Abstract
Introduction
The optimal mode of delivery for vaginal breech presentation remains a clinical dilemma. Planned vaginal delivery offers maternal advantages because it avoids major abdominal surgery and has no consequences for following pregnancies, while elective cesarean delivery proves advantageous for the neonate because adverse outcomes are less frequent. Patient selection for vaginal breech delivery is important based on the individual risk balance. A lack of consensus exists regarding the specific contraindications for vaginal breech delivery, largely due to limited scientific evidence. This systematic review aims to give an overview of contraindications for vaginal breech delivery, as presented in guidelines, analyze relevant literature, and offer evidence‐based recommendations for the contraindications stated in the guidelines.
Material and Methods
To identify national guidelines PubMed, the Cochrane Central Register of Controlled Trials, EMBASE, NICE, UpToDate, and ClinicalKey were searched using two keywords: “breech presentation” and “vaginal delivery.” We systematically reviewed the literature for existing evidence for contraindications for term vaginal breech delivery. The following databases were searched: PubMed (April 2024), the Cochrane Central Register of Controlled Trials, and EMBASE (1947 to 2024).
Results
Our search identified eight guidelines that stated a total of 11 contraindications for vaginal breech delivery. Among these guidelines, agreement was limited, with the sole consensus in all guidelines on the contraindication of footling breech. Our comprehensive literature search yielded 43 articles discussing 14 potential contraindications. We found supportive evidence for 7 of 11 contraindications from the guidelines, with only substantial and satisfactory evidence for two contraindications.
Conclusions
The findings of this study underscore the lack of consensus among national guidelines regarding contraindications for term vaginal breech delivery. Furthermore, we found a notable lack of substantial scientific evidence to support these contraindications. In light of these findings, we suggest a reduced list of contraindications in vaginal breech deliveries.
Keywords: contraindication, fetal breech position, guidelines, systematic review, vaginal breech delivery
There is little consensus between national guidelines on vaginal breech delivery and all are based on limited scientific evidence. We propose a list of contraindications limited to those with ample evidence: fetal growth restriction and footling breech.
Abbreviations
- CD
cesarean delivery
- VBD
vaginal breech delivery
Key message.
There is little consensus between national guidelines on vaginal breech delivery based on limited scientific evidence. We propose a list of contraindications limited to those with ample evidence.
1. INTRODUCTION
Catalyzed by the publication of the Term Breech Trial, common practice of mode of delivery in term breech pregnancy worldwide shifted strongly from a planned vaginal breech delivery (VBD) to a planned cesarean delivery (CD). 1 , 2 , 3 This randomized multicenter controlled trial demonstrated decreased composite adverse perinatal outcome with planned CD than with planned VBD (relative risk 0.33 [95% CI 0.19 to 0.56]). 4 However, the findings of the Term Breech Trial have been disputed by other cohort studies. 5 , 6 , 7 , 8 The PREMODA study, the largest prospective cohort study on this matter, showed that term VBD under the guidance of experienced physicians is as safe as CD. 9 Based on the advantages and disadvantages of both modes of delivery, and the remaining scientific uncertainty, the preferred mode of delivery in term breech pregnancies remains the topic of an ongoing clinical debate. 5 , 9 , 10
In the process of shared decision‐making, evidence‐based counseling is required for patient to make an informed choice. At the outset, patient selection by means of contraindications for term VBD could be helpful, if they are robust and backed up by empirical evidence.
With this systematic review, the primary objective was to get a clear oversight of contraindications for term VBD in national guidelines. Secondly, we aimed to systematically review the literature for evidence supporting the reported contraindications. Thirdly, we aimed to provide robust scientific recommendations of contraindications for vaginal delivery.
2. MATERIAL AND METHODS
For this systematic review, we followed the PRISMA guideline and executed the corresponding steps. 11
2.1. Search
2.1.1. Guidelines
To identify all guidelines, PubMed (April 2024), the Cochrane Central Register of Controlled Trials, EMBASE (1947 to 2024), NICE (2024), UpToDate, and ClinicalKey were searched for national guidelines on vaginal breech delivery.
2.1.2. Literature
The following databases were searched for studies reporting on term VBD and cited contraindications using keywords: “breech presentation” and “vaginal delivery,” PubMed (April 2024), the Cochrane Central Register of Controlled Trials, and EMBASE (1947 to April 2024). Synonymous terms were included and terms were combined using Boolean operators. References from identified publications were manually searched to identify additional relevant articles. Additionally, for all contraindications found in the guidelines and the literature, an additional search was executed with keywords from the contraindications to find all relevant literature. All studies written in English or Dutch were included and no time restrictions were applied. A list of all in‐ and exclusion criteria is shown in the appendix.
