Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

<37 weeks' gestation and in labor

1st line – specialist evaluation

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INITIAL
|
<37 weeks' gestation and in labor
1st line – 

specialist evaluation

A woman in labor 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 Preterm labor (Management).

≥37 weeks' gestation not in labor

1st line – external cephalic version (ECV)

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INITIAL
|
≥37 weeks' gestation not in labor
1st line – 

external cephalic version (ECV)

There is no upper time limit on the appropriate gestation for ECV; 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][32][33]​​

ECV involves applying external pressure and firmly pushing or palpating the mother's abdomen to coerce the fetus to somersault (either forward or backward) into a cephalic position.[35]

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 isoimmunization, other indications for cesarean section (e.g., placenta previa 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 preeclampsia/HELLP syndrome, or signs of fetal distress (abnormal cardiotocography and/or Doppler flow).[32]

Cardiotocography and ultrasound should be performed before and after the procedure.

If ECV is successful, pregnancy care should continue as usual for any cephalic presentation. A systematic review assessing the mode of delivery after a successful ECV found that these women were at increased risk for cesarean section and instrumental vaginal delivery compared with women with spontaneous cephalic pregnancies. However, they still had a lower rate of cesarean section following ECV (i.e., 47%) compared with the cesarean section rate for those with a persisting breech (i.e., 85%). With a number needed to treat of 3, ECV is still considered to be an effective means of preventing the need for cesarean section.[45]

Plus – tocolytic agents

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INITIAL
|
≥37 weeks' gestation not in labor
Plus – 

tocolytic agents

Treatment recommended for ALL patients in selected patient group

Tocolytic agents include adrenergic beta-2 receptor stimulants such as albuterol, terbutaline, or ritodrine (widely used with external cephalic version [ECV] in some countries, but not yet available in the US). They are used to delay or inhibit labor and increase the success rate of ECV.[33]​ 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 Food and Drug Administration has issued a warning against using injectable terbutaline beyond 48-72 hours, or acute or prolonged treatment with oral terbutaline, in pregnant women for the prevention or prolonged treatment of preterm labor, 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]

A systematic review found there was no evidence to support the use of nifedipine for tocolysis.[74]

There is insufficient evidence to evaluate other interventions to help ECV, such as fetal acoustic stimulation in midline fetal spine positions.[41]

Primary options

albuterol: see local specialist protocol for dosing guidelines

OR

terbutaline: see local specialist protocol for dosing guidelines

Consider – neuraxial analgesia

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INITIAL
|
≥37 weeks' gestation not in labor
Consider – 

neuraxial analgesia

Treatment recommended for SOME patients in selected patient group

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 recommend 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] Consult a specialist for guidance on choice of appropriate regimen.​​​

Consider – Rho(D) immune globulin

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INITIAL
|
≥37 weeks' gestation not in labor
Consider – 

Rho(D) immune globulin

Treatment recommended for SOME patients in selected patient group

Nonsensitized Rh-negative women should receive Rho(D) immune globulin.[31]

The indication for its administration is to prevent rhesus isoimmunization, which may affect subsequent pregnancy outcomes.

Rho(D) immune globulin needs to be given at the time of external cephalic version and should be given again postpartum to those women who give birth to an Rh-positive baby.[75]

It is best administered as soon as possible after the procedure, usually within 72 hours.

Dose depends on brand used. Dose given below pertains to most commonly used brands. Consult specialist for further guidance on dose.

Primary options

Rho(D) immune globulin: 300 micrograms intramuscularly as a single dose

Plus – elective cesarean section/vaginal breech delivery

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INITIAL
|
≥37 weeks' gestation not in labor
|
unsuccessful ECV with persistent breech
Plus – 

elective cesarean section/vaginal breech delivery

Treatment recommended for ALL patients in selected patient group

Mode of delivery (cesarean 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]

Cesarean section, at 39 weeks or greater, has been shown to significantly reduce perinatal mortality and neonatal morbidity compared with vaginal breech delivery (RR 0.33, 95% CI 0.19 to 0.56).[30] Although safer for these babies, there is a small increase in serious immediate maternal complications compared with vaginal birth (RR 1.29, 95% CI 1.03 to 1.61), as well as long-term risks for future pregnancies, including pulmonary embolism, bleeding, infection, damage to the bladder and bowel, slower recovery from the delivery, longer hospitalization, and delayed bonding and breast-feeding. [ Cochrane Clinical Answers logo ] [23][30][48][49][50][51][52][53][54][55][56][57][58][59]​​

