Abstract
BackgroundThe debate surrounding the management of term breech presentation has excessively focused on the mode of delivery. Indeed, a steady decline in the rate of vaginal breech delivery has been observed over the last three decades, and the soundness of the vaginal route was seriously challenged at the beginning of the 2000s. However, associations between adverse perinatal outcomes and antenatal risk factors have been observed in foetuses that remain in the breech presentation in late gestation, confirming older data and raising the question of the role of these antenatal risk factors in adverse perinatal outcomes. Thus, aspects beyond the mode of delivery must be considered regarding the awareness and adequate management of such situations in term breech pregnancies.Main bodyIn the context of the most recent meta-analysis and with the publication of large-scale epidemiologic studies from medical birth registries in countries that have not abruptly altered their criteria for individual decision-making regarding the breech delivery mode, the currently available data provide essential clues to understanding the underlying maternal-foetal conditions beyond the delivery mode that play a role in perinatal outcomes, such as foetal growth restriction and gestational diabetes mellitus. In view of such data, an accurate evaluation of these underlying conditions is necessary in cases of persistent term breech presentation. Timely breech detection, estimated foetal weight/growth curves and foetal/maternal well-being should be considered along with these possible antenatal risk factors; a thorough analysis of foetal presentation and an evaluation of the possible benefit of external cephalic version and pelvic adequacy in each specific situation of persistent breech presentation should be performed.ConclusionThe adequate management of term breech pregnancies requires screening and the efficient identification of breech presentation at 36 weeks of gestation, followed by thorough evaluations of foetal weight, growth and mobility, while obstetric history, antenatal gestational disorders and pelvis size/conformation are considered. The management plan, including external cephalic version and follow-up based on the maternal/foetal condition and potentially associated disorders, should be organized on a case-by-case basis by a skilled team after the woman is informed and helped to make a reasoned decision regarding delivery route.
Highlights
The debate surrounding the management of term breech presentation has excessively focused on the mode of delivery
When the Term Breech Trial (TBT) Collaborative Group published the 2-year analysis of paediatric outcomes, despite a large postrandomization loss to follow-up [9], these researchers found no reduction in the risk of death or neurodevelopmental delay in children at 2 years of age, raising questions regarding the real lessons to be drawn from this trial
They found that the stillbirth rate was significantly higher in cases of planned vaginal breech labour than in cases of cephalic presentation (0.2 vs 0.1%, respectively), which was correlated with foetal growth restriction, oligohydramnios, gestational diabetes mellitus (GDM) and a history of caesarean section (CS)
Summary
Term breech presentation is a condition for which personalized obstetrical care is needed. The best way is likely to be as follows: first, efficiently screen for breech presentation at 36–37 weeks of gestation; second, thoroughly evaluate the maternal/foetal condition, foetal weight and growth potential, and the type (frank, complete, or footling) and mobility of breech presentation; and three, consider the obstetric history and pelvic size/ conformation. The management plan, including ECV and follow-up during the last weeks, should be organized taking into account antenatal risk factors on a case-bycase basis by a skilled team after informing the woman, discussing her personal situation and criteria and helping her make a rational decision. Foetal overgrowth or growth restriction and/or oligohydramnios may necessitate timely CS, and the mode of delivery should be re-evaluated as necessary according to obstetric conditions (e.g., estimated foetal weight and Bishop score)
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