What Is Breech Sequence?
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Breech Sequence - Types, Risk Factors, and Complications

Published on Oct 28, 2022 and last reviewed on May 26, 2023   -  6 min read


When the baby presents with a bottom-down position at birth, it is called the breech position. Read this article to learn more about it.

What Is Parturition?

It is the process in which the child is brought out of the womb. Parturition is also known by the names childbirth, birth, or labor.

How Is Labor Initiated?

During the last weeks of pregnancy, the baby's brain undergoes full growth. After this growth takes place and all other vital organs are fully developed, the fetus gets ready to face the outside world. While the fetus reaches this stage, a protein is released, initiating the labor process. Of the important substances released to begin labor, placental inflammatory molecules, and oxytocin, a fetal hormone, have been linked to childbirth. Consequently, the placenta produces prostaglandins which bring about inflammation, thus stimulating forceful and frequent uterine contractions.

What Are the Stages of Labor?

Normal labor happens over a series of three stages, namely

  1. Dilation.

  2. Expulsion.

  3. Placental stage.

1. Dilation:

Uterine contractions mark the beginning of labor. As a result of these contractions, the amniotic sac (the bag of waters) and other contents of the uterus are compressed and forced toward the uterus's neck. In the earlier stages of labor, these types of contractions usually occur once every 20 to 30 minutes and last for up to 40 seconds. However, as the labor progresses, the intensity and frequency of contractions increase, with about severe contractions occurring every three minutes. At this stage, the dilation is complete, which signals the end of the first stage. In women who are pregnant for the time, the dilation stage lasts for 13 to 14 hours on average, while in women with previous births, it takes up to only 8 to 9 hours.

2. Expulsion:

After the cervix is fully dilated, the water breaks; in addition to the involuntary uterine contractions that occur, the mother has to make efforts to bear down. This involves taking a deep breath and contracting the abdominal muscles. The bearing-down efforts of the mother are very significant and have an additive effect on the already occurring involuntary uterine contractions.

The combined forces exert pressure on the buttocks of the child, which helps in driving the child's head through the pelvis. There is intense pain when the child moves through the birth canal, which is very much increased during the terminal stages. After the head is expelled, the neck and shoulders come out. It is then followed by the trunk, which usually does not require any special effort to come out. Like the dilation stage, mothers who give birth for the first time take around one hour and 45 minutes to complete the expulsion stage. With subsequent deliveries, the time is shorter.

3. Placental Stage:

The placental stage is the shortest of all the labor stages and lasts only up to 15 minutes. After the child is fully expelled, the size of the uterus is diminished. There is a reduction in the size of the placental attachment, which brings about the detachment of the placenta from the uterine lining. Uterine contractions occur within a few minutes, which pushes the placenta into the vagina and is expelled. In some cases, where there is a delay and an accompanied bleeding, surgical removal of the placenta may be needed.

How Is the Fetus Presented During Birth?

The shape of the pelvis and the baby's position determines the labor type and greatly determine the expulsion stage of labor.

The following are the possible fetal presentations:

1. Normal Presentation:

The child should be lying with its head in the lowermost position, and the child's back of the head should be facing the mother's left side. It should be in such a way that the top of the head of the child leads the labor.

2. Posterior Presentation:

Also called occiput anterior presentation, in this, the back of the head of the fetus is placed backward and lies either on the left or right side. In this presentation, the child rotates back to as it appears in normal presentation, and labor occurs. Therefore, these take about more extended labor periods.

3. Transverse Presentation:

In this presentation, the child lies almost transversely (horizontally). Although a rare presentation, giving birth naturally with this type of presentation is challenging. So, the cesarean section is the most preferred.

4. Face Presentation:

If the head of the child is extended backward and the face of the pelvis enters the pelvis first, it is called face presentation. Also called cephalic presentation, this type of presentation takes a short duration when the chin is expelled out of the uterus first.

