1) Epidemiology

• Breech = longitudinal lie with buttocks or feet presenting.

• ~3–4% of term singleton pregnancies.

• More common preterm (~25% at 28 weeks; many turn spontaneously).

• Associated with prematurity, uterine/fetal anomalies, placenta praevia, poly/oligohydramnios.

2) Types of breech

• Frank (65%): hips flexed, knees extended (buttocks first).

• Complete (25%): hips flexed, knees flexed (sitting).

• Footling/incomplete (10%): one/both hips extended, foot presenting (↑ risk cord prolapse).

3) Antenatal Management

External Cephalic Version (ECV) – cornerstone

• Timing: 36 weeks (nulliparas), 37 weeks (multiparas).

• Success rate: ~40% nullips, ~60% multips.

• Contraindications: placenta praevia, antepartum haemorrhage, abnormal CTG, multiple pregnancy (except 2nd twin), uterine scar is not absolute contraindication (counsel).

• Adjuncts: tocolysis (terbutaline) improves success; anti-D if Rh–.

• Complications: rare (<1%) – transient FHR abnormality, vaginal bleed, emergency CS.

• Offer to all women with singleton breech at term unless contraindicated.

4) Mode of Delivery – key GTG recommendations

• Planned CS reduces perinatal/neonatal morbidity & mortality compared to planned vaginal breech birth (Term Breech Trial, 2000).

• But: absolute risk small; long-term neurodevelopment similar.

• Planned vaginal breech delivery (VBD) remains an option in carefully selected women with appropriate expertise.

Selection criteria for VBD:

• Term singleton, frank or complete breech.

• No hyperextension of fetal head.

• Estimated fetal weight 2.5–3.8 kg.

• No antenatal evidence of fetopelvic disproportion.

• Facility with skilled operator, continuous fetal monitoring, immediate CS capability.

5) Intrapartum Management of Vaginal Breech

• Care principles:

  • Continuous CTG.

  • IV access, blood available.

  • Upright/lithotomy acceptable – many centres support upright (all-fours).

  • Avoid induction; cautious augmentation.

  • Second stage:

    • Passive descent → active pushing.

    • If breech not visible after 60 mins pushing → CS.

Key manoeuvres to know for MRCOG:

• Pinard manoeuvre → flex & deliver extended legs.

• Lovset manoeuvre → rotation & delivery of extended arms.

• Mauriceau-Smellie-Veit (MSV) or forceps → control after-coming head.

• Burns–Marshall method (less favoured today).

6) Special Situations

• Preterm breech: ↑ risks; delivery mode individualized. Vaginal possible if spontaneous & imminent, but CS usually considered.

• Second twin breech: often acceptable vaginally if first twin delivered cephalic, provided obstetrician skilled.

• Footling breech: usually CS (risk cord prolapse).

• Hyperextended head: contraindication to VBD.

7) Counselling Points (exam scenarios)

• Discuss risks/benefits of planned CS vs VBD.

• Document informed decision.

• Re-offer ECV if not yet attempted.

• Ensure intrapartum skilled support if VBD chosen.

8) Key Statements (memorise)

• Offer ECV to all at term unless contraindicated.

• Planned CS recommended, but VBD reasonable with strict criteria.

• Vaginal breech should only be managed by trained/skilled clinicians.

• Antenatal counselling must cover risks, benefits, recurrence (10%), and mode of delivery in future pregnancies.

9) Exam Tips

• MRCOG SAQ: “Discuss management of term breech.” → structure: confirm, ECV, CS vs VBD counselling, intrapartum selection & monitoring, manoeuvres.

• SBA/EMQ: likely to test ECV contraindications, manoeuvres, intrapartum complications (cord prolapse, head entrapment), counselling points.

📌 In summary (take-home for exam):

• ECV = first-line at term.

• Planned CS safer, but planned VBD is acceptable if strict criteria + skilled team.

• Know manoeuvres (Pinard, Lovset, MSV).

• Counselling & documentation are critical.

• Click below to attempt SBA/EMQs realted to this topic 👇