SOGC

POLI CY STATEA4ENT
No. 31, November 1994
THE CANADIAN CONSENSUS ON BREECH MANAGEMENT AT TERM
EDITOR IN CHIEF: Patrick J. Taylor, MD FRCSC
GUEST EDITOR/CHAIR: Walter J. Hannah, MD FRCSC
WORKSHOP MEMBERS:
Canada James Allardice, MB FRCSC
Kofi Amankwah, MD FRCSC
Thomas Baskett, MD FRCSC
Mary Cheng, MD
Barbara Fallis, MD FRCSC
Duncan Farquharson, MD FRCSC
Robert Gauthier, MD FRCSC
Mary Hannah, MDCM FRCSC
Sheila Hewson, BSc
Andre Lalonde, MD FRCSC
Ian Lange, MD FRCSC
Kenneth Milne, MD FRCSC
Bryan Mitchell, MD FRCSC
Paula Penkin, MD
Knox Ritchie, MD FRCSC
United Kingdom Gerald Hackett, MB FRCOG (Univ. of Cambridge)
Steve Walkinshaw, MB FRCOG (Univ. of Liverpool)
Ireland Michael Turner, MAO MRCPI
(Master, Coombe Hospital, Dublin)
Supported by grants from the Medical Research Council of Canada; institute of Clinical
Evaluative Sciences; and the Hospital for Sick Children Foundation.
This Policy Statement has been reviewed and approved by the Fetal-Maternal Me&he
Committee and Council of the Society of Obstetricians and Gynaecologists of Canada,
February, 1994.
Po@+tatements: This policy reflects emergmg clrnical and screnlrfrc advances as of the
date rssued and IS subject to change. The rnformatron should not be construed as dlctatlng
Declaratron de pnncrpe La Declaratton de pnncrpe fart etat des per&es recentes et des
an excluwe course of treatment or procedure to be followed. Local mstrtutrons can dictate
progres cllnlques et screnttflques a la date de publrcatton de celle-cr et peut farre tobjet de
amendments to these oprnions. They should be well documented 11 modrfred at the local level.
modrftcattons. II ne faut pas Interpreter Irnformatron qui y figure comme Irmposrtron dune
Copres avarlable for $5.00.
procedure ou dun mode de traitement exclusrfs a survre. Un etablrssement hospttalter est
lrbre de drcter des modrficatrons a apporter a la Declarahon de principe. En Ioccurrence. il
faut qurl y art documentation a Iapput a cet etablissement.
Copres drsponrbles. 5.00$ chacune.
BACKGROUND
4
The incidence of breech presentation at term is between three to four percent, although
a widespread policy of external cephalic version close to term might be expected to lower
this incidence. Associated with this malpresentation is an increased frequency of perinatal
mortality and morbidity, due principally to prematurity, congenital anomalies and birth
trauma/asphyxia. Numerous authors have suggested that a policy of elective Caesarean
section (CS) for the breech at term would minimize perinatal mortality and morbidity, while
conceding an inevitable increase in morbidity for the mother.*
The evidence for this recommendation is based largely on the results of imperfect data,
seriously compromised by selection bias. Hospital audits, which reveal the outcomes for
vaginal breech deliveries and those delivered by CS, rather than comparing a policy of
elective CS with a policy of selective, planned vaginal birth, have been used to bolster
the case for elective CS.3 Those studies which show higher rates of perinatal mortality
and morbidity with vaginal delivery do not emphasize, or completely ignore, the crucially
important issues of judicious selection of patients, the appropriate intrapartum
management, and the skill, experience and judgment of the obstetric attendant.* In the
only randomized trials comparing elective CS and planned vaginal delivery, there was no
difference in mortality between the two groups, no difference in low Apgar scores, but an
increase in short term neonatal morbidity in those delivered vaginally.4 These trials were,
however, much too small to provide a definitive answer to the question of which policy
is associated with a lower incidence of perinatal mortality and morbidity, although it is
clear that a policy of elective CS is associated with increased maternal morbidity.
