Professional Documents
Culture Documents
Australian and
New Zealand
College of
Obstetricians and
Gynaecologists
College Statement
C-Obs 11
1st Endorsed: February 2001
Current: March 2013
Review: March 2016
C-Obs 11
Objective
This review group sought to answer the following question:
What is the most appropriate mode of delivery for a singleton fetus at term in breech presentation
in Australian and New Zealand hospitals?
be an option to offer to appropriately counselled and selected women where appropriate personnel
and infrastructure to support such a birth are in place.9
Where vaginal breech delivery is to be considered, suggested minimum requirements for
management are provided in Recommendation 9 below, to ensure the safest possible conduct of
vaginal breech delivery for appropriately experienced Fellows.
Recommendations
Diagnosis of a Breech Presentation in the late third trimester
Where the diagnosis of breech presentation has been made late in the third trimester, ultrasound
should be performed by a suitably-experienced practitioner to determine whether any fetal or
maternal findings predisposing to malpresentation are present (such as a fetal congenital anomaly,
or undiagnosed placenta praevia, for example). Ultrasound is also used to locate the placenta,
quantify the liquor volume, estimate the fetal weight, and diagnose adverse fetal findings such as
hyperextension of the fetal head, or cord or footling presentation.
Good Practice Note
All caregivers providing antenatal care should be experienced in
palpation of the pregnant abdomen, including identification of the
presenting part to diagnose breech presentation. The caregiver
should have ready access to ultrasound to confirm presentation
where he/she has any doubt regarding the presentation.
Recommendation 1
For women with suspected breech presentation, an ultrasound should
be performed to confirm the examination findings.
Grade
Good Practice Note
Recommendation 2
Where diagnosis of breech presentation is made late in the third
trimester, a specialised obstetric ultrasound should be performed to
determine whether any fetal or maternal finding predisposing to
malpresentation is present (such as a fetal congenital anomaly, or
undiagnosed placenta praevia, for example).
Grade
Consensus-based
recommendation
Grade
Consensus-based
recommendation
Recommendation 3
Women with a breech presentation at term, with no contraindications
to ECV, should be informed about ECV, the likely success rate and
offered it if clinically appropriate.
Recommendation 4
ECV is inappropriate where a caesarean section is indicated on other
grounds.
Recommendation 5
Oligohydramnios
Antepartum haemorrhage
Fetal hypoxia
A uterine scar
Consensus-based
recommendation
10
Individualise management
Almost 90 per cent of fetuses presenting by the breech at term are now delivered by caesarean
section.2 However, with careful case selection and intrapartum management, in an institution with
adequate experience and infrastructure, it is possible to plan for attempted vaginal delivery in some
cases. This will depend upon the experience of the clinical team, and the infrastructure available.
Contraindications to vaginal breech delivery include:
a) Cord presentation
b) Fetal growth restriction or macrosomia
c) Any presentation other than frank or complete breech
d) Extension of the fetal head
e) Clinically inadequate maternal pelvis
f) Fetal anomaly incompatible with vaginal delivery
Many women will request planned caesarean delivery, and it is essential that women who request
a trial of vaginal delivery are counselled about the potential risks and benefits of vaginal breech
delivery, giving due regard to the experience of the clinical team and the infrastructure available.
Where a vaginal delivery of a breech presentation is planned, appropriate infrastructure must
include:
Recommendation 6
Any planned breech delivery must take place in an institution that can
meet minimum standards of experience and infrastructure.
Grade
Consensus-based
recommendation
Recommendation 7
A woman and her partners choice for delivery mode should be
respected.
Grade
Consensus-based
recommendation
Recommendation 8
Vaginal breech delivery may be offered provided there are no
contraindications to vaginal delivery.
Contraindications to vaginal breech delivery include:
a) Cord presentation
b) Fetal growth restriction or macrosomia
c) Any presentation other than frank or complete breech
d) Extension of the fetal head
e) Clinically inadequate maternal pelvis
f) Fetal anomaly incompatible with vaginal delivery
Grade
Consensus-based
recommendation
Recommendation 9
When attempting a planned vaginal delivery of a breech presentation
ensure the following:
Grade
Consensus-based
recommendation
Grade
Consensus-based
recommendation
Recommendation 11
Ultrasound should be performed where appropriate when breech
presentation is first diagnosed in labour.
The obstetrician available must make a decision, balancing the small
increase in maternal risk when the woman is not fasted and the
breech is low in the pelvis, against the risk to the fetus. These
decisions must include the informed wishes of the women.