Vaginal delivery may be considered particularly when maternal request is provided, when senior and experienced staff are available, when there is no absolute contraindication to vaginal birth (e.g., placenta previa, compromised fetal condition), and when other hospital specific guidelines for the management of labor are followed.[46]​ Other factors that make planned vaginal birth higher risk include hyperextended neck on ultrasound and footling presentation.[25]

Consider – corticosteroid

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INITIAL
|
≥37 weeks' gestation not in labor
|
unsuccessful ECV with persistent breech
Consider – 

corticosteroid

Treatment recommended for SOME patients in selected patient group

For women undergoing a planned cesarean section, the UK Royal College of Obstetricians and Gynaecologists recommends an informed discussion about the potential risks and benefits of a course of prenatal corticosteroids between 37 and 38+6 weeks' gestation. Although prenatal corticosteroids may reduce admission to the neonatal unit for respiratory morbidity, it is uncertain if there is any reduction in respiratory distress syndrome, transient tachypnea of the newborn, or neonatal unit admission overall. In addition, prenatal corticosteroids may result in harm to the neonate, including hypoglycemia and potential developmental delay.[67] The ACOG does not recommend corticosteroids in women >37 weeks’ gestation.[68]​​

Primary options

betamethasone sodium phosphate/betamethasone acetate: 12 mg intramuscularly every 24 hours for 2 doses

OR

dexamethasone sodium phosphate: 6 mg intramuscularly every 12 hours for 4 doses

Consider – Rho(D) immune globulin

Back
INITIAL
|
≥37 weeks' gestation not in labor
|
unsuccessful ECV with persistent breech
Consider – 

Rho(D) immune globulin

Treatment recommended for SOME patients in selected patient group

Nonsensitized Rh-negative women should receive Rho(D) immune globulin.[31]

The indication for its administration is to prevent rhesus isoimmunization, which may affect subsequent pregnancy outcomes.

It is best administered as soon as possible after delivery, usually within 72 hours.

Administration of postpartum Rho (D) immune globulin should not be affected by previous routine prenatal prophylaxis or previous administration for a potentially sensitizing event.[75]

Dose depends on brand used. Dose given below pertains to most commonly used brands. Consult specialist for further guidance on dose.

Primary options

Rho(D) immune globulin: 300 micrograms intramuscularly as a single dose

ACUTE

≥37 weeks' gestation in labor: no imminent delivery

1st line – cesarean section

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ACUTE
|
≥37 weeks' gestation in labor: no imminent delivery
1st line – 

cesarean section

For women with breech presentation in labor, cesarean section is the first option.

Although safer for these babies, there is a small increase in serious immediate maternal complications compared with vaginal birth (RR 1.29, 95% CI 1.03 to 1.61), as well as long-term risks for future pregnancies, including pulmonary embolism, infection, bleeding, damage to the bladder and bowel, slower recovery from the delivery, longer hospitalization, and delayed bonding and breast-feeding. [ Cochrane Clinical Answers logo ] [23][30][48][49][50][51][52][53][54][55][56][57][58][59]

Continuous cardiotocography monitoring should continue until delivery.​

Consider – corticosteroid

Back
ACUTE
|
≥37 weeks' gestation in labor: no imminent delivery
Consider – 

corticosteroid

Treatment recommended for SOME patients in selected patient group

For women undergoing a planned cesarean section, the UK Royal College of Obstetricians and Gynaecologists recommends an informed discussion about the potential risks and benefits of a course of prenatal corticosteroids between 37 and 38+6 weeks' gestation. Although prenatal corticosteroids may reduce admission to the neonatal unit for respiratory morbidity, it is uncertain if there is any reduction in respiratory distress syndrome, transient tachypnea of the newborn, or neonatal unit admission overall. In addition, prenatal corticosteroids may result in harm to the neonate, including hypoglycemia and potential developmental delay.[67] The ACOG does not recommend corticosteroids in women >37 weeks’ gestation.[68]​​

Primary options

betamethasone sodium phosphate/betamethasone acetate: 12 mg intramuscularly every 24 hours for 2 doses

OR

dexamethasone sodium phosphate: 6 mg intramuscularly every 12 hours for 4 doses

Consider – Rho(D) immune globulin

Back
ACUTE
|
≥37 weeks' gestation in labor: no imminent delivery
Consider – 

Rho(D) immune globulin

Treatment recommended for SOME patients in selected patient group

Nonsensitized Rh-negative women should receive Rho(D) immune globulin.[31]

The indication for its administration is to prevent rhesus isoimmunization, which may affect subsequent pregnancy outcomes.

