Breech presentation: labor management tactics

Breech presentation is a fetal position in which the buttocks or lower extremities face the pelvic outlet. At full term, this presentation occurs in approximately 3-4% of pregnancies and is associated with specific obstetric risks. Proper management begins with an accurate determination of the presentation type, risk assessment, discussion with the family, and a choice between external cephalic version, planned cesarean section, or carefully selected vaginal delivery under the guidance of a trained team. [1]

Approaches to breech birth have evolved over the past 20 years. Following the publication of a large randomized trial in 2000, many countries shifted to elective cesarean section. However, current guidelines recognize the possibility of elective vaginal birth with strict selection and an experienced team. The key principle is the safety of mother and baby, taking into account local experience and institutional resources. [2]

An important alternative is external cephalic version of the fetus in late pregnancy, which reduces the rate of breech births and cesarean sections. The decision to attempt version is made after assessing contraindications, obtaining informed consent, and being prepared for emergency delivery in the event of complications. [3]

Quality of care is determined not only by clinical decisions but also by the organization of the process: standardized protocols for selection and management, staff training in breech birth maneuvers, and access to ultrasound monitoring and neonatal care. The availability of specialized pathways and training programs reduces the incidence of adverse outcomes. [4]

Communication with the woman and partner is transparent: the likelihood of success of different strategies, short-term and long-term risks, and the possibility of changing the plan based on the dynamics of labor are discussed. This shared decision-making increases satisfaction and safety. [5]

Table 1. Decision chart for breech presentation

Stage	What to evaluate	Possible solutions
Before giving birth	Type of presentation, gestational age, fetal weight, cervix, uterine scars, family preferences	External cephalic version of the fetus, planned caesarean section, preparation for vaginal delivery with strict selection. [6]
During childbirth	Progress, contraction frequency, fetal heart rate, head position	Continuation of labor if criteria are met, transition to surgery if deviations occur. [7]
Organization	Readiness of the operating room and neonatologist, availability of an experienced team	Standardized protocol, simulation training, outcome audit. [8]

Types of breech presentation and how to recognize them

There are three main presentation types: pure breech (legs extended upwards along the body), complete breech (hips and knees flexed), and footless, where the feet are facing the birth canal. The type of presentation influences the risks of labor and the choice of strategy: footless presentation is associated with a higher risk of cord prolapse and adverse outcomes, while pure breech and complete presentation, with proper selection, allow for vaginal delivery. [9]

Diagnosis is based on external examination, vaginal examination, and ultrasound. Ultrasound assessment is necessary to confirm the type of presentation, position of the fetal head, degree of neck extension, fetal weight, and amniotic fluid volume. In doubtful situations and before the onset of active labor, repeat imaging is recommended. [10]

Ultrasound helps rule out associated risk factors—congenital malformations, placental anomalies, uterine tumors, placenta previa—that alter the delivery plan. The presence of head hyperextension, suspected macrosomia, or severe growth retardation tilts the balance in favor of surgery. [11]

Clinical assessment of the pelvis remains part of the selection process. Although routine X-ray pelvimetry is not recommended, an experienced team uses a combination of data on pelvic structure, presentation, and dilation dynamics to predict the success of vaginal delivery. [12]

Documentation of fetal and maternal status before onset of labour is essential for transparent management and subsequent audit of outcomes, particularly when vaginal delivery is the chosen option.[13]

Table 2. Types of presentation and influence on tactics

Type of presentation	Key Features	Tactical consequences
Pure gluteal	Legs up along the body	Vaginal birth is possible with strict selection. [14]
Full gluteal	Bent hips and knees	Similar approach to pure gluteal if criteria are met. [15]
Foot	Feet facing the exit	Higher risk of umbilical cord prolapse and intrapartum complications, more often surgery. [16]

Epidemiology and risk factors

Between 37 and 41 weeks, breech presentation occurs in 3-4% of pregnancies, more often in primiparous women. The incidence is higher in preterm births. Risk factors include multiple pregnancies, uterine abnormalities, fibroids, placenta previa, marginal cord insertion, polyhydramnios or oligohydramnios, and certain fetal malformations. [17]

