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International Journal of Gynecology andObstetrics 107 (2009) 169176

Contents lists available atcien ce!ir ect

International Journal of Gynecology and Obstetrics

" ou r na l #o$e%age & ' ' ' elsevier co$ loca t e i " go

OGC C*I+IC,* -.,C/IC GI!*I+

aginaldelivery of breec#%resentation

+o 2263 June 2009

/#is guideline #as beenrevie'edbyt#e

a b s t ra c t

4aternal5etal4edicineCo$$itteeand

a%%rovedby t#e ecutiveandCouncilof t#e ociety ofObstetricians andGynaecologists of Canada

-.I+CI-,* ,/O.

,ndre' 8otasa3 4!3:ello'nife+/avas4enticoglou3 4!3;inni%eg41)

/#is docu$ent reectse$erging clinical and scientiBcadvanceson t#e date issued and is sub"ecttoc#ange /#e infor$ation s#ould not be construed as dictatingan eclusive course of treat$ent or%rocedure to be follo'ed *ocal institutionscan dictatea$end$ents to t#ese o%inions /#ey s#ould be'ell docu$entedif $odiBedat t#e local level

,bbreviations& ,COG3 ,$erican College of Obstetricians and Gynecologists? C3 Caesarean section? C543 continuous electronic fetal $onitoring? .COG3 .oyal Collegeof

Obstetricians and Gynaecologists? /


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170 OGC C*I+IC,* -.,C/IC

/#e uality of evidence re%orted in t#ese guidelines #as been ada%tedfro$ /#e valuation of vidence criteriadescribed in t#e Canadian /as 5orce on -reventive ealt# Care H62

8ey'ords

1& vidence fro$ 'ell>designedcontrolled trials

'it#out rando$iDation

II>2& vidence fro$ 'ell>designed co#ort (%ros%ective or

retros%ective) or case>control studies3 %referably fro$

$oret#an one centre or researc# grou%II>@& vidence obtained fro$co$%arisons bet'een ti$es

or %laces 'it# or 'it#out t#eintervention!ra$atic

results inuncontrolled e%eri$ents (suc# ast#e results of

treat$ent 'it#%enicillin in t#e 190s) could alsobe

included in t#is category

III& O%inions of res%ected aut#orities3 based on

clinical e%erience3 descri%tive studies3or re%orts of

e%ert co$$ittees

, /#ere is good evidence toreco$$end t#e clinical

%reventive action

$aing

! /#ere is fair evidence toreco$$end against t#e

clinical%reventive action

/#ere is good evidence toreco$$end against t#e

clinical %reventive action

* /#ere is insufBcient evidence (inuantity or uality) to

$ae areco$$endation? #o'ever3 ot#erfactors $ay

inuence decision>$aing

/#e uality of evidence re%orted in t#ese guidelines #as been ada%tedfro$ /#e valuation of vidence criteriadescribed in t#e Canadian /as 5orce on -reventive ealt# Care H62

.eco$$endationsincluded in t#ese guidelines #ave been ada%tedfro$t#e ClassiBcation of .eco$$endationscriteria

described in t#e /#e Canadian /as 5orce on -reventive ealt# Care H62

@ -lanned vaginal delivery is reasonable in selected 'o$en 'it# a

ter$ singleton breec# fetus (I) ;it# careful case selection and labour $anage$ent3 %erinatal

$ortality occurs in a%%roi$ately 2 %er 1000 birt#s andserious s#ort>ter$ neonatal $orbidity in a%%roi$ately 2K of

breec# infants 4any recent retros%ective and%ros%ective re%ortsof vagi> nal breec# delivery t#at follo' s%eciBc %rotocols #avenoted e> cellentneonatal outco$es(II>1)

A *ong>ter$ neurological infant outco$es do notdifferby %lanned$ode of delivery even in t#e%resence of serious s#ort>ter$ neo>natal $orbidity(I)