2.1.3. Screening and selection of studies
Studies were selected in a two‐stage process. First, two reviewers (M.D. and C.P.) independently screened all titles and abstracts of any reference possibly reporting on contraindications for vaginal term breech delivery. For all selected studies, full manuscripts were obtained. Secondly, the same reviewers independently evaluated the full manuscripts and extracted contraindications for vaginal term breech delivery. Any disagreements in the selection process were resolved by consensus and, if necessary, by a third reviewer (J.V.).
2.2. Evidence synthesis for contraindications
2.2.1. Identifying contraindications
A list of potential contraindications was extracted from the national guidelines and included studies. The included studies were critically appraised by using the Newcastle‐Ottawa Scale, a 9‐point system for assessing the quality of non‐randomized studies in meta‐analyses. 12 , 13 The scale was divided into three categories: good, fair, and poor.
All possible contraindications were divided into three predetermined categories: fetal, maternal, and setting‐related factors. For each included study, necessary characteristics and outcomes were extracted on piloted data‐extraction forms.
2.2.2. Grading
To compile a list of contraindications for vaginal breech delivery, supported by robust scientific evidence, a grading system was used to show the strength of evidential support for each contraindication. 14 , 15 This grading involved an initial assessment based on study type (as presented in Table S1) and a subsequent consideration of consensus percentages between studies. Consistency thresholds were established, classifying findings as consistent (≥75% agreement), generally consistent (50%–75% agreement), or inconsistent (<50% agreement). The synthesis of these elements determined the grade of recommendation, presented in Table S2, wherein Grade A signified a strong recommendation and Grade D represented an optional recommendation.
3. RESULTS
3.1. Search
3.1.1. Guidelines
The search for guidelines yielded eight national guidelines on breech management. 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23
Table 1 shows an overview of all contraindications reported in the national guidelines. The Dutch Society of Obstetricians and Gynecologists and the American College of Obstetricians and Gynecologists did not state any contraindications in their respective guidelines. There are 11 different contraindications mentioned in the six other national guidelines. The number of contraindications mentioned per guideline ranged from four (in the French guideline) to eight (in the British guideline). Footling breech presentation is the only reported contraindication mentioned in the six guidelines. Hyperextension of the fetal head and fetal growth restriction are both included in five of six guidelines. Of the six guidelines that stated contraindications, all mentioned a maximum estimated fetal weight as a contraindication: above 3.8 kg in four guidelines and above 4 kg in the other two. Cord presentation, fetal anomaly, and antenatal fetal compromise are mentioned in three guidelines. Only two guidelines claim that a clinically inadequate maternal pelvis, limited access to experienced personnel, or an existing indication for a CD is a contraindication for a vaginal breech delivery.
TABLE 1.
Overview of contraindications for term breech delivery in seven international guidelines.
| Contraindications | Guidelines | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| RCOG a | SOGC b | RANZCOG c | IOGRCPI d | DSOG e | CNGOF f | NVOG g | ACOG h | Contraindication mentioned (n) | ||
| 1 | Footling breech presentation | + | + | + | + | + | + | − | − | 6 |
| 2 | Hyperextended fetal head | + | + | + | − | + | + | − | − | 5 |
| 3 | Fetal growth restriction | + | + | + | + | + | − | − | − | 5 |
| 4 | Estimated fetal weight >3.8 kg | + | − | + | + | − | + | − | − | 4 |
| 5 | Cord presentation | − | + | + | − | + | − | − | − | 3 |
| 6 | Fetal anomaly likely to interfere with vaginal delivery | + | + | + | − | − | − | − | − | 3 |
| 7 | Antenatal fetal compromise | + | − | + | + | − | − | − | − | 3 |
| 8 | Estimated fetal weight >4 kg | − | + | − | − | + | − | − | − | 2 |
| 9 | Clinically inadequate maternal pelvis | − | + | − | − | − | + | − | − | 2 |
| 10 | Limited access to experienced personnel | + | − | − | + | − | − | − | − | 2 |
| 11 | Existing indication for cesarean section | + | − | − | + | − | − | − | − | 2 |
| Contraindications per guideline (n) | 8 | 7 | 7 | 6 | 5 | 4 | 0 | 0 | ||
RCOG Royal College Obstetricians and Gynecologists.
