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Summary Table

Feature	Detail
Risk Factors	Prematurity (most common), multiparity, uterine anomalies (bicornuate/septate uterus), placenta previa, polyhydramnios, oligohydramnios, prior breech delivery, fetal anomalies (hydrocephalus, anencephaly), multiple gestation, contracted pelvis
Etiology	Failure of the fetus to undergo spontaneous version to cephalic presentation by 36-37 weeks; any condition that alters uterine cavity shape, fetal mobility, or fetal polarity predisposes to malpresentation
Patient Presentation	Often discovered incidentally during routine prenatal visit or on admission for labor; patient may report subcostal discomfort or "kicking" felt in the lower abdomen; round, hard (head) palpated at the fundus
Classic Physical Exam	Leopold maneuvers: ballottable hard mass (head) at the fundus, soft irregular mass (buttocks) at the pelvic inlet; fetal heart tones heard above the umbilicus; on vaginal exam during labor, palpation of sacrum, ischial tuberosities, or feet instead of a hard smooth vertex
Key Diagnostic Results	Ultrasound confirms fetal lie and type of breech; Leopold maneuvers raise clinical suspicion
Management	External cephalic version (ECV) at 37 weeks if no contraindications; if ECV fails or is contraindicated, planned cesarean delivery at 39 weeks; vaginal breech delivery reserved for highly selected cases with experienced operator
Keywords	"Hard mass at fundus," "soft mass at pelvis," "fetal heart tones above umbilicus," "footling," "frank breech," "external cephalic version," "head entrapment"

1. Pathophysiology

By approximately 32-34 weeks of gestation, most fetuses spontaneously rotate into a cephalic (vertex) presentation because the head is the heaviest pole of the fetus and the lower uterine segment is narrowest. Breech presentation persists when this rotation fails to occur or is physically prevented.

Prematurity is the single most common association because the fetus simply has not yet completed spontaneous version at the time of delivery. In a premature fetus, the relative proportions of the head and body are different compared to term, and there is more amniotic fluid relative to fetal size, which allows for greater mobility and less impetus to "settle" head-down.

Uterine anomalies such as a bicornuate or septate uterus distort the cavity shape. The fetus cannot rotate freely because the available intrauterine space does not favor the normal longitudinal lie with head down. Similarly, placenta previa occupies the lower segment and physically blocks the head from engaging in the pelvis.

Polyhydramnios provides excessive room for fetal movement, allowing the fetus to remain in an unstable lie. Conversely, oligohydramnios restricts movement altogether, preventing the fetus from completing version. Both extremes of amniotic fluid volume, through opposite mechanisms, converge on the same outcome.

The clinical significance of breech lies in the risk during vaginal delivery. In a cephalic presentation, the head (the largest and least compressible part) delivers first and dilates the birth canal for the body. In a breech delivery, the body delivers first through an incompletely dilated cervix. The aftercoming head can then become trapped, because the cervix was only dilated enough for the smaller trunk, not the larger head. This is the central danger of breech vaginal delivery and the primary reason cesarean section is preferred.

2. Classification and Clinical Manifestation

Type	Fetal Position	Frequency	Clinical Significance
Frank Breech	Hips flexed, knees extended; buttocks presenting, feet near the face	~65-70% of breech presentations	Most favorable for vaginal delivery if attempted; lower risk of cord prolapse because buttocks form a relatively complete presenting part that fills the pelvis
Complete Breech	Hips flexed, knees flexed; buttocks and both feet presenting	~10%	Moderate risk of cord prolapse; the presenting part does not fill the pelvis as completely as in frank breech
Incomplete (Footling) Breech	One or both hips extended; one foot (single footling) or both feet (double footling) presenting	~20-25%	Highest risk of umbilical cord prolapse because the small foot/feet do not fill the pelvic inlet, leaving space for the cord to slip past; this type is the strongest contraindication to vaginal breech delivery

Frank breech is the most commonly tested type and the only type even considered for vaginal delivery in select guidelines. The distinction between these types is clinically important because the risk of cord prolapse increases as the presenting part becomes smaller and less able to occlude the pelvic inlet. On vaginal examination during labor, palpating the sacrum and ischial tuberosities suggests frank breech, while palpating small parts (toes) suggests footling breech.

