Image: FromSoftware . Most Popular. Most Popular.

  22. Management of Breech Presentation

    Preparing publication <div id="alert_box" class="popup_container full noScript"> <div class="popup_content"> <div class="flex-container"> <div class="text"> <span ...

  23. CISA and Partners Release Advisory on PRC-sponsored Volt Typhoon

    Today, CISA, the National Security Agency (NSA), and the Federal Bureau of Investigation (FBI) released a joint Cybersecurity Advisory (CSA), PRC State-Sponsored Actors Compromise and Maintain Persistent Access to U.S. Critical Infrastructure alongside supplemental Joint Guidance: Identifying and Mitigating Living off the Land Techniques. The following federal agencies and international ...

  24. Repetitive Breech Presentations at Term

    The breech presentation is defined as the initial entrance of the gluteal region of the fetus into the maternal pelvis and is the most common abnormal fetal presentation. Breech delivery is a challenge in obstetric management and is associated with increased perinatal morbidity and mortality [ 1 - 3 ].

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    The Pokémon Company apparently looked at all the Direct news and said "Me too!" On February 27th at 6:00 AM PST, TPC will host a presentation on YouTube sharing what it calls "exciting ...