how to deliver breech presentation

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First, recognize breech presentation when the buttocks appear in the birth canal before the head does. Experienced providers can deliver some babies in frank or complete breech presentations. Have a cloth or surgical towel available as well as other instruments used for routine deliveries and prepare for what to do if vaginal delivery is unsuccessful.

This position is a frank breech.

This position is a complete breech.

And this position is an incomplete complete breech.

Allow delivery to the level of the umbilicus with maternal effort. If possible, do this without touching the infant. Anticipate umbilical cord compression and possibly fetal decelerations.

To deliver a leg, splint the medial thigh parallel to the femur and sweep the thigh laterally. Repeat this procedure to deliver the other leg.

Wrap a towel around the infant, putting your fingers on the anterior superior iliac spines and your thumbs on the sacrum.

Assist the mother’s efforts during contractions by applying gentle traction to help deliver the body to the level of the scapulas.

Rotate the body in either direction to make one shoulder anterior. Deliver the anterior arm by sweeping it across the chest. Rotate the infant 180 degrees in either direction. Deliver the arm that is now anterior the same way the other arm was delivered. Move the towel up to cover the arms and rotate the body to make the back anterior.

To deliver the head, place your index and middle fingers of one hand over the fetal maxilla to flex the head, while the body rests on your palm and forearm, as shown here. With your other hand, hook 2 fingers over the neck, grasp the shoulder, and apply gentle downward traction. Have an assistant apply suprapubic pressure to help maintain head flexion and deliver the head.

Procedure by Will Stone, MD, and Kate Leonard, MD, Walter Reed National Military Medical Center Residency in Obstetrics and Gynecology; and Shad Deering, COL, MD, Chair, Department of Obstetrics and Gynecology, Uniformed Services University. Assisted by Elizabeth N. Weissbrod, MA, CMI, Eric Wilson, 2LT, and Jamie Bradshaw at the Val G. Hemming Simulation Center at the Uniformed Services University.

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What to know if your baby is breech

Find out what breech position means, how to turn a breech baby, and what having a breech baby means for your labor and delivery.

Layan Alrahmani, M.D.

What does it mean when a baby is breech?

Signs of a breech baby, why are some babies breech, how to turn a breech baby: is it possible, will i need a c-section if my baby is breech, how to turn a breech baby naturally.

Breech is a term used to describe your baby's position in the womb. Breech position means your baby is bottom-down instead of head-down.

Babies are often active in early pregnancy, moving into different positions. But by around 8 months, there's not much room in the uterus. Most babies maximize their cramped quarters by settling in head down, in what's known as a cephalic or vertex presentation. But if you have a breech baby, it means they're poised to come out buttocks and/or feet first. At 28 weeks or less, about a quarter of babies are breech, and at 32 weeks, 7 percent are breech. By the end of pregnancy, only 3 to 4 percent of babies are in breech position. At term, a baby in breech position is unlikely to turn on their own.

There are several types of breech presentations:

  • Frank breech (bottom first with feet up near the head)
  • Complete breech (bottom first with legs crossed)
  • Incomplete or footling breech (one or both feet are poised to come out first)

(In rare cases, a baby will be sideways in the uterus with their shoulder, back, or arm presenting first – this is called a transverse lie.)

See what these breech presentations look like .

If your baby is in breech position, you may feel them kicking in your lower belly. Or you may feel pressure under your ribcage, from their head.

By the beginning of your third trimester , your practitioner may be able to tell what position your baby is in by feeling your abdomen and locating the baby's head, back, and bottom.

If your baby's position isn't clear during an abdominal exam at 36 weeks, your caregiver may do an internal exam to try to feel what part of the baby is in your pelvis. In some cases, they may use ultrasound to confirm the baby's position.

We don't usually know why some babies are breech – in most cases it seems to be chance. While sometimes a baby with certain birth defects may not turn to a head-down position, most babies in breech position are perfectly fine. Here are some things that might increase the risk of a breech presentation:

  • You're carrying multiples
  • You've been pregnant before
  • You've had a breech presentation before
  • There's too much amniotic fluid or not enough amniotic fluid
  • You have placenta previa (the placenta is covering all of part of the opening of the uterus)
  • Your baby is preterm
  • Your uterus is shaped abnormally or has growths, such as fibroids
  • The umbilical cord is short
  • You were a breech delivery, or your sibling or parent was a breech delivery
  • Advanced maternal age (especially age 45 and older)
  • Your baby is a low weight at delivery
  • You're having a girl

There is a procedure for turning a breech baby. It's called an external cephalic version (ECV). An ob/gyn turns your baby by applying pressure to your abdomen and manually manipulating the baby into a head-down position. Some women find it very uncomfortable or even painful.

An EVC has about a 58 percent success rate, and it's more likely to work if this isn't your first baby. It's not for everyone – you can't have the procedure if you're carrying multiples or if you have too little amniotic fluid or placental abruption , for example. Your provider also won't attempt to turn your breech baby if your baby has any health problems.

The procedure is done after 36 weeks and in the hospital, where your baby can be monitored and where you'll be near a delivery room should any complications arise.

It depends, and it's something you'll want to talk with your caregiver about ahead of time. Discuss your preferences, the advantages and risks of each option ( vaginal and cesarean delivery of a breech presentation), and their experience. The biggest risk of a breech delivery is when the body delivers but the head stays entrapped within the cervix.

In the United States, most breech babies are delivered via cesarean. You may wind up having a vaginal breech delivery if your labor is so rapid that you arrive at the hospital just about to deliver. Another scenario is if you have a twin pregnancy where the first baby is in the head-first position and the second baby is not. A baby who delivers head-first will make room for the breech baby.

However, the vast majority of babies who remain breech arrive by c-section. If a c-section is planned, it will usually be scheduled at 39 weeks. To make sure your baby hasn't changed position in the meantime, you'll have an ultrasound at the hospital to confirm their position just before the surgery.

If you go into labor or your water will break s before your planned c-section, be sure to call your provider right away and head for the hospital.

In rare circumstances, if you're at low risk of complications and your caregiver is experienced delivering breech babies vaginally, you may choose to have what is called a "trial of vaginal birth." This means that you can attempt to deliver vaginally but should be prepared to have a cesarean delivery if labor isn't progressing well. You and your baby will be closely monitored during labor.

In addition to ECV, there are some alternative, natural ways to try to turn your baby. There's no proof that any of them work – or that all of them are safe. Consult your practitioner before trying them.

There's no conclusive proof that the mother's position has any effect on the baby's position, but the idea is to employ gravity to help your baby somersault into a head-down position. A few tips:

  • Get into one of the following positions twice a day, starting at around 32 weeks.
  • Be sure to do these moves on an empty stomach, lest your lunch comes back up.
  • Make sure there's someone around to help you get up if you start feeling lightheaded.
  • If you find these positions uncomfortable, stop doing them.

Position 1: Lie flat on your back and raise your pelvis so that it's 9 to 12 inches off the floor. Support your hips with a pillow and stay in this position for five to 15 minutes. Position 2: Kneel down, with your forearms on the floor in front of you, so that your bottom sticks up in the air. Stay in this position for five to 15 minutes. Sleeping position

Many women wonder if there are sleeping positions to turn a breech baby. But the positions you use to try to coax your baby head down for a short time shouldn't be used while you're sleeping. (It's not safe to sleep flat on your back in late pregnancy, for example, because the weight of your baby may compress the blood vessels that provide oxygen and nutrients to them.)

The best position for sleeping during pregnancy is on your side. Placing a pillow between your legs in this position may help open your pelvis, giving your baby room to move more easily. Support your back with plenty of pillows, too. Again, there's no proof that this works, but since it's the best sleeping position for you and your baby, you may as well give it a try.

Moxibustion

This ancient Chinese technique burns herbs to stimulate key acupressure points. To help turn a breech baby, an acupuncturist or other practitioner burns mugwort near the acupressure point of your pinky toes. According to Chinese medicine, this should stimulate your baby's activity enough that they may change position on their own. Some studies show that moxibustion in combination with acupuncture and/or positioning methods may be of some benefit. Others show moxibustion to provide no help in coaxing a baby into cephalic position. If you've discussed it with your caregiver and want to give it a try, contact your state acupuncture or Chinese medicine association and ask for the names of licensed practitioners.

One small study found that women who are regularly hypnotized into a state of deep relaxation at 37 to 40 weeks are more likely to have their baby turn than other women. If you're willing to try this technique, look for a licensed hypnotherapist with experience working with pregnant women.

Chiropractic care

There's a technique – called The Webster Breech Technique – that aims to reduce stress on the pelvis by relaxing the uterus and surrounding ligaments. The idea is that a breech baby can turn more naturally in a relaxed uterus, but research is limited as to the risks and benefits of this technique. If you're interested, talk with your provider about working with a chiropractor who's experienced with the technique.

This is a safe – and again, unproven – method based on the fact that your baby can hear sounds outside the womb. Simply play music close to the lower part of your abdomen (some women use headphones) to encourage your baby to move in the direction of the sound.

Learn more:

  • C-section recovery
  • Third trimester pregnancy guide and checklist
  • Hospital bag checklist

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Breech, posterior, transverse lie: What position is my baby in?

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BabyCenter's editorial team is committed to providing the most helpful and trustworthy pregnancy and parenting information in the world. When creating and updating content, we rely on credible sources: respected health organizations, professional groups of doctors and other experts, and published studies in peer-reviewed journals. We believe you should always know the source of the information you're seeing. Learn more about our editorial and medical review policies .