.eco$$endations

*abour selection criteria

1 5or a 'o$an 'it# sus%ected breec# %resentation3%re> or earlylabour ultrasound s#ould be %erfor$ed to assess ty%e of

breec# %resentation3 fetal gro't# and esti$ated 'eig#t3 andattitude of fetal #ead If ultrasound is not available3 Caesareansection is reco$$ended (II>1,)

2 Contraindications to labourinclude

a Cord%resentation(II>@,)b 5etal gro't# restriction or $acroso$ia (I>,)c ,ny%resentation ot#er t#an a fran or co$%letebreec# 'it# a

eed or neutral #ead attitude (III>2 logical %elvic contraction .adiologic %elvi$etry is notnecessary for a safe trial of labour? good %rogress in labour is t#ebest indicator ofadeuate fetal>%elvic %ro%ortions (III>,);#en $e$branes ru%ture3 i$$ediate vaginal ea$ination isreco$> $ended to rule out %rola%sed cord (III>1,)

7 Induction of labour is not reco$$ended for breec#%resentation

(II>@1,)

E , %assive second stage 'it#out active %us#ing $ay last u% to90 $inutes3 allo'ing t#e breec# to descend 'ell into t#e %elvisOnce active %us#ing co$$ences3if delivery is not i$$inent after60 $inutes3 Caesarean section is reco$$ended (I>,)

9 /#e active second stage of labour s#ould tae %lace in or near ano%erating roo$ 'it# eui%$ent and %ersonnel available to

%erfor$ a ti$ely Caesareansection if necessary (III>,)10 , #ealt# care %rofessional silled in neonatalresuscitation s#ould

be in attendance at t#e ti$e ofdelivery (III>,)

!elivery tec#niue

11 /#e #ealt# care %rovider for a %lanned vaginalbreec# deliveryneeds to %ossess t#e reuisite sillsand e%erience (II>1,)

12 ,n e%erienced obstetrician>gynaecologist co$fortable in t#e%erfor$ance of vaginal breec# delivery s#ould be %resent at t#edelivery to su%ervise ot#er #ealt# care %roviders3 including atrainee (I>,)

1@ /#e reuire$ents for e$ergency Caesarean section3 includingavailability of t#e #os%italo%erating roo$ tea$ and t#e a%%ro>i$ate @0>$inute ti$eline to co$$ence a la%aroto$y3 $ust bein accordance 'it# t#e reco$$endations of t#e OGC -olicytate$ent3,ttendance at*abour and !elivery (C-G +o E9? u%>date in%ress32009) (III>,)

1 /#e #ealt# care %rovider s#ould #ave re#earsed a %lan of actionand s#ould be %re%ared to ac

t%ro$%tly in

t#erare

circu$>stance of a tra%%ed after>co$ing #ead or irreducible nuc#alar$s& sy$%#ysioto$y or e$ergency abdo$inal rescue can belife saving (III>2,)

16 ffective $aternal %us#ing efforts are essential to safe deliveryand s#ouldbe encouraged (II>1,)

17 ,t t#e ti$e of delivery of t#e after>co$ing #ead3 an assistants#ould be %resent to a%%ly su%ra%ubic%ressure to favour eionand engage$ent of t#efetal #ead (II>@tion s#ould be avoided3 and fetal $ani%ulation $ust be a%%liedonly after s%ontaneous delivery to t#e level of t#e u$bilicus(III>,)


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19 +uc#al ar$s $ay be reduced by t#e *Lvset or vres (III> $ented and co$$unicated tolabour>roo$ staff (III> #os%ital care (III>,)

2A /#e ociety of Obstetricians and Gynaecologists of Canada(OGC)3 in collaboration 'it# t#e ,ssociation of -rofessorsof Obstetrics and Gynaecology (,-OG)3 /#e College of 5a$ily-#ysicians of Canada (C5-C)3 and /#e Canadian ,ssociationof 4id'ives (C,4) s#ould revise t#e training reuire$ents att#e undergraduate and %ostgraduate levels OGC 'ill continueto %ro$ote training of current #ealt# care %roviders t#roug#t#e 4O.O,)

