Breech Presentation of the Fetus: Clinical Guidelines

List of Abbreviations

Terms and Definitions

Breech presentation (BP) (praesentatio pelvica) — a clinical situation in which the presenting part is the buttocks and/or foot/feet of the fetus.

Breech presentation:

a) frank breech presentation — the hips are flexed and the knees are extended; only the fetal buttocks are presenting;

b) complete breech presentation — both hips and knees are flexed; both the feet and buttocks are presenting.

Footling presentation:

c) complete footling presentation — both fetal legs (feet) are presenting, with both legs extended at the hip and knee joints;

d) incomplete footling presentation — the buttocks and one of the fetal legs (feet) are presenting, with one leg extended at the hip and knee joints;

e) knee presentation — one or both fetal knees are presenting, with one or both fetal legs extended at the hips and flexed at the knees.

External cephalic version — a procedure of external prophylactic version of the fetus from a breech to a cephalic presentation.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Fetal breech presentation is a clinical situation in which the presenting part is the buttocks and/or foot/feet of the fetus.

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

Etiological factors of fetal breech presentation include [1-5]:

• prematurity;

• history of breech presentation in close relatives; contracted pelvis, abnormal pelvic shape;

• uterine malformations (bicornuate, arcuate, septate uterus);

• excessive or limited fetal mobility (primigravida, multipara);

• polyhydramnios or oligohydramnios;

• multiple pregnancy;

• neoplasms of the internal genital organs (myoma nodules, adnexal tumors);

• placentation pathology (placenta previa or low-lying placenta);

• congenital malformations of the fetus (anencephaly, hydrocephalus, sacrococcygeal teratoma, neck mass);

• short umbilical cord;

• fetal growth restriction (FGR).

There is a hypothesis suggesting that normal fetal anatomy and motor activity, amniotic fluid volume, and placental location create conditions that make cephalic presentation optimal for the fetus. If alterations occur in any of these factors, the probability of fetal breech presentation increases. It is hypothesized that presentation also depends on the immaturity of the fetal vestibular apparatus [5].

1.3 Epidemiology of the Disease or Condition

The incidence of fetal breech presentation in term pregnancies is 3–5%. Among all breech presentations, frank (pure) breech accounts to 63.2–68%, complete (mixed) breech to 20.6–23.4%, and footling breech to 11.4–13.4% [5]. The lower the gestational age, the higher the incidence of fetal breech presentation. At gestational age < 28 weeks and fetal weight < 1000 g, the incidence of fetal breech presentation reaches 35%, whereas at 34–36 weeks with a fetal weight of 2000–2499 g it does not exceed 8% [6, 7], which dictates the need for clinical determination of fetal presentation at 36 weeks of gestation.

1.4 Features of Coding the Disease or Condition

O32.1 Breech presentation of fetus requiring medical care of mother

O32.6 Combined presentation of fetus requiring medical care of mother

O64.1 Obstructed labor due to breech presentation

O64.5 Obstructed labor due to combined presentation

O64.8 Obstructed labor due to other malposition and malpresentation of fetus

O80.1 Spontaneous delivery in breech presentation

O80.8 Other spontaneous single-born deliveries (in this protocol, this ICD code also implies other breech deliveries (aside from frank breech delivery): complete/incomplete footling breech, complete (mixed) breech, etc.).

O83.0 Breech extraction

O83.1 Other obstetric assistance in breech delivery O83.2 Delivery with other obstetric manipulations [manual maneuvers]

O32.0 Maternal care for known or suspected malpresentation of fetus

O32.2 Transverse and oblique lie requiring medical care of mother

1.5 Classification of the disease or condition

Classification — see Fig. 1 [5, 8-10]:

1) Breech presentation:

• Frank (pure)

• complete (mixed)

2) Footling presentation:

• incomplete

• complete

• knee presentation.

Figure 1. Types of breech presentation:

a) frank breech b) complete (mixed) breech c) complete footling d) incomplete footling

During labor, one type of breech presentation may transition into another.

Fetal position in breech presentation is determined conventionally by the relation of the fetal back to the left (I position) or right (II position) uterine walls, and the variety — by the relation of the back to the anterior/posterior uterine wall (anterior or posterior variety, respectively).

1.6 Clinical presentation of the disease or condition

Signs of fetal breech presentation upon external examination:

• high standing of the uterine fundus, since the fetal pelvic end is located high above the pelvic inlet;

• fetal head (a rounded, dense, ballottable formation) is located in the uterine fundus, while the buttocks (a smaller, soft presenting part) are located above the pelvic inlet, which is determined by abdominal palpation;

• fetal heart tones are auscultated at or above the navel level.

During labor, vaginal examination findings:

• in breech presentation, the presenting part is soft, the intergluteal cleft, sacrum, and fetal genitalia can be palpated;

• in frank (buttock) breech presentation, the inguinal fold can be identified;

• in complete breech presentation, the fetal foot/feet are palpated alongside the buttocks, the position and rotation can be determined by the location of the sacrum;

• in footling presentations, a fetal foot or feet are identified.

2. Diagnostics, medical indications and contraindications for diagnostic methods

Diagnostic criteria

See Section 1.6.

2.1 Complaints and Anamnesis

No specific complaints. Potential complaints in the presence of fetal malpresentation: discomfort in the hypochondriac regions due to the fetal head being located in the uterine fundus [5,11]. In complete breech or footling presentation, the woman may feel fetal movements predominantly in the lower abdomen.

2.2 Physical Examination

Comment: In fetal malpresentation, high standing of the uterine fundus is noted, the dense part (head) is determined in the uterine fundus, freely ballotable, and the fetal heart rate is auscultated at or above the navel level [5].

2.3 Laboratory Diagnostics

Laboratory screening is performed in accordance with the clinical guidelines «Normal Pregnancy» [92].

2.4 Instrumental Diagnostics

• To detect fetal malpresentation, it is recommended to perform a fetal ultrasound scan (USS) to determine the type, estimated fetal weight, amniotic fluid volume, placental localization, fetal developmental anomalies, and extension of the fetal head [5,12].

GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).

Comment: It is clinically important to confirm fetal malpresentation at 36 weeks of gestation. When performing a fetal ultrasound, it is necessary to determine: the type of fetal malpresentation; calculation of estimated fetal weight; amniotic fluid volume (amniotic fluid index); placental localization; fetal developmental anomalies; presence of fetal head extension.