ACOG. 2019. If your baby is breech. FAQ. The American College of Obstetricians and Gynecologists. https://www.acog.org/womens-health/faqs/if-your-baby-is-breech Opens a new window [Accessed November 2021]

ACOG. 2018. Mode of term singleton breech delivery. Committee opinion number 745. The American College of Obstetricians and Gynecologists. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/08/mode-of-term-singleton-breech-delivery Opens a new window [Accessed November 2021]

Brici P et al. 2019. Turning foetal breech presentation at 32-35 weeks of gestational age by acupuncture and moxibustion. Evidence-based Complementary and Alternative Medicine https://www.hindawi.com/journals/ecam/2019/8950924/ Opens a new window [Accessed November 2021]

Ekeus C et al. 2019. Vaginal breech delivery at term and neonatal morbidity and mortality — a population-based cohort study in Sweden. Journal of Maternal Fetal Neonatal Medicine 32(2):265. https://pubmed.ncbi.nlm.nih.gov/28889774/ Opens a new window [Accessed November 2021]

Fruscalzo A et al 2014. New and old predictive factors for breech presentation: our experience in 14433 singleton pregnancies and a literature review. Journal of Maternal Fetal Neonatal Medicine 27(2): 167-72. https://pubmed.ncbi.nlm.nih.gov/23688372/ Opens a new window [Accessed November 2021]

Garcia MM et al. 2019 Effectiveness and safety of acupuncture and moxibustion in pregnant women with noncephalic presentation: An overview of systematic reviews. Evidence Based Complementary Alternative Medicine 7036914. https://pubmed.ncbi.nlm.nih.gov/31885661/ Opens a new window [Accessed November 2021]

Gray C. 2021. Breech presentation. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK448063/ Opens a new window [Accessed November 2021]

Meaghan M et al. 2021. External cephalic version. NCBI StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK482475/ Opens a new window [Accessed November 2021]

MedlinePlus. 2020. Breech - series - Types of breech presentation. https://medlineplus.gov/ency/presentations/100193_3.htm Opens a new window [Accessed November 2020]

Noli SA et al. 2019. Preterm birth, low gestational age, low birth weight, parity, and other determinants of breech presentation: Results from a large retrospective population-based study. Biomed Research International https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6766171/ Opens a new window [Accessed November 2021]

Pistolese RA. 2002. The Webster Technique: A chiropractic technique with obstetric implications. Journal of Manipulative and Physiological Therapeutics 25(6): E1-9. https://pubmed.ncbi.nlm.nih.gov/12183701/ Opens a new window [Accessed November 2021]

Karen Miles

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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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how to deliver breech presentation

Enter search terms to find related medical topics, multimedia and more.

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  • Use “ “ for exact phrases.
  • For example: “pediatric abdominal pain”
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First, recognize breech presentation when the buttocks appear in the birth canal before the head does. Experienced providers can deliver some babies in frank or complete breech presentations. Have a cloth or surgical towel available as well as other instruments used for routine deliveries and prepare for what to do if vaginal delivery is unsuccessful.

This position is a frank breech.

This position is a complete breech.

And this position is an incomplete complete breech.

Allow delivery to the level of the umbilicus with maternal effort. If possible, do this without touching the infant. Anticipate umbilical cord compression and possibly fetal decelerations.

To deliver a leg, splint the medial thigh parallel to the femur and sweep the thigh laterally. Repeat this procedure to deliver the other leg.

Wrap a towel around the infant, putting your fingers on the anterior superior iliac spines and your thumbs on the sacrum.

Assist the mother’s efforts during contractions by applying gentle traction to help deliver the body to the level of the scapulas.

Rotate the body in either direction to make one shoulder anterior. Deliver the anterior arm by sweeping it across the chest. Rotate the infant 180 degrees in either direction. Deliver the arm that is now anterior the same way the other arm was delivered. Move the towel up to cover the arms and rotate the body to make the back anterior.

To deliver the head, place your index and middle fingers of one hand over the fetal maxilla to flex the head, while the body rests on your palm and forearm, as shown here. With your other hand, hook 2 fingers over the neck, grasp the shoulder, and apply gentle downward traction. Have an assistant apply suprapubic pressure to help maintain head flexion and deliver the head.

Procedure by Will Stone, MD, and Kate Leonard, MD, Walter Reed National Military Medical Center Residency in Obstetrics and Gynecology; and Shad Deering, COL, MD, Chair, Department of Obstetrics and Gynecology, Uniformed Services University. Assisted by Elizabeth N. Weissbrod, MA, CMI, Eric Wilson, 2LT, and Jamie Bradshaw at the Val G. Hemming Simulation Center at the Uniformed Services University.

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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. Christine Zink, MD, is a board-certified emergency medicine with expertise in the wilderness and global medicine. She completed her medical training at Weill Cornell Medical College and residency in emergency medicine at New York-Presbyterian Hospital. She utilizes 15-years of clinical experience in her medical writing.

6.1 Breech presentation

Presentation of the feet or buttocks of the foetus.

6.1.1 The different breech presentations

  • In a complete breech presentation, the legs are tucked, and the foetus is in a crouching position (Figure 6.1a).
  • In a frank breech presentation, the legs are extended, raised in front of the torso, with the feet near the head (Figure 6.1b).
  • In a footling breech presentation (rare), one or both feet present first, with the buttocks higher up and the lower limbs extended or half-bent (Figure 6.1c).

how to deliver breech presentation

6.1.2 Diagnosis

  • The cephalic pole is palpable in the uterine fundus; round, hard, and mobile; the indentation of the neck can be felt.
  • The inferior pole is voluminous, irregular, less hard, and less mobile than the head.
  • During labour, vaginal examination reveals a “soft mass” divided by the cleft between the buttocks, with a hard projection at end of the cleft (the coccyx and sacrum).
  • After rupture of the membranes: the anus can be felt in the middle of the cleft; a foot may also be felt.
  • The clinical diagnosis may be difficult: a hand may be mistaken for a foot, a face for a breech.

6.1.3 Management

Route of delivery.

Before labour, external version (Chapter 7, Section 7.7 ) may be attempted to avoid breech delivery.

If external version is contra-indicated or unsuccessful, the breech position alone – in the absence of any other anomaly – is not, strictly speaking, a dystocic presentation, and does not automatically require a caesarean section. Deliver vaginally, if possible – even if the woman is primiparous.

Breech deliveries must be done in a CEmONC facility, especially for primiparous women.

Favourable factors for vaginal delivery are:

  • Frank breech presentation;
  • A history of vaginal delivery (whatever the presentation);
  • Normally progressing dilation during labour.

The footling breech presentation is a very unfavourable position for vaginal delivery (risk of foot or cord prolapse). In this situation, the route of delivery depends on the number of previous births, the state of the membranes and how far advanced the labour is.

During labour

  • Monitor dilation every 2 to 4 hours. 
  • If contractions are of good quality, dilation is progressing, and the foetal heart rate is regular, an expectant approach is best. Do not rupture the membranes unless dilation stops.
  • If the uterine contractions are inadequate, labour can be actively managed with oxytocin.

Note : if the dilation stales, transfer the mother to a CEmONC facility unless already done, to ensure access to surgical facility for potential caesarean section.

At delivery

  • Insert an IV line before expulsion starts.
  • Consider episiotomy at expulsion. Episiotomy is performed when the perineum is sufficiently distended by the foetus's buttocks.
  • Presence of meconium or meconium-stained amniotic fluid is common during breech delivery and is not necessarily a sign of foetal distress.
  • The infant delivers unaided , as a result of the mother's pushing, simply supported by the birth attendant who gently holds the infant by the bony parts (hips and sacrum), with no traction. Do not pull on the legs.

Once the umbilicus is out, the rest of the delivery must be completed within 3 minutes, otherwise compression of the cord will deprive the infant of oxygen. Do not touch the infant until the shoulder blades appear to avoid triggering the respiratory reflex before the head is delivered.

  • Monitor the position of the infant's back; impede rotation into posterior position.

Figures 6.2 - Breech delivery

how to deliver breech presentation

6.1.4 Breech delivery problems

Posterior orientation.

If the infant’s back is posterior during expulsion, take hold of the hips and turn into an anterior position (this is a rare occurrence).

Obstructed shoulders

The shoulders can become stuck and hold back the infant's upper chest and head. This can occur when the arms are raised as the shoulders pass through the mother's pelvis. There are 2 methods for lowering the arms so that the shoulders can descend:

1 - Lovset's manoeuvre

  • With thumbs on the infant's sacrum, take hold of the hips and pelvis with the other fingers.
  • Turn the infant 90° (back to the left or to the right), to bring the anterior shoulder underneath the symphysis and engage the arm. Deliver the anterior arm.
  • Then do a 180° counter-rotation (back to the right or to the left); this engages the posterior arm, which is then delivered.

Figures 6.3 - Lovset's manoeuvre

how to deliver breech presentation

6.3c  - Delivering the anterior arm and shoulder

how to deliver breech presentation

2 - Suzor’s manoeuvre

In case the previous method fails:

  • Turn the infant 90° (its back to the right or to the left).
  • Pull the infant downward: insert one hand along the back to look for the anterior arm. With the operator thumb in the infant armpit and middle finger along the arm, bring down the arm (Figure 6.4a).
  • Lift infant upward by the feet in order to deliver the posterior shoulder (Figure 6.4b).

Figures 6.4 - Suzor's manoeuvre

how to deliver breech presentation

6.4b  - Delivering the posterior shoulder

how to deliver breech presentation

Head entrapment

The infant's head is bulkier than the body, and can get trapped in the mother's pelvis or soft tissue.

There are various manoeuvres for delivering the head by flexing it, so that it descends properly, and then pivoting it up and around the mother's symphysis. These manoeuvres must be done without delay, since the infant must be allowed to breathe as soon as possible. All these manoeuvres must be performed smoothly, without traction on the infant.

