Breech Presentation: Making the right delivery decisions

MedED: Obstetrics

Breech Presentation

A classic exam & labour room decision topic. Mechanistic understanding is crucial for making the right delivery decisions.

Created by Dr. Sharad Maheshwari MD

imagingsimplified@gmail.com

Table of Contents

• 1. Pathophysiology
• 2. Etiology & Epi
• 3. Types of Breech
• 4. Diagnosis
• 5. Investigations
• Interactive Tool
• 6. Management Guidelines
• 7. Delivery Maneuvers
• 8. Complications & DDx
• Flashcards
• Quick Quiz
• Further Readings

1. Pathophysiology (Core Concept)

Normally, the cephalic pole is heavier → settles in the pelvis. In breech, there is a failure of cephalic dominance or an abnormal uterine environment preventing natural version.

Mechanisms:

• Prematurity: Fetal head is relatively smaller compared to the body → doesn't engage well in the lower uterine segment.
• Uterine shape abnormality: Fetal orientation is restricted (e.g., septate or bicornuate uterus).
• Placental location: A cornual or fundal placenta displaces the head upward. Placenta previa prevents head engagement.
• Liquor abnormalities:
  • Polyhydramnios → excessive mobility, failure to stabilize.
  • Oligohydramnios → restricted movement, trapped in breech.

Key Clinical Insight

Breech is often a marker of underlying maternal/fetal pathology, not just a simple malpresentation.

2. Etiology & Epidemiology

3–4%

Incidence at Term

20–25%

Incidence < 28 weeks

Causes Checklist (Fetus, Uterus, Placenta)

Fetal

• Prematurity (Most common)
• Multiple gestation (Twins)
• Congenital anomalies (Anencephaly, Hydrocephalus)
• Neuromuscular disorders

Uterine

• Müllerian anomalies (Bicornuate/Septate)
• Lower segment Fibroids
• Grand multiparity (Lax uterus)
• Contracted pelvis

Placenta/Amnion

• Placenta previa
• Cornual/Fundal placenta
• Oligohydramnios
• Polyhydramnios

3. Types of Breech EXAM FAVORITE

Most Common (65%)

Frank Breech

Hips flexed, knees extended. Feet are adjacent to the fetal head.

Safest for trial of vaginal delivery. Acts as a good dilating wedge.

Complete Breech

Hips flexed, knees flexed. "Indian style" or tailored sitting position.

Incidence ~10%. Intermediate risk.

High Risk (25%)

Footling Breech

One or both hips extended. Foot presenting part.

Highest risk of cord prolapse (15-20%). Avoid vaginal delivery.

Clinical Diagnosis

Abdominal Exam (Leopold)

• Fundal Grip: Hard, ballotable mass (head)
• Pelvic Grip: Softer, irregular mass (buttocks)
• Auscultation: FHR heard above the umbilicus

PV Exam

Palpation of sacrum, ischial tuberosities, and anus.

Viva Trap ⚠️ Don't confuse anus with mouth (mouth has alveolar ridges, hard palate). Meconium on glove is physiological in breech due to abdominal squeezing, not always fetal distress.

Ultrasound (Mandatory)

Clinical diagnosis must be confirmed via USG to rule out contraindications to vaginal delivery.

Type of breech

EFW (Est. Fetal Weight) Target: 2.5 - 3.5kg

Head attitude Must be flexed

Placenta & Liquor

Absolute Contraindication

Hyperextended head ("stargazing fetus") > 90° angle. Vaginal delivery carries massive risk of spinal cord transection.

Interactive Tool: Mode of Delivery

Use this clinical simulation tool to determine the recommended mode of delivery based on standard obstetric guidelines (Term Breech Trial context).

Type of Breech -- Select -- Frank / Complete Breech Footling Breech

Fetal Head Attitude -- Select -- Flexed Hyperextended (>90°)

Estimated Fetal Weight (EFW) -- Select -- < 2.5 kg (Preterm/FGR) 2.5 kg - 3.5 kg > 3.8 kg (Macrosomia)

Maternal Pelvis & Provider -- Select -- Adequate Pelvis + Experienced Provider Contracted Pelvis OR No Experience

Select patient parameters to generate a clinical recommendation.

CORE SCORING AREA

6. Management Guidelines

Antenatal: External Cephalic Version (ECV)

Attempted at 36–37 weeks (allows spontaneous version before this; if done earlier, high reversion rate. If done later, fluid decreases). Success rate is ~50%. Tocolysis (e.g., Terbutaline) increases success.

