thesis on breech presentation

Breech presentation management: A critical review of leading clinical practice guidelines

Affiliations.

• 1 Edith Cowan University; King Edward Memorial Hopsital. Electronic address: [email protected].
• 2 Edith Cowan University.
• PMID: 34253466
• DOI: 10.1016/j.wombi.2021.06.011

Problem: Clinical practice guidelines are designed to guide clinicians and consumers of maternity services in clinical decision making, but recommendations are often consensus based and differ greatly between leading organisations.

Background: Breech birth is a divisive clinical issue, however vaginal breech births continue to occur despite a globally high caesarean section rate for breech presenting fetuses. Inconsistencies are known to exist between clinical practice guidelines relating to the management of breech presentation.

Aim: The aim of this review was to critically evaluate and compare leading obstetric clinical practice guidelines related to the management of breech presenting fetuses.

Methods: Leading obstetric guidelines were purposively obtained for review. Analysis was conducted using the International Centre for Allied Health Evidence (iCAHE) Guideline Quality Checklist and reviewing the content of each guideline.

Findings: Antenatal care recommendations and indications for Caesarean Section were relatively consistent between clinical guidelines. However, several inconsistencies were found among the other recommendations in terms of birth mode counselling, intrapartum management and the basis for recommendations.

Discussion: Inconsistencies noted in the clinical practice guidelines have the potential to cause issues related to valid consent and create confusion among clinicians and maternity consumers.

Conclusion: Clinical practice guidelines, which focus on the risks of a Vaginal Breech Birth without also discussing the risks of a Caesarean Section when a breech presentation is diagnosed, has the potential to sway clinician attitudes and impact birth mode decision-making in maternity consumers. To respect pregnant women's autonomy and fulfil the legal requirements of consent, clinicians should provide balanced counselling.

Keywords: Breech presentation; Clinical practice guidelines; Review.

Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.

Publication types

• Breech Presentation* / therapy
• Cesarean Section
• Delivery, Obstetric / methods
• Parturition
• Practice Guidelines as Topic

Complications and Management of Breech Presentation

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• Joseph V. Collea 7 , 8  

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The increased risk of perinatal morbidity and mortality associated with vaginal delivery of the fetus in breech presentation has attracted the attention of obstetricians and midwives for centuries. From the Dark Ages to well into the nineteenth century, the perinatal morbidity and mortality from birth anoxia, injuries, and congenital malformations instilled in the superstitious and the uneducated the belief that breech presentation was an evil omen. 1 Primitive African tribes believed that breech presentation foretold the death of the child’s parents, 2 while noble attendants to the crowned heads of Europe whispered in birthing rooms that “children brought forth by their feet are cursed—they are born as monsters, crippled in mind and body, and destined to bring misfortune into the world. It would be better if they were not born.” 3

• Cesarean Section
• Vaginal Delivery
• Perinatal Mortality
• Breech Presentation

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Joseph V. Collea

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Aubrey Milunsky MB.B.Ch., M.R.C.P., D.C.H.  & Emanuel A. Friedman M.D.  & 

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Aubrey Milunsky MB.B.Ch., M.R.C.P., D.C.H.

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Louis Gluck M.D.

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Collea, J.V. (1981). Complications and Management of Breech Presentation. In: Milunsky, A., Friedman, E.A., Gluck, L. (eds) Advances in Perinatal Medicine. Springer, Boston, MA. https://doi.org/10.1007/978-1-4757-4451-4_3

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• Published: 08 November 2016

Breech delivery at a University Hospital in Tanzania

• Ulf Högberg 1 ,
• Catrin Claeson 2 ,
• Lone Krebs 3 ,
• Agneta Skoog Svanberg 1 &
• Hussein Kidanto 1 , 4  

BMC Pregnancy and Childbirth volume  16 , Article number:  342 ( 2016 ) Cite this article

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There is a global increase in rates of Cesarean delivery (CD). A minor factor in this increase is a shift towards CD for breech presentation. The aim of this study was to analyze breech births by mode of delivery and investigate short-term fetal and maternal outcomes in a low-income setting.

The study design was cross-sectional and the setting was Muhimbili National Hospital (MNH), Dar-es-Salaam, Tanzania. Subjects were drawn from a clinical database (1999–2010) using the following inclusion criteria: breech presentation, birth weight ≥ 2,500 g, single pregnancy, fetal heart sound at admission, and absence of pregnancy-related complication as indication for CD. Of 2,765 mothers who had a breech delivery, 1,655 met the inclusion criteria. Analyses were stratified by mode of delivery, taking into account also other birth characteristics. The outcome measures were perinatal death (stillbirths + in-hospital neonatal deaths) and moderate asphyxia. Maternal outcomes, such as death, hemorrhage, and length of hospital stay, were also described.

