mode of delivery in breech presentation

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Breech Births

In the last weeks of pregnancy, a baby usually moves so his or her head is positioned to come out of the vagina first during birth. This is called a vertex presentation. A breech presentation occurs when the baby’s buttocks, feet, or both are positioned to come out first during birth. This happens in 3–4% of full-term births.

What are the different types of breech birth presentations?

• Complete breech: Here, the buttocks are pointing downward with the legs folded at the knees and feet near the buttocks.
• Frank breech: In this position, the baby’s buttocks are aimed at the birth canal with its legs sticking straight up in front of his or her body and the feet near the head.
• Footling breech: In this position, one or both of the baby’s feet point downward and will deliver before the rest of the body.

What causes a breech presentation?

The causes of breech presentations are not fully understood. However, the data show that breech birth is more common when:

• You have been pregnant before
• In pregnancies of multiples
• When there is a history of premature delivery
• When the uterus has too much or too little amniotic fluid
• When there is an abnormally shaped uterus or a uterus with abnormal growths, such as fibroids
• The placenta covers all or part of the opening of the uterus placenta previa

How is a breech presentation diagnosed?

A few weeks prior to the due date, the health care provider will place her hands on the mother’s lower abdomen to locate the baby’s head, back, and buttocks. If it appears that the baby might be in a breech position, they can use ultrasound or pelvic exam to confirm the position. Special x-rays can also be used to determine the baby’s position and the size of the pelvis to determine if a vaginal delivery of a breech baby can be safely attempted.

Can a breech presentation mean something is wrong?

Even though most breech babies are born healthy, there is a slightly elevated risk for certain problems. Birth defects are slightly more common in breech babies and the defect might be the reason that the baby failed to move into the right position prior to delivery.

Can a breech presentation be changed?

It is preferable to try to turn a breech baby between the 32nd and 37th weeks of pregnancy . The methods of turning a baby will vary and the success rate for each method can also vary. It is best to discuss the options with the health care provider to see which method she recommends.

Medical Techniques

External Cephalic Version (EVC)  is a non-surgical technique to move the baby in the uterus. In this procedure, a medication is given to help relax the uterus. There might also be the use of an ultrasound to determine the position of the baby, the location of the placenta and the amount of amniotic fluid in the uterus.

Gentle pushing on the lower abdomen can turn the baby into the head-down position. Throughout the external version the baby’s heartbeat will be closely monitored so that if a problem develops, the health care provider will immediately stop the procedure. ECV usually is done near a delivery room so if a problem occurs, a cesarean delivery can be performed quickly. The external version has a high success rate and can be considered if you have had a previous cesarean delivery.

ECV will not be tried if:

• You are carrying more than one fetus
• There are concerns about the health of the fetus
• You have certain abnormalities of the reproductive system
• The placenta is in the wrong place
• The placenta has come away from the wall of the uterus ( placental abruption )

Complications of EVC include:

• Prelabor rupture of membranes
• Changes in the fetus’s heart rate
• Placental abruption
• Preterm labor

Vaginal delivery versus cesarean for breech birth?

Most health care providers do not believe in attempting a vaginal delivery for a breech position. However, some will delay making a final decision until the woman is in labor. The following conditions are considered necessary in order to attempt a vaginal birth:

• The baby is full-term and in the frank breech presentation
• The baby does not show signs of distress while its heart rate is closely monitored.
• The process of labor is smooth and steady with the cervix widening as the baby descends.
• The health care provider estimates that the baby is not too big or the mother’s pelvis too narrow for the baby to pass safely through the birth canal.
• Anesthesia is available and a cesarean delivery possible on short notice

What are the risks and complications of a vaginal delivery?

In a breech birth, the baby’s head is the last part of its body to emerge making it more difficult to ease it through the birth canal. Sometimes forceps are used to guide the baby’s head out of the birth canal. Another potential problem is cord prolapse . In this situation the umbilical cord is squeezed as the baby moves toward the birth canal, thus slowing the baby’s supply of oxygen and blood. In a vaginal breech delivery, electronic fetal monitoring will be used to monitor the baby’s heartbeat throughout the course of labor. Cesarean delivery may be an option if signs develop that the baby may be in distress.

When is a cesarean delivery used with a breech presentation?