It is evident, therefore, that this important question cannot be properly answered without
a well-designed randomized controlled trial comparing these two policies, with a sample
size of sufficient magnitude that a significant difference in morbidity and mortality, if it
exists, will be detected. The question is deemed to be important because it affects three
to four percent of all pregnant women reaching term (in Canada, this is approximately
11,000 to 14,000 women per year); the policies being compared include the issues of
major abdominal surgery versus vaginal birth; the survival of the infant free from injury
and neurologic deficit, a matter of primary concern to the parents, the child, the physician
and society; and an answer to the question will have an important influence on clinical
practice and postgraduate training programmes in obstetrics in this country and
elsewhere. Because there has been a gradual trend in many centres towards the use of
elective CS for breech presentation at term, the number of physicians who possess or
have retained the skills to perform vaginal breech deliveries is diminishing, and it is
inevitable that within a relatively short time, with fewer and fewer trainees having the
opportunity to acquire these skills, they will be lost forever, and women will be denied the
option of a vaginal birth if their fetus presents by the breech.
Prior to any serious consideration of developing a proposal for a large, randomized
controlled trial comparing these two policies, an essential prerequisite is the development
of a strong consensus on the important issues associated with the management of
patients with a breech presentation at term in whom a planned vaginal birth is being
considered. There is no evidence that any such consensus exists.
Accordingly, plans for the organization of an International Workshop to develop such a
consensus were begun in the late summer of 1993 by a Steering Committee formed at
the University of Toronto for that purpose - (Walter Hannah, Mary Hannah, Knox Ritchie,
Kofi Amankwah, Mary Cheng, Paula Penkin and Sheila Hewson). Twelve obstetricians
from across Canada, the United Kingdom, and Ireland were invited to participate, along
with the members of the Steering Committee, in the Workshop whose principal objective
was to develop a protocol for the selection and intrapartum management of women at
term with a breech presentation, in whom a planned vaginal birth would be considered.
A secondary objective was to consider the feasibility of a large, international randomized,
controlled trial, comparing a policy of elective CS with a policy of planned vaginal birth
in term breech presentation. All those who were invited were known by members of the
Steering Committee to have a keen interest in this problem, and all of them responded
positively to the invitation to participate.
The Workshop was planned for January 15/l 6, 1994 in Toronto, and in preparation for
this event, the participants were provided with the following information to facilitate the
discussions that would take place:
1. The objectives of the Workshop
2. Summaries of a comprehensive literature review prepared by members of
the Steering Committee
3. A questionnaire designed to determine their position on a number of issues
concerning the selection and intrapartum management of term breech
presentations which would be discussed at the Workshop
4. A list of Workshop participants
Funding to support the costs of the Workshop was provided from three granting agencies
- Medical Research Council of Canada; Institute for Clinical Evaluative Sciences; and the
Foundation of the Hospital for Sick Children, and this support is gratefully acknowledged.
THE WORKSHOP PROCEEDINGS
There was general agreement at the outset that the objective of developing a realistic,
workable protocol for the selection and intrapartum management of women at term with
breech presentation could best be met by extensive reliance on the findings from the
scientific literature, together with the substantial collective experience of the Workshop
participants themselves. Further, it was recognized that the protocol must be acceptable
to all practising clinicians. For this reason, we must err on the side of caution on those
issues where research evidence was either lacking or equivocal.
It was also agreed that consensus was not necessarily synonymous with unanimity, but
elements of the proposed protocol did require overwhelming support before they would
be endorsed by the Workshop participants.
A. SUMMARY OF THE BREECH QUESTIONNAIRE RESPONSES
Prior to the Workshop, the participants were asked to respond to a series of questions
directly related to those matters which influence selection and management of term
breech patients, and which would be discussed at the Workshop. The purpose of this
questionnaire was to determine those areas where considerable agreement already
existed and those where it did not, acknowledging that the responses represented the
participants initial position and that they might change as a result of the consensus-
building process itself.
A summary of the questionnaire responses was presented at the start of the Workshop,
and as expected, some issues were characterized by almost universal agreement while
others showed considerable divergence. This knowledge allowed for an increased
allocation of time to the more controversial matters and reduced discussion time to those
matters which already enjoyed a strong consensus, although as might be expected, this
did not always happen.
