Mauriceau Maneuver Illustration Essay

Management of Breech Presentation

This is the fourth edition of this guideline originally published in 1999 and revised in 2001 and 2006 under the same title.

Executive summary of recommendations

What information should be given to women with breech presentation at term?

Women with a breech presentation at term should be offered external cephalic version (ECV) unless there is an absolute contraindication. They should be advised on the risks and benefits of ECV and the implications for mode of delivery. [New 2017]

Grade of recommendation: A

Women who have a breech presentation at term following an unsuccessful or declined offer of ECV should be counselled on the risks and benefits of planned vaginal breech delivery versus planned caesarean section.

Grade of recommendation: ✓

What information about the baby should be given to women with breech presentation at term regarding mode of delivery?

Women should be informed that planned caesarean section leads to a small reduction in perinatal mortality compared with planned vaginal breech delivery. Any decision to perform a caesarean section needs to be balanced against the potential adverse consequences that may result from this.

Grade of recommendation: A

Women should be informed that the reduced risk is due to three factors: the avoidance of stillbirth after 39 weeks of gestation, the avoidance of intrapartum risks and the risks of vaginal breech birth, and that only the last is unique to a breech baby. [New 2017]

Grade of recommendation: B

Women should be informed that when planning delivery for a breech baby, the risk of perinatal mortality is approximately 0.5/1000 with caesarean section after 39+0 weeks of gestation; and approximately 2.0/1000 with planned vaginal breech birth. This compares to approximately 1.0/1000 with planned cephalic birth.

Grade of recommendation: C

Selection of appropriate pregnancies and skilled intrapartum care may allow planned vaginal breech birth to be nearly as safe as planned vaginal cephalic birth. [New 2017]

Grade of recommendation: C

Women should be informed that planned vaginal breech birth increases the risk of low Apgar scores and serious short-term complications, but has not been shown to increase the risk of long-term morbidity. [New 2017]

Grade of recommendation: B

Clinicians should counsel women in an unbiased way that ensures a proper understanding of the absolute as well as relative risks of their different options. [New 2017]

Grade of recommendation: ✓

What information should women having breech births be given about their own immediate and future health?

Women should be informed that planned caesarean section for breech presentation at term carries a small increase in immediate complications for the mother compared with planned vaginal birth.

Grade of recommendation: A

Women should be informed that maternal complications are least with successful vaginal birth; planned caesarean section carries a higher risk, but the risk is highest with emergency caesarean section which is needed in approximately 40% of women planning a vaginal breech birth. [New 2017]

Grade of recommendation: B

Women should be informed that caesarean section increases the risk of complications in future pregnancy, including the risks of opting for vaginal birth after caesarean section, the increased risk of complications at repeat caesarean section and the risk of an abnormally invasive placenta. [New 2017]

Grade of recommendation: B

Women should be given an individualised assessment of the long-term risks of caesarean section based on their individual risk profile and reproductive intentions, and counselled accordingly. [New 2017]

Grade of recommendation: ✓

What information should women having breech births be given about the health of their future babies?

Women should be informed that caesarean section has been associated with a small increase in the risk of stillbirth for subsequent babies although this may not be causal. [New 2017]

Grade of recommendation: C

What factors affect the safety of vaginal breech delivery?

Antenatal assessment

Following the diagnosis of persistent breech presentation, women should be assessed for risk factors for a poorer outcome in planned vaginal breech birth. If any risk factor is identified, women should be counselled that planned vaginal birth is likely to be associated with increased perinatal risk and that delivery by caesarean section is recommended. [New 2017]

Grade of recommendation: ✓

Women should be informed that a higher risk planned vaginal breech birth is expected where there are independent indications for caesarean section and in the following circumstances:

Grade of recommendation: C

  • Hyperextended neck on ultrasound.
  • High estimated fetal weight (more than 3.8 kg).
  • Low estimated weight (less than tenth centile).
  • Footling presentation.
  • Evidence of antenatal fetal compromise. [New 2017]

The role of pelvimetry is unclear. [New 2017]

Grade of recommendation: C

Skill and experience of birth attendant

The presence of a skilled birth attendant is essential for safe vaginal breech birth.

Grade of recommendation: C

Units with limited access to experienced personnel should inform women that vaginal breech birth is likely to be associated with greater risk and offer antenatal referral to a unit where skill levels and experience are greater. [New 2017]

Grade of recommendation: ✓

Intrapartum assessment and management of women presenting unplanned with breech presentation in labour

Where a woman presents with an unplanned vaginal breech labour, management should depend on the stage of labour, whether factors associated with increased complications are found, availability of appropriate clinical expertise and informed consent. [New 2017]

Grade of recommendation: C

Women near or in active second stage of labour should not be routinely offered caesarean section. [New 2017]

Grade of recommendation: ✓

Where time and circumstances permit, the position of the fetal neck and legs, and the fetal weight should be estimated using ultrasound, and the woman counselled as with planned vaginal breech birth. [New 2017]

Grade of recommendation: ✓

All maternity units must be able to provide skilled supervision for vaginal breech birth where a woman is admitted in advanced labour and protocols for this eventuality should be developed. [New 2017]

Grade of recommendation: ✓

What is appropriate intrapartum management of the term breech?

Are induction and augmentation appropriate?

Women should be informed that induction of labour is not usually recommended. Augmentation of slow progress with oxytocin should only be considered if the contraction frequency is low in the presence of epidural analgesia. [New 2017]

Grade of recommendation: D

What is the role of epidural analgesia?

Women should be informed that the effect of epidural analgesia on the success of vaginal breech birth is unclear, but that it is likely to increase the risk of intervention. [New 2017]

Grade of recommendation: ✓

What fetal monitoring should be recommended?

Women should be informed that while evidence is lacking, continuous electronic fetal monitoring may lead to improved neonatal outcomes. [New 2017]

Grade of recommendation: D

Where should vaginal breech birth take place?

Birth in a hospital with facilities for immediate caesarean section should be recommended with planned vaginal breech birth, but birth in an operating theatre is not routinely recommended.

Grade of recommendation: D

What guidelines should be in place for the management of breech birth?

Women should be informed that adherence to a protocol for management reduces the chances of early neonatal morbidity. [New 2017]

Grade of recommendation: C

The essential components of planned vaginal breech birth are appropriate case selection, management according to a strict protocol and the availability of skilled attendants. [New 2017]

Grade of recommendation: ✓

Management of the first stage and passive second stage

Adequate descent of the breech in the passive second stage is a prerequisite for encouragement of the active second stage. [New 2017]

Grade of recommendation: D

What position should the woman be in for delivery during a vaginal breech birth?

