breech presentation cow

Beef Cattle

What is a breech birth, and what causes it?

During parturition, a breech birth describes fetal presentation. Breech birth is characterized with a calf presenting butt first with no front or hind limbs entering the birth canal. The tail and hindquarters of the calf can be palpated via the vagina.

The cause of breech birth is not known, but it does not appear to be related to cowherd nutrition or genetics.

When a breech birth is experienced, professional assistance (veterinarian) should be immediately consulted.

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Calving Management

Dystocia prevention and intervention, introduction.

Dystocia is derived from a Greek word meaning difficult birth. In cattle operations dystocia is a major cause of calf loss with some studies reporting that 1/3 of calf losses are associated with dystocia. Besides the immediate loss resulting from a calf that dies at or shortly after birth there are other losses that can occur over time. Calves born from dystocia events take longer to stand and nurse, and will subsequently absorb lower amounts of immunoglobulins from colostrum. During a difficult birth, calves can be deprived of oxygen (hypoxemia) if the umbilical cord is constricted and the calf is unable to breathe because the chest is compressed. Posterior or backwards calves also are at risk for hypoxemia because the umbilical cord is constricted before the calf’s nasal passages are exteriorized. Hypoxemia can cause calves to be weak at birth and negatively impact the calf’s ability to stand and suckle. Because dystocia can decrease the calf’s ability for adequate passive transfer of immunoglobulins from colostrum, dystocia calves are also more likely to have subsequent health issues such as calf scours, navel ill or pneumonia.

Typically, heifers have more problems with dystocia than mature cows because the main cause of dystocia is maternal/fetal disproportion, meaning that the calf is larger than what the female is capable of easily delivering. Heifers are still growing and their pelvic canal has not reached its mature size. Therefore, heifers are not capable of delivering the same size calf as a cow. Small increases in calf size or weight can mean the difference between a natural easy birth and a difficult pull. Even without maternal/fetal disproportion, the birthing process is longer and slightly more difficult in heifers as the soft tissue in the perineal region does not relax as rapidly compared to older cows. Although cows do not have as many problems with dystocia as heifers, when they do have problems it can be serious because maternal/fetal disproportion is usually not the problem. Dystocia in cows is more commonly associated with malpositioned or deformed calves that may take careful extraction to salvage a positive outcome.

Females also are negatively impacted by dystocia. Severe dystocia can cause trauma to the cow or heifer during calving. In many cases trauma is limited to local soft tissue tearing but can also involve nerve paralysis or skeletal involvement. Additionally, dystocia females are more likely to have increased days open and reduced fertility.

When a difficult birth arises, timely and appropriate intervention can result in a positive outcome for the cow and the calf. Regular observation, an understanding of the normal stages of delivery and adequate facilities and equipment are necessary for intervention to be beneficial. The goals of dystocia intervention include an uninjured cow that is capable of taking care of her calf and getting rebred and a healthy viable calf that has the capability of becoming a productive individual.

Dystocia Prevention

The major cause of dystocia is maternal/fetal disproportion; thus, prevention is focused on bull selection and heifer development. Malposition of the calf is not predictable and there are not any methods to prevent malposition ahead of time. Occasionally, genetic defects can lead to malformations that may cause dystocia. Careful selection of matings can minimize the chance of genetic defects appearing in your herd.

Bull Selection

Sires selected for use in yearling heifers are usually different than sires used in the mature cow herd. Breed associations publish expected progeny differences (EPDs) that can be used to select a sire that has a decreased chance of causing dystocia. There are several traits people use to select for reduced dystocia. Birth weight is a highly heritable trait that was historically used to select for reduced dystocia. The downside of selecting for light birth weight is that growth traits are typically related, so selecting for lighter birth weight in many instances also selects for lighter weaning and yearling weight which may impact long term profitability. Moreover, year-after-year selection for low birth weight will likely reduce the individual animal size and pelvic size of the cow herd over time.  Thus, selection solely for low birth weight can have negative long term effects on dystocia in herds where replacements heifers are developed from within. Calving ease direct is another EPD that can be used and is not solely associated with birth weight. In contrast to selecting only for birth weight EPD’s, calving ease direct reflects the estimated percentage of unassisted births that the bull will have when mated with heifers. Calving ease direct accounts for not only birth weight (about 60% influence) of the calf but shape and other intangible aspects and is not negatively associated with the other growth traits. Thus, a bull with high calving ease direct does not necessarily have lower weaning and yearling weights.

Heifer Development

Heifers are targeted to give birth for the first time at 24 months of age. Heifers that have been developed and managed properly will be about 85% of their mature cow size at calving time. Heifers that are under-developed may only be 70%-80% of their mature size at calving, thereby vastly increasing the potential for dystocia. A misconception of some beef producers is that restricting nutritional intake of a female can reduce dystocia by decreasing calf birth weight. However, research has demonstrated that although the calf may weigh less at birth the risk of dystocia is increased because of decreased pelvic size as growth of the heifer is restricted and thin heifers do not have the strength and stamina to complete the birthing process.

Maternal calving ease EPDs can be used to select for females that can improve calving ease in the herd. Additionally, many producers will use pelvic measurements prior to breeding to select heifers that have an acceptable size pelvis relative to the mature cow size of the herd.

Dystocia Intervention

Assessing the cow and calf.

Meconium staining

Meconium staining is present on the calf's feet and person's hands.This yellowish-brown tinged fluid indicates the calf is stressed. Image credit: Grant Dewell

You can never assist a cow too early in a dystocia event once stage 2 labor has started, but assisting too late can result in a dead or poor-doing calf. Prior to assessing the cow make sure that you and the perineal area (area under her tail) are clean to prevent contaminating the uterus. Ivory soap can be used to clean the cow’s vulva area if needed. OB sleeves should be used to protect the cow and yourself. Utilize plenty of obstetrical lubricant to ease the exam and prevent trauma. If you intervene too early and the cow or heifer has not dilated appropriately yet, use some patience and manually dilate the cervix and vagina by applying firm steady pressure with your hands and arms inserted into the birth canal. Make sure the cervix and vagina have dilated appropriately before you try pulling the calf, or you can cause some tearing of the tissue.

This also is a good time to check the viability of the calf. Calves that are vigorous will jerk their foot away if you grab it or pinch it. Calves may also suck on your finger if you can reach their mouth. If you can reach the calf’s thorax you should be able to feel the calf’s heartbeat. Backwards or breech calves can be assessed by checking feet (can pinch between the toes to see if they react) or checking to see if the anal sphincter has any tone to it (you can do this by placing a finger in the rectum to see if they have tone). Generally if you don’t get any reaction then the calf may be dead. However, some calves will not give a reaction even though they are still alive so don’t give up right away. Some calves that are moving excessively may be in distress and end up as a stillborn calf instead of just being a lively calf. Calves that have been dead for 12 hours or more will start to have a decomposing odor to them. With dead calves, you may also notice them slipping or shedding hair when you palpate them. Another way to assess stress of the calf is to check for meconium staining. Meconium is the fecal material the calf is born with. Calves that become stressed will defecate in utero causing the amniotic fluid to have a yellowish to greenish color and white hair of the calf will turn yellow.

The first step in assessing a dystocia is determining the presentation, position and posture of the calf. Presentation refers to which part of the calf is being presented for delivery. A normal presentation is an anterior (forward) presentation with the front legs and head coming out first. A posterior presentation, or backwards presentation, is a frequently seen type of dystocia. Occasionally, a transverse presentation is seen where the calf is lying on its side across the cow’s abdomen with all four legs (or the back) being presented for delivery. Calves can be pulled in either an anterior or posterior presentation. Transverse presentations need to be manipulated so that the calf is either coming anterior or posterior.

Position refers to the calf’s position relative to the cow. An upright calf is positioned with its vertebrae aligned with or pointed towards the cow’s vertebrae (right side up) which is the normal birthing position. An upside-down calf is positioned with its vertebra pointed towards the cow’s abdominal wall. An upside-down calf must be corrected by flipping over to right side up prior to pulling through the birth canal. Calves should be pulled in an arc through the cow’s pelvis towards the ground or the cow’s legs. Pulling an upside down calf could cause severe damage to calf’s back bone as it is arced through the pelvis and this should be avoided. Occasionally, a calf will be in a lateral position with its vertebrae pointing towards the cow’s side. These calves can be easily turned 90 degrees to an upright position.

Posture describes the position of the individual parts (head and limbs) of the calf in relation to its body. A normal posture is for both front legs and the head to be presented in the birth canal. Postures such as a leg or head back would be an abnormal posture. Abnormal posture needs to be corrected prior to pulling the calf so that both front legs and the head are being delivered first for an anterior presentation or both back legs and the tail for a posterior presentation.

If you cannot manipulate the calf into a correct posture and position for the presentation fairly quickly (typically 15 minutes or less), then professional assistance should be obtained. Delays in correcting the position or posture can further stress the calf and cow, potentially leading to an unsatisfactory outcome such as a dead or injured calf and/or cow. Just as early assistance is helpful, an early decision to seek veterinary assistance may be helpful and can prevent both calf and cow death loss. Abnormal calf postures and positions that cannot be corrected in 15 minutes need professional assistance and in many cases will necessitate a caesarian section. Besides time, any evidence of stress on the calf (swollen tongue, meconium staining of the calf, or presence of yellow-tinted amniotic fluid) is an indication to seek professional assistance.

Pulling the Calf

Before you start pulling the calf , (video) the first step is to determine if the calf can likely be pulled or if a caesarian section is the better option. It is best to make this determination early on in the process. Once the calf is about 1/3 of the way out, it is difficult to stop and switch to a cesarean section. If the calf is obviously too large then it is an easy decision to make. The harder decision is determining if a large calf that seems just a few pounds too large to be birthed naturally should be pulled or if a C-section would be the best method. A good rule of thumb is that if you can easily pull both of the calf’s fetlocks a hand’s breadth (about 4 inches) outside of the vulva and the calf’s head is completely in the pelvic canal then the calf can usually be pulled. At this stage the calf shoulders should be entering the birth canal, indicating that the rest of the calf should follow reasonably well. Remember the calf’s hips are bigger than the shoulders so if you had to pull hard just to get the shoulders in the birth canal the hips will be even more difficult. For a backwards calf, exteriorization of the calf’s hocks would indicate that the calf’s hips are in the pelvic canal and the rest of the calf should likely follow. Another important indicator is the position of the calf’s front legs. When shoulders of a large calf enter the birth canal, the pressure on the legs and joints can cause the front legs to be crossed. This is not a perfect indicator but does suggest that the difficulty of the pull may be hard and a C-section may be necessary, particularly if the legs are crossed and they cannot be exteriorized at least four inches from the vulva with the head in the pelvic canal. Remember to assess the level of stress the calf is under. If the uterine fluid is yellow-tinged, the calf’s tongue is swollen, or the calf is meconium-stained, that means the calf is stressed and time is of the essence.

Pulling the calf

Pull in a downward arc towards the cow's hocks or the ground. Image credit: Andrew Kingsbury

A normal presentation, posture, and position include the calf being presented right-side up with the forelegs and head coming through the pelvic canal first. Image credit: Andrew Kingsbury

As you prepare to pull the calf, be careful when applying chains or straps so that you do not injure the calf when you are pulling. A long 60-inch chain and 2 short 30-inch chains will allow you to accomplish most manipulations and extractions. Pulling straps may be used instead of chains. Compared to chains, straps are often wider and have a larger surface area for the pressure to be applied. But they can be harder to clean and disinfect compared to chains, may not be as adaptable as chains, and may not last as long as chains. Ideally, the chains or straps should be applied with first loop above the fetlock and then a half hitch just above the hoof. This will spread the pressure applied to the calf’s leg by the force on the chain over a wider area, greatly decreasing the likelihood that the calf’s legs will be damaged by pulling.

Avoid attaching straps or chains to the calf’s legs with only one loop. A single loop above the fetlock joint applies all the pressure on the growth plate of the cannon bone (the long bone just above the fetlock) and can either crush the growth plate or separate (break) it. If a single loop is used above the hoof then the coronary band can be damaged (causing problems with hoof growth later on) or the hoof wall may be pulled off.  An exception to using a single loop to pull is when you are using the strap or chain to help correct a malpresentation such as pulling a retained leg up into the pelvic canal. In these cases, when the strap or chain is being used to manipulate a leg and not to pull the calf from the birth canal, it is fine to use a single loop.

Apply the chains with the first loop above the fetlock and then a half hitchabove the hoof. Regardless of whether the cow is standing or lying down, it is important to pull in an arc towards the cow's hocks. Image credit: Andrew Kingsbury

Keep in mind that the object is not to pull the calf as fast as you can, but to provide assistance to the cow as she labors to deliver the calf. During the normal birthing process, a cow will lie down and standup repeatedly. When assisting with a calving, be prepared to move with the cow and avoid keeping her in a set position. One purpose of allowing the cow to move around is to shift how the calf and uterus is positioned in the abdomen to allow for easier delivery. In addition to allowing the cow to move around during delivery whenever possible, it is also important to pull the calf only when the cow pushes and then relax when she does. When you provide hard steady traction throughout the process, you don’t allow the cow or the calf to rest. Pulling on the calf will stimulate the cow to push but she needs time for her muscles to relax and to catch her breath in between efforts. As long as the cow is not exhausted, she will be able to provide a significant portion of the force needed to expel the calf. Additionally, the calf needs a break, too. Constant pulling on the calf may prevent good circulation of blood. Once the calf’s thorax is exposed but the hips are still inside, many calves will try to breathe. If there is constant traction on the calf they may not be able to properly expand their chest to breath. Once the thorax is exposed but the hips are still in the birth canal, the umbilical cord is often pinched in the pelvis and cannot provide oxygen from circulating blood. Thus, calves that are not provided breaks to breathe may die from asphyxiation.

During hard pulls, it is particularly advisable to stop and rest at least 30 seconds at each interval to allow the cow and calf to recover. The first stopping interval should occur once the calf is situated normally in the pelvic canal just prior to the nose becoming visible. Allow at least 30 seconds for the calf to rest before resuming pulling. Prior to resuming pulling, make sure the vulva is completely relaxed and the vaginal vault is dilated before beginning to pull again. If there is sufficient room in the pelvis for the calf to be born but the vulva is not relaxed and/or the vaginal vault has not dilated, it can be manually dilated. Vulva and vaginal vault dilation can be stimulated by inserting both hands and/or arms into the vaginal vault along both sides of the calf, then pushing your hands/elbows out against the vaginal wall.

The second resting interval during hard pulls should occur when the calf’s head is completely out of the vulva. Providing a resting period at this point allows circulation to the calf’s brain to resume properly and may prevent the calf from becoming unconscious due to lack of oxygen. The third resting interval should occur after the shoulders have become exposed. At this point, the umbilical cord will begin to be pinched off and the calf needs a chance to begin to breathe. At this stage the calf’s hips are approaching the dam’s pelvis which is normally the most difficult passage. As you start the next pulling phase it can be very beneficial to rotate the calf 90° to allow the calf’s hips to better fit in the pelvic canal. This rotation can be accomplished by crossing the calf’s front legs as you pull. Once the calf’s hips have traversed the birth canal, the calf is essentially delivered.

Avoid placing the chain only above the fetlock (left) or hooves (right) as it can injure the joint. Image credit: Andrew Kingsbury

Using a Calf Puller

A mechanical calf puller or calf jack can be used to assist in pulling a calf if you are by yourself and need additional assistance for a moderate pull; or, in some cases, may be used for a very difficult pull. If used inappropriately, a mechanical calf pull can lead to a dead calf and/or an injured or crippled cow. In some cases, a calf puller may be able to forcibly extract the calf but the outcome would have been better if a cesarean section had been initiated instead. It has been determined that the maximum force to apply when pulling a calf is that of two strong men pulling by hand or about 500 lbs of force. However, a calf puller can apply several 1000 lbs of direct force and when used as a fulcrum that force is further multiplied.