SOGC Society of Obstetricians and Gynecologists of Canada.
RANZCOG Royal Australian New Zealand College of Obstetricians and Gynecologists.
IOGRCPI Institute of Obstetricians and Gynecologists Royal College of Physicians of Ireland.
DSOG Danish Society of Obstetrics and Gynecology.
NVOG Dutch Society of Obstetricians and Gynecologists.
ACOG The American College of Obstetricians and Gynecologists.
CNGOF French Society of Obstetricians and Gynecologists.
3.2. Literature
Figure 1 shows the flowchart of included studies. The search yielded 992 studies. After removing duplicates and screening of title and abstract, 228 studies were retrieved for complete assessment. Another 188 studies were excluded after reading full text since no contraindication on VBD at term was mentioned. The additional search per contraindication added four more studies. A total of 43 studies were included in this review.
FIGURE 1.
Flowchart of literature search and included studies.
3.3. Evidence synthesis for contraindications
3.3.1. Identifying contraindications
In the literature, we found 14 different possible contraindications for VBD, of which 7 (50%) are mentioned in guidelines. Contraindications mentioned in the literature but not in any of the guidelines included: primigravid, vaginal breech delivery after cesarean section, estimated large fetal head, labor augmentation, <1500 annual births in the hospital, duration of second stage of labor, and induction.
Results of the critical appraisal are shown in Table S3. All included studies were cohort studies, 25 studies were considered good quality, 8 were fair quality, and 10 were poor quality, according to the Newcastle‐Ottawa Scale. Table 2 shows all contraindications reported in national guidelines and literature categorized by the three predetermined categories: fetal, maternal, and setting. All relevant reported outcomes of the included studies on the contraindication in their predetermined category are shown in Table S4.
TABLE 2.
Overview of all contraindications for term breech delivery reported in guidelines and literature.
| Guidelines (No. of guidelines) | Literature | |
|---|---|---|
| Fetal | Footling breech presentation (6) | Footling breech presentation |
| Hyperextended fetal head (5) | Hyperextended fetal head | |
| Fetal growth restriction (5) | Fetal growth restriction | |
| Estimated fetal weight > 3.8 kg (4) | Estimated fetal weight > 3.8 kg | |
| Estimated fetal weight > 4 kg (2) | Estimated fetal weight > 4 kg | |
| Fetal anomaly likely to interfere with vaginal delivery (3) | Estimated large fetal head | |
| Antenatal fetal compromise (3) | ||
| Cord presentation (3) | ||
| Maternal | Clinically inadequate maternal pelvis (2) | Clinically inadequate maternal pelvis |
| Primigravid | ||
| Vaginal breech delivery after cesarean section | ||
| Other | Limited access to experienced personnel (2) | Labor augmentation |
| Existing indication for cesarean section (2) | Limited access to experienced personnel | |
| <1500 births | ||
| Duration of second stage of labor | ||
| Induction |
The number of studies in favor or not in favor of each reported contraindication is demonstrated in Figure 2. This shows that 11 of the 43 included studies in this review report on primigravida as a possible contraindication for vaginal breech delivery. Only 1 of the 43 included studies report on an estimated large fetal head as a possible contraindication for vaginal breech delivery.
FIGURE 2.
Contraindication reported in the studies included in the systematic review and number of articles reporting on this contraindication. Data presented as 100% stacked bars; figures in stack represent number of studies reporting on this contraindication.
Fetal contraindications
Nine studies report an increase in adverse neonatal outcomes in case of fetal growth restriction (FGR) or a birthweight under 2 kg. One study reports no statistically significant difference. 24 Different outcome measures are described, one study using PREMODA data presents an adjusted odds ratio (aOR) of 5.75 for adverse perinatal outcomes in fetuses below the 10th percentile. 25
Eight studies report on the type of breech presentation, in which cord prolapse is reported to be higher in two studies in case of complete breech compared to frank breech position. One study with 10 749 patients reports an increased mortality risk in footling breech presentation when comparing VBD to CD (RR 3.3, 95% CI 1.9 to 5.9). 26
Of the eight included guidelines, two did not include an estimated fetal weight limit as a contraindication for VBD. The 12 included studies that researched an estimated fetal weight limit showed a broad difference in results. The studies with the largest patient population showed no statistically significant difference in adverse neonatal outcomes or mortality in birthweight >3.8 kg or >4 kg.