Either a semirecumbent or an all-fours position may be adopted for delivery and should depend on maternal preference and the experience of the attendant. If the latter position is used, women should be advised that recourse to the semirecumbent position may become necessary. [New 2017]

Grade of recommendation: ✓

What are the principles for the management of active second stage and vaginal breech birth?

Assistance, without traction, is required if there is delay or evidence of poor fetal condition. [New 2017]

Grade of recommendation: ✓

All obstetricians and midwives should be familiar with the techniques that can be used to assist vaginal breech birth. The choice of manoeuvres used, if required to assist with delivery of the breech, should depend on the individual experience/preference of the attending doctor or midwife. [New 2017]

Grade of recommendation: ✓

Management of the preterm breech

How should preterm singleton babies in breech presentation be delivered?

Women should be informed that routine caesarean section for breech presentation in spontaneous preterm labour is not recommended. The mode of delivery should be individualised based on the stage of labour, type of breech presentation, fetal wellbeing and availability of an operator skilled in vaginal breech delivery.

Grade of recommendation: C

Women should be informed that caesarean section for breech presentation in spontaneous preterm labour at the threshold of viability (22–25+6 weeks of gestation) is not routinely recommended.

Grade of recommendation: C

Women should be informed that planned caesarean section is recommended for preterm breech presentation where delivery is planned due to maternal and/or fetal compromise. [New 2017]

Grade of recommendation: ✓

How should labour with a singleton preterm breech be managed?

Labour with a preterm breech should be managed as with a term breech. [New 2017]

Grade of recommendation: C

Where there is head entrapment, incisions in the cervix (vaginal birth) or vertical uterine incision extension (caesarean section) may be used, with or without tocolysis.

Grade of recommendation: D

Management of the twin pregnancy with a breech presentation

How should a first twin in breech presentation be delivered?

Women should be informed that the evidence is limited, but that planned caesarean section for a twin pregnancy where the presenting twin is breech is recommended. [New 2017]

Grade of recommendation: C

Routine emergency caesarean section for a breech first twin in spontaneous labour, however, is not recommended. The mode of delivery should be individualised based on cervical dilatation, station of the presenting part, type of breech presentation, fetal wellbeing and availability of an operator skilled in vaginal breech delivery. [New 2017]

Grade of recommendation: C

How should a second twin in breech presentation be delivered?

Routine caesarean section for breech presentation of the second twin is not recommended in either term or preterm deliveries.

Grade of recommendation: B

What organisational and governance arrangements should be in place to support a routine vaginal breech delivery service?

Simulation equipment should be used to rehearse the skills that are needed during vaginal breech birth by all doctors and midwives.

Grade of recommendation: ✓

Guidance for the case selection and management of vaginal breech birth should be developed in each department by the healthcare professionals who supervise such births. Adherence to the guidelines is recommended to reduce the risk of intrapartum complications. [New 2017]

Grade of recommendation: C

Departments should consider developing a checklist to ensure comprehensive counselling of the woman regarding planned mode of delivery for babies presenting by the breech. [New 2017]

Grade of recommendation: ✓

1 Purpose and scope

The aim of this guideline is to provide up-to-date information on the modes of delivery for women with breech presentation. The scope is confined to decision making regarding the route of delivery and choice of various techniques used during delivery. It does not include antenatal or postnatal care. External cephalic version (ECV) is the topic of the separate Royal College of Obstetricians and Gynaecologists (RCOG) Green-top Guideline No. 20a: External Cephalic Version and Reducing the Incidence of Term Breech Presentation.[1]

2 Introduction and background epidemiology

Breech presentation occurs in 3–4% of term deliveries and is more common preterm. It is associated with uterine and congenital abnormalities, has a significant recurrence risk and is more common in nulliparous women.[2] Term babies presenting by the breech have worse outcomes than cephalic ones, irrespective of the mode of delivery.[3]

Publication of the Term Breech Trial (TBT)[4] was followed by a large reduction in the incidence of planned vaginal birth. Nevertheless, vaginal breech births will continue, not merely because of failure to detect breech presentation and the limitations of ECV, but for reasons of maternal choice. Lack of experience has led to a loss of skills essential for these deliveries. Conversely, caesarean section can have serious long-term consequences.

3 Identification and assessment of evidence

This guideline was developed using standard methodology for developing RCOG Green-top Guidelines. The Cochrane Library (including the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects [DARE] and the Cochrane Central Register of Controlled Trials [CENTRAL]), EMBASE, MEDLINE and Trip were searched for relevant papers. The search was inclusive of all relevant articles published between August 2005 and April 2016. The databases were searched using the relevant Medical Subject Headings (MeSH) terms, including all subheadings and synonyms, and this was combined with a keyword search. Search terms included ‘breech’, ‘breech near presentation’, ‘breech presentation’, ‘breech near delivery’, ‘breech delivery’, ‘breech presentation and delivery’, ‘breech near extraction’, ‘breech extraction’, ‘Mauriceau-Smellie-Veit’, ‘Burns-Marshall’, ‘after-coming head’ and ‘external cephalic version’. The search was limited to studies on humans and papers in the English language. Relevant guidelines were also searched for using the same criteria in the National Guideline Clearinghouse and the National Institute for Health and Care Excellence (NICE) Evidence Search.

Where possible, recommendations are based on available evidence. Areas lacking evidence are highlighted and annotated as ‘good practice points’. Further information about the assessment of evidence and the grading of recommendations may be found in Appendix I.

4 What information should be given to women with breech presentation at term?

Women with a breech presentation at term should be offered ECV unless there is an absolute contraindication. They should be advised on the risks and benefits of ECV and the implications for mode of delivery.

Grade of recommendation: A

Women who have a breech presentation at term following an unsuccessful or declined offer of ECV should be counselled on the risks and benefits of planned vaginal breech delivery versus planned caesarean section.

Grade of recommendation: ✓

Please refer to the RCOG Green-top Guideline No. 20a: External Cephalic Version and Reducing the Incidence of Term Breech Presentation.[1]

4.1 What information about the baby should be given to women with breech presentation at term regarding mode of delivery?

Women should be informed that planned caesarean section leads to a small reduction in perinatal mortality compared with planned vaginal breech delivery. Any decision to perform a caesarean section needs to be balanced against the potential adverse consequences that may result from this.

Grade of recommendation: A

Women should be informed that the reduced risk is due to three factors: the avoidance of stillbirth after 39 weeks of gestation, the avoidance of intrapartum risks and the risks of vaginal breech birth, and that only the last is unique to a breech baby.