Avoid pulling the calf in a horizontal direction. Image credit: Andrew Kingsbury

Do not begin to use the mechanical calf puller until the calf is in the proper presentation for delivery. Using a calf puller is similar to pulling by hand in that you do not want to pull at full force continuously. It’s important to use the calf puller to apply some additional force when the cow strains and then rest when she relaxes. Due to the amount of force applied by a calf puller, it is important that chains are applied with a loop above the fetlock and a second hitch below the fetlock as explained in the pulling the calf section. Since the force the calf puller applies is so high, make sure the cow’s cervix and vaginal vault is fully dilated and you are using plenty of lubrication to minimize damage to the cow. If you are not able to move the calf or other problems arise stop pulling and reassess the situation.

Vulva and vaginal vault dilation

Vulva and vaginal vault dilation can be stimulated by inserting both hands and/or arms into the vaginal vault along both sides of the calf, then pushing your hands/elbows out against the vaginal wall. Image credit: Grant Dewell

Once the chains are properly placed on the calf, place the calf puller strap over the top of the cow’s hips and base plate of the calf puller just below the cow’s vulva. Next, hook the calf chains to the puller. Once everything is set, take up any slack between the calf and the puller. While doing this, get a sense of the cow’s labor rhythm and be ready to apply pressure as needed when she pushes. There are two methods that can be used in assisting the cow when using a mechanical puller. One method keeps the calf puller is the same position perpendicular to cow’s hind end; when the cow pushes, the operator applies additional force by operating the ratchet mechanism of the puller. When the cow relaxes the operator stops ratcheting and holds the calf where it is. This can be successfully used- but in a hard pull the calf is always under constant force and may not be able to breathe properly. Just as a calf can’t breathe when its chest is compressed by the birth canal, it also can’t breathe properly if its legs are being stretched and its chest compressed and stretched. In these situations, you may need to stop occasionally and release the tension on the calf puller to allow the calf a chance to recover. This method works well for calf pullers that are designed with the rod having ratchet grooves in it and the mechanism walks the calf out by applying pressure on one leg at time.

Once the front legs and thorax are delivered, it can be very helpful to manually rotate the calf 90° to allow the calf's hips to better fit in the pelvic canal. Image credit: Andrew Kingsbury

Another pulling method when using a mechanical calf puller is to use the calf puller as a lever and the base plate (the metal part that goes under the cow’s vulva) as the fulcrum. When using this method, the pressure is just slightly relaxed when the cow is resting and the calf puller is held perpendicular to the cow’s hind end. When the cow begins to strain, the end of the calf puller is rotated towards the cow’s feet so that the calf is pulled in a downward arc. This can multiply the force so operators need to be careful of how much force they are applying. When the cow rests, the calf puller is returned to a perpendicular position and slack is taken up to allow both the dam and the calf to rest. This can let the calf recover and breathe a little as long as you don’t start stretch the calf back out. The arc method is believed to assist in pulling because it also mimics the arc the calf travels from the bottom of the cow’s abdomen and through the birth canal. Calf pullers that are designed with cable and come-a-long mechanism work well for this method. However, care must be taken as come-a-longs can apply excessive force by themselves without multiplying with a fulcrum. Ratcheted rod pullers can also be used in this manner but the rod may bend if you are not careful.

Positioning of calf puller

When the cow begins to strain, the end of the calf puller is rotated towards the cow's feet so that the calf is pulled in a downward arc (right picture). When the cow rests, the calf puller is returned to a perpendicular position and slack is taken up to allow both the dam and the calf to rest (left picture). Image credit: Andrew Kingsbury

With either method, it can be advantageous to rotate the calf 90° as the hips come into the birthing canal as described in the pulling the calf section. Pay careful attention to the calf and provide rest breaks for the calf during the pulling process. Pulling a calf is not a race and you should make it a point to consider the health of the calf throughout the process. If progress is not easy, seek professional help quickly. However, remember that once you start pulling with a calf puller there is probably no going back and trying a cesarean section. A calf puller is going to very rapidly pull the calf past where it is possible to get it back in the uterus. A calf that gets hung up in the birth canal when using a calf puller will probably need to be euthanized and then a fetotomy performed to remove the calf in pieces.

When to Call for Help

When providing calving assistance it is important that a difficult situation is not made worse. The goals of a cow-calf producer are to have calves to sell at the end of the year and a pregnant cow. Hard pulls when trying to assist the birthing process can put both of those goals in jeopardy. Some cattle producers may be concerned that the cost for veterinary assistance may not be worth it. However, a dead calf has zero value and if a young heifer does not breed back the cost to the operation far eclipses veterinary expenses for calving assistance. For veterinary assistance to have a chance to be beneficial the veterinarian needs to be called early enough in the process to be able to deliver a healthy calf and maintain the health of the mother. If the veterinarian isn’t called until the calf is already stressed or the cow injured then there is little opportunity for a positive outcome.

Knowing when to call a veterinarian is key to having a viable calf and cow following a difficult calving. When dealing with large calves, the decision to pull the calf or elect for a cesarean section should be done with careful consideration early on. The difficulty is that the calf’s hips are the most likely anatomical part to become hung up during the pulling process. However, the calf will be 2/3 to 3/4 delivered when the calf’s hips enter the birth canal. At that point it is impossible to decide that the calf is too large to be delivered through the birth canal and then try a push it back into the uterus and perform a c-section. If the calf does become hip-locked the odds that the calf will be die and cow be injured goes up substantially. The guidelines described in the pulling the calf section regarding easily exteriorizing both fetlocks a handbreath while the calf’s head is in the birth canal is the first step to determining if the calf should be pulled or a c-section considered instead. Anytime your ability to pull the calf abruptly becomes more difficult, you need to reassess if the calf can be pulled instead of just trying to pull through the difficulty. Once you begin pulling, routinely check for room in birth canal. One rule of thumb is that if you cannot get your hand between the calf and pelvic canal, then there is no more room left for the calf and a c-section may be necessary. If pulling is difficult but there is room in the pelvic canal then the problem could be that soft tissue around the vulva needs to relax more which can be facilitated by stretching the vulva manually and using plenty of lubrication. If the vulva is relaxed and there is room in the pelvis but pulling is difficult, then that may indicate a malformation or other problem that will require veterinary assistance.

If the size of the calf is not the problem but some form of malpresentation is causing the dystocia, then the art of calf delivery comes into play. Many malpresentations can be easily corrected and delivery accomplished swiftly. However, if you are not comfortable with the situation or are unfamiliar with how to correct the malpresentation then veterinary assistance should be sought quickly. Another important rule of thumb to use is if you have been working for 15-30 minutes and have not corrected the malpresentation and/or are not making significant progress in delivering the calf, then veterinary assistance should be pursued.

Common Dystocia Problems

When trying to correct an abnormal presentation, position, or posture it is important to work carefully and quickly, and use sufficient lubrication. During prolonged dystocias, most of the amniotic fluid that normally provides sufficient lubrication has already been expelled and the uterus will have contracted down around the fetus making repulsion and manipulation difficult. Without additional lubrication the uterus can be torn during the process which can lead to death from peritonitis. If you have identified a malposition early on in the birthing process there will still be fluid in the uterus and room to manipulate.

If you are able to successfully correct a dystocia and are ready to pull, be sure to check whether the calf is likely to be successfully pulled. Recall that a good rule of thumb is that if you can easily pull both of the calf’s fetlocks a hand’s breadth (about 4 inches) outside of the vulva and the calf’s head is completely in the pelvic canal, then the calf can usually be pulled. Remember to seek veterinary assistance if you do not know how to correct the problem, cannot correct the problem, or it is taking you longer than 30 minutes to correct the problem.

An elbow lock occurs when the forearm or elbow is locked against the brim of the pelvis and the presence of the shoulders in the pelvic opening prevents the leg from being advanced. Image credit: Andrew Kingsbury

An elbow lock of one or both front limbs is fairly common and easily corrected. The problem is identified by the foot being back by the calf’s nose instead of the fetlock extended out past the calf’s nose. In some circumstances, traction alone on the leg can correct the problem. However, a true elbow lock has the forearm or elbow locked against the brim of the pelvis and the presence of the shoulders in the pelvic opening prevents the leg from being advanced. In order to correct an elbow lock, repulse (push back) the calf back into the birth canal by pushing on the shoulders or head while applying traction on the limb until the elbow can clear the brim of the pelvis and be fully extended. Once both front feet are presented, be sure to assess the likelihood that you can continue to pull the calf out.

Lateral Deviation of the Head

Lateral deviation

Lateral (sideways) deviation of the head. Image credit: Andrew Kingsbury

Another common cause of dystocia is a lateral (sideways) deviation of the head. Some may mistake this for a backward calf initially since the head cannot be easily felt. However, both front legs should be presented normally but the calf’s head is turned back along its chest. This malposition can be corrected as long as there is enough room in the uterus to bend the head back around to face the birth canal. Before spending a lot of time and effort correcting this malposition, try to estimate if the calf can really be delivered vaginally or if a C-section is necessary. One reason for the calf’s head to be deviated to the side is that there was not enough room in the pelvis for both legs and the calf’s head. During labor the calf’s head may eventually go to the side if it won’t fit in the pelvis. If the calf’s feet are big (indicating large calf size), or the legs cannot be easily pulled a hand’s breadth from the vulva, or the cow’s pelvis is small, then correction of malposition may not allow for vaginal delivery. Additionally, make sure the calf is alive since live calves will often try to keep their head positioned on top of legs during calving.

Place the loop of the chain or strap around the calf's poll and then through the calf's mouth with the standing end of the rope or chain down at the calf's mouth. Once the loop is in position around the calf's head, repulse the calf by pushing on the calf’s chest while applying traction to pull the head around muzzle, then try grasping the top of the head to pull it around. Image credit: Andrew Kingsbury

When correcting a lateral head deviation, if you cannot get under the head to grasp the chin or muzzle, then try grasping the top of the head to pull it around. Image credit: Andrew Kingsbury

To correct a lateral head deviation, come under the calf's jaw with your hand and raise the head slightly while turning the head. Image credit: Andrew Kingsbury

If it appears that calf will fit through the pelvis then the abnormal posture can be corrected and the calf pulled out. You may need to repulse (push back) the calf in order to reach the calf’s head. Ideally if you can come under the calf’s jaw with your hand, you can raise the head slightly while turning the head. Grasp either the calf’s jaw or muzzle and gently swing the calf’s head around so that it presents in the birth canal. In some cases, it may work better to grasp the top of the calf’s head/muzzle.

Ventral Deviation of the Head

This image shows a ventral (downward) deviation of the calf's head. Many calves that present this way are not likely to result in a live delivery. Image credit: Andrew Kingsbury

A ventral (downward) deviation of the head presents similarly to a lateral deviation except that the calf’s head has fallen between its front legs. To correct this abnormal posture the calf will need to be repulsed and the head raised to a normal presentation using techniques just described above for lateral deviations of the head. It is important to determine the viability of the calf before trying to correct the problem. Many calves that are presented with a ventral deviation of the head are already dead. Most live calves will keep their heads on top of their forelegs as they entering the pelvic canal. Once the forelegs are pushed together in the pelvis, it is difficult for the head to fall down between the legs. If the calf is dead, a partial fetotomy may be the best solution.

Retention of One or Both Forelimbs

To manipulate a leg up into the birth canal, you may need to maneuver the leg with one hand while pulling the chain/strap with the other. Image credit: Andrew Kingsbury

A chain or strap may be applied to a retained forelimb to manipulate it to the birth canal. Image credit: Andrew Kingsbury

Overhead view of retention of both forelimbs. Image credit: Andrew Kingsbury

Retention of one forelimb. Image credit: Andrew Kingsbury

Retention of one or both forelimbs occurs when the head is presented for delivery but one or both forelimbs are retained outside of the birth canal. It is normally easily corrected as long as the uterus has not contracted down to where the calf cannot be repulsed. The first step after determining that the calf is viable is to put a chain around the calf’s poll and through the calf’s mouth and also but a chain on the extended leg if only one leg is back. When you repulse the calf to get the retained leg/legs up you don’t want to lose what you already have. Once a long chain is securely in place and with ample lubrication push the head back into the uterus to give you room to work. In many cases the carpus (knee) is just below the brim of the pelvis. Grasp the carpus and bring up to pelvic canal, then feel down the leg to the foot. Cup the hoof in your hand so it doesn’t tear the uterus. If the calf was able to be repulsed to create room the foot can be lifted up as you rotate the entire leg back. If the cow is straining or uterus is tight push the calf’s carpus back with one hand as you lift up the hoof up with the other.

Posterior Presentation

Posterior presentation

A normal backward presentation has both hind legs presented with the tail down over/between the legs. A backwards presentation is normally recognized because the bottom of the calf's hoof (sole) is facing up. Image credit: Andrew Kingsbury

A backwards calf is not necessarily considered an abnormal presentation but can be a cause of dystocia where assistance is required. A normal backward presentation has both hind legs presented with the tail down over/between the legs. A backwards presentation is normally recognized because the bottom of the calf’s hoof (sole) is facing up. When evaluating the calf, confirm that the calf is backwards instead of an upside down calf by differentiating between front leg or back leg. To do this, feel the joints of the leg to identify which way they bend. The fetlock and knee of the front leg bend in the same direction. The fetlock and hock of the back leg bend in the opposite directions. Once you have determined that it is indeed a backward calf, make sure the tail is in position and not bent over the back of the calf. The reason that backwards calves require more assistance than forward-facing calves is that the largest part of the calf (hips) is coming first. To assist delivery of the hips, you may need to rotate the calf to get the hips to slide into the birth canal. Additionally, the soft tissue structures may not have fully dilated so spend a little time manually dilating the vulva to encourage relaxation. The final difficulty with backwards calves is that the umbilical cord will be constricted or torn before the calf’s head is exteriorized to allow breathing. Therefore, once you start pulling a backwards calf you must move fairly rapidly so that the calf can breathe. When using mechanical pulling devices, come along type calf pullers are usually better for backwards calves than ratcheted pole pullers that walk the calf out slowly. When applying chains/straps to hind feet, be sure to use a loop above the fetlock and a half-hitch above the coronary band.

Breech Presentation

Breech presentation

Take the end of your long chain around the hock and make a loop by passing one end through the other and tighten until it is a loose loop around the leg. Now slide the chain down until it slips over the fetlock and tighten your loop with the chain coming over the front of the leg and passing between the claws. This way when you pull on the chain, it will curl the foot up so you are less likely to tear the uterus. Once the chain is in place, use one arm to repel the calf and rotate the leg by pushing forward on the calf’s hock while applying traction to the foot with your chain. Image credit: Andrew Kingsbury

A breech calf occurs when the calf is presented backwards with both hind limbs retained. Image credit: Andrew Kingsbury

A breech is an abnormal backwards presentation where both hind limbs are retained. Breech presentations are often missed because the cow does not move fully into stage 2 labor since the calf cannot enter the birth canal. For most people, a long chain is useful to help position the hind legs properly.

The first step is to reach up along one side of the calf and grasp the leg at the hock. Pull the hock up so that it is resting on the brim of the pelvis. It may be necessary to repulse the calf in order to move the hock up. Once the hock is in the pelvic canal it should stay there and keep the body of the calf pushed forward.

Next take the end of your long chain around the hock and make a loop by passing one end through the other and tighten until it is a loose loop around the leg. Now slide the chain down until it slips over the fetlock, tighten your loop with the chain coming over the front of the leg and passing between the claws. This way, when you pull on the chain it will curl the foot up so you are less likely to tear the uterus.

Once the chain is in place use one arm to repel the calf and rotate the leg by pushing forward on the calf’s hock while applying traction to the foot with your chain. Go slow and use care so that the hoof does not tear the uterus just below the brim of the pelvis, it is sometimes possible if the cow is not straining hard to cup the hoof with the hand you were pushing with to protect the uterus. Once one leg is positioned properly the second leg can be retracted in a similar manner. Once the breech is corrected, reposition the chains so that you have a loop above and below the fetlock and pull the calf as directed previously for a backwards calf.