Comment: MR pelvimetry allows for an objective assessment of the prognosis for vaginal delivery and patient counseling. The most important prognostic value is the interspinous diameter (transverse diameter of the narrow pelvis), which should be at least 10.5 cm; additional significance is attributed to the anteroposterior diameter of the pelvic inlet (at least 10.5 cm), the transverse diameter of the inlet (at least 12 cm), the intertuberous diameter (transverse diameter of the pelvic outlet plane, at least 10.9 cm), and the subpubic angle (at least 70°) [16],[17],[14]. The decision on the mode of delivery should be made taking into account the complex results of MR pelvimetry and other clinical data, primarily gestational age and fetal size [14].

2.5 Other Procedures

Not applicable.

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

3.1 Non-pharmacological treatments for fetal breech presentation

• Upon confirmation of fetal malpresentation at 36 weeks, it is recommended to inform the patient about the risks associated with labor in fetal malpresentation, medical interventions to reduce this risk, and possible delivery methods along with their complications [6, 18].

GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).

• Upon confirmation of fetal malpresentation, it is recommended to offer the patient an external cephalic version (ECV) (in the absence of contraindications to vaginal delivery) to reduce the likelihood of cesarean section (CS) [5-9, 18-21].

GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).

Comment: The success rate of external cephalic version is 30–80% [8]. Following a successful external cephalic version, spontaneous reversion of the fetus is observed in 5% of cases [19, 20]. The patient must be warned that the success of the procedure depends on many factors and can never be 100% guaranteed.

• Upon confirmation of fetal malpresentation, it is not recommended to offer the patient corrective exercises and acupuncture for spontaneous cephalic version [20].

GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).

Comment: The efficacy of corrective exercises (a set of gymnastic exercises according to the method of Grishchenko I.I., Shuleshova A.E., Dikaniy I.F.) and acupuncture has not been proven.

3.2 External cephalic version

Comment: External cephalic version must be performed in an obstetrical hospital equipped for emergency cesarean section, with anesthesiology, neonatology, and ultrasound diagnostics services available.

• It is recommended to perform external cephalic version at a gestational age >36 weeks, since spontaneous cephalic version is unlikely after this period [22,23].

GCR ALeE 1Grade of Recommendation A (Level of Evidence - 1).

Comment: external cephalic version at 34–35 weeks of gestation demonstrates higher efficacy than at 37–38 weeks (reduction in the probability of non-cephalic presentation RR 0.81; 95% CI 0.74–0.90; breech delivery RR 0.44; 95% CI 0.25–0.78), but increases the risk of late preterm birth by 2.3% (from 4.3% to 6.6%) [18].

• It is recommended to perform external cephalic version in the absence of contraindications to vaginal delivery, satisfactory fetal condition (according to cardiotocography (CTG), umbilical artery Doppler flowmetry), and normal amniotic fluid volume [19,20].

GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).

• It is not recommended to perform external cephalic version in the presence of the following contraindications: planned operative delivery via cesarean section; bleeding in the second half of pregnancy; pathological/suspicious CTG; impaired maternal-placental-fetal blood flow according to Doppler ultrasound; fetal growth restriction (FGR) with impaired umbilical artery blood flow; uterine anomalies, uterine tumors or adnexal masses preventing version; multiple pregnancy (except for version of the second twin after the birth of the first twin); uterine scar; gross fetal malformations, fetal demise; extension of the fetal head; preeclampsia or arterial hypertension; rupture of membranes; lack of voluntary informed consent for the external version procedure; oligohydramnios and polyhydramnios; unstable fetal lie [8, 19,20].

GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).

• Before performing external cephalic version, it is recommended to inform the patient about potential complications, the risk of which does not exceed 0.5% [8, 19,20]

GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).

Comments: potential complications of external cephalic version requiring emergency cesarean section include: placental abruption; preterm labor; premature rupture of membranes; uterine rupture; amniotic fluid embolism; fetal distress.

• Before performing external cephalic version, it is recommended to consider predictors of its successful execution, which include: high parity; abdominal palpation of the fetal head; absence of obesity; placental attachment on the posterior or lateral walls of the uterus; frank breech presentation; amniotic fluid index greater than 10 cm [9,10].

GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).

• To increase the success rate of external cephalic version, tocolysis with hexoprenaline** is recommended [24].

GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).

Comment: tocolysis with beta-mimetics increases the likelihood of fetal cephalic presentation at birth (RR 1.68, 95% CI 1.14–2.48), reduces the number of cesarean section deliveries (RR 0.77, 95% CI 0.67–0.88), and decreases the failure rate of external cephalic version (RR 0.70, 95% CI 0.60–0.82) [25],[26]. Sympathomimetics (tocolytic agents ATC: G02CA) are used for tocolysis (hexoprenaline** 2 ml in 10 ml of 0.9% sodium chloride solution** via syringe pump at a rate of 1.5 ml over 15 min and during the procedure).

Comment: Spinal or epidural anesthesia increases the success rate of external cephalic version from 37.6% to 59.7% [27]. For pain relief during the external cephalic version procedure, spinal or epidural anesthesia is indicated without routine crystalloid preloading, but with crystalloid co-infusion (ATC: B05BB: solutions affecting the electrolyte balance) using a restrictive approach (dextrose**, complex sodium chloride solution [Potassium chloride+Calcium chloride+Sodium chloride]**, complex sodium lactate solution [Potassium chloride+Calcium chloride+Sodium chloride+Sodium lactate]**, sodium chloride**, infusion solution (Potassium chloride + Calcium chloride + Magnesium chloride + Sodium acetate + Sodium chloride + Malic acid)**, and other electrolytes (ATC B05BB: solutions affecting water and electrolyte balance) with a similar effect may also be used).

• In case of successful external cephalic version, it is recommended to manage pregnancy according to the clinical guidelines «Normal Pregnancy» [92], and with the spontaneous onset of labor, manage delivery via the natural birth canal [9,20, 30-39].

UBR CLEL 5Level of Recommendation C (Level of Evidence - 5). 

• In the case of an ineffective external cephalic version, vaginal delivery is recommended in the absence of contraindications to vaginal delivery [9,20,30-39].

LoR CGoE 4Level of Recommendation C (Grade of Evidence - 4).

