Clinical Green Top Guidelines

The Management of Breech Presentation (20) - Apr 2001
1. Introduction
The incidence of breech presentation is about 20% at 28 weeks. Most of the fetuses turn spontaneously, so
the incidence at term is 3-4%. It has been widely recognised that there is higher perinatal mortality and
morbidity with breech presentation, due principally to prematurity, congenital malformations and birth
asphyxia or trauma.1,2 Breech presentation, whatever the mode of delivery, is a signal for potential fetal
handicap and this should inform antenatal, intrapartum and neonatal management. 3 Caesarean section for
breech presentation has been suggested as a way of reducing the associated fetal problems 2 and in many
countries in northern Europe and North America caesarean section has become the normal mode of delivery
in this situation.
2. Identification and assessment of evidence
The Cochrane Library, including the Cochrane Register of Controlled Trials, was searched for relevant
randomised controlled trials (RCTs), systematic reviews and meta-analyses. A search of MEDLINE from
1966-2001 was also carried out. The author also liaised with the MIDIRS midwifery database and used the
results of their search (November 1999). MIDIRS hand searches 300 journals in-house. Contents pages of a
further 150 journal titles were scanned on-line and copies of relevant articles obtained. Coverage is English
language journals worldwide and includes the majority of midwifery and obstetrics journals, plus a selection
of other general medical and specialist journals on subjects including epidemiology, primary health, health
education, statistics, dietetics, anaesthesia and ultrasound. Items added to the MIDIRS database all include
an abstract or short summary and are indexed using indexing terms based on the MeSH headings used in
Medline.
The databases were searched using the relevant MeSH terms: breech presentation, version, fetal, tocolysis
and tocolytic agents. This was combined with a keyword search using: breech, external cephalic version,
tocolysis; and limiting the search to human.
3. Reducing the incidence of breech presentation
3.1 Using posture
There is no evidence to support routine recommendation of the knee-chest position.
Four randomised trials have been undertaken to establish whether or not postural management
(knee-chest position) is effective in converting breech to cephalic presentations. In these studies
no significant benefits were found.4
3.2 Using external cephalic version (ECV)

Evidence
Level
Ia

All women with an uncomplicated breech pregnancy at term (37-42 weeks) should be offered
ECV.
ECV has been practised since the time of Hippocrates and through the European Middle Ages to
modern times.5,6 ECV has been subjected to rigorous scientific appraisal in six randomised
controlled trials. There is significant reduction in the risk of caesarean section in women where Evidence
there is an intention to undertake ECV (odds ratio 0.4; 95% confidence intervals 0.3-0.6) without Level
any increased risk to the baby.7 Published studies have not evaluated women's views of the Ia
procedure. Nevertheless, all women with an uncomplicated breech pregnancy at term (37-42
weeks) should be offered ECV.8

ECV itself should be undertaken by appropriately trained professionals.
Further research into development and maintenance of skills in this procedure is required.
Tocolysis is effective, both when used routinely and when used selectively.
Tocolysis is effective, both when used routinely and when used selectively.9 Five randomised
studies of tocolysis for ECV were identified 10 (the success rates ranging from 3% to 40%). The
two individual studies that showed a statistically significant benefit from routine tocolysis were
carried out in Hong Kong. Further work in other countries is clearly indicated and should include
outcome measures of patient satisfaction. Since the publication of the systematic review, 10
significant improvements in success rate of ECV were seen in a placebo-controlled trial of
subcutaneous terbutaline in the USA.9 However, there remains insufficient evidence upon which
to base recommendations of specific treatment. Because of the recognised adverse effects of
betasympathomimetics,11 there is considerable interest in the evaluation of alternative tocolytic
agents. A pilot placebo-controlled trial of glyceryl trinitrate spray has been published. 12 Anti-D
should be administered to women who are rhesus negative. 13

Evidence
Level
Ia

ECV should be done near to facilities for emergency delivery. A cardiotocograph is
necessary. Ultrasound is helpful.
ECV is best carried out with the mother awake and facilities for emergency delivery should be Evidence
Level
available nearby. Cardiotocography should be performed. 14 Ultrasound guidance can be III

