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OB Guideline 21: Management of Breech Presentations

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OB Guideline 21: Management of Breech Presentations

Related to: Clinical Guidelines, Communication, Nursing, Obstetrics, Teamwork Training

External Cephalic Version

  1. Patient Selection
  2. External cephalic version should be discussed with all women who are carrying a breech presenting singleton fetus as early as the clinician feels is suitable. The discussion and its conclusion should be documented in the prenatal record.

    Factors that may preclude version:

    • fetal compromise
    • non-reactive non-stress test
    • intrauterine growth restriction
    • oligohydramnios
    • placenta previa
    • abruption
    • premature rupture of the membranes
    • multiple gestation
    • significant uterine anomaly
    • hyperextended fetal head
    • contraindications to a vaginal delivery
    • observed nuchal cord
    • fetal anomalies
  3. Education/Consent
  4. A discussion with the patient should precede the performance of the procedure and include:

    • pregnancy management after a successful or unsuccessful version,
    • success rate of attempted version,
    • risks and benefits of the procedure, and
    • when to call following the procedure.

    See Appendix D for a sample consent form for this procedure. This, or a reasonable facsimile, should be reviewed with and signed by the patient prior to the procedure.

     

  5. Prior to the Procedure
    • arrange a location in close proximity to the delivery unit;
    • confirm that an immediate pre-procedure non-stress test is reactive;
    • perform an immediate pre-procedure sonogram to confirm presentation and that there is normal amniotic fluid volume;
    • perform a formal fetal anatomy survey (if one has not been performed previously), to evaluate the possibility of significant congenital anomalies;
    • consider a tocolytic agent (tocolytics are relatively contraindicated in patients with heart disease, diabetes, or disorders of the thyroid—See Guideline 11); and
    • consider regional anesthesia if the procedure is to be performed in the operating room.
  6. During the Procedure
  7. Monitor the fetal heart rate, at minimum, every 30 seconds during the procedure.

  8. Following the Procedure
    • observe the patient for at least one hour;
    • continuously monitor the fetal heart rate and pattern via electronic fetal monitor apparatus for a minimum of one hour;
    • confirm a Category I fetal heart rate tracing postprocedure, prior to discharge;
    • administer Rhogam if indicated;
    • instruct the patient about follow-up plans, and advise whom to call in the event of any issues;
    • give the patient a written discharge instruction sheet.
  9. Documentation of the Procedure
  10. The details on the procedure should be recorded in the patient’s medical record, including:

    • gestational age;
    • Rh blood type
    • results of pre-procedure testing;
    • medication administered;
    • details on the version attempt, whether it was successful or unsuccessful;
    • post-procedure testing; and
    • future plans.

Delivery Options: Breech Singleton

Cesarean delivery is the most usual method for delivery of a breech singleton living fetus without any significant congenital anomalies. Assessment of the fetal presentation should be performed immediately prior to a scheduled cesarean.

Planned vaginal delivery of a term singleton breech may be reasonable under hospital-specific protocol for both eligibility and management of labor.1,2  If the patient opts for a vaginal breech delivery, a detailed written informed consent shall be obtained and placed in the medical record. Women should be informed that the risk of perinatal or neonatal mortality or short-term serious morbidity may be higher than for cesarean delivery.

In this circumstance:

  • the obstetrician must be skilled in vaginal breech delivery or have adequate back-up consultants available;
  • the adequacy of the pelvis must be assessed; the estimated fetal weight, type of breech, and fetal attitude shall be determined;
  • oxytocin shall not be used for induction or augmentation; 
  • labor dysfunction of any type warrants delivery by cesarean; and 
  • breech delivery should be permitted to occur spontaneously, or by assisted breech delivery maneuvers as indicated.

  1. Mode of term singleton breech delivery. ACOG Committee Opinion No. 340. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2006;108:235–37.
  2. External cephalic version. ACOG Practice Bulletin No. 13. American College of Obstetricians and Gynecologists; February 2000. Reaffirmed 2012.

 

 << Guideline 20             Web Guideline Home Page              Guideline 22 >>

May 1, 2014
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