Revisiting the management of term breech presentation: a proposal for overcoming some of the controversies

Abstract

Background: The debate surrounding the management of term breech presentation has excessively focused on the mode of delivery. Indeed, a steady decline in the rate of vaginal breech delivery has been observed over the last three decades, and the soundness of the vaginal route was seriously challenged at the beginning of the 2000s. However, associations between adverse perinatal outcomes and antenatal risk factors have been observed in foetuses that remain in the breech presentation in late gestation, confirming older data and raising the question of the role of these antenatal risk factors in adverse perinatal outcomes. Thus, aspects beyond the mode of delivery must be considered regarding the awareness and adequate management of such situations in term breech pregnancies. Main body: In the context of the most recent meta-analysis and with the publication of large-scale epidemiologic studies from medical birth registries in countries that have not abruptly altered their criteria for individual decisionmaking regarding the breech delivery mode, the currently available data provide essential clues to understanding the underlying maternal-foetal conditions beyond the delivery mode that play a role in perinatal outcomes, such as foetal growth restriction and gestational diabetes mellitus. In view of such data, an accurate evaluation of these underlying conditions is necessary in cases of persistent term breech presentation. Timely breech detection, estimated foetal weight/growth curves and foetal/maternal well-being should be considered along with these possible antenatal risk factors; a thorough analysis of foetal presentation and an evaluation of the possible benefit of external cephalic version and pelvic adequacy in each specific situation of persistent breech presentation should be performed. Conclusion: The adequate management of term breech pregnancies requires screening and the efficient identification of breech presentation at 36 weeks of gestation, followed by thorough evaluations of foetal weight, growth and mobility, while obstetric history, antenatal gestational disorders and pelvis size/conformation are considered. The management plan, including external cephalic version and follow-up based on the maternal/foetal condition and potentially associated disorders, should be organized on a case-by-case basis by a skilled team after the woman is informed and helped to make a reasoned decision regarding delivery route.

Impact of Implementation of a Breech Clinic in a Tertiary Hospital.

“…This cannot be explained by differences in the maternal or labour characteristics between the two groups. However, breech presentation itself and not solely the mode of delivery appears to increase perinatal mortality and severe morbidity (30). In the PREMODA study, breech presentation was associated with increased perinatal mortality and severe morbidity with odds ratios of 1.60 (95% CI 1.14-2.17) in the planned vaginal delivery group and of 1.45…”

Combined Assessment of the Obstetrical Conjugate and Fetal Birth Weight Predicts Birth Mode Outcome in Vaginally Intended Breech Deliveries of Primiparous Women—A Frabat Study

“…In guidelines, birth weight restrictions apply and the role of pelvimetric measurements is stated as unclear [ 7 , 8 , 23 ]. Clinical management of breech presentation is evolving, considering the role of pelvic measurements [ 24 ]. Hoffmann et al document the importance of pelvic measurement in breech birth counseling [ 12 ].…”

Impact of implementation of a breech clinic in a tertiary hospital

“…This cannot be explained by differences in the maternal or labour characteristics between the two groups. However, breech presentation itself and not solely the mode of delivery appears to increase perinatal mortality and severe morbidity [ 30 ]. In the PREMODA study, breech presentation was associated with increased perinatal mortality and severe morbidity with odds ratios of 1.60 (95% CI 1.14–2.17) in the planned vaginal delivery group and of 1.45 (95% CI 1.16–1.81) in the planned C-section delivery group.…”