Most health care providers recommend a cesarean delivery for all babies in a breech position, especially babies that are premature. Since premature babies are small and more fragile, and because the head of a premature baby is relatively larger in proportion to its body, the baby is unlikely to stretch the cervix as much as a full-term baby. This means that there might be less room for the head to emerge.

Want to Know More?

• Creating Your Birth Plan
• Labor & Birth Terms to Know
• Cesarean Birth After Care

Compiled using information from the following sources:

• ACOG: If Your Baby is Breech
• William’s Obstetrics Twenty-Second Ed. Cunningham, F. Gary, et al, Ch. 24.
• Danforth’s Obstetrics and Gynecology Ninth Ed. Scott, James R., et al, Ch. 21.

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How might we maximize patient benefit from a safe external cephalic version attempt?

With the restrictive practice of breech vaginal delivery in the last 15 years, national colleges of obstetricians (RCOG, ACOG, SOGC and RANZCOG) and FIGO updated their guidelines and recommended external cephalic version (ECV) at term to limit the increase in elective CS rate for cases of term breech presentation. However, recent data urge us to develop a broader perspective and an accurate assessment of the real impact of various ECV policies.

Indeed, the true impact of ECV may first be limited by the timely detection of breech presentation. In a retrospective cohort study of 394 consecutive cases of breech presentation at term, Hemelaar et al. [ 40 ] found that over two periods separated by 10 years (1998–1999 and 2008–2009), the proportion of breech presentations not diagnosed antenatally increased from 23.2 to 32.5% ( P  = 0.04), causing 52.8% of women who were eligible for ECV to miss an attempt in 2008–2009. The authors also reported that the proportion of women who declined ECV during the same period decreased significantly from 19.1 to 9.0%.

Eligibility is a second limitation. In Australia, a large-scale survey [ 41 ] showed that 22.3% of 32,321 singleton breech pregnancies were considered ineligible (due to oligohydramnios, antepartum haemorrhage or abruption, previous CS or pelvic abnormality, placenta previa, placenta accreta, or an infant with major congenital anomalies). In this survey [ 41 ], only 10.5% of the singleton breech pregnancies had an ECV. In a systematic review, Rosman et al. [ 42 ] identified 60 studies that reported 39 different contraindications and five guidelines with 18 contraindications (varying from five to 13 contraindications per guideline), with oligohydramnios being the only contraindication that was consistently mentioned in all guidelines. Thus, there was no general consensus on the eligibility of patients for ECV, but contraindications generally include all conditions in which this procedure may be associated with a particular risk for the foetus or mother. These conditions include the following: severe intrauterine growth restriction, abnormal umbilical artery Doppler index and/or nonreassuring foetal heart rate, which may require an emergency CS birth; foetuses with a hyperextended head and significant foetal or uterine malformations, which may carry a particular foetal risk; rhesus alloimmunization, which might be reactivated by the procedure; and recent vaginal bleeding or ruptured membranes, which were associated with cord prolapse in 33% of reported cases after ECV attempt [ 43 ].

If CS or rapid delivery is indicated for another obstetric condition, ECV is also contraindicated, notably in cases of placenta previa, severe preeclampsia, and increased risk of placental abruption. Other situations, such as maternal obesity, nonsevere SGA foetuses, and nonsevere oligohydramnios, merely decrease the likelihood of ECV success. In contexts such as severe oligohydramnios or multiple gestations, ECV is simply impracticable, except for a second twin after delivery of the first. Furthermore, previous uterine surgery (CS delivery, myomectomy, or hysteroplasty) is considered a relative contraindication for ECV by some but not all authors [ 44 ]. On the other hand, in patients with gestational diabetes mellitus, incomplete or uncontrolled glucose levels are associated with an increased risk of foetal macrosomia in late pregnancy, and even if the estimated foetal weight seems compatible with a planned vaginal delivery when the mode of delivery is discussed, rapid foetal growth during the last weeks may lead to major difficulties during delivery. Therefore, in such a context, we believe there is potential for a particular benefit from successful ECV at 36 weeks.