3.3 Caesarean section in fetal breech presentation

• Patients with contraindications to vaginal delivery, as well as patients refusing vaginal delivery, are recommended to undergo delivery via caesarean section in accordance with the clinical guidelines «Singleton childbirth, delivery via caesarean section» [91]. Elective caesarean section is recommended at a gestational age of >39 weeks, which promotes optimal physiological maturation of the fetus, in the absence of indications for preterm delivery [40-42].

GCR ALeE 1Grade of Recommendation A (Level of Evidence - 1).

• Elective caesarean section is recommended in the presence of the following indications: fetal breech presentation in combination with other indications for caesarean section and a scarred uterus; footling breech presentation; estimated fetal body weight <2500 g or >3600 g; patient's refusal of spontaneous delivery in breech presentation [91].

GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).

Comment: Delivery of a fetus weighing <2500 g or >3600 g in breech presentation, despite an estimated fetal weight of <2500 g or >3600 g according to ultrasound data prior to delivery, is not a violation of the clinical guidelines. Surgical delivery of women with fetal breech presentation is advisory and depends on the patient's preference, parity, and the obstetric situation.

• Prior to elective caesarean section, fetal ultrasound or external maneuvers are recommended to determine fetal position and presentation, as spontaneous cephalic version is possible [9,43].

RG CLE 5Recommendation Grade C (Level of Evidence 5).

Comment: Perinatal mortality in vaginal deliveries with fetal breech presentation ranges from 0.8 to 1.7‰, for caesarean section after 39 weeks of gestation - from 0 to 0.8‰; for cephalic presentation deliveries - 1/1000 [6, 9]. It is recommended to inform the patient that, provided selection criteria are met, the choice of vaginal delivery in breech presentation is appropriate [30,32,34,41,44-60].

Comment: in case of difficult delivery of the fetal head during caesarean section in breech presentation, to reduce fetal trauma, it is recommended to administer 1-2 doses of #nitroglycerin ** (0.4 mg-0.8 mg) in the form of a sublingual spray (1% alcoholic solution of nitroglycerin in 96% ethanol) and/or expand the incision to prevent its spontaneous extension toward the vascular bundle of the uterus [65].

3.4 Vaginal delivery in fetal breech presentation

• Vaginal delivery is recommended to be managed by an obstetrician-gynecologist experienced in managing deliveries in fetal breech presentation and capable of providing maneuvers in the event of complications [43].

GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).

• Vaginal delivery in fetal breech presentation is recommended to be managed in a level 2 or 3 obstetric hospital [9,30,41].

Level of Evidence CGrade of Recommendation 5Level of recommendation C (level of evidence - 5).

Comment: Vaginal delivery in fetal breech presentation must be performed in an obstetric hospital equipped for emergency caesarean section, with anesthesiology and neonatal services available. Vaginal delivery in fetal breech presentation in a level 1 institution is possible only in emergency cases, such as precipitous labor [43].

• When managing vaginal delivery with fetal breech presentation, the obstetrician-gynecologist is recommended to take into account the following factors having a favorable impact on labor outcome: absence of conditions preventing uncomplicated vaginal delivery; gestational age >36 weeks; absence of anatomical pelvic contraction; absence of fetal growth restriction and signs of fetal compromise; estimated fetal body weight of at least 2500 g and not exceeding 3600 g; frank (buttock) presentation of the fetus; absence of head deflexion and/or arm entrapment; absence of fetal malformations that may cause dystocia; no history of caesarean section; medical personnel trained in managing breech deliveries; spontaneous onset of labor activity [5, 6, 8, 9, 31, 43,66-69].

LoR CGoE 4Level of Recommendation C (Grade of Evidence - 4).

Comments: parity is of definite importance when choosing the mode of delivery, as nulliparous women experience labor with a higher number of complications. Estimated fetal body weight is of great importance, as half of the perinatal deaths in deliveries with breech presentation occurred in fetuses with fetal growth restriction [67]. This may be due to an increased risk of developing acidosis resulting from chronic placental insufficiency, aggravated by the inevitable umbilical cord compression that occurs in the 2nd stage of labor [70]. Fetal breech presentation per se is not a contraindication to vaginal delivery [6].

• The obstetrician-gynecologist is recommended to take into account the patient's desire, insisting on vaginal delivery in fetal breech presentation, and not to refuse without the presence of contraindications to vaginal delivery, while informing the patient about potential difficulties during vaginal delivery in breech presentation [9].

GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).

• The obstetrician-gynecologist is recommended to take into account adverse factors for vaginal delivery in fetal breech presentation, such as the presence of contraindications to vaginal delivery (not related to fetal breech presentation); fetal growth restriction; absence of a specialist experienced in delivering breech presentations; footling breech presentation (except for cases when the patient is admitted in the 2nd stage of labor with adequate uterine activity); fetal head deflexion and/or arm entrapment confirmed by ultrasound; estimated fetal body weight: < 2500 g or >3600 g (depending on maternal constitution); fetal malformations precluding vaginal delivery; obesity (body mass index > 35 kg/m2); pregnant woman's refusal of vaginal delivery [5, 6,8,9,31,43,66-69].

LoR CGoE 4Level of Recommendation C (Grade of Evidence - 4).

Comment: The incidence of umbilical cord prolapse is approximately 1% in frank breech presentation (versus >10% in footling presentation).

• Continuous cardiotocography (CTG) monitoring is recommended during the 1st stage of labor in fetal breech presentation, given the increased risk of umbilical cord compression [9,73, 74].

GCR BLEL 3Recommendation Grade B (Level of Evidence — 3).

Comment: Modern neuraxial anesthesia techniques preserve the mother's ability to push effectively. When the buttocks have descended to the pelvic floor, the effect of neuraxial analgesia on the success rate of vaginal delivery in fetal breech presentation has not been sufficiently studied [30,75,76].

Comment: Studies conducted in France in 2019, 2022, and in Norway in 2021 support the use of labor preinduction methods in patients with a term fetus in breech presentation and do not associate induced labor with an increase in severe maternal and neonatal morbidity compared to spontaneous labor [79], [80], [81].

• In breech presentation, labor stimulation is not recommended [43].

GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).

• The woman's position in the 2nd stage of labor (lithotomy, upright, or all-fours) can be adapted to the patient's preferences. If an upright position is preferred, the patient should be warned that the position may be changed to lithotomy if necessary [6].

UBR CLEL 5Level of Recommendation C (Level of Evidence - 5). 