3. Diagnostic Workup

Test	Role	Key Findings
Leopold Maneuvers	Best initial clinical assessment	Hard, round, ballottable mass (head) at the fundus; soft, irregular mass (buttocks) at the pelvic inlet
Obstetric Ultrasound	Confirmatory test and standard of care	Identifies fetal lie, type of breech, estimated fetal weight, placental location, amniotic fluid volume, and presence of fetal anomalies or cord position
Vaginal Examination	Performed during labor	Palpation of sacrum, ischial tuberosities, or feet; absence of a smooth, hard vertex

Leopold maneuvers are the best initial clinical tool and should raise suspicion. During the third maneuver (Pawlik grip), the examiner grasps the presenting part above the symphysis pubis. In a breech presentation, the presenting part is soft, irregular, and not ballottable, which is in contrast to the hard, round, ballottable head felt in a cephalic presentation. Fetal heart tones auscultated above the umbilicus further support breech lie, whereas in cephalic presentations heart tones are typically heard below the umbilicus.

Ultrasound is the confirmatory study and should be performed whenever breech is suspected on clinical exam. It defines the exact type of breech (frank vs. complete vs. footling), estimates fetal weight, evaluates amniotic fluid index, identifies the placental location, rules out cord presentation, and screens for fetal anomalies that may themselves be contributing to the malpresentation. Ultrasound is also essential before any attempt at external cephalic version to confirm candidacy and assess safety.

A common exam pitfall is confusing the breech buttocks with the face on vaginal exam. The key discriminator: the ischial tuberosities and sacrum form a bony triangle, whereas the face has the mouth and malar eminences. Additionally, meconium on the examining finger can occur from pressure on the breech but should not be confused with fetal distress in this context.

4. Management and Treatment

Clinical Scenario	Management	Timing/Details
Breech at < 36 weeks	Observation and expectant management	Many will undergo spontaneous version; no active intervention needed
Persistent breech at 37-38 weeks	External Cephalic Version (ECV)	Performed at 37 weeks (to allow intervention if complications arise); success rate 40-60%; requires tocolysis (terbutaline 0.25 mg subcutaneous), continuous fetal monitoring, and ultrasound guidance
ECV successful	Proceed with routine obstetric care	Await spontaneous labor or induction per standard indications
ECV failed or contraindicated	Planned cesarean delivery	Scheduled at 39 weeks of gestation
Breech in active labor (undiagnosed)	Emergency cesarean delivery	Unless delivery is imminent and operator is experienced in breech extraction
Vaginal breech delivery (selected cases)	Only frank breech, estimated fetal weight 2500-3500 g, adequate pelvis, experienced operator	Rarely tested as the "correct" answer on exams; cesarean is the standard recommendation

External Cephalic Version (ECV)

ECV is the next best step for a patient at or beyond 37 weeks with a confirmed breech presentation and no contraindications. The procedure involves applying external pressure on the maternal abdomen to rotate the fetus from breech to cephalic. It is performed in a setting where emergency cesarean delivery is immediately available.

Prerequisites for ECV: A reactive nonstress test before the procedure, adequate amniotic fluid, and a reassuring fetal status. Tocolysis with terbutaline 0.25 mg subcutaneously is administered to relax the uterus and improve success. Rh-negative mothers must receive anti-D immunoglobulin (RhoGAM) after the procedure due to the risk of fetomaternal hemorrhage.

Contraindications to ECV include placenta previa, nonreassuring fetal status, ruptured membranes, multiple gestation, uterine anomalies, prior classical (vertical) cesarean scar, and significant vaginal bleeding. Any condition that would independently require cesarean delivery makes ECV unnecessary.

