Not too fast, not too slow: A review of historical trends in vaginal breech time management

Abstract

Problem: A lack of consistent professional guidance on when to intervene during emergence (buttocks and anus visible at the introitus to birth of the head) in vaginal breech birth (VBB).

Background: Hypoxia and asphyxia are common complications of VBB, especially due to umbilical cord compression around the time of emergence.

Aim: To gain insight into VBB time management trends, the evidence behind these practices and how they may have influenced outcomes.

Methods: Literature review of obstetric textbooks published between 1960 and 2000 contained in the Wellcome Collection and Royal College of Obstetricians and Gynaecologists Library in London.

Findings: 90 textbooks were reviewed. Recommendations for 'safe' intervals between birth of the umbilicus and the head ranged from 5 to 20 min. Many sources focused only on the time required to deliver the head, with 'up to 10 min' being the most common interval described. The review found no mention of cord compression causing concern earlier in breech births than once the umbilicus itself is delivered, nor any evidence to support the recommendations.

Discussion: These findings demonstrate a long-term pattern across the second half of the 20th century, whereby birth attendants were urged not to rush emergence nor delay intervention but were given little clear guidance on optimal timings.

Conclusion: Clear, evidence-based guidance should be provided in breech training materials to avoid unnecessary hypoxic injuries, and this guidance should be rigorously evaluated.

Keywords: Breech presentation; Cord compression; Evidence-based practice; Obstetric delivery; Practice gaps; Vaginal breech delivery.