The CD rate for breech presentation increased from 28 % in 1999 to 78 % in 2010. Perinatal deaths were associated with vaginal delivery (VD) (adjusted odds ratio (aOR) 6.2; 95 % confidence interval (CI) 3.0–12.6) and referral (aOR 2.1; 95 % CI 1.1–3.9), but not with parity, birth weight, or delivery year. Overall perinatal mortality was 5.8 % and this did not decline, due to an increase in stillbirths among vaginal breech deliveries. Mothers with CD had more hemorrhage compared to those with VD. One mother died in association with CD, and one died in association with VD.

A breech VD, compared to a breech CD, in this setting was associated with adverse perinatal outcome. However, despite a significant increase in CD rate, no overall improvement was observed due to an increase in stillbirths among VDs.

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In 2000, the Term Breech Trial (TBT) concluded that planned Cesarean delivery (CD) (compared to planned vaginal birth) for breech presentation improved fetal outcome, though only modestly increasing maternal morbidity [ 1 ]. A systematic review in 2015 by Berhan et al. reports a substantial increase in elective CDs for breech presentation in high-income countries since 2000; at the same time, a two- to fivefold risk increase in perinatal mortality and morbidity has been reported with planned vaginal delivery (VD) [ 2 , 3 ].

The TBT reports that, in settings with a low perinatal mortality rate (PMR) (≤ 20/1,000), the rate of perinatal mortality/serious morbidity was 0.4 % for planned CD and 5.3 % for planned vaginal delivery (VD), whereas in settings with a high PMR (> 20/1,000), in one low- and eight middle-income countries, the rate of perinatal mortality/serious morbidity was 2.9 % for planned CD and 4.4 % for VD [ 1 ]. These results challenge the TBT’s conclusions with respect to the effect of planned CD on perinatal outcome in a low-income setting, where CDs for breech presentation are increasing [ 3 ].

Maternal complications, such as blood transfusions, hysterectomy, and admission to the intensive care unit (ICU), as well as death, are estimated to be twice as common in CD as in VD in a low-income setting [ 4 ]. In low-resource settings, the maternal death rate for CD ranges between 0.1 and 1.9 % [ 3 , 5 , 6 ]. According to a study from the Netherlands, the overall maternal fatality rate since the TBT’s conclusions have been published has been 0.25 per 1,000 breech CD and 0.47 per 1,000 planned breech CD [ 7 ].

Vaginal delivery for breech presentation is still a recommended option where possible [ 2 , 8 , 9 ], especially in low-income settings where CD-associated maternal morbidity and mortality are a serious consideration [ 3 , 6 , 10 ]. The few observational studies of breech delivery in sub-Saharan African Hospitals report a wide range of short-term outcomes, reflecting resource constraints and policy differences [ 6 , 11 – 13 ]. There is a lack of continuous statistical surveillance in many busy hospital obstetrics units in low-income settings. More investigation is needed to better understand the consequences of a policy shift in mode of delivery in low-income settings. To this end, we analyzed maternal and fetal outcomes in breech delivery by mode of delivery and birth characteristics, specifically intrapartum fetal deaths, asphyxia, early neonatal deaths, and maternal outcomes. Our study was conducted at a University Hospital in Tanzania, a low-income setting.

This cross-sectional study was performed at a teaching and referral hospital, Muhimbili National Hospital (MNH), in Dar-es-Salaam, Tanzania. Recently, district hospitals in the region have been upgraded, resulting in fewer deliveries at MNH [ 14 ]. At MNH, the CD rate has increased, from 16 % in 1999 [ 15 ] to 49 % in 2011 [ 16 ]. Between 2000 and 2011, CDs for nulliparous and multiparous women increased by 131 and 171 %, respectively [ 16 ].

According to the recommendation from the Ministry of Health and Social Welfare, external cephalic version should be performed at 34–36 weeks in all persistent breech presentations if detected before labor. Breech presentation at admission to the delivery ward is diagnosed by external and internal examination. For primiparas, mode of delivery is based on the size of the fetus and the clinical assessment of the mother. All multiparas without previous CD undergo breech delivery assisted by a senior midwife or obstetrician. Fetal heart rate is monitored using a fetoscope/Doppler device. Mothers with uncomplicated VD are discharged early, usually 6 h after delivery. Indications for CD are a large baby, poor progress, fetal distress, a previous CD, a deformed pelvis, hydrocephalus, or umbilical cord prolapse. Antibiotics are prescribed for emergency CD.