Two articles studied hyperextension of the fetal head, with conflicting outcomes. One study including 33 patients had 22% more neurological sequelae in fetuses with a hyperextended fetal head, with no difference in perinatal mortality. 27 The other study, including 223 participants, had no perinatal mortality in fetuses with hyperextension of the fetal head in VBD. 28
Maternal contraindications
Studies to assess inadequate maternal pelvis, considering pelvimetry, failure to progress, and neonatal outcomes show conflicting results.
Primigravida is not mentioned as contraindication for VBD in guidelines. Nonetheless, findings from 10 studies reporting on neonatal outcomes in VBD indicate that primigravid women may experience more adverse neonatal outcomes or a heightened likelihood of undergoing CD. One study including 100.000 patients describes an odd ratio of 9.2 for neonatal morbidity or mortality in primigravid women undergoing VBD compared to elective CD. 29
Setting related factors
Two studies classify limited access to experienced personnel as a contraindication. 30 , 31 The study conducted by Su et al. shows supportive data for this contraindication, revealing a substantial increase in adverse perinatal outcomes in scenarios where there is no experienced personnel present in the delivery ward (OR 0.30, 95% CI 0.13 to 0.68, p = 0.004).
Intrapartum management is not discussed as contraindication in national guidelines. Of the included studies, labor augmentation and the duration of the second stage of labor are associated with an increased risk of adverse perinatal outcome, low Apgar, and admission to the neonatal ward. 30 , 32 , 33 , 34 , 35 , 36
3.3.2. Grading
Table 3 shows a shortened list of contraindications for VBD at term, with only contraindications that are based on sufficient empirical evidence and therefore were awarded with Grade Level A. This list shows only two contraindications: footling breech presentation and fetal growth restriction. All other contraindications that were mentioned in the guidelines and studies were not awarded with Grade Level A, and are therefore not included in the list.
TABLE 3.
Recommended restrictions of contraindications for vaginal breech delivery at term.
| Recommended contraindications for vaginal breech delivery at term |
| Footling breech (Level III/IV–Grade A) |
| Fetal growth restriction (Level III/IV–Grade A) |
4. DISCUSSION
In this review, we identified contraindications for term VBD in national guidelines and collated the underlying evidence for these contraindications from a systematic search. Six of eight guidelines report on 11 different contraindications for VBD. There is little consensus between the guidelines, with only footling breech presentation consistently recognized in all of the six guidelines as contraindication. In literature, we only found sufficient evidence for two contraindications: footling breech and fetal growth restriction. Therefore, the extensive number of contraindications that are not supported by sufficient scientific evidence indicates that VBD at term might potentially be withheld from a significant proportion of pregnant people with a fetus in breech position.
In this study, we successfully created a comprehensive overview to show both similarities and discrepancies in reported contraindications within national guidelines, thereby revealing a spectrum from more conservative to more liberal recommendations. Our study shows gaps in our understanding of which contraindications for VBD at term are applicable. Nevertheless, it is important to acknowledge certain limitations in our study. The evidence of the reported contraindications comes from cohort studies, a methodology that is susceptible to bias. For four contraindications mentioned in guidelines, scientific evidence could not be identified, potentially due to publication bias.
Discussing possible contraindications in vaginal breech delivery and their implications in guidelines is crucial. All guidelines mention suspected macrosomia as a contraindication. In our review, we found no evidence for a specific maximum weight as a contraindication for VBD. Birth weight is difficult to predict and interpretation differs according to the obstetric history. When a specific threshold is firmly articulated in clinical guidelines, it potentially results in exclusion of women with a history of uneventful deliveries of macrosomia from undergoing vaginal childbirth.
It is important to recognize that some contraindications do not require extensive scientific (randomized) evidence. As postulated by Gordon Smith in his systematic review on parachute use to prevent death and major trauma from gravitational challenges, randomized controlled trials are unnecessary to prove the need for parachutes. 37 For cord presentation, lack of labor progression, fatal fetal anomalies, or previous multiple cesarean deliveries, the superior safety of planned CD has already been substantiated. 38 , 39 , 40 It is unnecessary to prove this again in case of vaginal breech delivery.
To extend the list of contraindications for VBD, distinctions must be made between contraindications resulting in emergency CD when continuing with VBD due to a severe increased likelihood of neonatal mortality and emergency CD for less severe outcomes. In clinical practice, the decision to opt for CD will often be guided by the whole constellation of factors such as fetal, maternal, and intrapartum management.
