What is the best available evidence regarding the management of breech presentation? By Alexa McArthur RN RM MPHC
Clinical bottom line
Breech presentation occurs in 4 per cent of all singleton pregnancies, and as gestation increases, the proportion of breech presentation decreases. Only 3 per cent of term infants will present as breech, but at less than 28 weeks gestation, this will be as high as 30 per cent.1
There are a variety of factors for breech presentation, including uterine anomaly, nulliparity, previous breech birth, contracted pelvis, placenta praevia and prematurity.2 To promote breech presentation becoming cephalic before term, external cephalic version, moxibustion and postural management may be considered.1
• Evidence from a systematic review concluded that planned caesarean section for a breech presentation reduced perinatal or neonatal death or serious neonatal morbidity compared to planned vaginal breech birth. Planned caesarean section did however increase maternal morbidity, with increased abdominal pain reported. Other short-term complications may include haemorrhage, anaemia, blood transfusion or infection.2,3
• External cephalic version (ECV) – where the fetus is turned in either a forwards or backwards somersault by the application of pressure to the mother's abdomen – reduces the number of non-cephalic births by 60 per cent, and also decreases the caesarean section rate.1
• ECV performed before 37 weeks gestation does not decrease the rate of non-cephalic births.1
• Evidence supports the use of tocolytics (betamimetic drugs such as salbutamol, ritodrine) to increase the success rate of ECV after 37 weeks gestation.4
• Evidence suggests that the use of ultrasound factors such as posterior placental location, complete breech position and the amniotic fluid index may be useful in predicting the success rate of ECV.5
• There is insufficient evidence to support the use of moxibustion (an acupuncture technique that involves burning herbal preparations to stimulate the acupoint by the 5th toe), although it may be of some benefit in decreasing the need for ECV.3
• There is insufficient evidence to support the use of postural management (where a woman adopts different positions during pregnancy) to turn a fetus from breech to cephalic position.1
• For maintenance of expertise in vaginal breech birth skills for health professionals, local training programs are important to maintain acceptable skill levels.3
Best practice recommendations
• Women with an uncomplicated singleton breech presentation at 37 weeks gestation should be offered external cephalic version. This should not be offered to women in labour, or those who have a uterine scar or abnormality, ruptured membranes, any evidence of fetal compromise or any vaginal bleeding. The use of tocolytics, ultrasound and moxibustion may be useful in assisting this process.
• Women at term with an uncomplicated singleton breech presentation, who have had an unsuccessful external cephalic version attempted, or it is contra-indicated, should be offered a caesarean section. After an informed discussion about the risks and benefits to her and her baby, women may choose whether they want a vaginal or caesarean birth. This will also be influenced by the local facilities available, and level of health care expertise.
1. National Institute for Health and Clinical Excellence. Caesarean Section. 2004.
2. Hofmeyr GJ, Hannah M. Planned caesarean section for term breech delivery. Cochrane Database Syst Rev. 2003:2.
3. New Zealand Guidelines Group (NZGG). Care of women with breech presentation or previous caesarean birth. New Zealand Guidelines Group. 2004.
4. Hofmeyr GJ, Gyte GML. Interventions to help external cephalic version for breech presentation at term. Cochrane Database Syst Rev. 2004:1.
5. Kok M, Cnossen J, Gravendeel L, Van Der Post JA, Mols BW. Ultrasound factors to predict the outcome of external cephalic version: a meta-analysis. Ultrasound Obstet Gynecol 2009; 33:76-84.
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