26 /#eoretical and #ands>on breec# birt# trainingsi$ulation s#ouldbe %art of basic obstetrical sillstraining %rogra$s suc# as ,*,.43,*O (,dvanced *ife u%%ort /raining in Obstetrics)3 and4O.O< to %re%are #ealt# care %roviders for une%ectedvaginal breec# birt#s (III> lo's& (1) inadeuate case selection andintra%artu$ $anage$ent? (2) $aternity units 'it# $aredly differentsill levels grou%ed toget#er? and (@) s#ort>ter$ $orbidity used as asurrogate $arer for long>ter$ neurological i$%air$ent

/ or early labour ultrasound 'as not reuired3'#ic# $ay #aveallo'ed fetuses 'it# gro't# restrictiondue to %lacental insufBciencyto go undetected,tleastseven of t#e trialFs 16%erinatal deat#s 'erein gro't#>restricted fetuses H9316319321 /o '#at etent undetectedfetal $acroso$ia and deeed #ead %ositioncontributed to $orbidityand $ortality is unno'nContinuous electronic fetal $onitoring 'asalso not reuired3 and only one t#ird of fetuses received it /#e trial%rotocol allo'ed labour %rogress to be as slo' as0Ac$#r in t#e Brststage and u% to @A #ours for t#esecond stage H21 ,lt#oug# t#ey areacce%table for ce%#alic fetuses3 fe' e%erienced %ractitioners con>sider t#ese li$its acce%table for a breec# fetus3 and t#eAK of fetusesborn after an active second stage longer t#an 60 $inutesencountered increased $orbidity and $ortality H22 /#erefore it

can be learned fro$ t#e /ter$ $orbidity in vaginally born breec# fetuses is oftenincreased because of t#e cord co$%ression t#at co$$only occursduring t#e second stage and fetal e%ulsion In countries lie Canada'it#lo' %erinatal $ortality3t#e absolute difference inserious s#ort>ter$ $orbidity bet'een t#e ar$s of t#e /


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,t t'o years of age3 t#e only signiBcant difference in infant out>co$e 'as fe'er $edical%roble$s in t#e%ast several $ont#s in t#e/O* grou% (1AK vs 21K? -N002) /#e neonatal i$$une syste$is activated during labour3 and associations bet'een labour andreduced incidence of %ediatric allergic and auto>i$$unedisease $aybe causal H29@2

;it# t#e li$itations in t#e /year old3 regardless of %lanned$ode of birt# /#ose rando$iDed to a trial of labour #ad a 6Kabsolute lo'er c#ance (or @0K relative ris reduction) of #aving at'o>year>old c#ild 'it# uns%eciBed $edical %roble$s3 suggestingso$e lasting beneBt of labour to t#e ne'born i$$unesyste$

-re$odastudy

+u$erous retros%ective series co$%aring a /O* 'it# %lannedC #ave been %ublis#ed H263273@@@7 4any 'ere large enoug# tode$> onstrate acce%table safety of breec# birt# in individual units?#o'ever3 data 'ere collected retros%ectively and 'ere notnecessarilygeneral> iDable beyond t#ose e%erienced units In 20063inres%onse to t#e / or early labour ultrasoundandC54 in labour 'ereuniversal Contrary to standard%ractice in $any countries3 includingCanada3 radiologic %elvi$etry 'as e$%loyed in E2K 5ailure to

%rogress for $ore t#an t'o

#ours in t#e Brst stage of labour occurred in @EK of labours3 and anactive second stage longer t#an 60$inutes occurred in only 02K ofcases Only 06K of'o$en %lanning C eventually delivered vaginally3andall fetuses 'ere breec# at delivery

