Professional Recommendations: Delivery of Breech Presentation at Term

SUMMARY:

ACOG guidance addresses the trend in the United States to deliver term singleton fetuses in breech presentation by cesarean section and the concomitant decrease in the number of practitioners with the skills and experience to perform vaginal breech deliveries. In 2001, the ACOG committee on Obstetric Practice recommended that planned vaginal delivery of a singleton breech was no longer appropriate but due to additional publications since that time, the recommendations have been updated.

KEY POINTS:

Vaginal delivery of a term singleton breech fetus

  • Planning a vaginal deliver for term singleton breech fetus may be a reasonable option under hospital-specific protocol guidelines that address eligibility and labor management  
  • Decision making  
    • Consider patient’s wishes and the experience of the health care provider  
  • Criteria based on retrospective studies have resulted in “excellent” neonatal outcomes, using protocols similar to the following
    • > 37 weeks gestational age 
    • Frank or complete breech presentation 
    • No fetal anomalies on ultrasound examination 
    • Adequate maternal pelvis 
    • EFW between 2,500 g and 4,000 g 
    • One study also included  
      • Fetal head flexion 
      • AFV ≥3 cm vertical pocket  
      • No oxytocin induction or augmentation  
      • Strict criteria for normal labor progress 

Informed Consent 

If vaginal breech delivery is planned, a detailed informed consent should be documented that include risks and benefits  

  • Short term risk/benefit 
    • Term Breech Trial (2000) demonstrated that perinatal mortality, neonatal mortality, and serious neonatal morbidity were significantly lower in the planned cesarean delivery group (1.6%) vs planned vaginal delivery group (5%) with no difference in maternal morbidity or mortality 
    • Follow-up at 3 months: Risk of urinary incontinence was lower for women in the planned cesarean delivery group but no difference at 2 years 
  • Long term risk/benefit (2 years)  
    • No differences for risk of death or neurodevelopmental delay, although there may be multiple reasons to explain this discrepancy, described in the ACOG Committee Opinion (see ‘Learn More – Primary Sources’ below) 
    • No difference for most maternal parameters, such as breastfeeding, pain, depression, or upsetting memories of the birth experience in 79.1% of women  
  • ACOG states that  

Current evidence demonstrates short-term benefits in neonatal and maternal morbidity and mortality from planned cesarean delivery of the term fetus with a breech presentation. Long-term benefits of planned cesarean delivery for these infants and women are less clear.

The SOGC guidelines (2019; see ‘Learn More – Primary Sources’ below) address both oxytocin augmentation and induction as follows

Oxytocin augmentation is acceptable to correct weak uterine contractions. If progress in labour is poor despite adequate contractions, Caesarean section is recommended (strong recommendation; moderate quality evidence)

Although data are limited, induction of labour with breech presentation does not appear to be associated with poorer outcomes than spontaneous labour (weak recommendation; low quality evidence)

RCOG recommendations (2017; see Learn More – Primary Sources’ below) also address augmentation and induction and advises caution (D Grade Recommendation)

Women should be informed that induction of labour is not usually recommended.

Augmentation of slow progress with oxytocin should only be considered if the contraction frequency is low in the presence of epidural analgesia.

External cephalic version 

  • Offer as an alternative to planned cesarean delivery if the patient desires planned vaginal delivery of a vertex-presenting fetus and has no contraindications  
  • Only attempt external cephalic version in a setting where cesarean delivery services are readily available

Learn More – Primary Sources:  

ACOG Committee Opinion 745: Mode of Term Singleton Breech Delivery

Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group

SOGC Guideline 384: Management of Breech Presentation at Term

RCOG Green Top Guideline 20b: Management of Breech Presentation