1

they became even more significant in countries with a low perinatal mortality rate.07-0. 12 Neither vibroacoustic stimulation nor amnioinfusion has been proven to be effective in controlled trials and each requires further evaluation. P = 0. two small RCTs have studied the use of regional anaesthesia for a first attempt at ECV. respectively. over 80% in Africa 18). no studies have reported any outcomes related to maternal satisfaction.32 The overall risk of perinatal death for the term frank/complete breech fetus with planned caesarean birth was reduced by 75% (RR 0. substantial cost-savings are possible'. an overall success rate of 65% was found (and 97. which revealed outcomes for vaginal delivery and delivery by caesarean section rather than comparing a policy of Evidence Level intended caesarean section with a policy of intended vaginal birth.25.26 In the first study. The management of breech pregnancy at term was reviewed in 1993. Two groups Evidence Level have reported the success rate associated with epidural anaesthesia after failed conventional Ib ECV. or quality of life.g. CI 0.27.34 the results of the trial lead to an inescapable Ib recommendation that 'the best method of delivering a term frank or complete breech singleton is by planned LSCS'. A study of spinal anaesthesia has now been published. It should be noted that this study has not evaluated long-term outcomes for child or mother.6%) compared with 23/704 (3. The Term Breech trial was stopped early in April 2000 because it confirmed that vaginal delivery is indeed more hazardous than elective caesarean section.8). These include multiparity.91). ECV has also been carried out successfully after previous caesarean section20.22 and during early labour. which was significantly different to the rate of 32% (11/34) in the control group. neonatal mortality or serious neonatal morbidity with planned caesarean section compared with planned vaginal birth was 16/1006 Evidence (1. and those cases for whom there was no skilled or experienced clinician present at the birth. 4.3%) (RR 0.27 However. A number of other important questions were raised in subsequently published correspondence in The Lancet.helpful. better intrapartum monitoring. In a study from Hawaii. 26 the results were similar: the success rate in the epidural group was 59% (32/54). CI 0. adequate liquor volume and a station of the breech above the pelvic brim. In a further subanalysis. 29 Much of the remaining evidence supporting elective caesarean section comprised hospital audit. Following the first observational series examining the effectiveness of epidurals on the safety and success of ECV 24. Elective caesarean section versus planned vaginal breech delivery at term The best method of delivering a term frank or complete breech singleton is by planned caesarean section.5% of these remained cephalic after ECV).33 It has been suggested that the Term Breech trial. and all clinicians involved in maternity care. The findings suggested that the benefits of delivery by caesarean section were not as significant in countries with a higher perinatal mortality rate. This finding should be disseminated to pregnant women.15.16 ECV has been introduced successfully into practice in the UK. full pelvimetry and umbilical cord assessment might have improved the Evidence Level prospects for a vaginal breech delivery.34 Although it is possible that careful exclusion of growth restricted infants.19 Among published USA studies. In this subanalysis. an economic analysis has suggested that with epidural use 'in institutions where caesarean sections are systematically performed for breech presentations.18 A number of factors have been found to increase the likelihood of successful ECV. 2 In the two small randomised trials published by then.23. and thereby missed an opportunity to evaluate labour and 2 . Ib the Canadian MRC funded an international multicentre RCT of planned vaginal delivery versus planned elective caesarean section for the uncomplicated term breech. Level results were separated into those obtained in countries with higher perinatal mortality (> 20/1000) Ib and those from countries with a lower perinatal mortality ( 20/1000). Conversely. which does not support improved outcome with regional anaesthesia. With case selection it is possible to achieve higher success rates and operators improve with experience. A subanalysis was undertaken after excluding the following cases: deliveries that occurred after a prolonged labour. no differences in mortality between the groups were seen.49.7 There is insufficient evidence to support the use of regional anaesthesia to facilitate ECV.26-0. Further research in this area is required.31 Against this background.28 In these small studies the success rates increased from 57% to 75% and from 60% to 71%. generalisation of these results in the UK would result in a significant reduction in the numbers of caesarean sections.23 Various interventions for improving the success rate of ECV have been suggested.33 There were no differences between groups in terms of maternal mortality or serious early maternal morbidity.25 the success rate in the epidural group was 69% (24/35). by reflecting conventional 'expert' views. labours that were induced or augmented with oxytocin or prostaglandins. 30. sanctioned the conventional dorsal lithotomy position for delivery. the risk of the combined outcome of perinatal mortality. compared with 33% (18/45) in the control group.23 No adverse effects on the mother or fetus have been reported. which compared elective caesarean section and planned vaginal delivery. 17 Although the success rate (conversion to cephalic presentation) found in this study (46%) is less than that quoted in some (e. but an increase in short-term morbidity was noted in those babies delivered vaginally. their families.21 Although primarily intended for the management of the uncomplicated breech pregnancy at term.02). In addition. 20. cases where there was a footling or uncertain type of breech presentation at delivery.