Predictors of successful ECV

Pinard previously observed that unengaged breech presentation is an important predictor of successful ECV [ 45 ]; the same observation was made by Lau et al. [ 46 ], Aisenbrey et al. [ 47 ], and Hutton et al. [ 48 ]. In the large series of 1776 ECVs published by Hutton et al. [ 48 ], descent and impaction of the breech foetus were the most discriminating factors for predicting successful ECV, regardless of parity. Other predictors of success include parity [ 45 , 47 , 49 , 50 ], abundant amniotic fluid [ 49 , 50 , 51 ], nonfrank breech presentation [ 47 ], gestational age under 38 weeks [ 43 ], and posterior placenta [ 50 ]. In contrast, nulliparity and tense uterus are associated with a lower likelihood of success [ 44 , 48 , 52 ].

Velzel et al. [ 53 ] recently reviewed prediction models, most of which were developed without any external validation, and found that the most reliable predictors of successful ECV were nonimpacted breech presentation, parity and uterine softness (which usually go hand in hand), normal amniotic fluid index, posterior placental location, and, as noted by Pinard [ 45 ], foetal head in a palpable situation. These criteria might be used to support patient counselling and decision-making about ECV and to reduce the proportion of women declining ECV, particularly in the most favourable situations for ECV.

Obstetric outcomes after an ECV attempt

De Hundt et al. [ 54 ] conducted a systematic review and meta-analysis and showed that women who have had a successful ECV for breech presentation are at increased risk for CS delivery (OR 2.2; 95% CI 1.6–3.0) and instrumental vaginal delivery (OR 1.4; 95% CI 1.1–1.7) compared with women with spontaneous cephalic presentation. Interestingly, stratification by time delay between successful ECV and delivery revealed a trend for increased risk of CS during the first week after ECV [ 55 ]. Furthermore, in a cohort of 301 women with successful ECV, De Hundt et al. [ 56 ] found that nulliparity was the only of seven factors that predicted the risk of CS and instrumental vaginal delivery (OR 2.7; 95% CI 1.2–6.1). Based on a retrospective, population-based cohort study using the CDC’s birth data files from the US in 2006, Balayla et al. [ 57 ] also showed that relative to breech controls without an ECV attempt, cases of ECV failure with persistent breech presentation and labour attempts were associated with increased odds of CS delivery (adjusted OR 1.38; 95% CI 1.21–1.57), assisted ventilation at birth (aOR 1.50; 95% CI 1.27–1.78), 5-min Apgar score < 7 (aOR 1.35; 95% CI 1.20–1.51), and neonatal intensive care unit admission (aOR 1.48; 95% CI 1.20–1.82).

This information should also be considered in the dialog with women regarding the way in which late pregnancy and delivery should be managed based on existing data, their own situations and their wishes.

The true benefit of an active and systematic ECV policy is widely appreciated [ 58 , 59 ], and such evaluation may be subject to bias. Burgos et al. [ 58 ] found that their policy decreased the rate of breech presentation at delivery by 39.0% and decreased the CS rate for cases of breech presentation at term from 59 to 44%. On the other hand, Coppola et al. [ 59 ] reported that their CS rate was not significantly reduced in the planned ECV group, even after adjustments were made for age, parity and previous CS delivery. Thus, each perinatal centre should implement an appropriate and coherent policy in accordance with the prevalence of pathologies in the population.

Towards a consensus for a global shared vision and management of term breech presentation that could include the following

A policy of breech presentation screening at 36 weeks of gestation is efficient and cost effective [ 60 ].

Such screening should allow timely ECV and a careful evaluation of potential underlying antenatal risks, considering obstetric history, estimated foetal weight/growth and potential gestational disorders [ 23 , 24 , 25 , 26 , 27 , 29 ].

Foetal weight estimates based on clinical and ultrasound examinations are essential, despite the large confidence interval of all available algorithms for producing such estimates. Vaginal birth may be excluded when the estimated foetal weight approximates the upper limit used for selection in most national guidelines (3800 g) [ 18 , 19 , 20 ], particularly in the absence of previous successful vaginal delivery.