It is best administered as soon as possible after the procedure, usually within 72 hours.

Administration of postpartum Rho (D) immune globulin should not be affected by previous routine prenatal prophylaxis or previous administration for a potentially sensitizing event.[75]

Dose depends on brand used. Dose given below pertains to most commonly used brands. Consult specialist for further guidance on dose.

Primary options

Rho(D) immune globulin: 300 micrograms intramuscularly as a single dose

2nd line – vaginal breech delivery

Back
ACUTE
|
≥37 weeks' gestation in labor: no imminent delivery
2nd line – 

vaginal breech delivery

Mode of delivery (cesarean 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.

This mode of delivery may be considered by some clinicians as an option, particularly when maternal request is provided, when senior and experienced staff are available, when there is no absolute contraindication to vaginal birth (e.g., placenta previa, compromised fetal condition), and with optimal fetal growth (estimated weight above the tenth centile and up to 3800 g). Other factors that make planned vaginal birth higher risk include hyperextended neck on ultrasound and footling presentation.[25]

For women with persisting breech presentation, planned cesarean section has, however, been shown to significantly reduce perinatal mortality and neonatal morbidity compared with vaginal breech delivery (RR 0.33, 95% CI 0.19 to 0.56).[30]

Consider – Rho(D) immune globulin

Back
ACUTE
|
≥37 weeks' gestation in labor: no imminent delivery
Consider – 

Rho(D) immune globulin

Treatment recommended for SOME patients in selected patient group

Nonsensitized Rh-negative women should receive Rho(D) immune globulin.[31]

The indication for its administration is to prevent rhesus isoimmunization, which may affect subsequent pregnancy outcomes.

It is best administered as soon as possible after delivery, usually within 72 hours.

Administration of postpartum Rho (D) immune globulin should not be affected by previous routine prenatal prophylaxis or previous administration for a potentially sensitizing event.[75]

Dose depends on brand used. Dose given below pertains to most commonly used brands. Consult specialist for further guidance on dose.

Primary options

Rho(D) immune globulin: 300 micrograms intramuscularly as a single dose

3rd line – external cephalic version (ECV)

Back
ACUTE
|
≥37 weeks' gestation in labor: no imminent delivery
3rd line – 

external cephalic version (ECV)

ECV may also be considered an option for women with breech presentation in early labor, provided that the membranes are intact.

There is no upper time limit on the appropriate gestation for ECV.[31]

Involves applying external pressure and firmly pushing or palpating the mother's abdomen to coerce the fetus to somersault (either forward or backward) into a cephalic position.[35]

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 isoimmunization, other indications for cesarean section (e.g., placenta previa 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 preeclampsia/HELLP syndrome, or signs of fetal distress (abnormal cardiotocography and/or Doppler flow).[32]

Relative contraindications include placental abruption, severe preeclampsia/HELLP syndrome, and signs of fetal distress (abnormal cardiotocography and/or abnormal Doppler flow).[31][32]

Consider – Rho(D) immune globulin

Back
ACUTE
|
≥37 weeks' gestation in labor: no imminent delivery
Consider – 

Rho(D) immune globulin

Treatment recommended for SOME patients in selected patient group

Nonsensitized Rh-negative women should receive Rho(D) immune globulin.[31]

The indication for its administration is to prevent rhesus isoimmunization, which may affect subsequent pregnancy outcomes.

Rho(D) immune globulin needs to be given at the time of ECV and should be given again postpartum to those women who give birth to an Rh-positive baby.[75]

It is best administered as soon as possible after the procedure, usually within 72 hours.

Dose depends on brand used. Dose given below pertains to most commonly used brands. Consult specialist for further guidance on dose.