To facilitate delivery of the head an episiotomy is often performed. knees flexed but feet not below the fetal buttocks). Trauma was the sole cause of death in only one case. this is an area that would require further research by those clinicians and women who remain in equipoise. It remains possible that women will choose to deliver vaginally and that some women for whom a caesarean section is planned will labour too quickly for the operation to be undertaken (nearly 10% of women assigned to deliver by caesarean section in the Term Breech trial delivered vaginally). Consultants were informed in only half of these cases before delivery. the most common reasons for emergency caesarean section were 'failure to progress' (50%) and 'fetal distress' (29%).38 Although X-ray pelvimetry has figured prominently in protocols for planned vaginal birth. of whom 79% delivered their breech infants vaginally. models and scenario teaching). none of these studies was able to confirm the Evidence value of this examination in selecting those women who were more likely to succeed in a trial of Level labour or to have any effect on perinatal outcome. In the seventh Annual Report of the Confidential Evidence Enquiry into Stillbirth and Deaths in Infancy. experience and judgements of the intrapartum Level III attendant. and delays in staff response to fetal compromise occurred in nearly threequarters of cases. the numbers of vaginal breech deliveries will fall further following the Term Breech trial. Over the last ten years there have been major changes in the management of breech pregnancies and the organisation of junior doctors' work patterns. On reviewing trainee logbooks from one busy district general hospital (1987 and 1997). there was clinical evidence of hypoxia in all but one case before delivery. knees extended) or complete (hips flexed.delivery in upright positions (considered by some to be physiologically and anatomically more sound). induction or augmentation may be justified.36. There should be no evidence of fetopelvic disproportion with a clinically 'adequate' pelvis. 37 further guidelines on intrapartum management were drawn up. 37 In a subanalysis of the Term Breech trial the III use of radiological pelvimetry was not linked to improved outcome. In cases where IV the cardiotocograph was available for review. 41 In the Term Breech trial. Evidence Level assessment of the undiagnosed breech in labour by experienced medical staff can allow safe III 43 vaginal delivery. induction or augmentation may be justified. 4. In the Canadian consensus of breech management at term.1 Selection of patients A trial of labour should be precluded in the presence of medical or obstetric complications that are likely to be associated with mechanical difficulties at delivery. A trial of vaginal breech delivery is more likely to be successful if both mother and baby are of normal proportions.39 Ophir et al. in selected cases. Fetal blood sampling from the buttocks provides an accurate assessment of the acid-base status. Careful monitoring of fetal wellbeing and progress of labour were emphasised.37 The presentation should be either frank (hips flexed. it appears that there has been a ten-fold reduction in vaginal breech delivery experience for UK registrars.42 the single and most avoidable factor in causing Level breech stillbirths and death among breech babies was suboptimal care in labour.g.40 offered 66% of patients with a previous caesarean section a trial of labour. Fetal blood sampling from the buttocks provides an accurate assessment of the acid-base status. There should be no evidence of hyperextension of the fetal head. videos. who do fewer hours.37 4. 35 Clearly. There are already a reduced number of vaginal breech deliveries managed by an increased number of trainees. 37. when the fetal heart rate trace is suspect.2 Intrapartum management There is no evidence that epidural analgesia is essential and. Evidence appropriate intrapartum management and the skill. A trial of labour should be precluded in the presence of medical or obstetric complications which are likely to be associated with mechanical difficulties at delivery. In about 20% of cases forceps are used. 44-46 5. Clearly. Management of the preterm breech and twin breech 3 . Important issues to consider when planning a vaginal birth are the careful selection of patients. It remains important that clinicians and hospitals are prepared for vaginal breech delivery 4. There is no evidence that epidural analgesia is essential and. experience and judgement of the intrapartum attendant Any woman who gives birth to a breech vaginally should be cared for by an attendant with suitable experience.32 Although much emphasis is placed on adequate case selection prior to labour. Clinical judgement is adequate and pelvimetry need not be used routinely. when the fetal heart rate trace is suspect. Alternative methods of training urgently need to be introduced (e. These delays ranged from 30 minutes to ten hours. in selected cases. Clinical inexperience at the time of delivery exacerbated the risk for an already hypoxic baby in some cases.3 Training: skill.

