Just more than 15 years have elapsed since the publication of the Term Breech Trial. This is the largest randomized trial to compare planned vaginal and planned cesarean delivery for women carrying breech fetuses at term (Hannah, 2000). This monumental effort involved 121 centers in 26 countries. Its results provide many of the core tenets that shape current delivery practices. The authors interpreted their findings to indicate that planned cesarean delivery was the safest method to minimize neonatal morbidity and mortality rates. A secondary conclusion showed no difference in maternal morbidity rates between the two delivery routes. Obviously, they did not consider an abdominal incision and hysterotomy to be a morbid outcome.
The intent of this chapter is not to heap criticism on the conduct or interpretation of the Term Breech Trial—indeed, this has been done by others (Glezerman, 2006; Hauth, 2002; Keirse, 2002; Kotaska, 2004). But still, not all breech-presenting fetuses warrant cesarean delivery. Highly satisfactory outcomes of vaginal breech delivery have been documented at several centers since the Term Breech Trial. That said, achieving an atraumatic vaginal breech delivery for the fetus and the mother, in appropriately selected cases, requires knowledge, skill, and judgment on the part of the attendant. In this chapter, we present a conservative protocol to assist in selecting candidates for vaginal delivery of the term breech fetus and to emphasize the technical aspects of delivery that should optimize outcome.
Most reports of vaginal breech delivery focus on selection criteria and outcomes. Very little, if any, discussion of technique is provided. A review of 100 years of obstetric manuscripts and textbooks yields disparate views on what constituted proper technique for vaginal breech delivery (Yeomans, 2012). The approach presented here reflects this academic review and many combined years of clinical practice. At the same time, however, there is room for disagreement at almost every point of technique.
Even if the reader does not plan to offer vaginal breech delivery in his or her practice, many technical descriptions are relevant for cesarean delivery of the breech-presenting fetus. Moreover, it is undeniable that some women with a breech fetus may present with labor so advanced that it precludes cesarean delivery (Gilstrap, 2002). Others may refuse cesarean delivery, and in some low-resource settings, the option of cesarean delivery may not be readily available. Thus, the ability to safely deliver the breech fetus is an essential obstetric skill.
For the breech-presenting fetus, maternal morbidity and mortality rates are lower with vaginal birth compared with cesarean delivery. The converse is true for the fetuses, who experience higher morbidity and mortality rates compared with their vertex counterparts. Two of the leading contributors to that increase are prematurity and congenital malformations. Therefore, the degree to which mode of delivery increases morbidity and mortality rates is a key question. As noted, not all breeches require cesarean delivery. A much ...