Upside-Down Position

Upside-down position

Upside-down calf. Image credit: Andrew Kingsbury

An upside-down calf needs to be turned right side up before the calf is pulled to avoid injuring the calf. The arc of the pelvic canal can severely damage the calf’s spine if you try to pull it upside down. The calf will need to be repulsed enough for room to pull the calf. Before repulsing the calf put chains on both legs. After repulsing the calf cross the chains/legs so that as you pull it will naturally rotate calf to an upwards position. You can assist the rotation by reaching in with one arm along the side of the calf to help it turn.

Transverse Presentation

Transverse presentation

Overhead view of a transverse presentation with four legs being presented first. Image credit: Andrew Kingsbury

Overhead view of a transverse presentation with the back being presented first. Image credit: Andrew Kingsbury

All four legs being presented at once. Image credit: Andrew Kingsbury

Transverse presentations are rare. The calf may present on its side with all four feet in the pelvic opening or with its back to the pelvic opening. If all four feet are being presented, identify the 2 hind legs, apply chains and then repulse the front of the calf enough while pulling the hind legs to turn the calf. Pulling it backwards is easier than trying to get both front legs and the head to come at the same time. Transverse presentations where the back is presented first are extremely difficult to correct and a C-section may be necessary.

Many times twins can be born on their own since they are usually smaller than single calves. However, if both calves present at the same time they will block the birth canal. Usually, when this happens one calf is being presented in a normal anterior presentation while the other calf is backwards. Identify which legs go together and repulse the calf that is easiest to push back out of the way and then pull the other calf.

Uterine Torsion

A uterine torsion is a calving abnormality that often results in a dead calf on beef cattle farms. A cow’s uterus is relatively unstable compared to many other species, allowing it to rotate. Either movement of the calf or motion of the cow when lying or standing up can flip the uterus 90 degrees or more. This rotation will cause a twist in the uterine body in front of the cervix and prevent the calf from entering the birth canal. Prior to calving, a uterine torsion is not detrimental as the blood supply to the calf is usually not affected. However, once parturition begins the cow will not normally move into stage 2 labor because the fetus is not able to pass into the cervix and birth canal to stimulate stage 2 labor. Cows with a uterine torsion are often missed since the cow never reaches stage 2 labor. Typically, a history of “it looked like she was going to calve yesterday or the day before” is common with a uterine torsion. During stage 1, the cow may appear restless and isolate herself from the herd, but after 6-12 hours (and not moving into stage 2 labor) she will often rejoin the herd and appear normal. After 24-48 hours, the placenta will have separated from the uterine wall after the calf died and may be visible. A uterine torsion is diagnosed by feeling the spiral rotation of the uterus through a vaginal exam.

In most cases a uterine torsion can be corrected with veterinary intervention. In rare cases, a C-section is needed if the uterus torsion cannot be manually corrected. However, C-sections on dead calves are not optimal as the cow’s abdomen can be contaminated with decomposing or infected fetal fluids and result in peritonitis.

Iowa Beef Center, 313 Kildee Hall, 806 Stange Rd., Iowa State University Ames, IA 50011-1178 Phone: 515-294-BEEF (2333), Fax: 515-294-3795, [email protected] .

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INTRODUCTION

This topic will provide an overview of major issues related to breech presentation, including choosing the best route for delivery. Techniques for breech delivery, with a focus on the technique for vaginal breech delivery, are discussed separately. (See "Delivery of the singleton fetus in breech presentation" .)

TYPES OF BREECH PRESENTATION

● Frank breech – Both hips are flexed and both knees are extended so that the feet are adjacent to the head ( figure 1 ); accounts for 50 to 70 percent of breech fetuses at term.

● Complete breech – Both hips and both knees are flexed ( figure 2 ); accounts for 5 to 10 percent of breech fetuses at term.

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Calving: Delivering Backward Calves

by Heather Smith Thomas of Salmon, ID

Most calves are born head first, front feet extended. But a few are positioned backward (posterior presentation) and may not survive the birth process unless you are there to help. The number of backward calves in a herd during a calving season can vary from year to year, and all the factors influencing this presentation are not yet fully understood. While the fetus is growing in the uterus it is quite active and can change positions, especially while still relatively small. The position of a fetus when a cow is pregnancy-checked is not necessarily the position it will be in at the end of gestation when the birth process begins.

For instance, one fall (after a calving season with 5 backward deliveries in our herd of 170 cows), we asked our vet (Dr. Robert Cope) to check which way each calf was lying when he preg-tested the cows. He said at that stage of pregnancy (5 to 6 months) many calves are positioned backward, but shift to proper position before birth. We took note of the dozen that were backward at that time. Indeed, none of those calves were born backward, but three others were (calves that were not backward during the pregnancy test).

A number of factors may influence whether a calf ends up in a posterior or anterior (frontward) presentation at birth, but the most influential factor is heredity, according to Dr. Duane Mickelsen (bovine reproductive specialist at Washington State University, Pullman, Washington). He cites the work of an English veterinarian, Dr. G.H. Arthur, who found that almost all fetuses are carried backward and upside down during the first 6 to 6.5 months’ gestation and then rotate to anterior position, with only 5 percent or less remaining in posterior position. But this average 5 percent figure may increase when certain bulls are used.

Dr. Mickelsen says several ranchers he’s worked with have had much higher instances of backward calves some years, and began to suspect the sires had something to do with it. Certain bulls sired more backward-birth calves. When those sires were no longer used, incidences of backward births dropped back to more normal numbers.

More studies need to be done to confirm this but Dr. Mickelsen has heard and read of many similar situations – enough to suspect that heredity plays a major role. It may be that calves sired by some bulls grow too large by that stage of gestation when the fetus is rotating. If the calf doesn’t change to frontward position by the time he’s 6 to 6.5 months along, he gets too big and can’t turn over in the uterus. Dr. Mickelsen says size in itself does not mean a calf will be backward, since many huge calves are properly positioned, but there may be a correlation between fetal growth stages (which might be influenced by heredity) and whether the fetus shifts its position by the time it is 6 to 6.5 months along. He says, “If a rancher has a sudden increase in backward calves over what has been the usual herd average, suspect heredity. Take a look at the bull being used.” The incidence will usually drop again if the rancher changes bulls.

Dealing With Backward Births – Years ago our veterinarian told us a person is lucky to save one out of 10 backward calves. This is true when cows are not being checked frequently. But with closer observation – and assistance given at the proper time – you can beat those odds. In the 1960’s when our cows calved on pasture in late spring, we averaged a 4 percent birth loss. We’d find the newborn calf dead, and never know exactly what happened. But since 1969 we’ve been calving in winter, putting cows into pens or barns to calve, and we are there for every birth. As a result, our birth losses dropped dramatically, to less than 1 percent per year, with most years no birth losses at all.

During the past 38 years we’ve had a total of 56 backward and breech calves, an average of less than 2 per year (we usually have at least one, and some years as many as 5). We’ve lost only 4 of them. One died because we didn’t check inside the cow soon enough; the calf was breech (no legs entering the birth canal, presented rump first) so the cow was not straining yet. But the placenta was already detached and the calf was dead. The other three losses occurred during the birth process – big calves that were too difficult to deliver fast enough or were fatally injured during the delivery (broken rib punctured the lungs). But most posterior or breech presentations can be safely delivered.

A backward birth is an emergency. If hind legs don’t enter the birth canal or if the calf is in breech position (rump first, legs forward in sitting position), the calf cannot be born. The legs must be brought into the birth canal before the birth can continue. Even if the legs do enter the canal, birth is generally so slow and difficult the calf suffocates when the umbilical cord breaks or pinches off, since head and shoulders are still inside the cow. If a posterior or breech presentation is recognized early, however, there’s a better chance for saving the calf – by helping the cow and speeding the birth process, pulling the calf.

The backward calf is at a disadvantage; it’s not streamlined for coming through the birth canal in that direction. The hips are difficult to pass through the cow’s pelvis, and the ribcage tends to catch on the way through. Even the lay of the hair is wrong for streamlined movement through the narrow opening.

The umbilical cord may be pinched off or broken during birth, making it urgent the calf be delivered immediately. Occasionally the cord may be caught over a hind leg – stretched and broken before the calf is halfway out. This occurs if a hind leg passes under the cord as the legs straighten and enter the birth canal.

During early labor the calf moves a lot, and if he extends his hind legs and they enter the birth canal, he can usually be born successfully with human assistance. But he will need help. In all the backward calves we’ve had, there was only one born alive without being pulled. It was a small, streamlined calf (out of a roomy cow and by a bull that sired small calves). My husband and I arrived on the scene as the cow was laboring, with the calf halfway out as we approached.

We immediately saw the calf was backward, and rushed to grab onto it. But our running up to her startled the cow and she jumped to her feet, and the calf fell on out as she got up. The calf had been moving fairly well through the birth canal and he had not yet suffocated. Perhaps her jumping up was fortunate. If she had lain there for a few more minutes, he would have suffocated.

But most backward calves do not survive birth unless you pull them out and hasten the process. And if a calf doesn’t get its legs extended to enter the birth canal, it cannot be born at all, until you bring those hind legs into the canal. If this proves impossible, the calf will have to be delivered by C-section.

If the calf is breech (legs not entering birth canal), the cow is a long time in early labor and may not start straining at all. Abdominal contractions (second stage labor) do not begin until some part of the calf enters the birth canal, stimulating her to strain. If she does start to strain on a breech calf, she is jamming hocks or hips into the birth canal, but he can’t come through.

If a cow is in early labor a long time or doesn’t progress to hard straining when you think she should, check her. Usually a delay means the calf is positioned wrong and cannot come through the birth canal. The problem must be corrected before the cow is in labor too long and the calf dead. If help is given soon enough, legs can be brought into the birth canal and a live calf delivered.

If it is a “normal” posterior presentation (legs entering the birth canal) the feet often protrude from the vulva and you can tell they are hind feet; heels and dewclaws are up rather than down. Bottoms of the hoofs are pointing up. But before you assume the calf is backward, check. Occasionally a frontward calf will be upside down or sideways with legs twisted— when feet first appear they are pointed upward. Always be sure which part of the calf is presented before you start to pull. If they are front feet instead of hinds, be sure the head is there and not turned back, and rotate the calf into more proper position before you assist the birth. Don’t just assume the calf is backward and start pulling.

When helping a backward calf, go gently until his hips are free and ribcage safely through the cow’s pelvis. Once hips are clear of the vulva, hurry him on out. If you rush at first, you may injure the cow and kill the calf. It’s not uncommon for a calf’s ribcage to be crushed if you pull too forcefully too soon.

If the calf is large, you can’t deliver him fast enough without a mechanical calf puller or the help of several people. A puller can put a lot of traction on a calf, and care must be taken not to pull too fast, especially at first when you are easing the hips through. When using a puller with a winch/cable, stop for a moment and reposition the chains (from the lower legs, to above the calf’s hocks) after the hocks appear. This will give you more room (more length of cable) to winch. If the calf is long-legged, you may run out of cable about the time you need to be pulling fastest. There’s nothing more frustrating than getting a big calf almost out, then losing him because you run out of puller cable and don’t have the strength to get him on out by hand. To pull large backward calves, routinely switch your chains from above the ankle joints to above the hocks, to give yourself more leeway.

In breech presentation where you must bring the legs into the birth canal, it’s easier to manipulate the legs if the cow is standing rather than lying; you can more easily get both arms into the birth canal. The calf must be pushed back into the uterus as far as possible. Hold him forward with one hand and grasp a leg with the other, bending the hock and lifting it upward, rotating it as you lift. Draw the foot backward in an arc, keeping hock joint flexed tightly and calf pushed as far forward as possible. Lift the foot over the cow’s pelvis and cup your hand around it so it won’t tear the uterus. Do the same with the other leg. Once both are in the birth canal, you can attach chains and pull the calf.

After the calf is out, get the fluid out of his air passages and start him breathing. He may be alive but still in danger because air passages are full of fluid and he’s short of oxygen from extended time in the birth canal or because the umbilical cord pinched off or broke early in the delivery.

Some backward calves will seem dead at birth, limp and blue, eyes glassy. But a quick feel of the chest (behind the front leg, left side) will reveal a heartbeat. These calves can be saved if air passages can be cleared quickly and you can get them breathing. Stimulate him to cough by sticking a clean piece of straw up one nostril. If he’s unconscious and blue and won’t cough, close his mouth and cover one nostril with your hand, and blow gently into the other. Giving a calf artificial respiration can keep him alive and put enough oxygen into his system to revive him. We’ve saved several calves this way that seemed dead at birth and would not start breathing. Blow in a full breath (until you see the chest rise) then let the air come back out on its own. Keep breathing for the calf until he is able to begin breathing for himself.

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Calving Assistance Guidelines

Determining if the cow/heifer needs your help.

Four decisions dramatically affect the outcome of delivery. They are:

• Frequency of observation - Recommended frequency of observation is every 1-2 hours. The ability to perform this is based on staffing at your dairy. Once a cow/heifer in stage 2 of labor the frequency of observation should increase to every 30 minutes. It is important to see if the dam is making progress in that time or not.
• Knowing when to intervene - To make decisions about when to intervene it is important to know the normal range of time it takes for each stage of labor. All personnel should know the guidelines for intervention and understand why those guidelines are in place.

The guidelines below are based on the stage of labor.

• Stage 1 - Usually lasts 2-6 hours If you do not notice any progression to stage 2 after 4 hours the cow/heifer should be examined to determine if there is a problem. Low blood calcium (milk fever), uterine torsion, or a calf in breech presentation can prevent the cow from going into Stage 2 of labor.
• If the water sac has been visible for 2 hours and you have not seen any progression (the cow is not trying).
• If the cow has been trying for over 30 minutes and making no progress.
• If the cow has quit trying for more than a 15-20 minute period of time after a period of progress. Rest periods normally should not last longer than 5-10 minutes.
• If the cow or calf is showing signs of stress or fatigue -- like a swollen tongue in the calf, yellow staining (meconium) of the fetus, or severe bleeding from the rectum of the cow.
• If you suspect that the calf is in an abnormal presentation, position, or posture.
• Stage 3 - If the fetal membranes have not been passed within 12 hours after calving, intervention may be necessary. If they are retained, treatment may be indicated. In no instance should the membranes be manually removed. This may be detrimental to the cow's future reproductive performance. It may be beneficial to cut the membranes close to the vulva in order to decrease the opportunity for contaminants (dirt, bacteria) to obtain entrance into the reproductive tract of the cow. Be sure to consult with your veterinarian about proper treatment of retained fetal membranes in your dairy cows. It is important to realize that early intervention provides the greatest benefit for calf survivability and future reproductive performance of the cow.

3. Determine if the calf can be delivered by forced extraction (pulling). Once you have decided to intervene you should palpate the calf and the birth canal: 1) to determine if the calf is alive or not and 2) to see if it can be delivered through the birth canal of the cow.

• If the birth canal is abnormal it is time to call for professional help.
• If the cervix is not fully dilated the cow should be given more time for dilation or checked for other signs of milk fever.
• If the calf's head is too large to fit through the birth canal forced extraction should not be performed.
• Studies have shown that calves delivered by c-section after forced extraction has failed have a decreased chance of survival compared to calves delivered by c-section alone. Therefore the decision to perform a c-section should be made a early as possible and the decision to pull the calf should be based on a realistic assessment of the likelihood of success.
• If the decision is made to pull the calf, you should know when to keep pulling and when to quit.
• Be sure to always correct any malpositions prior to forced extraction.
• For a forwards (anterior) presented calf, the head and shoulders must be able to pass the pelvic canal or the calf cannot be delivered. The shoulders of the calf are through the pelvis of the cow when the knees (carpi) of the calf are at the vulva. If you cannot get both knees to the vulva, the calf cannot be pulled without damage to the calf or cow.
• For a backwards (posterior) calf, if the hocks are one hand width beyond (outside) the vulva, the hips should be through the birth canal and you should be able to deliver the calf.

