In addition to these evidence-based recommendations, the guideline development group also identifies points of best clinical practice in the original guideline document.
Levels of evidence (Ia-IV) and grading of recommendations (A-C) are defined at the end of the "Major Recommendations" field.
What Information Should be Given to Women With Breech Presentation Regarding Mode of Delivery?
A - Women should be informed of the benefits and risks, both for the current and for future pregnancies, of planned caesarean section versus planned vaginal delivery for breech presentation at term.
What Information About the Baby Should Be Given to Women With Breech Presentation Regarding Mode of Delivery?
A - Women should be informed that planned caesarean section carries a reduced perinatal mortality and early neonatal morbidity for babies with a breech presentation at term compared with planned vaginal birth.
A - Women should be informed that there is no evidence that the long term health of babies with a breech presentation delivered at term is influenced by how the baby is born.
What Information Should Women Having Breech Births Be Given About Their Own Immediate and Future Health?
A - Women should be advised that planned caesarean section for breech presentation carries a small increase in serious immediate complications for them compared with planned vaginal birth.
A - Women should be advised that planned caesarean section for breech presentation does not carry any additional risk to long-term health outside pregnancy.
C - Women should be advised that the long-term effects of planned caesarean section for term breech presentation on future pregnancy outcomes for them and their babies are uncertain.
What Factors Affect the Safety of Vaginal Breech Delivery?
C - Women should be assessed carefully before selection for vaginal breech birth.
B - Routine radiological pelvimetry is not necessary.
C - Diagnosis of breech presentation for the first time during labour should not be a contraindication for vaginal breech birth.
Factors regarded as unfavourable for vaginal breech birth include the following:
- Other contraindications to vaginal birth (e.g., placenta praevia, compromised fetal condition)
- Clinically inadequate pelvis
- Footling or kneeling breech presentation
- Large baby (usually defined as larger than 3800 g)
- Growth-restricted baby (usually defined as smaller than 2000 g)
- Hyperextended fetal neck in labour (diagnosed with ultrasound or X-ray where ultrasound is not available)
- Lack of presence of a clinician trained in vaginal breech delivery
- Previous caesarean section
(Evidence level IV)
Some women with breech presentation choose to deliver vaginally and some women for whom a caesarean section is planned 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.
Intrapartum Management
Where Should Vaginal Breech Birth Take Place?
Ready access to caesarean section is considered important, particularly in the event of poor progress in the second stage of labour. No systemic evidence exists on the complications of breech birth outside the hospital setting. (Evidence level Ib)
What is the Place of Labour Induction, Labour Augmentation, and Epidural Analgesia in Breech Labour?
C - Labour augmentation is not recommended.
There is no evidence that epidural analgesia is essential and, in selected cases, induction or augmentation may be justified. However, augmentation of established labour is controversial as poor progress in established labour may be a sign of fetopelvic disproportion. In the Term Breech Trial cohort (both groups), labour augmentation was associated with adverse perinatal outcome. (Evidence level IV)
What is the Place of Fetal Monitoring During Breech Labour?
C - Continuous electronic fetal heart rate monitoring should be offered to women with a breech presentation in labour.
How Should Delayed Second Stage of Labour With Breech Presentation be Managed?
C - Caesarean section should be considered if there is delay in the descent of the breech at any stage in the second stage of labour.
Failure of the presenting part to descend may be a sign of relative fetopelvic disproportion. Caesarean section should be considered. (Evidence level IV)
What Maternal Position Should be Used for Breech Delivery?
C - Women should be advised that, as most experience with vaginal breech birth is in the dorsal or lithotomy position, that this position is advised.
Should Routine Episiotomy be Performed?
C - Episiotomy should be performed when indicated to facilitate delivery.
Should Breech Extraction be Performed Routinely?
C - Breech extraction should not be used routinely.
How Should Delayed Delivery of the Arms be Managed?
C - The arms should be delivered by sweeping them across the baby's face and downwards or by the Lovset manoeuvre (rotation of the baby to facilitate delivery of the arms).
How Should Delayed Engagement in the Pelvis of the Aftercoming Head Be Managed?
C - Suprapubic pressure by an assistant should be used to assist flexion of the head.
C - The Mauriceau-Smellie-Veit manoeuvre should be considered, if necessary, displacing the head upwards and rotating to the oblique diameter to facilitate engagement.
How Should the Aftercoming Head be Delivered?
C - The aftercoming head may be delivered with forceps, the Mauriceau-Smellie-Veit manoeuvre, or the Burns-Marshall method.
How Should Obstructed Delivery of the Aftercoming Head be Managed?
C - If conservative methods fail, symphysiotomy or caesarean section should be performed.
Management of the Preterm Breech and Twin Breech
How Should Preterm Babies in Breech Presentation be Delivered?
C - Routine caesarean section for the delivery of preterm breech presentation should not be advised.
A specific problem encountered during preterm breech delivery is delivery of the truck through an incompletely dilated cervix. In this situation, lateral cervical incisions have been used to release the aftercoming head. Similar rates of head entrapment have been described for vaginal and abdominal delivery. (Evidence level IV)
In the absence of god 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 woman and her partner. (Evidence level IV)
How Should a First Twin in Breech Presentation at Term be Delivered?
C - Women should be informed of the benefits, including reduced perinatal mortality, and risks, both for the current and for future pregnancies, of planned caesarean section for breech presentation.
C - Women should be advised that planned caesarean section for breech presentation carries a very small increase in serious immediate complications for them compared with planned vaginal birth.
How Should a Second Twin in Breech Presentation be Delivered?
C - Routine caesarean section for twin pregnancy with breech presentation of the second twin should not be performed.
Definitions:
Grading of Recommendations
Grade A - 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)
Grade B - Requires the availability of well controlled clinical studies but no randomised clinical trials on the topic of recommendations. (Evidence levels IIa, IIb, III)
Grade C - 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)
Levels of Evidence
Ia: Evidence obtained from meta-analyses 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