,lt#oug# not strictly co$%arable3 t#e -.4O!, outco$es con>trast 'it# t#ose of t#e / %erinatal>$ortality subset of t#e /1)

A *ong>ter$ neurological infant outco$es do notdifferby %lanned$ode of delivery even in t#e%resence of serious s#ort>ter$ neo>natal $orbidity(I)

.eco$$endations

aginal breec# birt# is a co$%le%#eno$enonelection criteria3intra%artu$ $anage$ent%ara$eters3 and delivery tec#niues aredifBcult to isolate and study3 and t#ere is little rigorous evidence tosu%%ort or refute t#e$ individually /#e criteria outlined #ere arebased u%on t#e %#ysiology ofbreec#birt#3 t#e results of t#e /,)c ,ny%resentation ot#er t#an a fran or co$%letebreec# 'it# a

eed or neutral #ead attitude (III>2


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;#en a 'o$an is ad$itted for a %lanned vaginalbreec# birt#3#aving been follo'ed by a fa$ily %ractitioner or a $id'ife3a consultation 'it# anobstetrician>gynaecologist s#ould be obtained

-re> or early>labour ultrasound assess$ent is essential todeter$ine ty%e of breec# %resentation3 assess fetal gro't#3 anddetect t#e rare etended fetal nec at increased ris ofentra%$ent HA36 /o be eligible for a /O*3 esti$ated fetal'eig#t s#ould be bet'een 2A00 g and 000 g /#e lo'er $argin is

intended to eclude gro't#>restricted fetuses3 t#e u%%er $arginto avoid fetal>%elvic dis%ro%ortion Clinical %elvic ea$inations#ould be %erfor$ed to rule out %at#ological %elvic contraction,lt#oug# used in E2K of labours in t#e -.4O!, study3radiological %elvi$etry re$ains controversial3 and $any centres#ave de$onstrated safety 'it#out it H263@3@A3@7 /#e bestindication of adeuate fetal%elvic%ro%ortions is good %rogress inlabour

,breec# fetus #as a #ig#er c#ance of cord%resentation -ersistentcord %resentation is anindication for C to %revent cord %rola%se H7,breec# fetus also #as a #ig#er ris of cord %rola%se in labourt#an ace%#alic fetus /#is ris varies fro$ less t#an 1K for fran breec# to

%er#a%s 10K for footling breec# %resentation HE 5or a 'o$anto be eligible for a /O*3 #er fetus $ust be in a fran or co$%letebreec# %resentation , footling breec#3 deBned as #aving at leastone e> tended fetal #i%3 is a contraindication to labour3 and a Cs#ould be %erfor$ed unless delivery is i$$inent , fetus 'it# feet

%resentingbut eed #i%sand nees is a co$%letebreec#3 t#ereforeeligible for a /O*

*abour $anage$ent

Clinical %elvic ea$ination s#ould be %erfor$ed to rule out%at#> ological %elvic contraction .adiologic %elvi$etry is notnecessary for a safe trial of labour?good %rogress in labour is t#ebest indi> cator ofadeuate fetal>%elvic %ro%ortions (III>,);#en $e$branes ru%ture3 i$$ediate vaginal ea$ination isreco$> $ended to rule out %rola%sed cord (III>1,)

7 Induction of labour is not reco$$ended for breec#%resentation(II>@1,)

E , %assive second stage 'it#out active %us#ing $ay last u%to

90 $inutes3 allo'ing t#e breec# to descend 'ell into t#e%elvis Once active %us#ing co$$ences3 if delivery is noti$$inent after

60 $inutes3 Caesarean section is reco$$ended (I>,)9 /#e active second stage of labour s#ould tae %lace in or near an

o%erating roo$ 'it# eui%$ent and%ersonnel available to %er>

for$ a ti$ely Caesareansection if necessary (III>,)10 , #ealt# care %rofessional silled in neonatalresuscitation s#ould

be in attendance at t#e ti$e ofdelivery (III>,)

