American College of Obstetrics and Gynecology (ACOG) recommendations for breech birth.
Society of Obstetricians and Gynecologists of Canada’s (SOGC) statement about vaginal breech delivery including information about the Term Breech Trial and clinical guidelines.
Royal College of Obstetricians and Gynaecologists (RCOG) guidelines for breech presentation and birth.
Netherlands Association of Obstetrics and Gynaecology (NVOG) guidelines on breech presentation (in Dutch).
Royal Australian and New Zealand College of Obstetricians and Gynaecology guidelines on breech presentation.
The Cochrane Collaboration search for breech birth research.
The Childbirth Connection (Evidence-based Maternity Care Resource Directory) search for breech birth resources.
The Term Breech Trial (TBT) changed the way the medical world looked at and managed breech birth. It was later noted for its errors and misinterpretations. For more detailed information, click here.
Management of Breech Presentation at Term.
Kotaska, A., Menticoglou, S.
J Obstet Gynecol Canada. 2010 Aug;41(8):1193-1205. Management of Breech Presentation at Term.
“Summary Statements: 1-External cephalic version is recommended to reduce the likelihood of Caesarean section. If unsuccessful, options include planned vaginal breech birth or planned Caesarean section (high). 2-In appropriately selected women in hospitals with obstetricians skilled in vaginal breech birth, perinatal mortality is between 0.8 and 1.7/1000 for planned vaginal breech birth and between 0 and 0.8/1000 for planned Caesarean section (moderate). 3-In appropriately selected women, planned vaginal breech birth is associated with greater short- but not long-term neonatal neurological morbidity. Regardless of planned mode of birth, cerebral palsy occurs in approximately 1.5/1000 breech births, and any abnormal neurological development occurs in approximately 3/100 (moderate). 4-During planned vaginal breech birth, a clinician experienced in vaginal breech birth should supervise the first stage of labour and be present for the active second stage of labour and delivery (IA). Staff required for rapid Caesarean section and skilled neonatal resuscitation should be in-hospital during the active second stage of labour (low). 5-Vaginal breech birth requires a high degree of skill and support. To avoid the increased risk of out-of-hospital vaginal breech birth, women who choose planned vaginal breech birth should be accommodated in-hospital. To facilitate this, referral to more experienced centres, back-up on-call arrangements, and continuing medical training in vaginal breech birth skills should be promoted (very low).”
Is planned vaginal delivery for breech presentation at term still an option? Results of an observational prospective survey in France and Belgium.
Goffinet F, Carayol M, Foidart JM, Alexander S, Uzan S, Subtil D, Bréart G;
PREMODA Study Group.
Am J Obstet Gynecol. 2006 Apr;194(4):1002-11. PREMODA abstract.
“In places where planned vaginal delivery is a common practice and when strict criteria are met before and during labor, planned vaginal delivery of singleton fetuses in breech presentation at term remains a safe option that can be offered to women.”
Interpreting the PREMODA study.
The risks of planned vaginal breech delivery versus planned cesarean section for term breech birth: a meta-analysis including observational studies.
Berhan, Y., Haileamlak, A.
BJOG. 2016 Jan;123(1):49-57. The risks of planned vaginal breech delivery versus planned cesarean section for term breech birth: a meta-analysis including observational studies.
“Perinatal mortality and morbidity in the planned vaginal breech delivery were significantly higher than with planned caesarean delivery. Even taking into account the relatively low absolute risks of vaginal breech delivery, the current study substantiates the practice of individualised decision-making on the route of delivery in a term breech presentation.”
Management of breech presentation at term: a retrospective cohort study of 10 years of experience.
Burgos, J.; Rodriguez, L.; Cobos, P.; Osuna, C.; del mar Centeno, M.; Larrieta, R.; Martinez-Astorquiza, T.; and Fernandez-Llebrez, L.
Journal of Perinatology. 2015;10.1038. Management of breech presentation at term.
“Management of breech presentation with a protocol that includes ECV, careful selection criteria and active management of vaginal delivery achieve a great decrease in the rate of CS for breech presentation.”
Vaginal breech delivery: results of a prospective registration study.
Ingvild Vistad, Milada Cvancarova, Berit L Hustad, and Tore Henriksen
BMC Pregnancy Childbirth. 2013; 13: 153. Results of Norway’s study.