Before vaginal delivery is considered, clinical pelvic examination is universally recommended to rule out pathological pelvic contraction. Radiologic or magnetic resonance imaging (MRI) pelvimetry is not universally conducted [ 20 , 23 , 24 , 31 , 32 ]. However, Van Loon et al. [ 33 ] demonstrated in a randomized controlled trial that the use of MRI pelvimetry in breech presentation at term allowed better selection of delivery route, with a significantly lower emergency CS rate. More specifically, several recent studies [ 34 , 35 ] have evaluated the contribution of pelvimetry and found that MRI pelvimetry provided useful criteria for the preselection and counselling of women with breech presentation and the desire for vaginal delivery. Therefore, pelvimetry is diversely used in Europe for the preselection and counselling of women (particularly nulliparous women) with breech presentation and is specifically used in regions where vaginal delivery is still considered an option [ 35 ].

In cases of failed ECV with persistent breech presentation, this policy should allow customized care tailored to each situation in the last weeks of pregnancy.

A discussion with the informed patient is essential. One must thoroughly consider the experience of the health care team/the availability of clinical skills required for conducting a vaginal breech delivery and carefully select women who are eligible for planned vaginal delivery (considering obstetric history and the criteria described above for the choice between planned vaginal and CS deliveries) [ 20 , 23 , 24 , 26 , 28 ].

Regardless of the planned mode of delivery [ 22 ], adequate follow-up during the last weeks of pregnancy is mandatory, with particular consideration of possible associated underlying disorders (particularly foetal growth restriction or excessive foetal weight in cases of gestational diabetes mellitus) [ 24 , 25 , 26 ]. Thus, the foetal weight estimation should be carefully considered in the 37th week of gestation, even in cases of minor glycaemic disorder, with regular reassessments and a plan for CS delivery if the patient remains pregnant for many more weeks and if foetal weight estimates reach approximately 3600–3800 g.

If vaginal delivery is planned, careful labour management by a skilled team is needed, accompanied by continuous foetal heart rate monitoring [ 36 ] and a particular focus on the rate of progress in the second delivery stage [ 37 ]. When such conditions are not or cannot be fulfilled, a planned CS may be the best choice.

When a CS has been planned, adequate follow-up during the last weeks of pregnancy and careful calculation of the delivery date are needed, taking into account possible comorbidities and gestational disorders.

Term breech presentation is a condition for which personalized obstetrical care is particularly needed. The best way is likely to be as follows: first, efficiently screen for breech presentation at 36–37 weeks of gestation; second, thoroughly evaluate the maternal/foetal condition, foetal weight and growth potential, and the type (frank, complete, or footling) and mobility of breech presentation; and three, consider the obstetric history and pelvic size/conformation. The management plan, including ECV and follow-up during the last weeks, should then be organized taking into account antenatal risk factors on a case-by-case basis by a skilled team after informing the woman, discussing her personal situation and criteria and helping her make a rational decision. Foetal overgrowth or growth restriction and/or oligohydramnios may necessitate timely CS, and the mode of delivery should be re-evaluated as necessary according to obstetric conditions (e.g., estimated foetal weight and Bishop score).

Availability of data and materials

Not applicable.

Abbreviations

American College of Obstetricians and Gynecologists

Caesarean section

External cephalic version

International Federation of Gynecology and Obstetrics

Royal Australian and New Zealand College of Obstetricians and Gynaecologists

Royal College of Obstetricians and Gynaecologists

• Severe maternal morbidity

Society of Obstetricians and Gynaecologists of Canada

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Acknowledgements

Author information, authors and affiliations.

Department of Obstetrics and Gynecology, Sorbonne Paris Nord University, Assistance Publique – Hopitaux de Paris, Avenue du 14 juillet, Hôpital Jean Verdier, 93140, Bondy Cedex, France

Lionel Carbillon

Department of Obstetrics and Gynecology, Assistance Publique – Hôpitaux de Paris, Hôpital Jean Verdier, Bondy, France

Lionel Carbillon, Amelie Benbara, Ahmed Tigaizin, Rouba Murtada, Marion Fermaut, Fatma Belmaghni, Alexandre Bricou & Jeremy Boujenah

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Study conception and design: LC, AB, JB, AT, FB, AB. Analysis and interpretation of data: LC, JB. Drafting of manuscript: LC. Critical revision: LC, JB, RM, MF. The authors read and approved the final manuscript.