1 - Bracht's manoeuvre

  • After the arms are delivered, the infant is grasped by the hips and lifted with two hands toward the mother's stomach, without any traction, the neck pivoting around the symphysis.
  • Having an assistant apply suprapubic pressure facilitates delivery of the aftercoming head.

how to deliver breech presentation

2 - Modified Mauriceau manoeuvre

  • Infant's head occiput anterior.
  • Kneel to get a good traction angle: 45° downward.
  • Support the infant on the hand and forearm, then insert the index and middle fingers, placing them on the infant’s maxilla. Placing the index and middle fingers into the infant’s mouth is not recommended, as this can fracture the mandible.
  • Place the index and middle fingers of the other hand on either side of the infant's neck and lower the infant's head to bring the sub-occiput under the symphysis (Figure 6.6a).
  • Tip the infant’s head and with a sweeping motion bring the back up toward the mother's abdomen, pivoting the occiput around her symphysis pubis (Figure 6.6b).
  • Suprapubic pressure on the infant's head along the pelvic axis helps delivery of the head.
  • As a last resort, symphysiotomy (Chapter 5, Section 5.7 ) can be combined with this manoeuvre.

Figures 6.6 - Modified Mauriceau manoeuvre

6.6a - Step 1 Infant straddles the birth attendant's forearm; the head, occiput anterior, is lowered to bring the occiput in contact with the symphysis.

how to deliver breech presentation

6.6b  - Step 2 The infant's back is tipped up toward the mother's abdomen.

how to deliver breech presentation

3 - Forceps on aftercoming head 

This procedure can only be performed by an operator experienced in using forceps.

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What Causes Breech Presentation?

Learn more about the types, causes, and risks of breech presentation, along with how breech babies are typically delivered.

What Is Breech Presentation?

Types of breech presentation, what causes a breech baby, can you turn a breech baby, how are breech babies delivered.

FatCamera/Getty Images

Toward the end of pregnancy, your baby will start to get into position for delivery, with their head pointed down toward the vagina. This is otherwise known as vertex presentation. However, some babies turn inside the womb so that their feet or buttocks are poised to be delivered first, which is commonly referred to as breech presentation, or a breech baby.

As you near the end of your pregnancy journey, an OB-GYN or health care provider will check your baby's positioning. You might find yourself wondering: What causes breech presentation? Are there risks involved? And how are breech babies delivered? We turned to experts and research to answer some of the most common questions surrounding breech presentation, along with what causes this positioning in the first place.

During your pregnancy, your baby constantly moves around the uterus. Indeed, most babies do somersaults up until the 36th week of pregnancy , when they pick their final position in the womb, says Laura Riley , MD, an OB-GYN in New York City. Approximately 3-4% of babies end up “upside-down” in breech presentation, with their feet or buttocks near the cervix.

Breech presentation is typically diagnosed during a visit to an OB-GYN, midwife, or health care provider. Your physician can feel the position of your baby's head through your abdominal wall—or they can conduct a vaginal exam if your cervix is open. A suspected breech presentation should ultimately be confirmed via an ultrasound, after which you and your provider would have a discussion about delivery options, potential issues, and risks.

There are three types of breech babies: frank, footling, and complete. Learn about the differences between these breech presentations.

Frank Breech

With frank breech presentation, your baby’s bottom faces the cervix and their legs are straight up. This is the most common type of breech presentation.

Footling Breech

Like its name suggests, a footling breech is when one (single footling) or both (double footling) of the baby's feet are in the birth canal, where they’re positioned to be delivered first .

Complete Breech

In a complete breech presentation, baby’s bottom faces the cervix. Their legs are bent at the knees, and their feet are near their bottom. A complete breech is the least common type of breech presentation.

Other Types of Mal Presentations

The baby can also be in a transverse position, meaning that they're sideways in the uterus. Another type is called oblique presentation, which means they're pointing toward one of the pregnant person’s hips.

Typically, your baby's positioning is determined by the fetus itself and the shape of your uterus. Because you can't can’t control either of these factors, breech presentation typically isn’t considered preventable. And while the cause often isn't known, there are certain risk factors that may increase your risk of a breech baby, including the following:

  • The fetus may have abnormalities involving the muscular or central nervous system
  • The uterus may have abnormal growths or fibroids
  • There might be insufficient amniotic fluid in the uterus (too much or too little)
  • This isn’t your first pregnancy
  • You have a history of premature delivery
  • You have placenta previa (the placenta partially or fully covers the cervix)
  • You’re pregnant with multiples
  • You’ve had a previous breech baby

In some cases, your health care provider may attempt to help turn a baby in breech presentation through a procedure known as external cephalic version (ECV). This is when a health care professional applies gentle pressure on your lower abdomen to try and coax your baby into a head-down position. During the entire procedure, the fetus's health will be monitored, and an ECV is often performed near a delivery room, in the event of any potential issues or complications.

However, it's important to note that ECVs aren't for everyone. If you're carrying multiples, there's health concerns about you or the baby, or you've experienced certain complications with your placenta or based on placental location, a health care provider will not attempt an ECV.

The majority of breech babies are born through C-sections . These are usually scheduled between 38 and 39 weeks of pregnancy, before labor can begin naturally. However, with a health care provider experienced in delivering breech babies vaginally, a natural delivery might be a safe option for some people. In fact, a 2017 study showed similar complication and success rates with vaginal and C-section deliveries of breech babies.

That said, there are certain known risks and complications that can arise with an attempt to deliver a breech baby vaginally, many of which relate to problems with the umbilical cord. If you and your medical team decide on a vaginal delivery, your baby will be monitored closely for any potential signs of distress.

Ultimately, it's important to know that most breech babies are born healthy. Your provider will consider your specific medical condition and the position of your baby to determine which type of delivery will be the safest option for a healthy and successful birth.

ACOG. If Your Baby Is Breech .

American Pregnancy Association. Breech Presentation .

Gray CJ, Shanahan MM. Breech Presentation . [Updated 2022 Nov 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.

Mount Sinai. Breech Babies .

Takeda J, Ishikawa G, Takeda S. Clinical Tips of Cesarean Section in Case of Breech, Transverse Presentation, and Incarcerated Uterus . Surg J (N Y). 2020 Mar 18;6(Suppl 2):S81-S91. doi: 10.1055/s-0040-1702985. PMID: 32760790; PMCID: PMC7396468.

Shanahan MM, Gray CJ. External Cephalic Version . [Updated 2022 Nov 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. 

Fonseca A, Silva R, Rato I, Neves AR, Peixoto C, Ferraz Z, Ramalho I, Carocha A, Félix N, Valdoleiros S, Galvão A, Gonçalves D, Curado J, Palma MJ, Antunes IL, Clode N, Graça LM. Breech Presentation: Vaginal Versus Cesarean Delivery, Which Intervention Leads to the Best Outcomes? Acta Med Port. 2017 Jun 30;30(6):479-484. doi: 10.20344/amp.7920. Epub 2017 Jun 30. PMID: 28898615.

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Emergency Medicine Procedures, 2e

Chapter 134. Breech Delivery

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  • Introduction
  • Anatomy and Pathophysiology
  • Indications
  • Contraindications
  • Patient Preparation
  • Assisted Vaginal Frank Breech Delivery
  • Delivery of the Fetal Head
  • Total Breech Extraction
  • Complete and Incomplete Breech Deliveries
  • Complications
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The breech presentation exists when the cephalic pole of the fetus is positioned in a longitudinal lie and the buttocks or feet of the fetus enter the maternal pelvis before the head. 1 Management of the breech presentation in labor is an area of much trepidation and controversy, even among seasoned clinicians. A breech delivery is considered a high-risk obstetric complication that is best handled by an Obstetrician.

There are, however, unavoidable situations when a pregnant woman will present to the Emergency Department in active labor with a fetus in the breech position. A vaginal breech delivery may be the best delivery option in situations such as advanced labor, the absence of surgical assistance, the presence of an acute situation, fetal distress, or umbilical cord prolapse. Knowledge and preparedness facilitate comfort and promote success in approaching any emergent procedure. The breech delivery is no exception to this rule.

The breech presentation may be associated with a variety of maternal and fetal conditions. 1 , 2 Maternal abnormalities that increase the risk of a breech presentation include a small pelvis and uterine anomalies. Fetal conditions associated with a breech presentation include low birth weight, prematurity, abnormal amniotic fluid volume, fetal malformations (e.g., hydrocephalus, cystic hygroma, and anencephaly), neurologic disorders, and genetic abnormalities.

Prematurity is a risk factor for a breech presentation. The incidence of breech presentations is inversely related to the fetal gestational age. 1 , 2 At 28 weeks of gestation, 24% of fetuses are in the breech presentation. The fetus usually turns spontaneously to a cephalic presentation so that at term, only 3% to 4% are in the breech presentation. 1 , 2

There are three main types of breech presentation ( Figure 134-1 ). The most common is the frank breech, accounting for 50% to 73% of breech presentations. The fetus is flexed at the hips and extended at the knees ( Figure 134-1 A ). The fetus is in the “pike” position. The complete breech is the least common type and accounts for approximately 5% to 11% of breech presentations. The fetus is flexed at both the hips and the knees ( Figure 134-1 B ). The footling or incomplete breech accounts for approximately 12% to 38% of breech presentations. The fetus is incompletely deflexed at one or both knees or hips ( Figure 134-1 C ). This results in one or both feet presenting before the buttocks. The risks of umbilical cord prolapse and prematurity associated with the breech presentation are listed in Table 134-1 .

Figure 134-1.

image

The main types of breech presentations. A. The frank breech. B. The complete breech. C. The incomplete breech.

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Ems prehospital deliveries.

Dallas T. Beaird ; Megan Ladd ; Suzanne M. Jenkins ; Chadi I. Kahwaji .

