A breech presentation occurs when the longitudinal lie of the foetus remains oriented so that the buttocks or lower extremities present first into the maternal pelvis, rather than the cephalic pole. This presentation is classified as a malpresentation and occurs in roughly three to four percent of term pregnancies. During the early and mid-trimesters, a breech lie is common and physiological because the relatively large volume of amniotic fluid compared to foetal size allows the baby to tumble freely. However, as pregnancy advances toward term, the normal growth dynamics and the pear-shaped anatomy of the uterine cavity usually encourage spontaneous internal version into a cephalic presentation. When this rotation fails to occur, various anatomical or physiological factors are often implicated. Common contributors include uterine abnormalities such as fibroids or a septate uterus, placenta previa, pelvic tumors, polyhydramnios, oligohydramnios, multiple gestations, or foetal structural and chromosomal anomalies. Midwives working in Nigerian clinical settings must recognise that grand multiparity, due to laxity of the abdominal wall and uterine muscles, also raises the likelihood of a breech lie. Understanding these underlying associations helps clinicians anticipate potential complications and plan appropriate antenatal surveillance from the primary healthcare clinic up to tertiary referral centres.
Breech presentations are categorized into distinct types based on the attitude of the foetal lower limbs and hips. Recognising these variations is vital because the specific type influences the mechanism of labour and the safety of a vaginal delivery.
Identifying a breech presentation early allows the healthcare team to discuss options such as external cephalic version or planned caesarean section. Midwives utilize clinical palpation alongside diagnostic imaging to confirm the lie and presentation.
When a breech baby delivers vaginally, the mechanism of labour follows a distinct series of passive movements to navigate the maternal pelvis. Unlike a cephalic birth where the largest part (the head) delivers first, a breech birth delivers the smaller parts first, culminating in the delivery of the aftercoming head which is the largest and least compressible part.
The mechanism proceeds through the engagement and descent of the bitrochanteric diameter in one of the oblique diameters of the pelvis. Internal rotation of the buttocks occurs so that the bitrochanteric diameter lies in the anteroposterior diameter of the outlet, followed by lateral flexion of the trunk to deliver the buttocks. Next, the shoulders engage and rotate internally, followed by their birth. Finally, the head enters the pelvis in an oblique or transverse diameter, undergoes internal rotation so the suboccipito-bregmatic or equivalent diameter aligns anteroposteriorly, and delivers either by flexion or via assistance techniques.
Conducting a vaginal breech delivery requires exceptional skill, patience, and adherence to the rule of 'hands-off the breech' until the umbilicus is born. Midwives and doctors must avoid premature traction, which can cause the arms to extend or the head to become trapped.
Breech presentations carry higher perinatal morbidity and mortality rates compared to cephalic presentations due to mechanical challenges during labour.
For the foetus, the most terrifying emergency is cord compression or prolapse, which cuts off oxygen supply as the baby's body passes through the pelvis. Birth asphyxia can occur if the aftercoming head is delayed. Furthermore, traumatic injuries such as fractures of the clavicle, humerus, or femur, brachial plexus injuries, intracranial haemorrhage, and abdominal organ damage can happen during difficult extractions.
For the mother, the risks include a significantly higher rate of operative delivery (caesarean section), extensive perineal lacerations, extension of uterine incisions, postpartum haemorrhage due to uterine atony from prolonged labour, and puerperal sepsis. Midwives must remain vigilant for signs of foetal distress and maternal exhaustion in any breech labor setting.
Because breech deliveries carry an elevated risk of birth depression and traumatic injury, immediate and structured neonatal resuscitation preparedness is mandatory. The delivery room must be equipped with a functional radiant warmer, suction apparatus, bag-valve-mask device, and appropriately sized masks.
Immediately upon birth, the newborn should be received warmly, dried, and stimulated while the midwife assesses tone, breathing, and heart rate. If the infant fails to breathe spontaneously or has a low heart rate, standard neonatal resuscitation protocols must begin without delay. Midwives also perform a thorough physical examination of the newborn to check for hip instability or dislocation (using Barlow and Ortolani tests), clavicular fractures, and soft tissue bruising. Post-delivery care for the mother involves monitoring uterine tone and lochia to prevent postpartum haemorrhage, providing pain relief, and offering emotional reassurance regarding the birth experience.