Grade of recommendation: B

Women should be informed that when planning delivery for a breech baby, the risk of perinatal mortality is approximately 0.5/1000 with caesarean section after 39+0 weeks of gestation; and approximately 2.0/1000 with planned vaginal breech birth. This compares to approximately 1.0/1000 with planned cephalic birth.

Grade of recommendation: C

Selection of appropriate pregnancies and skilled intrapartum care may allow planned vaginal breech birth to be nearly as safe as planned vaginal cephalic birth.

Grade of recommendation: C

Women should be informed that planned vaginal breech birth increases the risk of low Apgar scores and serious short-term complications, but has not been shown to increase the risk of long-term morbidity.

Grade of recommendation: B

Clinicians should counsel women in an unbiased way that ensures a proper understanding of the absolute as well as relative risks of their different options.

Grade of recommendation: ✓

Observational, usually retrospective, series have consistently favoured elective caesarean birth over vaginal breech delivery. A meta-analysis of 27 studies examining term breech birth,[5] which included 258 953 births between 1993 and 2014, suggested that elective caesarean section was associated with a two- to five-fold reduction in perinatal mortality when compared with vaginal breech delivery although the absolute risk of perinatal mortality with vaginal delivery was 3/1000. This meta-analysis is limited by the retrospective nature of many of the studies and the absence of complete intention to treat analysis. The increased practice of caesarean section accounts for only a small proportion (16%) of the decline in delivery-related perinatal death.[6]Evidence level 2++

The TBT[4] randomised 2088 women to either planned caesarean section or planned vaginal birth at 121 centres in 26 countries. This trial was by far the major contributor to the Cochrane Review[7] which demonstrated a reduction in perinatal mortality with planned caesarean section (RR 0.29, 95% CI 0.10–0.86) from 1.3 to 0.3%. This trial also reported a reduction in the composite outcome of serious neonatal morbidity (RR 0.36, 95% CI 0.19–0.65). A number of subanalyses examining operator experience, prolonged labour or augmentation, and national (high or low) perinatal mortality rates failed to identify a group for whom morbidity was not increased with planned vaginal delivery although they were underpowered to assess mortality rates.

A 2-year follow-up of 923 out of 1159 children from the TBT[8] showed no difference in ‘death or neurodevelopmental delay’ (RR 1.09, 95% CI 0.52–2.30). This renders the morbidity, but not mortality, findings (and therefore the ‘intention to treat’ analysis in the original trial paper) less important.

Evidence level 1+
The TBT led to wide-scale elective caesarean section for breech presentation, with a corresponding reduction in perinatal mortality.[9] However, criticism of the trial followed,[10-12] particularly regarding case selection and intrapartum management. For instance, 31% had no ultrasound (to exclude an extended neck), growth-restricted babies were included and a few women were randomised in violation of the protocol and included in the ‘intention to treat’ analysis. A senior obstetrician was absent from 31.9% of births and any obstetrician was absent from 13% of births in the planned vaginal delivery group. Electronic fetal monitoring (EFM) was not used in most and prolonged active second stage was not prohibited which, when it occurred, was associated with increased morbidity.[13] ‘Serious’ neonatal morbidity encompassed some frequently benign outcomes and was twice as common in countries with a low perinatal mortality rate (5.1% versus 2.5%). Both short-term morbidity and mortality (1.3%) in the planned vaginal delivery group were higher than subsequent series have reported.[14, 15] Glezerman,[10] commenting on analysis by Su et al.,[13] argued that in only 16 of the 69 neonates with the primary composite outcome could this be related to mode of delivery. However, while some of the deaths may not be attributable to the vaginal breech birth, it is still reasonable to assume some would not have happened if a caesarean section had been performed at 39 weeks of gestation. This highlights a fundamental issue: by eliminating the last 1–3 weeks of pregnancy and labour, the perinatal death of at least 1/1000 babies,[16] cephalic or breech, could be prevented.Evidence level 2+
The limitations of the TBT meant planned vaginal breech birth continued, notably in Scandinavia, France and the Netherlands. As a result, further mortality and short-term morbidity data have become available. Vlemmix et al.[15] published a population-based cohort study of 58 320 nonanomalous term babies presenting by the breech delivered between 1997 and 2007 from the Netherlands Perinatal Registry, evaluating the effect of increased elective caesarean following the TBT. The perinatal mortality of babies presenting by the breech halved from 0.13 to 0.07% (OR 0.51, 95% CI 0.28–0.93). For planned vaginal breech birth, however, it remained stable (OR 0.96, 95% CI 0.52–1.76). More importantly, the perinatal mortality was 0.16% in the planned vaginal birth group and 0% in the elective caesarean section group (P < 0.0001) post publication of the TBT report although this mortality rate with vaginal delivery was notably lower than that reported in the TBT (0.16% versus 1.3%). Elective caesarean also reduced the risk of low Apgar scores (less than 7 at 5 minutes; OR 0.12, 95% CI 0.09–0.16) and neonatal ‘trauma’ (OR 0.24, 95% CI 0.15–0.37) compared with planned vaginal birth. The differences in mortality and morbidity persisted among different birth weights, with parity and with type of breech. The authors estimated that 338 additional caesarean sections were performed for each perinatal death prevented.Evidence level 2++
More strict selection and management protocols than those employed in the TBT have been employed in smaller retrospective studies from individual institutions. These have limited statistical power to detect an effect on mortality, but most report reassuring results.[17-21] Indeed, the lower rates of short-term morbidity compared with those reported in either the TBT or the Dutch study[4, 15] suggest that although evidence for the individual components is poor, the selection and management criteria employed were beneficial. They might, therefore, reasonably be expected to improve mortality.Evidence level 3
Examining the effect of more strict selection and management was the intention of the much larger PREMODA study.[14] The outcomes of 2526 planned vaginal breech deliveries were compared with 5579 planned caesarean deliveries in 174 units in France and Belgium over a 12-month period. The strict criteria included ‘normal’ (definition unstated) radiological pelvimetry which was performed in 82.5% of planned vaginal births, continuous EFM and routine ultrasound. As with the TBT,[4] induction or augmentation with oxytocin was allowed. Only 0.2% had an active second stage of more than 60 minutes, while 18.1% had a passive second stage (60 minutes or longer) compared with 5 and 3.1%, respectively, in the TBT.[4] Only 3.8% of vaginal deliveries had ‘failed to progress’ for more than 2 hours. Outcomes were analysed for neonates with no lethal congenital abnormality. In the planned vaginal delivery group, of whom 79% delivered vaginally, there were two deaths (0.08%); in the planned caesarean group, of whom 0.16% delivered vaginally, there were seven deaths (0.12%) (OR 0.64, 95% CI 0.13–3.06). Planned vaginal birth showed significant increases in Apgar scores of less than 7 at 5 minutes (OR 3.20, 95% CI 1.93–5.3) and total injuries, most of which were clavicular fractures or haematomata (OR 3.90, 95% CI 2.40–6.34). However, there was no difference in neonatal unit admissions (OR 1.33, 95% CI 0.94–1.86), or a composite measure of mortality or serious neonatal morbidity (OR 1.10, 95% CI 0.75–0.61). This remained after adjustment for other factors associated with this outcome (adjusted OR 1.40, 95% CI 0.89–2.23). The absolute risks for a 5-minute Apgar score of less than 7 (1.3%) and for perinatal mortality (0.08%) compared favourably to both the TBT and the Dutch cohort study.[4, 15]Evidence level 2++
Although data were collected prospectively in each centre, participants were not registered at inclusion, potentially enabling accusations of bias; furthermore, classification regarding the intended mode of delivery was made retrospectively. In addition, demographic differences existed between the two groups: notably, the planned vaginal birth babies were smaller. The study does not enable an accurate comparison of planned caesarean with breech birth; with a later gestation at planned vaginal birth but all babies alive at inclusion, it examines the effect of strictly managed labour more than the effect of planned elective caesarean delivery after 39+0 weeks of gestation.Evidence level 2++
Elective caesarean section exerts a protective effect on perinatal mortality, as well as short-term, but probably not long-term, morbidity[8] although the effect is smaller than suggested by the TBT. Some of the risk is due to the earlier gestation at which elective caesarean section is performed, while some is due to the elimination of labour which, even for a cephalic baby, can lead to mortality. The excess risk of breech compared with cephalic labour is relatively small (1/1000), and implementation of strict selection and intrapartum management criteria, together with skilled support, may reduce it further.[14] Perinatal mortality is also slightly increased by vaginal birth after caesarean section (VBAC), which nevertheless remains a common option.[22] Any benefit from elective caesarean section must be viewed in the light of the small increase in complications associated with subsequent pregnancies. Furthermore, caesarean birth has been associated with long-term health issues in the offspring.[23]Evidence level 2+