• In the 2nd stage of labor with fetal breech presentation, continuous fetal monitoring using cardiotocography (CTG) is recommended for the timely diagnosis of fetal distress [6, 9].

UBR CLEL 5Level of Recommendation C (Level of Evidence - 5). 

Comment: Mediolateral episiotomy may be performed according to indications.

Comments: In domestic clinical practice, for frank breech presentation after the torso has been delivered to the navel, the first manual obstetric maneuver by N.A. Tsovyanov is used. The purpose of the Tsovyanov maneuver is to maintain the physiological flexion of the fetus and prevent serious complications such as arm entrapment and extension of the fetal head (Appendix G, Figure 2). For footling presentation, the Tsovyanov II maneuver is used, the main purpose of which is to convert a complete footling presentation into a frank breech presentation, which helps increase the volume of the presenting part and achieve complete dilation of the uterine os [82] (Appendix G, Figure 3). In rare cases, if fetal extraction is necessary in a frank breech presentation, the Pinard maneuver may be used, which consists of converting a frank breech presentation into a footling presentation (Appendix G, Figure 4). After the delivery of the upper abdomen and lower chest, pulsation in the umbilical cord should be checked, and a small loop should be pulled down to prevent compression of the stretched umbilical cord [6, 83].

• If there is a delay in the baby's descent after delivery up to the lower angle of the scapulae, it is recommended to attempt arm delivery with torso rotation (Appendix G, Figure 6). In case of arm entrapment, it is recommended to perform the classical manual maneuver for delivering the fetal arms accepted in domestic practice (Appendix G, Figure 8) [82] or the Lovset maneuver (Appendix G, Figure 7) [9].

GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).

• If the hairline is not defined after the shoulders are born, it is recommended to rotate the fetal torso so that its anterior surface faces the floor, followed by suprapubic pressure leading to flexion of the head and its descent into the pelvic cavity [9, 67].

GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).

Comment: Eliminating pulling movements by the physician and applying suprapubic pressure reduces perinatal mortality from 3.2% to 0% [67].

• If the head does not deliver spontaneously, the obstetrician-gynecologist is recommended to perform one of the following maneuvers: the Bracht method [6, 9] (Appendix G, Figure 8); the Mauriceau-Smellie-Veit maneuver [9] (Appendix G, Figure 9); application of Piper forceps [9, 43] (Appendix G, Figures 10, 11).

GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).

Comments: The Bracht method differs from the Tsovyanov method by the assistant's help in applying suprapubic pressure to the fetal head. Due to the unavailability of Piper forceps in Russia, Simpson forceps can be used for the same purposes.

• Extraction of the aftercoming fetal head using forceps in breech presentation is recommended to be performed only by a trained obstetrician-gynecologist [5, 6, 9, 18].

GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).

Comments: Regardless of whether spontaneous delivery occurs or obstetric forceps are used, the angle between the fetal torso and the horizontal plane must not exceed 45 degrees to avoid traction on the cervical spine during delivery of the head. If the torso is excessively flexed posteriorly (i.e., toward the mother's abdomen), hyperextension of the head can lead to occlusion of the vertebral arteries and necrosis of the cervical spinal cord. Excessive pressure on the cervical spine exerted during downward tractions can have the exact same effect and lead to spinal dislocation.

Comment: Exceptions include acute fetal distress, intrapartum hemorrhage threatening the mother and fetus, provided the conditions for fetal extraction by the pelvic end are met.

3.5 Management of preterm labour in fetal breech presentation

Comments: There are currently no adequate high-quality studies regarding delivery in breech presentation during preterm gestation; the frequency of adverse fetal outcomes is primarily determined by prematurity, regardless of the method of delivery [6]. The frequency of adverse outcomes is particularly high in breech deliveries at 25–28 weeks [87].

• When managing vaginal delivery with fetal breech presentation, the obstetrician-gynecologist is recommended to consider the following factors that adversely affect the outcome of preterm labor: maternal obesity, smoking, congenital anomalies, preterm premature rupture of membranes (PPROM), oligohydramnios, epidural anesthesia, and intrauterine growth restriction (IUGR) [88].

GCR CLOE 4Grade of Recommendation C, Level of Evidence — 4.

4. Medical Rehabilitation and Sanatorium-Resort Treatment

Not applicable.

5. Prevention and Dispensary Observation

Comments: None of the methods for preventing fetal breech presentation have proven effective.

6. Organization of Medical Care

All maternity wards must provide qualified assistance for vaginal deliveries in fetal breech presentation and have developed protocols for managing such deliveries [6].

Medical care for patients during delivery in fetal breech presentation is provided as part of specialized, including high-tech, and emergency, including specialized emergency, medical care in medical organizations licensed to carry out medical activities, including works (services) in "obstetrics and gynecology (excluding the use of assisted reproductive technologies and artificial termination of pregnancy)."

The provision of medical care to women during delivery in fetal breech presentation is carried out based on routing sheets that make it possible to determine the category of the obstetric hospital where delivery is performed depending on the degree of risk of potential maternal and fetal complications. Indications for selecting the obstetric hospital category are determined based on the requirements of Order No. 572n of the Ministry of Health of the Russian Federation dated November 1, 2012, "Approval of the Procedure for Providing Medical Care in the Profile 'Obstetrics and Gynecology (Excluding the Use of Assisted Reproductive Technologies)'."

The organization of medical care and routing of pregnant women with fetal breech presentation are carried out in accordance with regional protocols and standards.

Simulation-based training is recommended for acquiring skills in managing vaginal delivery in fetal breech presentation by obstetrician-gynecologists [9].

7. Additional Information

Factors influencing the outcome of delivery in fetal breech presentation include:

• prenatal preparation of the pregnant woman;

• informing the patient about the risks and benefits of external cephalic version, as well as indications for a particular method of delivery;

• informing the patient that cesarean section leads to a slight reduction in perinatal mortality and neonatal morbidity compared to vaginal delivery in fetal breech presentation [30, 32, 34, 41, 44–54, 56–60];

• informing the patient about factors affecting the safety of vaginal delivery in fetal breech presentation [46, 55, 56, 66, 90].

Criteria for Evaluating the Quality of Medical Care

References

Appendix A1. Working Group Composition

1. Malyshkina Anna Ivanovna — MD, Professor, Director of the V.N. Gorodkov Ivanovo Research Institute of Motherhood and Childhood of the Russian Ministry of Health (Ivanovo). No conflict of interest.