4. When to call for professional assistance. Professional assistance may not always mean a veterinarian, it may just be someone with more experience then yourself. Call for assistance if:

• You cannot assess the problem.
• You know what you are dealing with but you do not know how to correct it.
• You have been trying to correct the problem for 30 minutes and have not made any progress

Special Care for the Dystocia Calf

• Calving difficulty, sometimes called dystocia, affects between 13 to 15% of Holstein calves.
• 48-hour survival rates drop drastically for calves when deliveries require 2 or more persons, mechanical or surgical intervention compared to unassisted births.
• 120-day survival rates for calves when deliveries require 2 or more persons, mechanical or surgical intervention are 70 % less than unassisted births.
• Treatment rates are higher for dystocia calves (scours 17%, pneumonia 70%) compared to calves experiencing unassisted births.
• Providing special care, both in the first few hours and first two weeks, can cut both death losses and treatments for scours and/or pneumonia.

Lots of stimulation during first few hours. When these calves hit the ground they typically are "out of it." Compared to calves with unassisted deliveries, usually they are

• less alert,
• slower to lift their head and roll onto their belly,
• longer to attempt to stand,
• slower heart beat,
• sub-normal body temperature,
• erratic breathing and
• less responsive to stimulation (for example, tweaking nose with a piece of straw to encourage breathing).

Actions for the first 15 to 30 minutes?

Using a large cloth (for example a bath-size towel) rub the calf. Keep at it. Use more than one towel. Get the calf hair coat "fluff-dry." Work at getting a strong breathing pattern. Experience suggests that lots of attention to the neck and shoulders helps. The name of the game here is stimulation – as intense as you can manage and be persistent. Increase the oxygen: carbon dioxide exchange rate – regular breathing is our goal to overcome oxygen deprivation. Normal heart rate should be in the range of 100 to 150 beats per minute.

If oxygen is available start supplementation as soon as the calf is on the ground. Welding grade oxygen will work if medical-grade is not available. Start oxygen flowing through a small plastic tube. Adjust the flow to get a gentle flow on your cheek. If you do not have a mask slip the tube up into the calf's nose roughly the width of your hand. If you can tape the tube in place fine. At least keep oxygen flowing until the calf is too active to keep the tube in place.

Feeding colostrum?

It is fairly common for calves with unassisted deliveries to nurse within one to two hours. Unless there is a lot of swelling in the tongue and mouth that clearly prevents nursing and you cannot feel any suckling response within two hours, work at getting the dystocia calf to drink from a nursing bottle.

If necessary, come back several times in the first three to four hours. Compared to feeding with an esophageal tube feeder using a nursing bottle provides a good opportunity to persistently stimulate the calf. Use this opportunity to do more rubbing with a towel. Try to get the calf to stand.

Follow up for the next two weeks

• Be sure the persons giving calf care know which calves had hard deliveries.
• Encourage identification of dystocia calves. Mark the pen or hutch – use duct tape, colored clothes pins, or shower curtain rings. Mark the calf as soon as she is dry – keep an all-weather livestock marker (for example, Twist-Stik, LA-CO Markal) right in the calving area.
• Routinely plan to give extra attention to these flagged calves. In individual pens watch to see how quickly she gets up and moves at feeding time. Look for abnormally loose manure. At feeding time keep track of whether or not she drinks all her milk. Is she slower than usual in drinking today? Any cloudy or discolored nasal discharge? In group pens have a checklist to be sure every flagged calf is observed carefully at least four times a day. Look for signs of scours – wet soiled tail, slowness in getting up and moving around that might be a sign of dehydration. Look for signs of a respiratory infection – shallow breathing, more rapid that normal breathing rate, abnormal discharge from her nose – amount and color.
• Timely treatment is essential for successful therapy. Work with the herd veterinarian to establish the appropriate antibiotic therapy for these "high-risk" calves. Agree on the drug, dose, duration and route of administration. Write this down. Train every calf care person to achieve timely and consistent treatment.

Assisted-Birth Calf Care Checklist

Have you selected the appropriate procedures? Do they provide the opportunity for your employees to work to their full potential in providing quality calf care at assisted-birth calvings?

Let's consider your procedures for calf care at calving time. Compare your actions with the standards in this checklist. When making this evaluation I like to use these scores:

1=never, 2=seldom, 3=often, 4=usually, and 5=almost always.

Sam Leadley, Calf & Heifer Sam Leadley, Calf & Heifer Management Specialist [email protected], www.atticacows.com, Attica Vet. Assoc. 2011 All Rights Reserved.

Calf Blankets

All of us have heard of calf blankets. Many of us have seen them in use but only a few of us have actually used them. What are they and what are the pros and cons of their use?

What are calf blankets?

They are calf-size coats. Often they fasten in place with straps and/or ties. Velcro is a popular fastener. They are made of insulating-type fabrics such as wool, polyester blends and insulating foams. Producers prefer those that are machine washable. Costs seem to range from about $22 to $40 each.

Why would a calf need a coat or blanket?

The obvious answer is to keep warm in cold weather. But, what's "cold" to a newborn calf? There is a temperature range where the amount of body heat produced by a calf is balanced by her body heat losses. That range is called "thermoneutral." For an eighty-five pound newborn calf this range is about 55 to 78 degrees (assuming she is dry and in a draft-free environment). As temperatures fall below 55 for an extended period of time she has to burn extra energy to maintain her body core temperature.

Ways heat escapes from a calf?

Now, let’s do a quick review of four ways heat escapes from a calf no matter what the weather. Evaporation. Heat from her body is used to evaporate water primarily on her skin and hair coat. This is easy to solve at birth. After her dam licks her off, just finish the drying and fluff up her coat. For more information on drying calves see www.atticacows.com, click on Calving Ease and select the section "Calving Ease Back Issues: 2009-2010." Scroll down to the March 2010 issue, "Drying Off a Calf." Calf Blankets How well does her housing during the first month provide a dry place to keep out of rain and snow? A water repellent blanket can keep her dryer.

Conduction is another way heat moves away from a calf. Most calves less than a week old spend ninety percent of their time lying down. But, on what kind of bedding are they lying? Dry wood shavings? Dry straw? Wet bedding? Direct contact with wet straw results in three times as much heat loss (conduction) as contact with dry wood shavings. A moisture repellent blanket can slow down conduction heat losses through damp bedding.

Radiation losses occur when heat is transferred through the air from a warm object (calf) to a cold one (concrete, snow). These losses are reduced for calves if they can lie down some distance away from the cold object. A blanket can serve as an insulating barrier to reduce heat moving away from the calf’s body.

Convection losses occur when air passes over the calf's body. On one hand, when the housing is draft-free and a calf can snuggle down into a bed of straw, these losses are minimal. On the other hand, when the bedding does not allow any hollowed out nest and the pen is wide open for air movement (as in most greenhouse-like structures or pole barns), convection losses can be higher. A blanket can serve to minimize heat loss by radiation that is subsequently carried away by convection.

So, how do blankets fit?

First, the smaller the calf the greater the potential for her to lose body heat. That’s because her ratio of surface to body mass is much greater than for even a 130 pound heifer. These small calves may be the youngest ones or calves with especially low birth weights like twins. Rather than just depending on extra bedding (I always bedding these little girls with an extra flake or two of straw), blankets can used. Second, the greater the air movement around the calves, the greater potential benefits of calf blankets. Housing that does not allow calves to seek out a draft-free environment may have considerable potential for calf blankets (for example, open pens in a barn). This is especially true for very small and the young calves. Third, the greater the difference between the calf’s body temperature and the air around her, the greater the potential for benefits from using calf blankets. In very cold weather, North Dakota State University researchers demonstrated an increase of 0.2 pounds average daily gain (1.2# without blankets and 1.4# with blankets from birth to four weeks) using blankets in hutch-housed calves.

Management Tips

Blankets are more effective when put on dry calves rather than wet ones. Aim for a “fluff-dry” hair coat to take maximum advantage of blankets. The drier and cleaner the blanket, the better it will insulate a calf. Aim for bedding that keeps blankets relatively clean and dry. Blankets are most cost effective for short-term use. With a limited number of blankets, give priority in cold weather to blanketing smaller and younger calves.

Commercial Sources of Calf Blankets Select Sires is the U.S.A. distributor for Woolover brand blankets. Check your local yellow pages for Insemination Services – Artificial. Marting Manufacturing produces the "Cafghan" blanket. (Fax 641-843-4432 or 800-392-5632). Breslin Canvas Works in Cannon Falls MI makes a blanket with a nylon outer shell and thinsulate lining (Fax 507-263-3065, [email protected])

240 Farrier Road Ithaca, NY 14853

Phone: (607) 253-3900 Fax: (607) 253-3943 Email: [email protected]

Business Hours Monday-Friday: 8 a.m.-5 p.m. Saturday (limited service): 9 a.m.-1 p.m.

Calving Part 2 - Calving Problems (Dystocia)

Incomplete cervical dilation.

Incomplete cervical dilation occurs very occasionally in heifers but the true incidence is difficult to determine because in most situations the onset of first stage labour has not been noted.

It is probable that some dystocia cases are classified as incomplete cervical dilation but merely represent over-zealous interference during early first stage labour. Typically, the opening is only 5-10 cm in diameter which may just allow passage of one hand.

Fig 1: Some dystocia cases are classified as incomplete cervical dilation but may represent over-zealous interference.

Manual pressure applied for 10 to 15 minutes may gradually dilate the cervix in some cases but such cases may well represent those heifers disturbed during early first stage labour. In some cases the vulva may also fail to dilate properly because there has been no pressure from the water bag and veterinary attention is necessary. Natural dilation is achieved by pressure from an intact water bag being pressed through the cervix into the vagina by contractions of the uterus. For this reason it is unwise to manually rupture the waterbag until full dilation is complete.

Management/Prevention/Control measures

Too early/frequent human interference may delay normal progression of first stage labour especially in heifers. Farmers should be encouraged to leave cattle undisturbed for four hours after the appearance of a mucus string or allanto-chorion at the vulva, especially in heifers. However, frequent bouts of powerful abdominal contractions occurring more frequently than every five minutes or so must be investigated.

Oversized calf

Dystocia caused by an oversized calf in normal anterior longitudinal presentation is common in beef cattle. The calf's muzzle and forefeet are presented at the cow's vulva.

Reasonable traction should deliver the calf when two people pulling can extend both front legs such that the fetlock joints protrude one hand's breadth beyond the vulva within 10 minutes' traction. Such movement of the calf's forelegs represents extension of both elbow joints into the cow's pelvis. Veterinary attention is necessary if greater traction is applied without obvious progress and the elbows are not extended easily.

Fig 2: The fetlock joints protrude more than one hand's breadth beyond the vulva - this calf will be delivered safely.

• Review bull selection especially in heifers, with reference to EBV's
• Do not calve cows in BCS >3 (scale 1 to 5).
• Restrict breeding period to nine weeks to prevent an extended tail to the calving period with consequences of reduced cow supervision and increased BCS especially in spring-calving herds at pasture.

Potential problems

Vaginal tear.

Tears in the vaginal wall during delivery of the calf may be sufficient to allow the protrusion of submucosal fat or extend to cause rupture of the uterine artery with life-threatening consequences.

Haemorrhage from a major artery in the vagina must be identified immediately after the calf has been delivered and veterinary attention sought urgently.

Fig 3: Protrusion of submucosal fat from a vaginal tear acquired during delivery of an oversized calf. Fortunately, the tear did not extend to a major blood vessel.

Hip lock often arises when excessive and inappropriate traction has been applied to an oversized calf in anterior longitudinal presentation. The cow quickly becomes exhausted with the calf protruding to the back of the rib cage but firmly lodged as the hips enter the cow's pelvis.

Fig 4: Excessive and inappropriate traction has been applied to this oversized calf in anterior presentation resulting in hip lock.

Further traction whilst attempting to rotate the calf or roll the cow is rarely successful and risks obturator/sciatic nerve damage of the cow. Immediate veterinary attention is essential.

The calf's forequarters are removed and the remaining vertebral column and pelvis are divided using embryotomy wire. The split hindquarters can be pushed apart and easily removed.

Fig 5: The calf's forequarters are removed using embryotomy wire then the remaining vertebral column and pelvis are divided.

Veterinary expertise is essential where there are doubts whether the oversized calf can be safely delivered.

Leg back (Anterior longitudinal presentation with unilateral shoulder flexion)

Leg back is a common malposture in cattle obstetrics. The calf's head and one foreleg are presented at the vulva.

Fig 6: Leg back is a common malposture.

Correction of this malposture is best achieved after extradural injection by a veterinary surgeon to prevent forceful straining. After five minutes the calf's head and protruding foreleg are well lubricated and slowly repelled until the calf's poll is level with the pelvic inlet. By first grasping the calf's forearm then the mid metacarpal region, the elbow and carpal joints of the retained leg are fully flexed which brings the foot towards the pelvic inlet. With the fetlock joint fully flexed, and the foot cupped in your hand to protect the uterus, the foot is drawn forward into the pelvic canal extending the fetlock joint. Traction on the distal limb extends the elbow joint and the foot appears at the vulva where a calving rope is applied above the fetlock joint. Click for video simulation

The cow should now be haltered and tethered low down to a post in the calving box. Steady traction of two people pulling on the calving ropes applied to both legs will generally result in the heifer/cow assuming lateral recumbency which aids delivery of the calf.

The calf's umbilicus should be immediately fully immersed in strong veterinary iodine and repeated 2 and 4 hours later. Three litres of colostrum are administered by orogastric tube to ensure adequate antibody transfer because the calf will be unable to suck as a result of its swollen tongue.

Head back (Anterior longitudinal presentation with lateral deviation of the head)

Definition/overview.

Lateral deviation of the head is a common calving problem; the calf is often dead. Both fore feet are presented in the maternal pelvis (and possibly at the vulva).

The head back is often mistaken for a calf in posterior presentation (coming backwards) because you can feel two legs but no head. Note than the hooves face down not up and you are able to feel the carpal joints (knees) not the hocks or calf's tail.

Correction of the malposture is not easy especially when the calf is dead and veterinary attendance is often necessary. After extradural anaesthesia, the calf's forelegs and neck are carefully repelled as far as possible. A finger can be placed into the calf's mouth or an eye socket in an attempt to pull the head around into the pelvic inlet. Click for video simulation Alternatively, a leg rope placed around the calf's lower jaw. Once corrected, a head rope is placed behind the calf's poll and through its mouth to assist alignment into the pelvic inlet. Click for video simulation The calf is then delivered by traction as described above.

Recognition that second stage labour has not progressed and timely intervention.

Calf coming backwards

(posterior longitudinal presentation).

Posterior presentation is a common cause of dystocia in cattle. Typically, the calf pelvic limbs protrude from the cow's vulva about one hand's breadth short of the hock joints.

Two strong people pulling on calving ropes should be able to extend both hocks more than one hand's breadth beyond the cow's vulva (calf's hindquarters now fully within the pelvic inlet) within 10 minutes. Further traction will deliver the calf safely. Other guidelines include whether your hand can be extended over the calf's tail head and underneath both stifle joints when the calf is drawn into the pelvic inlet.

Fig 7: Only moderate traction should be necessary to extend both hocks of the calf more than one hand's breadth beyond the cow's vulva.

Potential complications - calf

Multiple rib fractures. Rupture of the liver.

Prolonged delivery resulting in compression of umbilical vessels causing lack of oxygen.

Breech presentation (Posterior longitudinal presentation with bilateral hip flexion)

The calf's pelvis is firmly lodged at the entrance to the maternal pelvis with both hindlegs extended alongside the body.

Cattle show typical signs of first stage labour when they appear restless and isolate themselves wherever possible but abdominal straining is not seen because the foetus does not engage within the maternal pelvis.

Fig 8: Cattle with a breech presentation show initial signs of first stage labour but then appear restless with the tail raised.

The waterbag may rupture but remnants of the foetal membrane may not appear at the vulva. The calf's tail is readily palpable on vaginal examination. In some cases the calving problem is not noted until the calf/calves die and the cow develops severe toxaemia.

Fig 9: Calf in breech presentation - the calf tail protrudes from the cow's vulva.