There are also transient factors, such as late fixation of the head with decreased fetal mobility, as well as functional characteristics of the myometrium. In some cases, the cause remains unclear, which reinforces the importance of prevention through methods of repositioning the fetus and well-thought-out organizational tactics during labor. [18]

Following a major trial in 2000, in which elective surgery demonstrated a reduction in perinatal risk compared with planned vaginal birth, the proportion of vaginal breech births declined sharply in many health systems. However, subsequent guidelines emphasize the role of selection and competence: with strict criteria and a trained team, vaginal birth can be an acceptable option. [19]

New population-based studies confirm that planned vaginal breech birth carries higher neonatal risks on average than planned surgery, requiring increased vigilance, clear thresholds for proceeding to surgery, and institutional protocols. [20]

Infrastructure also influences outcomes: simulation training programs, specialized bridge clinics, and team checklists are associated with increased rates of successful completion of selected vaginal deliveries without worsening neonatal outcomes.[21]

Table 3. Factors increasing the risk of adverse outcomes

Factor	Commentary for practice
Foot presentation, head hyperextension	High risk of intrapartum complications, preference for surgery. [22]
Estimated weight greater than 3.8 kg or severe growth retardation	Increased risk, more often surgery. [23]
Lack of an experienced team, no protocol	Risk of errors and delays, worsening outcomes. [24]
Lack of readiness of the operating room and neonatologist	Not acceptable when choosing vaginal breech delivery. [25]

Antenatal management: external fetal version and alternatives

External cephalic version of the fetus at around 36-37 weeks reduces the rate of breech births and decreases the likelihood of cesarean section. Most guidelines recommend this method in the absence of absolute contraindications, performed under ultrasound guidance, and with readiness for emergency surgery. [26]

The success rate of rotation averages approximately 50%, with higher rates in multiparous women. The use of tocolysis with beta-mimetics increases the success rate. Neuraxial analgesia is not routinely indicated but may be considered for repeated attempts or if the procedure is poorly tolerated. Women with Rh-negative status are recommended to undergo anti-D prophylaxis after the procedure. [27]

The procedure is performed only in facilities with continuous fetal monitoring and immediate cesarean section. Both the mother and fetus are assessed before and after the procedure. Complications are rare if the technique is followed and the patient is prepared for the procedure. [28]

Positions and home exercises have been considered as non-pharmacological approaches to reducing the incidence of breech births, but evidence of effectiveness is insufficient. Moxibustion therapy at 33-35 weeks may be considered at the woman's request under the supervision of a trained professional with informed consent, although the quality of evidence is moderate. [29]

If the rotation is not completed or is unsuccessful, re-counseling is carried out regarding delivery options taking into account individual risks, family preferences and facility protocols. [30]

Table 4. Checklist for external fetal version

Checklist position	The essence
Indications and exceptions	No absolute contraindications, informed consent. [31]
Preparation	Ultrasound assessment, operating room readiness, tocolysis as indicated. [32]
Execution	Ultrasound-guided technique, gentle maneuvers, short-term analgesia if necessary. [33]
After the procedure	Fetal monitoring, anti-D in case of Rh negative status, further management plan. [34]

Choosing the method of delivery in full-term pregnancy

For full-term singleton pregnancies with a living fetus, most institutions prefer planned cesarean section due to its lower average neonatal risk compared to planned vaginal breech delivery. This is reflected in the positions of professional societies and is based on the results of multicenter studies and meta-analyses. [35]

However, planning a vaginal birth is permitted under strict criteria: pure breech or complete presentation, estimated birth weight of 2.5-3.8 kg, absence of head hyperextension on ultrasound, clinically adequate pelvis, absence of associated high-risk factors, informed consent, and the constant presence of a team skilled in breech birth techniques. The facility must have a protocol with clear criteria for initiating and terminating the attempt. [36]

The woman is explained that even if all conditions are met, the likelihood of emergency surgery remains, and the thresholds for it are lower than for a cephalic presentation. Any signs of fetal distress, slow progress, cord prolapse, or technical difficulties indicate immediate surgical intervention. [37]

