History and exam

Key diagnostic factors

common

buttocks or feet as the presenting part

Pelvic or vaginal examination reveals the buttocks and/or feet, felt as a yielding, irregular mass, as the presenting part.[24] In cephalic presentation, a hard, round, regular fetal head can be palpated.[24]

fetal head under costal margin

The Leopold maneuver on examination suggests breech position by palpation of the fetal head under the costal margin.[24]

fetal heartbeat above the maternal umbilicus

The baby's heartbeat should be auscultated using a Pinard stethoscope or a hand-held Doppler to indicate the position of the fetus. The fetal heartbeat lies above the maternal umbilicus in breech presentation.[1]

Other diagnostic factors

uncommon

subcostal tenderness

Tenderness under one or other costal margin as a result of pressure by the harder fetal head.

pelvic or bladder pain

Pain due to fetal kicks in the maternal pelvis or bladder.

Risk factors

strong

premature fetus

Prematurity is consistently associated with breech presentation.[6][9] This may be due to the smaller size of preterm infants, who are more likely to change their in utero position.

Increasing duration of pregnancy may allow breech-presenting fetuses time to grow, turn spontaneously or by external cephalic version, and remain cephalic-presenting.

Larger fetuses may be forced into a cephalic presentation in late pregnancy due to space or alignment constraints within the uterus.

small for gestational age fetus

Low birth-weight is a risk factor for breech presentation.[9][11][12][13][14] Term breech births are associated with a smaller fetal size for gestational age, highlighting the association with low birth-weight rather than prematurity.[6]

nulliparity

Women having a first birth have increased rates of breech presentation, probably due to the increased likelihood of smaller fetal size.[6][9]

Relaxation of the uterine wall in multiparous women may reduce the odds of breech birth and contribute to a higher spontaneous or external cephalic version rate.[10]

fetal congenital anomalies

Congenital anomalies in the fetus may result in a small fetal size or inappropriate fetal growth.[9][12][14][15]

Anencephaly, hydrocephaly, Down syndrome, and fetal neuromuscular dysfunction are associated with breech presentation, the latter due to its effect on the quality of fetal movements.[9][14]

previous breech delivery

The risk of recurrent breech delivery is 8%, the risk increasing from 4% after one breech delivery to 28% after three.[16]

The effects of recurrence may be due to recurring specific causal factors, either genetic or environmental in origin.

uterine abnormalities

Women with uterine abnormalities have a high incidence of breech presentation.[14][17][18][19]

female fetus

Fifty-four percent of breech-presenting fetuses are female.[14]

weak

abnormal amniotic fluid volume

Both oligohydramnios and polyhydramnios are associated with breech presentation.[1][12][14]

Low amniotic fluid volume decreases the likelihood of a fetus turning to a cephalic position; an increased amniotic fluid volume may facilitate frequent change in position.

placental abnormalities

An association between placental implantation in the cornual-fundal region and breech presentation has been reported, although some studies have not found it a risk factor.[8][10][14]​​[20][21][22]

The association with placenta previa is also inconsistent.[8][9][22] Placenta previa is associated with preterm birth and may be an indirect risk factor.

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