What are the recommended approaches for managing a breech presentation in pregnancy?

Management of Breech Presentation in Pregnancy

For breech presentations at term, external cephalic version (ECV) should be attempted as the first-line approach to reduce breech presentation at birth and decrease cesarean section rates. 1

External Cephalic Version (ECV)

• ECV is associated with a decreased rate of breech presentation at birth and potentially lower rates of cesarean section without increasing severe maternal or perinatal morbidity 1
• ECV should be performed from 36 weeks gestation in a facility equipped for emergency cesarean section 1, 2
• Success rates for ECV are approximately 65%, making it a valuable intervention for managing breech presentation 2
• Factors associated with successful ECV include:
  • Multiparity (higher success rates in women who have had previous pregnancies) 1
  • Absence of maternal obesity 1

ECV Technique and Considerations

• After gently disengaging the fetal head, the fetus is manipulated by either a forward roll or back flip technique 2
• Parenteral tocolysis (medications that relax the uterus) should be used during ECV attempts at term to increase success rates 1
• Cardiotocography (fetal heart rate monitoring) should be performed prior to and for 30 minutes after the procedure 1
• For Rh-negative women, Rh prophylaxis should be administered 1
• If unsuccessful, ECV can be reattempted at a later time 2

Alternative Management Options for Persistent Breech

When ECV is unsuccessful or contraindicated, the following options should be considered:

Cesarean Delivery

• Currently the most common approach for breech presentation in many countries 2
• May be necessary when vaginal breech delivery is contraindicated or when expertise for vaginal breech delivery is unavailable 3

Vaginal Breech Delivery Techniques

For cases where vaginal delivery is attempted:

• Reverse Breech Extraction (Pull Technique) is recommended by experts, involving:

  • Grasping one or both feet
  • Applying traction toward the woman's feet to deliver legs and abdomen
  • Rotating the body to deliver each arm
  • Applying traction toward the woman's head to deliver the baby's head 3

• Patwardhan Method is a modification where:

  • An assistant introduces their hand into the vagina to cup the baby's head
  • The woman's legs are supported in semilithotomy position 3

Important Safety Considerations

• Proper technique is crucial as errors in performing breech extractions may increase risk of femoral and humeral fractures 3
• Single forceps blade or ventouse as a lever to disimpact the fetal head should be avoided as they are considered dangerous 3
• Specialist training is required for breech delivery techniques, and many obstetricians may not be familiar with proper execution 3
• Alternative methods such as acupuncture, moxibustion, and postural methods are not effective in reducing breech presentation at birth and are not recommended 1

Management Algorithm

1. Diagnosis of breech presentation at 36+ weeks
2. Attempt ECV with tocolysis unless contraindicated
3. If ECV successful: Continue routine prenatal care with regular monitoring
4. If ECV unsuccessful:
   • Reassess at 37-38 weeks for possible repeat ECV attempt
   • If still breech after repeat attempt or ECV contraindicated:
     • Plan for cesarean delivery (most common approach)
     • OR consider vaginal breech delivery only if:
       • Provider has appropriate expertise
       • No contraindications to vaginal delivery exist
       • Proper facilities for emergency cesarean are available

Potential Complications

• ECV is associated with transient fetal heart rate abnormalities, though serious complications are rare 1
• Impacted fetal head during cesarean delivery can lead to:
  • Unintentional extension of the uterine incision
  • Hemorrhage
  • Bladder and ureteric injuries 4

By following this evidence-based approach to breech presentation, providers can optimize outcomes while minimizing risks to both mother and baby.