Breech Presentation; a matrix management of term

pregnancy
No

Guidline

Williams Text

Management

Book
24Th edition

Factors Favoring Cesarean Delivery of the Breech Fetus.

1. Lack of operator experience
2. Patient request for cesarean delivery
3. Large fetus: > 3800 to 4000 g
4. Apparently healthy and viable preterm fetus either with
active labor or with indicated delivery
5. Severe fetal-growth restriction
6. Fetal anomaly incompatible with vaginal delivery
7. Prior perinatal death or neonatal birth trauma
8. Incomplete or footling breech presentation
9. Hyperextended head
10.Pelvic contraction or unfavorable pelvic shape

determined clinically or with pelvimetry

11.
Prior cesarean delivery
Data regarding superior perinatal outcomes for planned
cesarean

delivery

of

singleton

term

breech

are

conflicting, at least in this country, rates of planned vaginal

delivery attempts continue to decline. And as predicted,
the number of skilled operators able to safely select and
vaginally deliver breech fetuses continues to dwindle.
Moreover, obvious medicolegal concerns makes physician
training in such deliveries difficult. In response, some
institutions have developed birth simulators to improve
resident competence in vaginal breech delivery.

DC DUTTAs

Text Book

PREVENTION OF THE FETAL HAZARDS

1. The incidence of breech can be minimized by external
cephalic version where possible.
2. If the version fails or is contraindicated, delivery is done
by elective cesarean section.
3. Vaginal breech delivery should be conducted by a
skilled obstetrician along with an organized team
consisting of a skilled anesthesist and neonatologist.
4. Vaginal manipulative delivery should be done by a
skilled person with utmost gentleness, especially during
delivery of the head.

Elective Cesarean Section: Because of the complications

involved in vaginal breech delivery, there is atendency to
liberalize the use of cesarean section in breech. The
indications of CS in breech are: Big baby (estimated fetal
weight > 3.5 kg), hyperextension of the head (stargazing
fetus),

footling

suspected

presentation

pelvic

(risk

contraction

or

of

cord

severe

prolapse),
IUGR.

Any

associated complications (obstetric or medical) is often

considered for CS in breech. The overall incidence of
cesarean section in breech ranges from 15-50%, out of
which about 80% is elective. Delivery of preterm breech
(weight < 1500 g) by cesarean section is commonly done
but it should be reserved in selected centers, equipped
with intensive neonatal care unit.

Vaginal breech delivery: Criteria to be fulfilled are;

1. Average fetal weight (between 1.5 and 3.5 kg),
2. Flexed fetal head.
3. Adequate pelvis.
4. Without any other (medical or obstetric) complications.
5. Availability of facilities for emergency caesarean section
(anesthetists, neonatologist).
6. Facilities for continuous labor monitoring (preferably
electronic)
and
(vii)
Presence
of
obstetrician
experienced with vaginal Breech delivery. Frank breech
is preferred.

DC DUTTAs
Text Book

ALARM

The following selection criteria for vaginal breech delivery

are recommended:
1. Planned vaginal birth should be recommended for either
frank or complete breech presentations at 36 weeks or
more gestation and/or when the estimated birth weight
is 2500 to 4000 grams.
2. Planned vaginal birth should be offered for either frank
or complete breech presentations at 31 to 35 weeks
gestation and/or when the estimated birth weight is
1500 to 2500 grams.
3. Cesarean section should be offered (there was less
certainty about the adequacy of the data) for either
frank or complete breech presentation at 30 weeks or
less gestation and/or when the estimated birth weight is

less than 1500 grams.

4. There was insufficient data on which to base a
recommendation

for

frank

or

complete

breech

presentations when the estimated birth weight is more

than 4000 grams. The attending physicians judgement
about the most appropriate course of action should
determine which delivery method is suggested.

In addition, ultrasonography also provides the following

useful information:
1. Amniotic fluid assessment
2. Cord position
3. Assessment for congenital anomalies
4. Confirms placenta localisation

The Royal

Factors regarded as unfavourable for vaginal breech birth

include the following:
1. Other contraindications to vaginal birth (e.g. placenta

college of
obstetricians
and

2.
3.
4.
5.

gynecologist
(RCOG)

praevia, compromised fetal condition)

Clinically inadequate pelvis
Footling or kneeling breech presentation
Flarge baby (usually defined as larger than 3800 g)
Growth-restricted baby (usually defined as smaller than

2000 g)
6. Hyperextended fetal neck in labour (diagnosed with
ultrasound or X-ray where ultrasound is not available)
7. Lack of presence of a clinician trained in vaginal breech
delivery
8. Previous caesarean section.

Women should be advised that planned caesarean section

for breech presentation carries a small increase in serious
immediate complications for them compared with planned
vaginal birth.

Women should be advised that planned caesarean section

for breech presentation does not carry any additional risk
to long-term health outside pregnancy.

The American

The American college of obstetricians and gynecologist

college of

committee on obstetric practice in 2001 recommended

obstetricians

that planned vaginal delivery of a term singleton breech

and
gynecologist
(ACOG)

was no longer appropriate.

In light of the recent publications that further clarify the
long term risks of vaginal delivery, the American college
of obstetricians and gynecologist on obstetric practice
issues the following recommendation:
1. The decision regarding the mode of delivery
should depend on the experience of the health
care provider. Cesarean delivery will be the
preferred mode of delivery for the most physician
because of the diminishing expertise in vaginal
delivery
2. Obstetrician should offer and perform external
cephalic version whenever possible.
3. Planned vagina delivery of the term singleton
breech fetus may be reasonable under hospital
specific protocol guideline for both eligibility and
labor management
4. In those instance in which vaginal delivery are
pursue, great caution should be exercise, and
detailed patient informed consent should be
documented.
5. Before embarking on a plan for vaginal breech
delivery, women should be informed that the risk
of perinatal or neonatal mortality or short term
serious neonatal morbidity may be higher than if
a cesarean is planned.