B. DEVELOPMENT OF THE PROTOCOL
In coming to grips with the principal objective of the Workshop, it was agreed that we
would subdivide the protocol elements into two separate categories:
a) Selection Criteria
b) lntrapartum Management
We would then deal with the items in each of those categories on an individual basis,
continuing the discussion until consensus was reached. For each item, Dr. Mary Cheng,
who had assumed responsibility, along with Drs. Paula Penkin and Mary Hannah, for
providing the participants with a comprehensive review of the literature, summarized the
evidence on that particular item. The item was then open for general discussion, and this
included the opportunity for participants to provide the group with data from their own *
units which might have a bearing on the matter at hand. In those circumstances where
the questionnaire responses had revealed a divergence of views, debate was lively but
constructive. On those issues where the literature was persuasive, consensus was most
often reached early, but when that was not the case and particularly in those situations
where there appeared to be no difference between two different approaches, the
participants agreed to avoid imposing a single approach.
The following paragraphs outline the conclusions reached by the participants, on the
basis of the published scientific literature, their own clinical experience and that of their
colleagues, and as a result of the thoughtful exchange of ideas made possible by the
Workshop forum. A brief summary of the issues discussed will be included to assist the
reader in understanding how the conclusions were reached.
a) SELECTION CRITERIA
I. Type of Breech Presentation
The literature showed a significantly increased perinatal mortality/morbidity in footling
breech, due principally to an increased incidence of cord prolapse, and entrapment of the
aftercoming head by an incompletely dilated cervix.53 This was in accord with the clinical
experience of the participants.
It was agreed that complete breech should be defined as flexion of hips and knees, but
that the feet should not lie below the fetal buttocks.
CONCLUSION: ONLY THOSE WOMEN WHOSE BREECH IS EITHER FRANK OR
COMPLETE SHOULD UNDERGO A TRIAL OF LABOUR IN ANTICIPATION
OF A VAGINAL DELIVERY.
2. Influence of Parity
There was virtual unanimity that parity should not influence a decision for planned vaginal
birth, and this was supported by the Iiterature.7-12*142g It was pointed out, however, by one
participant that, in his unit, over a twenty-year period (1972 to 1991), perinatal mortality
was higher in primigravid breech presentation delivered vaginally, than in multiparas,
although these figures included breech presentation at all gestational ages. Thus, parity
should be considered as a separate factor in the analysis of vaginal breech outcome.
CONCLUSION: IT IS REASONABLE TO ALLOW A TRIAL OF LABOUR IN BREECH
PRESENTATION AT TERM IN BOTH NULLIPARAS AND MULTIPARAS.
3. Maternal Age
A careful review of the literature failed to show any relationship between adverse perinatal
outcome and maternal age, in the absence of other risk factors, which, by themselves,
might lead to increased perinatal mortality/morbidity.0~2P26~30 It was acknowledged that the
conventional view that elderly gravidas, especially primigravidas, should likely be best
delivered abdominally is based more on anecdotal and emotional grounds than on
scientific evidence. In fact, it was felt by most to be a reflection of the widespread belief
that a breech presentation, in association with any perceived risk factor, should prompt
serious consideration for CS, when this view would not necessarily apply in the case of
cephalic presentation. After thoughtful refection of this matter, there was agreement that
there was simply no evidence for this position, unless the risk factor was likely to lead to
mechanical problems at delivery.
CONCLUSION: IN THE ABSENCE OF ANY OTHER RISK FACTORS, MATERNAL
AGE ALONE SHOULD NOT PRECLUDE PLANNED VAGINAL BIRTH.
4. Pelvlmetry
The research literature revealed that X-ray pelvimetry figured prominently in protocols for
planned vaginal birth, and often included lower limits for pelvic dimensions. Nevertheless,
none of these studies was able to confirm the value of this examination in selecting those
women who are more likely to succeed in a trial of labour, nor has it been shown to have
any effect on perinatal outcome.12~2g*3~4 Concern was expressed about womens anxiety
about radiologic exposure, as well as the reduced level of expertise in performing this
examination in most Canadian centres. Documentation of pelvic adequacy by clinical
assessment was felt to be important, but a part of normal obstetric practice.
CONCLUSION: X-RAY PELVIMETRY SHOULD NOT BE A PREREQUISITE FOR
PLANNED VAGINAL BIRTH.
