The theory behind a successful upright breech birth: A single-center systematic video-based analysis

Safe vaginal breech birth requires timely recognition of stagnation and skilled execution of maneuvers, yet detailed descriptions of upright (all-fours) breech techniques remain scarce. Video-based approaches provide an opportunity to capture real-life practice and inform refinement of existing algorithms. The aim was to describe the management of vaginal breech birth on all fours using systematic video analysis, document maneuvers applied, and generate exploratory insights to refine the physiological breech birth algorithm.

Retrospective analysis of 66 video-recorded successful vaginal breech births at a single teaching hospital (2017-2024). Baseline data and time intervals were recorded, and all maneuvers were described. Team discussions focused on differences with the algorithm, evolving practices, lessons learned, and the identification of effective maneuvers during stalled progress.

Sixty-six videos were analyzed, with 65% (n = 43) performed in the all-fours position. Most were primiparous and < 41 weeks. The all‑fours position was associated with a higher proportion of spontaneous births and shorter pelvis‑to‑head intervals, births requiring multiple maneuvers were associated with longer pelvis-to-head intervals. Prompt intervention appeared associated with smoother progression since maneuvers executed before fetal compromise appeared more effective. Releasing the fetal arm at the maternal pubic bone was identified as a critical maneuver, and pro-active manual assistance was found to be frequently used and beneficial when birth stagnated.

These exploratory findings generate the hypothesis that the Breech Birth Algorithm could be refined to encourage earlier intervention at the first sign of stalled progress, potentially reducing adverse neonatal outcomes. Further evaluation is needed, as the level of evidence remains limited.