It is interesting to see the absence of contraindications related to intrapartum management or setting factors in the included guidelines. Our review shows scientific data indicating a reduced risk of adverse perinatal outcomes under the guidance of experienced personnel during birth. 30 We also show data indicating that intrapartum management, such as a prolonged duration of the second stage of labor, increases the risk of adverse neonatal outcomes. 30 , 32 , 33 , 34 , 35 , 36 The existing guidelines do not address intrapartum management, despite compelling evidence supporting their significance.
The age of the guidelines is a critical factor to consider. The guidelines we reviewed span from 2006 to 2021, with only few specifying when the guidelines should be updated. Our literature search identified articles published between 1978 and 2024, with half of these articles published before 2006. This suggests that some contraindications could be reconsidered if the guidelines were updated on a regular basis. Thereby it is important to mention that most studies from our search were not referenced in the guidelines. For instance, several guidelines rely on studies with outcomes stating no significant difference in adverse neonatal outcomes between cesarean or VBD. However, most of those studies have many restrictions in inclusion criteria for vaginal breech delivery and not on specific risk factors for adverse neonatal or maternal outcomes. Regular updates to these guidelines would ensure they incorporate the latest evidence and reflect current best practices.
While some contraindications in the guidelines are indeed evidence based, much of this evidence comes from older studies, and expert opinion remains influential due to the scarcity of high‐quality research. Expert opinion, while valuable, cannot replace robust, evidence‐based research since those writing the guidelines can be biased by many factors including their population or recent experience. Regular updates to these guidelines are essential, even with the relatively low incidence of VBD, to ensure they reflect the most current research and do not unduly restrict motivated pregnant people from considering VBD.
In the pursuit of a sustainable approach to vaginal breech deliveries, several pivotal facets warrant consideration. A promising shift toward improving safety of VBD is centralization of care, which has already been proven in other specialties where low volume, high complex care exists, such as specific cancer treatments and surgeries. 41 , 42 , 43 It is important to enhance the expertise of healthcare providers in handling complex deliveries and maintain this knowledge for pregnant people and future gynecologists. In a survey among Dutch residents, 65% of the final‐year residents did not feel qualified to guide VBD due to inadequate exposure and training. 44 , 45 Furthermore, there is a compelling need to refine the criteria for patient selection and to promote training in physiological breech birth techniques, endeavors that have the potential to substantially optimize safety outcomes. In future research, focus should be directed toward patient‐oriented care, emphasizing factors that will support a successful and safe VBD, rather than an extensive list of scientifically unproven contraindications or where there is scientific evidence that there is no contraindication. Additionally, large‐scale cohort studies can help overcome the challenges of strict inclusion criteria in many existing studies.
5. CONCLUSION
In this review, we created a clear oversight of reported contraindications for VBD. There is lack of consensus between national guidelines. We searched for scientific evidence to support these contraindications. Most of the reported contraindications lack robust scientific support, further highlighting the complexity of decision‐making in this context and indicating that VBD might potentially be withheld from a significant proportion of pregnant people. We found sufficient evidence for only two contraindications, footling breech and fetal growth restriction. We, therefore, propose to limit the contraindications in the national guidelines to these two until ample evidence is found for others.
AUTHOR CONTRIBUTIONS
Merle R. van Dijk: Data curation, formal analysis, investigation, project administration, visualization, writing—original draft, and writing—review & editing. Christiaan Papatsonis: Data curation, formal analysis, investigation, and writing—original draft. Wessel Ganzevoort, Etelka Moll, and Fedde Scheele: Writing—review & editing. Joost Velzel: Conceptualization, formal analysis, methodology, project administration, supervision, validation, visualization, and writing—review & editing.
CONFLICT OF INTEREST STATEMENT
None.
Supporting information
Tables S1–S4.
ACKNOWLEDGMENTS
We would like to thank Mr. B. Berenschot, information specialist in the OLVG library, for his help with the search for national guidelines.
van Dijk MR, Papatsonis C, Ganzevoort W, Moll E, Scheele F, Velzel J. Contraindications in national guidelines for vaginal breech delivery at term: Comparison, consensus, and controversy. Acta Obstet Gynecol Scand. 2024;103:2373‐2380. doi: 10.1111/aogs.14947
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Supplementary Materials
Tables S1–S4.