What clinical or other information is important to know when considering a vaginal breech delivery (VBD)?
At what point should a cesarean section (C-section) be performed when faced with a breech presentation in a laboring patient?
What techniques are best used when attempting a VBD, and how should complications be handled when they occur?
How should I obtain consent from a patient who wishes to undergo VBD?
In the United States, VBD has largely become relegated to the history books, as study after study has demonstrated increased risks of neonatal morbidity and mortality associated with the procedure.1–3 Many of the earlier studies were retrospective in nature or were small prospective ones without the power to look comprehensively at VBD safety.4–10 The question of safety was finally answered with a large, prospective randomized control trial (RCT) that demonstrated higher rates of neonatal morbidity and mortality with planned VBD compared to planned C-section.1 This study, as well as follow-up research on the same population, addressed both maternal and newborn outcomes and demonstrated no negative impact on the mother and only a negative impact on the newborn's immediate morbidity and mortality.1,11–13
With this rapid decline in VBD, skilled practitioners have become less available to perform these deliveries due to a lack of training of new providers and knowledgeable ones retiring.1 In spite of this attrition, there are often times when, unexpectedly, a patient who has a fetus in breech presentation presents in advanced labor, and the only option is to perform a VBD. Another scenario is the woman who knows that she is in breech position and refuses a C-section. In these cases, the obstetric (OB) provider must be able to safely deliver the breech baby vaginally.
The American College of Obstetrics and Gynecology (ACOG) recognizes that, despite the small but real risk of perinatal morbidity and mortality associated with VBD, some patients may still desire and seek out providers who will perform routine VBD. If those providers want to perform VBDs, they must set up hospital-based protocols utilizing best practices in order to optimize outcomes and provide adequate informed consent.14 In addition, the maneuvers involved in a VBD are very similar to those done when delivering a breech fetus by C-section, and understanding these maneuvers with both routes of delivery is critical.
Up until the late 1970s, VBD was the route of delivery chosen by most women who presented breech late in gestation. Breech presentation late in the third trimester represents about 3% to 5% of all pregnancies, but it is associated with a higher rate of congenital malformations or syndromes compared to their vertex counterparts, which may have caused the fetus to be breech in the first place.15–18 Often, a VBD newborn who was not “normal” led the parents to look for ...