2. Shmakov Roman Georgievich – MD, Professor, Professor of the RAS, Director of the Academician V.I. Krasnopolsky Moscow Regional Research Institute of Obstetrics and Gynecology (Moscow). No conflict of interest.

3. Baev Oleg Radomirovich - MD, Professor, Honored Doctor of the Russian Federation, Head of the 1st Maternity Ward, Academician V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology of the Russian Ministry of Health (Moscow). No conflict of interest.

4. Artymuk Natalia Vladimirovna - MD, Professor, Head of the Department of Obstetrics and Gynecology named after Professor G.A. Ushakova, Kemerovo State Medical University of the Russian Ministry of Health, Chief Freelance Specialist of the Russian Ministry of Health in Obstetrics and Gynecology in the Siberian Federal District (Kemerovo). No conflict of interest.

5. Bashmakova Nadezhda Vasilievna - MD, Professor, Chief Researcher at the Ural Research Institute for Maternal and Infant Care of the Russian Ministry of Health, Chief Freelance Specialist of the Russian Ministry of Health in Obstetrics and Gynecology in the Ural Federal District (Yekaterinburg). No conflict of interest.

6. Belokrinitskaya Tatiana Evgenievna - MD, Professor, Head of the Department of Obstetrics and Gynecology of the Faculty of Advanced Training and Professional Retraining of Chita State Medical Academy of the Russian Ministry of Health, Honored Doctor of the Russian Federation, Chief Freelance Specialist of the Russian Ministry of Health in Obstetrics and Gynecology in the Far Eastern Federal District (Chita). No conflict of interest.

7. Vagushchenko Ulyana Andreevna - Obstetrician-gynecologist at the organizational and methodological department of the Yekaterinburg Clinical Perinatal Center, Assistant at the Department of Obstetrics and Gynecology, Faculty of Medicine and Prophylaxis, Ural State Medical University (Yekaterinburg). No conflict of interest.

8. Gagaev Chelebi Hasanovich - MD, Professor of the Department of Obstetrics and Gynecology with a Course in Perinatology, Medical Institute of RUDN University. No conflict of interest.

9. Gracheva Marina Sergeevna - Head of the Pregnancy Pathology Department, Yekaterinburg Clinical Perinatal Center (Yekaterinburg). No conflict of interest.

10. Koltasheva Irina Mikhailovna - Head of Quality Management and Medical Safety Department, Yekaterinburg Clinical Perinatal Center (Yekaterinburg). No conflict of interest.

11. Ksenofontova Olga Leonidovna - Candidate of Medical Sciences, Deputy Chief Medical Officer, Yekaterinburg Clinical Perinatal Center (Yekaterinburg). No conflict of interest.

12. Martirosyan Sergey Valerievich - Candidate of Medical Sciences, Associate Professor of the Department of Obstetrics and Gynecology, Faculty of Fundamental Medicine, Lomonosov Moscow State University (Moscow), Expert at the National Institute of Quality of Roszdravnadzor. No conflict of interest.

13. Mikhailov Anton Valerievich - MD, Professor, Chief Medical Officer of St. Petersburg Maternity Hospital No. 17, Chief Freelance Specialist in Obstetrics and Gynecology of the St. Petersburg Health Committee (St. Petersburg). No conflict of interest.

14. Panova Irina Alexandrovna - MD, Professor, Head of the Department of Obstetrics, Gynecology, Neonatology, Intensive Care and Anesthesiology, V.N. Gorodkov Ivanovo Research Institute of Motherhood and Childhood of the Russian Ministry of Health (Ivanovo). No conflict of interest.

15. Pesikin Oleg Nikolaevich - Candidate of Medical Sciences, Deputy Director for Medical Work, V.N. Gorodkov Ivanovo Research Institute of Motherhood and Childhood of the Russian Ministry of Health (Ivanovo). No conflict of interest.

16. Rokotyanskaya Elena Arkadievna - Candidate of Medical Sciences, Associate Professor of the Department of Obstetrics, Gynecology, Neonatology, Intensive Care and Anesthesiology, V.N. Gorodkov Ivanovo Research Institute of Motherhood and Childhood of the Russian Ministry of Health (Ivanovo). No conflict of interest.

17. Salakhova Lilia Munavirovna – Candidate of Medical Sciences, Associate Professor of the Department of Obstetrics, Gynecology, Neonatology, Intensive Care and Anesthesiology, V.N. Gorodkov Ivanovo Research Institute of Motherhood and Childhood of the Russian Ministry of Health (Ivanovo). No conflict of interest.

18. Silaev Borislav Vladimirovich - Candidate of Medical Sciences, Director of the Institute of Anesthesiology, Intensive Care and Transfusiology, Academician V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology of the Russian Ministry of Health (Moscow), Associate Professor of the Department of Anesthesiology and Intensive Care, Institute of Clinical Medicine, I.M. Sechenov First Moscow State Medical University of the Russian Ministry of Health. No conflict of interest.

19. Oboskalova Tatiana Anatolievna - MD, Professor, Head of the Department of Obstetrics and Gynecology, Faculty of Medicine and Prophylaxis, Ural State Medical University (Yekaterinburg). No conflict of interest.

20. Perevozknina Olga Vladimirovna - Candidate of Medical Sciences, Head of the Clinical and Expert Work Department of the Perinatal Center at City Clinical Hospital No. 67 named after L.A. Vorokhobov, Assistant at the Department of Obstetrics and Gynecology, Faculty of Fundamental Medicine, Lomonosov Moscow State University (Moscow). No conflict of interest.

21. Radzinsky Viktor Evseevich - MD, Professor, Corresponding Member of the RAS, Honored Scientist of the Russian Federation, Head of the Department of Obstetrics and Gynecology with a Course in Perinatology, Medical Institute of the Peoples' Friendship University of Russia (Moscow). No conflict of interest.

22. Savelieva Galina Mikhailovna - MD, Professor, Academician of the RAS, Honorary Head of the Department of Obstetrics and Gynecology, Pediatric Faculty, Pirogov Russian National Research Medical University of the Russian Ministry of Health (Moscow). No conflict of interest.

23. Tysyachny Oleg Vladimirovich - Candidate of Medical Sciences, physician of the 1st maternity ward, Assistant at the Department of Obstetrics and Gynecology, Academician V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology of the Russian Ministry of Health (Moscow). No conflict of interest.

