Snapshot A 28-year-old G1P0 woman at 37 weeks of gestation presents to her obstetrician for a prenatal care appointment. She describes feeling some soreness under her ribs in the past few weeks and feels her baby kicking in her lower abdomen. An ultrasound is performed and is seen in the image. The obstetrician describes management approaches, including an external cephalic version before labor. Introduction Overview breech presentation occurs when a fetus is positioned logitudinally with the buttocks or feet closest to the mother's cervix complete breech flexion of the hips and knees incomplete (footling) breech some deflexion of one hip and knee frank breech flexion of both hips with extension of both knees Epidemiology Incidence 3-4% of all deliveries ↓ with advancing gestational age 22-25% of births before 28 weeks of gestation 7-15% of births at 32 weeks of gestation 3-4% of births at term Risk factors prematurity uterine malformations uterine fibroids polyhydramnios placenta previa multiple gestations Presentation Symptoms subcostal discomfort (due to fetal head in the uterine fundus) feeling of kicking in the lower abdomen Physical exam presence of soft mass (buttocks) and absence of hard fetal skull on transabdominal examination of the lower uterine segment observation of the soft buttocks or feet on transvaginal examination when cervix is dilated Imaging Ultrasound indications monitoring of fetal presentation detection of breech presentation prior to 37 weeks does not warrant intervention findings fetal head in the uterine fundus buttocks in the lower uterine segment hyperextension of the fetal head, if present, is a contradiction of vaginal delivery extension angle > 90 degrees Treatment Procedural external cephalic version before labor at 37 weeks gestation or later perform trial of vaginal delivery if the version is successful Surgical cesarean delivery may be planned for breech presentation, without a trial of external cephalic version may be performed if trial of vaginal delivery is unsuccessful after external cephalic labor Complications Perinatal mortality incidence ↑ up to 4-fold with breech presetnation associated with malformations, prematurity, and intrauterine fetal demise Fetal abnormalities incidence 17% of preterm breech deliveries 9% of term breech deliveries abnormalities include CNS malformations, neck masses, and aneuploidy