Contraindications to ECV:

Placenta previa

Severe Oligo

Fetal distress

Multiple gestation

Mode of Delivery Decision

Post Term Breech Trial (2000), most units offer Planned LSCS due to reduced perinatal mortality. However, Assisted Vaginal Breech Delivery is viable if criteria are met.

Indications for Elective Cesarean Section:

Footling breech EFW > 3.8 kg EFW < 2.5 kg (Preterm) Hyperextended head Previous LSCS Fetal distress

7. Assisted Vaginal Breech Delivery Maneuvers

Golden Rule of Breech Delivery

"Hands off the breech!" — Avoid premature traction. Touching the fetus prematurely stimulates reflex breathing (aspiration risk) and extension of arms/head (entrapment risk). Wait until the umbilicus is visible.

Pinard Maneuver

For Extended Legs (Frank Breech)

Two fingers are passed along the fetal thigh to the popliteal fossa. Pressure is applied to abduct the thigh and flex the knee. The foot is then grasped and brought down to deliver the leg.

Lovset Maneuver

For Extended Arms

Exploits pelvic geometry (anterior wall is shorter). Grasp fetus by the bony pelvis (iliac crests, thumbs on sacrum). Rotate fetus 180 degrees while applying gentle downward traction. The posterior shoulder comes under the symphysis pubis and the arm is swept out. Rotate 180 degrees back to deliver the other arm.

Mauriceau-Smellie-Veit (MSV) Maneuver

For the After-Coming Head (Standard)

Fetus rests along the obstetrician's forearm. Index and middle fingers of the lower hand are placed on the fetal maxilla (NOT the mouth) to maintain head flexion. The other hand is placed over the fetal back, hooking fingers over the shoulders for gentle downward traction until subocciput appears, then upward traction.

Burns-Marshall Technique

For the After-Coming Head (Alternative)

Let the fetus hang by its own weight to promote flexion of the head. Once the nape of the neck (subocciput) is visible under the symphysis pubis, the fetus is grasped by the ankles and swept upwards in a wide arc over the maternal abdomen.

Piper Forceps

For the After-Coming Head (Instrumental)

Specialized forceps applied to the after-coming head while an assistant holds the fetal body elevated. Used when MSV fails. Prevents excessive traction on the cervical spine.

8. Complications & DDx

Fetal Morbidity/Mortality

• Cord prolapse (High in footling due to poor pelvic fit)
• Head entrapment (Cervix dilates for body, not head)
• Birth asphyxia (Umbilical cord compression during head delivery)
• Intracranial hemorrhage (Rapid decompression of head)
• Erb's Palsy / Brachial plexus injury

Maternal Complications

• Prolonged labour
• Deep perineal tears & cervical lacerations (Due to rushed manipulations)
• Increased risk of operative interventions
• PPH (Uterine atony / trauma)

Differential Diagnosis on PV Exam

Face Presentation (Malar eminences, alveolar ridges)

Anencephaly (Soft irregular mass)

Compound Presentation (Hand + Head)

9. Rapid Recall Flashcards

Click the cards to reveal the answers. Great for quick Viva prep.

What is the most common type of breech presentation?

Frank Breech (Hips flexed, knees extended) ~65% of cases.

Which maneuver is used to deliver extended fetal arms?

Lovset Maneuver (180° rotation of the trunk).

What is the absolute ultrasound contraindication for vaginal breech delivery?

Hyperextended head ("Stargazing fetus") due to risk of spinal cord transection.

Why is footling breech a primary indication for LSCS?

Massive risk of umbilical cord prolapse (15-20%) because the irregular presenting part does not fill the pelvis.

10. Clinical Quiz

11. Further Readings & Guidelines

Expand your knowledge with these internationally recognized obstetric guidelines. (Click to open in new tab)

ACOG Practice Bulletin No. 161

Management of Breech Presentation

RCOG Green-top Guideline No. 20b

Management of Breech Presentation

UpToDate®

Breech presentation: Delivery Management

MedED: Obstetrics & Gynecology Clinical Study Guides

Created by Dr. Sharad Maheshwari MD | imagingsimplified@gmail.com

Disclaimer: This guide is for educational purposes only and does not substitute institutional clinical guidelines or professional medical judgment.