Organizational elements are critical: a prepared operating room, the presence of a neonatologist, the possibility of instrumental assistance for the head, continuous cardiac monitoring, access to ultrasound and medications for emergency uterine relaxation. Regular simulations and outcome audits are mandatory. [38]

The choice of analgesia is individual. Neuraxial analgesia is acceptable, but excessive block density may weaken pushing; some protocols recommend balanced regimens that allow for active maternal participation. The decision is made in consultation with the anesthesiologist. [39]

Table 5. Selection criteria for planned vaginal breech delivery

Criterion	Example of wording
Type of presentation	Pure gluteal or complete, no leg variant. [40]
Head	No hyperextension by ultrasound. [41]
Fruit weight	Estimate 2.5-3.8 kg, avoid severe macrosomia and severe growth retardation. [42]
The pelvis and the birth process	Clinically adequate pelvis, confident progress, readiness for immediate surgery. [43]
Team and conditions	Experienced obstetrician, trained team, neonatologist, prepared operating room, protocol. [44]

Vaginal delivery in breech presentation: technique and safety

The basic principle is "hands off the breech" to the level of the navel: this allows for a free birth of the torso. Once the pelvic end has emerged, gentle maneuvers are used, if necessary, to bring the legs and arms out, followed by techniques for the head, including the Morisot-Smellie-Waite and Lovett maneuvers, as well as Piper forceps for occipito-anterior insertion. Precise mastery of these skills and practice on simulators are essential. [45]

Induction is generally not recommended, and oxytocin stimulation is discussed sparingly and primarily for infrequent contractions in a patient with epidural analgesia. Fetal heart rate is monitored continuously. The threshold for surgery is low for any sign of distress. [46]

If there is a risk of retained head delivery, instruments and medications are prepared for emergency uterine relaxation. Short-acting medications, such as sublingual nitroglycerin, can be used to quickly relax the cervix and uterus, according to a local protocol, facilitating delivery of the head and reducing trauma. In exceptional cases, a Durssen cervical incision is performed. Decisions are made by an experienced team based on the indications. [47]

Episiotomy is performed selectively when it improves conditions for delivery of the shoulder girdle and head. Excessive cord tension and traction on the torso are unacceptable; manipulations are performed in a measured manner and only when necessary to avoid injury. [48]

After the birth of the head, the newborn's condition is assessed and, if necessary, resuscitation support is provided. The third stage of labor is simultaneously managed, with hemorrhage prevention and maternal monitoring. [49]

Table 6. Quick Reference Guide to Maneuvers

Stage	Target	Example of reception
Up to the navel level	Spontaneous birth of the breech end	Observation without intervention, monitoring progress. [50]
Legs and arms	Release of limbs during delay	Pinard's maneuver, Lovett's maneuver. [51]
Head	Birth of the head with preserved flexion	Morisot-Smellie-Waite maneuver, Piper forceps. [52]
Emergency relaxation	Relieve spasms of the uterus and cervix	Nitroglycerin according to the local protocol. [53]

Preterm birth with breech presentation: special considerations

In preterm infants, the choice of delivery method is individualized: no universal benefit has been demonstrated from elective surgery over vaginal delivery for preterm breech fetuses, while overall morbidity and mortality are higher regardless of the method. The decision is made based on gestational age, fetal weight, fetal position, and the fetal fetal position, as well as the feasibility of ensuring a safe vaginal delivery or quickly proceeding to surgery. [54]

Of particular concern is the risk of retained head and cord prolapse. An experienced team, preparedness to provide instrumental assistance and medications for relaxation, are essential. [55]

For twins, with the first fetus in a breech presentation, surgery is often the preferred option. For a second twin, the approach depends on the position of the first fetus after birth, the team's expertise, and the progress of labor. [56]

Anesthetic strategy and neonatologist preparedness are critical given the potential need for intensive care in the preterm infant. [57]

Documentation of the clinical basis for the choice of delivery method and informed consent is particularly important in this high-risk clinical area.[58]

Table 7. Premature terms: what to consider

Parameter	Practical significance
Gestational age and weight	Prognosis and risk profile of complications. [59]
Position and extension of the head	The key to choosing tactics and predicting labor. [60]
Institution resources	Experience and readiness for surgery worsen or improve outcomes. [61]
Neonatological readiness	Probability of resuscitation and intensive care. [62]