In 1998, an obstetric database was created at MNH, an electronic registry to support research and quality development. To validate the data, a quality control program and manual checks of selected variables are run weekly [ 17 ].

In this study, we selected a sample to investigate perinatal outcomes following breech presentation between 1999 and 2010 (Fig.  1 ). The primary selection from the database was drawn only from the first hierarchy variable giving the maternal diagnosis as “breech” ( N  = 2,765). Although breech presentation was also noted among the second and third maternal diagnostic variables, those subjects had mainly “twin pregnancy” and “hypertension” as first diagnosis. The inclusion criteria included delivery between 1999 and 2010, live fetus at admission, and delivery of a singleton baby with a birth weight (BW) ≥ 2,500 g. Exclusion criteria are described in Fig.  1 . Mothers with conditions ( n  = 74) that were potential indications for CD (e.g., hypertension, eclampsia, antepartum hemorrhage, and abruptio placentae) were excluded.

Flow chart. Inclusion and exclusion criteria for the study sample of breech deliveries at Muhimbili National Hospital (MNH), Dar-es-Salaam, Tanzania, 1999–2010

The final sample consisted of 1,655 breech deliveries. The following patient characteristics were recorded: age, parity, mode of delivery, BW, referral (yes/no), insurance status, and year of delivery (stratified by period). By “referral” is meant whether the mothers had been transferred from a district hospital. Regarding “private insurance,” patients at MNH are either private or public. “Mode of delivery” was categorized into VD or CD. The option “emergency or elective CD” has been available since 2005, but was missing in 75 % of cases, with < 10 % of cases being categorized as “elective;” hence, this option was not used. The variable “mode of delivery” therefore contained information about whether the delivery was a CD, or a spontaneous or assisted breech VD, but only 4 % of VDs were coded into one category together with the assisted breech VDs.

The analysis was stratified by mode of delivery (VD/CD). The other independent variables, parity (primiparous/multiparous), BW (2.5–3.6 kg/3.7–4.7 kg), referral (yes/no), privately insured (yes/no), and year of delivery (1999–2004/2005–2006/2007–2010), were separately analyzed. Five outcome variables were recorded: (1) hemorrhage = blood loss ≥ 1,000 ml; (2) moderate asphyxia = Apgar score < 4 at 5 min (code P21.1B, International Classification of Diseases and Related Health, 10 th revision (ICD10); (3) stillbirth = fetuses with presence of heartbeat at admission, but no sign of vitality at birth; (4) in-hospital neonatal death = death before discharge from MNH; and (5) perinatal death = fetuses with presence of heartbeat at admission, but no sign of vitality at birth, or with death before discharge from MNH.

Data were analyzed in IBM SPSS statistics version 23 (IBM Inc., Armonk, NY, USA) using Pearson’s chi-square test, Fisher’s exact test, and Mantel-Haenszel chi-square test for linear trends. P -values < 0.05 were considered statistically significant. Crude odds ratios (ORs) and 95 % confidence intervals (95 % CIs) were calculated. In the final model of the multivariate analysis by logistic regression, relevant exposure variables were included when estimating adjusted odds ratios (aORs).

In our sample of 1,655 women with breech presentation, 908 (54.8 %) had a VD and 747 (45.1 %) had a CD (Fig.  1 ). The rate of CDs for breech increased from 28 % in 1999 to 78 % in 2010 (Fig.  2 ).

Cesarean delivery (CD) rate for breech presentation at Muhimbili National Hospital (MNH), Dar-es-Salaam, Tanzania, 1999–2010

The percentage alive at discharge was 97.5 % for the CD group and 91.5 % for the VD group. In the CD group, rates of stillbirths, in-hospital neonatal deaths, and asphyxia were 1.6, 0.9, and 0.7 %, respectively; in the VD group, corresponding rates were 3.9, 4.6, and 3.3 %. All differences were statistically significant (Table  1 ). Every eleventh vaginally delivered infant died, compared to every 39th infant delivered by Cesarean section. Cause of death was registered in approximately half of the infants who did not survive. The vast majority in both groups (84 %) died from birth asphyxia. Both the CD and the VD groups had one death due to meconium aspiration. In the VD group, there were two deaths from severe hypoxic ischemic encephalopathy (HIE) and three from “prematurity-related complications,” although these cases met our inclusion criteria.

Cesarean delivery was associated with fewer stillbirths, in-hospital neonatal deaths, and moderate asphyxia, irrespective of parity, presence or absence of referral, BW (2.5–3.6 kg), and insurance status. For infants with BW between 3.7 and 4.7 kg, CD was associated with less moderate asphyxia (Table  1 ). Regarding year of delivery, there was an increasing trend, over time, of stillbirths among VD breech babies of women not referred, but not of in-hospital neonatal deaths. The low survival of VD breech babies referred to MNH did not change over time. For breech babies delivered by Cesarean section, there were no changes over time in survival with respect to whether the mother had been referred or not (Table  2 ).

