Vaginal Breech Delivery

Vaginal Breech Delivery

Michael A. Belfort

Hennie Lombaard

Michael Lucas


  • The planned vaginal delivery of a term baby in a breech presentation is associated with an increased risk of neonatal mortality and morbidity when compared with a term baby delivered from a cephalic presentation. In some cases, women will decline the offer of cesarean delivery, or one is not possible, and vaginal delivery must be safely performed. This chapter is written to help clinicians doing a planned breech delivery and does not necessarily reflect a personal and/or institutional recommendation for this. In fact, in most institutions worldwide where safe cesarean delivery is available, that is the preferred method of delivery.

Physical Examination

  • On abdominal palpation: The head can be palpated in the fundus of the uterus. The presenting part does not feel as round and firm as a fetal head.

  • On vaginal examination during the late first stage and second stage, the type of breech determines what part of the baby will be palpated:

    • With a frank breech, the buttocks will be palpated.

    • Occasionally, a face presentation may be confused with a breech presentation. The easiest way to distinguish the two is with ultrasound. If this is not available, the examiner should try to identify the palpable boney prominences (ischial spines in a breech, cheekbones in a face presentation) and soft tissue opening (anus in a breech and mouth in a face presentation): In a breech presentation, the ischial spines and anus form a relatively straight line. In a face presentation, the cheekbones and the mouth form a triangle. In addition, a mouth is generally larger, and the tongue and lips may be palpated. Care should be taken not to palpate a suspected face presentation vigorously because of the risk of ocular trauma.

    • With a complete breech, the feet will be felt under the buttocks. The heel of the foot usually forms a 90-degree angle with the leg.

    • With a footling breech, a single foot will be felt in the vagina.

  • With ultrasound, the head will be confirmed in the fundus of the uterus.

Risk Factors for Breech Presentation

  • Prematurity

  • Fetal anomalies—May be associated with 2× to 3× increased risk

  • Placenta previa

  • Uterine anomalies

  • Polyhydramnios

  • Previous breech delivery

  • Multiple pregnancies

  • Short umbilical cord

Differential Diagnosis

  • Breech

  • Face presentation

  • For a footling breech, a shoulder presentation with prolapsed arm and hand is a differential diagnosis.


ECV of a baby presenting as a breech is a preferred option in most circumstances to avoid vaginal breech delivery. The patient will need to consent and specific contraindications exist (see below) (1).

Absolute Contraindications

  • Any obstetrical indication for cesarean delivery

  • Rupture of the membranes

  • Severe oligohydramnios

  • Fetal anomaly

  • Nonreassuring fetal heart rate monitoring

  • Uterine anomaly

  • Multiple gestations

Relative Contraindications

  • Controlled maternal hypertension

  • Maternal obesity

  • Fetal growth restriction

  • Previous cesarean delivery (except for a classical scar), but this contraindication remains controversial.

  • Fetal heart rate abnormalities during the procedure

  • HIV infection


  • Check the mother for development of abdominal pain.

  • Administer 300 micrograms (1500IU) of Anti-D Rhogam if she is Rh-negative.

  • Perform a nonstress test (NST) and monitor the fetus postprocedure for at least 2 hours.

  • Consider performing a Kleihauer-Betke test to rule out a significant abruption if the procedure was complicated or if the patient is experiencing pain and/or contractions postprocedure.

Management of Vaginal Breech Delivery

Consent and Considerations

  • Inform the mother of the potential for increased fetal and neonatal mortality and morbidity as compared with cesarean delivery.

  • Cesarean delivery as an alternative to labor and vaginal delivery should be discussed, and the patient’s decision should be documented.

  • Consent for episiotomy and regional anesthesia (combined spinal-epidural or epidural) should be obtained. Regional anesthesia is very important to enable a controlled delivery.

  • Parity: The patient should understand that primiparity is not a contraindication but does reduce the chances of successful vaginal delivery.

  • Pitocin: Although Pitocin is an option under some circumstances in experienced hands, the patient should understand that this is unusual and that few data support this option.

    • Care should be taken that labor progresses at least at a normal rate. Do not attempt to speed up a protracted first stage with Pitocin—labor arrest or protraction is a sign of high risk for complications.

  • Previous cesarean delivery: Additional information should be part of the consent before attempting trial of labor after cesarean (TOLAC) and breech delivery. This is an unresolved issue in the literature.

  • If not in labor and no contraindications exist, the patient should be offered the option of an ECV and her decision documented.