24. Filippov Oleg Semenovich – MD, Professor, Honored Doctor of the Russian Federation, Chief Freelance Obstetrician-Gynecologist of the FMBA of Russia, Deputy Director of the Federal Research and Clinical Center of Children and Adolescents of the FMBA of Russia, Professor of the Department of Obstetrics, Gynecology and Reproductive Medicine, Russian University of Medicine. No conflict of interest (Moscow)

25. Fatkullin Ildar Faridovich - MD, Professor, Honored Scientist of the Republic of Tatarstan, Head of the Department of Obstetrics and Gynecology No. 2, Kazan State Medical University of the Russian Ministry of Health (Kazan). No conflict of interest.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience for these clinical guidelines:

1. obstetrician-gynecologists

2. students; residents, PhD students, obstetrician-gynecologists

3. lecturers, researchers

Table 1. Level of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)

Table 2. Level of evidence (LoE) grading scale for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)

Table 3. Grade of Recommendation (GoR) scale for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions)

Appendix A3. Reference Materials

Technique of basic obstetric maneuvers in fetal breech presentations

Technique of external cephalic version:

• Obtain written informed voluntary consent from the patient.

• Maintain constant verbal contact with the patient.

• Perform ultrasound and cardiotocography (CTG) on the day of the procedure.

• Ensure the capability to perform an emergency Caesarean section in the event of complications threatening the mother or fetus.

• Assess and record baseline maternal data: pulse, blood pressure.

• The woman should not be fasting.

• The woman should be placed in the supine position with a tilt of 10–15 degrees (to prevent aortocaval compression syndrome). If the patient is comfortable in the supine position and inferior vena cava compression syndrome does not develop, the procedure may be performed in the supine position.

• Empty the bladder.

• The patient is asked to relax and breathe deeply during the procedure. The procedure may be accompanied by discomfort, but should not cause sharp pain. Pronounced pain can be a reason to stop the procedure (it may be resumed after pain relief).

• The duration of the procedure should not exceed 5 minutes; no more than two version attempts are recommended.

• The procedure is performed with periodic ultrasound monitoring by the assistant of the displacement of the fetal head and breech while simultaneously monitoring the fetal heart rate — if bradycardia occurs, the procedure should be stopped immediately. If the fetal heart rate returns to normal, the procedure is continued. If the normal rhythm is not restored and prolonged deceleration develops, the patient must be transferred to the operating room for an emergency Caesarean section.

Sequence of actions for the forward somersault external cephalic version:

• stand to the side of the woman, opposite to the side of the fetal back;

• lift the fetal breech out of the woman's pelvic cavity;

• one hand remains on the breech, the other is placed on the fetal head, the buttocks are displaced towards the fetal back, first into the first oblique, then into the transverse, and then into the second

• oblique position;

• grasp the fetal head with the palm of the hand, advancing it toward the pelvic inlet plane, while using the other hand to move the buttocks to the uterine fundus;

• movements must be continuous and sustained;

• all manipulations must be gentle and preserve the flexor posture of the fetus.

Sequence of actions for the backward somersault external cephalic version:

• stand on the side of the fetal back, lift the fetal breech out of the woman's pelvic cavity, hold the buttocks with the edge of the hand and direct them laterally and upward;

• apply maximum pressure to the buttocks to keep the fetus in a flexed state while the head is gently turned.

Figure 1. Technique of external cephalic version

After completion of the procedure:

• Perform ultrasound monitoring of the presentation part position and perform fetal CTG for 30 minutes.

• Monitor the mother's pulse, blood pressure, pain, and vaginal discharge for 30 minutes (immediately after the procedure, then 15 minutes later).

• If the results of maternal observation are normal, CTG type is normal, and there are no signs of onset of labor, amniotic fluid leakage, genital bleeding, or abdominal pain, discharge from the hospital is possible.

• The woman should be advised to seek medical attention immediately if any of these abnormalities or changes in fetal motor activity occur.

Technique of Tsovyanov's maneuver for frank (buttock) breech presentation

Upon crowning of the buttocks, they are grasped with both hands so that the thumbs lie on the fetal thighs pressed against the abdomen, and the remaining fingers rest on the surface of the sacrum. As the fetal torso is born, the physician, keeping their hands near the vulvar ring, supports the fetal torso by gently pressing the extended legs to the abdomen with the thumbs while moving the remaining fingers along the back. When the baby is born, the legs are pressed against the torso, thereby preventing them from being born prematurely. In addition, the crossed arms are pressed against the chest by the fetal legs, which prevents them from extending upward. Since at the level of the chest the volume of the torso together with the crossed arms and legs is larger than the volume of the head, it is delivered without difficulty.

Figure 2. Technique of Tsovyanov's maneuver for frank breech presentation

Technique of Tsovyanov's maneuver for footling and complete breech presentation

Upon crowning of the fetal foot (feet), covering the parturient woman's vulvar cleft with a sterile sheet, the palmar surface of the right hand applied to the vulvar cleft opposes the premature delivery of the legs. The buttocks exert pressure on the cervical canal and contribute to complete dilation of the uterine os, descend into the vagina, and form a complete breech presentation with the legs located there.

Figure 3. Technique of Tsovyanov's maneuver for footling and complete breech presentation

Technique of Pinard's maneuver

Using fingers, the obstetrician presses on the popliteal fossa and abducts the thigh in the direction opposite to the torso. This leads to flexion of the knee joint and facilitates the delivery of the foot and leg. This maneuver can be repeated for the delivery of the opposite leg and foot.

Figure 4. Technique of Pinard's maneuver

Rule of torso grasp

The obstetrician fixes the fetal thighs with their hands, placing the thumbs on the sacrum and the remaining fingers on the iliac crest. To prevent the hands from slipping, a small sterile wipe can be used. It is important not to compress the fetal abdomen!

Figure 5. Technique of torso grasp

Technique of delivery of the arms by torso rotation

If the fetal arms are flexed and located anteriorly on the chest, two fingers are slid along the fetal shoulder and further down the humerus, then the elbow joint and forearm of the fetus are brought out along the face to the fetal chest, which allows the upper (anterior) arm to be born freely, then the fetus is rotated by 90° from the back side, the second scapula is visualized, and the manipulations are repeated on the other side.