An extradural injection is given by a veterinary surgeon to block the cow's forceful abdominal contractions. The calf's tail head is slowly repelled beyond the level of the cow's pelvic inlet as far as your reach allows. Commencing distally, one calf's foot is cupped in your hand and the fetlock joint fully flexed. As the hind foot is drawn toward the maternal pelvis, the hock and stifle joints are fully flexed. Correction now involves extending each hip joint in turn while the distal limb joints (stifle, hock and fetlock joints) remain fully flexed. Further gentle repulsion of the calf may be necessary at this stage. In this manner a breech presentation is converted to a posterior presentation. Click for video simulation

Possible complications

Premature rupture of the umbilical vessels if the umbilicus has become hooked around one hind leg while correcting the hip flexion.

Uterine rupture during repulsion of the calf or correction of the hip flexion causing fatal peritonitis.

Fig 10: Uterine rupture during repulsion of the calf or correction of the hip flexion has caused peritonitis in this cow.

Simultaneous presentation of two calves.

There are many possible combinations of heads and legs when two calves are presented simultaneously. It is necessary to identify which leg corresponds to which head by tracing the leg to the shoulder region, and then to the neck and head. Once both legs and head have been correctly identified and roped, the other calf is gently repelled as traction is applied to the first. Only slight/moderate traction should be necessary to deliver a twin calf in this situation; if little progress is being made it is essential to check that you have selected the correct anatomy. It is important to differentiate simultaneous presentation of two calves from foetal abnormalities.

General Management/Prevention/Control measures

Regular supervision of calving cows. Examine those cattle suspected of first stage labour exceeding six hours.

In most cases, any malpresentation of the calf will be more easily corrected with the cow in the standing position as this allows the calf to be repelled. Once the presentation is correct, delivery is best achieved with the cow in full lateral recumbency as, in that position, the pelvis is at its maximum diameter.

Immediate Post-partum checks.

Immediately after the calf has been delivered and the airways cleared, the cow must be examined for:

1) Uterine tear/rupture

Uterine rupture occurs during assisted delivery most commonly with the calf presented in breech presentation but also with lateral deviation of the calf's head.

If the condition is not recognised immediately the cow may appear to be normal for several hours after delivery. She then becomes increasingly dull and depressed with a painful expression, no appetite and little milk production. As peritonitis develops over several days, the abdomen becomes increasingly distended which contrasts with the cow's much reduced appetite.

Fig 11: As peritonitis develops over several days, the abdomen becomes increasingly distended which contrasts with the cow's much reduced appetite.

Treatment of diffuse peritonitis involving small intestine is invariably hopeless and cow must be euthanased for welfare reasons when this diagnosis is confirmed.

2) Vaginal tears/laceration

Haemorrhage from a major uterine artery may result from excessive traction in over-conditioned heifers and is apparent once the pressure has been removed with delivery of the calf. Haemorrhage from a major artery in the vagina must be identified immediately the calf has been delivered and veterinary attention urgently requested.

Prevention/control measures

Monitor dry cow and heifer body condition scores regularly especially during the summer months. An episiotomy should be carefully considered in overfat heifers. Avoid excessive traction by electing to perform a caesarean operation.

Uterine Torsion

Uterine torsion is relatively common in cattle. It is often associated with an oversized foetus. Uterine torsion, from 180 to 720°, prevents entry of the foetus/fluids into the twisted vaginal lumen such that the animal shows no sign to indicate the end of first stage labour. Failure of the cervix to dilate fully is a common consequence.

The cow may isolate herself from others in the group and show signs of first stage labour including slackening of the sacro-iliac ligaments but the foetal membranes (allanto-chorion) do not appear at the vulva. The vulva and tail head are slack which contrasts with the constricted (tight) vaginal lumen which is typically dry lacking mucus. As your hand passes into the vagina there is a distinct twist (corkscrew effect) with can be either clockwise or anti-clockwise. With a torsion less than 360° it may be possible to reach the cervix which is dilated with foetal extremities distally. In those cases where the torsion is more than 360°, or when the calf cannot be reached a caesarean operation is the best way of ensuring the delivery of a live calf and an undamaged dam.

If left unattended for several days, the cow becomes sick due to death of the calf and development of a septic metritis.

A uterine torsion can be identified by the tight vagina with an obvious "corkscrew" feel. Veterinary attention is necessary to correct the twisted uterus.

Uterine Inertia

Uterine inertia is not uncommon in dairy cows and older beef cows with clinical hypocalcaemia (milk fever). Parturition does not progress beyond the end of first stage labour. Vaginal examination reveals the cervix to be fully dilated with the foetal membranes intact. Often the calf is already dead. There may be other signs of hypocalcaemia including recumbency and inability to rise, and free gas bloat.

Fig 12: Uterine inertia is not uncommon in dairy cows and older beef cows with clinical hypocalcaemia (milk fever).

Fig 13: Parturition does not progress beyond the end of first stage labour.

400 mls of 40% calcium borogluconate injected intravenously. If the calf is alive, it is usual to leave the cow for up to two hours to allow parturition to progress naturally.

Hypocalcaemia is discussed further in the bulletin on metabolic diseases.

Related NADIS Bulletins

• Calving Part 1 The Basics
• Calving Part 3 - Nerve Damage
• Beef Herd Fertility 1
• Beef Herd Fertility 2
• Bull Fertility
• Synchronised Breeding in Beef Herds
• Part 1 - The Basics of Reproduction
• Part 2 - Heat Detection
• Part 3 - Treating the Normal Cow - Missed Heats and Synchronisation
• Part 4 - Identifying and Treating the Abnormally Cycling Cow
• Part 5 - Pregnancy Diagnosis
• Part 6 - Dealing with Abortion
• Part 7 - Uterine Infection

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What Is Breech?

When a fetus is delivered buttocks or feet first

• Types of Presentation

Risk Factors

Complications.

Breech concerns the position of the fetus before labor . Typically, the fetus comes out headfirst, but in a breech delivery, the buttocks or feet come out first. This type of delivery is risky for both the pregnant person and the fetus.

This article discusses the different types of breech presentations, risk factors that might make a breech presentation more likely, treatment options, and complications associated with a breech delivery.

Verywell / Jessica Olah

Types of Breech Presentation

During the last few weeks of pregnancy, a fetus usually rotates so that the head is positioned downward to come out of the vagina first. This is called the vertex position.

In a breech presentation, the fetus does not turn to lie in the correct position. Instead, the fetus’s buttocks or feet are positioned to come out of the vagina first.

At 28 weeks of gestation, approximately 20% of fetuses are in a breech position. However, the majority of these rotate to the proper vertex position. At full term, around 3%–4% of births are breech.

The different types of breech presentations include:

• Complete : The fetus’s knees are bent, and the buttocks are presenting first.
• Frank : The fetus’s legs are stretched upward toward the head, and the buttocks are presenting first.
• Footling : The fetus’s foot is showing first.

Signs of Breech

There are no specific symptoms associated with a breech presentation.

Diagnosing breech before the last few weeks of pregnancy is not helpful, since the fetus is likely to turn to the proper vertex position before 35 weeks gestation.

A healthcare provider may be able to tell which direction the fetus is facing by touching a pregnant person’s abdomen. However, an ultrasound examination is the best way to determine how the fetus is lying in the uterus.

Most breech presentations are not related to any specific risk factor. However, certain circumstances can increase the risk for breech presentation.

These can include:

• Previous pregnancies
• Multiple fetuses in the uterus
• An abnormally shaped uterus
• Uterine fibroids , which are noncancerous growths of the uterus that usually appear during the childbearing years
• Placenta previa, a condition in which the placenta covers the opening to the uterus
• Preterm labor or prematurity of the fetus
• Too much or too little amniotic fluid (the liquid that surrounds the fetus during pregnancy)
• Fetal congenital abnormalities

Most fetuses that are breech are born by cesarean delivery (cesarean section or C-section), a surgical procedure in which the baby is born through an incision in the pregnant person’s abdomen.

In rare instances, a healthcare provider may plan a vaginal birth of a breech fetus. However, there are more risks associated with this type of delivery than there are with cesarean delivery. 

Before cesarean delivery, a healthcare provider might utilize the external cephalic version (ECV) procedure to turn the fetus so that the head is down and in the vertex position. This procedure involves pushing on the pregnant person’s belly to turn the fetus while viewing the maneuvers on an ultrasound. This can be an uncomfortable procedure, and it is usually done around 37 weeks gestation.

ECV reduces the risks associated with having a cesarean delivery. It is successful approximately 40%–60% of the time. The procedure cannot be done once a pregnant person is in active labor.

Complications related to ECV are low and include the placenta tearing away from the uterine lining, changes in the fetus’s heart rate, and preterm labor.

ECV is usually not recommended if the:

• Pregnant person is carrying more than one fetus
• Placenta is in the wrong place
• Healthcare provider has concerns about the health of the fetus
• Pregnant person has specific abnormalities of the reproductive system

Recommendations for Previous C-Sections

The American College of Obstetricians and Gynecologists (ACOG) says that ECV can be considered if a person has had a previous cesarean delivery.

During a breech delivery, the umbilical cord might come out first and be pinched by the exiting fetus. This is called cord prolapse and puts the fetus at risk for decreased oxygen and blood flow. There’s also a risk that the fetus’s head or shoulders will get stuck inside the mother’s pelvis, leading to suffocation.

Complications associated with cesarean delivery include infection, bleeding, injury to other internal organs, and problems with future pregnancies.

A healthcare provider needs to weigh the risks and benefits of ECV, delivering a breech fetus vaginally, and cesarean delivery.

In a breech delivery, the fetus comes out buttocks or feet first rather than headfirst (vertex), the preferred and usual method. This type of delivery can be more dangerous than a vertex delivery and lead to complications. If your baby is in breech, your healthcare provider will likely recommend a C-section.

A Word From Verywell

Knowing that your baby is in the wrong position and that you may be facing a breech delivery can be extremely stressful. However, most fetuses turn to have their head down before a person goes into labor. It is not a cause for concern if your fetus is breech before 36 weeks. It is common for the fetus to move around in many different positions before that time.

At the end of your pregnancy, if your fetus is in a breech position, your healthcare provider can perform maneuvers to turn the fetus around. If these maneuvers are unsuccessful or not appropriate for your situation, cesarean delivery is most often recommended. Discussing all of these options in advance can help you feel prepared should you be faced with a breech delivery.

American College of Obstetricians and Gynecologists. If your baby is breech .

TeachMeObGyn. Breech presentation .

MedlinePlus. Breech birth .

Hofmeyr GJ, Kulier R, West HM. External cephalic version for breech presentation at term . Cochrane Database Syst Rev . 2015 Apr 1;2015(4):CD000083. doi:10.1002/14651858.CD000083.pub3

By Christine Zink, MD Dr. Zink is a board-certified emergency medicine physician with expertise in the wilderness and global medicine.

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• Management of breech presentation

Evidence review M

NICE Guideline, No. 201

National Guideline Alliance (UK) .

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Review question

What is the most effective way of managing a longitudinal lie fetal malpresentation (breech presentation) in late pregnancy?

Introduction

Breech presentation of the fetus in late pregnancy may result in prolonged or obstructed labour with resulting risks to both woman and fetus. Interventions to correct breech presentation (to cephalic) before labour and birth are important for the woman’s and the baby’s health. The aim of this review is to determine the most effective way of managing a breech presentation in late pregnancy.

Summary of the protocol

Please see Table 1 for a summary of the Population, Intervention, Comparison and Outcome (PICO) characteristics of this review.

Summary of the protocol (PICO table).

For further details see the review protocol in appendix A .

Methods and process

This evidence review was developed using the methods and process described in Developing NICE guidelines: the manual 2014 . Methods specific to this review question are described in the review protocol in appendix A .

Declarations of interest were recorded according to NICE’s conflicts of interest policy .

Clinical evidence

Included studies.

Thirty-six randomised controlled trials (RCTs) were identified for this review.

The included studies are summarised in Table 2 .

Three studies reported on external cephalic version (ECV) versus no intervention ( Dafallah 2004 , Hofmeyr 1983 , Rita 2011 ). One study reported on a 4-arm trial comparing acupuncture, sweeping of fetal membranes, acupuncture plus sweeping, and no intervention ( Andersen 2013 ). Two studies reported on postural management versus no intervention ( Chenia 1987 , Smith 1999 ).

Seven studies reported on ECV plus anaesthesia ( Chalifoux 2017 , Dugoff 1999 , Khaw 2015 , Mancuso 2000 , Schorr 1997 , Sullivan 2009 , Weiniger 2010 ). Of these studies, 1 study compared ECV plus anaesthesia to ECV plus other dosages of the same anaesthetic ( Chalifoux 2017 ); 4 studies compared ECV plus anaesthesia to ECV only ( Dugoff 1999 , Mancuso 2000 , Schorr 1997 , Weiniger 2010 ); and 2 studies compared ECV plus anaesthesia to ECV plus a different anaesthetic ( Khaw 2015 , Sullivan 2009 ).

Ten studies reported ECV plus a β2 receptor agonist ( Brocks 1984 , Fernandez 1997 , Hindawi 2005 , Impey 2005 , Mahomed 1991 , Marquette 1996 , Nor Azlin 2005 , Robertson 1987 , Van Dorsten 1981 , Vani 2009 ). Of these studies, 5 studies compared ECV plus a β2 receptor agonist to ECV plus placebo ( Fernandez 1997 , Impey 2005 , Marquette 1996 , Nor Azlin 2005 , Vani 2009 ); 1 study compared ECV plus a β2 receptor agonist to ECV alone ( Robertson 1987 ); and 4 studies compared ECV plus a β2 receptor agonist to no intervention ( Brocks 1984 , Hindawi 2005 , Mahomed 1991 , Van Dorsten 1981 ).

One study reported on ECV plus Ca 2+ channel blocker versus ECV plus placebo ( Kok 2008 ). Two studies reported on ECV plus β2 receptor agonist versus ECV plus Ca 2+ channel blocker ( Collaris 2009 , Mohamed Ismail 2008 ). Four studies reported on ECV plus a µ-receptor agonist ( Burgos 2016 , Liu 2016 , Munoz 2014 , Wang 2017 ), of which 3 compared against ECV plus placebo ( Liu 2016 , Munoz 2014 , Wang 2017 ) and 1 compared to ECV plus nitrous oxide ( Burgos 2016 ).

Four studies reported on ECV plus nitroglycerin ( Bujold 2003a , Bujold 2003b , El-Sayed 2004 , Hilton 2009 ), of which 2 compared it to ECV plus β2 receptor agonist ( Bujold 2003b , El-Sayed 2004 ) and compared it to ECV plus placebo ( Bujold 2003a , Hilton 2009 ). One study compared ECV plus amnioinfusion versus ECV alone ( Diguisto 2018 ) and 1 study compared ECV plus talcum powder to ECV plus gel ( Vallikkannu 2014 ).

One study was conducted in Australia ( Smith 1999 ); 4 studies in Canada ( Bujold 2003a , Bujold 2003b , Hilton 2009 , Marquette 1996 ); 2 studies in China ( Liu 2016 , Wang 2017 ); 2 studies in Denmark ( Andersen 2013 , Brocks 1984 ); 1 study in France ( Diguisto 2018 ); 1 study in Hong Kong ( Khaw 2015 ); 1 study in India ( Rita 2011 ); 1 study in Israel ( Weiniger 2010 ); 1 study in Jordan ( Hindawi 2005 ); 5 studies in Malaysia ( Collaris 2009 , Mohamed Ismail 2008 , Nor Azlin 2005 , Vallikkannu 2014 , Vani 2009 ); 1 study in South Africa ( Hofmeyr 1983 ); 2 studies in Spain ( Burgos 2016 , Munoz 2014 ); 1 study in Sudan ( Dafallah 2004 ); 1 study in The Netherlands ( Kok 2008 ); 2 studies in the UK ( Impey 2005 , Chenia 1987 ); 9 studies in US ( Chalifoux 2017 , Dugoff 1999 , El-Sayed 2004 , Fernandez 1997 , Mancuso 2000 , Robertson 1987 , Schorr 1997 , Sullivan 2009 , Van Dorsten 1981 ); and 1 study in Zimbabwe ( Mahomed 1991 ).

