What is the recommended management approach for term breech presentation?

Management of Term Breech Presentation

Planned cesarean delivery is the recommended management approach for term breech presentation, as it is associated with better neonatal outcomes compared to planned vaginal delivery. 1, 2

Primary Management Options

• External cephalic version (ECV) should be attempted first when a breech presentation is diagnosed at term, as successful version eliminates the risks associated with breech delivery 1
• If ECV is unsuccessful or contraindicated, planned cesarean delivery is the most common and recommended approach in most countries 1, 2
• Vaginal breech delivery may be considered only under specific circumstances with strict selection criteria 1, 3

Criteria for Considering Vaginal Breech Delivery

Vaginal breech delivery should only be considered when all of the following conditions are met:

• Provider has appropriate expertise in breech delivery techniques 1, 3
• No contraindications to vaginal delivery exist 1
• Frank breech presentation (not footling or complete breech) 4
• Estimated fetal weight between 2500-3500g 4
• Adequate maternal pelvimetry confirmed 4
• No hyperextension of the fetal head 4
• Proper facilities for emergency cesarean are immediately available 1
• Continuous fetal monitoring capability 4

Evidence Supporting Cesarean Delivery

• The Term Breech Trial, a landmark randomized multicenter trial, demonstrated that planned cesarean section significantly reduced perinatal mortality, neonatal mortality, and serious neonatal morbidity compared to planned vaginal birth (1.6% vs 5.0%; relative risk 0.33) 2
• Cochrane review confirmed that planned cesarean section reduced perinatal or neonatal death (excluding fatal anomalies) with a relative risk of 0.29 compared to planned vaginal birth 5
• Maternal morbidity was only modestly increased with planned cesarean section (RR 1.29) 5

Breech Delivery Techniques

If vaginal breech delivery is attempted, proper technique is crucial:

• Reverse Breech Extraction (Pull Technique) is recommended, which involves:

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

• The Patwardhan Method is an alternative technique:

  • Modification of reverse breech extraction
  • Requires an assistant to introduce their whole hand into the vagina
  • Used to cup the baby's head with woman's legs in semilithotomy position 3

Potential Complications

• Impacted fetal head during cesarean delivery can lead to:

  • Unintentional extension of the uterine incision
  • Hemorrhage
  • Bladder and ureteric injuries 1

• Errors in performing breech extractions may increase risk of:

  • Femoral fractures
  • Humeral fractures 3

Important Considerations

• Many obstetricians lack adequate training and confidence to perform vaginal breech deliveries 3, 6
• High-fidelity simulation and standardized care pathways represent the safest and most effective form of training for difficult deliveries 6
• The use of a single forceps blade or ventouse as a lever to disimpact the fetal head is dangerous and should be avoided 3
• Vacuum-assisted delivery for breech presentations carries significant risks and is generally contraindicated 6

Conclusion

While vaginal breech delivery may be considered in carefully selected cases with experienced providers, the evidence strongly supports planned cesarean section as the safer option for term breech presentation, with significantly better neonatal outcomes and only modestly increased maternal morbidity 2, 5.