!uring breec# labour3 C54 is reco$$endedbecause of t#eincreased ris of cord %rola%se!etection of cord %rola%se in #os%ital'it# ti$ely access to C is usually associated 'it# good fetaloutco$e H2739 -rior to dee% engage$ent in labour3 $e$braness#ould be ru%tured artiBcially only 'it# aclear indication and careful$onitor> ing ;#en $e$branes ru%ture3 i$$ediate vaginalea$ination is indicated to rule out %rola%sed cord If $e$branesru%ture at #o$e3 a 'o$an 'it# a no'n breec# %resentations#ould be advised to %resent i$$ediately to #os%ital forassess$ent !uring t#e second stage of labour3 descent of t#ebreec# and entry of t#e u$bilical insertion into t#e %elvis areco$$only associated 'it# an increased incidence of cordco$%ression and variable decelerations C54 is universallyreuired in t#e second stage , fetal scal% CG electrode $ay be

inserted into t#e buttoc for C543 and one s$all study


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su%%orts t#e validity of ca%illaryblood gas sa$%lesdra'n fro$ t#efetal buttocs to assess fetal 'ell>beingHA0

-rogress in labour is an i$%ortant factor in breec# labour $an>age$ent In t#e absence of data to t#e contrary3 t#e /gynaecologist 'it# t#e

reuisite sil ls s#ould be available for a %lanned vaginal birt#3alt#oug# itis recogniDed t#at co$%lications at birt# $ay occur evenunder t#e best %ossible circu$stances

/#e second stage of labour can be divided into a%assive %#ase3%rior to active %us#ing3 and an active%us#ing %#ase /#e %assive%#ase 'as + 60 $inutes in 1EK of labouring 'o$en in-.4O!, ,ctive%us#ing lasted for + 60 $inutes in only 02K ,%rudent li$it for t#e overall duration of t#e second stage3 t#erefore3'ould be 2A #ours If delivery is not i$$inent after 60 $inutes ofactive %us#ing3 C is indicated3 even if t#e buttocs are on t#e

%erineu$ ,)


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1 /#e #ealt# care %rovider s#ould #ave re#earsed a %lan ofaction and s#ould be %re%ared to act %ro$%tly in t#e rarecir> cu$stance of a tra%%ed after>co$ing #ead or irreduciblenuc#al ar$s& sy$%#ysioto$y or e$ergency abdo$inal rescuecan be life saving(III>2,)

16 ffective $aternal %us#ing efforts are essential to safe delivery

and s#ouldbe encouraged (II>1,)17 ,t t#e ti$e of delivery of t#e after>co$ing #ead3 anassistant s#ould be %resent to a%%ly su%ra%ubic %ressure tofavour eion and engage$ent of t#efetal #ead (II>@tion s#ould be avoided3andfetal $ani%ulation $ust be a%%liedonly after s%ontaneous delivery to t#e level of t#e u$bilicus(III>,)

19 +uc#al ar$s $ay be reduced by t#e *Lvset orco$ing fetal %arts %ontaneous birt# #el%s $ini$iDet#is ris3 and $any breec# infants deliver s%ontaneously in ati$ely fas#ion 'it# $aternal e%ulsive efforts alone ;#et#er usedroutinely or only if s%ontaneous birt# is not fort#co$ing3 fetal

$anoeuvress#ould be e$%loyed only after s%ontaneous deliveryto t#e u$bilicus3 and traction s#ouldbe $ini$iDedHA@

