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

helpful.15,16
ECV has been introduced successfully into practice in the UK. 17 Although the success rate (conversion to
cephalic presentation) found in this study (46%) is less than that quoted in some (e.g. over 80% in Africa 18),
generalisation of these results in the UK would result in a significant reduction in the numbers of caesarean
sections. With case selection it is possible to achieve higher success rates and operators improve with
experience.19 Among published USA studies, an overall success rate of 65% was found (and 97.5% of these
remained cephalic after ECV).18
A number of factors have been found to increase the likelihood of successful ECV. These include multiparity,
adequate liquor volume and a station of the breech above the pelvic brim. 20,21 Although primarily intended for
the management of the uncomplicated breech pregnancy at term, ECV has also been carried out
successfully after previous caesarean section20,22 and during early labour.7
There is insufficient evidence to support the use of regional anaesthesia to facilitate ECV.23
Various interventions for improving the success rate of ECV have been suggested. 12 Neither
vibroacoustic stimulation nor amnioinfusion has been proven to be effective in controlled trials and
each requires further evaluation. Following the first observational series examining the
effectiveness of epidurals on the safety and success of ECV 24, two small RCTs have studied the
use of regional anaesthesia for a first attempt at ECV.25,26 In the first study,25 the success rate in
the epidural group was 69% (24/35), which was significantly different to the rate of 32% (11/34) in
the control group. In a study from Hawaii, 26 the results were similar: the success rate in the
epidural group was 59% (32/54), compared with 33% (18/45) in the control group. Two groups Evidence
Level
have reported the success rate associated with epidural anaesthesia after failed conventional Ib
ECV.27,28 In these small studies the success rates increased from 57% to 75% and from 60% to
71%, respectively. A study of spinal anaesthesia has now been published, which does not support
improved outcome with regional anaesthesia.23 No adverse effects on the mother or fetus have
been reported. In addition, an economic analysis has suggested that with epidural use 'in
institutions where caesarean sections are systematically performed for breech presentations,
substantial cost-savings are possible'.27 However, no studies have reported any outcomes related
to maternal satisfaction, or quality of life. Further research in this area is required.
4. 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.
The management of breech pregnancy at term was reviewed in 1993. 2 In the two small
randomised trials published by then, which compared elective caesarean section and planned
vaginal delivery, no differences in mortality between the groups were seen, but an increase in
short-term morbidity was noted in those babies delivered vaginally. 29 Much of the remaining
evidence supporting elective caesarean section comprised hospital audit, 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. 30,31 Against this background, Ib
the Canadian MRC funded an international multicentre RCT of planned vaginal delivery versus
planned elective caesarean section for the uncomplicated term breech. The Term Breech trial was
stopped early in April 2000 because it confirmed that vaginal delivery is indeed more hazardous
than elective caesarean section.32 The overall risk of perinatal death for the term frank/complete
breech fetus with planned caesarean birth was reduced by 75% (RR 0.23; CI 0.07-0.8).
A subanalysis was undertaken after excluding the following cases: deliveries that occurred after a
prolonged labour, labours that were induced or augmented with oxytocin or prostaglandins, cases
where there was a footling or uncertain type of breech presentation at delivery, and those cases
for whom there was no skilled or experienced clinician present at the birth. In this subanalysis, the
risk of the combined outcome of perinatal mortality, neonatal mortality or serious neonatal
morbidity with planned caesarean section compared with planned vaginal birth was 16/1006 Evidence
(1.6%) compared with 23/704 (3.3%) (RR 0.49; CI 0.26-0.91); P = 0.02). In a further subanalysis, 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). The findings suggested that
the benefits of delivery by caesarean section were not as significant in countries with a higher
perinatal mortality rate. Conversely, they became even more significant in countries with a low
perinatal mortality rate.33 There were no differences between groups in terms of maternal mortality
or serious early maternal morbidity.
