The danger increased when the skill disappeared.
Breech presentation may be fetal variation rather than pathology; many historical restrictions lack robust scientific evidence from recent decades. Routine pelvimetry shows weak correlation with adverse outcomes; only intertuberous space below 7cm consistently indicates cesarean necessity.
- Frank Louwen has managed over 2,200 vaginal breech births throughout his career
- The restriction on fetal neck hyperextension rested on three case reports from the 1970s
- Intertuberous distance below 7 cm is the only pelvic measurement consistently associated with cesarean necessity
- The 63rd Brazilian Congress of Gynecology and Obstetrics took place May 27-30, 2026 in Belo Horizonte
Medical experts at Brazil's gynecology congress debate whether breech presentation warrants automatic cesarean delivery, advocating for evidence-based practices and individualized obstetric decisions over routine interventions.
At Brazil's largest annual gathering of obstetricians, a conversation that seemed settled for decades is being reopened. During the 63rd Brazilian Congress of Gynecology and Obstetrics in May 2026, experts challenged the near-automatic reach for cesarean delivery when a baby presents buttocks-first in the womb—a position that has become so routinely managed with surgery that an entire generation of doctors may have never attended a vaginal breech birth.
The discussion, led by Roseli Nomura from the Federal University of São Paulo and featuring Frank Louwen, president of the International Federation of Gynecology and Obstetrics, centered on a deceptively simple question: Is breech presentation actually a medical problem, or simply a variation of normal fetal position? The answer, speakers suggested, hinges on evidence rather than habit. Louwen brought the weight of personal experience—more than 2,200 breech births managed vaginally over his career—to argue that many of the restrictions obstetricians have inherited were built on surprisingly thin ground.
Consider the case of fetal neck hyperextension. For decades, obstetrics textbooks listed this as a contraindication to vaginal breech delivery, a reason to opt for surgery. Yet when speakers examined the scientific foundation for this rule, they found it rested on exactly three case reports published in the 1970s. Three cases. Not a clinical trial. Not a systematic review. Three anecdotes from fifty years ago, yet they had calcified into absolute restrictions that shaped how millions of women were counseled about their births.
The same scrutiny was applied to pelvimetry—the measurement of a woman's pelvis to determine if it is "adequate" for vaginal delivery. Routine pelvimetry has long been standard practice, a way to screen out women deemed unsuitable for vaginal breech birth. But the evidence shows that pelvic measurements alone do not reliably predict which women will have complications. The only measurement that held up under examination was the intertuberous distance—the space between the sitting bones—when it measured less than seven centimeters, a threshold associated with genuine mechanical difficulty. Everything else, speakers suggested, was being done out of caution rather than necessity. Fetal weight above 3.8 kilograms, another common reason for cesarean delivery in breech cases, similarly lacked robust justification for automatic surgery.
Another theme emerged: the position in which labor unfolds matters. Historically, women gave birth upright—squatting, kneeling, standing—positions that use gravity and pelvic mechanics to facilitate descent. Modern obstetrics moved births to the lithotomy position, flat on the back with legs elevated, a posture that was convenient for the attendant but potentially disadvantageous for the laboring woman. Speakers raised the possibility that some complications attributed to breech presentation might actually stem from this modern positioning choice, not from the breech itself.
When complications do arise during breech labor—situations analogous to shoulder dystocia in head-down births, where the baby's trunk fails to rotate properly—specific maneuvers exist to resolve them. These involve precise fetal rotation, first 180 degrees in one direction, then 90 degrees in the physiologic direction, combined with pressure against the fetal shoulder to facilitate passage. The point was not that breech birth is simple, but that it is manageable with skill and knowledge, not merely preventable through surgery.
The congress also highlighted that shared decision-making, not unilateral medical directive, should guide the choice of delivery method. This requires obstetricians to have the training and confidence to offer vaginal breech birth as an option when circumstances permit, and to discuss with women what the evidence actually shows rather than what tradition dictates. For a generation of physicians trained in an era when cesarean delivery became the default, this represents a significant shift—not a return to the past, but a recalibration toward what the evidence supports.
Notable Quotes
Many recommendations historically used in breech birth management were based not on robust evidence but on old case reports and expert opinion— Frank Louwen, FIGO president, speaking at CBGO 2026
The Hearth Conversation Another angle on the story
Why would doctors have held onto restrictions based on three case reports for fifty years?
Because once something becomes standard practice, it becomes invisible. No one questions it. The three cases probably seemed alarming at the time, and the restriction felt like the safe choice. But "safe" and "evidence-based" are not the same thing.
So the issue is not that breech birth is dangerous, but that we stopped learning how to do it safely?
Exactly. The danger increased when the skill disappeared. If no one is trained in vaginal breech delivery, then cesarean becomes the only option—not because it is the best option, but because it is the only one available.
What changed? Why is this conversation happening now?
Partly because some countries never abandoned the skill. Louwen and others in Europe kept the knowledge alive, kept the numbers, kept asking whether the evidence supported what we were doing. And now the data is clear enough that it cannot be ignored.
Does this mean every woman with a breech baby should try vaginal delivery?
No. It means every woman should have the choice, with honest information about what the evidence shows. For some, cesarean is the right call. But for others, vaginal delivery is safe and possible—and that option should exist.
What about the pelvimetry measurements? Are they useless?
Not useless. One measurement—the space between the sitting bones—still matters. But measuring the pelvis routinely, looking for reasons to say no, is not supported by evidence. It is screening for a problem that does not reliably exist.
How long before this changes practice in Brazil?
That depends on training. You cannot change practice without doctors who know how to manage breech birth. That takes time, mentorship, and the willingness to learn something that was considered obsolete.