Glossary What does it mean when a fetus is breech? In the last weeks of pregnancy, a fetus usually moves so his or her head is positioned to come out of the vagina first during birth. This is called a vertex presentation. What factors are related to breech presentation? It is not always known why a fetus is breech.
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Additional updates have been made to reflect current practice regarding vaginal breech delivery. The number of practitioners with the skills and experience to perform vaginal breech delivery has decreased.
The decision regarding the mode of delivery should consider patient wishes and the experience of the health care provider. Obstetrician—gynecologists and other obstetric care providers should offer external cephalic version as an alternative to planned cesarean for a woman who has a term singleton breech fetus, desires a planned vaginal delivery of a vertex-presenting fetus, and has no contraindications.
External cephalic version should be attempted only in settings in which cesarean delivery services are readily available. Planned vaginal delivery of a term singleton breech fetus may be reasonable under hospital-specific protocol guidelines for eligibility and labor management. If a vaginal breech delivery is planned, a detailed informed consent should be documented—including risks that perinatal or neonatal mortality or short-term serious neonatal morbidity may be higher than if a cesarean delivery is planned.
Recommendations The American College of Obstetricians and Gynecologists makes the following recommendations: The decision regarding the mode of delivery should consider patient wishes and the experience of the health care provider. There is a trend in the United States to perform cesarean delivery for term singleton fetuses in a breech presentation.
In , the rate of cesarean deliveries for women in labor with breech presentation was Even in academic medical centers where faculty support for teaching vaginal breech delivery to residents remains high, there may be insufficient volume of vaginal breech deliveries to adequately teach this procedure 2. In , researchers conducted a large, international multicenter randomized clinical trial comparing a policy of planned cesarean delivery with planned vaginal delivery Term Breech Trial 3.
The benefits of planned cesarean delivery remained for all subgroups identified by the baseline variables eg, older and younger women, nulliparous and multiparous women, frank and complete type of breech presentation. They found that the reduction in risk attributable to planned cesarean delivery was greatest among centers in industrialized nations with low overall perinatal mortality rates 0.
Since that time, there have been additional publications that modify the original conclusions of the Term Breech Trial. The same researchers have published three follow-up studies examining maternal outcomes at 3 months postpartum, as well as outcomes for mothers and children 2 years after the births 4 5 6.
At 3 months postpartum, the risk of urinary incontinence was lower for women in the planned cesarean delivery group; however, there was no difference at 2 years.
At 2 years postpartum, the majority of women The follow-up study to address outcomes of the children at 2 years involved 85 centers with both high and low perinatal mortality rates that were chosen at the start of the original trial.
Most children, of 1, All abnormal results were further evaluated with a clinical neurodevelopment assessment. The risk of death or neurodevelopmental delay was no different in the planned cesarean delivery group compared with the planned vaginal delivery group 14 children [3.
There are several explanations for this seemingly contradictory finding. The follow-up study was underpowered to show a clinically important benefit from cesarean delivery if this were true. Only 6 of the 16 infants who died in the neonatal period were from centers participating in the follow-up to 2 years one in the planned cesarean delivery group, five in the planned vaginal delivery group , and most of the children with serious neonatal morbidity after birth survived and developed normally.
In this cohort, 17 out of 18 children with serious morbidity in the original study were normal at this month follow-up. Another explanation is that the use of pooled mortality and morbidity data at the time of birth overstated the true long-term risks of vaginal delivery 7.
A recent retrospective observational report reviewed neonatal outcomes in the Netherlands before and after the publication of the Term Breech Trial 8. Between and , 35, term infants were delivered. The combined neonatal mortality rate decreased from 0.
Of interest, a decrease in mortality also was seen in the emergency cesarean delivery group and the vaginal delivery group, a finding that the authors attribute to better selection of candidates for vaginal breech delivery.
Obstetrician—gynecologists and other obstetric care providers should offer external cephalic version as an alternative to planned cesarean for a woman who has a term singleton breech fetus, desires a planned vaginal delivery of a vertex-presenting fetus, and has no contraindications 9.
The studies included in this meta-analysis did not employ analgesia for the external cephalic version. A systematic review and meta-analysis of six randomized controlled trials found that using epidural or spinal anesthesia significantly increased the success rate of external cephalic version from The frequency of adverse events was not significantly different between groups receiving and not receiving regional anesthesia for external cephalic version External cephalic version should be attempted only in settings in which cesarean delivery services are readily available 9.
