This handout is for breech presentation at term. Your care team identified this based on: ultrasound-confirmed breech presentation at ≥ 36-37 wk gestation — gateway finding (acog co 745 pmid 30045211).
Other reasons your team may use this plan: suspected breech presentation on leopold maneuvers + funbalandic fetal heart sounds above the umbilicus — confirm with bedside ultrasound; patient presents in active labor with confirmed breech — assess for trial of vaginal breech vs emergent cesarean per institutional protocol (acog co 745 pmid 30045211); cord prolapse after rupture of membranes with breech presentation — emergent cesarean; place patient knee-chest + elevate presenting part manually + transport to or.
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| external cephalic version (ECV) at gestational age ≥ 37 weeks | — | — | — | PregCat: N/A — procedure. | Lactation: N/A — procedure. | ACOG CO 745 (PMID 30045211) endorses ECV as alternative to planned cesarean; performed at L&D with OR backup; continuous EFM; success ~ 50-60% (higher in multiparas, polyhydramnios, posterior placenta, normal BMI); contraindications include placenta previa, non-reassuring FHR, hyperextended fetal head, severe FGR, recent vaginal bleeding; relative contraindications include prior classical cesarean and multifetal gestation. |
| terbutaline | 0.25 mg SC ×1 15 min before ECV | SC | single dose | PregCat: former B — long obstetric experience for short-term tocolysis; FDA black box for chronic tocolysis (cardiac death risk with prolonged use) but single-dose ECV use is acceptable. | Lactation: compatible with caution per LactMed — small amounts in milk; transient infant tachycardia possible; single-dose ECV use does not constrain lactation. | Facilitates ECV by relaxing uterine smooth muscle; nifedipine 20 mg PO is acceptable alternative; salbutamol IV / nitroglycerin IV are alternatives; monitor maternal HR + BP. |
| Rho(D) immune globulin | 300 µg IM ×1 within 72 h of ECV | IM | single dose within 72 h | PregCat: former C — labeling categorises but routinely used in Rh-negative pregnancy without harm signal. | Lactation: compatible per LactMed — IgG isotype with negligible milk transfer; routine postpartum use. | Small fetomaternal hemorrhage risk from ECV can sensitise Rh-negative mothers; Rho(D) IG within 72 h prevents alloimmunisation that would affect future pregnancies; ACOG CO 745 standard practice. |
| planned cesarean delivery at 39 weeks for persistent breech | — | — | — | PregCat: N/A — obstetric mode of delivery. | Lactation: N/A — delivery event. | Hannah 2000 Term Breech Trial Lancet (PMID 11052579) showed planned cesarean superior to planned vaginal breech for perinatal mortality / serious neonatal morbidity (1.6% vs 5.0%, RR 0.33); default for persistent breech when ECV fails/declined/contraindicated and patient not a candidate for trial of vaginal breech; schedule at 39+0 wk if elective; spinal or epidural anesthesia preferred. |
| selective trial of vaginal breech delivery per strict criteria | — | — | — | PregCat: N/A — obstetric mode of delivery. | Lactation: N/A — delivery event. | ACOG CO 745 (PMID 30045211) — may be reasonable under hospital-specific protocol with detailed informed consent including Term Breech Trial findings (Hannah 2000 PMID 11052579) AND Goffinet 2006 PREMODA AJOG (PMID 16580289) safe-in-select-units findings; criteria: frank or complete breech (NOT footling), EFW 2500-4000 g, experienced provider, hospital-specific protocol, no fetal anomaly, pelvic adequacy, favorable cervical exam; readiness for emergent cesarean throughout labor. |
| emergent cesarean for cord prolapse | — | — | — | PregCat: N/A — obstetric emergency intervention. | Lactation: N/A. | Cord prolapse after rupture of membranes with breech presentation → IMMEDIATE knee-chest position + manual elevation of presenting part + emergent cesarean (target time-to-delivery < 30 min); preserves fetal blood flow until OR available. |
Plan: Breech management — ECV at ≥ 37 wk with terbutaline tocolytic + Rho(D) IG if Rh-negative + planned cesarean if ECV fails/contraindicated + selective trial of vaginal breech per strict criteria (Hannah 2000 Term Breech Trial Lancet PMID 11052579 + Goffinet 2006 PREMODA AJOG PMID 16580289 + ACOG CO 745 PMID 30045211)
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
Postpartum debrief if cesarean for breech — counsel TOLAC eligibility in subsequent pregnancies (~ 10% recurrence of breech; most subsequent pregnancies vertex). Breastfeeding support per standard postpartum care. Routine 6-wk visit. Genetic counseling if anomalies found. If ECV-failure cesarean — counsel ECV may be re-offered in subsequent pregnancy if breech recurs.
Guideline: ACOG Committee Opinion 745 (2018) Mode of Term Singleton Breech Delivery + Hannah Term Breech Trial Lancet 2000 + Goffinet PREMODA AJOG 2006 + LactMed for terbutaline + Rho(D) IG