Adjusted OR for perinatal death for VD breech was 6.2 (95 % CI 3.0–12.6) and for referral, 2.05 (95 % CI 1.09–3.86). Neither parity, nor BW, insurance status, or year of delivery was associated with perinatal death with respect to mode of delivery (Table  3 ).

Hemorrhage was more common for the CD (7.2 %) than the VD group (1.0 %) ( p  = 0.0001). There were two maternal deaths: in the CD group, one mother died from “anesthetic complications;” in the VD group, one mother died from a ruptured uterus.

This study is one of the few studies to analyze, in a large sample, the difference in outcome between breech VD and breech CD in a low-income country. During the study period, there was an almost threefold increase in breech CDs. The risks of perinatal death and moderate asphyxia were significantly higher among infants delivered vaginally; and for perinatal death, they were higher if the mother had been referred, irrespective of parity, BW, insurance status, and delivery year. Despite the increase in breech CDs, overall perinatal mortality in breech births did not decrease as there was an increase in stillbirths among vaginally delivered breech babies.

In agreement with earlier studies, the present study shows improved fetal outcome for breech fetuses, in terms of intrapartum deaths, early neonatal deaths, and asphyxia, when delivered by CD compared to VD [ 1 , 2 , 4 , 8 ]. Results from other, similar settings do not, however, completely agree with our findings. Studies from Guinea and Nigeria found low Apgar scores to be more frequent among VD than CD for breech presentation [ 12 , 13 , 18 ] although the Guinean study showed no difference in PMR between the groups [ 18 ]. As in our study, a study from Zimbabwe demonstrated a significant reduction in PMR for breech presentation (OR 5.4, p  < 0.001), but saw no correlation between changes in CD rate and PMR [ 6 ]. In 2006, a Nigerian study showed a significant reduction in PMR for infants of primigravidae with BW > 3,500 g when delivered by CD compared to VD [ 11 ].

The almost threefold increase in CD rate for breech presentation was not associated with an overall improvement in breech births or improved survival for breech-delivered infants. This is contrary to the TBT study and other studies in Western settings [ 1 , 8 , 19 , 20 ]. One explanation, at least a partial explanation, for this difference might be selection bias, as there was a gradual improvement in maternity care in Dar-es-Salaam as the surrounding district hospitals improved [ 17 ]. Muhimbili National Hospital had a 40 % decrease in deliveries between 2000 and 2002 and between 2009 and 2011, which was concomitant to an increase in referral cases, from 7 to 28 % [ 16 ]. The higher proportion of referred patients also includes patients with breech presentation in labor, and they had worse outcome, irrespective of mode of delivery. Another reason for this difference could have been reduced staff skills in assisted breech delivery, as, in our sample, the number of vaginal breech deliveries decreased from three per week to one every 2 weeks [ 3 ]. Van Roosmalen and Meguid highlight that settings that increasingly use CD may not have trained staff with the skills to assist vaginal breech delivery, and that this staff will need skills training in this area [ 3 ]. Hannah et al. found that planned CD for breech presentation did not reduce serious morbidity in newborns in high-PMR countries as much as in low-PMR countries. They recognized the possibility of the caregivers being more experienced in breech deliveries in the low-PMR countries, which traditionally have low CD rates [ 1 ].

It is unclear how selection for the two different modes of delivery in this study was carried out. Women who delivered vaginally might have represented good candidates for a trial of labor, although facilities for such assessments are not the same at MNH as in a facility in a high-income country. Lead time from decision to operate can in this low-income setting be extended by several hours [ 21 ], meaning that VDs could represent a group of most urgent cases that did not make the necessary conversion to CD. This might be one explanation for the clustering of VD stillbirths, indicating the difficult conditions prevailing in this setting, especially as the study sample comprised of presumed intrapartal deaths. Birth asphyxia was the cause of neonatal death for all CDs and nine out of ten VDs.

Mothers with private insurance had excellent reported perinatal outcomes, which might indicate socioeconomic disparities and/or different quality of care. However, they constituted only 6 % of the sample, and did not influence the overall results.

