VAGINAL BREECH DELIVERY: IS THIS THE LAST WE HEARD OF IT?
Raul Artal, M.D.
Professor and Chairman
Saint Louis University
Department of Obstetrics, Gynecology and Women’s Health
The management of breech presentation and its route of delivery have always been controversial
and considered a challenge for obstetricians.
Prior to 1960 less than 10% of patients with breech presentation underwent Cesarean sections.
During the past three decades, particularly in the USA, it has been reported a steady decline in
singleton vaginal breech deliveries. In year 2000 the National Center for Health Statistics
reported that 84.2% of pregnancies with breech presentation in the USA were delivered by
Cesarean section.
Several factors have led to this dramatic change in the standard of practice. Foremost the strive
to continuously lower maternal and perinatal morbidity and mortality and the prevailing
consensus that planned Cesarean sections have consistently better outcome. With the decline in
vaginal deliveries fewer and fewer individuals were either trained or gained expertise in vaginal
breech deliveries. Another significant factor influencing the obstetrician’s current choice of
practice has also been the progressive impact of legal liability.
Prior to 1960 the reported incidence of significant fetal morbidity and mortality in many
institutions was 10-25%. After 1960 the reported fetal mortality was still significant 1-3%, while
the maternal morbidity associated with these deliveries was as high as 50%. (2) Several studies
and reviews over the past decade have reached the inescapable conclusion that even the most
skilful obstetricians experienced/reported significant morbidity while performing vaginal breech
deliveries. By year 2000 many reports and institutions have instituted the policy that planned
Cesarean delivery for term breech presentation is significantly safer than vaginal delivery.
(Table I, II)
Table I
Effect of Vaginal Delivery for Term Breech
Presentation Neonatal Morbidity
No. injured/no of deliveries
Anderman et al
Barlov & Larsson
Bistoletti et al
Collea et al
Flanagan et al
Gimovsky & Petrie
Kaupilla
Ohlsen
Songane et al
Typical odds ratio
Vaginal
8/108
7/125
22/313
2/115
14/232
6/204
53/790
16/288
19/599
Cesarean
2/117
1/100
0.53
0.93
3/357
2/463
0/222
0/52
1/255
Odds Ratio
3.80
3.80
3.46
6.16
6.36
8.28
3.86
3.44
3.37
3.96
85% CI
1.107-13.49
0.92-15.88
1.102-11.75
0.38-99.99
2.37-17.05
1.83-37.87
1.98-7.53
0.85-18.84
1.28-8.87
2.76-5.67
Table II
Effect of Vaginal Delivery for Term Breech
Presentation on Corrected Perinatal Mortality
No. of deaths/No. of deliveries
Bistoletti et al
Collea et al
Flanagan et al
Gimovsky & Petrie
Kauppila
Ohlsen
Roumen & Luyben
Songane et al
Thorpe-Beeston et al
Woodward & Callahan
Typical odds ratio
Vaginal
0/309
0/114
0/244
0/204
22/1383
5/288
2/234
6/602
8/1990
2/95
Cesarean
0/52
0/93
0/375
1/463
0/287
0/52
0/13
0/255
1/1457
0/5
Odds Ratio
1.00
1.00
1.00
5.50
3.40
3.30
2.89
4.19
3.60
2.90
3.86
95% CI
1.00-1.00
1.00-1.00
1.00-1.00
0.47-64.35
1.11-10.36
0.29-38.26
0.01-.99
0.72-4.22
0.96-18.52
0.00-99.99
2/22-6.69
Between 1965-1975 emphasis was placed on carefully planned vaginal deliveries by “skilled
obstetricians” who included in their management scheme pelvimetry, limited fetal weight to
below 3500 gm, anesthesia and closely assessed labor progress. With this approach the perinatal
morbidity and mortality was lowered in some centers, however it still exceeded the one reported
for planned Cesarean sections.