Figure 6. Delivery of arms by torso rotation

Technique of Lovset's maneuver

The fetus is held by the thighs or pelvic bones (not by the abdomen). For a more secure grip, the fetus's legs/pelvis can be wrapped in a sheet. The fetal torso is gently pulled downward, then the fetal body is elevated laterally upward, which helps lower the posterior shoulder below the sacral promontory. The fetus is rotated by gentle traction 180 degrees so that the first upper (anterior) shoulder and arm are born.

If the arm is not delivered, assist in the delivery of the arm by placing one or two fingers on its upper part. Lower the arm down across the chest with a flexed elbow and the hand guided across the face. To deliver the second arm, rotate the baby back by a half-turn, keeping the back upward, and, pulling it downward, release the second arm in the same way.

Figure 7. Technique of Lovset's maneuver

Technique of classical manual assistance for the delivery of the fetal arms

The fetal arm is released by the obstetrician's corresponding hand (right with right, left with left). The posterior arm is released first, since the capacity of the sacral hollow is larger and there is more room for maneuver. The obstetrician grasps the fetal legs (with the left hand for the first position, with the right hand for the second position) and abducts them toward the inguinal fold opposite to the fetal position. With the corresponding hand, the obstetrician releases the fetal arm located on the side of the sacral hollow. The hand is guided along the fetal back and shoulder, the humerus is palpated, and it is grasped at the level of the elbow bend so that the arm passes along the face while flexing and is brought down ("washing motion"). To release the second arm, the fetal torso is rotated by 180°, passing the back under the pubic symphysis. The anterior arm of the fetus thus becomes posterior and is released by the obstetrician's corresponding hand, just like the first one.

Bracht method

To facilitate the delivery of the aftercoming head, the assistant presses above the pubic bone to flex the head, while the physician lifts the fetal torso toward the maternal symphysis.

Figure 8. Bracht method

Technique of the Mauriceau-Smellie-Veit maneuver

Place the baby's body on your palm and forearm, with the legs and arms hanging down on both sides. The index and middle fingers of this hand are placed on the maxilla on both sides of the nose to flex the head. Do not place one finger in the mouth and apply pressure to the lower jaw. This can lead to dislocation of the lower jaw. The other hand is placed on the fetal back, and the middle finger gently presses on the occipital protuberance, which leads to flexion of the head. The remaining fingers of this hand rest loosely on the newborn's shoulders. This maneuver involves gentle pressure for head flexion, weak traction in a posterior direction, then anterior. The direction of traction is carried out relative to the vertically standing woman.

Figure 9. Mauriceau-Smellie-Veit maneuver

Technique of forceps application to the aftercoming fetal head in breech presentation labor.

The operating surgeon kneels down, as forceps are applied beneath the baby's body. The assistant holds the baby's body in a sheet at or slightly above the horizontal line level (deviation by no more than 45° is permitted).

Piper forceps have a reverse handle curve, which makes them more convenient to use than other forceps, as the mother's body does not need to be lifted too high to keep it clear of the forceps handles. Four fingers of the right hand are inserted between the vaginal wall and the fetal head on the left at the level between 4 and 5 o'clock on an imaginary clock face. The forceps are positioned so that the lower blade enters along the ring finger, while the thumb guides the insertion of the blade. The left hand gradually moves the handle down and toward the midline, while the fingers of the right hand guide the blade and protect the vaginal wall and the lateral part of the fetal head. There must be no forceful movements. Then the procedure is performed on the other side. The blade is inserted between 7 and 8 o'clock on the imaginary clock face. Then the blades are locked. The baby is placed on top of the forceps handles. The doctor holds the forceps with one hand and places the other hand on top of the baby's body. The forceps handles are lifted and moderate traction is applied posteriorly until a fixation point is formed under the pubic symphysis, then anteriorly. The direction of traction is relative to the woman standing vertically.

Figure 10. Piper forceps (general view).

Figure 11. Application of Piper forceps to the aftercoming fetal head 54

Related Documents

1. Federal Law No. 323-FZ dated November 21, 2011, "On the Fundamentals of Protecting Citizens' Health in the Russian Federation".

2. Order of the Ministry of Health of the Russian Federation No. 203n dated May 10, 2017 "On Approval of Criteria for Assessing the Quality of Medical Care".

3. Order of the Russian Ministry of Health No. 1130 dated October 20, 2020, "On Approval of the Procedure for Providing Medical Care in the Field of 'Obstetrics and Gynecology (excluding the use of assisted reproductive technologies)'".

4. Obstetrics: National Guidelines / ed. by G.M. Savelieva, G.T. Sukhikh, V.N. Serov, V.E. Radzinsky. - 2nd ed. - M.: GEOTAR-Media, 2018.

5. Fetal Breech Presentation (Management of Pregnancy and Labor). Clinical Guidelines (Protocol). Letter of the Ministry of Health of the Russian Federation dated May 18, 2017, No. 15-4/10/2-3299 - 35 p.

6. Breech Presentation, External Cephalic Version (ECV) and Breech Presentation in Labour. Clinical Guideline. Royal Cornwall Hospitals. NHS Trust service Equality and Diversity statement. -2015. - 13 p.

7. SOGC Clinical Practice Guideline: Vaginal Delivery of Breech Presentation. No. 226, June 2009 / A. Kotaska [et al.] // Int. J. Gynaecol Obstet. - 2009. - Vol. 37, № 6. - P. 557-566.

8. Management of Breech Presentation: Green-top Guideline No. 20b. / L.W.M. Impey, D.J. Murphy, M. Griffiths, L.K. Penna // BJOG. - 2017.

9. Guidelines for The Management of Breech Presentation Including External Cephalic Version (ECV) // NHS. - 2014. - 23 p.

10. Guidelines for The Management of Breech Presentation Including External Cephalic Version (ECV) // NHS. - 2014. - 23 p.

11. External Cephalic Version. Clinical Guidelines Obstetrics and Midwifery King Edward Memorial Hospital Clinical Guidelines: Obstetrics & Midwifery Perth Western Australia, 2015.

12. External Cephalic Version and Reducing the Incidence of Breech Presentation (Guideline No. 20a) // RCOG. -2010. - 8 p.