As expected, women with CD suffered from hemorrhage more often, and one out of 25 had significant blood loss. One maternal death was caused by anesthetic complications. We had no information about postoperative complications such as rupture of the wound, infection, thromboembolism, or readmissions. Lack of registrated postpartum complications is a major weakness of the study as it makes it difficult to properly evaluate risks connected to CD. In high-income settings, 17 % of CDs may be complicated by maternal infectious morbidity [ 22 ]; the TBT study found a postpartum systemic infection rate of 1.5 % and a wound infection rate of 1.5 % for CD [ 1 ]. However, Litorp et al. report, in a study conducted at MNH in 2012 and published in 2014, an overall CD complication risk per 1,000 operations for maternal death of 1.0 (0.1–3.6) and for life-threatening complications of 6.0 (3.1–10) [ 5 ]. Based on these figures, two to four cases of life-threatening complications among CDs in this study could have occurred in this sample [ 5 ].

Consideration of complications is important when assessing indications for CD in developing countries and these should be weighed against the benefits of operation. The risk of uterine rupture is increased by up to 35 times for women in labor who have had a previous CD, compared to no history of CD [ 23 ]. Placenta accreta is three times more common in women with previous CD [ 24 ]. However, neither short-term complications after discharge nor long-term outcome could be addressed in this study.

In a cost-effectiveness analysis of strategies for maternal and neonatal health in developing countries, CD performed for breech presentation, obstructed labor, and fetal distress in conjunction with emergency neonatal care was estimated to be cost-effective in East African and South East Asian countries [ 25 ]. A cost analysis of hospital deliveries in low-PMR countries that was conducted in 2006 reports that, with regard to breech presentation, CD was less expensive compared to VD (US$7,165 versus US$8,042) [ 26 ].

Concerns about the increasing CD rates in low-income countries have been raised [ 4 , 6 , 10 , 16 , 27 ], although breech presentation represents a small percentage (1.7 %) of indications for CD at MNH and although breech benefits from CD [ 1 , 4 , 11 , 12 , 25 ]. Vaginal delivery of breech presentation still remains an option and the systematic review by Berhan et al. supports “the practice of individualised decision-making on the route of delivery” [ 2 ].

One strength of this study is its unique database: All the deliveries were performed in a busy University Hospital in a low-income setting. However, the database has limitations. There may have been underreporting of breech deliveries. Also, it was not possible to determine whether the decision to perform CD was made before or during labor; this could not be analyzed because the variable “elective/emergency” was missing in 75 % of cases. Most of the decisions to perform CDs were probably made during labor, which may explain the high mortality and morbidity rate related to CD in this setting.

We were unable to describe early neonatal mortality. Discharge is normally 6 h after a VD and 3 days after a CD, so the rate of neonatal deaths may have been underestimated, especially among the VD cases.

In conclusion, this study in a Tanzanian population shows that CD for breech presentation was associated with improved perinatal outcome, but that there was no overall improvement in perinatal outcome for breech presentation. Indications for CD should always be carefully evaluated, but this is especially important in resource-poor settings such as sub-Saharan Africa. Skills training for assisted vaginal breech delivery needs to be strengthen and maintained.

Key message

Cesarean delivery for breech in a Tanzanian University Hospital was associated with improved perinatal outcome. Overall mortality was, however, unchanged due to an increase in stillbirth among vaginal deliveries.

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Acknowledgement

We acknowledge Muhimbili National Hospital for their approval to use the electronic registry for this study.

No funding received for this study.

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Authors’ contributions

UH and HK had the primary responsibility of the study design, acquisition of data, analysis, and interpretation of the study results, and revised the manuscript. CC performed the primary data analysis, interpretation of the results and writing the manuscript. LK and ASS contributed to the analysis and interpretation of the data and study results and revised the manuscript. All authors have read and approved the final manuscript.

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Högberg, U., Claeson, C., Krebs, L. et al. Breech delivery at a University Hospital in Tanzania. BMC Pregnancy Childbirth 16 , 342 (2016). https://doi.org/10.1186/s12884-016-1136-0

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Review question

What is the effectiveness of routine scanning between 36+0 and 38+6 weeks of pregnancy compared to standard care regarding breech presentation?

Introduction

Breech presentation in late pregnancy may result in prolonged or obstructed labour for the woman. There are interventions that can correct or assist breech presentation which are important for the woman’s and the baby’s health. This review aims to determine the most effective way of identifying a breech presentation in late pregnancy.

Summary of the protocol

Please see Table 1 for a summary of the Population, Intervention, Comparison and Outcome (PICO) characteristics of this review.

Summary of the protocol (PICO table).

For further details see the review protocol in appendix A .

Methods and process

This evidence review was developed using the methods and process described in Developing NICE guidelines: the manual 2014 . Methods specific to this review question are described in the review protocol in appendix A .

Declarations of interest were recorded according to NICE’s conflicts of interest policy .

Clinical evidence

Included studies.