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  • Continuing Education Activity

While most deliveries take place in hospitals, there are cases where emergency medical services (EMS) are called to help with out-of-hospital deliveries, whether they are unexpected or planned but facing complications. In such situations, the initial priority is to swiftly transport both the mother and the infant, if the baby has already been delivered, to a hospital where they can receive appropriate care. Healthcare practitioners involved in these situations should possess the skills to assess the gestational age quickly, recognize if delivery is imminent, and be prepared to address any sudden issues that may arise.

Prehospital delivery primarily involves ensuring a controlled and guided delivery of the infant, managing immediate postpartum maternal bleeding, and providing limited care for the newborn until the patient can be safely transferred to a hospital. It's important to note that studies have demonstrated a higher risk of perinatal mortality in deliveries occurring outside a hospital compared to those within a hospital setting. Consequently, healthcare practitioners must be well-informed about prehospital delivery procedures, immediate postpartum care for both the mother and newborn, resuscitation techniques, and the management of common delivery complications.

The purpose of this activity for healthcare professionals is to enhance their competence when dealing with prehospital deliveries. It equips them with updated knowledge, skills, and strategies for promptly identifying complications, implementing effective interventions, and improving care coordination. Ultimately, this improves patient outcomes and reduces maternal and fetal morbidity.

  • Identify indications for prehospital deliveries and recognize when an imminent birth is occurring.
  • Assess pregnant patients in the prehospital setting to determine the stage of labor and maternal and fetal well-being.
  • Implement appropriate prehospital obstetric protocols for managing labor and delivery, including techniques for delivering a baby in emergent situations.
  • Collaborate with other EMS personnel and healthcare providers to ensure seamless care for both mother and newborn.
  • Introduction

Prehospital delivery, often termed an unplanned out-of-hospital birth or birth before arrival, occurs when an infant is unintentionally born outside a hospital setting. In contrast to planned home births, these situations involve no prior preparations or access to healthcare practitioners and equipment. Sometimes, EMS personnel are summoned to transport planned home birth patients facing complications. [1]  

When EMS is called to aid an actively laboring patient, the foremost objective should be expeditiously transporting the mother to a hospital with obstetric services, if feasible. These facilities have obstetrically trained clinicians and the resources to handle potential complications. The American Academy of Pediatrics (AAP) and the American College of Obstetrics and Gynecology (ACOG) concur that hospitals and accredited birth centers offer the safest birthing environments. [2] However, sometimes there's insufficient time for transport before delivery. EMS healthcare practitioners are often summoned when a precipitous delivery has occurred or is imminent or the patient delivers en route. [3]

Unplanned prehospital deliveries have been linked to elevated perinatal mortality and morbidity risks for both the neonate and the mother. [4] [5] [6] [1] This is largely attributed to inadequate EMS obstetrical training in managing emergent deliveries and intrapartum complications, along with a failure to provide recommended neonatal resuscitation. [3] [7] [3] Hence, EMS practitioners must be well-versed in appropriate delivery techniques and immediate postpartum assessment and management for both the mother and neonate.

  • Anatomy and Physiology

Pelvic Girdle

The pelvis forms a bony ring, which the fetus must pass through during delivery. The size and shape of the maternal bony pelvis, in correlation with fetal size and position, significantly impact the ease of delivery. In up to 3% of deliveries, the anterior fetal shoulder unexpectedly gets stuck behind the maternal pubic bone during delivery, resulting in an obstetric emergency called shoulder dystocia. [8] [9]

The uterus is a hollow, pear-shaped muscle in a female's pelvis. It houses the fetus, placenta, and fluid-filled amniotic sac during pregnancy. During labor, the uterus generates powerful rhythmic muscular contractions, forcing the baby through the pelvis outlet and ultimately out of the vaginal opening. [9]

The cervix is a fibromuscular tubular structure that forms the opening of the uterus, leading into the vagina. During labor, uterine contractions push the fetal head against the cervix, helping it to dilate and thin out (ie, efface), which allows passage of the fetus out of the uterus and into the vagina. [9]

The cervix is assessed on a vaginal exam using a sterile technique to monitor labor progress during labor. Cervical dilation is measured in centimeters through digital examination with 2 fingers. Full dilation is typically defined as reaching a dilation of 10 centimeters. Effacement is measured as a percentage of thinning; a cervix that is 100% effaced refers to a cervix that has become paper-thin. [9]  In active labor, before full dilation and effacement, the cervix can be felt as a rim of tissue on top of the infant's presenting body part, usually the head. When the cervix is fully dilated and effaced, it falls behind the fetal presenting part and is no longer palpable. Delivery may be imminent if the cervix is no longer palpable and the fetal head can be seen at the vaginal introitus. [9]

Fundal Height

The fundus is the upper part of the uterus, easily felt during an abdominal examination as a firm, rounded dome. Fundal height is the distance, measured in centimeters, from the top of the fundus to the top of the pubic bone. It's a quick way to estimate gestational age during the later stages of pregnancy. When the fundal height aligns with the umbilicus, it suggests around 20 weeks of gestation. For each centimeter above the umbilicus, another week is added to estimate gestational age. This method helps calculate the approximate gestational age based on fundal height. [8] [10] [8]

After delivery of the infant, the uterus should contract down, beginning its return to a nonpregnant size. As the uterus contracts down, it clamps off small blood vessels in the uterine muscle and significantly slows postpartum bleeding. Massaging the fundus can help stimulate this contraction and is useful in managing postpartum bleeding and hemorrhage. [11]

Placenta and Umbilical Cord

The placenta is the vital organ that links the fetus to the mother, facilitating the exchange of nutrients and gases. One side of the placenta adheres to the uterine wall, while the other side faces the infant. Typically, the umbilical cord attaches to the center of the placenta. After the baby is born, the uterus continues to contract, aiding in the detachment and expulsion of the placenta. Placental delivery is recognized by a sudden flow of blood and the lengthening of the umbilical cord. However, if the placenta separates prematurely, it can lead to fetal and maternal hemorrhage, and if the umbilical cord gets torn, it can cause rapid blood loss in the baby. [11]  

Stages of Labor

There are 3 stages of labor. Delivery of the fetus occurs in the second stage of labor.

  • Stage 1: Begins with the onset of regular uterine contractions and cervical change and concludes when the cervix is fully dilated (ie, 10 cm). Labor tends to progress more slowly for women during their first delivery and faster with each subsequent delivery, but there are wide variations in what is considered normal. Active labor typically refers to when a patient's cervix begins to dilate quickly over time, which may not occur until 6 cm. [12] [9]
  • Stage 2: Begins when the cervix is fully dilated at 10 cm and concludes after delivery of the fetus. Once the cervix is fully dilated, the average time to delivery in a woman laboring for the first time without an epidural is 36 minutes. The median time decreases with each successive delivery, up until the third delivery, to an average of 12 minutes with the second delivery and 6 minutes for any delivery after that. [12]  
  • Stage 3: Begins immediately after delivery of the infant and ends after delivery of the placenta. Placental delivery usually occurs within 9 minutes of infant delivery on average. A retained placenta is typically defined as one that has not been delivered after 30 minutes. [11]
  • Indications

Indications that delivery is imminent include:

  • A strong, reflexive maternal urge to push or defecate [13]
  • Intense contractions at regular intervals, ≤2 minutes apart
  • Bulging perineum
  • Crowning of the fetal head (ie, the fetal head is visible at the vaginal opening) or spontaneous separation of the labia by the presenting fetal part [14] [15] [16]
  • Contraindications

There are few contraindications to unplanned prehospital delivery. The EMS healthcare practitioner can do little to delay or prevent delivery during spontaneous labor. If the EMS practitioner is close to the hospital, discouraging the woman from pushing may delay the delivery for a short while, depending on her dilation and the number of previous deliveries. During a precipitous delivery, uterine contractions are involuntary and are often strong enough to deliver an infant without much additional maternal effort. A strong and reflexive urge to bear down that the patient may be unable to suppress is usually present. Therefore, delivery may occur regardless of the patient's intentions, so EMS healthcare professionals must be prepared to deliver the infant en route to the hospital.

Two relative contraindications to vaginal delivery that EMS clinicians should be aware of are umbilical cord prolapse and breech, especially footling breech presentations. Umbilical cord prolapse, in which the umbilical cord is the presenting part, results in compression of the umbilical cord, which can lead to complications such as hypoxic brain injury and cerebral palsy. An emergent cesarean delivery is typically preferred; therefore, decompression of the cord should be attempted consisting of manual elevation of the fetal presenting part using 2 fingers or the whole hand through the vagina and placing the patient in a steep Trendelenburg or knee-chest position until experienced clinicians can perform a cesarean delivery in a hospital setting. [17]

A frank breech (ie, when the infant's buttocks are the presenting part) or a footling breech (ie, when the infant's foot is the presenting part) presentation occurs more frequently in preterm pregnancies and has a higher risk of complications compared to infants with a cephalic presentation. These patients also often require a cesarean delivery. EMS personnel should not perform any traction, and patients should be instructed to pant during contractions until the hospital can be reached, as specialized expertise is essential for these types of deliveries. [18] [19]

For most uncomplicated deliveries, minimal equipment is necessary. Ideally, in the prehospital setting, emergency medical professionals should have something to clamp and cut the umbilical cord and a dry cloth to dry and stimulate the infant, such as a towel. In emergency settings, typical obstetric and gynecological equipment may not be available, but if possible, EMS personnel should have the following items ready:

  • Personal protective equipment (eg, a mask with face shield, gown, booties, sterile gloves)
  • Towels or clean, dry cloths
  • Blankets and infant hat
  • Two umbilical cord clamps or hemostats
  • Medical scissors or scalpel to cut the cord
  • Container for the placenta
  • Bulb suction
  • Supplemental oxygen
  • IV access equipment and crystalloid fluid
  • Infant ventilation bags or a manometer to monitor inflating pressures during ventilation [7]