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Carbillon, L., Benbara, A., Tigaizin, A. et al. Revisiting the management of term breech presentation: a proposal for overcoming some of the controversies. BMC Pregnancy Childbirth 20 , 263 (2020). https://doi.org/10.1186/s12884-020-2831-4

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DOI : https://doi.org/10.1186/s12884-020-2831-4

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• Term breech delivery
• Small-for-gestational-age
• Foetal growth restriction
• Oligohydramnios
• Delivery route
• Perinatal mortality
• Perinatal morbidity

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• J Obstet Gynaecol India
• v.62(4); 2012 Aug

Delivery in Breech Presentation: The Decision Making

Department of Obstetrics and Gynaecology, Pt.J.N.M. Medical College and Dr. B.R.A.M Hospital, E-8, Shankar Nagar, Raipur, Chhattisgarh 492001 India

Nalini Mishra

Rajni dewangan.

To optimize the fetomaternal oucome using different modes of delivery in breech presentation.

Materials and Methods

265 women with different parity and gestational age having singleton breech were studied during Jan 2007 to Sep 2009 at Pt. J.N.M. Medical College and associated Dr. B.R.A.M. Hospital Raipur Chhattisgarh and were assigned to either planned or emergency cesarean section or trial of vaginal delivery after counseling. Fetomaternal outcome was compared in various modes of delivery.

Observations

Incidence of breech presentation was 2.1 %, prematurity was the most common cause. 113 (42.6 %) women delivered vaginally. 54 (20.4 %) were planned for cesarean section. Emergency cesarean section was done in 98 (37 %). Although perinatal morbidity and mortality was lower in caesarean section group as compared to vaginal delivery group, but the difference became statistically insignificant after adjustment for confounding factors. ( p  = 0.14)

In view of insignificant difference in the fetomaternal outcome balanced decision about mode of delivery on a case by case basis will go a long way in improving both foetal and maternal outcome. Regular drill and conduct of vaginal breech delivery should be pursued in all maternity hospitals.

Introduction

About 3–4 % of all pregnancies have breech presentation at term. The management of term breech is highly controversial and varies among different institutions and even among different clinicians in the same institution. The decision to perform cesarean delivery is often based on personal experience or a fear of litigation.

From the historical perspective, vaginal delivery of the persistent breech presentation had been the tradition since the first century a . d . Intended vaginal delivery is the common practice in most developing countries. Probably, the obstetricians are also more conversant in the technique of assisted breech delivery. This protocol received a major setback in the year 2000 when Lancet published the results of the Term Breech Trial by Mary E Hannah, which clearly concluded that planned cesarean section is better than planned vaginal birth for the term fetus with breech presentation in terms of neonatal outcome [ 1 ]. Serious maternal complication was similar between the two groups. It evoked stinging criticism, itemizing the methodological errors and unsupportable conclusions [ 2 ]. There is an urgent need to evaluate it in context of the resource poor countries before accepting it as the “Last word.” An overall policy of planned cesarean section in all term breeches would prevent complications of vaginal delivery because there would be no vaginal breech delivery. This might result in shifting of the contemporary art of conducting such delivery to the shelves of medical history. On further analysis of the Term Breech Trial, an important interaction involved a country’s perinatal mortality rate. In the countries with a low perinatal mortality rate, planned cesarean section had much greater benefits for the infant, whereas in countries where the perinatal mortality rate is high, the same benefits were much lower than the entire group as a whole. As many as 39 additional cesareans might be needed to avoid one serious infant morbidity or death in comparison to as few as seven additional cesarean sections in countries with a low perinatal mortality rate. This important observation is much more pertinent in countries with limited facilities for cesarean section.

Unfortunately, the number of obstetricians able to conduct the vaginal breech delivery is declining quite fast. If the trend continues, what will happen when a woman with breech presentation at term gets admitted in advanced labor at a center where cesarean section cannot be performed urgently and the obstetrician present has never conducted a vaginal breech delivery? It will indeed be a very sad day for our specialty.

As the controversy continues, repeated evaluations and reviews of management in this subset of women are needed. The present study was conducted with an objective to optimize the perinatal outcome, while keeping the art of conducting and training vaginal breech deliveries alive.

A total of 265 women with singleton breech presentation with >28 weeks gestational age were included in the present study during the period from Jan 2007 to Sep. 2009 (33 months).

