Management of Breech Presentation
Scope
This guideline addresses route of delivery and intrapartum technique for breech presentation at term and preterm. Antenatal care is not covered, and external cephalic version (ECV) is addressed separately in the companion guideline GTG 20a — not duplicated here.
Mode-of-Delivery Counselling
Women with a breech presentation at term following an unsuccessful or declined offer of ECV should be counselled on planned vaginal breech birth (VBB) versus planned caesarean section (CS), in an unbiased way covering absolute and relative risks:
- Perinatal mortality: approximately 0.5/1000 with planned CS after 39+0 weeks, versus approximately 2.0/1000 with planned VBB, compared with approximately 1.0/1000 with planned cephalic birth.
- The reduced mortality risk with CS reflects three factors — avoidance of stillbirth beyond 39 weeks, avoidance of intrapartum risk, and risks intrinsic to VBB — and only the third factor is unique to breech presentation.
- Planned VBB increases the risk of low Apgar scores and serious short-term complications but has not been shown to increase long-term morbidity.
- With appropriate case selection and skilled intrapartum care, planned VBB can be made nearly as safe as planned vaginal cephalic birth.
- Maternal complications are lowest with successful vaginal birth; CS carries a higher maternal risk, greatest with emergency CS, which is needed in approximately 40% of women planning a VBB.
- CS increases risks in future pregnancies, including complications of attempting vaginal birth after caesarean, complications at repeat CS, and risk of an abnormally invasive placenta; CS has also been associated with a small (possibly non-causal) increase in stillbirth in a subsequent pregnancy.
Eligibility for Planned Vaginal Breech Birth
Following diagnosis of persistent breech presentation, women should be assessed for risk factors predicting a poorer VBB outcome; if present, planned CS is recommended. A higher-risk planned VBB is expected where there are independent indications for CS, or with:
- Hyperextended fetal neck on ultrasound
- High estimated fetal weight (>3.8 kg)
- Low estimated fetal weight (<10th centile)
- Footling presentation
- Evidence of antenatal fetal compromise
The role of pelvimetry is unclear. A skilled birth attendant is essential for safe VBB; units with limited access to experienced personnel should advise women that VBB carries greater risk locally and offer antenatal referral to a unit with greater skill and experience.
Intrapartum Management
- Induction of labour is not usually recommended; augmentation of slow progress with oxytocin should only be considered if contraction frequency is low in the presence of epidural analgesia.
- The effect of epidural analgesia on VBB success is unclear, but it is likely to increase the risk of intervention.
- Continuous electronic fetal monitoring may improve neonatal outcomes, though evidence is limited.
- Birth in a hospital with facilities for immediate CS is recommended; birth in an operating theatre is not routinely necessary.
- Adherence to a departmental protocol reduces early neonatal morbidity; essential components of a VBB service are appropriate case selection, management according to a strict protocol, and availability of skilled attendants.
- Adequate descent of the breech during the passive second stage is a prerequisite before encouraging active pushing.
- Either a semirecumbent or an all-fours position may be adopted for delivery, depending on maternal preference and attendant experience; if all-fours is used, women should be advised that recourse to semirecumbent may become necessary.
- Assistance, without traction, is required only if there is delay or evidence of poor fetal condition; choice of manoeuvre depends on the individual experience of the attending doctor or midwife.
- For women presenting unplanned in labour with breech presentation, management depends on stage of labour, presence of risk factors, available clinical expertise, and informed consent; women near or in active second stage should not routinely be offered CS.
- Simulation training and departmental checklists for case selection and counselling are recommended to maintain skills and reduce intrapartum complications.
High-Yield Exam Points
- Know the three perinatal mortality figures: ~0.5/1000 (planned CS ≥39 weeks) vs ~2.0/1000 (planned VBB) vs ~1.0/1000 (planned cephalic birth).
- The Term Breech Trial drove the shift toward routine CS but has been criticised for case-selection and intrapartum-management flaws (e.g. absence of a senior obstetrician in ~32% of vaginal births); 2-year follow-up showed no difference in death or neurodevelopmental delay by mode of delivery.
- Higher-risk-for-VBB features: hyperextended neck, EFW >3.8 kg or <10th centile, footling presentation, antenatal fetal compromise.
- Emergency CS is needed in roughly 40% of women who plan a VBB.
- Induction of labour is not usually recommended for breech; oxytocin augmentation only with low contraction frequency and epidural in place.
- GTG 20a (ECV) is the companion guideline — this guideline (20b) excludes antenatal/ECV content by design.
Source: RCOG Green-top Guideline No. 20b (March 2017 (4th edition; originally published 1999, revised 2001 and 2006). Impey LWM, Murphy DJ, Griffiths M, Penna LK. BJOG 2017;124:e151–e177.)
Read the original on rcog.org.uk
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