Too late to back out? Options for breech presentation management

The decline of vaginal breech delivery (VBD) over the past two decades reflects very real concerns that VBD can unexpectedly go wrong, with the worst imaginable neonatal outcomes.1 In this context, caesarean delivery (CD) is now viewed as a safer option for the neonate; CD is performed for 85% of women with term breech presentation.2 This management paradigm for breech presentation reflects a significant shift during the last century. During the last two decades, planned CD has been considered by some to be superior to VBD for complicated breech presentation.3 Unfortunately, this ‘safer’ option is the reason for almost one-fifth of all primary CDs, despite breech presentation comprising only 4% of term deliveries.2 ,4 Once primary CD is performed for breech presentation, subsequent deliveries are almost always by CD.5 Repeat CD is associated with increased risks for haemorrhage and adherent placentation, and6 maternal morbidity is higher with CD than with uncomplicated vaginal delivery. Therefore a management option that minimises maternal morbidity while ensuring neonatal beneficence, is urgently required. In this commentary, we review the history of obstetric care for breech presentation, and present current management options. Breech presentation is associated with insufficient intrauterine space available for fetal movements, or other exogenous maternal and medical factors.7 Maternal constitutional factors include nulliparity, grand multiparity, contracted pelvis, high maternal age and uterine anomalies including fibroma. Pregnancy complications associated with breech presentation include fetal malformations, fetal growth retardation, hydramnios, oligohydramnios, placenta previa and short umbilical cord.7 ,8 There are different types of breech presentation such as complete, frank, footling or kneeling breech. ### Timeline of breech presentation management Women with term breech presentation in the period 1930–1960 had the option to attempt a VBD, or undergo a CD or external cephalic version (ECV). VBD was associated with a 5% risk

Breech presentation · Context (archaeology) · External cephalic version · Fetus · Obstetrics · Oligohydramnios · Placenta · Placenta previa · Pregnancy · Presentation (obstetrics) · Vaginal delivery · Assisted Reproductive Technology and Twin Pregnancy · Maternal and fetal healthcare · Maternal and Perinatal Health Interventions · Medicine · Pediatrics