The majority of studies were 2-arm trials, but there was one 3-arm trial ( Khaw 2015 ) and two 4-arm trials ( Andersen 2013 , Chalifoux 2017 ). All studies were conducted in a hospital or an outpatient ward connected to a hospital.

See the literature search strategy in appendix B and study selection flow chart in appendix C .

Excluded studies

Studies not included in this review with reasons for their exclusions are provided in appendix K .

Summary of clinical studies included in the evidence review

Summaries of the studies that were included in this review are presented in Table 2 .

Summary of included studies.

See the full evidence tables in appendix D and the forest plots in appendix E .

Quality assessment of clinical outcomes included in the evidence review

See the evidence profiles in appendix F .

Economic evidence

A systematic review of the economic literature was conducted but no economic studies were identified which were applicable to this review question.

A single economic search was undertaken for all topics included in the scope of this guideline. See supplementary material 2 for details.

Economic studies not included in this review are listed, and reasons for their exclusion are provided in appendix K .

Summary of studies included in the economic evidence review

No economic studies were identified which were applicable to this review question.

Economic model

No economic modelling was undertaken for this review because the committee agreed that other topics were higher priorities for economic evaluation.

Evidence statements

Clinical evidence statements, comparison 1. complementary therapy versus control (no intervention), critical outcomes, cephalic presentation in labour.

No evidence was identified to inform this outcome.

Method of birth

Caesarean section.

• Very low quality evidence from 1 RCT (N=204) showed that there is no clinically important difference between acupuncture and control (no intervention) on the number of caesarean sections in pregnant women with breech presentation: RR 0.74 (95% CI 0.38 to 1.43).
• Very low quality evidence from 1 RCT (N=200) showed that there is no clinically important difference between acupuncture plus membrane sweeping and control (no intervention) on the number of caesarean sections in pregnant women with breech presentation: RR 1.29 (95% CI 0.73 to 2.29).

Admission to SCBU/NICU

• Very low quality evidence from 1 RCT (N=204) showed that there is no clinically important difference between acupuncture and control (no intervention) on admission to SCBU/NICU in pregnant women with breech presentation: RR 0.19 (95% CI 0.02 to 1.62).
• Very low quality evidence from 1 RCT (N=200) showed that there is no clinically important difference between acupuncture plus membrane sweeping and control (no intervention) on admission to SCBU/NICU in pregnant women with breech presentation: RR 0.40 (0.08 to 2.01).

Fetal death after 36 +0 weeks gestation

Infant death up to 4 weeks chronological age, important outcomes, apgar score <7 at 5 minutes.

• Very low quality evidence from 1 RCT (N=204) showed that there is no clinically important difference between acupuncture and control (no intervention) on Apgar score <7 at 5 minutes in pregnant women with breech presentation: RR 0.32 (95% CI 0.01 to 7.78).
• Very low quality evidence from 1 RCT (N=200) showed that there is no clinically important difference between acupuncture plus membrane sweeping and control (no intervention) on Apgar score <7 at 5 minutes in pregnant women with breech presentation: RR 0.33 (0.01 to 8.09).

Birth before 39 +0 weeks of gestation

Comparison 2. complementary therapy versus other treatment.

• Low quality evidence from 1 RCT (N=207) showed that there is no clinically important difference between acupuncture and membrane sweeping on the number of caesarean sections in pregnant women with breech presentation: RR 0.64 (95% CI 0.34 to 1.22).
• Low quality evidence from 1 RCT (N=204) showed that there is no clinically important difference between acupuncture and acupuncture plus membrane sweeping on the number of caesarean sections in pregnant women with breech presentation: RR 0.57 (95% CI 0.30 to 1.07).
• Very low quality evidence from 1 RCT (N=203) showed that there is no clinically important difference between acupuncture plus membrane sweeping and membrane sweeping on the number of caesarean sections in pregnant women with breech presentation: RR 1.13 (95% CI 0.66 to 1.94).
• Very low quality evidence from 1 RCT (N=207) showed that there is no clinically important difference between acupuncture and membrane sweeping on admission to SCBU/NICU in pregnant women with breech presentation: RR 0.33 (95% CI 0.03 to 3.12).
• Very low quality evidence from 1 RCT (N=204) showed that there is no clinically important difference between acupuncture and acupuncture plus membrane sweeping on admission to SCBU/NICU in pregnant women with breech presentation: RR 0.48 (95% CI 0.04 to 5.22).
• Very low quality evidence from 1 RCT (N=203) showed that there is no clinically important difference between acupuncture plus membrane sweeping and membrane sweeping on admission to SCBU/NICU in pregnant women with breech presentation: RR 0.69 (95% CI 0.12 to 4.02).
• Low quality evidence from 1 RCT (N=207) showed that there is no clinically important difference between acupuncture and membrane sweeping on Apgar score <7 at 5 minutes in pregnant women with breech presentation: RD 0.00 (95% CI −0.02 to 0.02).
• Low quality evidence from 1 RCT (N=204) showed that there is no clinically important difference between acupuncture and acupuncture plus membrane sweeping on Apgar score <7 at 5 minutes in pregnant women with breech presentation: RD 0.00 (95% CI −0.02 to 0.02).
• Low quality evidence from 1 RCT (N=203) showed that there is no clinically important difference between acupuncture plus membrane sweeping and membrane sweeping on Apgar score <7 at 5 minutes in pregnant women with breech presentation: RD 0.00 (95% CI −0.02 to 0.02).

Comparison 3. ECV versus no ECV

• Moderate quality evidence from 2 RCTs (N=680) showed that there is clinically important difference favouring ECV over no ECV on cephalic presentation in labour in pregnant women with breech presentation: RR 1.83 (95% CI 1.53 to 2.18).

Cephalic vaginal birth

• Very low quality evidence from 3 RCTs (N=740) showed that there is a clinically important difference favouring ECV over no ECV on cephalic vaginal birth in pregnant women with breech presentation: RR 1.67 (95% CI 1.20 to 2.31).

Breech vaginal birth

• Very low quality evidence from 2 RCTs (N=680) showed that there is no clinically important difference between ECV and no ECV on breech vaginal birth in pregnant women with breech presentation: RR 0.29 (95% CI 0.03 to 2.84).
• Very low quality evidence from 3 RCTs (N=740) showed that there is no clinically important difference between ECV and no ECV on the number of caesarean sections in pregnant women with breech presentation: RR 0.52 (95% CI 0.23 to 1.20).
• Very low quality evidence from 1 RCT (N=60) showed that there is no clinically important difference between ECV and no ECV on admission to SCBU//NICU in pregnant women with breech presentation: RR 0.50 (95% CI 0.14 to 1.82).
• Very low evidence from 3 RCTs (N=740) showed that there is no statistically significant difference between ECV and no ECV on fetal death after 36 +0 weeks gestation in pregnant women with breech presentation: Peto OR 0.29 (95% CI 0.05 to 1.73) p=0.18.
• Very low quality evidence from 2 RCTs (N=120) showed that there is no clinically important difference between ECV and no ECV on Apgar score <7 at 5 minutes in pregnant women with breech presentation: Peto OR 0.28 (95% CI 0.04 to 1.70).

Comparison 4. ECV + Amnioinfusion versus ECV only

• Very low quality evidence from 1 RCT (N=109) showed that there is no clinically important difference between ECV plus amnioinfusion and ECV alone on cephalic presentation in labour in pregnant women with breech presentation: RR 1.74 (95% CI 0.74 to 4.12).
• Low quality evidence from 1 RCT (N=109) showed that there is no clinically important difference between ECV plus amnioinfusion and ECV alone on the number of caesarean sections in pregnant women with breech presentation: RR 0.95 (95% CI 0.75 to 1.19).

Comparison 5. ECV + Anaesthesia versus ECV only

• Very low quality evidence from 2 RCTs (N=210) showed that there is no clinically important difference between ECV plus anaesthesia and ECV alone on cephalic presentation in labour in pregnant women with breech presentation: RR 1.16 (95% CI 0.56 to 2.41).
• Very low quality evidence from 5 RCTs (N=435) showed that there is no clinically important difference between ECV plus anaesthesia and ECV alone on cephalic vaginal birth in pregnant women with breech presentation: RR 1.16 (95% CI 0.77 to 1.74).
• Very low quality evidence from 1 RCT (N=108) showed that there is no clinically important difference between ECV plus anaesthesia and ECV alone on breech vaginal birth in pregnant women with breech presentation: RR 0.33 (95% CI 0.04 to 3.10).
• Very low quality evidence from 3 RCTs (N=263) showed that there is no clinically important difference between ECV plus anaesthesia and ECV alone on the number of caesarean sections in pregnant women with breech presentation: RR 0.76 (95% CI 0.42 to 1.38).
• Moderate quality evidence from 1 RCT (N=69) showed that there is a clinically important difference favouring ECV plus anaesthesia over ECV alone on admission to SCBU/NICU in pregnant women with breech presentation: MD −1.80 (95% CI −2.53 to −1.07).
• Low quality evidence from 1 RCT (N=126) showed that there is no clinically important difference between ECV plus anaesthesia and ECV alone on Apgar score <7 at 5 minutes in pregnant women with breech presentation: RD 0.00 (95% CI −0.03 to 0.03).

Comparison 6. ECV + Anaesthesia versus ECV + Anaesthesia

• Very low quality evidence from 1 RCT (N=120) showed that there is no clinically important difference between ECV plus 2.5mg Bupivacaine plus 0.015mg Fentanyl and ECV plus 5mg Bupivacaine plus 0.015mg Fentanyl on cephalic vaginal birth in pregnant women with breech presentation: RR 1.13 (95% CI 0.73 to 1.74).
• Low quality evidence from 1 RCT (N=119) showed that there is no clinically important difference between ECV plus 2.5mg Bupivacaine plus 0.015mg Fentanyl and ECV plus 7.5mg Bupivacaine plus 0.015mg Fentanyl on cephalic vaginal birth in pregnant women with breech presentation: RR 0.81 (95% CI 0.53 to 1.23).
• Very low quality evidence from 1 RCT (N=120) showed that there is no clinically important difference between ECV plus 2.5mg Bupivacaine plus 0.015mg Fentanyl and ECV plus 10mg Bupivacaine plus 0.015mg Fentanyl on cephalic vaginal birth in pregnant women with breech presentation: RR 0.96 (95% CI 0.61 to 1.50).
• Very low quality evidence from 1 RCT (N=95) showed that there is no clinically important difference between ECV plus 2.5mg Bupivacaine plus 0.015mg Fentanyl and ECV plus 0.05mg Fentanyl on cephalic vaginal birth in pregnant women with breech presentation: RR 0.69 (95% CI 0.37 to 1.28).
• Low quality evidence from 1 RCT (N=119) showed that there is no clinically important difference between ECV plus 5mg Bupivacaine plus 0.015mg Fentanyl and ECV plus 7.5mg Bupivacaine plus 0.015mg Fentanyl on cephalic vaginal birth in pregnant women with breech presentation: RR 0.81 (95% CI 0.53 to 1.23).
• Very low quality evidence from 1 RCT (N=120) showed that there is no clinically important difference between ECV plus 5mg Bupivacaine plus 0.015mg Fentanyl and ECV plus 10mg Bupivacaine plus 0.015mg Fentanyl on cephalic vaginal birth in pregnant women with breech presentation: RR 0.96 (95% CI 0.61 to 1.50).
• Very low evidence from 1 RCT (N=119) showed that there is no clinically important difference between ECV plus 7.5mg Bupivacaine plus 0.015mg Fentanyl and ECV plus 10mg Bupivacaine plus 0.015mg Fentanyl on cephalic vaginal birth in pregnant women with breech presentation: RR 1.19 (95% CI 0.79 to 1.79).
• Low quality evidence from 1 RCT (N=120) showed that there is no clinically important difference between ECV plus 2.5mg Bupivacaine plus 0.015mg Fentanyl and ECV plus 5mg Bupivacaine plus 0.015mg Fentanyl on the number of caesarean sections in pregnant women with breech presentation: RR 0.92 (95% CI 0.68 to 1.24).
• Very low evidence from 1 RCT (N=119) showed that there is no clinically important difference between ECV plus 2.5mg Bupivacaine plus 0.015mg Fentanyl and ECV plus 7.5mg Bupivacaine plus 0.015mg Fentanyl on the number of caesarean sections in pregnant women with breech presentation: RR 1.08 (95% CI 0.78 to 1.50).
• Very low evidence from 1 RCT (N=120) showed that there is no clinically important difference between ECV plus 2.5mg Bupivacaine plus 0.015mg Fentanyl and ECV plus 10mg Bupivacaine plus 0.015mg Fentanyl on the number of caesarean sections in pregnant women with breech presentation: RR 0.94 (95% CI 0.70 to 1.28).
• Low quality evidence from 1 RCT (N=119) showed that there is no clinically important difference between ECV plus 5mg Bupivacaine plus 0.015mg Fentanyl and ECV plus 7.5mg Bupivacaine plus 0.015mg Fentanyl on the number of caesarean sections in pregnant women with breech presentation: RR 1.17 (95% CI 0.86 to 1.61).
• Very low quality evidence from 1 RCT (N=120) showed that there is no clinically important difference between ECV plus 5mg Bupivacaine plus 0.015mg Fentanyl and ECV plus 10mg Bupivacaine plus 0.015mg Fentanyl on the number of caesarean sections in pregnant women with breech presentation: RR 1.03 (95% CI 0.77 to 1.37).
• Low quality evidence from 1 RCT (N=119) showed that there is no clinically important difference between ECV plus 7.5mg Bupivacaine plus 0.015mg Fentanyl and ECV plus 10mg Bupivacaine plus 0.015mg Fentanyl on the number of caesarean sections in pregnant women with breech presentation: RR 0.88 (95% CI 0.64 to 1.20).

Comparison 7. ECV + β2 agonist versus Control (no intervention)

• Moderate quality evidence from 2 RCTs (N=256) showed that there is a clinically important difference favouring ECV plus β2 agonist over control (no intervention) on cephalic presentation in labour in pregnant women with breech presentation: RR 4.83 (95% CI 3.27 to 7.11).
• Very low quality evidence from 3 RCTs (N=265) showed that there no clinically important difference between ECV plus β2 agonist and control (no intervention) on cephalic vaginal birth in pregnant women with breech presentation: RR 2.03 (95% CI 0.22 to 19.01).
• Very low quality evidence from 4 RCTs (N=513) showed that there is a clinically important difference favouring ECV plus β2 agonist over control (no intervention) on breech vaginal birth in pregnant women with breech presentation: RR 0.38 (95% CI 0.20 to 0.69).
• Low quality evidence from 4 RCTs (N=513) showed that there is a clinically important difference favouring ECV plus β2 agonist over control (no intervention) on the number of caesarean sections in pregnant women with breech presentation: RR 0.53 (95% CI 0.41 to 0.67).
• Very low quality evidence from 1 RCT (N=48) showed that there is no clinically important difference between ECV plus β2 agonist and control (no intervention) on admission to SCBU/NICU in pregnant women with breech presentation: RD 0.00 (95% CI −0.08 to 0.08).
• Very low quality evidence from 3 RCTs (N=208) showed that there is no statistically significant difference between ECV plus β2 agonist and control (no intervention) on fetal death after 36 +0 weeks gestation in pregnant women with breech presentation: RD −0.01 (95% CI −0.03 to 0.01) p=0.66.
• Very low quality evidence from 2 RCTs (N=208) showed that there is no clinically important difference between ECV plus β2 agonist and control (no intervention) on Apgar score <7 at 5 minutes in pregnant women with breech presentation: Peto OR 0.80 (95% CI 0.31 to 2.10).