,fter t#e breec# cro'ns3 fetal e%ulsion is invariablyacco$%aniedby cord co$%ression and fetalbradycardia/#e nor$ally gro'n fetusenters t#is %#ase'ell oygenated 'it#out acide$ia It $ay tolerate anu$ber of $inutes of delay 'it# etrinsic cord co$%ression3resulting in a res%iratory acidosis3 easily reversed once ventilationis estab> lis#ed , gro't#>restricted fetus3 #o'ever3 #as a #ig#lieli#ood of $etabolic acide$ia in labour due to %re>eistingco$%ro$ise in %lacental function3 '#ic# reduces its tolerance tocord co$%ression during e%ulsion /#erefore3 fetal gro't#restriction is a contra> indication to labour

igniBcant cord co$%ression beyond several $inutes 'ill even>tually lead to severe acidosis even in anor$al fetus3 and %revention

and treat$ent ofe%ulsive delay are critical co$%onents of deliverytec#niue 4ec#anis$s t#at $ai$iDe %o'er fro$ above $ay beassociated 'it# lo'er ris of tra%%ed after>co$ing fetal %artst#an $anoeuvres t#at involve fetal traction H13@6 4aternalcoo%eration is essential3 and #eavy sedation or dense e%iduralanalgesia s#ould be avoided to $ai$iDe e%ulsive efforts HA24et#ods of increasing%o'er fro$ above once t#e buttocs #ave cro'nedinclude $ai$iD>ing $aternal %us#ing efforts3 u%rig#t %osture3 and su%ra%ubic%ressure HA36 +one#ave been 'ell studied inde%endently4ai$iD>ing$aternal %us#ing is considered safe3 and t#e use of anassistant toa%%ly su%ra%ubic %ressure after cro'ning to $aintain eion of t#efetal #ead and facilitate its engage$ent $ay be #el%ful (co$ing fetal

%arts /otal breec# etraction is ina%%ro%riate for ter$ singletonbreec# delivery in a $odern #os%ital 'it# ready access to C /#efetal #ead $ay deliver s%ontaneously3 by 4auriceau>$ellie>eit

$anoeuvre3 'it# t#e assistance of su%ra%ubic %ressure (,)

22 /#e consent discussion and c#osen %lan s#ould be 'elldocu> $ented and co$$unicated tolabour>roo$ staff (III>#os%ital care (III>,)

2A /#e ociety of Obstetricians and Gynaecologists of Canada(OGC)3 in collaboration 'it# t#e ,ssociation of -rofessors ofObstetrics and Gynaecology (,-OG)3 /#e College of 5a$ily-#ysicians of Canada (C5-C)3 and /#e Canadian ,ssociation of4id'ives (C,4) s#ould revise t#e training reuire$ents at t#eundergraduate and%ostgraduate levels OGC 'ill continue to

%ro$ote training of current #ealt# care %roviders t#roug# t#e4O.O,)

26 /#eoretical and #ands>on breec# birt# trainingsi$ulation s#ouldbe %art of basic obstetrical sills training %rogra$s suc# as,*,.43 ,*O (,dvanced *ife u%%ort /raining in Obstetrics)3and 4O.O< to %re%are #ealt# care %roviders for une%ectedvaginal breec# birt#s (III>ter$ ne'born ris of vaginal breec# delivery and t#e $any co#ortre%orts noting ecellent neonatal outco$es in settings 'it# s%eciBc%rotocols3 it is acce%table for #os%itals to offer vaginal breec# de>

livery os%itals offering vaginal breec# birt#s#ould #ave a 'ritten%rotocol for eligibility and intra%artu$ $anage$ent3 including noti>Bcation of t#e$ost res%onsible #ealt# care %rovider u%on ad$issioninlabour

5aced 'it# a%arturient reuesting a /O*3 t#e #ealt#care %rovider$ust evaluate #is or #er o'n syste$ ofbreec# selection3 intra%artu$$anage$ent3 delivery tec#niue3 and clinical e%erience ;o$ens#ould be infor$ed t#at t#e r is of s#ort>ter$ neonatal$orbidity $aybe #ig#er for a %lanned vaginal delivery t#an for a%lanned Cbut t#at long>ter$ infant neurological outco$e is notdifferent In t#e lo'>%erinatal>$ortality>country ar$ of t#e /