“Our findings reflect a well-functioning health care system where vaginal delivery of breech babies has been practiced even after the results of the TBT was published. The present study does not have enough power to make a definite conclusion that vaginal breech delivery is completely safe. Yet, our results indicate that vaginal delivery of term breech infants is acceptable provided the following conditions: Selection guidelines are followed, the fetal monitoring is of high quality, and the volume of breeches delivered vaginally is sufficient to maintain a high level of competence among obstetricians. The women should also be counseled about the increased risk of short-term NICU admission.”
Maternal deaths after elective cesarean section for breech presentation in the Netherlands.
Schutte JM, Steegers EA, , Santa JG, Schuitemaker NW, van Roosmalen J
Maternal Mortality Committee Of The Netherlands Society Of Obstetrics
Acta Obstet Gynecol Scand. 2007;86(2):240-3.Pub Med abstract.
“Elective cesarean section does not guarantee the improved outcome of the child, but may increase risks for the mother, compared to vaginal delivery.”
Mode of First Delivery and Severe Maternal Complications in the Subsequent Pregnancy.
K. Klungsøyr, M. Jakobsson, A-M.Tapper, M. Gissler, P.G Lindqvist, K. Källen, K. Gottvall, P.E. Bordahl, R.I. Bjarnadóttir, J. Langhoff-Roos
Acta Obstet Gynecol Scand. 2017. Mode of First Delivery and Severe Maternal Complications in the Subsequent Pregnancy Abstract.
“Women with a first elective versus emergency cesarean have increased risk of severe complications in the second pregnancy.”
Routine cesarean for breech: the unmeasured cost.
Birth 38(2), June 2011. Routine Cesarean for Breech: The Unmeasured Cost.
“During the decade since publication of the term breech trial, it has become commonplace in many jurisdictions for specialist obstetricians to advise performance of cesarean section as the only option for breech presentation at term. In a misunderstanding of informed consent, the 2001 American College of Obstetricians and Gynecologists’ breech guideline advised cesarean section for all breeches, suggesting informed consent be obtained only if the woman refused cesarean section (9). For consent to be informed, a woman must first be made aware of her options, including the option of doing nothing; and the risks and benefits of each option must be discussed. She should then have the freedom to choose without prejudice, even if it is not the option recommended by the consultant. This has not been occurring for breech presentation. “
Neonatal outcome of singleton term breech deliveries in Norway from 1991 to 2011.
Vistad, I., Klungsøyr, K., Albrechtsen, S., Skjeldestad, FE.
Acta Obstet Gynecol Scand. 2015 Sep;94(9):997-1004. Neonatal outcome of singleton term breech deliveries in Norway from 1991 to 2011.
“Overall intrapartum and neonatal mortality decreased during the entire period. Higher mortality in planned vaginal delivery relative to planned cesarean delivery in the second period was not statistically significant. However, neonatal morbidity was significantly higher in planned vaginal than planned cesarean deliveries in both periods. This warrants continuous surveillance of breech deliveries.”
Term breech deliveries in the Netherlands: did the increased cesarean rate affect neonatal outcome? A population-based cohort study.
Floortje Vlemmix, Lester Bergenhenegouwen, Jelle M. Schaaf, Sabine Ensing, Ageeth N. Rosman, Anita C. J. Ravelli, Joris A. M. van der Post, Arno Verhoeven, Gerard H. Visser, Ben W. J. Mol, and Marjolein Kok.
Acta Obstet Gynecol Scand. 2014;93(9):888-896.A retrospective cohort study.
“Adjustment of the national guidelines after publication of the Term Breech Trial resulted in a shift towards elective cesarean and a decrease of perinatal mortality and morbidity among women delivering a child in breech at term. Still, 40% of these women attempt vaginal birth. The relative safety of an elective cesarean should be weighed against the consequences of a scarred uterus in future pregnancies.”
Response to the flawed retrospective cohort study.
“If this study does not address the central concerns of women and their partners, why should it take precedence in the information given to aid informed decision-making? If the authors have not performed an intention-to-treat analysis, how can they possibly claim to know that their treatment will have the predicted result? If the study has demonstrated a risk similar to that of planning a VBAC, why are both choices not considered equally reasonable?”
Can cesarean section improve child and maternal health? The case of breech babies.
Vibeke Myrup Jensen and Miriam Wust.
Journal of Health Economics. 2014;10.1016.Regression discontinuity design study.
“We find that CS decreases the child’s probability of having a low APGAR score and the number of family doctor visits in the first year of life. We find no significant effects for severe neonatal morbidity or hospitalizations. While mothers are hospitalized longer after birth, we find no effects of CS for maternal post-birth complications or infections. Although the change in mode of delivery for the marginal breech babies increases direct costs, the health benefits show that CS is the safest option for these children.”