Complications and their prevention

Common problems include cord prolapse, delayed delivery of the arms and head, soft tissue trauma, and hypoxia. Prevention begins with selecting the right cases for vaginal delivery, adequate monitoring, and timely transition to surgery if abnormalities occur. [63]

Retention of the head is a critical situation. Prevention includes maintaining flexion of the head, timely episiotomy when indicated, readiness to apply Piper forceps, and, in case of spasm, short-term pharmacological relaxation. In rare cases, cervical incisions are performed. [64]

Umbilical cord prolapse is more common with the foot-assisted method and with interventions performed before full dilation. Prevention involves avoiding artificial opening of the membranes before full dilation and closely monitoring progress. If the umbilical cord prolapses, proceed immediately to surgery. [65]

Neonatal trauma and asphyxia are minimized by following the principle of minimal traction, performing maneuvers correctly, and having a neonatologist present. Regular team training reduces the incidence of errors. [66]

After delivery, active prevention of maternal bleeding is carried out and early assessment of the newborn is ensured, including examination for injuries and neurological symptoms. [67]

Table 8. Complications and team actions

Complication	First steps	The next step
Prolapse of the umbilical cord	Knee-elbow position, hand for lifting the presenting part	Immediate caesarean section. [68]
Handle delay	Lovett maneuver	Reassessment of the condition of the fetus and the speed of labor. [69]
Head delay	Flexion maintenance, Piper forceps	Nitroglycerin according to protocol, if necessary, Durssen incisions. [70]

Postpartum care and long-term issues

Following a vaginal breech birth, the pelvic floor and perineum are assessed, analgesia is adjusted, and thrombosis prophylaxis is administered based on individual risk. The child's tone, posture, and possible shoulder and spinal injuries are assessed, and a neonatologist is consulted for a more comprehensive assessment if necessary. [71]

During surgery, the focus is on early mobilization, adequate analgesia, and the prevention of infectious complications. The woman is given recommendations on lactation and recovery. [72]

A discussion of the outcomes and reasons for the chosen method of delivery is recommended in the weeks following discharge. This discussion helps the family understand the rationale behind the decisions and influences planning for subsequent pregnancies. [73]

In subsequent pregnancies, the risk of recurrent breech presentation is increased, so early ultrasound assessment of fetal position and early discussion of possible external version are a sensible part of the plan.[74]

Institutions are encouraged to regularly audit all breech deliveries, reviewing selection, manoeuvres adopted and time logistics to maintain skills and reduce practice variability.[75]

Table 9. After discharge: what to discuss at the in-person meeting

Topic	The purpose of the conversation
The course of labor and reasons for decisions	Understanding the logic of tactics and trust in the team. [76]
Outcomes for the child and mother	Early problem correction and routing. [77]
Plan for the next pregnancy	Prevention of breech presentation and early planning. [78]

Short answers to frequently asked questions

Is it true that vaginal breech birth is always more dangerous?
The average neonatal risk is lower with elective surgery, but with strict selection and in the hands of an experienced team, vaginal birth can be an acceptable option, provided you are prepared for immediate surgery. The choice is personalized. [79]

When is the best time to perform an external version of the fetus?
Typically, 36-37 weeks is considered, taking into account parity and other factors. Success rates are approximately 50%, with tocolysis increasing the effectiveness. The procedure is performed where emergency cesarean sections are available. [80]

Is it possible to reduce the risk of breech presentation without surgery?
Positioning and home exercises have not been proven effective. Moxibustion at 33-35 weeks may be considered optionally, with moderate evidence and under specialist supervision. [81]

What signs prompt immediate surgical intervention during labor?
Slow progress, abnormal cardiotocogram, umbilical cord prolapse, hyperextension of the head, technical difficulties with delivery of the arms or head. The threshold for surgery is low. [82]

How does the team prepare for rare breech births?
Through simulations, checklists, case analysis, and maintaining maneuver skills. Protocols and training are directly related to safety. [83]