5. Breech Presentation:

Of 100 deliveries, around three to four deliveries exhibit this type of presentation. The legs and buttocks of the fetus are the first ones to be expelled, and the head becomes the last one to come out in this type of presentation. Since the head comes last, the chances of the umbilical cord to twine around the head are high, which might lead to asphyxia (breathing difficulty). This type of presentation exhibits severe complications and requires more attention. Delivery can be made possible either by manipulating the baby to turn into a head-on position or through a cesarean section.

What Are the Types of Breech?

The breech is classified into three types depending on which part of the fetus is exposed, which includes

1. Extended Breech:

In this type, the legs of the baby are extended so that the feet are seen near the head, and the buttocks of the baby are seen first.

2. Footling Breech:

The feet of the fetus, either one or both, present first and are lowered down over the cervix.

3. Complete or Flexed Breech:

When both the hips and knees are flexed, and the feet are raised above the buttocks, it is called complete or flexed breech.

What Risk Factors Increase The Chances of Breech Delivery?

The risk factors are categorized into maternal and fetal factors.

The maternal factors include:

  • Premature or early labor.

  • History of breech birth.

  • Abnormality in the shape of the uterus.

  • Conceived with two or more babies.

  • When there is the presence of fibroids in the uterus.

  • There is an increased or decreased level of amniotic fluid.

  • Facing first pregnancy.

  • Placental abnormalities.

The fetal factors are:

  • Poor fetal growth.

  • The length of the umbilical cord is short.

  • Fetal abnormality.

  • The legs of the fetus are much extended.

How Is Breech Identified?

Breech can be identified initially through clinical examination, which involves the following:

  • When the abdomen is examined, the presenting part of the fetus appears irregular. The upper part of the uterus exhibits a hard and round part.

  • During the pelvic examination, the head of the fetus is not felt, and only the feet or the soft buttocks are felt.

  • The heart sound of the fetus can be heard only at a higher portion above the umbilicus or navel.

After a breech has been suspected, an ultrasound scan is done to confirm the presence of breech.

How Is Delivery Carried Out With Breech?

If a breech has been diagnosed, carrying out delivery in the hospital with adequate surgical facilities is essential.

1. External Version:

An external version is tried when breech presentation occurs after the 37th week. It should be carried out only when the amniotic fluid is intact, and there are no associated fetal and maternal complications. Normal delivery can be carried out if an external version is made possible; otherwise, vaginal breech delivery or cesarean delivery is done.

2. Vaginal Breech Delivery:

A breech presentation can also be delivered vaginally, but there are a few things to note, which includes:

  • History of cesarean section.

  • Type of breech.

  • Size of fetus.

  • Head flexion of the fetus.

When the fetus is of larger size, there is a history of C-section, it is a complete or frank breech, and there is increased head flexion, vaginal breech delivery is not possible. If there is membrane rupture, prolapse of the umbilical cord, abnormality in the fetus's heart rate, and prolonged delivery, the cesarean section should be carried out.

3. Cesarean Section:

When the breech is of type double footling, the fetus is of larger size, there is hyperextension of the head of the fetus, malformation in the pelvis, or there is a history of cesarean section, then opting to C-section is indicated in breech presentation.

What Are the Complications of Breech?

The following are the complications associated with breech presentation:

  • Trauma to the fetus during birth.

  • Broken neck.

  • Prolapse of the umbilical cord.

  • Asphyxia (difficulty breathing).

  • Head entrapment.

  • Umbilical cord compression.

  • Detachment of placenta.

  • Damage to the abdominal organs.


Breech presentation is ubiquitous with preterm deliveries. Having adequate prenatal check-ups with the gynecologist is recommended to prevent complications during labor. Breech can be identified during regular prenatal examination thus, leading to appropriate management. Reach out to a healthcare provider soon after conceiving to have a track of your gestation period and deliver the baby most safely.

Last reviewed at:
26 May 2023  -  6 min read




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