Breech and other malpresentation

What is it?

Most babies settle head down before labor. Some do not.

Frank breech means the bottom is down with the legs straight up. Complete breech means the bottom is down with the knees bent. Footling breech means one or both feet are lowest.

Transverse lie means the baby lies sideways. A transverse baby cannot be born vaginally.

Other malpresentations include a face-first or brow-first position, and a head that is turned so a larger diameter has to pass.

Why breech changes the delivery

In a head-first birth, the head passes first. It is the largest part, it molds as it comes, and once it is through, the rest follows easily.

In a breech birth that order is reversed. The body comes first, and the head is last. It has no time to mold, and by the time there is a problem the body is already delivered. That is the central reason breech vaginal birth is handled differently. ¹

The cord is also more exposed, because the presenting part does not seal the pelvis as a head does. That raises the risk of umbilical cord prolapse. ²

Turning the baby

External cephalic version is a procedure in which a clinician presses on the abdomen to turn the baby head down, usually from around 37 weeks. It is done where fetal monitoring and an operating room are available, because a small number of attempts lead to immediate delivery. ¹

What does standard care look like?

Presentation is checked in late pregnancy, and confirmed by ultrasound where there is doubt.

External cephalic version is offered where there is no contraindication, usually from around 37 weeks, with monitoring and with facilities for delivery available. ¹

The mode of delivery is discussed. Guidance states that the decision should depend on the experience of the provider, that planned vaginal breech delivery may be reasonable under a hospital-specific protocol, and that the patient should be informed of the risks. ¹

Continuous fetal monitoring in labor.

Anti-D immune globulin for an Rh-negative person having a version, since the procedure can allow mixing of blood. ³

Hip imaging for the baby afterward, because breech position is the strongest risk factor for hip dysplasia. ¹

What can go wrong?

Presentation not identified before labor. A breech discovered in advanced labor removes the options.

external cephalic version not offered or not discussed, where there was no contraindication. ¹

A vaginal breech birth undertaken without the required experience or protocol. Guidance ties this to provider experience and to a hospital-specific protocol. ¹

A head that would not deliver, which is the specific catastrophe of vaginal breech birth, and the reason the technique matters.

Traction applied to the body, which is associated with nerve and spinal injury.

umbilical cord prolapse not anticipated, where the risk is higher. ²

Hip imaging not arranged afterward. ¹

A transverse baby labored, when vaginal birth is not possible from that position.

Whether any of this amounts to a departure from the standard takes a physician expert reading the whole record.

Which injuries can follow?

For the baby

• Hypoxic-ischemic encephalopathy, where the head delivery is delayed or the cord is compressed. ⁴
• Brachial plexus injury, from traction on the body and arms. ⁵
• Spinal cord injury, which is rare and is specifically associated with a difficult head delivery in breech. ⁶
• Skull fracture and intracranial hemorrhage.
• Hip dysplasia, which is the most common lasting association and is highly treatable when found early. ¹
• Clavicle fracture and other fractures.

For the mother

• Severe perineal tearing in vaginal breech birth. ⁷
• Cesarean-related risks where a cesarean is performed. ⁸

What does this look like in the records?

From the prenatal record

• When breech presentation was first documented.
• Whether ultrasound confirmed it.
• Whether external cephalic version was offered, attempted or declined, and why.
• The documented discussion about mode of delivery. ¹

From the labor and delivery record

• The presentation and position on admission.
• The fetal monitoring strip. ²
• The delivery note, including which maneuvers were used and the interval from body to head.
• Whether a cesarean was planned or became an emergency.
• The cord blood gas results and Apgar score scores. ⁹

From the newborn record

• The examination, including arm movement and tone. ⁵
• Whether hip imaging was arranged. ¹
• Any imaging of the head or spine. ⁶

The records request builder generates a letter naming these documents. ¹⁰

What can you do this week?

1. Request the complete labor and delivery record for you and your baby. The records request builder writes the letters for you.
2. Write down what you remember while it is fresh, using the delivery timeline builder.
3. Read how to read your labor and delivery records before the records arrive.
4. Check the deadline to file in your state with the statute of limitations lookup.