One single centre randomised controlled trial (RCT) was included in this review ( McKenna 2003 ). The study was carried out in Northern Ireland, UK. The study compared ultrasound examination at 30-32 and 36-37 weeks with maternal abdomen palpation during the same gestation period. The intervention group in the study had the ultrasound scans in addition to the abdomen palpation, while the control group had only the abdomen palpation. Clinical management options reported in the study based on the ultrasound scan or the abdomen palpation include referral for full biophysical assessment which included umbilical artery Doppler ultrasound, early antenatal review, admission to antenatal ward, and induction of labour.

The included study is summarised in Table 2 .

See the literature search strategy in appendix B and study selection flow chart in appendix C .

Excluded studies

Studies not included in this review are listed, and reasons for their exclusion are provided in appendix K .

Summary of clinical studies included in the evidence review

Summaries of the studies that were included in this review are presented in Table 2 .

Summary of included studies.

See the full evidence tables in appendix D . No meta-analysis was conducted (and so there are no forest plots in appendix E ).

Quality assessment of clinical outcomes included in the evidence review

See the evidence profiles in appendix F .

Economic evidence

One study, a cost utility analysis was included ( Wastlund 2019 ).

See the literature search strategy in appendix B and economic study selection flow chart in appendix G .

Studies not included in this review with reasons for their exclusions are provided in appendix K .

Summary of studies included in the economic evidence review

For full details of the economic evidence, see the economic evidence tables in appendix H and economic evidence profiles in appendix I .

Wastlund (2019) assessed the cost effectiveness of universal ultrasound scanning for breech presentation at 36 weeks’ gestational age in nulliparous woman (N=3879). The comparator was selective ultrasound scanning which was reported as current practice. In this instance, fetal presentation was assessed by palpation of the abdomen by a midwife, obstetrician or general practitioner. The sensitivity of this method ranges between 57%-70% whereas ultrasound scanning is detected with 100% sensitivity and 100% specificity. Women in the selective ultrasound scan arm only received an ultrasound scan after detection of a breech presentation by abdominal palpation. Where a breech was detected, a woman was offered external cephalic version (ECV). The structure of the model undertook a decision tree, with end states being the mode of birth; either vaginal, elective or emergency caesarean section. Long term health outcomes were modelled based on the mortality risk associated with each mode of birth. Average lifetime quality-adjusted life years (QALYs) were estimated from Euroqol general UK population values.

Only the probabilistic results (n=100000 simulations) were reported which showed that on average, universal ultrasound resulted in an absolute decrease in breech deliveries by 0.39% compared with selective ultrasound scanning. The expected cost per person with breech presentation of universal ultrasound was £2957 (95% Credibility Interval [CrI]: £2922 to £2991), compared to £2,949 (95%CrI: £2915 to £2984) from selective ultrasound. The expected QALYs per person was 24.27615 in the universal ultrasound cohort and 24.27582 in the selective ultrasound cohort. The incremental cost effectiveness ratio (ICER) from the probabilistic analysis was £23611 (95%CrI: £8184 to £44851).

A series of one-way sensitivity analysis were conducted which showed that the most important cost parameter was the unit cost of a universal ultrasound scan. This parameter is particularly noteworthy as the study costed this scan at a much lower value than the ‘standard antenatal ultrasound’ scan in NHS reference costs on the basis that such a scan can be performed by a midwife during a routine antenatal care visit in primary care. According to the NICE guideline manual economic evaluation checklist this model was assessed as being directly applicable with potentially severe limitations. The limitations were mostly attributable to the limitations of the clinical inputs.

Economic model

No economic modelling was undertaken for this review because the committee agreed that other topics were higher priorities for economic evaluation.

Evidence statements

Clinical evidence statements, comparison 1. routine ultrasound scan versus selective ultrasound scan, critical outcomes, unexpected breech presentation in labour.

No evidence was identified to inform this outcome.

Mode of birth

• Moderate quality evidence from 1 RCT (N=1993) showed that there is no clinically important difference between routine ultrasound scan at 36-37 weeks and selective ultrasound scan on the number of women who had elective caesarean section: RR 1.22 (95% CI 0.91 to 1.63).
• Moderate quality evidence from 1 RCT (N=1993) showed that there is no clinically important difference between routine ultrasound scan at 36-37 weeks and selective ultrasound scan on number of women who had emergency caesarean section: RR 1.20 (95% CI 0.90 to 1.60).
• High quality evidence from 1 RCT (N=1993) showed that there is no clinically important difference between routine ultrasound scan at 36-37 weeks and selective ultrasound scan on number of women who had vaginal birth: RR 0.95 (95% CI 0.89 to 1.01).

Important outcomes

Maternal anxiety, women’s experience and satisfaction of care, gestational age at birth.

