Singleton Breech Presentation
Approximately 3-4% of pregnancies at term are breech presentations. Presentation should be assessed in all pregnancies 36 weeks and beyond and suspected breech presentation confirmed by ultrasound. Eighty-five percent of persistent breech presentations are delivered by cesarean. Fetal malpresentations constitute 17% of all indicated cesarean deliveries.
A large multi-national prospective study concluded that vaginal delivery of breech infants should not be attempted 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 be safe when strict selection protocols are utilized.
External cephalic version (ECV) should be recommended whenever possible when term breech is diagnosed. The success rate of external version varies between 35-86%, with an average success rate of 58%. When successful, most women will have vaginal delivery. Attempted external cephalic version is underutilized with a rate of 46%. 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. The fetus should be at least 37 weeks gestation and there should be no fetal or placental concerns precluding vaginal delivery. Use of a tocolytic and regional anesthesia may increase success rates. A reactive nonstress test should be obtained before and after the procedure regardless of the procedure’s success. The procedure should be stopped if the patient is too uncomfortable or there is fetal distress. Rh immune globulin should be administered after the procedure in Rh negative women. External cephalic version after 37 0/7 weeks is preferred. Early ECV (34-35 wks) is associated with higher risk of reversion to breech, preterm labor, and possible preterm delivery. Limited data suggest similar successful ECV rates in women with a prior cesarean delivery, but the risk of uterine rupture is unknown.
When external version is unsuccessful, a planned vaginal breech delivery may be considered in certain circumstances. The physician should be experienced in vaginal breech delivery, aware of hospital policy on delivery of term breech infants, and comfortable in counseling the patient and managing complications including cord prolapse and head entrapment.
The patient should be informed of 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. The infant should be 37 weeks or older, have an estimated fetal weight between 2500 and 4000g, and be in a frank or complete breech presentation. There should be an adequate maternal pelvis, normal amniotic fluid index, no fetal anomalies predisposing to dystocia, and the fetal neck should not be hyperflexed. Labor induction should be avoided. Augmentation should be reserved for inadequate contraction patterns prior to active phase labor. The fetus should undergo continuous heart rate monitoring and labor progress followed closely. For further details on management of a breech delivery please refer to our Pearl: Management of the Breech Presenting at the Introitus.
American College of Obstetricians and Gynecologists' Committee on Practice Bulletins--Obstetrics. Practice Bulletin No. 161: External Cephalic Version. Obstet Gynecol. 2016 Feb;127(2):e54-61. doi: 10.1097/AOG.0000000000001312.
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
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