Comparison 8. ECV + β2 agonist versus ECV only

• Very low quality evidence from 2 RCTs (N=172) showed that there is no clinically important difference between ECV plus β2 agonist and ECV only on cephalic vaginal birth in pregnant women with breech presentation: RR 1.32 (95% CI 0.67 to 2.62).
• Very low quality evidence from 1 RCT (N=58) showed that there is no clinically important difference between ECV plus β2 agonist and ECV only on breech vaginal birth in pregnant women with breech presentation: RR 0.75 (95% CI 0.22 to 2.50).
• Very low quality evidence from 2 RCTs (N=172) showed that there is no clinically important difference between ECV plus β2 agonist and ECV only on the number of caesarean sections in pregnant women with breech presentation: RR 0.79 (95% CI 0.27 to 2.28).
• Very low quality evidence from 1 RCT (N=114) showed that there is no clinically important difference between ECV plus β2 agonist and ECV only on admission to SCBU/NICU in pregnant women with breech presentation: RR 1.00 (95% CI 0.21 to 4.75).

Comparison 9. ECV + β2 agonist versus ECV + Placebo

• Very low quality evidence from 2 RCTs (N=146) showed that there is no clinically important difference between ECV plus β2 agonist and ECV plus placebo on cephalic presentation in labour in pregnant women with breech presentation: RR 1.54 (95% CI 0.24 to 9.76).
• Very low quality evidence from 2 RCTs (N=125) showed that there is no clinically important difference between ECV plus β2 agonist and ECV plus placebo on cephalic vaginal birth in pregnant women with breech presentation: RR 1.27 (95% CI 0.41 to 3.89).
• Very low quality evidence from 2 RCTs (N=227) showed that there is no clinically important difference between ECV plus β2 agonist and ECV plus placebo on breech vaginal birth in pregnant women with breech presentation: RR 1.00 (95% CI 0.33 to 2.97).
• Low quality evidence from 4 RCTs (N=532) showed that there is no clinically important difference between ECV plus β2 agonist and ECV plus placebo on the number of caesarean sections in pregnant women with breech presentation: RR 0.81 (95% CI 0.72 to 0.92)
• Very low quality evidence from 2 RCTs (N=146) showed that there is no clinically important difference between ECV plus β2 agonist and ECV plus placebo on admission to SCBU/NICU in pregnant women with breech presentation: RR 0.78 (95% CI 0.17 to 3.63).
• Very low quality evidence from 1 RCT (N=124) showed that there is no clinically important difference between ECV plus β2 agonist and ECV plus placebo on Apgar score <7 at 5 minutes in pregnant women with breech presentation: RD 0.00 (95% CI −0.03 to 0.03).

Comparison 10. ECV + Ca 2+ channel blocker versus ECV + Placebo

• Moderate quality evidence from 1 RCT (N=310) showed that there is no clinically important difference between ECV plus Ca 2+ channel blocker and ECV plus placebo on cephalic presentation in labour in pregnant women with breech presentation: RR 1.13 (95% CI 0.87 to 1.48).
• Moderate quality evidence from 1 RCT (N=310) showed that there is no clinically important difference between ECV plus Ca 2+ channel blocker and ECV plus placebo on cephalic vaginal birth in pregnant women with breech presentation: RR 0.90 (95% CI 0.73 to 1.12).
• Moderate quality evidence from 1 RCT (N=310) showed that there is no clinically important difference between ECV plus Ca 2+ channel blocker and ECV plus placebo on the number of caesarean sections in pregnant women with breech presentation: RR 1.11 (95% CI 0.88 to 1.40).
• High quality evidence from 1 RCT (N=310) showed that there is no clinically important difference between ECV plus Ca 2+ channel blocker and ECV plus placebo on admission to SCBU/NICU in pregnant women with breech presentation: MD −0.20 (95% CI −0.70 to 0.30).
• Moderate quality evidence from 1 RCT (N=310) showed that there is no statistically significant difference between ECV plus Ca 2+ channel blocker and ECV plus placebo on fetal death after 36 +0 weeks gestation in pregnant women with breech presentation: RD 0.00 (95% CI −0.01 to 0.01) p=1.00.
• Low quality evidence from 1 RCT (N=310) showed that there is no clinically important difference between ECV plus Ca 2+ channel blocker and ECV plus placebo on Apgar score <7 at 5 minutes in pregnant women with breech presentation: Peto OR 0.52 (95% 0.05 to 5.02).

Comparison 11. ECV + Ca2+ channel blocker versus ECV + β2 agonist

• Low quality evidence from 1 RCT (N=90) showed that there is a clinically important difference favouring ECV plus β2 agonist over ECV plus Ca 2+ channel blocker on cephalic presentation in labour in pregnant women with breech presentation: RR 0.62 (95% CI 0.39 to 0.98).
• Very low quality evidence from 2 RCTs (N=126) showed that there is no clinically important difference between ECV plus Ca 2+ channel blocker and ECV plus β2 agonist on cephalic vaginal birth in pregnant women with breech presentation: RR 1.26 (95% CI 0.55 to 2.89).
• Very low quality evidence from 2 RCTs (N=132) showed that there is a clinically important difference favouring ECV plus β2 agonist over ECV plus Ca 2+ channel blocker on the number of caesarean sections in pregnant women with breech presentation: RR 1.42 (95% CI 1.06 to 1.91).
• Very low quality evidence from 2 RCTs (N=176) showed that there is no clinically important difference between ECV plus Ca 2+ channel blocker and ECV plus β2 agonist on admission to SCBU/NICU in pregnant women with breech presentation: Peto OR 0.53 (95% CI 0.05 to 5.22).
• Very low quality evidence from 2 RCTs (N=176) showed that there is no clinically important difference between ECV plus Ca 2+ channel blocker and ECV plus β2 agonist on Apgar score <7 at 5 minutes in pregnant women with breech presentation: RD 0.00 (95% CI −0.03 to 0.03).

Comparison 12. ECV + µ-receptor agonist versus ECV only

• High quality evidence from 1 RCT (N=80) showed that there is no clinically important difference between ECV plus µ-receptor agonist and ECV alone on cephalic vaginal birth in pregnant women with breech presentation: RR 1.00 (95% CI 0.80 to 1.24).
• Low quality evidence from 1 RCT (N=80) showed that there is no clinically important difference between ECV plus µ-receptor agonist and ECV alone on the number of caesarean sections in pregnant women with breech presentation: RR 1.00 (95% CI 0.42 to 2.40).
• Low quality evidence from 1 RCT (N=126) showed that there is no clinically important difference between ECV plus µ-receptor agonist and ECV alone on Apgar score <7 at 5 minutes in pregnant women with breech presentation: RD 0.00 (95% CI −0.03 to 0.03).

Comparison 13. ECV + µ-receptor agonist versus ECV + Placebo

Cephalic vaginal birth after successful ecv.

• High quality evidence from 2 RCTs (N=98) showed that there is no clinically important difference between ECV plus µ-receptor agonist and ECV plus placebo on cephalic vaginal birth after successful ECV in pregnant women with breech presentation: RR 1.00 (95% CI 0.86 to 1.17).

Caesarean section after successful ECV

• Low quality evidence from 2 RCTs (N=98) showed that there is no clinically important difference between ECV plus µ-receptor agonist and ECV plus placebo on caesarean section after successful ECV in pregnant women with breech presentation: RR 0.97 (95% CI 0.33 to 2.84).

Breech vaginal birth after unsuccessful ECV

• High quality evidence from 3 RCTs (N=186) showed that there is a clinically important difference favouring ECV plus µ-receptor agonist over ECV plus placebo on breech vaginal birth after unsuccessful ECV in pregnant women with breech presentation: RR 0.10 (95% CI 0.02 to 0.53).

Caesarean section after unsuccessful ECV

• Moderate quality evidence from 3 RCTs (N=186) showed that there is no clinically important difference between ECV plus µ-receptor agonist and ECV plus placebo on caesarean section after unsuccessful ECV in pregnant women with breech presentation: RR 1.19 (95% CI 1.09 to 1.31).
• Low quality evidence from 1 RCT (N=137) showed that there is no statistically significant difference between ECV plus µ-receptor agonist and ECV plus placebo on fetal death after 36 +0 weeks gestation in pregnant women with breech presentation: RD 0.00 (95% CI −0.03 to 0.03) p=1.00.

Comparison 14. ECV + µ-receptor agonist versus ECV + Anaesthesia

• Moderate quality evidence from 1 RCT (N=92) showed that there is no clinically important difference between ECV plus µ-receptor agonist and ECV plus anaesthesia on cephalic vaginal birth in pregnant women with breech presentation: RR 1.04 (95% CI 0.84 to 1.29).
• Very low quality evidence from 2 RCTs (N=212) showed that there is no clinically important difference between ECV plus µ-receptor agonist and ECV plus anaesthesia on the number of caesarean sections in pregnant women with breech presentation: RR 0.90 (95% CI 0.61 to 1.34).
• Very low quality evidence from 1 RCT (N=129) showed that there is no clinically important difference between ECV plus µ-receptor agonist and ECV plus anaesthesia on admission to SCBU/NICU in pregnant women with breech presentation: RR 2.30 (95% CI 0.21 to 24.74).
• Low quality evidence from 2 RCTs (N=255) showed that there is no clinically important difference between ECV plus µ-receptor agonist and ECV plus anaesthesia on Apgar score <7 at 5 minutes in pregnant women with breech presentation: RD 0.00 (95% CI −0.02 to 0.02).

Comparison 15. ECV + Nitric oxide donor versus ECV + Placebo

• Very low quality evidence from 3 RCTs (N=224) showed that there is no clinically important difference between ECV plus nitric oxide donor and ECV plus placebo on cephalic presentation in labour in pregnant women with breech presentation: RR 1.13 (95% CI 0.59 to 2.16).
• Low quality evidence from 1 RCT (N=99) showed that there is no clinically important difference between ECV plus nitric oxide donor and ECV plus placebo on cephalic vaginal birth in pregnant women with breech presentation: RR 0.78 (95% CI 0.49 to 1.22).
• Low quality evidence from 2 RCTs (N=125) showed that there is no clinically important difference between ECV plus nitric oxide donor and ECV plus placebo on the number of caesarean sections in pregnant women with breech presentation: RR 0.83 (95% CI 0.68 to 1.01).

Comparison 16. ECV + Nitric oxide donor versus ECV + β2 agonist

• Low quality evidence from 1 RCT (N=74) showed that there is no clinically important difference between ECV plus β2 agonist and ECV plus nitric oxide donor on cephalic presentation in labour in pregnant women with breech presentation: RR 0.56 (95% CI 0.29 to 1.09).
• Very low quality evidence from 2 RCTs (N=97) showed that there is no clinically important difference between ECV plus nitric oxide donor and ECV plus β2 agonist on cephalic vaginal birth in pregnant women with breech presentation: RR 0.98 (95% CI 0.47 to 2.05).
• Very low quality evidence from 1 RCT (N=59) showed that there is no clinically important difference between ECV plus nitric oxide donor and ECV plus β2 agonist on the number of caesarean sections in pregnant women with breech presentation: RR 1.07 (95% CI 0.73 to 1.57).

Comparison 17. ECV + Talcum powder versus ECV + Gel

• Low quality evidence from 1 RCT (N=95) showed that there is no clinically important difference between ECV plus talcum powder and ECV plus gel on cephalic presentation in labour in pregnant women with breech presentation: RR 1.02 (95% CI 0.68 to 1.53).
• Low quality evidence from 1 RCT (N=95) showed that there is no clinically important difference between ECV plus talcum powder and ECV plus gel on cephalic vaginal birth in pregnant women with breech presentation: RR 1.08 (95% CI 0.67 to 1.74).
• Low quality evidence from 1 RCT (N=95) showed that there is no clinically important difference between ECV plus talcum powder and ECV plus gel on the number of caesarean sections in pregnant women with breech presentation: RR 0.94 (95% CI 0.67 to 1.33).
• Low quality evidence from 1 RCT (N=95) showed that there is no clinically important difference between ECV plus talcum powder and ECV plus gel on admission to SCBU/NICU in pregnant women with breech presentation: RR 1.96 (95% CI 0.38 to 10.19).

Comparison 18. Postural management versus No postural management

• Low quality evidence from 1 RCT (N=76) showed that there is no clinically important difference between postural management and no postural management on cephalic presentation in labour in pregnant women with breech presentation: RR 1.26 (95% CI 0.70 to 2.30).
• Low quality evidence from 1 RCT (N=76) showed that there is no clinically important difference between postural management and no postural management on cephalic vaginal birth in pregnant women with breech presentation: RR 1.11 (95% CI 0.59 to 2.07).

Breech vaginal delivery

• Low quality evidence from 1 RCT (N=76) showed that there is no clinically important difference between postural management and no postural management on breech vaginal delivery in pregnant women with breech presentation: RR 1.15 (95% CI 0.67 to 1.99).
• Low quality evidence from 1 RCT (N=76) showed that there is no clinically important difference between postural management and no postural management on the number of caesarean sections in pregnant women with breech presentation: RR 0.69 (95% CI 0.31 to 1.52).
• Low quality evidence from 1 RCT (N=76) showed that there is no clinically important difference between postural management and no postural management on Apgar score <7 at 5 minutes in pregnant women with breech presentation: RR 0.24 (95% CI 0.03 to 2.03).

Comparison 19. Postural management + ECV versus ECV only

• Moderate quality evidence from 1 RCT (N=100) showed that there is no clinically important difference between postural management plus ECV and ECV only on the number of caesarean sections in pregnant women with breech presentation: RR 1.05 (95% CI 0.80 to 1.38).
• Low quality evidence from 1 RCT (N=100) showed that there is no clinically important difference between postural management plus ECV and ECV only on Apgar score <7 at 5 minutes in pregnant women with breech presentation: Peto OR 0.13 (95% CI 0.00 to 6.55).

Economic evidence statements

No economic evidence was identified which was applicable to this review question.

The committee’s discussion of the evidence

Interpreting the evidence, the outcomes that matter most.

Provision of antenatal care is important for the health and wellbeing of both mother and baby with the aim of avoiding adverse pregnancy outcomes and enhancing maternal satisfaction and wellbeing. Breech presentation in labour may be associated with adverse outcomes for the fetus, which has contributed to an increased likelihood of caesarean birth. The committee therefore agreed that cephalic presentation in labour and method of birth were critical outcomes for the woman, and admission to SCBU/NICU, fetal death after 36 +0 weeks gestation, and infant death up to 4 weeks chronological age were critical outcomes for the baby. Apgar score <7 at 5 minutes and birth before 39 +0 weeks of gestation were important outcomes for the baby.

The quality of the evidence

The quality of the evidence for interventions for managing a longitudinal lie fetal malpresentation (that is breech presentation) in late pregnancy ranged from very low to high, with most of the evidence being of a very low or low quality.

This was predominately due to serious overall risk of bias in some outcomes; imprecision around the effect estimate in some outcomes; indirect population in some outcomes; and the presence of serious heterogeneity in some outcomes, which was unresolved by subgroup analysis. The majority of included studies had a small sample size, which contributed to imprecision around the effect estimate.

No evidence was identified to inform the outcomes of infant death up to 4 weeks chronological age and birth before 39 +0 weeks of gestation.

There was no publication bias identified in the evidence. However, the committee noted the influence pharmacological developers may have in these trials as funders, and took this into account in their decision making.

Benefits and harms

The committee discussed that in the case of breech presentation, a discussion with the woman about the different options and their potential benefits, harms and implications is needed to ensure an informed decision. The committee discussed that some women may prefer a breech vaginal birth or choose an elective caesarean birth, and that her preferences should be supported, in line with shared decision making.

The committee discussed that external cephalic version is standard practice for managing breech presentation in uncomplicated singleton pregnancies at or after 36+0 weeks. The committee discussed that there could be variation in the success rates of ECV based on the experience of the healthcare professional providing the ECV. There was some evidence supporting the use of ECV for managing a breech presentation in late pregnancy. The evidence showed ECV had a clinically important benefit in terms of cephalic presentations in labour and cephalic vaginal deliveries, when compared to no intervention. The committee noted that the evidence suggested that ECV was not harmful to the baby, although the effect estimate was imprecise relating to the relative rarity of the fetal death as an outcome.