4.2 What information should women having breech births be given about their own immediate and future health?

Women should be informed that planned caesarean section for breech presentation at term carries a small increase in immediate complications for the mother compared with planned vaginal birth.

Grade of recommendation: A

Women should be informed that maternal complications are least with successful vaginal birth; planned caesarean section carries a higher risk, but the risk is highest with emergency caesarean section which is needed in approximately 40% of women planning a vaginal breech birth.

Grade of recommendation: B

Women should be informed that caesarean section increases the risk of complications in future pregnancy, including the risks of opting for VBAC, the increased risk of complications at repeat caesarean section and the risk of an abnormally invasive placenta.

Grade of recommendation: B

Women should be given an individualised assessment of the long-term risks of caesarean section based on their individual risk profile and reproductive intentions, and counselled accordingly.

Grade of recommendation: ✓

Maternal outcomes, particularly short term, depend on the category of lower segment caesarean section, with emergency carrying a higher risk than elective. Emergency caesarean section rates with planned vaginal birth vary from 29%[14] to 45%.[15]Evidence level 2+
A modest short-term increase in maternal morbidity (RR 1.29, 95% CI 1.03–1.61) is reported with planned caesarean section in a meta-analysis of randomised controlled trials.[7] Longer term morbidity in the TBT was similar[24] although other risks have been documented. The risks associated with caesarean section are documented in the RCOG patient information leaflet: Choosing to have a caesarean section.[23]Evidence level 1+

For subsequent pregnancies, having had a planned caesarean (compared with planned vaginal) birth causes a three-fold increase in uterine scarring; more than half of all women with at least one prior caesarean section have another.[25] The risks of blood transfusion, endometritis, hysterectomy and death are increased in women with a previous caesarean section (irrespective of whether they attempt a VBAC) when compared with those who have previously delivered vaginally.[22] The risk of scar rupture during attempted vaginal birth after one caesarean section is approximately 0.5%.[22, 26, 27] In developing countries, particularly where birth outside hospital is usual and access to healthcare is poor, the effect on maternal outcomes is likely to be considerably greater.[28]

A further maternal issue is that of placenta praevia and placenta accreta,[29] or abnormally invasive placentation, for which prior caesarean delivery is the principal risk factor. The risk of abnormally invasive placentation increases from 0.31% with one prior caesarean section to 2.33% with four[30] and the incidence is rising. The risk is higher after elective compared with emergency caesarean section.[31] This complication can lead to massive haemorrhage, hysterectomy, urinary tract injury and maternal death.

Evidence level 2+

4.3 What information should women having breech births be given about the health of their future babies?

Women should be informed that caesarean section has been associated with a small increase in the risk of stillbirth for subsequent babies although this may not be causal.

Grade of recommendation: C

In a systematic review and meta-analysis, O'Neill et al.[32] compared the risk of stillbirth and miscarriage in a subsequent pregnancy with a previous caesarean or vaginal delivery. Examining data from 1 961 829 pregnancies and 7308 events, they reported an increase in the risk of all stillbirths and unexplained stillbirths (OR 1.47, 95% CI 1.20–1.80). These findings have been disputed:[33] the indication for the caesarean may account for the increase.

Future pregnancies are also at risk of uterine rupture when VBAC is attempted; the risk of delivery-related perinatal mortality after one caesarean is up to 12.9/10 000, much of which is attributable to uterine rupture. Please refer to the RCOG Green-top Guideline No. 45: Birth after previous caesarean birth.[22]

Evidence level 2++

5 What factors affect the safety of vaginal breech delivery?

5.1 Antenatal assessment

Following the diagnosis of persistent breech presentation, women should be assessed for risk factors for a poorer outcome in planned vaginal breech birth. If any risk factor is identified, women should be counselled that planned vaginal birth is likely to be associated with increased perinatal risk and that delivery by caesarean section is recommended.

Grade of recommendation: ✓

Women should be informed that a higher risk planned vaginal breech birth is expected where there are independent indications for caesarean section and in the following circumstances:

Grade of recommendation: C

  • Hyperextended neck on ultrasound.
  • High estimated fetal weight (more than 3.8 kg).
  • Low estimated weight (less than tenth centile).
  • Footling presentation.
  • Evidence of antenatal fetal compromise.

The role of pelvimetry is unclear.