Equipment should be quickly and easily accessible to EMS healthcare practitioners or their assistants. Often, these items can be stored in an ambulance as part of an emergency delivery kit. However, equipment storage capacity within an ambulance is often limited, and some equipment may not be considered cost-effective. Furthermore, stocking may vary among different EMS systems. [8] [7]  Clean clothing can dry, stimulate, and warm the infant if no medical equipment is available during delivery. [7]

In a prehospital delivery, the EMS practitioner must make do with the personnel available. Ideally, the emergency medical professional performing the delivery should have at least 1 assistant. Hospital clinicians (eg, emergency, neonatologist, and obstetric physicians and nurses) should be notified ahead of the patient's arrival so that they may prepare necessary equipment for treatment (eg, infant warmers). [8] [10]

  • Preparation

History and Physical Examination

The initial evaluation of a laboring patient by EMS is primarily to determine whether the patient is stable for transport to a hospital; a patient who demonstrates clinical signs of imminent delivery is considered unstable, and EMS may decide to perform a field delivery before transporting the patient and neonate to the hospital. Upon arrival, EMS personnel should attempt to rapidly obtain a focused history and physically examine the laboring patient to make this determination. [20] [13] Important information to obtain from the history includes:

  • The estimated due date and gestational age of the pregnancy, if known. The first day of the last menstrual period to calculate an estimated due date and gestational age may be used if the patient does not know an estimated due date. [8]
  • Number of pregnancies and the number of prior vaginal and cesarean deliveries
  • Any pregnancy complications in current or prior pregnancies
  • The onset of the contractions and their frequency 
  • Clear yellow: normal
  • Bloody: may indicate placental abruption or placenta previa
  • Green: consistent with meconium, which increases the neonatal risk for respiratory complications  [8]
  • If and where the patient received prenatal care
  • Number of fetuses (singleton or twins) and perceived fetal movement
  • Any nonobstetric health problems, allergies, and medications
  • If the position of the fetus is known from a recent assessment (eg, recent ultrasound)  [8]

Maternal vital signs should be obtained in patients not delivered when EMS arrives, and fetal heart tones should be auscultated if a fetal heart Doppler is available. [10]  In addition to a focused chest examination, a rapid fundal height assessment should be performed to estimate the gestational age of the pregnancy. The diagnosis of active labor is beyond the scope of practice for EMS clinicians. Laboring patients should be transported to facilities with obstetric capabilities unless delivery appears imminent. This should be evaluated through visual inspection of the perineum if the patient has symptoms of rectal pressure, an urge to push, or contractions less than 2 minutes apart. EMS clinicians noting signs of an imminent delivery, including distention of the perineum by the presenting fetal part or the emergence of the fetal head past the vaginal introitus with contractions, should be aware that these are indications of an impending delivery and that preparation for a field procedure is required. [13]  

Unless intervention is indicated due to a breech delivery or prolapsed umbilical cord, a sterile digital examination of the vagina is typically not needed until the patient can be triaged by hospital clinicians who will assess cervical dilation and effacement, identify the presenting fetal part, and gauge the descent (ie, station) of the fetus. [13] Especially when there's noticeable vaginal bleeding, it's important to refrain from performing a digital examination until placenta previa can be ruled out as a potential cause. [10]  Examination of the perineum is most accessible for the EMS practitioner to perform with the patient in the dorsal lithotomy position (ie, supine with flexed hips and knees). [21]

Patient Positioning

Common Western delivery positions include the left-tilted dorsal lithotomy or semi-Fowler positions. Nevertheless, safe delivery can occur in various positions, such as left lateral decubitus, kneeling, squatting, or on hands and knees. EMS personnel should prioritize the mother's comfort, ensure accessibility for healthcare practitioners, and establish a secure area for the baby to prevent birth-related neonatal falls, which have been documented as causing birth trauma. [22] [21]

However, pregnant patients should not lie flat on their backs because this can reduce uteroplacental blood flow and the fetus due to aortic compression. Therefore, if lying supine, they should always have a rolled-up towel tucked under the left hip to tilt the patient or have the patient in a semi-reclined posture, sitting up at a 45-degree angle. [21]

  • Technique or Treatment

In general, the goals of the delivering clinician are to reduce the risk of pelvic floor trauma for the parturient, provide initial neonatal support and resuscitation, and manage maternal and neonatal complications to optimize outcomes. If only 1 trained EMS practitioner is available, assistance from the patient's family, friends, or another nonclinical person to assist with the birth and provide maternal support is an option. [15]  In preparation for delivery, available supplies or the emergency delivery kit should be readily accessible to the EMS clinician assisting. Women delivering in the semirecumbent or left-tilted dorsal lithotomy positions should flex their hips and legs to open up the pelvic inlet. [9] The perineum and area below the patient's buttocks should be draped with clean towels. If time allows, the perineum and vaginal area should be quickly swabbed with a povidone-iodine solution. [10]

Active Pushing

As the fetal head emerges from the vaginal introitus, laboring patients will feel the urge to push or bear down due to the increased rectal pressure from the fetal head as it descends. Parturients delivering outside of a hospital should be encouraged to push when they feel a contraction begin. This typically will occur reflexively. [15] Additionally, parturients should be encouraged to breathe in a natural way, which often includes pushing with an open glottis (eg, moaning or screaming while bearing down) instead of pushing with a closed glottis (eg, Valsalva pushing). Although a common technique has been to coach parturients to push for 3 sets of 10 seconds while holding a deep breath, there is no evidence to suggest this approach provides any clinical benefit over parturient-driven pushing. [23]  It is important to note that a mother's perception of her birth experience depends on their clinician's empathy and interpersonal skills as much as their clinical abilities. Patients should be offered verbal encouragement to help keep them calm and focused while pushing with their preferred method. [24] [25]  

Approach to Delivery 

The majority of EMS-assisted deliveries involve quick and straightforward vaginal births. In this scenario, the primary responsibility of the EMS clinician is to assist in safely guiding and managing the baby's delivery to prevent any harm to the mother or the newborn. [10] [9]  Traditionally, the delivering clinician places 1 hand on the fetal head as it emerges and provides very gentle counter pressure, preventing the rapid expulsion of the fetus, while the other gloved hand is at the perineum, applying moderate manual pressure to provide perineal support as the fetal head emerges. However, studies have not shown this method to be any more beneficial than allowing the fetal head to emerge on its own using a hands-off approach. [26] [10] [9]  Routine use of episiotomy is  not recommended and should not be performed. [27] [9]

Usually, the fetal head emerges either facing down towards the maternal rectum or, less commonly, facing up towards the maternal abdomen during delivery. As the fetal body moves through the pelvis, a natural process called restitution occurs, where the head automatically turns to face one of the maternal thighs. This rotation usually takes a few seconds.

Once the fetal head has fully emerged and this rotation occurs, the delivering clinician should sweep their fingers around the fetal neck and feel for a nuchal cord. A nuchal cord is an umbilical cord wrapped around the neonate's neck. A nuchal cord, if present, may be wrapped more than once, tightly or loosely. If the umbilical cord is felt wrapped around the neck, the EMS clinician should attempt to reduce it by gently pulling the cord over the infant's head, taking care not to lacerate or avulse the cord; this should be repeated until all loops have been removed. [10] [9]  If the nuchal cord is too tight to pull over the infant's head, it may be left in place if delivery of the rest of the neonate is not impeded and removed from the neck as soon as the neonate is delivered. If a tight nuchal cord prevents the delivery from proceeding, the cord can be doubly clamped and cut before the body delivers. This should be an option of last resort; delivery of the anterior shoulder should be attempted first before clamping and cutting a tight nuchal cord to avoid neonatal asphyxia in case shoulder dystocia is encountered. [28]

After delivery of the fetal head and restitution, the neonate's shoulders will be delivered. With the infant's head facing 1 of the maternal thighs, the EMS clinician should gently grasp both sides of the head with a hand on each side. The delivering clinician should then apply gentle posterior traction (ie, toward the maternal rectum) to help guide the infant's anterior shoulder underneath the pubic bone. Immediately following delivery of the anterior shoulder, the neonate should be guided upwards (ie, toward the maternal abdomen) to deliver the posterior shoulder. From there, the passage of the rest of the body should happen quickly; clinicians should hold tightly to the neonate's head and body as it delivers, placing it gently on the maternal abdomen. [10] [9]

Delayed Umbilical Cord Clamping

There is no rush for the prehospital clinician to clamp the umbilical cord. Evidence shows that except for infants requiring immediate cardiopulmonary resuscitation (CPR), the umbilical cord should not be clamped until it has stopped pulsating, approximately 30 to 60 seconds following delivery. Some professional organizations recommend waiting up to 3 minutes. [29] [30]  Delayed cord clamping allows for the autotransfusion of up to 100 mL of oxygenated blood within the first 3 minutes after birth and is especially beneficial for preterm infants. [29]  Therefore, in most cases, the initial care (eg, clearing the airway, drying, stimulating, and warming the infant) and assessment of the newborn (eg, respiratory effort, tone, and heart rate [HR]) may be performed  before clamping  the cord.