On admission, the demographic profile of the women, as well as a detailed menstrual and obstetric history, was noted. General, systemic, and obstetric examination was carried out. All women were subjected to a routine investigation and obstetric ultrasonography and afterward, they were assigned to either cesarean section (planned/emergency) or vaginal delivery on the basis of the obstetric examination (clinical and sonographical) and the presence of complicating factors. Women having standard indications of cesarean section in breech like fetopelvic disproportion, hyperextension of the head, footling presentation, and associated complications (medical or obstetric) were assigned to the planned cesarean section group, whereas the remaining women having term breech were given a trial of vaginal breech delivery. The plan of delivery for the both term and preterm breech was discussed with the women and their attendants because of limited beds in the intensive neonatal care unit as well as probable course and complication of vaginal delivery. A trial of vaginal delivery was given to those who consented to it.

Regular drills of vaginal breech delivery are conducted in the department. During a trial of vaginal delivery, monitoring of fetal heart rate and progress of labor was done. Assisted breech delivery was the method of choice, maintaining a principle of noninterference till the delivery of the scapula. The delivery of the extended arms was accomplished by Lovset’s method, whereas the delivery of the aftercoming head was conducted by the Burns Marshall Method or Mauriceau Smellie Veit maneuver. After delivery, the baby was attended by the pediatrician and the Apgar Score at 1 and 5 min was noted and the baby was admitted to the neonatal intensive care unit if needed.

If fetal distress and arrest of progress in labor were suspected, the women were taken for emergency cesarean section. All the mothers and newborns were followed up for 7 days in the postnatal period. Data regarding the fetomaternal outcome were analyzed. Comparisons were made in terms of morbidity and mortality between groups of mothers and infants stratified by the mode of delivery.

The incidence of breech presentation in the present study was 2.1 %. It varies from 3 to 4 % in various studies [ 3 – 8 ]. A majority of the women were unbooked (55.5 %) and nulliparous (40.4 %). 77.3 % women were having term pregnancy (Table  1 ).

Table 1

Demographic profile ( n  = 265)

Overall, 113 (42.6 %) women delivered vaginally, a majority of these were term. Planned cesarean section was done in 54 (20.4 %) for indications shown in Table  2 . Since this is the largest teaching hospital in the state with a greater number of referrals, a majority of unbooked women get admitted in labor and therefore could not be assigned the mode of delivery before hand. Emergency cesarean section had to be resorted to in 98 (37 %) women for various indications. A comparatively larger number of women in our study delivered vaginally as compared to the Term Breech Trial (33.2 %) [ 1 ], and the difference was alarming from the largest series containing 10,0730 women with only 4.9 % delivering vaginally [ 6 ]. As we have a very limited neonatal intensive care unit, we motivated women with low birth weight babies to deliver vaginally, but only after obtaining due consent for the same. A large number of vaginal births provided us with the opportunity to train our residents to conduct the vaginal breech delivery and to avoid cesarean section, thereby reducing operative burden upon the already over-worked obstetrics units. It also prevented uterine scar in a woman whose dwindling chances of hospital delivery in the next pregnancy could have compromised her obstetric future.

Table 2

Mode of delivery (N-265)

The incidence of overall neonatal morbidity was 3.4 % (Table  3 ), out of which 2.3 % was present in the vaginal delivery group, but this subgroup was constituted mainly by preterm babies (5 out of 9). Damage to soft tissue was sustained equally by the preterm infants of both the vaginal and cesarean groups (2 each). Such damage can be attributed to the fact that delivering the infants even by cesarean section is essentially the process of breech extraction. None of the injuries were life threatening.

Table 3

Neonatal morbidity in relation to different modes of delivery (N-265)

p value of preterm vaginal versus preterm cesarean section = 0.08 (nonsignificant)

Table  4 shows the overall incidence of perinatal mortality in the present study; it is 51 (19.2 %), out of which 40 (15.8 %) were found in the vaginal delivery group with only 13 (4.9 %) term and 27 (10.9 %) preterm deliveries. Only one (0.4 %) fatality was found in the planned cesarean section group in contrast to 10 (3.9 %) in the emergency cesarean section group. Perinatal mortality, neonatal mortality, and neonatal morbidity were significantly lower for the planned cesarean section group than for the planned vaginal birth group as reported by the Term Breech Trial and others [ 1 , 6 , 8 – 10 ]. In our study also, the perinatal mortality seems to be significantly higher in the vaginal delivery group, but since the primary objective of the study was to see the effect of mode of delivery on perinatal outcome, we have reassessed the perinatal mortality after excluding 24 cases of women admitted with intrauterine fetal demise (which also included 11 with congenital malformation). The adjusted number of 16 (6 %) is not significantly greater than the 11 (4.2 %) in the cesarean section group.

