What is the recommended course of action for a pregnancy with a breech presentation?

Management of Breech Presentation in Pregnancy

For pregnancies with breech presentation, external cephalic version (ECV) should be attempted at 36-37 weeks gestation to reduce the likelihood of breech presentation at birth and decrease cesarean section rates. 1

Understanding Breech Presentation

Breech presentation occurs when the fetus is positioned with the buttocks or feet toward the birth canal rather than the head. This presentation is associated with increased complications during delivery and occurs in approximately 3-4% of pregnancies at term 2.

Recommended Management Algorithm

1. External Cephalic Version (ECV)

• Timing: Should be performed from 36 weeks gestation 1
• Preparation:
  • Ensure immediate access to an operating room for emergency cesarean 1
  • Perform cardiotocography before the procedure 1
  • Use parenteral tocolysis (β-mimetics or atosiban) to increase success rate 1
  • For RH-negative women, ensure RH prophylaxis 1

2. Factors Affecting ECV Success

• Higher success rates are associated with:
  • Multiparity 1
  • Non-obese mothers 1
  • Earlier intervention (37 weeks shows 81.25% success rate) 2

3. Post-ECV Monitoring

• Perform cardiotocography for 30 minutes after the procedure 1
• Kleihauer test is not routinely recommended (risk of significant positivity >30mL is <0.1%) 1

4. If ECV is Successful

• Plan for normal vaginal delivery
• Success rates for vaginal delivery after successful ECV are approximately 71.9% 2

5. If ECV is Unsuccessful or Contraindicated

• Consider cesarean delivery as the safest option for delivery of breech presentation

Effectiveness of ECV

ECV significantly reduces:

• Non-cephalic presentation at birth (RR 0.42,95% CI 0.29 to 0.61) 3
• Failure to achieve vaginal cephalic birth (RR 0.46,95% CI 0.33 to 0.62) 3
• Cesarean section rates (RR 0.57,95% CI 0.40 to 0.82) 3

Safety Considerations

• Complications from ECV are rare 3
• Transient fetal heart rate abnormalities may occur during the procedure 1
• Emergency cesarean section due to persistent fetal bradycardia is uncommon (reported in only 1 case in a series of 51 procedures) 2

Interventions to Improve ECV Success

• Tocolytic medications: Parenteral beta-stimulants increase success rates (RR 0.74,95% CI 0.64 to 0.87) 4
• Regional analgesia with tocolysis: More effective than tocolysis alone for successful versions (RR 0.61,95% CI 0.43 to 0.86) 5

Ineffective Interventions

The following interventions are not recommended as they have not shown effectiveness in reducing breech presentation at birth 1:

• Acupuncture
• Moxibustion
• Postural methods

Common Pitfalls to Avoid

1. Delaying ECV: Attempting ECV too late reduces success rates
2. Omitting tocolysis: Parenteral tocolysis significantly improves success rates
3. Inadequate monitoring: Always perform cardiotocography before and after the procedure
4. Forgetting RH prophylaxis: Essential for RH-negative women
5. Using ineffective methods: Avoid recommending acupuncture, moxibustion, or postural methods as alternatives

Special Considerations for Impacted Fetal Head During Cesarean

If cesarean delivery becomes necessary and an impacted fetal head is encountered, several techniques may be employed 6:

• Uterine relaxation with tocolysis
• Abdominal cephalic disimpaction
• Manual vaginal disimpaction
• Reverse breech extraction
• Patwardhan method (a modification of reverse breech extraction)