To safely cut the cord, 2 clamps are placed on the umbilical cord, and the cord is transected between the clamps. Generally, it is advised that the proximal umbilical clamp be placed approximately 10 centimeters from the umbilicus. If necessary, this provides an adequate cord distance to place an umbilical catheter once the neonate reaches the hospital if they require resuscitation. The second clamp should be placed approximately 5 cm beyond the first, allowing adequate space to safely cut the umbilical cord with a sharp, ideally sterile, pair of scissors or scalpel. [10] [9]  

The cord should be kept clean and dry. If a standard aseptic technique (eg, use of sterile gloves, clamps, and scissors) was used to cut the cord, keeping the remaining umbilical stump clean typically does not require antiseptics (eg, chlorhexidine or alcohol swabs). However, antiseptics may be reasonable to prevent infection, depending on the delivery environment, such as in settings where sterile equipment is unavailable or if the cord becomes contaminated (eg, falling in the dirt). [31]

Immediate Postpartum Neonatal Evaluation

The AAP, among other international societies, recommends newborn care immediately following birth, including drying and stimulating the neonate, clearing the airway of secretions, ensuring adequate respiratory effort, and keeping them warm. After the infant is delivered, the EMS clinician should gently wipe the infant's nose and mouth to clear the mucus as they are placed directly skin-to-skin on the mother's chest or abdomen; bulb suctioning may not routinely be needed. [32] [33] The infant should be dried and rubbed vigorously within the first 60 seconds of birth with a clean towel or cloth to help stimulate the infant to breathe and cry, allowing it to clear its lungs from any remaining amniotic fluid. Most infants will have a strong respiratory effort after this initial stimulation. After ensuring the baby is dry and has a robust respiratory drive, it's essential to wrap them in a warm, dry towel or cloth. If a cloth isn't available, having direct skin-to-skin contact fosters bonding and helps maintain the infant's warmth. [32]  A food- or medical-grade, heat-resistant plastic bag can be used if skin-to-skin contact can not be maintained. [32]

Immediately after this initial drying and stimulating, or if additional help is available, the infant should be assessed on the maternal abdomen within 30 to 60 seconds of birth to determine if the neonate requires further resuscitative efforts. Key factors to consider include:

  • Heart rate: An average newborn HR should be ≥100 bpm; it can be assessed by auscultation or palpation at the base of the umbilical cord.
  • Respiratory effort: Normal effort should appear as vigorous crying or nonlabored breathing without gasping or apnea. An average newborn respiratory rate is 40 to 60 breaths/min.
  • Color: The newborn's skin should be assessed for cyanosis. Any cyanosis should be documented in the record and carefully monitored, as cyanosis of the trunk or lips may indicate cardiorespiratory abnormalities. Isolated cyanosis of the distal extremities (ie, blue hands or feet) is common in the first few minutes of life and typically resolves within a few minutes.
  • Tone: Newborns should display active movement in all their limbs and have regular muscle tone, meaning they should not appear limp.
  • Reflex irritability (grimace response): The infant should spontaneously grimace, cough, sneeze, or vigorously cry in response to stimulation. [34] [35]

Additional assessments of the HR, respiratory effort, color, tone, and reflex irritability, components of the APGAR score, should be performed at 5 and 10 minutes of life. Findings from these initial assessments   are essential for hospital clinicians and must be documented in the record. [34] [35]  Infants who can breathe without difficulty and have good muscle tone typically do not require any additional immediate intervention. About 10% of infants may require additional stimulation beyond routine drying, which can be accomplished by rubbing the newborn's trunk or back or gently slapping the soles of the feet. Infants with difficulty breathing or an HR less than 100 bpm require additional neonatal resuscitation maneuvers. [34] [35] See the Complications section below.

After the initial assessment is complete and the infant and mother are determined to be stable, breastfeeding can be encouraged, which will help the infant maintain its blood glucose levels. Infants at risk for hypoglycemia should have their blood sugar level checked within the first hour of life, and they need to be monitored closely for evidence of hypoglycemia for the first few days. Infants at high risk for hypoglycemia include those born to mothers with diabetes, gestational or pregestational, and large or small infants of gestational age. [34] [35]

The infant should be reassessed every 30 to 60 minutes during the first 4 to 8 hours after birth and have a full general assessment within the first 24 hours of life. Therefore, neonates should be transferred into the care of clinicians trained in newborn care after an unplanned prehospital delivery. [34] [35]  

  Delivering the Placenta

The placenta often will deliver after the neonate has been successfully delivered and initially assessed to be stable. This typically occurs between 5 and 15 minutes after delivery but may take up to 30 minutes. Therefore, the patient and newborn should be transported at this time if a field delivery has been performed; the placenta does not have to be delivered first. If the placenta has not been delivered within 30 minutes, the patient should be transferred to an obstetric clinician to assist with removing the placenta, which may have implanted abnormally. These patients are at high risk for bleeding. In most cases, the placenta can deliver spontaneously with maternal effort alone. [36]  

While gentle traction on the umbilical cord reduces the risk of some postpartum hemorrhages and, therefore, is typically used by trained birth attendants to help deliver the placenta, cord traction can also result in cord avulsion and uterine inversion, which, although rare, can lead to significant morbidity. [37] [38]  Due to these risks and the somewhat limited benefits, controlled cord traction for placental delivery typically is not needed during prehospital deliveries by nonobstetric clinicians who lack dedicated training in this particular skill.  [38]  EMS clinicians should never pull on the cord. The placenta should naturally detach from the uterine wall as the uterus contracts following delivery; it should not require external force to separate.

If the placenta shows signs of separation from the uterine wall, the patient may be asked to bear down to deliver the placenta. Signs of placental separation include:

  • The uterus becomes firmer.
  • A sudden gush of blood from the vagina is noted.
  • The umbilical cord begins to lengthen. [37]  

When the placenta is visible at the vaginal opening, it may be grasped by the cord as the patient pushes and gently guided outward. Once the placenta has been delivered, it needs to be inspected for any missing pieces because if the placenta is not intact, the retained products must be removed to prevent bleeding or infection. [36]  Therefore, the placenta should be kept in a container that can be transferred to hospital staff for evaluation by trained obstetric clinicians upon arrival.

  • Complications

Obstetric Lacerations

Lacerations are common after vaginal deliveries, especially with the first delivery. Lacerations may involve the perineum, vagina, vulva, periclitoral, or periurethral tissue. Perineal tears are the most common and are classified by degrees of severity as follows:

  • First degree: laceration of the perineal skin only
  • Second degree: extension of a laceration from the perineal skin to the perineal muscles 
  • Third degree: laceration involving the anal sphincter
  • Fourth degree: laceration extending from the perineal skin through to the anal sphincter complex and anal epithelium  [39]

Nonperineal lacerations are often superficial and do not need to be repaired unless actively bleeding; however, if performed, repair of lacerations requires appropriate training, lighting, visualization, and pain control. ACOG recommends that the judgment of an obstetrically trained clinician be used to determine whether or not a first or second-degree laceration should be repaired. [39]  Most second-degree lacerations are repaired, but no evidence supports surgical repair over expectant management. However, a trained obstetric clinician should surgically repair third- and fourth-degree lacerations. If significant bleeding from a laceration is identified, it typically can be conservatively managed by applying pressure until an appropriately trained clinician can evaluate and provide treatment as indicated. [39]  

Breech Delivery

Breech presentations are the most common type of malposition encountered. Breech vaginal deliveries are associated with higher levels of neonatal morbidity and mortality. [40] This is because the fetal head, the largest and hardest fetal body part to move through the maternal pelvis, can become entrapped within the pelvis after the body delivers. During this time, the umbilical cord can become compressed as it runs alongside the fetal head, and the fetus is deprived of oxygen until the head is delivered. Whenever feasible, these patients should be taken to the hospital for delivery. Even if a fetal foot or buttock is visible at the vaginal opening, reaching a hospital facility for a safer delivery may still be possible. However, once the fetus has been delivered to the level of the neonatal umbilicus, a breech delivery is imminent, and the EMS clinician should be prepared for on-scene delivery. [10]

For the delivering clinician to perform the maneuvers of a breech delivery, the mother should be placed in the semi-recumbent position. The infant should be allowed to deliver spontaneously, without any assistance from the EMS clinician, to the level of the neonatal umbilicus. The EMS clinician can then hook their fingers around the infant's hips and apply downward traction; additionally, if not already facing down, the infant should be rotated so that its spine is facing up. As the fetal body continues to deliver, the delivering clinician may support the fetal body on their forearm and deliver the legs, 1 at a time, by grasping the thigh and sweeping the leg up and out while flexing the knee. [10]  When the scapulas are visible, the neonate should be rotated 90 degrees to face 1 of the maternal thighs. The EMS clinician should then sweep their fingers over the anterior arm, bending at the elbow and moving it down and across the infant's chest until the arm is out of the vagina. The infant should then be rotated 180 degrees to the other side, and the process should be repeated to deliver the second arm. [10]

To deliver the head, the infant should be placed so that it is lying on the forearm of the delivering clinician with the fetal legs straddling the forearm. The clinician should use the other hand to grasp the shoulders and apply downward traction until the back of the head is visible. At this point, the index and middle fingers of the bottom hand should be placed on the infant's face to apply downward pressure to the infant's maxilla while an assistant applies firm maternal suprapubic pressure. These maneuvers should allow the fetal head to flex and move under the pubic bone. Keeping downward pressure on the face and suprapubic pressure on the maternal abdomen, the delivering clinician elevates the infant's body straight up into the air toward the maternal abdomen, with the infant held between the clinician's 2 forearms, allowing the face and the entire head to deliver. [10]

Shoulder Dystocia

Shoulder dystocia occurs when the infant's shoulder becomes impacted behind the maternal pubic bone, causing the infant's body to get stuck in the birth canal. This complication is difficult to anticipate, but risk factors include macrosomia, maternal diabetes, maternal obesity, and fetal postdates. Recognizing and managing this complication quickly is crucial because prolonged dystocia can result in severe fetal morbidity (eg, asphyxiation, clavicle fracture, and brachial plexus injury). [41]

