Breech Presentation

localisation
Excessive or reduced amniotic fluid
Fetal abnormalities
Fetal attitude – extended legs
Just

chance

of the baby is coming last”
Increased risk of long term

“handicap” even when delivered by CS

patients for breech birth
Techniques in vaginal breech delivery
Pre term breech

and the twin breech
The detection of breech presentation
The Role of ECV
Is it effective
Is it safe
When should it be performed
How is it best achieved

of reports of intrauterine death
But it was done at 33

– 35 weeks
And therefore possibly unnecessary
Most Pre term breech delivered by CS
Because of concerns about incomplete cervical dilatation
But there was no good evidence to support this
Confusion about the Primigravid Breech
With the “untried pelvis”
Breech skills were being lost

countries & 2088 women
To prove that vaginal breech was safe

& to maintain breech skills
Multiparous or nulliparous at term with a singleton breech
Non-footling, EFW <4000g & morphologically normal
Randomised to elective CS or trial of vaginal delivery
Induction & augmentation of labour permitted
Experienced accoucheur to be present
But this trial was stopped prematurely because increased perinatal risk with vaginal breech delivery

of deaths from congenital malformation the risk of perinatal death

or serious morbidity is reduced by elective CS (RR 0.29, CI 0.10 – 0.86)
After excluding cases with:
Epidural anaesthesia
Prolonged labour
Labours induced or augmented
Footling breech
No experienced accoucheur present
Risk with vaginal birth still 3.3% but 1.3% with elective CS (RR 0.49, CI 0.26 – 0.91)
This data from systematic analysis of the Term Breech Trial plus two smaller prior trials

is increased by vaginal delivery (RR 1.29 CI 1.03 –

1.61)
Urinary incontinence
More perineal pain
Long term morbidity from uterine scar needs evaluation
Estimated that for each baby saved by CS there will be one scar rupture in attempted VBAC later
In the Netherlands, in the 4 years after 2000, 8500 CS were done, “saved” 19 babies but 4 maternal deaths occurred
Needs 53 additional CS for each baby saved

of the Trial
Follow up of the Term Breech Trial babies

found no long term benefit from CS
A prospective study of 2526 women in France and Belgium analyzed on an intention-to-treat basis found no benefit from elective CS
RCOG, RANZCOG and Canadian guidelines state that trial of vaginal breech delivery is a safe option
All also recommend attempting ECV

and Belgium analyzed on an intention-to-treat basis found no benefit

from elective CS

Dutch study of 58,320 term breech 1999-2007
Elective CS rose from 24% to 60%
PNM fell from 1.3 to 0.7 per 1000
PNM for those having vaginal birth did not change

in developed countries
Subgroup analysis suggests that the outcome cannot be

extrapolated to resource poor countries
Many of the centres involved had historically low rates of vaginal breech birth
Raises questions about the experience of the “skilled accoucheur”
Criteria for patients for trial of vaginal birth were too liberal
Lumping fetal mortality and morbidity was inappropriate for long term outcomes
3 deaths in the vaginal group vs none in the CS group is NS (and one death was a surviving twin)

Trial…
Was conducted in those Centres thought to achieve 80% follow

up
Outcomes measured were perinatal death and neurodevelopmental delay
There were no significant differences (RR 1.09 CI 0.52 – 2.30)
The smaller number of perinatal deaths in the CS group was balanced by a higher number of 2 year-olds with neuro-developmental delay
Calls into question the measures of neonatal morbidity (which were more frequent in the vaginal birth group)

placenta previa, compromised fetus and previous CS
Footling or kneeling breech
EFW

>3800 or <2000g
Hyper extended neck – ultrasound or X-ray
Routine radiological pelvimetry not required but patients with a small pelvis not suitable
But maybe a role for CT pelvimetry
Experienced accoucheur not available
Diagnosis of the breech in labour is not a contraindication

not recommended
Epidural according to the mother’s wishes
Continuous CTG is recommended
CS

should be performed for failure to progress on the 1st stage and failure of the breech to descend in the second stage
40 – 50% of patients attempting vaginal birth will require Caesarean
And, because both baby and maternal outcomes are worse with emergency CS, this is why I prefer elective CS

delivery should not be unduly delayed)
Delivery of the arms
Sweep them

down or…
Lovset’s maneuvre
Delayed engagement of the head
Suprapubic pressure or…
Mauriceau-Smellie-Veit with or without rotation
Delivery of the head
Burns-Marshall or…
Mauriceau-Smellie-Veit
Symphysiotomy and forceps for trapped head

advantage to the baby
Especially for the very pre term
But the

data is biased
And maternal risk needs to be taken into account
So the best option is to make individual decisions
With the involvement of the patient
Incomplete dilation is a problem
Cervical incisions recommended

is breech
But data is lacking to confirm this trend
And locked

twins are very rare
Routine CS for a second twin that is breech is not recommended
But is sometimes required
Some RCT’s have been performed and CS not shown to confer any benefit
More studies are underway
Breech extraction of the second twin is an option

detection in labour is too late because…
Maternal counseling is compromised
Place

of labour may be inappropriate
Risks to mother and baby both increased regardless of the mode of delivery
In a study of 1633 women attending the antenatal clinic of a tertiary Sydney hospital
30% of breech presentations were missed
Conclusion:
Ultrasound for presentation at 36 – 37 weeks should be a component of routine antenatal care

the criteria for a screening procedure
The Role of External Cephalic

Version

(5 trials and 433 women)
Reduce the rate of breech presentation

in labour (RR 0.38, CI 0.18 – 0.80)
Reduce the rate of CS (RR 0.55, CI 0.33 – 0.91)
Overall success rate is:
60% in multipara
40% in primipara
Lower when the legs are extended
Or the breech is deeply engaged

with a known nuchal cord
Premature labour and PROM
Not a problem

if it is deferred until >37w
Antepartum haemorrhage
Anti-D for those patients who are Rh Neg
Maternal pain
Limits continuation with the attempt in ~ 5%
Fetal reversion to breech
Overall less than 5% and is usually predictable

maternal outcome in the RCT’s
Has a low rate of complications

in large observational studies
O.5% rate of emergency CS in 805 consecutive cases in Oxford
One Term PROM in a personal series of >200 attempted ECV’s over 15 years
No documented case of procedure-related perinatal loss in the large trials
And few in the literature overall

scar
History of prior APH
Maternal hypertension
Oligohydramnios
A nuchal cord

And is

usually limited only by the maternal willingness to consider and continue the procedure
Which in turn is usually proportional to the counseling that is initially and subsequently provided

with or without acupuncture
3 trials 597 women
The need for

ECV was reduced in one study

But ECV is facilitated by…
Tocolysis with IV or SC betamimetic agents
Betamimetics better than oral Nifedipine & sublingual nitroglycerine is not recommended
Epidural but not spinal anaesthesia
Fetal acoustic stimulation

34 – 36w may be okay
Should attempts be repeated
How many

times
How often
Role in the fetus who has an unstable lie
Role with amnioreduction and amnioinfusion
Teaching and maintaining skills

at 34 – 36 weeks or
>37 weeks
Fewer breeches at term

from early ECV
RR 0.84 CI 0.75 – 0.94 (41% vs 48%)
But rate of Caesarean not reduced
Inexplicable
Early ECV appears safe
No difference in fetal/neonatal morbidity
But a meta analysis suggests increased risk of preterm labour
Discuss benefits and risks and choose