What are the indications for cesarean section (CS) in breech presentation?

Indications for Cesarean Section in Breech Presentation

Cesarean section is recommended as the preferred delivery method for singleton term breech presentations to reduce perinatal mortality and serious neonatal morbidity.

Absolute Indications for CS in Breech Presentation

• Fetal distress with irreversible causes including major placental abruption, fetal hemorrhage, and umbilical cord prolapse with sustained bradycardia 1
• Footling breech presentation is a relative contraindication to vaginal delivery and generally requires CS 2
• Fetal weight <1500g is a relative contraindication to vaginal delivery 2
• Hyperextension of the fetal head is a contraindication to vaginal delivery 2
• Feto-pelvic disproportion makes vaginal delivery unsafe and requires CS 2
• Umbilical cord presentation is a contraindication to vaginal delivery 2

Evidence Supporting CS for Breech Presentation

• Planned cesarean section for singleton breech presentation at term reduces perinatal or neonatal death (RR 0.29,95% CI 0.10 to 0.86) compared to planned vaginal delivery 3
• Serious neonatal morbidity is significantly reduced with planned cesarean section (RR 0.33,95% CI 0.19 to 0.56) 3
• Infants delivered vaginally in breech presentation have 13.3 times higher odds of Apgar score <7 at 5 minutes compared to those delivered by elective CS 4
• Risk of intracranial hemorrhage or convulsions is 6.7 times higher with vaginal breech delivery compared to elective CS 4
• Brachial plexus injury risk is 23.8 times higher with vaginal breech delivery compared to elective CS 4
• Perinatal mortality is 7.6 times higher with vaginal breech delivery compared to elective CS 4

Maternal Considerations

• Planned cesarean section is associated with modestly increased short-term maternal morbidity (RR 1.29,95% CI 1.03 to 1.61) 3
• At 3 months postpartum, women who had planned CS report:
  • Less urinary incontinence (RR 0.62,95% CI 0.41 to 0.93) 3
  • More abdominal pain (RR 1.89,95% CI 1.29 to 2.79) 3
  • Less perineal pain (RR 0.32,95% CI 0.18 to 0.58) 3

Special Circumstances for CS in Breech

• Early labor or ruptured membranes: If cervical dilation is minimal and a long period of labor is anticipated, CS should be performed to minimize duration of membrane rupture 5
• Rapid labor progression: If labor is progressing rapidly with breech presentation, vaginal delivery may be allowed 5
• HIV-positive status: Scheduled cesarean delivery is recommended for women with HIV-1 RNA >1,000 copies/mL near delivery time 1
• Maternal cardiac conditions: Severe pulmonary hypertension, significant aortopathy, and maternal cardiac instability are indications for CS regardless of fetal presentation 1

Timing of Elective CS for Breech

• Elective cesarean section for breech presentation should be performed at 38 completed weeks of gestation 1
• If the woman presents in early labor or shortly after rupture of membranes, intravenous medications should be started immediately 5

Potential Risks of CS to Consider

• Increased risk of chronic wound pain (15.4% at 3-6 months postpartum) 6
• Higher risk of placenta previa and accreta in subsequent pregnancies 6
• Risk of uterine rupture in subsequent pregnancies (22 per 10,000 births in women with previous CS) 6
• Increased risk of venous thromboembolism (2.6 per 1000 CS births) 6
• Secondary infertility (reported in up to 43% of women) 6

When Vaginal Breech Delivery Might Be Considered

• Despite the evidence favoring CS, approximately 40% of breech presentations could potentially be delivered vaginally without endangering neonatal outcome in carefully selected cases 2
• However, even with careful selection of candidates for vaginal breech delivery, the risks of neonatal complications remain substantially higher than with elective CS 4

Common Pitfalls to Avoid

• Inadequate preparation: Failure to have appropriate equipment and multidisciplinary team available for breech delivery 1
• Delayed decision-making: In cases of true fetal distress with breech presentation, delays can result in worse neonatal outcomes 1
• Overlooking maternal cardiac status: Women with cardiac disease require careful hemodynamic monitoring during delivery 1
• Inappropriate selection: Attempting vaginal breech delivery in cases with contraindications significantly increases risks 2