Shoulder dystocia can be expected when, following the delivery of the fetal head, it either firmly retracts against the perineum or starts moving back into the vagina during the intervals between contractions. This is known as the turtle sign because it can appear like a turtle pulling its head back into its shell. This occurs because the fetal head is expelled as the mother pushes, but because the fetal shoulder is stuck behind the pelvic brim when the mother stops pushing, the head gets pulled back into the vaginal canal. The delivering clinician should call for additional help when this sign is observed. [42]

Several maneuvers can be used to resolve the dystocia. Before attempting maneuvers, the delivering clinician should check for a nuchal cord and remove it if possible. If a tight nuchal cord is noted, the cord can be doubly clamped and cut before the body delivers. This should be an option of last resort; the anterior shoulder should be delivered before clamping and cutting a tight nuchal cord to avoid neonatal asphyxia due to shoulder dystocia. [28]

The first maneuver to attempt should be the McRoberts maneuver. [43] To perform this maneuver, assistants should sharply flex the parturient's thighs up onto her abdomen/chest (resulting in hyperflexion at the hips). If no one is available to help, the mother can be instructed to "pull your knees up to your armpits" or "pull your thighs onto your chest." This position alters the angles within the pelvis, allowing more room for the shoulders to move through the pelvis. [44]  Simultaneously with or immediately after a short trial in the McRoberts position, the assistant should be asked to apply pressure above the maternal pubic bone to help manually dislodge the impacted shoulder. [45]  If both of these maneuvers are unsuccessful, the delivering clinician can reach their hand into the posterior vagina and attempt to grasp the posterior forearm of the fetus, flexing it at the elbow. Then, the clinician can sweep the arm up and across the fetal chest, delivering the posterior arm. This alters the angle of the shoulder girdle and is often enough to relieve the dystocia. [28] [43]  They can also attempt to rotate the fetus in the birth canal by pushing on the back side of the anterior fetal shoulder and rotating 30 degrees toward the fetal face. [28] [43]  If the infant still has not been delivered, the mother can be flipped onto her hands and knees, and these maneuvers can be repeated in the new position.

Umbilical Cord Prolapse

Umbilical cord prolapse is when a loop of the umbilical cord gets stuck below the head of the fetus. This is concerning because the fetal head can compress the cord as the delivery progresses, preventing oxygenated blood from getting to the baby. These patients should be taken to a facility capable of performing a cesarean delivery. If the EMS clinician feels a pulsating cord of tissue consistent with a prolapsed umbilical cord on the vaginal exam, the mother should be instructed to stop pushing and be placed in the Trendelenburg position. The delivering clinician should attempt to decompress the cord by placing their hand into the vagina and pushing the fetal presenting part, typically the head, back up into the vagina and holding it there until instructed to remove their hand by the delivering surgeon at the hospital. [18]  The clinician elevating the head should be prepared to maintain that position with the patient in the operating room. [28]

Postpartum Hemorrhage

Postpartum hemorrhage (PPH) is when the mother loses more than 500 mL of blood after a vaginal delivery. [46]  It is one of the leading causes of pregnancy-related maternal death worldwide. [47]  Much of the treatment involves getting the patient to a hospital that provides obstetric care. Still, there are several things the prehospital delivering clinician can do to assist in this situation.

EMS personnel should take the patient's vitals, establish IV access, and administer fluids similar to any traumatic hemorrhage. EMS clinicians should communicate to the receiving hospital that postpartum hemorrhage is suspected so that preparations for management can be made (eg, massive transfusion protocol). [11] They should also attempt to identify the cause of the hemorrhage so they can attempt to stop the bleeding. The most common cause of PPH is uterine atony, which causes 70% to 80% of cases. [48] Usually, the uterus begins to contract spontaneously after the baby has been successfully delivered. Thus, the myometrium effectively clamps down on the hemorrhaging spiral arteries, preventing further blood loss. Vigorous massage of the uterine fundus can stimulate this uterine contraction. If this is insufficient, bimanual uterine massage can be done by placing 1 hand within the vagina and the other on the maternal abdomen over the uterine fundus and compressing the uterus between their hands, similar to putting pressure on a wound. [49]

In a hospital setting, administering oxytocin immediately following the delivery of the infant is the most critical intervention for reducing the risk of PPH. For this reason, ACOG, the World Health Organization, and the American Academy of Family Physicians all recommend the universal administration of a uterotonic agent, usually oxytocin, following all births by obstetric clinicians. [48]  

Estimation of maternal blood loss (EBL) should be recorded. Typical vaginal deliveries have an EBL of less than 500 mL, and blood loss may be significantly less. (One standard soda can is approximately 300 mL.) Estimating blood loss can be difficult, as up to several hundred milliliters of amniotic fluid may be mixed with the blood. In general, bleeding should slow significantly within the first few minutes after delivery, especially after delivery of the placenta. If bleeding persists at a significant rate or if large blood clots, such as those the size of an apple, are observed, clinicians should be concerned about the possibility of a postpartum hemorrhage. Uterine massage should be continued until bleeding improves, or hospital clinicians can administer oxytocin. It can be administered intramuscularly (IM) or by slow IV infusion. IV bolus has been associated with cardiovascular collapse. A standard dosage is either 10 units administered IM or 5 to 10 units given as an IV bolus. It can be given at any time after the delivery of the infant's anterior shoulder, as there is no clearly defined optimal timing for its administration. [48] [11]  If the patient has IV access, up to 30 units can be added to 500 to 1000 mL of fluid and given as a continuous infusion. [48]

In addition to uterine atony, other less common causes of PPH include heavy bleeding from lacerations, retained placental fragments or membranes, or an acute coagulopathy (eg, disseminated intravascular coagulation). Therefore, a careful pelvic exam and rapid transfer to a hospital with obstetric clinicians are also appropriate. [11]

Neonatal Resuscitation

About 1% of infants struggle with the transition to extrauterine life and require some level of CPR beyond standard warming, drying, and stimulation (eg, rubbing the trunk). [50] Neonatal resuscitation is similar to standard CPR for a young infant. It may include positive pressure ventilation (PPV), endotracheal intubation and airway suctioning, chest compressions, and other interventions. Neonates should be assessed to determine if they require further resuscitative interventions  within the first 60 seconds after birth. The following are indications that further resuscitation is required: a preterm neonate, absence of vigorous crying or effective breathing, and poor muscle tone. The following resuscitation protocol is recommended by the AAP, ACOG, the American Heart Association (AHA), and a 2022 international consensus for neonates demonstrating difficulty with birth transition. [50] [32]

  • Bulb suction the mouth first, then the nose, to prevent aspiration if the neonate gasps during nasal suctioning. 
  • Avoid vigorous suctioning of the posterior pharynx. This may cause reflex bradycardia and damage the mucosa, which can interfere with feeding.
  • Warm, dry, and stimulate the neonate by replacing wet towels or cloths and rubbing with a dry towel.
  • Monitor blood oxygen saturation (SPO 2 ). The target SPO 2  increases with increasing minutes since birth. The target SPO 2  at 1 minute of life is only 60% to 65%; this target increases by 5% every minute for up to 5 minutes. At that point, the SPO 2  target is 80% to 85%; at 10 minutes of life, it is 85% to 95%.
  • Consider continuous positive airway pressure. [32] [50]
  • Most term babies do not require supplemental oxygen with PPV.
  • Supplemental oxygen should be used judiciously and guided by pulse oximetry readings and target SPO 2  levels. Adequate ventilation alone is usually enough to restore HR in newborn infants.
  • Monitor SPO 2  with pulse oximetry.
  • Consider electrocardiography (ECG) monitoring.
  • If the HR stays <100 bpm despite PPV, check ventilation and consider intubation. [32] [50]
  • Start chest compressions, coordinated with PPV.
  • Perform neonatal intubation if not done already.
  • Give 100% oxygen.
  • Perform ECG monitoring.
  • If there is no response after 45 to 60 seconds of effective compressions, give epinephrine 0.1 to 0.3 mL/kg of 1:10,000 solution IV, equaling 0.01 to 0.03 mg/kg. [32] [50]

Neonatal Hypothermia

Neonatal hypothermia is associated with increased mortality, and this risk increases as the neonate's temperature drops further from 97.7 °F (36.5 °C). [51]  This risk is even more pronounced in premature infants. Hypothermia may also be associated with intraventricular hemorrhage and neonatal respiratory issues. Additionally, the temperature of infants (without asphyxiation) on admission strongly predicts morbidity and mortality.

The AHA 2022 CPR guidelines recommend maintaining infant temperatures between 97.7 °F (36.5 °C) and 99.5 °F (37.5 °C) for optimal outcomes. [50]  The best options for maintaining normal temperatures include the following:

  • Skin-to-skin contact, covered by a blanket with healthy neonates.
  • Use of a radiant warmer, if available.
  • Placing the infant in a clean, food-grade plastic bag up to the neck level, swaddling them, and holding them against the warm bodies of appropriate adults (eg, parent, EMS personnel) may be beneficial in highly low-birth-weight infants.
  • Getting the baby into a warm, temperature-controlled room or increasing the temperature in the room to ≥78.8 °F (23 °C). [50]  
  • Clinical Significance

While prehospital deliveries are rare for EMS practitioners, the practitioners must have a solid understanding of proper delivery techniques and how to manage common emergency complications. Ideally, laboring patients should be transported to a medical facility equipped for obstetric and neonatal care before delivery takes place. However, there are situations where there isn't enough time for transportation, and the delivery occurs either upon EMS arrival or during transport. [3]

Unplanned prehospital deliveries have been linked to increased perinatal mortality and morbidity for both the newborn and the mother. [4] [5] [6] [1] This is often due to insufficient training among EMS personnel in managing emergent deliveries, handling common intrapartum complications, and providing basic recommended neonatal resuscitation. [3] [7] Therefore, healthcare practitioners should continually update their knowledge, skills, and strategies for promptly identifying complications, performing effective interventions, and coordinating care. This ensures that EMS clinicians remain composed during prehospital deliveries and strive for the best possible outcomes for the mother and the newborn.