Grade of recommendation: C

The safety of planned vaginal breech birth is dependent on case selection, operator skill and intrapartum management. There is, however, a paucity of good evidence regarding factors that increase the risks of vaginal breech birth. Traditional contraindications and those which caused women to be ineligible for the TBT included an estimated fetal weight greater than 4 kg, footling breech presentation, an extended neck, ‘obstructing’ fetal abnormalities and an existing indication for caesarean birth. The lower perinatal mortality and morbidity in the PREMODA study[14] and in the post TBT population-based cohorts[15] are partly attributable to stricter case selection and management. The findings of these studies, therefore, have limited applicability where their inclusion criteria were not met or their management protocols were not followed. Indeed, in a French cohort, composite morbidity and mortality were lower (OR 0.27, 95% CI 0.09–0.85) among units that applied the consensus guidelines.[34]

Factors associated with increased perinatal morbidity at vaginal breech birth in the PREMODA cohort included non-European or African origin, gestational age of less than 39 weeks at birth, birthweight less than the tenth centile and annual number of maternity unit births less than 1500.[35] Molkenboer et al.[36] assessed 183 children, born by vaginal breech delivery, at 2 years of age and, from multiple logistic regression, concluded that there was an increased risk of neurodevelopmental delay when the birthweight had been more than 3.5 kg. As the PREMODA study[14] used an estimated weight upper limit of 3.8 kg, the reassuring outcomes of the study cannot be extrapolated for larger babies.

Evidence level 2+
The role of pelvimetry is unclear. Largely abandoned in the UK, it was employed in 82.5% of planned vaginal births in the PREMODA study[14] and van Loon et al.[37] reported that the use of pelvimetry reduced the emergency caesarean section rate. Further evidence is required to more clearly delineate the role of pelvimetry in breech presentation.Evidence level 2−

5.2 Skill and experience of birth attendant

The presence of a skilled birth attendant is essential for safe vaginal breech birth.

Grade of recommendation: C

Units with limited access to experienced personnel should inform women that vaginal breech birth is likely to be associated with greater risk and offer antenatal referral to a unit where skill levels and experience are greater.

Grade of recommendation: ✓

Although largely unproven, the availability of skilled personnel is likely to strongly influence perinatal outcomes. A senior obstetrician was present at 92.3% of all vaginal deliveries in the PREMODA series;[14] similar figures apply to the smaller consecutive case series describing successful vaginal breech birth.[17-21, 38]Evidence level 2+

The decline in vaginal breech delivery in the UK has led to a widespread lack of experience which itself threatens the safety of planned, and the unplanned but inevitable, vaginal breech birth. An inability of a unit to reliably provide experienced personnel for the delivery is a contraindication to a recommendation of planned vaginal birth.

5.3 Intrapartum assessment and management of women presenting unplanned with breech presentation in labour

Where a woman presents with an unplanned vaginal breech labour, management should depend on the stage of labour, whether factors associated with increased complications are found, availability of appropriate clinical expertise and informed consent.

Grade of recommendation: C

Women near or in active second stage of labour should not be routinely offered caesarean section.

Grade of recommendation: ✓

Where time and circumstances permit, the position of the fetal neck and legs, and the fetal weight should be estimated using ultrasound, and the woman counselled as with planned vaginal breech birth.

Grade of recommendation: ✓

All maternity units must be able to provide skilled supervision for vaginal breech birth where a woman is admitted in advanced labour and protocols for this eventuality should be developed.

Grade of recommendation: ✓

UK data reported that breech presentation at term is not diagnosed until labour in about 25% of women.[39] In some women, labour will be so quick that vaginal breech birth is inevitable and assessment using ultrasound is impossible. Unplanned vaginal breech birth is associated with increased risk,[13] but the data on planned vaginal birth cannot be simply extrapolated to support routine late labour caesarean section.Evidence level 2+

Where labour is progressing rapidly, there is a balance of risks: attempting caesarean section where the breech is very low is likely to be associated with increased perinatal and maternal risk; assessment should include what is feasible. Attempts at vaginal delivery in theatre with spinal anaesthesia or caesarean section with the breech on the perineum are likely to be associated with both increased perinatal and maternal risk.

6 What is appropriate intrapartum management of the term breech?

There is a paucity of evidence regarding the best management of the breech fetus in labour. Recommendations are based on physiology, best practice experience and the management protocols of series with low complication rates. The limited evidence and expert opinion broadly divides into two groups: a more interventionist approach supported by data from the large PREMODA study[14] and a less medicalised approach[21, 40] which is more traditional in the UK. Both strategies advocate close supervision and the not infrequent need for caesarean section or intervention during breech birth.Evidence level 4

6.1 Are induction and augmentation appropriate?

Women should be informed that induction of labour is not usually recommended. Augmentation of slow progress with oxytocin should only be considered if the contraction frequency is low in the presence of epidural analgesia.

Grade of recommendation: D

Both induction and augmentation of labour were used in the PREMODA study[14] in 8.9 and 74.1% of vaginal breech births, respectively. This very high rate of augmentation, coupled with a very low incidence of ‘slow dilatation’, suggests a more prophylactic than a therapeutic role. As a means to treat dystocia, augmentation should usually be avoided as adequate progress may be the best evidence for adequate fetopelvic proportions. However, if epidural analgesia has been used and the contraction frequency is low, its use should not be excluded. Notably, labour augmentation is not supported by many experienced advocates of vaginal breech birth[40] who favour a less interventionist approach. Continuous support is known to reduce labour length and operative delivery with a cephalic presentation.[41]Evidence level 2−

6.2 What is the role of epidural analgesia?

Women should be informed that the effect of epidural analgesia on the success of vaginal breech birth is unclear, but that it is likely to increase the risk of intervention.

Grade of recommendation: ✓

There is limited evidence addressing this. However, with a cephalic presentation, a Cochrane meta-analysis[42] concluded that epidural anaesthesia increases the risk of assisted vaginal delivery. As vaginal breech delivery cannot be expedited until its final stages, epidural anaesthesia might increase the risk of caesarean section. Vaginal breech birth is usually easier if a mother is able to bear down effectively and an epidural may interfere with this. A less interventionist approach advocates a calm atmosphere with continuous support as a means to avoid epidural analgesia.[41] With a more interventionist approach,[14] seldom used in the UK, epidural analgesia is less likely to have a detrimental effect.Evidence level 2−

6.3 What fetal monitoring should be recommended?

Women should be informed that while evidence is lacking, continuous EFM may lead to improved neonatal outcomes.

Grade of recommendation: D

EFM was employed in the PREMODA study,[14] where excellent results of planned vaginal breech birth are documented. Breech presentation is associated with an increased risk of cord prolapse. During delivery, cord compression as the head enters the pelvis is common; this is likely to be better tolerated by a fetus that is not hypoxic. Equally, good fetal tone enables easier breech birth and is more likely in a nonhypoxic fetus. While good evidence is lacking and higher intrapartum caesarean section rates should be expected, EFM is likely to improve neonatal outcomes.Evidence level 3

Where EFM is declined, intermittent auscultation should be performed as for a cephalic fetus, with conversion to EFM if any abnormality is detected.

