Footling (incomplete) with one or both thighs extended. Breech with fully flexed legs (complete). Breech with extended legs (frank) is the most common presentation. Of note, due to lack of recruitment, no prospective clinical trials are examining this issue.Breech presentation occurs when the the fetus presents 'bottom-down' in the uterus. One large retrospective cohort study recently concluded that from 28 to 31 6/7 weeks, there is a significant decrease in perinatal morbidity and mortality in a planned cesarean delivery versus intended vaginal delivery, while there is no difference in perinatal morbidity and mortality in gestational age 32 to 36 weeks. Before 26 weeks, there is a lack of quality clinical evidence to guide mode of delivery. Regarding the premature breech, gestational age will determine the mode of delivery. CT pelvimetry did determine an adequate maternal pelvis.ĭespite debate on both sides, the current recommendation for the breech presentation at term includes offering external cephalic version (ECV) to those patients that meet criteria, and for those whom are not candidates or decline external cephalic version, a planned cesarean section for delivery sometime after 39 weeks. Oxytocin induction or augmentation was not offered, and strict criteria were established for normal labor progress. In addition, the protocol presented by one report required documentation of fetal head flexion and adequate amniotic fluid volume, defined as a 3-cm vertical pocket. The initial criteria used in these reports were similar: gestational age greater than 37 weeks, frank or complete breech presentation, no fetal anomalies on ultrasound examination, adequate maternal pelvis, and estimated fetal weight between 2500 g and 4000 g. Many smaller retrospective studies have reported no difference in neonatal morbidity or mortality using these specific criteria. Since the TBT, many authors since have argued that there are still some specific situations that vaginal breech delivery is a potential, safe alternative to planned cesarean. Although these reports did not show any significant difference in the risk of death and neurodevelopmental, these studies were felt to be underpowered. Follow-up studies to the TBT have been published looking at maternal morbidity and outcomes of the children at two years. Since that time, the rate of term breech infants delivered by planned cesarean has increased dramatically. Also, there was no significant difference in maternal morbidity or mortality between the two groups. The investigators reported that delivery by planned cesarean resulted in significantly lower perinatal mortality, neonatal mortality, and serious neonatal morbidity. BREECH POSITION TRIAL
The Term Breech Trial (TBT), a well-designed, multicenter, international, randomized controlled trial published in 2000 compared planned vaginal delivery to planned cesarean delivery for the term breech infant. Expertise in the delivery of the vaginal breech baby is becoming less common due to fewer vaginal breech deliveries being offered throughout the United States and in most industrialized countries.
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