Recommendation 12
If the fetus is in breech presentation during labour and is exhibiting
signsof fetal distress, it would be more appropriate to deliver by
caesarean section than undertake fetal blood sampling (FBS).
Grade
Consensus-based
recommendation
Grade
Consensus-based
recommendation
Appendices
Appendix A Committee details
i.
Committee membership
This RANZCOG statement has been reviewed by the Womens Health Committee and is
approved by the RANZCOG Board and Council.
Womens Health Committee members include:
Chair
Deputy Chair
(Obstetrics)
Deputy Chair
(Gynaecology)
Members
Chair of Indigenous
Womens Health
Committee
GP Obstetrics Advisory
Committee
Representative
Trainee Representative
Consumer
Representatives
Midwifery
Representative
Dr Louise Sterling
ii.
robust evidence was available but there was sufficient consensus within the
Womens Health Committee, consensus-based recommendations were developed
and are identifiable as such. Consensus-based recommendations were agreed to
by the entire committee. Good Practice Notes are highlighted throughout and
provide practical guidance to facilitate implementation. These were also developed
through consensus of the entire committee.
Recommendation
category and grade
Evidence-based
A
recommendation
B
C
D
Consensus-based
recommendation
Description
Body of evidence can be trusted to guide practice
Body of evidence can be trusted to guide practice
in most situations
Body of evidence provides some support for
recommendation(s) but care should be taken in its
application
The body of evidence is weak and the
recommendation must be applied with caution
Consensus-based recommendations based on
expert opinion where the available evidence was
inadequate or could not be applied in the
Australian and NZ healthcare context
Practical advice and information based on expert
opinion to aid in the implementation of the
statement
References
1. Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigol S, Willan AR. Planned
caesarean section versus planned vaginal birth for breech presentation at term: a
randomised multi-centre trial. Lancet 2000; 356: 1375-85.
2. Australias Mothers and Babies 2010. PERINATAL STATISTICS SERIES, Number 27.
Australian Institute of Health and Welfare. Canberra. 2010.
3. Whyte H et al., Outcomes of children at 2 years after planned caesarean birth versus
planned vaginal birth for breech presentation at term: The international randomised term
breech trial. Am J Obstet Gynecol 2004; 191: 864.
4. Goffinet F, Carayol M, Foidart J-M, Alexander S, Uzan S, Subtil D, Breart G. For the
PREMODA Study Group. Is planned vaginal delivery for breech presentation at term still an
option? Results of an observational prospective survey in France and Belgium. Am J
Obstet Gynecol 2006; 194: 1002-11.
5. Daviss B, et al., Evolving evidence since the term breech trial: Canadian response,
European dissent, and potential solutions. J Obstet Gynaecol Can 200; 32: 217.
6. Kotaska A. Inappropriate use of randomised trials to evaluate complex phenomena: Case
study of vaginal breech delivery. BMJ 2004; 329: 1029.
7. Lawson GW. The term breech trial ten years on: primum non nocere? Birth 2011; 39: 3.
8. Glezerman M. Five years to the term breech trial: The rise and fall of a randomised
controlled trial. Am J Obstet Gynecol 2006; 194: 20.
9. Rietberg CT, Elferink-Stinkens PM, Visser GHA. The effect of the Term Breech Trial on
medical intervention behaviour and neonatal outcome in the Netherlands: an analysis of
35,453 breech infants. BJOG 2005; 112: 205-9.
10. Hofmeyr GJ, Kulier R. External cephalic version for breech presentation at term. Cochrane
Database Syst Rev 2000.
11. National Health and Medical Research Council. NHMRC additional levels of evidence and
grades for recommendations for developers of guidelines. Canberra; 2009.
Links to other related College Statements
(C-Gen 2) Guidelines for consent and the provision of information regarding proposed treatment
http://www.ranzcog.edu.au/component/docman/doc_download/899-c-gen-02-guidelines-for-consent-and-theprovision-of-information-regarding-proposed-treatment-.html
Disclaimer
This College Statement is intended to provide general advice to Practitioners. The statement should never be relied on as a
substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient.
The statement has been prepared having regard to general circumstances. It is the responsibility of each Practitioner to have regard
to the particular circumstances of each case, and the application of this statement in each case. In particular, clinical management
must always be responsive to the needs of the individual patient and the particular circumstances of each case.
This College statement has been prepared having regard to the information available at the time of its preparation, and each
Practitioner must have regard to relevant information, research or material which may have been published or become available
subsequently.
Whilst the College endeavours to ensure that College statements are accurate and current at the time of their preparation, it takes no
responsibility for matters arising from changed circumstances or information or material that may have become available after the date
of the statements.