Where EFM is considered abnormal before the active second stage, caesarean delivery is recommended unless the buttocks are visible or progress is rapid. Fetal blood sampling of the buttocks although technically possible, is not recommended.Evidence level 4

6.4 Where should vaginal breech birth take place?

Birth in a hospital with facilities for immediate caesarean section should be recommended with planned vaginal breech birth, but birth in an operating theatre is not routinely recommended.

Grade of recommendation: D

Labour complications, including the need for caesarean section in up to 45% of women, are more common with breech presentation.[4, 14]Evidence level 2−
No studies have looked at the effect of delivery in theatre versus delivery in a labour room on the outcome of labour. However, transfer from the relative familiarity of the labour room to theatre is likely to increase stress in the mother. Birth in water is not recommended due to the lack of gravity and difficulty anticipated if intervention during breech delivery is required.Evidence level 4

6.5 What guidelines should be in place for the management of breech birth?

Women should be informed that adherence to a protocol for management reduces the chances of early neonatal morbidity.

Grade of recommendation: C

The essential components of planned vaginal breech birth are appropriate case selection, management according to a strict protocol and the availability of skilled attendants.

Grade of recommendation: ✓

Evidence from a number of retrospective studies shows that vaginal breech birth is more successful in women where strict guidelines for selection are used.[34, 43]Evidence level 2−
A Cochrane review of expedited versus conservative approaches to breech delivery found no studies that address this issue.[44] Accepted principles, however, are established. These include assisted breech delivery rather than breech extraction and continuous support for and communication with the mother.Evidence level 3

6.6 Management of the first stage and passive second stage

Adequate descent of the breech in the passive second stage is a prerequisite for encouragement of the active second stage.

Grade of recommendation: D

The first stage of labour should be managed according to the same principles as with a cephalic presentation. To reduce the risk of cord compression, amniotomy is reserved for definite clinical indications. Where the progress is slow, caesarean section should be considered. In the presence of epidural analgesia and a contraction frequency of fewer than four in ten, however, oxytocin may be considered. A passive second stage to allow the descent of the breech to the perineum prior to active pushing is recommended.[14] If the breech is not visible within 2 hours of the passive second stage, caesarean section should normally be recommended.Evidence level 2−

6.7 What position should the woman be in for delivery during a vaginal breech birth?

Either a semirecumbent or an all-fours position may be adopted for delivery and should depend on maternal preference and the experience of the attendant. If the latter position is used, women should be advised that recourse to the semirecumbent position may become necessary.

Grade of recommendation: ✓

There are limited data in relation to position and outcome of delivery in vaginal breech birth. Comparison of an upright position with historical data is favourable,[45] with the rate of maternal perineal injuries being lower. In a cephalic presentation, an upright position is associated with a shorter second stage.[46] Compared with the dorsal supine position, the all-fours position considerably increases pelvic dimensions on magnetic resonance imaging.[47] Delivery with the woman in a forward-facing position (squatting or all fours) is the position favoured by many experienced operators[40] claiming, particularly, that it is easier to observe for signs that the delivery will be more difficult.Evidence level 3
The principal difficulty with an all-fours position is when manoeuvres are required. Most obstetricians are more familiar with performing these in a difficult breech birth with the woman in the dorsal position. If a woman chooses a forward-facing position, they should be made aware that if interventions are required, they may be given assistance to move into a dorsal recumbent position. Manoeuvres in an all-fours position can be performed, however,[40] and if the operator has the skills of undertaking the manoeuvres with the mother in a forward position these should be performed without delay.Evidence level 4

6.8 What are the principles for the management of active second stage and vaginal breech birth?

Assistance, without traction, is required if there is delay or evidence of poor fetal condition.

Grade of recommendation: ✓

All obstetricians and midwives should be familiar with the techniques that can be used to assist vaginal breech birth. The choice of manoeuvres used, if required to assist with delivery of the breech, should depend on the individual experience/preference of the attending doctor or midwife.

Grade of recommendation: ✓

While involuntary pushing may occur earlier, encouragement of maternal effort should not start until the breech is visible. Once the buttocks have passed the perineum, significant cord compression is common. Traction should also be avoided; a ‘hands-off’ approach is required, but with appropriate and timely intervention if progress is not made once the umbilicus has delivered or there is poor tone, extended arms or an extended neck. Tactile stimulation of the fetus may result in reflex extension of the arms or head, and should be minimised. Care must be taken in all manoeuvres to avoid fetal trauma: the fetus should be grasped around the pelvic girdle (not soft tissues) and the neck should never be hyperextended. Selective rather than routine episiotomy is recommended.

External cephalic version (ECV) is the transabdominal manual rotation of the fetus into a cephalic presentation.

Historical considerations

Initially popular in the 1960s and 1970s, ECV virtually disappeared after reports of fetal deaths following the procedure. Reintroduced to the United States in the 1980s, it became increasingly popular in the 1990s.

Improved outcome may be related to the use of nonstress tests both before and after ECV, improved selection of low-risk fetuses, and Rh immune globulin to prevent isoimmunization.

Procedure

Prepare for the possibility of cesarean delivery. Obtain a type and screen as well as an anesthesia consult. The patient should have nothing by mouth for at least 8 hours prior to the procedure. Recent ultrasonography should have been performed for fetal position, to check growth and amniotic fluid volume, to rule out a placenta previa, and to rule out anomalies associated with breech. Another sonogram should be performed on the day of the procedure to confirm that the fetus is still breech.

A nonstress test (biophysical profile as backup) should be performed prior to ECV to confirm fetal well-being.

Perform ECV in or near a delivery suite in the unlikely event of fetal compromise during or following the procedure, which may require emergent delivery.

ECV can be performed with 1 or 2 operators. Some prefer to have an assistant to help turn the fetus, elevate the breech out of the pelvis, or to monitor the position of the baby with ultrasonography. Others prefer a single operator approach, as there may be better coordination between the forces that are raising the breech and moving the head.

ECV is accomplished by judicious manipulation of the fetal head toward the pelvis while the breech is brought up toward the fundus. Attempt a forward roll first and then a backward roll if the initial attempts are unsuccessful. No consensus has been reached regarding how many ECV attempts are appropriate at one time. Excessive force should not be used at any time, as this may increase the risk of fetal trauma.