5. Ultrasonography (U/S)
Because ultrasonography provides a wealth of important information in term breech
presentation (congenital anomalies, type of breech, hyperextension of fetal head, cord
position, estimated fetal weight (EFW), and amniotic fluid volume), it was felt that this
examination should be performed before making a decision for planned vaginal birth.42-43
It is recognized, however, that predicting EFW by ultrasonography is imprecise and has
not been shown to be of any greater value in the term fetus than clinical assessment,
especially in suspected macrosomia.30 Nevertheless, because there is evidence that a
birthweight greater than 4,000 gms may be associated with increased perinatal
mortality/morbidity due to mechanical difficulties at delivery, it was felt that planned
vaginal birth should be restricted to those cases where the EFW, by U/S or clinical
assessment, is less than 4,000 gms10*27*37*44-47. If the diagnosis of breech presentation is
made for the first time in labour, and the estimate of fetal weight, by clinical examination
or U/S, is greater than 4,000 gms, delivery by CS is recommended. Hyperextension of
*
5
the fetal head is associated with significant perinatal mortality and neonatal neurologic
morbidity when vaginal delivery is undertaken.348-53
CONCLUSION: WHEN BREECH PRESENTATION IS DIAGNOSED ATTERM BEFORE
LABOUR, ULTRASONOGRAPHY IS RECOMMENDED. TRIAL OF LABOUR IS
REASONABLE IF EFW, BY CLINICAL OR U/S ASSESSMENT, IS JUDGED TO BE
LESS THAN 4,000 GRAMS, AND IF THERE IS NO HYPEREXTENSION OF THE
FETAL HEAD. FOR THE BREECH DIAGNOSED IN LABOUR, FETAL ATTITUDE CAN
BE ASSESSED CLINICALLY, BY U/S OR BY X-RAY. BREECH PRESENTATION, IN
WHICH HYPEREXTENSION OF THE FETAL HEAD IS DIAGNOSED, SHOULD BE
DELIVERED BY CS.
6. Medlcal/Obstetrlcal Complications
As indicated earlier, there is no scientific evidence to support the belief that breech
presentation in association with another risk factor such as mild pre-eclampsia, post-term
pregnancy etc. should preclude a trial of labour, unless that risk factor is likely to be
associated with mechanical difficulties at delivery.0V27V37V44-47
CONCLUSION: THE PRESENCE OF MEDICAL OR OBSTETRIC COMPLICATIONS
SHOULD NOT PRECLUDE A TRIAL OF LABOUR UNLESS THE COMPLICATION IS
LIKELY TO LEAD TO MECHANICAL DIFFICULTIES AT DELIVERY.
\sI
B) INTRAPARTUM MANAGEMENT
7. Induction of Labour
Nowhere in the literature was there any evidence to justify a prohibition of induction of
labour in term breech when there was a medical or obstetric indication to do
so. 2017*2g,3g*53-56 Conversely, breech presentation, by itself, is not an indication for induction.
The usual precautions advised for vaginal breech delivery and for induction of labour
should be observed.
CONCLUSION: BREECH PRESENTATION ALONE IS NOT A CONTRA-INDICATION
TO MEDICALLY INDICATED INDUCTION OF LABOUR.
8. Augmentation of Labour
There are no scientific data to preclude the judicious use of oxytocin augmentation to
correct inadequate uterine activity.5*i792102g*34*3g045V54V55*57-5g Because there was concern
among some of the participants about the possible relationship between a reduction in
uterine activity and feto-pelvic disproportion, especially in the multiparous woman, every
effort should be made to exclude such disproportion before resorting to augmentation.
Although it must be said that such disproportion, in the case of cephalic presentation, is
*
most appropriately recognised by failure of dilatation of the cervix or descent of the
presenting part in the presence of adequate contractions, there was a strong feeling
among some of the participants that this was not necessarily the case with breech
presentation. Unlike cephalic presentation, oxytocin should not be used to overcome
relative feto-pelvic disproportion.
CONCLUSION: CAREFUL OXYTOCIN AUGMENTATION OF LABOUR TO CORRECT
INADEQUATE UTERINE ACTIVITY IS REASONABLE PRACTICE, PROVIDED THAT
CAUTION IS EXERCISEDTO EXCLUDE FETO-PELVIC DISPROPORTION.THlS IS OF
PARTICULAR IMPORTANCE IN THE MULTIPAROUS WOMAN.