They did. MacDonald PC. Danielian PJ. The main problems with vaginal breech delivery in the Term Breech trial related to fetal distress in labour and difficult delivery. External cephalic version facilitation for breech presentation at term. Wang J. which remains an area of clinical controversy. 54 reported 'interlocking' occurring only once in 817 twin pregnancies. Enkin M. Kulier R. Dystocia caused by abnormalities in presentation. find an increase in maternal mortality in association with a III caesarean section delivery. this is currently being further investigated in the Early ECV trial from Toronto. Evidence Level 1a There is insufficient evidence to support routine caesarean section for the delivery of preterm breech. Pregnancy. 65365.4748 ECV before term has not been shown to offer any benefits. Williams Obstetrics. Bloom SL. 787-96. If the second twin is non-vertex (which occurs in about 40% of twins). Jordan B. A randomized placebo-controlled evaluation of terbutaline for external cephalic version. Wendel GD Jr. Issue 4. 4. Hofmeyr GJ. this complication is extremely rare. Hannah M. Hofmeyr GJ. Documentation It is essential that all details of care are clearly documented. Obstet Gynecol 1997. 55 compared the outcome of breech presenting twins over two time periods where the caesarean Evidence section rate increased from 21% to almost 95%. Breech delivery at term: a critical review of the literature. Effective Care in Pregnancy and Childbirth.51 The poor outcome for very low birthweight infants is mainly Evidence related to complications of prematurity and not the mode of delivery.52 Grant53 has reviewed the Level controlled trials assessing the value of elective versus selective caesarean delivery of the small III baby. Norwalk. Although the majority of obstetricians will use caesarean section for the uncomplicated preterm breech. 5. 2.48 There is insufficient evidence to support caesarean section for the delivery of the first or second twin. only a minority believe that there is sufficient evidence to justify this policy. 1980. Twins are smaller than singletons and continuous electronic fetal monitoring in labour is standard practice. Royal College of Obstetricians and Gynaecologists Clinical Audit Unit. Oettinger and et al. 1997. Rabinovici et al. however. Ananth CV. 9. The worldwide atosiban versus beta-agonists study group. Oxford: Oxford University Press. Evidence from the Term Breech trial cannot be directly extrapolated to preterm breech delivery. the results showed no difference in five-minute Apgar scores or in any other indices in neonatal morbidity between the two groups. Cheng M. 32. In: Chalmers I. p. including the identity of all those involved in the procedures. 7. and found no change in neonatal morbidity or Level mortality. There are other non-randomised reports on the safety of vaginal delivery for non-vertex second twin. 3. Cohen et al. position. In the absence of good evidence that a preterm baby needs to be delivered by caesarean section. Volume 1. BMJ 1996. because of concern about 'interlocking'. 6. However. 47 There is general acknowledgement that the numerous retrospective studies which suggest that caesarean section confers a better outcome in this situation have been subject to bias. 10.312:1451-3. External cephalic version as an alternative to breech delivery and caesarean section. Obstet Gynecol 1993. or development of the fetus. He felt that the data 'are not sufficient to justify a policy of elective caesarean section'. 6. Effective Procedures in Maternity Care Suitable for Audit. Pritchard JA. Smulian JC. 50 This is acknowledged in some reports. Laros57 had no fetal losses in either group of second twins with 74 being delivered by caesarean and 76 delivered vaginally.49 However. Hofmeyr GJ. Cochrane Database Syst Rev 2000. the decision about the mode of delivery should be made after close consultation with the labouring woman and her partner. Cochrane Database Syst Rev 2000. Cochrane Database Syst Rev Issue 2000. the plan for delivery will need careful consideration and full discussion with the parents. editors. vaginal delivery is considered safe. 8. issue 4. Long-term outcome by method of delivery of fetuses in breech presentation at term: population-based follow up. Hofmeyr GJ. CT: Appleton-Century-Crofts. 11. London: RCOG Press. Effectiveness and safety of the oxytocin antagonist 4 . Breech presentation and abnormal lie in late pregnancy. p. It can be argued that a twin breech is different. 1989. Although the study only included 60 twins. Kulier R. Nevertheless.ECV before term has not been shown to offer any benefits. the trial only included singleton pregnancies. p. Issue 4. Keirse MJ. Cephalic version by postural management for breech presentation.82:605-18. Fernandez CO. 56 carried out a randomised study of twin deliveries where the second twins presentation was non-vertex. 4. Hall MH.5:775-9. Soc Sci Med 1984. REFERENCES 1.18:637-51. External cephalic version for breech presentation at term.7 Breech presentation at term. Although many clinicians choose caesarean section when the first twin presents as a breech.