Following an ECV attempt, whether successful or not, repeat the nonstress test (biophysical profile if needed) prior to discharge. Also, administer Rh immune globulin to women who are Rh negative. Some physicians traditionally induce labor following successful ECV. However, as virtually all of these recently converted fetuses are unengaged, many practitioners will discharge the patient and wait for spontaneous labor to ensue, thereby avoiding the risk of a failed induction of labor. Additionally, as most ECV’s are attempted prior to 39 weeks, as long as there are no obstetrical or medical indications for induction, discharging the patient to await spontaneous labor would seem most prudent.

In those with an unsuccessful ECV, the practitioner has the option of sending the patient home or proceeding with a cesarean delivery. Expectant management allows for the possibility of spontaneous version. Alternatively, cesarean delivery may be performed at the time of the failed ECV, especially if regional anesthesia is used and the patient is already in the delivery room (see Regional anesthesia). This would minimize the risk of a second regional analgesia.

In those with an unsuccessful ECV, the practitioner may send the patient home, if less than 39 weeks, with plans for either a vaginal breech delivery or scheduled cesarean after 39 weeks. Expectant management allows for the possibility of a spontaneous version. Alternatively, if ECV is attempted after 39 weeks, cesarean delivery may be performed at the time of the failed ECV, especially if regional anesthesia is used and the patient is already in the delivery room (see Regional anesthesia). This would minimize the risk of a second regional analgesia.

Success rate

Success rates vary widely but range from 35% to 86% (average success rate in the 2004 National Vital Statistics was 58%). Improved success rates occur with multiparity, earlier gestational age, frank (versus complete or footling) breech presentation, transverse lie, and in African American patients.

Opinions differ regarding the influence of maternal weight, placental position, and amniotic fluid volume. Some practitioners find that thinner patients, posterior placentas, and adequate fluid volumes facilitate successful ECV. However, both patients and physicians need to be prepared for an unsuccessful ECV; version failure is not necessarily a reflection of the skill of the practitioner.

Zhang et al reviewed 25 studies of ECV in the United States, Europe, Africa, and Israel. [16] The average success rate in the United States was 65%. Of successful ECVs, 2.5% reverted back to breech presentation (other estimates range from 3% to 5%), while 2% of unsuccessful ECVs had spontaneous version to cephalic presentation prior to labor (other estimates range from 12% to 26%). Spontaneous version rates depend on the gestational age when the breech is discovered, with earlier breeches more likely to undergo spontaneous version.

A systematic review in 2015 looked at the effectiveness of ECV with eight randomized trials of ECV at term. Compared to women with no attempt at ECV, ECV reduced non-cephalic presentation at birth by 60% and reduced cesarean sections by 40% in the same group. [17] Although the rate of cesarean section is lower when ECV is performed than if not, the overall rate of cesarean section remains nearly twice as high after successful ECV due to both dystocia and non-reassuring fetal heart rate patterns [18] . Nulliparity was the only factor shown in follow-up to increase the risk of instrumental delivery following successful ECV [19] .

While most studies of ECV have been performed in university hospitals, Cook showed that ECV has also been effective in the private practice setting. [20] Of 65 patients with term breeches, 60 were offered ECV. ECV was successful in 32 (53%) of the 60 patients, with vaginal delivery in 23 (72%) of the 32 patients. Of the remaining breech fetuses believed to be candidates for vaginal delivery, 8 (80%) had successful vaginal delivery. The overall vaginal delivery rate was 48% (31 of 65 patients), with no significant morbidity.

Cost analysis

In 1995, Gifford et al performed a cost analysis of 4 options for breech presentations at term: (1) ECV attempt on all breeches, with attempted vaginal breech delivery for selected persistent breeches; (2) ECV on all breeches, with cesarean delivery for persistent breeches; (3) trial of labor for selected breeches, with scheduled cesarean delivery for all others; and (4) scheduled cesarean delivery for all breeches prior to labor. [21]

ECV attempt on all breeches with attempted vaginal breech delivery on selected persistent breeches was associated with the lowest cesarean delivery rate and was the most cost-effective approach. The second most cost-effective approach was ECV attempt on all breeches, with cesarean delivery for persistent breeches.

Risks

Uncommon risks of ECV include fractured fetal bones, precipitation of labor or premature rupture of membranes, abruptio placentae, fetomaternal hemorrhage (0-5%), and cord entanglement (< 1.5%). A more common risk of ECV is transient slowing of the fetal heart rate (in as many as 40% of cases). This risk is believed to be a vagal response to head compression with ECV. It usually resolves within a few minutes after cessation of the ECV attempt and is not usually associated with adverse sequelae for the fetus.

Trials have not been large enough to determine whether the overall risk of perinatal mortality is increased with ECV. The Cochrane review from 2015 reported perinatal death in 2 of 644 in ECV and 6 of 661 in the group that did not attempt ECV. [17]

Candidates

A 2016 Practice Bulletin by ACOG recommended that all women who are near term with breech presentations should be offered an ECV attempt if there are no contraindications (see Contraindications below). [22]

ECV is usually not performed on preterm breeches because they are more likely to undergo spontaneous version to cephalic presentation and are more likely to revert to breech after successful ECV (approximately 50%). Earlier studies of preterm ECV did not show a difference in the rates of breech presentations at term or overall rates of cesarean delivery. Additionally, if complications of ECV were to arise that warranted emergent delivery, it would result in a preterm neonate with its inherent risks. The Early External Cephalic Version (ECV) 2 trial was an international, multicentered, randomized clinical trial that compared ECV performed at 34-35 weeks’ gestation compared with 37 weeks’ gestation or more. [23] Early ECV increased the chance of cephalic presentation at birth; however, no difference in cesarean delivery rates was noted, along with a nonstatistical increase in preterm births.

A systematic review from 2015 looked at 5 studies of ECV completed prior to 37 weeks and concluded that compared with no ECV attempt, ECV commenced before term reduces the non-cephalic presentation at birth, however early ECV may increase the risk of late preterm birth. [24]

Given the increasing awareness of the risks of late preterm birth and early term deliveries, the higher success of earlier ECV should be weighed against the risks of iatrogenic prematurity should a complication arise necessitating delivery.

Contraindications

Absolute contraindications for ECV include multiple gestations with a breech presenting fetus, contraindications to vaginal delivery (eg, herpes simplex virus infection, placenta previa), and nonreassuring fetal heart rate tracing.

Relative contraindications include polyhydramnios or oligohydramnios, fetal growth restriction, uterine malformation, and major fetal anomaly.

Controversial candidates

Women with prior uterine incisions may be candidates for ECV, but data are scant. In 1991, Flamm et al attempted ECV on 56 women with one or more prior low transverse cesarean deliveries. [25] The success rate of ECV was 82%, with successful vaginal births in 65% of patients with successful ECVs. No uterine ruptures occurred during attempted ECV or subsequent labor, and no significant fetal complications occurred.

