Breech Presentation
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Direct answer
Breech presentation, where the buttocks or feet present, affects roughly 3 to 4 per cent of term pregnancies and is much commoner preterm. It is classified as frank (flexed hips, extended knees — the commonest), complete (flexed hips and knees) and incomplete or footling, with rising risk of cord prolapse across that order. External cephalic version is offered at 36 to 37 weeks; if it fails or is contraindicated, a term frank breech in a nullipara is generally delivered by planned caesarean, while selected cases with a flexed head, adequate pelvis and expected weight of about 2.5 to 3.5 kg may deliver vaginally using the Burns-Marshall, Mauriceau-Smellie-Veit and Lovset manoeuvres.
What you must remember
- Frank breech is commonest at term; footling breech carries the highest risk of cord prolapse and entrapment of the after-coming head, especially preterm.
- Causes: prematurity (overall the commonest), grand multiparity, placenta praevia, fibroids and uterine anomalies, polyhydramnios, multiple pregnancy, and fetal anomalies such as hydrocephalus.
- Diagnosis: Leopold manoeuvres find the hard, ballotable head in the fundus, the fetal heart is heard above the umbilicus, and ultrasound confirms type, attitude, weight and head flexion.
- External cephalic version is attempted at 36 to 37 weeks with tocolysis and monitoring; contraindications include praevia, multiple pregnancy, ruptured membranes, severe preeclampsia and, in most policies, previous caesarean.
- Following the Term Breech Trial, planned caesarean is standard for a term singleton breech, especially in a nullipara; vaginal birth suits only selected cases with an experienced accoucheur.
- Vaginal delivery skills: Lovset's rotation for the shoulders, the Burns-Marshall and Mauriceau-Smellie-Veit manoeuvres for the after-coming head, and forceps (Piper's) to that head.
- Hazards: cord prolapse, asphyxia of the after-coming head, nuchal arms, brachial plexus injury (Klumpke palsy) and traumatic intracranial haemorrhage.
Common confusion
The examinable contrast is which breech prolapses the cord — footling, not frank. Candidates also swap the manoeuvres: Lovset rotates the shoulders through 180 degrees, while Mauriceau-Smellie-Veit and Burns-Marshall flex and deliver the after-coming head. Note the version timing too — 36 to 37 weeks balances success against the risk of spontaneous reversion, with caesarean rescue available during the attempt.
Exam-focused takeaway
FMGE frames breech as classification, cause and route: identify the type from the attitude, pick prematurity or praevia as the cause, choose planned caesarean for a term frank nulliparous breech, and match Lovset to the shoulders. The recurring emergency stem — ruptured membranes with a footling breech and fetal bradycardia — answers cord prolapse managed by elevation and urgent caesarean. Manoeuvre-name pairings are pure one-mark items.
Frequently asked questions
What are the types of breech presentation?
Frank breech with flexed hips and extended knees (commonest at term), complete breech with hips and knees flexed, and incomplete or footling breech with one or both feet presenting.
When is external cephalic version attempted?
Around 36 to 37 weeks, with tocolysis and fetal monitoring, after excluding praevia, ruptured membranes, multiple pregnancy and other contraindications.
Which manoeuvre delivers the shoulders in a vaginal breech?
Lovset's manoeuvre — rotating the body through 180 degrees to bring each shoulder anterior, then repeating for the second arm.
Why is footling breech dangerous?
The footling fits the pelvis poorly, so the cord can prolapse, and a partially dilated cervix can trap the after-coming head, particularly in preterm infants.
Which breech is best delivered by planned caesarean?
A term singleton breech in a nullipara, or any case with an unfavourable pelvis, weight above about 3.5 kg, a deflexed head or complications — consistent with the Term Breech Trial.
What is the role of forceps in breech delivery?
Forceps (classically Piper's) protect and control delivery of the after-coming head, applied with an assistant holding the body.