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Excerpt
There is an increasing trend to perform cesarean delivery for term singleton fetuses in a breech presentation. The number of practitioners with the skills and experience to perform vaginal breech delivery has decreased. Results of a large international multicenter randomized clinical trial (2000 Term Breech Trial) indicated that perinatal mortality, neonatal mortality, and serious neonatal morbidity were significantly lower in the planned cesarean delivery group compared with the planned vaginal delivery group (1.6% vs. 5%); maternal morbidity or mortality did not differ between the groups. On the basis of this study, ACOG in 2001 recommended that planned vaginal delivery of a term singleton breech fetus was no longer appropriate.
Since then many studies have modified the original conclusions of the Term Breech Trial. Follow-up studies showed a lower risk of urinary incontinence in women in the planned cesarean delivery group at 3 mo but no difference at 2 yr. Maternal morbidity at 2 yr postpartum did not differ between the groups. For follow-up of the children, the risk of death or neurodevelopmental delay did not differ between the two groups.
Many retrospective reports of vaginal breech delivery that follow specific protocols have had excellent neonatal outcomes. In light of recent publications that clarify the long-term risks of vaginal breech delivery, ACOG recommends the following. (1) The decision on the mode of delivery should depend on the experience of the care provider. Cesarean delivery will be preferred because of the declining expertise in vaginal breech delivery. (2) Obstetricians should perform external cephalic version whenever possible. (3) Planned vaginal delivery may be reasonable with a specific protocol for patient eligibility and labor management. (4) For breech vaginal delivery, considerable caution is necessary and detailed patient informed consent must be documented. (5) Patients must be informed that vaginal breech delivery carries the risks of perinatal or neonatal mortality or short-term serious neonatal morbidity, risks that are higher than if a cesarean delivery is used. (6) No recent data are available to support the recommendation of cesarean delivery to patients whose second twin is in a non-vertex presentation.
