What is the best treatment for breech presentation?

From the Guidelines

The best treatment for breech presentation is typically external cephalic version (ECV) at 36-38 weeks of gestation, followed by planned cesarean delivery if version is unsuccessful or contraindicated. This approach prioritizes the reduction of risks associated with breech presentation, such as birth trauma and perinatal mortality, as highlighted in the most recent and highest quality studies 1.

Key Considerations

• ECV involves manually rotating the fetus to a head-down position through the mother's abdomen, with success rates of 40-60% 1.
• Before attempting ECV, ultrasound confirmation of breech position, fetal well-being assessment, and cardiotocography monitoring are essential to ensure the safety of the procedure 1.
• Tocolytic medications like terbutaline (0.25mg subcutaneously) may be administered to relax the uterus during the procedure, enhancing the chances of successful version 1.
• If ECV fails or isn't appropriate, planned cesarean delivery at 39 weeks is generally recommended for singleton breech presentations to minimize risks of birth trauma and perinatal mortality 1.
• In rare, carefully selected cases with specific criteria (frank breech, adequate pelvis, experienced provider), vaginal breech delivery may be considered after thorough counseling about risks, as it carries higher risks during vaginal delivery, including cord prolapse, head entrapment, and birth trauma 1.

Management of Impacted Fetal Head

The management of impacted fetal head at cesarean delivery is crucial and involves techniques such as uterine relaxation, abdominal cephalic disimpaction, manual vaginal disimpaction (vaginal push method), reverse breech extraction, and the Patwardhan method 1. However, the choice of technique should be based on the most recent evidence and the specific clinical scenario, prioritizing the safety of both the mother and the fetus.

Recent Evidence

Recent studies have highlighted the importance of careful selection of patients for vaginal breech delivery and the need for skilled and experienced healthcare providers to perform such deliveries safely 1. The use of the Fetal Pillow has been investigated as a potential tool to facilitate delivery in cases of impacted fetal head, but its effectiveness and safety are still under evaluation, with conflicting evidence regarding its benefits for maternal and neonatal outcomes 1.

Conclusion Not Applicable

As per the guidelines, the focus is on providing a direct and evidence-based answer without a conclusion section. The emphasis is on the best treatment approach for breech presentation, prioritizing morbidity, mortality, and quality of life outcomes, based on the most recent and highest quality studies available.

From the Research

Treatment Options for Breech Presentation

• External cephalic version (ECV) is a recommended procedure to reduce the rate of breech presentation at birth and potentially lower the rate of cesarean section 2
• ECV attempt should be performed with immediate access to an operating room for emergency cesarean 2
• The main factors associated with successful ECV attempt are multiparity and no maternal obesity 2
• Parenteral tocolysis for ECV attempt at term is associated with a higher success rate, higher rate of achieved cephalic presentation in labor, and a lower cesarean section rate 2

Timing of ECV Attempt

• ECV attempt before 37 weeks, compared to ECV attempt after 37 weeks, increases the rate of cephalic presentation at birth but with a small increase risk of moderate prematurity 2
• ECV attempt should be performed from 36 weeks of gestation 2
• Women with breech presentation diagnosed before 38 weeks' estimated gestational age have a higher likelihood of ECV attempt and a lower likelihood of cesarean delivery 3

Safety and Efficacy of ECV

• ECV is associated with a decrease in the rate of breech presentation at birth and potentially with a lower rate of cesarean section without an increase in severe maternal and perinatal morbidity 2
• ECV attempt is associated with an increase in transient fetal heart rate abnormalities, and cardiotocography should be performed prior to and during 30 minutes after the procedure 2
• The risk of significant positivity of the Kleihauer test after ECV attempt is low, and it is not recommended to systematically perform a Kleihauer test after ECV attempt 2

Alternative Methods

• Acupuncture, moxibustion, and postural methods are not effective in reducing breech presentation at birth and are not recommended 2
• Vaginal delivery of a breech presenting fetus is complex and may involve many difficulties, and planned cesarean section is generally considered better than planned vaginal birth for the fetus in breech presentation at term 4