• High quality evidence from 1 RCT (N=1993) showed that there is no clinically important difference between routine ultrasound scan at 36-37 weeks and selective ultrasound scan on the number of babies’ born between 39-42 gestational weeks: RR 0.98 (95% CI 0.94 to 1.02).

Admission to neonatal unit

• Low quality evidence from 1 RCT (N=1993) showed that there is no clinically important difference between routine ultrasound scan at 36-37 weeks and selective ultrasound scan on the number of babies admitted into the neonatal unit: RR 0.83 (95% CI 0.51 to 1.35).

Economic evidence statements

One directly applicable cost-utility analysis from the UK with potentially serious limitations compared universal ultrasound scanning for breech presentation at 36 weeks’ gestational age with selective ultrasound scanning, stated as current practice. Universal ultrasound scanning was found to be borderline cost effective; the incremental cost-effectiveness ratio was £23611 per QALY gained. The cost of the scan was seen to be a key driver in the cost effectiveness result.

The committee’s discussion of the evidence

Interpreting the evidence, the outcomes that matter most.

Unexpected breech presentation in labour and mode of birth were prioritised as critical outcomes by the committee. This reflects the different options available to women with a known breech presentation in pregnancy and the different choices that women make. There are some women and/or clinicians who may feel uncomfortable with the risks of aiming for vaginal breech birth, and for these women and/or clinicians avoiding an unexpected breech presentation in labour would be the preferred option.

As existing evidence suggests that aiming for vaginal breech birth carries greater risk to the fetus than planned caesarean birth, it is important to consider whether earlier detection of the breech presentation would reduce the risk of these outcomes.

The committee agreed that maternal anxiety and women’s experience and satisfaction of care were important outcomes to consider as the introduction of an additional routine scan during pregnancy could have a treatment burden for women. Gestational age at birth and admission to neonatal unit were also chosen as important outcomes as the committee wanted to find out whether earlier detection of breech presentation would have an impact on whether the baby was born preterm, and as a consequence admitted to the neonatal unit. These outcomes were agreed to be important rather than critical as they are indirect outcomes of earlier detection of breech presentation.

The quality of the evidence

The quality of the evidence ranged from low to high. Most of the evidence was rated high or moderate, with only 1 outcome rated as low. The quality of the evidence was downgraded due to imprecision around the effect estimates for emergency caesarean section, elective caesarean section and admissions to neonatal unit.

No evidence was identified for the following outcomes: unexpected breech presentation in labour, maternal anxiety, women’s experiences and satisfaction of care.

The committee had hoped to find evidence that would inform whether early identification of breech presentation had an impact on preterm births, and although the review reported evidence for gestational age as birth, the available evidence was for births 39-42 weeks of gestation.

Benefits and harms

The available evidence compared routine ultrasound scanning with selective ultrasound scanning, and found no clinically important differences for mode of birth, gestational age at birth, or admissions to the neonatal unit. However, the committee discussed that it was important to note that the study did not focus on identifying breech presentation. The committee discussed the differences between the intervention in the study, which was an ultrasound scan to assess placental maturity, liquor volume, and fetal weight, to an ultrasound scan used to detect breech presentation. Whilst the ultrasound scan in the study has the ability to determine breech presentation, there are additional and costlier training required for the assessment of the other criteria. As such, it is important to separate the interventions. The committee also highlighted that the study did not look at whether an identification of breech presentation had an impact on the outcomes which were selected for this review.

In light of this, the committee felt that they were unable to reach a conclusion as to whether routine scanning to identify breech presentation, was associated with any benefits or harms. The committee agreed that while this review suggests routine ultrasound scanning to be no more effective than selective scanning, it does not definitively establish equivalence. Therefore, the committee agreed to recommend a continuation of the current practice with selective scanning and make a research recommendation to compare the clinical and cost effectiveness of routine ultrasound scanning versus selective ultrasound scanning from 36 weeks to identify fetal breech presentation.

Cost effectiveness and resource use

The committee acknowledged that there was included economic evidence on the effectiveness of routine scanning between 36+0 and 38+6 weeks of pregnancy compared to standard care regarding breech presentation.

The 1 included study suggested that offering a routine scan for breech is borderline cost effective. A key driver of cost effectiveness was the cost of the scan, which was substantially lower in the economic model than the figure quoted in NHS reference costs for routine ultrasound scanning. The committee noted that a scan for breech presentation only is a simpler technique and uses a cheaper machine. The committee agreed that the other costing assumptions presented in the study seemed appropriate.

