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Management of the Breech Presenting at the Introitus

Author: Joseph E. Peterson, MD

Mentor: Julie DeCesare, MD
Editor: Daniel Martingano, DO, PhD, FACOG

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Breech presentation occurs in 2-3% of pregnancies at term. Frank breech accounts for over 50% of breech presentations. Risk factors vary by gestational age, with at term include advanced maternal age, nulliparity, mullerian abnormalities. maternal hypothyroidism, pre-gestational diabetes, placenta previa, prelabor rupture of membranes, oligohydramnios, and fetal congenital anomalies

Intended cesarean delivery may reduce the risk of perinatal mortality/morbidity as well as maternal morbidity compared with intended vaginal delivery, thus most breech presentations are managed via cesarean delivery.  However, if the patient presents with fetal breech at the introitus, it is unlikely that a cesarean delivery can be accomplished without causing equal or greater complications than a breech vaginal delivery.

Maternal expulsive efforts alone should accomplish the delivery of the fetal umbilicus to the perineum without traction. The Pinard maneuver is performed to assist delivery of the legs by applying pressure in the popliteal space of the knee, which results in external rotation of the thigh and flexion of the knee. Afterward, the fetus should be supported in the prone position with a dry towel wrapped around the fetal pelvis. The clinician should only manipulate the fetal bony parts, such as the pelvic bones, as opposed to soft tissues.

Once both scapulae have passed through the introitus, the arms are delivered using the Lovset maneuver by splinting the humerus and sweeping the arm downward across the fetal thorax, which should be rotated. Hence, the shoulder of the arm being delivered is anterior. The fetus is then rotated 180 degrees to accomplish delivery of the other arm similarly.

Efforts should be made to ensure that flexion of the fetal head is maintained throughout. This may be accomplished using the Mauriceau-Smellie-Veit maneuver by supporting the fetus on the forearm with the middle and index fingers on the fetal maxillae and using the other hand to apply pressure to the fetal occiput. Other options include performing the modified Prague maneuver by holding the fetal body with one hand, elevating fetal lower limbs with the other hand and rotating the baby around the maternal symphysis pubis to achieve flexion of the fetal head and ultimately delivery.

Preparations for potential head entrapment should be made promptly and include alerting anesthesia personnel, Piper forceps, and required surgical instruments to perform Duhrssen’s incisions.

When using Piper forceps, the blades of the forceps should not be applied until the fetal head is in engaged in the pelvis. Because the forceps blades are directed upward from the level of the perineum, some clinicians use a one-knee kneeling position. Once in place, the blades are articulated, and the fetal body rests across the shanks. The head is delivered by pulling gently outward and raising the handle simultaneously.

The clinician should be familiar with the technique of performing Duhrssen’s incisions of the cervix in order to decrease the risk of injury to the cervical blood vessels. The incisions are performed at the 2 and 10 o’clock location, with occasionally needing a third incision at the 6 o’clock position.

Further reading:

Wängberg Nordborg J, Svanberg T, Strandell A, Carlsson Y. Term breech presentation-Intended cesarean section versus intended vaginal delivery-A systematic review and meta-analysis. Acta Obstet Gynecol Scand. 2022 Jun;101(6):564-576. doi: 10.1111/aogs.14333. PMID: 35633052; PMCID: PMC9564601.

Toijonen AE, Heinonen ST, Gissler MVM, Macharey G. A comparison of risk factors for breech presentation in preterm and term labor: a nationwide, population-based case-control study. Arch Gynecol Obstet. 2020 Feb;301(2):393-403. doi: 10.1007/s00404-019-05385-5. Epub 2019 Nov 18. PMID: 31741046; PMCID: PMC7033046.

Ayres-de-Campos D, Ayres-de-Campos D. Retention of the After-Coming Head. Obstetric Emergencies: A Practical Guide. 2017:41-50.

Cunningham F, Leveno KJ, Bloom SL, et. Al; Breech Delivery.  Williams Obstetrics, 25e New York, NY: McGraw-Hill; 2018.


Initial Approval May 2016; Reaffirmed September 2017; Revised March 2019. Reaffirmed September 2020, Reaffirmed March 2022, Revised January 2024.


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This document is designed to aid practitioners in providing appropriate obstetric and gynecologic care. Recommendations are derived from major society guidelines and high-quality evidence when available, supplemented by the opinion of the author and editorial board when necessary. It should not be construed as dictating an exclusive course of treatment or procedure to be followed.

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