What to do when it is breech? A state-of-the-art review on management of breech presentation

Abstract

Any non-cephalic presentation in a fetus is regarded as malpresentation. The most common malpresentation, breech, contributes to 3%-5% of term pregnancies and is a leading indication for cesarean delivery. Identification of risk factors and a proper physical examination are beneficial; however, ultrasound is the gold standard for the diagnosis of malpresentations. External cephalic version (ECV) refers to a procedure aimed to convert a non-cephalic presenting fetus to cephalic presentation. This procedure is performed manually through the mother’s abdomen by a trained health care provider, to reduce the likelihood of a cesarean section. Studies have reported a version success rate of above 50% by ECV. The main objective of this review is to present a broad perspective on fetal malpresentation, ECV, and delivery of a breech fetus. The focus is to elaborate all clinical scenarios of breech and to provide an evidence-based clinical approach for them. After discussing breech prevalence, risk factors, diagnosis, and management, an updated review of ECV is presented. Moreover, ECV indications/contraindications, alternatives, clinical techniques on how to perform ECV and breech vaginal delivery, and obstetrical considerations for the delivery of malpresentations are thoroughly discussed.

Keywords: Labor presentation; Breech presentation; Obstetric delivery; Cesarean section; External cephalic version; Fetal version

Core Tip: Breech presentation is a leading indication for cesarean surgery. However, external cephalic version (ECV), with a success chance of above 50%, can be performed at 36 wk of gestation or at 39 wk of gestation in order to convert a non-cephalic presenting fetus to a cephalic presenting. A trial of labor or cesarean delivery can be planned after an unsuccessful ECV. Fetus breech can be delivered by vaginal breech delivery or cesarean delivery. The main objective of this review is to present a broad perspective on fetal malpresentation, ECV, and delivery of a breech fetus.