Table 4

Perinatal mortality in correlation with different modes of delivery ( n  = 265)

p value (after excluding intrauterine demised) of vaginal versus cesarean section = 0.24 (nonsignificant)

Prematurity was the largest factor contributing to perinatal mortality. After excluding 31 (11.7 %) preterm births, the statistical difference between the term breech delivery in the vaginal delivery versus the cesarean section was not significant ( p  = 0.14), although definitely higher for the vaginal group. The planned cesarean group at term pregnancy had a significantly better perinatal outcome ( p  = 0.001), but the emergency cesarean section group did not prove to have the same advantage.

There was no maternal death in either group. Maternal morbidity in the cesarean section group was 3.4 % and in the vaginal group, it was 4.2 %. The difference was not significant statistically ( p  = 0.5).

Table  5 depicts the comparable data of various studies after the Term Breech trial and shows a gradually increasing trend toward vaginal breech delivery, although almost universally concluding planned cesarean section to be better for the perinatal outcome. Our study is also in accordance with them, but the opportunity to plan the mode of delivery before labor is not provided to the obstetrician in a referral hospital like ours, and emergency cesarean section yielded comparable results in terms of perinatal outcome, a point also made by others [ 7 , 11 , 12 ]. We therefore recommend a very balanced decision regarding the mode of delivery in the tertiary centers of developing countries.

Table 5

Comparison of fetomaternal outcomes in different studies

When assisted vaginal breech delivery is accomplished after proper selection and counseling for women with breech presentation, cesarean section in preterm as well as term pregnancy can be avoided because the difference in terms of perinatal mortality and morbidity rates is not significant statistically between the vaginal and overall cesarean section groups after adjustment for confounding factors like prematurity and intrauterine fetal demise. Planned cesarean section is undoubtedly better. In countries where the majority of cesarean sections for breech presentation are done in emergency, a trial of vaginal delivery yields comparable results. Therefore, it is concluded that the balanced decision about the mode of delivery on a case by case basis as well as conduct, training, and regular drills of assisted breech delivery will go a long way to optimize the outcome of breech presentation in countries like ours.

Delivery in breech presentation: the decision making

Affiliation.

• 1 Department of Obstetrics and Gynaecology, Pt.J.N.M. Medical College and Dr. B.R.A.M Hospital, E-8, Shankar Nagar, Raipur, Chhattisgarh 492001 India.
• PMID: 23904698
• PMCID: PMC3500939
• DOI: 10.1007/s13224-012-0289-7

Objective: To optimize the fetomaternal oucome using different modes of delivery in breech presentation.

Materials and methods: 265 women with different parity and gestational age having singleton breech were studied during Jan 2007 to Sep 2009 at Pt. J.N.M. Medical College and associated Dr. B.R.A.M. Hospital Raipur Chhattisgarh and were assigned to either planned or emergency cesarean section or trial of vaginal delivery after counseling. Fetomaternal outcome was compared in various modes of delivery.

Observations: Incidence of breech presentation was 2.1 %, prematurity was the most common cause. 113 (42.6 %) women delivered vaginally. 54 (20.4 %) were planned for cesarean section. Emergency cesarean section was done in 98 (37 %). Although perinatal morbidity and mortality was lower in caesarean section group as compared to vaginal delivery group, but the difference became statistically insignificant after adjustment for confounding factors. (p = 0.14).

Conclusion: In view of insignificant difference in the fetomaternal outcome balanced decision about mode of delivery on a case by case basis will go a long way in improving both foetal and maternal outcome. Regular drill and conduct of vaginal breech delivery should be pursued in all maternity hospitals.

Keywords: Breech presentation; Caesarean section; Perinatal outcome.