Contraindications for a Trial of Breech Delivery Can Be Divided into Fetal and Maternal

  • Pertinent fetal factors include the following:

    • Table 4.2.2 shows contraindications for vaginal breech delivery, and Table 4.2.3 shows prerequisites for safe vaginal breech delivery.

    • Fetal weight <2,000 g and >4,000 g (although some authors recommend a lower limit of 1,500 g and an upper limit of 3,500 g)

      • Babies that are too small are at risk of having cervical head entrapment.

      • Babies that are too big are at risk for intrapartum dystocia but do not usually suffer cervical head entrapment. Both clinical (Leopold maneuvers) and sonographic estimates are recommended, with careful consideration of the source if the discrepancy is large. In addition, we recommend taking note of the mother’s opinion on whether her current baby weighs more or less than her previous baby/ies.

    • The sonographic biometrics should also be checked for disproportion (i.e., head circumference vs. abdominal circumference [HC/AC] or femur length vs. biparietal diameter [FL/BPD], particularly at the extremes of weight estimates). If there is a large discrepancy between these measurements, there is an increased risk of head entrapment.

    • Flexion of the cervical spine, and the specifics of the breech presentation.

      • A fetus with a hyperextended cervical spine is labeled “stargazing” and indicates a maximally extended neck. A stargazing fetus is ineligible for a vaginal breech delivery based on the increased risk of cervical spinal cord injury reported in that circumstance. If a stargazing fetus is encountered, the cause of the fetal head and neck extension should be sought—often found to be associated with a neck swelling (thyroid/branchial arch cyst) or tumor, hydrocephalus, or a spinal malformation.

    • Position of the sacrum: A posterior sacrum is a concern because if the baby descends and delivers in that position, the head will be much more difficult to deliver. This is because head descent and flexion are opposed by the sacral curve, leading to greater presenting head diameters.

    • The location of the umbilical cord: Cord prolapse is more common in complex breech presentations. In a frank breech presentation, the rate of cord prolapse is similar to that in cephalic presentation. However, cord prolapse in a complete breech presentation is two to four times more common than in a cephalic presentation and up to 10-fold increased in a footling or incomplete breech presentation.

    • The shape of the maternal pelvis/pelvic capacity: In only ˜40% of cases are all of the qualitatively assessed pelvic diameters of average or better length. The only clinical measure that can be made is of the diagonal conjugate (DC), and it should exceed 11.5 cm (to correlate with an obstetrical conjugate of 10 cm).

    • Android pelvis: A classic android pelvis that funnels and constricts toward the outlet from a heart-shaped inlet is a contradiction to a planned breech delivery. An assessment of the DC, sacral hollow, shape of the pelvic sidewalls, the prominence of the ischial spines, the retropubic angle, the subpubic angle and arch, and the intertuberosity diameter should all be assessed and compared with those of a classic gynecoid pelvis of ample dimensions.

    • Narrow subpubic arch: A common disqualifier of planned breech delivery is a significantly narrow subpubic arch. The ability to have two fingers straddle the urethra is consistent with a “Norman” (rounded) rather than a “Gothic” (pointed) arch, and the latter can be an indicator of a narrow subpubic angle.

    • Retropubic arch: Placement of two fingers along the posterior surface of the inferior pubic rami extending from the symphysis pubis can also be helpful to gain an impression of the angle (90 degrees or more is adequate/gynecoid), and this assessment is of particular importance in predicting the potential for atraumatic reduction of the fetal limbs. An angle of <70 degrees has been associated with dystocia.

    • Maternal obesity is associated with fetopelvic dystocia, and pre- or retroperitoneal fat may compromise the adequacy of pelvic soft tissue volume. If the pelvic sidewalls, sacrum, and superior pubic rami are difficult to palpate, this may represent increased subcutaneous/retroperitoneal fat. Despite maternal obesity, if the pelvis feels ample in dimension, planned vaginal breech delivery may still be appropriate.

Nonoperative Management

  • Table 4.2.4 summarizes the steps and maneuvers for a breech delivery. Table 4.2.5 summarizes the management of possible complications with a breech delivery.

  • The most important piece of advice these authors can give in the management of a vaginal breech delivery is to be patient! As long as the baby is stable and not compromised, the mother should be kept pain-free and calm.

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Sep 8, 2022 | Posted by in OBSTETRICS | Comments Off on Vaginal Breech Delivery
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