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Breech Presentation

NICE guideline [NG201] Antenatal care. Published: Aug 2021. RCOG Green-top Guideline No. 20a External Cephalic Version and Reducing the Incidence of Term Breech Presentation. Last reviewed Mar 2017. RCOG Green-top Guideline No. 20b Management of Breech Presentation. Last reviewed Mar 2017.

Background Information

Breech presentation:  buttocks or feet are the presenting fetal part

Types:
 
Type Description
Frank breech Buttocks presenting (flexed hips + extended knees)
Complete breech Buttocks presenting (flexed hips + flexed knes)
Single (incomplete) footling breech 1 foot presenting (one leg fully flexed + one leg fully extended)
Double (complete) footling breech 2 feet presenting (both legs fully extended)
 

Guidelines

ALL women should be offered abdominal palpation after 36 weeks to identify possible breech presentation.
  • If breech suspected → confirm with ultrasound

  

Breech presentation suspected / identified before 36 weeks is of limited significance. The fetus is likely to spontaneously revert to cephalic presentation before 36 weeks.

NICE recommends that if breech presentation is confirmed after 36 weeks → discuss the following options:
  • External cephalic version (ECV) followed by vaginal birth (if successful)
  • Vaginal breech birth - generally not recommended due to higher risk of complications
  • Elective caesarean delivery

If the women prefers vaginal delivery → offer an attempt of ECV (see below for more details)
  • If ECV is successful (fetus in cephalic presentation) → proceed with vaginal delivery

 

If Caesarean section is planned or indicated, there is no need to offer ECV. 

As the purpose of performing ECV is to allow vaginal delivery.

RCOG advises that there are no consensus contraindications but outlined the following:

  • Presence of indications for caesarean delivery
  • Multiple pregnancy (except after delivery of a first twin)
  • Rhesus isoimunisation
  • Vaginal bleeding within 1 week
  • Ruptured membrane 
  • Abnormal CTG
  • Caution if oligohydramnios / hypertension 

Independent indications for Caesarean section (making ECV inappropriate):
  • Footling presentation
  • Hyperextended neck on ultrasound
  • High fetal weight (>3.8 kg)
  • Low fetal weight (<10th centile)
  • Evidence of fetal compromise

Description: external manipulation (through the maternal abdomen) of fetus into the cephalic presentation

Offer at:
  • Nulliparous → 36 weeks 
  • Multiparous → 37 weeks

Tocolysis with betamimetics (e.g. terbutaline, salbutamol, ritodrine) is recommended by RCOG to improve the success rate of ECV.

Points outlined by RCOG:
  • ~ 50% success rate 
  • After an unsuccessful ECV attempt at 36 weeks, it is unlikely the baby will spontaneously return to cephalic presentation
 
  • Advise women that most people tolerate but it can be a painful procedure
  • Slightly increased rate of caesarean section and instrumental delivery
    • But if ECV is successful, it reduces the chance of caesarean section

References

Author: Adams Lau
Reviewer:
Last edited: 10/07/25