9 / 101
E
lective
cesarean
section
for
term
breech
delivery
R
ev
A
ssoc
M
ed
B
ras
2015; 61(5):391-402
391
GUIDELINES IN FOCUS
Elective cesarean section for term breech delivery
C
esariana
eletiva
na
apresentação
pélvica
em
gestações
a
termo
Authorship:
Febrasgo
Participants:
Ricardo Simões
1,2
, João de Deus Valadares Neto
1
, Wanderley M. Bernardo
2
, Antonio J. Salomão
1
,
Edmund C. Baracat
1
Conflict of interest:
none
1
Federação Brasileira das Associações de Ginecologia e Obstetrícia (Febrasgo)
2
Guidelines Project, Associação Médica Brasileira
http://dx.doi.org/10.1590/1806-9282.61.05.391The Guidelines Project, an initiative of the Brazilian Medical Association, aims to combine information from the medical field in order to standard-
ize procedures to assist the reasoning and decision-making of doctors.
The information provided through this project must be assessed and criticized by the physician responsible for the conduct that will be adopted, de-
pending on the conditions and the clinical status of each patient.
I
ntroduction
Breech delivery, with incidence ranging from3 to 4% in term
gestations, is the second most common delivery presenta-
tion
1
(
D
). It is a condition in which the baby, at the time of
birth, exits the mother’s pelvis buttocks- or feet-first. Based
on the relation between the baby’s lower limbs and the bot-
tom, breech presentation can be classified as: complete (the
baby’s hips and knees are flexed so that the baby is sitting
with feet beside the bottom), and incomplete breech (the
baby’s legs are folded flat up against the chest); most breech
babies are in the incomplete breech position, with bottom
coming first. Other types of incomplete breech presenta-
tion are the kneeling breech and footling breech
1,5
(
D
).
Factors that have been associated with breech presen-
tation include nulliparity, uterine abnormalities, low in-
sertion of placenta, polyhydramnios, oligohydramnios,
multiple pregnancy, prematurity, decreased fetal activity,
fetal abnormalities and fetal death. Moreover, there is in-
creased risk of recurrence of this type of presentation in
subsequent pregnancies.
Many of the factors described above, regardless of the
type of presentation and type of delivery chosen, are consid-
ered as bad perinatal prognostic markers, associated with
increased risk of adverse consequences to the fetus/newborn
baby
4
(
B
). In addition, breech vaginal delivery is a type of
birth with growing difficulties and, in such circumstances,
there is increased risk of complications including cord pro-
lapse, difficult delivery and higher maternal and perinatal
morbidity. For a long time and even today, the best mode of
delivery in this presentation remains, therefore, controver-
sial
2
(
D
)
3
(
B
). Thus, while there is no consensus in the liter-
ature regarding the best type of delivery, elective C-section
has been often performed in cases of breech presentation.
Considering the great importance of this issue for
both mother and baby, as well as the existing controver-
sies, a systematic review should be conducted with the
purpose of guiding obstetricians, based on the retrieval
of the best scientific evidence available, to improve pre-
natal care and labor in cases of singleton term pregnan-
cies in breech position.
O
bjective
The objective of this review is to provide the best evidence
currently available on maternal, perinatal and neonatal
morbidity and mortality, according to mode of delivery
selected for singleton breech pregnancies at term.
M
ethods
The evidence used for analysis of maternal, perinatal and
neonatal morbidity and mortality, according to mode of
delivery chosen in cases of singleton term pregnancies in
breech presentation, was obtained according to the fol-
lowing steps: preparation of the clinical question, struc-
turing of the question, search for evidence, critical eval-
uation, and selection of evidence.
Clinical question
Is the performance of elective C-section in singleton term
pregnancies in breech presentation related to lower ma-
ternal, peri- and neonatal morbidity and mortality com-
pared with vaginal delivery?
Structured question
The clinical question is structured according to the
P.I.C.O.
components (
P
[Patient];
I
[Intervention];
C
[Compari-
son];
O
[Outcome]).
•
•
P:
Breech pregnancies at term;
•
•
I:
Cesarean-section;
•
•
C:
Vaginal deliver;