Cephalic (head-down) vaginal birth is preferred by many women and the evidence suggests that external cephalic version is an effective way to achieve this. The evidence suggested ECV increased the chance for a cephalic vaginal birth and the committee agreed that it was important to explain this to the woman during her consultation.

The committee discussed the optimum timing for ECV. Timing of ECV must take into account the likelihood of the baby turning naturally before a woman commences labour and the possibility of the baby turning back to a breech presentation after ECV if it is done too early. The committee noted that in their experience, current practice was to perform ECV at 37 gestational weeks. The majority of the evidence demonstrating a benefit of ECV in this review involved ECV performed around 37 gestational weeks, although the review did not look for studies directly comparing different timings of ECV and their relative success rates.

The evidence in this review excluded women with previous complicated pregnancies, such as those with previous caesarean section or uterine surgery. The committee discussed that a previous caesarean section indicates a complicated pregnancy and that this population of women are not the focus of this guideline, which concentrates on women with uncomplicated pregnancies.

The committee’s recommendations align with other NICE guidance and cross references to the NICE guideline on caesarean birth and the section on breech presenting in labour in the NICE guideline on intrapartum care for women with existing medical conditions or obstetric complications and their babies were made.

ECV combined with pharmacological agents

There were some small studies comparing a variety of pharmacological agents (including β2 agonists, Ca 2+ channel blockers, µ-receptor agonists and nitric oxide donors) given alongside ECV. Overall the evidence typically showed no clinically important benefit of adding any pharmacological agent to ECV except in comparisons with a control arm with no ECV where it was not possible to isolate the effect of the ECV versus the pharmacological agent. The evidence tended toward benefit most for β2 agonists and µ-receptor agonists however there was no consistent or high quality evidence of benefit even for these agents. The committee agreed that although these pharmacological agents are used in practice, there was insufficient evidence to make a recommendation supporting or refuting their use or on which pharmacological agent should be used.

The committee discussed that the evidence suggesting µ-receptor agonist, remifentanil, had a clinically important benefit in terms reducing breech vaginal births after unsuccessful ECV was biologically implausible. The committee noted that this pharmacological agent has strong sedative effects, depending on the dosage, and therefore studies comparing it to a placebo had possible design flaws as it would be obvious to all parties whether placebo or active drug had been received. The committee discussed that the risks associated with using remifentanil such as respiratory depression, likely outweigh any potential added benefit it may have on managing breech presentation.

There was some evidence comparing different anaesthetics together with ECV. Although there was little consistent evidence of benefit overall, one small study of low quality showed a combination of 2% lidocaine and epinephrine via epidural catheter (anaesthesia) with ECV showed a clinically important benefit in terms of cephalic presentations in labour and the method of birth. The committee discussed the evidence and agreed the use of anaesthesia via epidural catheter during ECV was uncommon practice in the UK and could be expensive, overall they agreed the strength of the evidence available was insufficient to support a change in practice.

Postural management

There was limited evidence on postural management as an intervention for managing breech presentation in late pregnancy, which showed no difference in effectiveness. Postural management was defined as ‘knee-chest position for 15 minutes, 3 times a day’. The committee agreed that in their experience women valued trying interventions at home first which might make postural management an attractive option for some women, however, there was no evidence that postural management was beneficial. The committee also noted that in their experience postural management can cause notable discomfort so it is not an intervention without disadvantages.

Cost effectiveness and resource use

A systematic review of the economic literature was conducted but no relevant studies were identified which were applicable to this review question.

The committee’s recommendations to offer external cephalic version reinforces current practice. The committee noted that, compared to no intervention, external cephalic version results in clinically important benefits and that there would also be overall downstream cost savings from lower adverse events. It was therefore the committee’s view that offering external cephalic version is cost effective and would not entail any resource impact.

Andersen 2013

Brocks 1984

Bujold 2003

Burgos 2016

Chalifoux 2017

Chenia 1987

Collaris 2009

Dafallah 2004

Diguisto 2018

Dugoff 1999

El-Sayed 2004

Fernandez 1997

Hindawi 2005

Hilton 2009

Hofmeyr 1983

Mahomed 1991

Mancuso 2000

Marquette 1996

Mohamed Ismail 2008

NorAzlin 2005

Robertson 1987

Schorr 1997

Sullivan 2009

VanDorsten 1981

Vallikkannu 2014

Weiniger 2010

Appendix A. Review protocols

Review protocol for review question: What is the most effective way of managing a longitudinal lie fetal malpresentation (breech presentation) in late pregnancy? (PDF, 260K)

Appendix B. Literature search strategies

Literature search strategies for review question: What is the most effective way of managing a longitudinal lie fetal malpresentation (breech presentation) in late pregnancy? (PDF, 281K)

Appendix C. Clinical evidence study selection

Clinical study selection for: What is the most effective way of managing a longitudinal lie fetal malpresentation (breech presentation) in late pregnancy? (PDF, 113K)

Appendix D. Clinical evidence tables

Clinical evidence tables for review question: What is the most effective way of managing a longitudinal lie fetal malpresentation (breech presentation) in late pregnancy? (PDF, 1.2M)

Appendix E. Forest plots

Forest plots for review question: What is the most effective way of managing a longitudinal lie fetal malpresentation (breech presentation) in late pregnancy? (PDF, 678K)

Appendix F. GRADE tables

GRADE tables for review question: What is the most effective way of managing a longitudinal lie fetal malpresentation (breech presentation) in late pregnancy? (PDF, 1.0M)

Appendix G. Economic evidence study selection

Economic evidence study selection for review question: what is the most effective way of managing a longitudinal lie fetal malpresentation (breech presentation) in late pregnancy, appendix h. economic evidence tables, economic evidence tables for review question: what is the most effective way of managing a longitudinal lie fetal malpresentation (breech presentation) in late pregnancy, appendix i. economic evidence profiles, economic evidence profiles for review question: what is the most effective way of managing a longitudinal lie fetal malpresentation (breech presentation) in late pregnancy, appendix j. economic analysis, economic evidence analysis for review question: what is the most effective way of managing a longitudinal lie fetal malpresentation (breech presentation) in late pregnancy.

No economic analysis was conducted for this review question.

Appendix K. Excluded studies

Excluded clinical and economic studies for review question: what is the most effective way of managing a longitudinal lie fetal malpresentation (breech presentation) in late pregnancy, clinical studies, table 24 excluded studies.

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Economic studies

No economic evidence was identified for this review.

Appendix L. Research recommendations

Research recommendations for review question: what is the most effective way of managing a longitudinal lie fetal malpresentation (breech presentation) in late pregnancy.

No research recommendations were made for this review question.

Evidence reviews underpinning recommendation 1.2.38

These evidence reviews were developed by the National Guideline Alliance, which is a part of the Royal College of Obstetricians and Gynaecologists

Disclaimer : The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.

Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.

NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government , Scottish Government , and Northern Ireland Executive . All NICE guidance is subject to regular review and may be updated or withdrawn.

• Cite this Page National Guideline Alliance (UK). Management of breech presentation: Antenatal care: Evidence review M. London: National Institute for Health and Care Excellence (NICE); 2021 Aug. (NICE Guideline, No. 201.)
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Related NICE guidance and evidence

• NICE Guideline 201: Antenatal care

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• Supplement 1: Methods (PDF)
• Supplement 2: Health economics (PDF)

Related information

• PMC PubMed Central citations
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Similar articles in PubMed

• Review Identification of breech presentation: Antenatal care: Evidence review L [ 2021] Review Identification of breech presentation: Antenatal care: Evidence review L National Guideline Alliance (UK). 2021 Aug
• Vaginal delivery of breech presentation. [J Obstet Gynaecol Can. 2009] Vaginal delivery of breech presentation. Kotaska A, Menticoglou S, Gagnon R, MATERNAL FETAL MEDICINE COMMITTEE. J Obstet Gynaecol Can. 2009 Jun; 31(6):557-566.
• Review Cephalic version by moxibustion for breech presentation. [Cochrane Database Syst Rev. 2005] Review Cephalic version by moxibustion for breech presentation. Coyle ME, Smith CA, Peat B. Cochrane Database Syst Rev. 2005 Apr 18; (2):CD003928. Epub 2005 Apr 18.
• [Fetal expulsion: Which interventions for perineal prevention? CNGOF Perineal Prevention and Protection in Obstetrics Guidelines]. [Gynecol Obstet Fertil Senol. 2...] [Fetal expulsion: Which interventions for perineal prevention? CNGOF Perineal Prevention and Protection in Obstetrics Guidelines]. Riethmuller D, Ramanah R, Mottet N. Gynecol Obstet Fertil Senol. 2018 Dec; 46(12):937-947. Epub 2018 Oct 28.
• Foetal weight, presentaion and the progress of labour. II. Breech and occipito-posterior presentation related to the baby's weight and the length of the first stage of labour. [J Obstet Gynaecol Br Emp. 1961] Foetal weight, presentaion and the progress of labour. II. Breech and occipito-posterior presentation related to the baby's weight and the length of the first stage of labour. BAINBRIDGE MN, NIXON WC, SMYTH CN. J Obstet Gynaecol Br Emp. 1961 Oct; 68:748-54.

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Management of Breech Presentation (Green-top Guideline No. 20b)

Summary: The aim of this guideline is to aid decision making regarding the route of delivery and choice of various techniques used during delivery. It does not include antenatal or postnatal care. Information regarding external cephalic version is the topic of the separate Royal College of Obstetricians and Gynaecologists Green-top Guideline No. 20a,  External Cephalic Version and Reducing the Incidence of Term Breech Presentation .

Breech presentation occurs in 3–4% of term deliveries and is more common in preterm deliveries and nulliparous women. Breech presentation is associated with uterine and congenital abnormalities, and has a significant recurrence risk. Term babies presenting by the breech have worse outcomes than cephalic presenting babies, irrespective of the mode of delivery.

A large reduction in the incidence of planned vaginal breech birth followed publication of the Term Breech Trial. Nevertheless, due to various circumstances vaginal breech births will continue. Lack of experience has led to a loss of skills essential for these deliveries. Conversely, caesarean section can has serious long-term consequences.

COVID disclaimer: This guideline was developed as part of the regular updates to programme of Green-top Guidelines, as outlined in our document  Developing a Green-top Guideline: Guidance for developers , and prior to the emergence of COVID-19.

Version history: This is the fourth edition of this guideline.

Please note that the RCOG Guidelines Committee regularly assesses the need to update the information provided in this publication. Further information on this review is available on request.

Developer declaration of interests:

Mr M Griffiths  is a member of Doctors for a Woman's right to Choose on Abortion. He is an unpaid member of a Quality Standards Advisory Committee at NICE, for which he does receive expenses for related travel, accommodation and meals.

Mr LWM Impey  is Director of Oxford Fetal Medicine Ltd. and a member of the International Society of Ultrasound in Obstetrics and Gynecology. He also holds patents related to ultrasound processing, which are of no relevance to the Breech guidelines.

Professor DJ Murphy  provides medicolegal expert opinions in Scotland and Ireland for which she is remunerated.

Dr LK Penna:  None declared.

• Access the PDF version of this guideline on Wiley
• Access the web version of this guideline on Wiley

This page was last reviewed 16 March 2017.

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Breech Births

In the last weeks of pregnancy, a baby usually moves so his or her head is positioned to come out of the vagina first during birth. This is called a vertex presentation. A breech presentation occurs when the baby’s buttocks, feet, or both are positioned to come out first during birth. This happens in 3–4% of full-term births.

What are the different types of breech birth presentations?

• Complete breech: Here, the buttocks are pointing downward with the legs folded at the knees and feet near the buttocks.
• Frank breech: In this position, the baby’s buttocks are aimed at the birth canal with its legs sticking straight up in front of his or her body and the feet near the head.
• Footling breech: In this position, one or both of the baby’s feet point downward and will deliver before the rest of the body.

What causes a breech presentation?

The causes of breech presentations are not fully understood. However, the data show that breech birth is more common when:

• You have been pregnant before
• In pregnancies of multiples
• When there is a history of premature delivery
• When the uterus has too much or too little amniotic fluid
• When there is an abnormally shaped uterus or a uterus with abnormal growths, such as fibroids
• The placenta covers all or part of the opening of the uterus placenta previa

How is a breech presentation diagnosed?

A few weeks prior to the due date, the health care provider will place her hands on the mother’s lower abdomen to locate the baby’s head, back, and buttocks. If it appears that the baby might be in a breech position, they can use ultrasound or pelvic exam to confirm the position. Special x-rays can also be used to determine the baby’s position and the size of the pelvis to determine if a vaginal delivery of a breech baby can be safely attempted.

Can a breech presentation mean something is wrong?

Even though most breech babies are born healthy, there is a slightly elevated risk for certain problems. Birth defects are slightly more common in breech babies and the defect might be the reason that the baby failed to move into the right position prior to delivery.

Can a breech presentation be changed?

It is preferable to try to turn a breech baby between the 32nd and 37th weeks of pregnancy . The methods of turning a baby will vary and the success rate for each method can also vary. It is best to discuss the options with the health care provider to see which method she recommends.

Medical Techniques

External Cephalic Version (EVC)  is a non-surgical technique to move the baby in the uterus. In this procedure, a medication is given to help relax the uterus. There might also be the use of an ultrasound to determine the position of the baby, the location of the placenta and the amount of amniotic fluid in the uterus.

Gentle pushing on the lower abdomen can turn the baby into the head-down position. Throughout the external version the baby’s heartbeat will be closely monitored so that if a problem develops, the health care provider will immediately stop the procedure. ECV usually is done near a delivery room so if a problem occurs, a cesarean delivery can be performed quickly. The external version has a high success rate and can be considered if you have had a previous cesarean delivery.

ECV will not be tried if:

• You are carrying more than one fetus
• There are concerns about the health of the fetus
• You have certain abnormalities of the reproductive system
• The placenta is in the wrong place
• The placenta has come away from the wall of the uterus ( placental abruption )

Complications of EVC include:

• Prelabor rupture of membranes
• Changes in the fetus’s heart rate
• Placental abruption
• Preterm labor

Vaginal delivery versus cesarean for breech birth?

Most health care providers do not believe in attempting a vaginal delivery for a breech position. However, some will delay making a final decision until the woman is in labor. The following conditions are considered necessary in order to attempt a vaginal birth:

• The baby is full-term and in the frank breech presentation
• The baby does not show signs of distress while its heart rate is closely monitored.
• The process of labor is smooth and steady with the cervix widening as the baby descends.
• The health care provider estimates that the baby is not too big or the mother’s pelvis too narrow for the baby to pass safely through the birth canal.
• Anesthesia is available and a cesarean delivery possible on short notice

What are the risks and complications of a vaginal delivery?

In a breech birth, the baby’s head is the last part of its body to emerge making it more difficult to ease it through the birth canal. Sometimes forceps are used to guide the baby’s head out of the birth canal. Another potential problem is cord prolapse . In this situation the umbilical cord is squeezed as the baby moves toward the birth canal, thus slowing the baby’s supply of oxygen and blood. In a vaginal breech delivery, electronic fetal monitoring will be used to monitor the baby’s heartbeat throughout the course of labor. Cesarean delivery may be an option if signs develop that the baby may be in distress.

When is a cesarean delivery used with a breech presentation?

Most health care providers recommend a cesarean delivery for all babies in a breech position, especially babies that are premature. Since premature babies are small and more fragile, and because the head of a premature baby is relatively larger in proportion to its body, the baby is unlikely to stretch the cervix as much as a full-term baby. This means that there might be less room for the head to emerge.

Want to Know More?

• Creating Your Birth Plan
• Labor & Birth Terms to Know
• Cesarean Birth After Care

Compiled using information from the following sources:

• ACOG: If Your Baby is Breech
• William’s Obstetrics Twenty-Second Ed. Cunningham, F. Gary, et al, Ch. 24.
• Danforth’s Obstetrics and Gynecology Ninth Ed. Scott, James R., et al, Ch. 21.

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