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12/1/2011

Singleton Breech Presentation

Approximately 3-4% of pregnancies at term are breech presentations. All pregnancies should undergo assessment of presentation beginning at 36 weeks, and confirmatory ultrasound should occur for all suspected breech presentations.  The large majority (85%) of persistent breech presentations a undergo delivery by cesarean. Fetal malpresentations constitute 17% of all indicated cesarean deliveries.

A large multi-national prospective study conducted in 2000 concluded that vaginal delivery of breech infants should not occur because of increased neonatal morbidity and mortality. Follow up studies show less perinatal morbidity and mortality, but at the expense of an increased cesarean rate. Some small and nonrandomized studies suggest that in appropriately counseled patients, breech vaginal delivery may occur safely using strict selection protocols and when patients receive appropriate counseling.

At the time of term breech diagnosis, external cephalic version (ECV) should be recommended. . The success rate of external version varies between 35-86%, with an average success rate of 58%. When successful, most patients can successfully delivery vaginally.  ECV is underutilized, occurring in only a rate of 46% of term breech pregnancies. Counseling regarding risks of external version should include fetus reverting to breech presentation, abruption, cord prolapse, rupture of membranes, fetal distress potentially resulting in emergency cesarean delivery, and extremely rarely, fetal death. To safely undergo an external cephalic version, the patient should be at least 37 weeks gestation and have no fetal or placental concerns precluding vaginal delivery. Use of a tocolytic and regional anesthesia may increase success rates. The team should obtain a reactive nonstress test before and after the procedure regardless of the procedure’s success and administer Rh immune globulin in Rh negative patients. If the patient feels too much discomfort or fetal distress occurs, the procedure should end immediately. Early ECV (34-35 wks) may have a higher risk of reversion to breech, preterm labor, and possible preterm delivery. Limited data suggest similar successful ECV rates in patients with a prior cesarean delivery, with insufficient evidence to establish an association with uterine rupture.

In the setting of an unsuccessful ECV, a planned vaginal breech delivery may be considered in certain circumstances. The physician should have experience in vaginal breech delivery, understand the hospital policy on delivery of term breech infants, and counsel the patient  on the potential risks, including cord prolapse and head entrapment.

Patients considering vaginal breech delivery received counseling on the increased risk for neonatal morbidity and mortality with vaginal breech delivery (including prolonged cord compression and fetal birth trauma) compared to planned cesarean delivery. For planned vaginal breech delivery, the infant should have at least 37 weeks gestation, an estimated fetal weight between 2500 and 4000g, and a frank or complete breech presentation. The maternal pelvis should measure as adequate on exam, and the pregnancy should have a normal amniotic fluid index, no fetal anomalies predisposing to dystocia, and a non-hyperextended fetal neck. Avoiding labor induction, and using augmentation only inadequate contraction patterns prior to active phase labor may improve outcomes. Both labor progress and fetal status should undergo close monitoring. For further details on management of a breech delivery please refer to our Pearl: Management of the Breech Presenting at the Introitus.

Further Reading:

ACOG Committee Opinion No. 745: Mode of Term Singleton Breech Delivery. Obstet Gynecol. 2018 Aug;132(2):e60-e63. doi: 10.1097/AOG.0000000000002755. PMID: 30045211.

American College of Obstetricians and Gynecologists; Society for Maternal-Fetal Medicine. Obstetric care consensus no. 1: safe prevention of the primary cesarean delivery. Obstet Gynecol. 2014 Mar;123(3):693-711. doi: 10.1097/01.AOG.0000444441.04111.1d.

Initial Approval: December 2011, Revised: March 2018, Reaffirmed September 2019; Revised May 2021; Revised November 2022.

 

 

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