Roman et al (15) reported on 15,818-singleton term breech vaginal deliveries conducted in
Sweden between 1987-1993. The authors of this large study indicated that most obstetricians in
Sweden followed the recommendation that breech vaginal delivery should be attempted only if
the following conditions are met: gestational age is more than 34 completed weeks, estimated
fetal weight (by ultrasound) is more than 2000 grams but less than 4000 grams and pelvic size
considered adequate after pelvimetry. Nevertheless this very large retrospective cohort study
conclusions were that vaginal delivery of term breech presenting infants is associated with higher
risk of neonatal mortality and morbidity compared with delivery by elective cesarean section,
and that term singleton infants in the breech presentation would benefit from an elective cesarean
section.
In 1998 Kwang-Sun Lee et al (16) reported on the U.S.A. experience between 1989-1991, which
included a total of 371,692 singleton live births with breech presentation. In this very large study
singleton live births with breech presentation delivered by cesarean section had a lower birth
weight- specific neonatal mortality as compared with vaginal births 3.2 vs. 5.3.
And ultimately a pivotal study was published in 2000 by Hannah et al (18). The study strengths
were in its design and the large number of subjects. Conducted in 121 centers, 26 countries,
2088 women with a singleton fetus in a frank or complete breech presentation were randomly
assigned to planned cesarean section or planned vaginal birth.
The study clearly defined the eligibility criteria (term, breech singletons etc.) and clearly defined
exclusion criteria (fetopelvic disproportion, fetal anomalies and other). Management of labor
and delivery were clearly stated and carried out: elective cesarean section at 38 weeks after
documented mature fetal lung profile. Cesarean section was also done for footling breech, fetal
heart rate abnormalities or dysfunctional labor. The deliveries were conducted by “experienced”
obstetricians. The randomization was properly conducted by parity with a block size of two.
The treatment groups were clearly defined and a follow-up was conducted at 6 weeks
postpartum. The study also included appropriate primary and secondary maternal and neonatal
outcomes.
The statistical analysis was appropriate. The researchers collected and recorded all appropriate
outcome data. The primary outcome included perinatal and neonatal morbidity (such as
neurological sequelae, Apgar scores less than 4 at 5 minutes, cord blood base deficit greater than
15, intubation within 24 hours of delivery).
The secondary outcome included maternal mortality or significant morbidity (postpartum
hemorrhage, hysterectomy, cervical lacerations and other).
The statistical analysis was a multiple logistic regression, which tested between baseline
characteristics and a multitude of outcomes.
The sample size of the Hannah et al study was calculated to yield an 80% power to detect a
reduction in perinatal and neonatal mortality or significant morbidity from 0.8% to 0.1% after
elective cesarean section.
The results of the Hannah et al study were compelling in that planned cesarean section for term
singleton breech presentation would save one infant from death or significant morbidity for
every seven cesareans.
The Hannah et al study had limitations. There was poorer compliance for women allocated to
planned vaginal vs. cesarean delivery (56.7% vs. 90.4%).
The information on physician skill for delivering breech infants was limited.
There was a possible detection bias from under-reporting significant neonatal morbidity (0.4% in
planned c/section vs. 5.1% in the planned vaginal delivery group) for countries with high
perinatal rates.
However, despite all the above pitfalls, a thorough analysis under evidence-based guidelines is
conclusive and difficult to argue with. This is a first rate clinical trial without limitations.
The treatment effect had a significant relative risk reduction (RRR). Based on the study design
and results the evidence-based clinical practice recommendation and grading is a 1A.
In 2001 the Cochrane registry has observed that 550 of 1227 (45%) women with term breech
presentations assigned to vaginal delivery protocols were delivered by cesarean section and that
planned cesarean delivery was associated with greatly reduced risks of corrected perinatal and
neonatal death (OR 0.29, 95% CI O. l0,086). (17)
Low risk patients that had delivered vaginally experience a more than X3 fold increase in infant
mortality.
In 2001 the Royal College of Obstetricians and Gynecologists (Guide line No. 20) recommended
that: “The Best method of delivering a term frank or complete breech singleton is by planned
cesarean section.”
Currently there is insufficient evidence to support routine cesarean section for the delivery of
term breech and to support cesarean section for the delivery of the first or second twin.