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Cochrane Database Syst Rev 2000. III Evidence obtained from well-designed non-experimental descriptive studies.org. Ophir E.158:1330-8.rcog. Karrison T. Requires evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities.156:52-6. Fetal interlocking complicating twin gestation. 6 . They must be evaluated with reference to individual patient needs. Roisenthal AH. Factors influencing neonatal outcomes in the very low birthweight fetus (< 1500 g) with a breech presentation. Markovitz J. correlation studies and case studies.35:38-43. These recommendations are not intended to dictate an exclusive course of management or treatment. IIa Evidence obtained from at least one well-designed controlled study without randomisation.uk/clingov1). Brown L. Grant A. Attention is drawn to areas of clinical uncertainty where further research may be indicated. Ib Evidence obtained from at least one randomised controlled trial. Kohl SG. such as comparative studies. resources and limitations unique to the institution and variations in local populations. Ib). Cohen M. Stolero E. 54. III). The evidence used in this guideline was graded using the scheme below and the recommendations formulated in a similar fashion with a standardised grading scheme. Grades of recommendations Requires at least one randomised controlled trial as part of a body of literature of overall good quality and consistency addressing the specific recommendation (evidence levels Ia. IIb. This guideline was produced on behalf of the Guidelines and Audit Committee of the Royal College of Obstetricians and Gynaecologists by: Mr RB Johanson MRCOG. Am J Obstet Gynecol 1988.52. It is hoped that this process of local ownership will help to incorporate these guidelines into routine practice. IV Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities. Am J Obstet Gynecol 1994. Clinical guidelines are: 'systematically developed statements which assist clinicians and patients in making decisions about appropriate treatment for specific conditions'. IIb Evidence obtained from at least one other type of well-designed quasi-experimental study. Serr DM. Barkai G. Odeh M. Each guideline is systematically developed using a standardised methodology. Am J Obstet Gynecol 1987. Good practice point Recommended best practice based on the clinical experience of the guideline development group. Requires the availability of well-controlled clinical studies but no randomised clinical trials on the topic of recommendations (Evidence levels IIa. 53. Laros RK Jr. Exact details of this process can be found in Clinical Governance Advice No 1: Guidance for the Development of RCOG Green-top Guidelines (available on the RCOG website www. Cibils LA. 56. Dattel BJ. Indicates an absence of directly applicable clinical studies of good quality (evidence level IV).171:35-42. selective caesarean for delivery of the small baby. Elective vs. Classification of evidence levels Ia Evidence obtained from meta-analysis of randomised controlled trials. 57. Am J Obstet Gynecol 1965. Mashiach S. Oettinger M. Stoke-on-Trent Peer reviewed by: The Guidelines and Audit Committee Valid until April 2004 unless otherwise indicated This revised guideline replaces The Management of Breech Presentation (20) published July 1999.91:407. Issue 4. Rabinovici J. Is caesarean section necessary for delivery of a breech first twin? Gynecol Obstet Invest 1993. Reichman B. Randomised management of the second nonvertex twin: vaginal delivery or caesarean section. 55. Management of twin pregnancy: the vaginal route is still safe.