However, the committee expressed concerns about the cohort study which underpinned the economic analysis which had a high risk of bias. The committee noted that a number of assumptions in the model which were key drivers of cost effectiveness, including the palpation diagnosis rates and prevalence of breech position, were from this 1 cohort study. This increased the uncertainty around the cost effectiveness of the routine scan. The committee also noted that, whilst the cost of the scan was fairly inexpensive, the resource impact would be substantial if a routine scan for breech presentation was offered to all pregnant women.

Overall, the committee felt that the clinical and cost effectiveness evidence presented was not strong enough to recommend offering a routine ultrasound scan given the potential for a significant resource impact. The recommendation to offer abdominal palpation to all pregnant women, and to offer an ultrasound scan where breech is suspected reflects current practice and so no substantial resource impact is anticipated.

McKenna 2003

Wastlund 2019

Appendix A. Review protocols

Review protocol for review question: What is the effectiveness of routine scanning between 36+0 and 38+6 weeks of pregnancy compared to standard care regarding breech presentation? (PDF, 244K)

Appendix B. Literature search strategies

Literature search strategies for review question: What is the effectiveness of routine scanning between 36+0 and 38+6 weeks of pregnancy compared to standard care regarding breech presentation? (PDF, 370K)

Appendix C. Clinical evidence study selection

Clinical study selection for review question: What is the effectiveness of routine scanning between 36+0 and 38+6 weeks of pregnancy compared to standard care regarding breech presentation? (PDF, 117K)

Appendix D. Clinical evidence tables

Clinical evidence tables for review question: What is the effectiveness of routine scanning between 36+0 and 38+6 weeks of pregnancy compared to standard care regarding breech presentation? (PDF, 213K)

Appendix E. Forest plots

Forest plots for review question: what is the effectiveness of routine scanning between 36+0 and 38+6 weeks of pregnancy compared to standard care regarding breech presentation.

This section includes forest plots only for outcomes that are meta-analysed. Outcomes from single studies are not presented here, but the quality assessment for these outcomes is provided in the GRADE profiles in appendix F .

Appendix F. GRADE tables

GRADE tables for review question: What is the effectiveness of routine scanning between 36+0 and 38+6 weeks of pregnancy compared to standard care regarding breech presentation? (PDF, 196K)

Appendix G. Economic evidence study selection

Economic evidence study selection for review question: what is the effectiveness of routine scanning between 36+0 and 38+6 weeks of pregnancy compared to standard care regarding breech presentation.

A single economic search was undertaken for all topics included in the scope of this guideline. One economic study was identified which was applicable to this review question. See supplementary material 2 for details.

Appendix H. Economic evidence tables

Economic evidence tables for review question: What is the effectiveness of routine scanning between 36+0 and 38+6 weeks of pregnancy compared to standard care regarding breech presentation? (PDF, 143K)

Appendix I. Economic evidence profiles

Economic evidence profiles for review question: What is the effectiveness of routine scanning between 36+0 and 38+6 weeks of pregnancy compared to standard care regarding breech presentation? (PDF, 129K)

Appendix J. Economic analysis

Economic evidence analysis for review question: what is the effectiveness of routine scanning between 36+0 and 38+6 weeks of pregnancy compared to standard care regarding breech presentation.

No economic analysis was conducted for this review question.

Appendix K. Excluded studies

Excluded clinical and economic studies for review question: what is the effectiveness of routine scanning between 36+0 and 38+6 weeks of pregnancy compared to standard care regarding breech presentation, clinical studies, table 8 excluded studies and reasons for their exclusion.

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Economic studies

A single economic search was undertaken for all topics included in the scope of this guideline. No economic studies were identified which were applicable to this review question. See supplementary material 2 for details.

Appendix L. Research recommendations

Research recommendations for review question: What is the effectiveness of routine scanning between 36+0 and 38+6 weeks of pregnancy compared to standard care regarding breech presentation? (PDF, 164K)

Evidence reviews underpinning recommendations 1.2.36 to 1.2.37

These evidence reviews were developed by the National Guideline Alliance, which is a part of the Royal College of Obstetricians and Gynaecologists

Disclaimer : The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.

Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.

NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government , Scottish Government , and Northern Ireland Executive . All NICE guidance is subject to regular review and may be updated or withdrawn.

• Cite this Page National Guideline Alliance (UK). Identification of breech presentation: Antenatal care: Evidence review L. London: National Institute for Health and Care Excellence (NICE); 2021 Aug. (NICE Guideline, No. 201.)
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• NICE Evidence Reviews Collection

Related NICE guidance and evidence

• NICE Guideline 201: Antenatal care

Supplemental NICE documents

• Supplement 1: Methods (PDF)
• Supplement 2: Health economics (PDF)

Related information

• PMC PubMed Central citations
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