Approach
There is good evidence available for the management of breech presentation in late pregnancy. External cephalic version and/or planned caesarean section are optimally performed at gestational ages of 37 and 39 weeks, respectively.[29][30]
Breech presentation <37 weeks' gestation, in labour
A woman in labour with a breech presentation <37 weeks' gestation is an area of clinical controversy. Optimal mode of delivery for preterm breech has not been fully evaluated in clinical trials and the relative risks for the preterm infant and mother remain unclear. In the absence of good evidence, if diagnosis of breech presentation prior to 37 weeks' gestation is made, prematurity and clinical circumstances should determine management and mode of delivery. See Premature labour (Management).
Breech presentation ≥37 weeks' gestation, before labour
External cephalic version (ECV)
ECV is the initial treatment for a breech presentation at term when the patient is not in labour. It involves turning a fetus presenting by the breech to a cephalic (head-down) presentation to increase the likelihood of vaginal birth.[31][32] Where available, it should be offered to all women in late pregnancy, by an experienced clinician, in hospitals with facilities for emergency delivery, and no contraindications to the procedure.[31][33] There is no upper time limit on the appropriate gestation for ECV, with success reported at 42 weeks.[31][34]
There is no general consensus on contraindications to ECV. Contraindications include multiple pregnancy (except after delivery of a first twin), ruptured membranes, current or recent (<1 week) vaginal bleeding, rhesus isoimmunisation, other indications for caesarean section (e.g., placenta praevia or uterine malformation), or abnormal electronic fetal monitoring.[31] One systematic review of relative contraindications for ECV highlighted that most contraindications do not have clear empirical evidence. Exceptions include placental abruption, severe pre-eclampsia/HELLP syndrome, or signs of fetal distress (abnormal cardiotocography and/or Doppler flow).[32]
The procedure involves applying external pressure and firmly pushing or palpating the mother's abdomen to coerce the fetus to somersault (either forwards or backwards) into a cephalic position.[35]
The overall ECV success rate varies but, in a large series, 47% of women following an ECV attempt had a cephalic presentation at birth.[31][36] Various factors influence the success rate. One systematic review found ECV success rates to be 68% overall, with the rate significantly higher for women from African countries (89%) compared with women from non-African countries (62%), and higher among multiparous (78%) than nulliparous women (48%).[37] Overall, the ECV success rates for nulliparous and multiparous non-African women were 43% and 73%, respectively, while for nulliparous and multiparous African women rates were 79% and 91%, respectively. Another study reported no difference in success rate or rate of caesarean section among women with previous caesarean section undergoing ECV compared with women with previous vaginal birth. However, numbers were small and further studies in this regard are required.[38]
Women’s preference for vaginal delivery is a major contributing factor in their decision for ECV. However, studies suggest women with a breech presentation at term may not receive complete and/or evidence-based information about the benefits and risks of ECV.[39][40] Although up to 60% of women reported ECV as painful, the majority highlighted the benefits outweigh the risks (71%) and would recommend ECV to their friends or be willing to repeat for themselves (84%).[39][40]
Cardiotocography and ultrasound should be performed before and after the procedure.
Anti-D immunoglobulin should be administered to women who are Rhesus negative if delivery is not anticipated in the preceding 72 hours.[31][33]
Tocolysis should be used to facilitate the manoeuvre.[33] Tocolytic agents include adrenergic beta-2 receptor stimulants such as albuterol, terbutaline, or ritodrine (widely used with ECV in some countries, but not yet available in the US). One Cochrane review of tocolytic beta stimulants demonstrates that these are less likely to be associated with failed ECV, and are effective in increasing cephalic presentation and reducing caesarean section.[41] There is no current evidence to recommend one beta-2 adrenergic receptor agonist over another. Until these data are available, adherence to a local protocol for tocolysis is recommended. The US Food and Drug Administration has issued a warning against using injectable terbutaline beyond 48 to 72 hours, or acute or prolonged treatment with oral terbutaline, in pregnant women for the prevention or prolonged treatment of preterm labour, due to potential serious maternal cardiac adverse effects and death.[42] Whether this warning applies to the subcutaneous administration of terbutaline in ECV is still unclear; however, studies currently support this use. The European Medicines Agency (EMA) recommends that injectable beta agonists should be used for up to 48 hours between the 22nd and 37th week of pregnancy only. They should be used under specialist supervision with continuous monitoring of the mother and unborn baby owing to the risk of adverse cardiovascular effects in both the mother and baby. The EMA no longer recommends oral or rectal formulations for obstetric indications.[43]