In 2010 ACOG acknowledged that although there is limited data in both the above study and one more recently, [26] no serious adverse events occurred in these series. A larger prospective cohort study that was published in 2014 reported similar success rates of ECV among women with and without prior cesarean section, although lower vaginal birth rates. There were, however, no cases of uterine rupture or other adverse outcomes. [27]

Another controversial area is performing ECV on a woman in active labor. In 1985, Ferguson and Dyson reported on 15 women in labor with term breeches and intact membranes. [28] Four patients were dilated greater than 5 cm (2 women were dilated 8 cm). Tocolysis was administered, and intrapartum ECV was attempted. ECV was successful in 11 of 15 patients, with successful vaginal births in 10 patients. No adverse effects were noted. Further studies are needed to evaluate the safety and efficacy of intrapartum ECV.

Tocolytics

Data regarding the benefit of intravenous or subcutaneous beta-mimetics in improving ECV rates are conflicting.

In 1996, Marquette et al performed a prospective, randomized, double-blinded study on 283 subjects with breech presentations between 36 and 41 weeks' gestation. [29] Subjects received either intravenous ritodrine or placebo. The success rate of ECV was 52% in the ritodrine group versus 42% in the placebo group (P = .35). When only nulliparous subjects were analyzed, significant differences were observed in the success of ECV (43% vs 25%, P < .03). ECV success rates were significantly higher in parous versus nulliparous subjects (61% vs 34%, P < .0001), with no additional improvement with ritodrine.

A systematic review published in 2015 of six randomized controlled trials of ECV that compared the use of parenteral beta-mimetic tocolysis during ECV concluded that tocolysis was effective in increasing the rate of cephalic presentation in labor and reducing the cesarean delivery rate by almost 25% in both nulliparous and multiparous women. [30] Data on adverse effects and other tocolytics was insufficient. A review published in 2011 on Nifedipine did not show an improvement in ECV success. [31]

Regional anesthesia

Regional analgesia, either epidural or spinal, may be used to facilitate external cephalic version (ECV) success. When analgesia levels similar to that for cesarean delivery are given, it allows relaxation of the anterior abdominal wall, making palpation and manipulation of the fetal head easier. Epidural or spinal analgesia also eliminates maternal pain that may cause bearing down and tensing of the abdominal muscles. If ECV is successful, the epidural can be removed and the patient sent home to await spontaneous labor. If ECV is unsuccessful, a patient can proceed to cesarean delivery under her current anesthesia, if the gestational age is more than 39 weeks.

The main disadvantage is the inherent risk of regional analgesia, which is considered small. Additionally, lack of maternal pain could potentially result in excessive force being applied to the fetus without the knowledge of the operator.

In 1994, Carlan et al retrospectively analyzed 61 women who were at more than 36 weeks' gestation and had ECV with or without epidural. [32] The success rate of ECV was 59% in the epidural group and 24% in the nonepidural group (P < .05). In 7 of 8 women with unsuccessful ECV without epidural, a repeat ECV attempt after epidural was successful. No adverse effects on maternal or perinatal morbidity or mortality occurred.

In 1997, Schorr et al randomized 69 subjects who were at least 37 weeks' gestation to either epidural or control groups prior to attempted ECV. [33] Those in whom ECV failed underwent cesarean delivery. The success rate of ECV was 69% in the epidural group and 32% in the control group (RR, 2.12; 95% CI, 1.24-3.62). The cesarean delivery rate was 79% in the control group and 34% in the epidural group (P = .001). No complications of epidural anesthesia and no adverse fetal effects occurred.

In 1999, Dugoff et al randomized 102 subjects who were at more than 36 weeks' gestation with breech presentations to either spinal anesthesia or a control group. [34] All subjects received 0.25 mg terbutaline subcutaneously. The success rate of ECV was 44% in the spinal group and 42% in the nonspinal group, which was not statistically significant.

In contrast, a 2007 randomized clinical trial of spinal analgesia versus no analgesia in 74 women showed a significant improvement in ECV success (66.7% vs 32.4%, p = .004), with a significantly lower pain score by the patient. [35]

The 2015 systematic review asserted that regional analgesia in combination with a tocolytic was more effective than the tocolytic alone for increasing ECV success; however there was no difference in cephalic presentation in labor. Data from the same review was insufficient to assess regional analgesia without tocolysis [30]

Acoustic stimulation

Johnson and Elliott performed a randomized, blinded trial on 23 subjects to compare acoustic stimulation prior to ECV with a control group when the fetal spine was in the midline (directly back up or back down). [36] Of those who received acoustic stimulation, 12 of 12 fetuses shifted to a spine-lateral position after acoustic stimulation, and 11 (91%) underwent successful ECV. In the control group, 0 of 11 shifts and 1 (9%) successful ECV (P < .0001) occurred. Additional studies are needed.

Amnioinfusion

Although an earlier study reported on the utility of amnioinfusion to successfully turn 6 fetuses who initially failed ECV, [37] a subsequent study was published of 7 women with failed ECV who underwent amniocentesis and amnioinfusion of up to 1 liter of crystalloid. [38] Repeat attempts of ECV were unsuccessful in all 7 cases. Amnioinfusion to facilitate ECV cannot be recommended at this time.

Vaginal delivery rates after successful version

The rate of cesarean delivery ranges from 0-31% after successful external cephalic version (ECV). Controversy has existed on whether there is a higher rate of cesarean delivery for labor dystocia following ECV. In 1994, a retrospective study by Egge et al of 76 successful ECVs matched with cephalic controls by delivery date, parity, and gestational age failed to note any significant difference in the cesarean delivery rate (8% in ECV group, 6% in control group). [39]

However, in 1997, Lau et al compared 154 successful ECVs to 308 spontaneously occurring cephalic controls (matched for age, parity, and type of labor onset) with regard to the cesarean delivery rate. [40] Cesarean delivery rates were higher after ECV (16.9% vs 7.5%, P < .005) because of higher rates of cephalopelvic disproportion and nonreassuring fetal heart rate tracings. This may be related to an increased frequency of compound presentations after ECV. Immediate induction of labor after successful ECV may also contribute to an increase in the cesarean delivery rate due to failed induction in women with unripe cervices and unengaged fetal heads.

Further, in another cohort study from 2015, factors were described which decreased the vaginal delivery rate after successful ECV including labor induction, less than two weeks between ECV and delivery, high body mass index and previous cesarean. [41] The overall caesarean delivery rate in this cohort was 15%.

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