Later in 2001 ACOG, as a result of findings of the study (Hannah et al), recommended that
planned vaginal delivery of a singleton term breech may no longer be appropriate. In those
instances in which breech vaginal deliveries are pursued, great caution should be exercised.
Patients with persistent breech presentation at term in singleton gestation should undergo a
planned cesarean section.
In view of these recommendations and other realities in the U.S., several practice guidelines
prevail:






1.
2.
3.
4.
5.
6.
7.
The recommended method of delivery for a term breech is elective C/section.
Occasional inevitable vaginal breech deliveries will still occur.
Vaginal breech deliveries will be taught in residency programs.
External cephalic versions will be increasingly used.
Individual patients will be delivered vaginally at request only (with informed
consent).
Will the pendulum swing back? Difficult to say, but probably not. It appears the
skill to conduct a vaginal breech delivery will slowly disappear.
References
ACOG Committee Opinion No. 265: Mode of Term Singleton Breech
Delivery Obstet Gynecol 2001;98:1189-90
Collea JV, Chein C., Quilligan EJ. The randomized management of term
frank breech presentation: A study of 208 cases. Am J Obstet Gynecol
1980;137:235
Anderman S, Ellenbogen A, Jaschevatzky OE, Grunstein S. Is term
breech presentation in primigravida an absolute indication for cesarean
section? Eur J Obstet Gynecol Reprod Biol 1984;18:11-16.
Bistoletti P, Nesell H, Palme C, Lagercrantz H. Term breech delivery:
Early and late complications. Acta Obstet Gynecol Scand 1981;60:16571.
Barlov K, Larsson G. Results of a five-year prospective study using a
feto-pelvic scoring system for term singleton breech delivery after
uncomplicated pregnancy. Act Obstet Gynecol Scan 1986;65:315-19.
Flanagan TA, Mulchahey KM, Korenbrot CC, Green R, Laros RK.
Management of term breech presentation. Am J Obst Gynecol
1987;156:1492-1502
Gimovsky ML, Petrie RH. The intrapartum management of the breech
presentation. Clin Perinatol 1989;16:976-86.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
Kaupilla O. The perinatal mortality in breech deliveries and observations
on affecting factors: A retrospective study on 2,227 cases. Acta Obstet
Gynecol Scand Suppl 1975;39:1-79.
Ohlsen H. Outcome of term breech delivery in primigravidae. A fetopelvic breech index. Acta Obstet Gynecol Scand. 1975;54:141-51.
Songane FF, Thobani S, Malik H, Bingham P, Lilford RJ. Balancing the
risks of planned elective cesarean section and trial of vaginal delivery for
the mature, selected singleton breech.
Roumen FJME, Luyben AG. Safety of term vaginal breech. Eur J Obstet
Gynecol Reprod Biol. 1991;40:171-77.
Thorpe Beeston JG, Bonfield PJ, Saunders NJ. Outcome of breech
delivery at term. Br Med J. 1992;305:746-47.
Woodward RW, Callahan WE. Breech labor and delivery in the
primigravida. Obstet Gynecol 1969;34:260-65.
Cheng M, Hannah M. Breech delivery at term: A critical review of the
literature. Obstet Gynecol 1993;82:605-18.
Roman J, Bakos O, Cnattingius S. Pregnancy outcomes by mode of
delivery among term breech births: Swedish experience 1987-1993.
Obstet Gynecol 1998;92:945-50.
Kwang-Sun Lee, Khoshnood B. Siriam S. Hsieh HL, Singh J and
Mittdendorf R. Relationship of cesarean delivery to lower birth weightspecific neonatal mortality in singleton breech infants in the United States.
Obstet Gynecol 1998;92:769-74.
Cochrane Database Syst Rev 2001;1:CD00166
Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR,
et al. Planned cesarean section versus planned vaginal birth for breech
presentation at term: a randomized multicentre trial. Lancet
2000;356:1375-83.
Royal College of Obstetricians and Gynecologists: Guideline No. 20,
2001