Response to the concerning regression discontinuity design study.
“So Jensen and Wust have given us more research indicating an increase in short-term morbidity (with mortality being rare and insignificant?) but no difference in significant neonatal morbidity and the need for increased medical care after 2 years. This matches the information from the Term Breech Trial. Despite the authors insistence they have uncovered evidence that CS is best for all breech babies, and that it is ultimately cheaper (based on their non-evidence-based speculation on future costs of CP only), it actually adds to the literature confirming no concrete evidence of a difference in long-term outcomes for breech babies.”
Cesarean without labor safest for breech delivery.
Medscape. Apr 17, 2015.Review of current research study titled:
Delivery of breech presentation at term gestation in Canada, 2003-2011.
Janet Lyons, Tracy Pressey, Sharon Bartholomew, Shiliang Liu, Robert M. Liston, and K.S. Joseph
Obstetrics & Gynecology. 2015. Abstract of Canada’s study.
“Among term, nonanomalous singletons in breech presentation at term, composite neonatal mortality and morbidity rates were significantly higher after vaginal delivery and cesarean delivery in labor compared with cesarean delivery without labor.”
“These [assumptions of the qualifications of practitioners, planned/unplanned vaginal or cesarean delivery, parity] are some of the same major flaws of the Term Breech Trial (TBT) and are inherent when using a retrospective review of discharge records. Thus, this paper is open to some of the same critiques used to discredit the TBT…
I found this grouping of injuries which were all lumped together to come up with a “composite” risk to be problematic. I could not rectify why they might include injured scrotum and potentially serious intracranial hemorrhaging in the same grouping for statistical analysis. This also combines transient morbidity such as assisted ventilation or a bone fracture with injuries that are much more severe and long lasting. Also, there is no explanation of how neonates who might have more than one morbidity were classified. Of importance is there were no neonatal deaths in the vaginal delivery group (8 year total of 1,593 births)…
There are many limitations to any scientific study. It is impossible to control for all variables. The authors here admit to this and other weaknesses and I believe did not have any conformational bias when they set out to look at the numbers. Dr. Lyons concludes that composite risks [death, assisted ventilation, convulsions, or specific birth injury] were “significantly higher after a vaginal breech delivery and after a cesarean delivery in labor as compared with cesarean delivery before labor onset. The risks associated with vaginal and cesarean delivery should be carefully considered by women contemplating a singleton breech delivery at term gestation and by their physicians.” I agree that all risks and benefits of reasonable birth choices should be carefully considered by women and their families but her last few words are very concerning to me. Although Dr. Lyons does not and would not say vaginal birth is contraindicated her message will almost certainly be construed that way.”
Maternal Experiences of Vaginal Breech Delivery.
Toivonen, Elli; Palomaki, Outi; Huhtala, Heini; Uotila, Jukka.
Birth 41(4), December 2014. Maternal Experiences of Vaginal Breech Delivery.
“The birth experience of vaginal breech birth seems to be at least as positive as the vaginal vertex birth experience.“
Women’s Experiences of Planning a Vaginal Breech Birth in Australia.
Homer, Caroline SE; Watts, Nicole P; Petrovska, Karolina; Sjostedt, Chauncey M; Bisits, Andrew.
BMC Pregnancy and Childbirth 2015, 15. Women’s Experiences of Planning a Vaginal Breech Birth in Australia.
“Women seeking a VBB value clear, consistent and relevant information in deciding about mode of birth. Women desire autonomy to choose vaginal breech birth and to be supported in their choice with high quality care.“
‘Stress, anger, fear, and injustice:’ An international qualitative survey of women’s experiences planning a vaginal breech birth.
Petrovska, Karolina; Watts, Nicole P; Catling C.; Bisits, Andrew; Homer, Caroline SE.
Midwifery 2017, Jan; 44: 41-47. ‘Stress, anger, fear, and injustice:’ An international qualitative survey of women’s experiences planning a vaginal breech birth.
“For women seeking vaginal breech birth, limited system and clinical support can impede access to balanced information and options for care. Recognition of existing evidence on the safety of vaginal breech birth, as well as the presence of clinical guidelines that support it, may assist in promoting vaginal breech birth as a legitimate option that should be available to women.”
Supporting Women Planning a Vaginal Breech Birth: an International Survey.
Petrovska, Karolina; Watts, Nicole P; Catling C.; Bisits, Andrew; Homer, Caroline SE.
