Reconsideration of planned vaginal breech delivery in selected cases

INTRODUCTION: The debate surrounding the management of term breech presentation (BP) has resulted in the presence of a multitude of guidelines, reviews, and directives. The vaginal delivery of a breech baby requires sound obstetric skills since approximately 3-4% of babies at term are breech presentations. BP is the commonest of all malpresentations. However, expertise required to deliver breech babies vaginally has virtually disappeared. There is no convincing evidence that Caesarean Section (CS) is better than assisted vaginal delivery when conducted in appropriate settings, with experienced obstetricians and strict prevailing protocols. Unfortunately, planned vaginal breech delivery (VBD) is becoming an uncommon event. This has led to fewer opportunities for obstetric residents to master the skills of vaginal birth of breech presentations.

MATERIALS AND METHODS: The BP has always been a challenge for obstetricians, due to special skills required to deliver the breech safely. In addition, the immediate perinatal outcome, in terms of APGAR scores and acid-base status of the breech babies is of great concern. Thus, in 2000, in order to provide more evidence-based data, the Term Breech Trial (TBT) was published which compared the outcome of VBD with planned CS. In their 2003 Clinical Guideline, the National Institute for Health and Clinical Excellence (NICE) recommended external cephalic version (ECV) for breech presentation at 36 weeks of gestation a ns elective CS if the procedure is declined or failed. The first edition, Green-top Guidelines by the Royal College of Obstetricians and Gynaecologists (RCOG) regarding the breech delivery was first published in 1999 and revised in 2001, 2006 (Nos. 20a and 20b) and March 2017. In 2020, the Guideline Committee meeting decided on a further revision and deferred the decision for further 3 years (2023). The aim of this Guideline is to aid decision making regarding the route of delivery and choice of various techniques used during delivery. In March 2005, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) issued a formal statement concerning breech delivery at term. Through their Committee on Obstetric Practice, the American College of Obstetricians and Gynecologists (ACOG) issued a Committee Opinion paper on "Mode of term singleton breech delivery" in 2006.

RESULTS: Almost immediately, the medical community all over the world embraced the conclusions of the trial highlighting the superiority of outcomes in planned CS compared to VBD in terms of maternal, neonatal mortality and morbidity. Clinicians, in consultation with their patients, must make the final decisions regarding mode of breech delivery in the light of the updated clinical guidelines and committee opinions for a rational choice for the mode of delivery.

CONCLUSION: There is a place for planned VBD, the prerequisites are: strict case selection, operator skills and vigilant intrapartum monitoring. Provision of basic skills training by utilizing birthing pelvic models and mannikins, hands-on practice of External Cephalic Version (ECV) in clinical settings, may result in larger reduction in the risk of CS.