Planned vaginal delivery of a term singleton breech fetus may be reasonable under hospital-specific protocol guidelines for both eligibility and labor management. There are many retrospective reports of vaginal breech delivery that follow very specific protocols and note excellent neonatal outcomes. One report noted women in a vaginal breech trial with no perinatal morbidity and mortality Another report noted similar outcomes in women with planned vaginal delivery Although they are not randomized trials, these reports detail the outcomes of specific management protocols and document the potential safety of a vaginal delivery in the properly selected patient.
The initial criteria used in these reports were similar: gestational age greater than 37 weeks, frank or complete breech presentation, no fetal anomalies on ultrasound examination, adequate maternal pelvis, and estimated fetal weight between 2, g and 4, g.
In addition, the protocol presented by one report required documentation of fetal head flexion and adequate amniotic fluid volume, defined as a 3-cm vertical pocket Oxytocin induction or augmentation was not offered, and strict criteria were established for normal labor progress. Current evidence demonstrates short-term benefits in neonatal and maternal morbidity and mortality from planned cesarean delivery of the term fetus with a breech presentation. Long-term benefits of planned cesarean delivery for these infants and women are less clear 14 Offering external cephalic version provides an opportunity to potentially reduce cesarean delivery for these pregnancies 10 Finally, a planned vaginal delivery of a term singleton breech fetus may be reasonable under hospital-specific guidelines 12 Cesarean delivery will be the preferred mode of delivery for most physicians because of the diminishing expertise in vaginal breech delivery.
Obstetricians should offer and perform external cephalic version whenever possible. In those instances in which breech vaginal deliveries are pursued, great caution should be exercised, and detailed patient informed consent should be documented. Before embarking on a plan for a 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 delivery is planned.
Births: final data for Natl Vital Stat Rep ;52 10 :1— Teaching vaginal breech delivery and external cephalic version. A survey of faculty attitudes. J Reprod Med ;— Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial.
Term Breech Trial Collaborative Group. Lancet ;— Outcomes of children at 2 years after planned cesarean birth versus planned vaginal birth for breech presentation at term: the International Randomized Term Breech Trial. Am J Obstet Gynecol ;— Maternal outcomes at 2 years after planned cesarean section versus planned vaginal birth for breech presentation at term: the international randomized Term Breech Trial.
Planned caesarean section decreases the risk of adverse perinatal outcome due to both labour and delivery complications in the Term Breech Trial. BJOG ;— Article Locations: Kotaska A. Inappropriate use of randomised trials to evaluate complex phenomena: case study of vaginal breech delivery [published erratum appears in BMJ ;].
BMJ ;— The effect of the Term Breech Trial on medical intervention behaviour and neonatal outcome in The Netherlands: an analysis of 35, term breech infants.
BJOG ;—9. Article Locations: External cephalic version. Practice Bulletin No. American College of Obstetricians and Gynecologists. Obstet Gynecol ;e54— External cephalic version for breech presentation at term. Cochrane Database of Systematic Reviews , Issue 4.
DOI: Effect of regional anesthesia on the success rate of external cephalic version: a systematic review and meta-analysis. Obstet Gynecol ;— Singleton vaginal breech delivery at term: still a safe option. Mode of delivery and outcome of term singleton breech deliveries at a single center.
Am J Obstet Gynecol ;—8. The risks of planned vaginal breech delivery versus planned caesarean section for term breech birth: a meta-analysis including observational studies. Planned caesarean section for term breech delivery. Cochrane Database of Systematic Reviews , Issue 7.
Neuraxial analgesia to increase the success rate of external cephalic version: a systematic review and meta-analysis of randomized controlled trials [published erratum appears Am J Obstet Gynecol. Copyright by the American College of Obstetricians and Gynecologists. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, posted on the Internet, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher.
Obstet Gynecol ;e60—3. This information is designed as an educational resource to aid clinicians in providing obstetric and gynecologic care, and use of this information is voluntary.
This information should not be considered as inclusive of all proper treatments or methods of care or as a statement of the standard of care. It is not intended to substitute for the independent professional judgment of the treating clinician. Variations in practice may be warranted when, in the reasonable judgment of the treating clinician, such course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or technology.
The American College of Obstetricians and Gynecologists reviews its publications regularly; however, its publications may not reflect the most recent evidence. Any updates to this document can be found on www. ACOG does not guarantee, warrant, or endorse the products or services of any firm, organization, or person.
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Management of Breech Presentation (Green-top Guideline No. 20b)
You can also access this guideline in HTML. This is the fourth edition of this guideline, first published in and revised in and under the same title. The aim of this guideline is to aid decision making regarding the route of delivery and choice of various techniques used during delivery. It does not include antenatal or postnatal care. Information regarding external cephalic version is the topic of the separate Royal College of Obstetricians and Gynaecologists Green-top Guideline No.
External Cephalic Version