Typically, uncomplicated deliveries require minimal intervention from EMS personnel, mainly providing support and conducting basic assessments. Critical aspects of the delivery process include assisting with expulsing the fetal head and anterior shoulder and performing the initial steps of neonatal resuscitation. EMS clinicians should also be able to address common complications that may arise during childbirth, such as shoulder dystocia, umbilical cord prolapse, postpartum hemorrhage, and neonatal respiratory distress, until the patient can be safely transported to a hospital.

  • Enhancing Healthcare Team Outcomes

When responding to a call for assistance during labor, the initial priority should be to swiftly transport the mother to a hospital equipped with obstetric care. It's essential to notify hospital clinicians, including emergency, neonatologists, obstetric physicians, and nurses, before the patient's arrival so they can prepare the necessary equipment, such as infant warmers, and be ready for treatment if required. In a hospital setting, trained obstetric professionals can conduct the delivery in a controlled environment, equipped to handle any potential complications. [8] [10]

However, circumstances may not always allow sufficient time to transport the mother to the appropriate facility. In such cases, EMS practitioners must be well-versed in the proper delivery techniques. [22] [52] To optimize patient outcomes, it is essential to maintain detailed documentation of the EMS team's interventions and ensure sound clinical care to facilitate effective communication between healthcare professionals. This is crucial because the delivery circumstances and the newborn's initial condition can influence how physicians or other advanced practitioners manage these patients upon their transfer to the hospital. Additionally, EMS clinicians should be capable of providing a verbal report when transferring patients to hospital-based clinicians.

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Disclosure: Dallas Beaird declares no relevant financial relationships with ineligible companies.

Disclosure: Megan Ladd declares no relevant financial relationships with ineligible companies.

Disclosure: Suzanne Jenkins declares no relevant financial relationships with ineligible companies.

Disclosure: Chadi Kahwaji declares no relevant financial relationships with ineligible companies.

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  • Cite this Page Beaird DT, Ladd M, Jenkins SM, et al. EMS Prehospital Deliveries. [Updated 2023 Oct 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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  2. Assisted Breech Delivery

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  3. types of presentation in delivery

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  4. Breech Presentation and Turning a Breech Baby in the Womb (External

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  6. Breech Presentation and Delivery

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  1. Breech delivery/उल्टे बच्चे की डिलीवरी। डा० कल्पना अग्रवाल

  2. Breech baby presentation

  3. #breech delivery c section

  4. How to Help,Revive Breech Puppy almost Dead

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COMMENTS

  1. How to Deliver a Baby in Breech Presentation

    Move the towel up to cover the arms and rotate the body to make the back anterior. To deliver the head, place your index and middle fingers of one hand over the fetal maxilla to flex the head, while the body rests on your palm and forearm, as shown here. With your other hand, hook 2 fingers over the neck, grasp the shoulder, and apply gentle ...

  2. Breech Baby: Causes, Complications, Turning & Delivery

    A breech baby, or breech birth, is when your baby's feet or buttocks are positioned to come out of your vagina first. Your baby's head is up closest to your chest and its bottom is closest to your vagina. Most babies will naturally move so their head is positioned to come out of the vagina first during birth. Breech is common in early ...

  3. Breech Presentation

    Breech presentation refers to the fetus in the longitudinal lie with the buttocks or lower extremity entering the pelvis first. The three types of breech presentation include frank breech, complete breech, and incomplete breech. In a frank breech, the fetus has flexion of both hips, and the legs are straight with the feet near the fetal face, in a pike position. The complete breech has the ...

  4. How to Deliver a Baby in Breech Presentation

    -Learn how to deliver a baby in breech presentation vaginally: https://www.merckmanuals.com/professional/gynecology-and-obstetrics/abnormalities-and-complica...

  5. Fetal Presentation, Position, and Lie (Including Breech Presentation

    Breech presentation makes delivery difficult ,primarily because the presenting part is a poor dilating wedge. Having a poor dilating wedge can lead to incomplete cervical dilation, because the presenting part is narrower than the head that follows. The head, which is the part with the largest diameter, can then be trapped during delivery.

  6. Breech position baby: How to turn a breech baby

    Discuss your preferences, the advantages and risks of each option (vaginal and cesarean delivery of a breech presentation), and their experience. The biggest risk of a breech delivery is when the body delivers but the head stays entrapped within the cervix. ... Vaginal breech delivery at term and neonatal morbidity and mortality — a ...

  7. Breech Presentation: Overview, Vaginal Breech Delivery, Cesarean Delivery

    Breech presentation is defined as a fetus in a longitudinal lie with the buttocks or feet closest to the cervix. This occurs in 3-4% of all deliveries. The percentage of breech deliveries decreases with advancing gestational age from 22-25% of births prior to 28 weeks' gestation to 7-15% of births at 32 weeks' gestation to 3-4% of births at term.

  8. Breech Presentation

    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.

  9. If Your Baby Is Breech

    In a breech presentation, the body comes out first, leaving the baby's head to be delivered last. The baby's body may not stretch the cervix enough to allow room for the baby's head to come out easily. There is a risk that the baby's head or shoulders may become wedged against the bones of the mother's pelvis.

  10. How to Deliver a Baby in Breech Presentation

    Vaginal breech delivery with audio commentary. This is the conventional assisted vaginal breech method.subscribe comment like&share

  11. Breech Delivery

    Breech delivery is the single most common abnormal presentation. The incidence is highly dependent on the gestational age. At 20 weeks, about one in four pregnancies are breech presentation. By full term, the incidence is about 4%. Other contributing factors include: Abnormal shape of the pelvis, uterus, or abdominal wall,

  12. Mode of Term Singleton Breech Delivery

    Between 1998 and 2002, 35,453 term infants were delivered. The cesarean delivery rate for breech presentation increased from 50% to 80% within 2 months of the trial's publication and remained elevated. The combined neonatal mortality rate decreased from 0.35% to 0.18%, and the incidence of reported birth trauma decreased from 0.29% to 0.08%.

  13. How to Deliver a Baby in Breech Presentation

    Move the towel up to cover the arms and rotate the body to make the back anterior. To deliver the head, place your index and middle fingers of one hand over the fetal maxilla to flex the head, while the body rests on your palm and forearm, as shown here. With your other hand, hook 2 fingers over the neck, grasp the shoulder, and apply gentle ...

  14. Breech: Types, Risk Factors, Treatment, Complications

    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.

  15. 6.1 Breech presentation

    Presentation of the feet or buttocks of the foetus. 6.1.1 The different breech presentations. In a complete breech presentation, the legs are tucked, and the foetus is in a crouching position (Figure 6.1a).; In a frank breech presentation, the legs are extended, raised in front of the torso, with the feet near the head (Figure 6.1b).; In a footling breech presentation (rare), one or both feet ...

  16. Breech Presentation: Types, Causes, Risks

    Breech Presentation: Vaginal Versus Cesarean Delivery, Which Intervention Leads to the Best Outcomes? Acta Med Port. 2017 Jun 30;30(6):479-484. doi: 10.20344/amp.7920. Epub 2017 Jun 30.

  17. Management of breech presentation

    Breech presentation in labour may be associated with adverse outcomes for the fetus, which has contributed to an increased likelihood of caesarean birth. ... Does advice to assume the knee-chest position reduce the incidence of breech presentation at delivery? A randomized clinical trial, Birth (Berkeley, Calif.), 14, 75-78, 1987 [PubMed ...

  18. Chapter 134. Breech Delivery

    The breech presentation exists when the cephalic pole of the fetus is positioned in a longitudinal lie and the buttocks or feet of the fetus enter the maternal pelvis before the head. 1 Management of the breech presentation in labor is an area of much trepidation and controversy, even among seasoned clinicians. A breech delivery is considered a ...

  19. Breech presentation management: A critical review of leading clinical

    Breech presentation: clinical practice guideline from the French College of Gynaecologists and Obstetricians [2020] French College of Gynaecologists and Obstetricians (CNGOF) France: HAS framework: 3: 10/14 (71.43) 12: Y: Mode of term singleton breech delivery [2018] The American College of Obstetricians and Gynaecologists (ACOG) United States ...

  20. Breech Presentation

    The mother may be offered an epidural, as vaginal breech delivery can be very painful. 6. Contraindications for vaginal delivery in a breech presentation include: Footling breech: the baby's head and trunk are more likely to be trapped if the feet pass through the dilated cervix too soon; Macrosomia: usually defined as larger than 3800g

  21. EMS Prehospital Deliveries

    Breech Delivery. Breech presentations are the most common type of malposition encountered. Breech vaginal deliveries are associated with higher levels of neonatal morbidity and mortality. This is because the fetal head, the largest and hardest fetal body part to move through the maternal pelvis, can become entrapped within the pelvis after the ...

  22. Breech Delivery: When Is It Safe & When Is It Avoided?

    In general, attempting a vaginal delivery for a breech presentation is avoided due to risks to the baby. Usually, the doctor will attempt to turn the fetus into the head down position to prepare for a vaginal birth, or a Caesarean ( C-section) will be recommended. Situations in which a breech delivery may be considered include:

  23. The Fact Store on Instagram: "A C-section, also called a cesarean

    1,779 likes, 13 comments - thefactstore on February 12, 2024: "A C-section, also called a cesarean section or cesarean delivery, is a surgical procedure in whic..." The Fact Store on Instagram: "A C-section, also called a cesarean section or cesarean delivery, is a surgical procedure in which a baby is delivered through incisions in your ...