Singleton breech presentation at term: Review of the evidence and international guidelines for application to the New Zealand context

Abstract

Background: Over the last few decades the management of a breech baby at term has been immersed in controversy. It is important that New Zealand midwives and doctors have sufficient understanding of the evidence to be able to effectively counsel women to make an informed decision when a baby presents in a breech position at term. Aims: To review the evidence and international guidance related to mode of birth for singleton breech presentation at term, identify the current evidence and gaps in knowledge and highlight how the evidence can be used to support women within the New Zealand context of maternity care. Method: We searched Scopus, PubMed and the Cochrane Database of Systematic Reviews for peer reviewed publications about term breech presentation. The search terms used were "breech presentation" and "term". Limiters were set for the time period between 2000 and 2015, English language, human pregnancies, and peer reviewed journals. Findings: We found 456 published papers covering breech presentation related to clinical outcomes, professional commentaries, professional guidelines and the woman's perspectives. We identified and retrieved 37 papers as relevant to our search criteria. We report specifically on the papers that provided professional commentary (detailed critique of the evidence), clinical studies, systematic reviews, meta-analyses and professional guidelines. Following the publication of the Term Breech Trial there was a change in practice to that of recommending planned caesarean section for term breech presentation. Subsequent critiques and reviews have identified concerns with the study which undermine its reliability. Further retrospective/ prospective studies, a systematic review and a meta-analysis have demonstrated equivocal results and suggest that perinatal mortality during vaginal breech births can be reduced when strict criteria are applied and an experienced clinician is involved. Many professional guidelines now advise that offering women the option of a vaginal breech birth is reasonable. Conclusion: New Zealand midwives and doctors need to be in a position to inform women with breech presenting babies about factors that support the safety of vaginal breech birth, as well as about the benefits and potential harms of both caesarean section and vaginal breech birth, to support their decision making.