Primary options

Rho(D) immune globulin: 300 micrograms intramuscularly as a single dose

≥37 weeks' gestation in labor: imminent delivery

1st line – cesarean section

Back
ACUTE
|
≥37 weeks' gestation in labor: imminent delivery
1st line – 

cesarean section

For women with persistent breech presentation, planned cesarean section has been shown to significantly reduce perinatal mortality and neonatal morbidity compared with vaginal breech delivery (RR 0.33, 95% CI 0.19 to 0.56).[30] Although safer for these babies, there is a small increase in serious immediate maternal complications compared with vaginal birth (RR 1.29, 95% CI 1.03 to 1.61), as well as long-term risks for future pregnancies, including pulmonary embolism, infection, bleeding, damage to the bladder and bowel, slower recovery from the delivery, longer hospitalization, and delayed bonding and breast-feeding. [ Cochrane Clinical Answers logo ] [23][30][48][49][50][51][52][53][54][55][56][57][58][59]

Undiagnosed breech in labor generally results in cesarean section after the onset of labor, higher rates of emergency cesarean section associated with the least favorable maternal outcomes, a greater likelihood of cord prolapse, and other poor infant outcomes.[23][50][69]​​[70][71][72][73]

Continuous cardiotocography monitoring should continue until delivery.​

Consider – corticosteroid

Back
ACUTE
|
≥37 weeks' gestation in labor: imminent delivery
Consider – 

corticosteroid

Treatment recommended for SOME patients in selected patient group

For women undergoing a planned cesarean section, the UK Royal College of Obstetricians and Gynaecologists recommends an informed discussion about the potential risks and benefits of a course of prenatal corticosteroids between 37 and 38+6 weeks' gestation. Although prenatal corticosteroids may reduce admission to the neonatal unit for respiratory morbidity, it is uncertain if there is any reduction in respiratory distress syndrome, transient tachypnea of the newborn, or neonatal unit admission overall. In addition, prenatal corticosteroids may result in harm to the neonate, including hypoglycemia and potential developmental delay.[67] The ACOG does not recommend corticosteroids in women >37 weeks’ gestation.[68]​​​

Primary options

betamethasone sodium phosphate/betamethasone acetate: 12 mg intramuscularly every 24 hours for 2 doses

OR

dexamethasone sodium phosphate: 6 mg intramuscularly every 12 hours for 4 doses

Consider – Rho(D) immune globulin

Back
ACUTE
|
≥37 weeks' gestation in labor: imminent delivery
Consider – 

Rho(D) immune globulin

Treatment recommended for SOME patients in selected patient group

Nonsensitized Rh-negative women should receive Rho(D) immune globulin.[31]

The indication for its administration is to prevent rhesus isoimmunization, which may affect subsequent pregnancy outcomes.

It is best administered as soon as possible after the procedure, usually within 72 hours.

Administration of postpartum Rho (D) immune globulin should not be affected by previous routine prenatal prophylaxis or previous administration for a potentially sensitizing event.[75]

Dose depends on brand used. Dose given below pertains to most commonly used brands. Consult specialist for further guidance on dose.

Primary options

Rho(D) immune globulin: 300 micrograms intramuscularly as a single dose

2nd line – vaginal breech delivery

Back
ACUTE
|
≥37 weeks' gestation in labor: imminent delivery
2nd line – 

vaginal breech delivery

This mode of delivery may be considered, when delivery is imminent, maternal request is provided, when senior and experienced staff are available, when there is no absolute contraindication to vaginal birth (e.g., placenta previa, compromised fetal condition), and ​other hospital specific guidelines for the management of labor are followed.[46]

Consider – Rho(D) immune globulin

Back
ACUTE
|
≥37 weeks' gestation in labor: imminent delivery
Consider – 

Rho(D) immune globulin

Treatment recommended for SOME patients in selected patient group

Nonsensitized Rh-negative women should receive Rho(D) immune globulin.[31]

The indication for its administration is to prevent rhesus isoimmunization, which may affect subsequent pregnancy outcomes.

It is best administered as soon as possible after the delivery, usually within 72 hours.

Administration of postpartum Rho (D) immune globulin should not be affected by previous routine prenatal prophylaxis or previous administration for a potentially sensitizing event.[75]

Dose depends on brand used. Dose given below pertains to most commonly used brands. Consult specialist for further guidance on dose.

Primary options

Rho(D) immune globulin: 300 micrograms intramuscularly as a single dose

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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