Breech presentation patient care

Revised: December 14, 2018

Introduction

Breech presentation of the fetus occurs in about 3% to 4% of all full-term births, 7% to 16% of fetuses at 32
weeks' gestation, and 20% to 25% of fetuses at less than 28 weeks' gestation, placing the fetus at risk for
umbilical cord prolapse. Breech presentation of a fetus is diagnosed using Leopold maneuvers or vaginal
examination and confirmed using ultrasonography. Ultrasonography also confirms which of the four types of
breech presentation (frank, complete, single-footling, double-footling) is present. (See Breech presentations.)1 2
Several factors increase the risk of fetal breech presentation, including prematurity (the fetus may not have had
time to turn to a cephalic presentation), prior pregnancy, intrauterine growth restriction, uterine malformations or
fibroids, placenta previa, congenital fetal anomalies, multiple gestation, polyhydramnios, and oligohydramnios.3

Since the number of practitioners with skills and experience to perform vaginal breech delivery has decreased,
there’s a trend to perform cesarean delivery for term singleton fetuses in the breech position. The decision
regarding the mode of delivery should consider the patient’s wishes and the practitioner’s experience. If a
vaginal breech delivery is planned, the patient should be informed that neonatal morbidity and mortality may be
higher than with cesarean delivery. Many patients with a fetus in breech presentation undergo external cephalic
version. (See the "Antepartum external cephalic version, assisting" procedure.) However, if the fetus remains in
or returns to breech presentation, in the case of a single-footling or double-footling breech presentation, the
patient may undergo a trial of labor for a vaginal delivery. If the labor trial is unsuccessful, the patient then
undergoes preparation for cesarean delivery.2 In the case of a frank breech or complete breech presentation, a
cesarean delivery is generally planned to reduce the risk of complications.4

COMPLICATIONS

BREECH PRESENTATIONS

There are four types of breech presentation.

Frank breech

In a frank breech presentation, the fetus's thighs are flexed and the legs lie along the body.

 
 

Complete breech

In a complete breech presentation, the fetus's legs are flexed at the thighs and the feet present with the
buttocks.

 
 

Single-footling breech

In a single-footling breech presentation, one of the fetus's feet presents through the birth canal before the
buttocks.

 
 

Double-footling breech

In a double-footling breech presentation, both of the fetus's feet present through the birth canal before the
buttocks.

 
  

Equipment

External fetal monitoring equipment

Optional: IV catheter insertion equipment, prescribed IV fluids, oxygen administration equipment,
ultrasonography equipment, blood pressure monitoring equipment

Implementation

Perform hand hygiene.5 6 7 8 9 10

Confirm the patient's identity using at least two patient identifiers.11
Provide privacy for the patient.12 13 14 15
If not already done, confirm that the fetus is in breech presentation using ultrasonography, Leopold
maneuvers, or vaginal examination. (See the "Vaginal examination during labor" procedure.)1 2
Notify the practitioner of the fetal breech presentation.
Explain fetal breech presentation and its complications to the patient and her partner.
Attach the patient to an external fetal monitor for continuous monitoring. (See the "Fetal monitoring,
external" procedure.) Continuous external fetal monitoring helps assess the fetus for indeterminate (category
II) or abnormal (category III) fetal heart rate (FHR) patterns, which may indicate worsening fetal status and the
need for additional measures to safeguard the fetus's health. If you observe an indeterminate or abnormal
FHR pattern, intervene appropriately: reposition the patient laterally, administer supplemental oxygen to the
patient, discontinue any labor-inducing agents, monitor maternal blood pressure, obtain IV access,
administer a fluid bolus as prescribed, and inform the practitioner immediately.16 17
Continue to monitor the patient and the fetus while the practitioner evaluates whether vaginal or cesarean
delivery is appropriate.
 Provide nursing care appropriate for the delivery method chosen by the practitioner.
Perform hand hygiene.5 6 7 8 9 10
Document the procedure.18 19 20 21

Special Considerations

Be aware that mechanical assistance is required generally to extract the fetal head in a vaginal breech
delivery.

Complications
Vaginal delivery of a fetus in breech presentation may cause neonatal complications, including asphyxia from
prolonged umbilical cord compression, head trauma, and fractures.

Documentation
Document confirmation of the fetal breech presentation. Include the date and time that the practitioner was
notified and the practitioner's name. Document any nursing interventions performed and measures taken to
prepare the patient for delivery. Document fetal monitoring as indicated by your facility's documentation
format. Document teaching provided to the patient and family (if applicable), their understanding of that
teaching, and whether they require follow-up teaching.