13. Birth after Previous Caesarean Birth (Green-top Guideline No. 45) // RCOG. - London, 2015.

14. Management of Breech Presentation (Green-top Guideline No. 20b) // RCOG. -2016.-23 P-

Appendix B. Physician Action Algorithms

Appendix C. Patient Information

During pregnancy, the fetus changes position many times. Toward the end of pregnancy, it becomes less mobile due to increased size combined with a decreasing volume of amniotic fluid. By the time labor begins, most fetuses are positioned in the uterus with the head at the bottom (cephalic presentation). However, 3–4% of fetuses are in a breech presentation (buttocks or one/both feet at the bottom, while the head is in the uterine fundus).

Most often, the cause cannot be identified. And unfortunately, there is no single method that can genuinely help prevent a breech presentation by the time of delivery. The gestational age at which fetal presentation must be determined is 36 weeks of pregnancy. The doctor will do this via external examination during your next visit.

To clarify the diagnosis, an ultrasound scan must be performed. In addition to fetal presentation, the volume of amniotic fluid and the placental location will be determined during the scan. If the doctor determines a breech presentation, you may be offered an external cephalic version. This procedure is performed in a hospital setting. The average success rate of attempts is 50% (ranging from 30% to 80%). A spontaneous reversion back to breech presentation is possible, but its rate does not exceed 5%.

Contraindications for external version: other indications for cesarean section, uterine bleeding during pregnancy, uterine anomalies preventing version, premature rupture of membranes, multiple pregnancy, oligohydramnios, uterine scar, elevated blood pressure (preeclampsia), fetal developmental anomalies, unstable fetal lie, umbilical cord around the neck. Informed consent will be obtained prior to the procedure.

If the version attempt is successful, there is no need for fetal immobilization or further hospital observation. If the breech presentation persists by the time of delivery, you will be informed about the possible delivery methods: cesarean section or vaginal delivery. The outcome of the counseling should be obtaining informed consent for the chosen method of delivery.

Management of labor in breech presentation is almost indistinguishable from vertex delivery. Most often, especially with average fetal sizes, labor proceeds without complications. The baby is born spontaneously, practically without the assistance of a midwife or doctor.

So, if your unborn child is in a breech presentation by the time of delivery, consult a doctor and make your own decision based on your knowledge and preferences.

INFORMED VOLUNTARY CONSENT TO MEDICAL INTERVENTION

External cephalic version for breech presentation

You should be aware that there is a risk of complications with any treatment, medical or surgical procedure (operation). Breech delivery is classified as pathological due to the increased risk of complications for the baby during labor, mainly due to umbilical cord compression and trauma during the delivery of the shoulders and aftercoming head. If the breech presentation persists at term, it is necessary to determine the further management of your pregnancy and choose the method for delivering your baby.

The purpose of the upcoming intervention is to correct the fetal position, specifically, to convert it to a cephalic presentation, due to the higher rate of complications in breech presentation. A successful external version attempt avoids the risks and complications associated with vaginal breech delivery and cesarean section.

The procedure consists of changing the fetal presentation, turning the baby from the current breech presentation to a cephalic one. Following an ultrasound scan, dopplerometry, and fetal heart rate recording (CTG), a final decision is made regarding the feasibility of attempting an external fetal version.

The doctor gently lifts and turns the baby head-down using both hands. To facilitate the version, talcum powder or oil is applied to the abdominal skin. After the version attempt, an ultrasound and CTG are performed. If the version attempt is successful, there is no need to immobilize the fetus with a binder or continue hospital observation of the pregnant woman.

The following form is designed to help you make an informed decision regarding the possibility of changing the fetal position by performing an external cephalic version.

Doctor____________________________________________________ (Full Name) explained

to me,_____________________________________________________ (Full Name), that

the child I am currently carrying is in a breech presentation, and to improve the outcome of pregnancy and labor, I have been offered an attempt at external cephalic version.

I confirm that I have received information from the doctor in a form accessible to me regarding the indications, contraindications, and potential complications of external cephalic version in breech presentation.

Indications: fetal breech presentation.

Contraindications: planned operative delivery via CS; bleeding in the second half of pregnancy; pathological/suspicious CTG; impaired blood flow in the mother-placenta-fetus system according to dopplerometry; IUGR with impaired umbilical artery blood flow; uterine anomalies, uterine or adnexal tumors preventing version; multiple pregnancy (except for version of the second twin after the birth of the first twin); uterine scar; gross fetal malformations, fetal demise; fetal head deflexion; preeclampsia or arterial hypertension; rupture of membranes; lack of informed voluntary consent for external version; oligohydramnios and polyhydramnios; unstable fetal lie.

I have been informed that:

With careful selection of candidates for external version, complications are infrequent; however, the procedure is not entirely without risk.

Side effects from tocolytic medications used to relax the uterus before the procedure are possible (drowsiness, chills, palpitations).

External cephalic version is a major surgical intervention during which complications are possible during and after the procedure; the most common are:

• discomfort; in case of sharp pain, you must inform the Doctor;

• unsuccessful version attempt; the baby may not turn or may revert to the initial position shortly after a successful version; a repeated version attempt may be considered;

• placental abruption;

• preterm labor;

• premature rupture of membranes;

• fetal blood entering the maternal circulation (Rh immunization): in case of maternal Rh-negative blood type, prophylactic administration of anti-RhO [D] human immunoglobulin is performed **;

• fetomaternal hemorrhage (Rh immunization);

• uterine rupture;

• amniotic fluid embolism;

• transient fetal bradycardia;

• fetal distress, rarely antenatal fetal death.

My decision is free and represents an informed and voluntary consent to this intervention.

My signature below indicates that I:

- have read and understood the contents of this document;

- confirm that the doctor has informed me about external cephalic version for breech presentation, alternative management options for pregnancy and childbirth;

- agree with all of the above points of this informed consent;

- had the opportunity to ask any questions of interest regarding the upcoming medical intervention and received comprehensive answers that I understand regarding both the nature of the intervention and the associated risk;

- understand that attempting an external cephalic version carries a risk of complications associated with my individual characteristics and circumstances;

- understand that it is impossible to guarantee the success of an external cephalic version attempt;

- understand that there are risks and dangers associated with the need to perform an emergency cesarean section for fetal distress during the version attempt;

- voluntarily, without pressure or coercion from anyone, give my consent to

(name of medical intervention)

Date___________________ Signature______________________ (

Attending physician___________________________________ Signature_____________________

(Full name)

(date of execution) « » 20 .

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Not applicable.