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/#e %otential ris ofcoercion

/#e 2001 ,COG and .COGbreec# guidelines left little roo$for %arturient autono$y H10311 ince t#eir %ublication3 it #as

been routine %ractice in $any "urisdictions for obstetrician>gynaecologists to refuse 'o$en a breec# /O* in #os%ital Onoccasion3 'o$en so denied #ave given birt# unattended at #o$e3and %erinatal deat#s #ave resulted HAE ,lso3 t#e volu$e of

$id'ife>attended breec# #o$e birt#s a%%ears to #ave increasedven 'it# t#e uality of care li$itations of t#e /ter$outco$e 'as euivalent in t#e %lanned vaginal birt# and %lannedC grou%s3 and %arturient auto> no$y taes %recedence over

%ractitioner concerns about s$all levels of fetal ris ;o$en s#ouldbe infor$ed of t#e safety of a /O* in a setting 'it# e%eriencedcare %roviders

;o$en '#o #ave a contraindication to labour or '#o are con>sidered %oor candidates for a /O* s#ouldbe advised to deliverby Co'ever3 it is t#e %atientFs rig#t to decline any reco$$ended$edical %rocedure or treat$ent If a 'o$an c#ooses to labourdes%ite t#is reco$$endation3 s#e s#ould be cared for in #os%italIn>#os%ital breec# birt# in a $odern obstetrical setting is al$ostcertainly safer t#an #o$e birt#3 and a 'o$an $ust not beabandoned if s#e doesnot tae $edical advice HA9

yste$factors

In 20063 t#e .oyal College of Obstetricians andGynaecologists andt#e ,$erican College of Obstetrics and Gynecology re%laced t#eirrestrictive 2001 breec# guidelines 'it# ne' versions su%%ortive ofselected vaginal breec# birt# H60361 /#e 2006 .COG Green /o%Guideline on breec# birt# outlines t#e obstetrical co$$unityFsres%onsibility to t#e individual %arturient& If a unit is unableto offer t#ec#oice of a%lanned vaginal breec# birt#3 'o$en '#o'is#to c#oose t#is o%tion s#ould be referred to a unit'#ere t#is o%tionis available

4any ne'ly ualiBed obstetrician>gynaecologists donot #ave t#e

e%erience necessary to su%ervise a breec# /O*3 and $entoring by$ore senior colleagues 'ill be necessary if t#ey are to attaint#ese sills ,s %reci%itous breec# birt#s 'ill occur in all settings3t#eoretical and #ands>on breec# birt# training using $odelss#ould be %art of basic obstetrical and $id'ifery training and of

training %rogra$s suc# as,*,.43 ,*O3 and 4O.O


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H12 -#i%%s 3 .obertsC*3+assar+3 .aynes>Greeno'C3 -eat age$ent of breec# %regnancies in ,ustralia and +e' Qealand ,us +Q JObstet Gynaecol200@?@&297

H1@ ogle 8*3 8ilburn *3 e'son 3 Gafni ,3 ;all .3 anna# 4 I$%act oft#e international ter$ breec# trial on clinical %racticeand concerns& a survey ofcentre collaborators JObstet Gynaecol Can 200@?2A&16

H1 GofBnet 53 year e%erience at adistrict general #os%ital


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HA venningsen +;3 ;estgren 43 Inge$arsson I 4odern strategy for t#e ter$breec# delivery, study 'it# >year follo'>u% of t#e infants J -erinat 4ed19EA?1@&

11726

H6 ;estgren 43 Grundsell 3 Inge$arsson I3 4#lo' ,3 venningsen +;y%er> etensionof t#e fetal #ead in breec# %resentation , study'it# long>ter$follo'> u%


11/15

SOGC KLINIK PRAKTEK PEDOMANPersalinan pervaina! s"nsan presen#asi

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