9. Limits to Duration of Labour
On the basis of the published literature, and the collective experience of the participants,
it was not felt that there should be a limit to the duration of the first stage of labour,
provided that there is continued progress of at least 0.5 cm./hour in cervical dilatation
after reaching 3 cm dilatation. Unlike labour in cephalic presentation, progress slower
than this was felt to be a sign of potential feto-pelvic disproportion. These views are
based on those studies which show an increase in adverse perinatal outcome where
active labour is prolonged beyond 20 hours.0~2~28~3g~40~41~60
As in cephalic presentation, active pushing should not be encouraged until the breech has
descended to the pelvic floor. If the breech has not descended to the pelvic floor after two
hours in the second stage without active pushing, or if vaginal delivery is not imminent
after one hour of active pushing, CS is recommended. This admonition is based on the
collective view of the participants that abnormal prolongation of the second stage of *
labour in a breech presentation is a strong indication of potential feto-pelvic disproportion.
CONCLUSION: THERE SHOULD BE NO LIMIT TO THE DURATION OF THE FIRST
STAGE OF LABOUR AS LONG AS CERVICAL DILATATION IS PROCEEDING AT A
RATE OF AT LEAST 0.5 CM/HOUR AFTER THREE CM DILATATION. CAESAREAN
SECTION IS RECOMMENDED IF THE BREECH HAS NOT DESCENDED TO THE
PERINEUM IN THE SECOND STAGE OF LABOUR AFTER TWO HOURS, IN THE
ABSENCE OF ACTIVE PUSHING, OR IF VAGINAL DELIVERY IS NOT IMMINENT
AFTER ONE HOUR OF ACTIVE PUSHING.
10. lntrapartum Fetal Monitoring
In view of the extensive literature, of excellent quality, casting doubt on the superiority of
continuous electronic fetal monitoring (EFM) over properly performed intermittent
auscultation (IA) in both low-risk and high-risk labouring women, there was general
agreement that breech presentation, by itself, was not an indication for continuous EFM-
66. In those units where this form of monitoring is used for patients at risk, it can be used
for the same indications as for cephalic presentation. The point was made that continuous
EFM might detect cord prolapse earlier than IA, leading to the second part of the
recommendation incorporated in the following conclusion.
8
CONCLUSION: BREECH PRESENTATION, BY ITSELF, IS NOT AN INDICATION FOR
i- CONTINUOUS EFM, WHICH MAY BE USED FOR THE SAME INDICATIONS AS FOR
CEPHALIC PRESENTATIONS. VAGINAL EXAMINATION SHOULD BE PERFORMED
AS SOON AS POSSIBLE AFTER SPONTANEOUS RUPTURE OF MEMBRANES TO
EXCLUDECORDPROLAPSE.
11. Analgesla/Anaesthesla
While epidural analgesia/anaesthesia is a favourite choice of all the participants, there is
no convincing evidence that it offers any unique advantages for term breech presentation,
and it may be associated with some prolongation of the second stage.7~30~31~53~67~71
CONCLUSION: THE TYPE OF PAIN RELIEF SHOULD BE INDIVIDUALIZED AFTER
DISCUSSION WITH THE PREGNANT WOMAN. BREECH PRESENTATION, BY
ITSELF, IS NOT AN INDICATION FOR, OR GROUNDS FOR WITHHOLDING
EPIDURAL ANAESTHESIA.
12. Amnlotomy
A policy of deliberate amniotomy versus membrane preservation in established labour
does not appear to influence perinatal outcome.6,72-74
3
CONCLUSION: AMNIOTOMY MAY BE PERFORMED FOR THE SAME INDICATIONS
AS IN CEPHALIC PRESENTATION.
13. Delivery Technique
The published literature and the collective experience of the participants leave no room
for doubt that total breech extraction has no place as a method of delivery in the term,
singleton breech. Perinatal mortality and morbidity are significantly increased when this
delivery method is u~ed.Q~~0~~2~~5~~7~22,26,2Q,75-79
Assisted breech delivery is the preferred
method, although spontaneous delivery is acceptable as long as control of the
aftercoming head is maintained. The important elements of assisted breech delivery are:
no intervention until there has been spontaneous exit of the infant to the umbilicus;
minimum intervention thereafter with no traction on the body, and controlled delivery of
the aftercoming head, either with the use of forceps or the Mauriceau-Smellie-Veit
manoeuvre.
CONCLUSION: ASSISTED BREECH DELIVERY IS STRONGLY RECOMMENDED AS
THE DELIVERY METHOD OF CHOICE, IN ASSOCIATION WITH THE USE OF
FORCEPS OR MAURICEAU-SMELLIE-VEIT MANOEUVRE FORTHE AFTERCOMING
HEAD. TOTAL BREECH EXTRACTION SHOULD NOT BE PERFORMED AS A
DELIVERY METHOD IN THE SINGLETON BREECH.
