What is the best mode of delivery for a preterm breech presentation in a primigravida?

Preterm Breech Presentation in Primigravida: Cesarean Delivery is Recommended

For preterm breech presentation in a primigravida, planned cesarean delivery is the recommended mode of delivery, as it significantly reduces neonatal mortality compared to vaginal delivery.

Evidence Supporting Cesarean Delivery for Preterm Breech

The most compelling evidence comes from systematic review data showing that cesarean section reduces neonatal mortality in preterm breech presentation, with a weighted neonatal mortality risk of 3.8% in the cesarean group versus 11.5% in the vaginal delivery group (pooled RR 0.63,95% CI 0.48-0.81) 1. This represents a nearly 40% reduction in neonatal death risk with planned cesarean delivery.

Key Considerations for Preterm Breech Management

Gestational Age-Specific Recommendations:

• At 32 weeks gestation, neonatal survival is excellent at 95% with low neurological sequelae risk, making this a viable gestational age for delivery when indicated 2
• The American College of Obstetricians and Gynecologists recommends strong consideration for cesarean delivery in preterm scenarios due to high rates of intrapartum complications 2

Essential Pre-Delivery Interventions:

• Administer antenatal corticosteroids if delivery is anticipated before 33 6/7 weeks (GRADE 1A recommendation) 2
• Administer magnesium sulfate for neuroprotection for pregnancies <32 weeks gestation (GRADE 1A recommendation) 2
• Coordinate care with neonatology to optimize neonatal resuscitation 2

Why Vaginal Delivery is Not Recommended in This Population

Higher Neonatal Morbidity and Mortality:

Multiple studies demonstrate that planned vaginal delivery for breech presentation is associated with significantly increased adverse neonatal outcomes, including higher rates of 5-minute Apgar scores <4, need for intubation, and birth trauma 3. In the preterm population specifically, these risks are amplified due to the increased vulnerability of premature infants 1.

Technical Challenges in Preterm Breech:

• The preterm fetal head has a larger head-to-body ratio, increasing the risk of head entrapment during vaginal breech delivery 4
• Primigravida status adds additional risk due to an unproven pelvis and potentially less favorable cervical conditions 5
• Most obstetricians lack adequate training in breech delivery techniques, particularly for preterm infants 6

Delivery Planning and Technique

If Cesarean Delivery is Performed:

• Delivery should take place in a tertiary center with specialist multidisciplinary team care 7
• Use standard perioperative antibiotic prophylaxis 7
• Be prepared for potential complications including impacted fetal head, though this is less common in preterm deliveries 7

Critical Caveat - If Vaginal Delivery Becomes Unavoidable:

Should an unplanned vaginal breech delivery occur (e.g., precipitous labor), the American College of Obstetricians and Gynecologists recommends the Reverse Breech Extraction technique, which involves grasping one or both feet, applying traction toward the woman's feet to deliver the legs and abdomen, rotating the body to deliver each arm, and applying traction toward the woman's head to deliver the baby's head 6. However, this requires specialist training that most obstetricians lack 6.

Common Pitfalls to Avoid

• Do not attempt vaginal delivery based on outdated criteria that may apply to term breech but not preterm breech 4
• Avoid digital pressure with only 2-3 fingers during any delivery maneuvers, as this increases risk of skull fractures 6
• Never use single forceps blade as a lever or vacuum extraction abdominally, as these can cause significant fetal injury 6
• Do not delay cesarean delivery in hopes of achieving vaginal delivery, as this increases both maternal and neonatal morbidity 1

Maternal Considerations

While cesarean delivery does carry increased maternal morbidity compared to vaginal delivery, including higher risks of blood loss, infection, and venous thromboembolism 7, these maternal risks must be weighed against the substantially higher neonatal mortality and morbidity associated with planned vaginal delivery in preterm breech presentation 1. In the preterm breech primigravida, the balance clearly favors cesarean delivery for optimal neonatal outcomes.