Breech presentation

1. Max Brinsmead MB BS PhD
August 2014

2. Background
 Incidence
○ 20% at 28 weeks
○ 4% at term
 Reasons for a breech
○ Uterine abnormalities
○ Placental localisation
○ Excessive or reduced amniotic fluid
○ Fetal abnormalities
○ Fetal attitude – extended legs
○ Just chance

3. Perinatal mortality is increased
because…
 Prematurity
 Congenital malformations
 Birth asphyxia
 Birth trauma
 “the biggest part of the baby is coming
last”
 Increased risk of long term “handicap”
even when delivered by CS

4. Current Controversies
 Management of term breech
 Elective Caesarean or vaginal birth
 Selection of 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

5. Recent History
 By 1990
 The practice of ECV had been mostly abandoned
 Because 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

6. 2000 The Term Breech Trial
 RCT in 121 centres in 26 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

7. Risks to the baby & the mode of
delivery…
 After exclusion 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

8. Risks to the mother & mode of
delivery…
 Short term morbidity 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

9. Events since the publication of the Term
Breech Trial…
 Many criticisms 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

10. Other Major Studies
 A prospective study of 2526 women in
France 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

11. Problems with the Term Breech Trial…
 Most of the patients recruited 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)

12. Two year follow up of babies in the
Term Breech 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)

13. Patients not suitable for vaginal breech
birth…
 Other obstetric contraindications incl. 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

14. Optimal intrapartum management…
 Induction of labour is okay
 But augmentation of labour 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

15. The breech delivery…
 Episiotomy when clinically indicated
 Routine breech extraction not recommended
 (But 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

16. Pre term Breech
 Retrospective studies suggest that delivery
by CS confers 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

17. Twins and Breech
 Many clinicians recommend CS when the
leading twin 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

18. Detection of breech presentation…
 Antenatal diagnosis is inconsequential before 35
weeks
 But 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

19. Because breech delivery is a
preventable condition that meets all
the criteria for a screening procedure
The Role of External Cephalic
Version

20. ECV is Effective
RCT’s of external version at or near term (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

21. Risks with ECV
 Cord entanglement
 Post procedure monitoring by CTG
 Transient decelerations common 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

22. ECV is Safe
 No differences in any measure of baby or
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

23. An attempt at ECV is not
contraindicated by…
 Advanced gestation
 A uterine 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

24. ECV is not successively achieved by…
 Maternal posturing
 5 trials 392 women
 Moxibustion 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

25. Unanswered Questions about
ECV
 When it should be attempted
 Beginning earlier at 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

26. The Early ECV Trial
 1543 ♀ in 21 countries randomised to:
 ECV 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

27. Please leave a note on the Welcome Page to this
website