14. intrapartum Consultation
d
Extensive discussion took place concerning the desirability and feasibility of providing a
back-up system in obstetric units whereby a second obstetrician could be available in the
obstetric unit for the second stage and delivery of a term breech. This was thought by
many of the participants to be of particular value in those circumstances where the
attending obstetrician might appreciate the presence of additional expertise from a
colleague, especially when that individual is more experienced in vaginal breech
management. While there was general acknowledgment of the value of such an
arrangement, it was equally recognized that, for many smaller units, this may not be
feasible. Nevertheless, the value of intrapartum consultation with an experienced
colleague cannot be denied and should be encouraged.
CONCLUSION: RECOGNIZING THAT THE TRAINING EXPERIENCE OF MANY
PRACTISING OBSTETRICIANS IN VAGINAL BREECH DELIVERY MAY BE
VARIABLE, INTRAPARTUM COt;lSULTATiON WI T H A C OL L E A GU E I S
ENCOURAGED. MEDICAL PERSONNEL TO PROVIDE ANAESTHESIA AND
IMMEDIATE NEONATAL CARE SHOULD BE AVAILABLE AT THE TIME OF VAGINAL
BREECH DELIVERY, AS IN CEPHALIC PRESENTATION.
15. External Cephalic Version (ECV)
Although the issue of external cephalic version, strictly speaking, does not properly
belong to a protocol defining the selection of women and their intrapartum management
who present at term with a breech presentation, and for whom a trial of labour and
vaginal delivery is planned, the Workshop participants felt that their work would be
incomplete if they did not discuss this matter and reach a conclusion about its proper
place in contemporary obstetric practice.
The research evidence in support of the efficacy of external cephalic version at term to
reduce the number of breech presentations entering labour, as well as the number of
CSs, is the most powerful and persuasive in all the published breech literature, because
the findings are based on well designed randomized, controlled trials.*-B6 The rates of
success are variable and appear to be related to experience. There is no evidence that
tocolysis increases the success rate, though as might be expected, this rate is higher in
the multiparous woman. Although the published studies do not refer to the type of breech
presentation, there was agreement that it might be expected that the success rate will be
higher in non-frank presentations. It is evident that the studies are not large enough to
provide a precise estimate of perinatal risk. For this reason, it was felt that ECV should
be performed in the labour/delivery suite, or clinic area.
CONCLUSION: EXTERNAL CEPHALIC VERSION IS ENCOURAGED FOR THOSE BREECH
PRESENTATIONS IN WHICH NO CONTRA-INDICATION EXISTS (CLASSICAL CS SCAR,
PLACENTA PRAEVIA ETC.). THIS SHOULD BE DONE AT OR AFTER 37 WEEKS, AND IN
THE LABOUR/DELIVERY SUITE, OR CLINIC AREA. TRAINING OF OBSTETRIC PERSONNEL
IN THIS PROCEDURE SHOULD BE ENCOURAGED.
vk
b
CLOSING REMARKS
III conclusion, it must be said that all participants were sensitive to the potential for
criticism from their colleagues across the country and abroad for presuming to establish
a clinical protocol in this controversial area. Nevertheless, there was a strong feeling that
thi& needed to be done, and done soon, to allow the members of our discipline to work
with guidelines that have been formulated by peer discussion, based on the best literature
available and the extensive, collective experience of a representative group of concerned
and experienced obstetricians. There was unanimity among the Workshop participants
that the skills and judgment required for selecting and managing women who reach term
with a breech presentation are rapidly being lost, and the practice of vaginal breech
delivery is in grave danger of disappearing by default, without any of us ever being
certain that this will lead to more good than harm. The definitive answer to this question,
it was agreed, is to compare a policy of elective CS with a policy of selective vaginal
delivery by an appropriately-sized randomized trial. The difficulties in establishing such
a trial are obvious to everyone, but the answer will not be found without it, and there was
strong support from the participants for further exploration of the feasibility of such a trial.
It is hoped that the development of this protocol will assist all obstetricians to become
more comfortable with the principle of carefully selected vaginal breech delivery, and
acquire or renew their skills in its performance.
s
The Steering Committee expresses its gratitude to all the participants for their
commitment of time and energy in the fulfilment of the Workshop objectives.
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