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imageHigh-level evidence in the Cochrane Library shows that planned vaginal breech delivery is associated with a higher chance of the baby dying in labour or being seriously ill soon after birth than if delivered by planned Caesarean section. Because of this, most learned bodies have recommended that the preferred option in a woman with a breech presentation at term is to perform a Caesarean section. In women who were planned to have a vaginal delivery, the risk of the baby dying in countries like Australia is about 0.6%, with a risk of serious illness in the baby of about 5%. About 45% of the women planned to have a vaginal delivery ended up with a Caesarean section.
The major trial demonstrating the advantages of planned Caesarean section was not published until after I had done the bulk of my training, so I have experience in vaginal breech delivery, and enjoy supervising it. If pregnant woman is aware of the risks, but still wishes to attempt vaginal breech delivery, I am happy to assist her. However, the following conditions must be met:

  • For a woman with suspected breech presentation, pre- or early labour ultrasound should be performed to assess type of breech presentation, fetal growth and estimated weight, and attitude of fetal head. If ultrasound is not available, Caesarean section is recommended.
  • Contraindications to labour include
    • Cord presentation
    • Fetal growth restriction or macrosomia
    • Any presentation other than a frank or complete breech with a flexed or neutral head attitude (III-B)
    • Clinically inadequate maternal pelvis
    • Fetal anomaly incompatible with vaginal delivery 
  • Vaginal breech delivery can be offered when the estimated fetal weight is between 2500g and 4000 g.
  • Labour Management
  • Clinical pelvic examination should be performed to rule out pathological pelvic contraction. Radiologic pelvimetry is not necessary for a safe trial of labour; good progress in labour is the best indicator of adequate fetal-pelvic proportions).
  • Continuous electronic fetal heart monitoring is preferable in the first stage and mandatory in the second stage of labour. When membranes rupture, immediate vaginal examination is recommended to rule out prolapsed cord. 
  • In the absence of adequate progress in labour, Caesarean section is advised. 
  • Induction or augmentation of labour are not recommended for breech presentation
  • A passive second stage without active pushing may last up to 90 minutes, allowing the breech to descend well into the pelvis. Once active pushing commences, if delivery is not imminent after 60 minutes, Caesarean section is recommended. 
  • The active second stage of labour should take place in or near an operating room with equipment and personnel available to perform a timely Caesarean section if necessary. 
  • A health care professional skilled in neonatal resuscitation should be in attendance at the time of delivery.