The use of neuraxial analgesia in combination with tocolytics has been shown to significantly increase the incidence of vaginal delivery.[44] The American College of Obstetricians and Gynecologists (ACOG) guidelines recommended that neuraxial analgesia can be considered to increase the success rate of ECV.[33] However, Royal College of Obstetrician and Gynaecologist guidelines currently do not recommend its routine use, but suggest it may be considered for a repeat ECV attempt or for women who require ECV with analgesia.[31]
If ECV is successful, pregnancy care should continue as usual for any cephalic presentation. One systematic review assessing the mode of delivery after a successful ECV found that these women were at increased risk for caesarean section and instrumental vaginal delivery compared with women with spontaneous cephalic pregnancies. However, they still had a lower rate of caesarean section following ECV (i.e., 47%) compared with the caesarean section rate for those with a persisting breech (i.e., 85%). With a number needed to treat of three, ECV is still considered to be an effective means of preventing the need for caesarean section.[45]
Unsuccessful ECV with persistent breech
Planned mode of delivery (caesarean section or vaginal breech delivery) should be based on the experience of the attending clinician, hospital policies, maternal request, and the presence or absence of complicating factors.[46] Planned caesarean section carries a small increase in immediate maternal complications but reduces the risk of perinatal or neonatal death compared with planned vaginal breech delivery.[30] [
]
Findings from one systematic review of 27 observational studies revealed that the absolute risks of perinatal mortality, fetal neurological morbidity, birth trauma, 5-minute Apgar Score <7, and neonatal asphyxia in the planned vaginal delivery group were low at 0.3%, 0.7%, 0.7%, 2.4%, and 3.3%, respectively. However, the relative risks of perinatal mortality and morbidity were 2- to 5-fold higher in the planned vaginal than in the planned caesarean delivery group.[47]A vaginal mode of delivery may be considered when maternal request is provided, senior and experienced staff are available, there is no absolute contraindication to vaginal birth (e.g., placenta praevia, compromised fetal condition), and other hospital specific guidelines for the management of labour are followed.[46] Other factors that make planned vaginal birth higher risk include hyperextended neck on ultrasound and footling presentation.[25]
Breech presentation ≥37 weeks' gestation, during labour
Mode of delivery (caesarean section or vaginal breech delivery) should be based on the experience of the attending clinician, hospital policies, maternal request, and the presence or absence of complicating factors. A senior and experienced obstetrician, an anaesthetist, a paediatrician, and a midwife should be present at delivery. Continuous cardiotocography monitoring should continue until delivery.
Caesarean section
The first option should be a caesarean section.
There is a small increase in the risk of serious immediate maternal complications compared with vaginal birth (RR 1.29, 95% CI 1.03 to 1.61), including pulmonary embolism, infection, bleeding, damage to the bladder and bowel, slower recovery from the delivery, longer hospitalisation, and delayed bonding and breastfeeding. [
]
[23][30][48][49][50][51][52][53][54][55][56][57][58][59] The long-term maternal risks include potential compromise of future obstetric performance, increased risk of repeat caesarean section, infertility, uterine rupture, placenta accreta, placental abruption, and emergency hysterectomy.[60][61][62][63]
Planned caesarean section is safer for babies, but is associated with increased neonatal respiratory distress. The risk is reduced when the section is performed at 39 weeks' gestation.[64][65][66] For women undergoing a planned caesarean section, RCOG recommends an informed discussion about the potential risks and benefits of a course of antenatal corticosteroids between 37 and 38+6 weeks' gestation. Although antenatal corticosteroids may reduce admission to the neonatal unit for respiratory morbidity, it is uncertain if there is any reduction in respiratory distress syndrome, transient tachypnoea of the newborn, or neonatal unit admission overall. In addition, antenatal corticosteroids may result in harm to the neonate, including hypoglycaemia and potential developmental delay.[67] ACOG does not recommend corticosteroids in women >37 weeks’ gestation.[68]
Undiagnosed breech in labour generally results in caesarean section after the onset of labour, higher rates of emergency caesarean section associated with the least favourable maternal outcomes, a greater likelihood of cord prolapse, and other poor infant outcomes.[23][49][69][70][71][72][73]
Vaginal breech delivery
This mode of delivery may be considered, particularly when delivery is imminent. If delivery is not imminent, vaginal breech delivery may be considered, where maternal request is provided, senior and experienced staff are available, there is no absolute contraindication to vaginal birth (e.g., placenta praevia, compromised fetal condition), and other hospital specific guidelines for the management of labour are followed.[46] Other factors that make planned vaginal birth higher risk include hyperextended neck on ultrasound and footling presentation.[25]
External cephalic version (ECV)
ECV may also be considered an option for women with breech presentation in early labour, when delivery is not imminent, provided that the membranes are intact.
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