References

1. Hofmeyr, G. J. Overview of issues related to breech presentation. (2018). In: UpToDate, Lockwood, C. J.
(Ed.).
2.  Pillitterri, A. (2014). Maternal & child health nursing: Care of the childbearing and childrearing family (7th
ed.). Philadelphia, PA: Wolters Kluwer.
3. American Congress of Obstetricians and Gynecologists. (2017). "Frequently asked questions: If your baby
is breech" [Online]. Accessed October 2018 via the Web at http://www.acog.org/-/media/For-
Patients/faq079.pdf?dmc=1&ts=20150512T0922420089 (Level VII)
4. American Congress of Obstetricians and Gynecologists, Committee on Obstetric Practice. (2018). ACOG
Committee Opinion No. 745: Mode of term singleton breech delivery. Obstetrics and Gynecology, 132, e60–
e63. Accessed October 2018 via the Web at https://www.acog.org/-/media/Committee-
Opinions/Committee-on-Obstetric-Practice/co745.pdf (Level VII)
5. The Joint Commission. (2018). Standard NPSG.07.01.01. Comprehensive accreditation manual for
hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
6. Centers for Disease Control and Prevention. (2002). Guideline for hand hygiene in health-care settings:
Recommendations of the Healthcare Infection Control Practices Advisory Committee and the
HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR Recommendations and Reports, 51(RR-16),
1–45. Accessed October 2018 via the Web at https://www.cdc.gov/mmwr/pdf/rr/rr5116.pdf (Level II)
7. World Health Organization. (2009). "WHO guidelines on hand hygiene in health care: First global patient
safety challenge, clean care is safer care" [Online]. Accessed October 2018 via the Web at
http://apps.who.int/iris/bitstream/10665/44102/1/9789241597906_eng.pdf (Level IV)
8. Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2015).
Condition of participation: Infection control. 42 C.F.R. § 482.42.
9. Accreditation Association for Hospitals and Health Systems. (2017). Standard 07.01.21. Healthcare
Facilities Accreditation Program: Accreditation requirements for acute care hospitals. Chicago, IL:
Accreditation Association for Hospitals and Health Systems. (Level VII)
10. DNV GL-Healthcare USA, Inc. (2016). IC.1.SR.1. NIAHO® accreditation requirements: Interpretive guidelines
& surveyor guidance – revision 16. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)
11. The Joint Commission. (2018). Standard NPSG.01.01.01. Comprehensive accreditation manual for
hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
12. Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2015).
Condition of participation: Patient's rights. 42 C.F.R. § 482.13(c)(1).
13. The Joint Commission. (2018). Standard RI.01.01.01. Comprehensive accreditation manual for hospitals.
Oakbrook Terrace, IL: The Joint Commission. (Level VII)
14. Accreditation Association for Hospitals and Health Systems. (2017). Standard 15.01.16. Healthcare
Facilities Accreditation Program: Accreditation requirements for acute care hospitals. Chicago, IL:
Accreditation Association for Hospitals and Health Systems. (Level VII)
15. DNV GL-Healthcare USA, Inc. (2016). PR.1.SR.5. NIAHO® accreditation requirements: Interpretive guidelines
& surveyor guidance – revision 16. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)
16. American Congress of Obstetricians and Gynecologists, Committee on Practice Bulletins. (2009,
reaffirmed 2015). ACOG Practice Bulletin No. 106: Intrapartum fetal heart rate monitoring; Nomenclature,
interpretation, and general management principles. Obstetrics and Gynecology, 114(1), 192–202. Accessed
October 2018 via the Web at http://obgyn.med.sc.edu/documents/antepartum_fetal_2.pdf (Level VII)
17. National Certification Corporation. (2010). NICHD definitions and classifications: Application to electronic
fetal monitoring interpretation. NCC Monograph, 3(1), 1–20. (Level VII)
18. The Joint Commission. (2018). Standard RC.01.03.01. Comprehensive accreditation manual for hospitals.
Oakbrook Terrace, IL: The Joint Commission. (Level VII)
19. Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2015).
Condition of participation: Medical record services. 42 C.F.R. § 482.24(b).
20. Accreditation Association for Hospitals and Health Systems. (2017). Standard 10.00.03. Healthcare
Facilities Accreditation Program: Accreditation requirements for acute care hospitals. Chicago, IL:
Accreditation Association for Hospitals and Health Systems. (Level VII)
21. DNV GL-Healthcare USA, Inc. (2016). MR.2.SR.1. NIAHO® accreditation requirements: Interpretive guidelines
& surveyor guidance – revision 16. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)

Additional References
Bienstock, J. L., et al. (2015). The Johns Hopkins manual of gynecology and obstetrics (5th ed.). Philadelphia, PA: Wolters Kluwer.
Burgos J., et al. (2015). Management of breech presentation at term: a retrospective cohort study of 10 years of experience.
Journal of Perinatology, 35, 803–808. (Level IV)