Why is Lower Segment Caesarean Section (LSCS) often indicated in cases of breech presentation?

Why LSCS is Indicated in Breech Presentation

Cesarean section is indicated for breech presentation because it dramatically reduces perinatal mortality by 71% and neonatal morbidity by 69% compared to vaginal breech delivery, despite causing modest increases in maternal morbidity. 1

Primary Evidence for Cesarean Delivery in Breech

The most compelling evidence comes from randomized controlled trials showing that planned cesarean section for term breech reduces perinatal/neonatal death (excluding fatal anomalies) with a relative risk of 0.29 (95% CI 0.10-0.86), meaning approximately 70% reduction in death. 1 This benefit extends to combined perinatal death or serious neonatal morbidity (RR 0.31,95% CI 0.19-0.52). 1

Population-based data from Sweden reinforces these findings dramatically: 2

• Infants delivered vaginally in breech presentation had 23.8 times higher odds of brachial plexus injury compared to elective cesarean section 2
• 13.3 times higher odds of Apgar score <7 at 5 minutes 2
• 6.7 times higher odds of intracranial hemorrhage or convulsions 2
• 7.6 times higher odds of perinatal mortality 2

These risks persisted even among carefully selected low-risk women deemed suitable for vaginal breech delivery, indicating that patient selection alone cannot eliminate the inherent risks. 2

Anatomical and Technical Reasons for LSCS Indication

Unfavorable Cervical Mechanics

The presenting buttocks or feet do not mold or flex the cervix in the same manner as a fetal head, which adversely affects cervical dilation patterns and lower uterine segment development. 3 This anatomical disadvantage creates suboptimal conditions for safe vaginal delivery. 3

Risk of Impacted Fetal Head

During cesarean delivery for breech, the primary technical concern is impacted fetal head, occurring in at least 5% of cases, particularly at full dilation. 3 This creates dangerous situations where lack of space between the fetal head and maternal pubic symphysis makes standard delivery techniques impossible. 3

Inherent Perinatal Risk Profile

Breech presentation itself carries perinatal mortality and morbidity estimated at three times that of comparable vertex presentations, independent of delivery mode. 4 This baseline increased risk is compounded by the mechanical challenges of vaginal breech delivery. 4

Current Guideline Recommendations

Elective cesarean section for breech presentation should be performed at 38 completed weeks of gestation. 5 This timing balances fetal maturity against the risk of spontaneous labor onset. 5

The American College of Obstetricians and Gynecologists states that vaginal breech delivery should only be considered when: 3

• The provider has appropriate expertise in vaginal breech delivery 3
• No contraindications to vaginal delivery exist 3
• Proper facilities for emergency cesarean are immediately available 3

Given that most contemporary obstetricians lack training and expertise in vaginal breech delivery, cesarean section has become the standard approach in many countries. 3

Maternal Trade-offs

The maternal cost of this fetal benefit is modest but real: 1

• Planned cesarean section increases maternal morbidity with a relative risk of 1.29 (95% CI 1.03-1.61) 1
• Chronic wound pain occurs in 15.4% of women at 3-6 months postpartum 5
• Increased risk of placenta previa and accreta in subsequent pregnancies 5
• Uterine rupture risk of 22 per 10,000 births in subsequent pregnancies 5
• Venous thromboembolism incidence of 2.6 per 1,000 cesarean births 5

Critical Technical Considerations During Breech Cesarean

When performing cesarean for breech presentation, specific technical modifications are essential: 6

• Make a wider uterine incision than standard to prevent uterine injury during fetal manipulation and delivery 6
• Identify the presenting part first and guide it to the incision opening, as delivering the presenting part first is fundamental 6
• Prepare for reverse breech extraction as the primary technique if standard delivery fails, involving grasping one or both fetal feet and delivering feet-first 3
• Have tocolysis immediately available to relax the uterus if head impaction occurs 3

Common Pitfalls to Avoid

The most dangerous error is improper execution of disimpaction techniques, particularly misplaced digital pressure causing fetal head hyperextension rather than flexion, which compounds impaction and increases skull fracture risk. 5 Never attempt vaginal disimpaction with only 2-3 fingers; use the entire hand to cup the fetal head. 3, 5

Inadequate preparation including failure to have appropriate equipment and multidisciplinary team available leads to worse outcomes. 5 Most clinicians lack formal training in breech delivery techniques, making cesarean section the safer default option. 5

Alternative: External Cephalic Version

Before defaulting to cesarean, external cephalic version (ECV) should be offered, with a success rate of approximately 55%. 7 After successful ECV, the vaginal birth rate reaches 80.6%, with 79% delivering spontaneously without complications. 7 This provides an opportunity to avoid cesarean section while maintaining safety. 7