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Breech and other malpresentations
A breech fetus at term is first offered external cephalic version from 37 weeks; if version fails, most are delivered by planned caesarean, and in every malpresentation remember the danger of cord prolapse.
Why it matters in the exam
Breech presentation occurs in about 3%–4% of pregnancies at term. Exam questions ask what is offered to a woman at 36–37 weeks with a breech fetus (external cephalic version, ECV), the contraindications to version (placenta praevia, abnormal monitoring, multiple pregnancy, a major uterine anomaly), and what follows it (monitoring, and anti-D for an Rh-negative woman). The success rate of external version is about 50%. Since the Term Breech Trial of 2000, breech is usually delivered by planned caesarean, although vaginal birth is possible in selected conditions with an experienced team.
Other malpresentations are asked mainly through the decision on mode of delivery: a transverse lie that persists in labour requires caesarean section; a face presentation with the chin anterior can deliver vaginally, but with the chin posterior it cannot; a persistent brow presentation usually requires caesarean section. Occiput posterior lengthens labour and causes back pain, and is sometimes rotated manually. In any presentation where the presenting part does not fill the pelvis — footling breech and transverse lie — the risk of cord prolapse is high, and this is an emergency.
Key points
- Breech at term: external version from 37 weeks, and if it fails — usually planned caesarean.
- Contraindications to version: placenta praevia, abnormal monitoring, multiple pregnancy.
- Transverse lie in labour or chin posterior → caesarean.
- Footling breech and transverse lie → risk of cord prolapse.
- Cord prolapse: lift the presenting part and emergency caesarean.
Summary table
| Presentation | Frequency or feature | Mode of delivery | Exam notes |
|---|---|---|---|
| Breech at term | About 3%–4% | External version from 37 weeks; if it fails — usually planned caesarean | Vaginal birth only in selected conditions with an experienced team |
| Footling breech | One or both feet lead | Caesarean section | High risk of cord prolapse |
| Transverse lie | More common with high parity and placenta praevia | Caesarean if it persists in labour | After membrane rupture — danger of cord prolapse |
| Face presentation | Chin anterior or posterior | Chin anterior — vaginal possible; chin posterior — caesarean | No vacuum in face presentation |
| Brow presentation | Head in an intermediate position | Usually caesarean if it does not change | The largest diameter of the head |
| Cord prolapse | Cord ahead of the presenting part, fetal bradycardia | Emergency caesarean | Lift the presenting part manually until delivery |
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Sources
- ACOG Committee Opinion No. 745, 2018 — Mode of Term Singleton Breech Delivery
- ACOG Practice Bulletin No. 221, 2020 — External Cephalic Version
- RCOG Green-top Guideline No. 20b, 2017 — Management of Breech Presentation
- Williams Obstetrics, 26th edition (2022) — Breech Delivery; Abnormal Labor
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.