Birth 2016, Dec; 43 (4): 3. 53-357. Supporting Women Planning a Vaginal Breech Birth: an International Survey.
“The women who responded to this international survey sought the option of a vaginal breech birth, were subsequently happy with this decision, and would attempt a vaginal breech birth in their next pregnancy. Access to vaginal breech birth is important for some women; however, this choice may be challenging to achieve. Consistent information and support from clinicians is important to assist decision-making.”
How do social discourses of risk impact on women’s choice for vaginal breech birth? A qualitative study of women’s experiences.
Petrovska, Karolina; Watts, Nicole P; Sheehan, A; Bisits, Andrew; Homer, C.
Health, Risk & Society 2017, 19 (1-2): 19-37. How do social discourses of risk impact on women’s choice for vaginal breech birth? A qualitative study of women’s experiences.
“We identified four related strands in women’s talk about resisting the dominate discourse: acknowledgment that they would be considered irrational for wanting a vaginal birth; having confidence in and believing that their body could give birth vaginally; convincing significant others that a vaginal birth was possible and desirable and looking for sources of support, for example, from new online social networks.”
Does breech delivery in an upright position instead of on the back improve outcomes and avoid cesareans?
Louwen, F., Daviss, B-A., Johnson, K. C., Reitter, A.
Int. Journal of Obstetrics & Gynecology, 10.1002/ijgo.12033. Does breech delivery in an upright position instead of on the back improve outcomes and avoid cesareans?
“Upright vaginal breech delivery was associated with reductions in duration of the second stage of labor, maneuvers required, maternal/neonatal injuries, and cesarean rate when compared with vaginal delivery in the dorsal position.“
Breech delivery in the all fours position: a prospective observational comparative study with classic assistance.
Bogner, G.; Strobl, M.; Schausberger, C.; Fischer, T.; Reisenberger, K.; Jacobs, V.R.
J Perinat Med, September 2014. Breech delivery in the all fours position: a prospective observational comparative study with classic assistance.
“This is the first clinical evaluation of breech delivery in the all fours position. It is a feasible non-interventional obstetric delivery method. It seems to be safe for the fetus with reduced maternal morbidity. Vaginal delivery of fetal breech presentation, even in the all fours position, creates stress for the newborn.”
“Home birth” with an Obstetrician: A Series of 135 Out of Hospital Births.
Fischbein, Stuart J.
Obstetrics & Gynecology International Journal, July 2015. “Home birth” with an Obstetrician: A Series of 135 Out of Hospital Births
“The births include singleton, VBAC, breech, and twin deliveries… Birth at homer properly selected women with a skilled practitioner is a reasonable and ethical option.”
C-section Not the Best Option for Breech Birth
What is the evidence for using an External Cephalic Version for turning a breech baby?
External Cephalic Version and Reducing the Incidence of Term Breech Presentation.
Impey LWM, Murphy DJ, Griffiths M, Penna LK on behalf of the Royal College of Obstetricians and Gynaecologists.
BJOG, March 2017. External Cephalic Version and Reducing the Incidence of Term Breech Presentation.
Maternal outcomes of term breech presentation delivery: impact of a successful external cephalic version in a nationwide sample of delivery admissions in the United States.
Weiniger, C.F.; Lyell, D.J.; Tsen, L.C.; Butwick, A.J.; Shachar, B.; Callaghan, W.M.; Creanga, A.A.; Bateman, B.T.
BMC Pregnancy Childbirth, 2016; 16: 150. Maternal outcomes of term breech presentation delivery: impact of a successful external cephalic version in a nationwide sample of delivery admissions in the United States.
“Overall a low proportion of women with breech presentation undergo successful external cephalic version, and it is associated with significant reduction in the frequency of cesarean delivery and a number of measures of maternal morbidity. Increased external cephalic version use may be an important approach to mitigate the high rate of cesarean delivery observed in the United States.”
Complications of external cephalic version: a retrospective analysis of 1121 patients at a tertiary hospital in Sydney.
Rodgers, N; Biek, N; Nassar, N.; Brito, I; DeVries, B
BJOG, June 2016. Complications of external cephalic version: a retrospective analysis of 1121 patients at a tertiary hospital in Sydney.
“ECV at term is associated with a low rate of serious complications.”
External cephalic version: is it effective? is it safe?
External Cephalic Version (ECV)– 5 Things to Consider Before Having One
Evidence for Using Moxibustion for Turning Breech Babies