It should be noted that this study has not evaluated long-term outcomes for child or mother. A
number of other important questions were raised in subsequently published correspondence in
The Lancet.34 Although it is possible that careful exclusion of growth restricted infants, better
intrapartum monitoring, full pelvimetry and umbilical cord assessment might have improved the Evidence
Level
prospects for a vaginal breech delivery,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'. This finding should be disseminated to pregnant women, their families, and all
clinicians involved in maternity care.33
It has been suggested that the Term Breech trial, by reflecting conventional 'expert' views, sanctioned the
conventional dorsal lithotomy position for delivery, and thereby missed an opportunity to evaluate labour and

delivery in upright positions (considered by some to be physiologically and anatomically more sound). 35
Clearly, 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).
It remains important that clinicians and hospitals are prepared for vaginal breech delivery
4.1 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.
Important issues to consider when planning a vaginal birth are the careful selection of patients, Evidence
appropriate intrapartum management and the skill, experience and judgements of the intrapartum Level
III
attendant.
A trial of vaginal breech delivery is more likely to be successful if both mother and baby are of
normal proportions.36,37 The presentation should be either frank (hips flexed, knees extended) or
complete (hips flexed, knees flexed but feet not below the fetal buttocks). There should be no
evidence of fetopelvic disproportion with a clinically 'adequate' pelvis. Clinical judgement is
adequate and pelvimetry need not be used routinely.38 Although X-ray pelvimetry has figured
prominently in protocols for planned vaginal birth, 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. 37 In a subanalysis of the Term Breech trial the III
use of radiological pelvimetry was not linked to improved outcome. There should be no evidence
of hyperextension of the fetal head. 37,39 Ophir et al.40 offered 66% of patients with a previous
caesarean section a trial of labour, of whom 79% delivered their breech infants vaginally. 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.37
4.2 Intrapartum management
There is no evidence that epidural analgesia is essential and, in selected cases, induction or
augmentation may be justified. Fetal blood sampling from the buttocks provides an accurate
assessment of the acid-base status, when the fetal heart rate trace is suspect.
In the Canadian consensus of breech management at term, 37 further guidelines on intrapartum
management were drawn up. Careful monitoring of fetal wellbeing and progress of labour were
emphasised. There is no evidence that epidural analgesia is essential and, in selected cases,
induction or augmentation may be justified. Fetal blood sampling from the buttocks provides an
accurate assessment of the acid-base status, when the fetal heart rate trace is suspect. 41 In the
Term Breech trial, the most common reasons for emergency caesarean section were 'failure to
progress' (50%) and 'fetal distress' (29%). In the seventh Annual Report of the Confidential Evidence
Enquiry into Stillbirth and Deaths in Infancy,42 the single and most avoidable factor in causing Level
breech stillbirths and death among breech babies was suboptimal care in labour. In cases where IV
the cardiotocograph was available for review, there was clinical evidence of hypoxia in all but one
case before delivery, and delays in staff response to fetal compromise occurred in nearly threequarters of cases. These delays ranged from 30 minutes to ten hours. Consultants were informed
in only half of these cases before delivery. Clinical inexperience at the time of delivery
exacerbated the risk for an already hypoxic baby in some cases. Trauma was the sole cause of
death in only one case.
To facilitate delivery of the head an episiotomy is often performed. In about 20% of cases forceps
are used.32 Although much emphasis is placed on adequate case selection prior to labour, Evidence
Level
assessment of the undiagnosed breech in labour by experienced medical staff can allow safe III
43
vaginal delivery.
4.3 Training: skill, 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.
Over the last ten years there have been major changes in the management of breech pregnancies and the
organisation of junior doctors' work patterns. There are already a reduced number of vaginal breech
deliveries managed by an increased number of trainees, who do fewer hours. On reviewing trainee logbooks
from one busy district general hospital (1987 and 1997), it appears that there has been a ten-fold reduction in
vaginal breech delivery experience for UK registrars. Clearly, the numbers of vaginal breech deliveries will
fall further following the Term Breech trial. Alternative methods of training urgently need to be introduced (e.g.
videos, models and scenario teaching). 44-46
5. Management of the preterm breech and twin breech

ECV before term has not been shown to offer any benefits.