Cesarean Delivery

When ECV fails or is contraindicated, planned cesarean delivery at 39 weeks is the standard of care. This recommendation is grounded in the Term Breech Trial, which demonstrated that planned cesarean delivery for term breech reduces perinatal mortality and serious neonatal morbidity compared to planned vaginal breech delivery. On exams, cesarean delivery is almost always the correct answer for persistent breech at term.

Head Entrapment

If vaginal breech delivery is attempted or occurs precipitously, the dreaded complication is entrapment of the aftercoming head. Management includes Mauriceau-Smellie-Veit maneuver (the fetal body is placed over the operator's forearm, two fingers are placed on the maxilla to flex the head, and the other hand applies suprapubic pressure) or, if this fails, Piper forceps applied to the aftercoming head. Duhrssen incisions (cervical incisions at 2, 10, and 6 o'clock) may be used as a last resort for a trapped head through an incompletely dilated cervix.

5. Differential Diagnosis and Distractors

Differential	Why It Is Similar	Key Discriminator
Face presentation	Soft tissue palpated on vaginal exam in both; may confuse buttocks with face	Face presentation: palpate mouth, nose, orbital ridges, and malar eminences; breech: palpate sacrum, ischial tuberosities, and anus forming a straight line (not a triangle of facial landmarks)
Brow presentation	Malpresentation on exam; hard part palpated vaginally	Brow: anterior fontanelle and orbital ridge palpable simultaneously; does not have the soft, irregular feel of buttocks
Transverse lie	Also a malpresentation with abnormal Leopold maneuvers; no presenting part in the pelvis	Transverse: no fetal pole at the fundus or pelvic inlet; shoulder or arm may present; ultrasound shows a horizontal fetal axis
Compound presentation	Extremity palpated alongside the presenting part	Compound: an extremity (usually a hand) presents alongside the head or buttocks; the primary presenting part is still identifiable
Cord prolapse	Associated with breech (especially footling); sudden fetal bradycardia	Cord prolapse: palpation of a pulsating loop of cord on vaginal exam; requires emergent cesarean; occurs as a complication of breech, not as the breech itself
Placenta previa	Can coexist with breech; both may present with malpresentation	Previa: painless vaginal bleeding in the third trimester; ultrasound shows placenta over the internal os; breech alone does not cause bleeding

6. Traps and High-Yield Pearls

The most common way students miss breech questions is by selecting vaginal delivery when the answer should be cesarean. Unless the vignette explicitly states frank breech, estimated fetal weight between 2500-3500 g, adequate pelvimetry, and an experienced operator, the answer is cesarean delivery. Exams rarely construct a scenario where vaginal breech delivery is correct.

Another frequent trap involves timing of ECV. Students sometimes choose ECV at 34-35 weeks. The correct timing is 37 weeks, because if a complication occurs (abruption, nonreassuring tracing), the fetus is at a viable gestational age for delivery without the risks of late prematurity. Choosing ECV too early also has a higher reversion rate (the fetus can flip back to breech).

Watch for vignettes describing a patient in labor with a "soft, irregular presenting part" and sudden fetal bradycardia. This is a footling breech with cord prolapse, and the answer is emergent cesarean with manual elevation of the presenting part off the cord (not ECV, not vaginal delivery, not oxytocin augmentation).

A subtle pearl: if a vignette describes breech presentation at 34 weeks with no labor, the answer is expectant management, not ECV. Many fetuses will spontaneously convert to vertex between 34 and 37 weeks. Intervening too early is a distractor designed to test whether you know that ECV is a term procedure.

Finally, always remember that an Rh-negative mother undergoing ECV must receive RhoGAM. This is a commonly tested association that links maternal-fetal medicine with immunology and is easy to overlook when focusing on the procedural aspects of version.

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