Evidence from the Term Breech trial cannot be directly extrapolated to preterm breech delivery,
which remains an area of clinical controversy.4748 ECV before term has not been shown to offer
any benefits.49 However, 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.
Although the majority of obstetricians will use caesarean section for the uncomplicated preterm
breech, only a minority believe that there is sufficient evidence to justify this policy. 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. 50 This is
acknowledged in some reports.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. He felt that the data 'are not sufficient to justify a policy of elective caesarean section'. In the
absence of good evidence that a preterm baby needs to be delivered by caesarean section, the
decision about the mode of delivery should be made after close consultation with the labouring
woman and her partner.48

There is insufficient evidence to support caesarean section for the delivery of the first or
second twin.
The main problems with vaginal breech delivery in the Term Breech trial related to fetal distress in
labour and difficult delivery. However, the trial only included singleton pregnancies. It can be
argued that a twin breech is different. Twins are smaller than singletons and continuous electronic
fetal monitoring in labour is standard practice. Nevertheless, the plan for delivery will need careful
consideration and full discussion with the parents.
Although many clinicians choose caesarean section when the first twin presents as a breech,
because of concern about 'interlocking', this complication is extremely rare. Cohen et al. 54
reported 'interlocking' occurring only once in 817 twin pregnancies. Oettinger and et al. 55
compared the outcome of breech presenting twins over two time periods where the caesarean Evidence
section rate increased from 21% to almost 95%, and found no change in neonatal morbidity or Level
mortality. They did, however, find an increase in maternal mortality in association with a III
caesarean section delivery. If the second twin is non-vertex (which occurs in about 40% of twins),
vaginal delivery is considered safe. Rabinovici et al. 56 carried out a randomised study of twin
deliveries where the second twins presentation was non-vertex. Although the study only included
60 twins, the results showed no difference in five-minute Apgar scores or in any other indices in
neonatal morbidity between the two groups.
There are other non-randomised reports on the safety of vaginal delivery for non-vertex second
twin. Laros57 had no fetal losses in either group of second twins with 74 being delivered by
caesarean and 76 delivered vaginally.
6. Documentation
It is essential that all details of care are clearly documented, including the identity of all those involved in the
procedures.
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Clinical guidelines are: 'systematically developed statements which assist clinicians and patients in making
decisions about appropriate treatment for specific conditions'. Each guideline is systematically developed
using a standardised methodology. 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.rcog.org.uk/clingov1). These recommendations are not intended to dictate an exclusive course of
management or treatment. They must be evaluated with reference to individual patient needs, resources and
limitations unique to the institution and variations in local populations. It is hoped that this process of local
ownership will help to incorporate these guidelines into routine practice. Attention is drawn to areas of clinical
uncertainty where further research may be indicated.
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.
Classification of evidence levels
Ia
Evidence obtained from meta-analysis of randomised controlled trials.
Ib
Evidence obtained from at least one randomised controlled trial.
IIa
Evidence obtained from at least one well-designed controlled study without randomisation.
IIb
Evidence obtained from at least one other type of well-designed quasi-experimental study.
III
Evidence obtained from well-designed non-experimental descriptive studies, such as comparative
studies, correlation studies and case studies.
IV
Evidence obtained from expert committee reports or opinions and/or clinical experience of respected
authorities.
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, Ib).
Requires the availability of well-controlled clinical studies but no randomised clinical trials on the topic
of recommendations (Evidence levels IIa, IIb, III).
Requires evidence obtained from expert committee reports or opinions and/or clinical experiences of
respected authorities. Indicates an absence of directly applicable clinical studies of good quality
(evidence level IV).
Good practice point
Recommended best practice based on the clinical experience of the guideline development group.
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, 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.