8A) Antenatal Care: Breech and ECV

Question 1

Incidence of breech presentation at term

Answer 1

3-4%

Question 2

Proportion of breech presentations at term which are undetected until labour

Answer 2

25%

Question 3

Proportion of breech presentations which will spontaneously vert after 36 weeks

Answer 3

8%

Question 4

Perinatal mortality associated with breech, CS, cephalic and VBAC

Answer 4

CS breech 0.5/1000
Cephalic NVD 1/1000
Breech VD 2/1000
VBAC 1.4/1000

Question 5

Factors contributing to reduced risk of perinatal mortality in breech CS

Answer 5

• Delivery at 39 weeks (reduces perinatal mortality by 1/1000)
• Avoidance of intrapartum events
• Avoidance of vaginal breech delivery

Question 6

Risk factors for breech presentation

Answer 6

Nulliparity
Previous breech (recurrence rate 10%)
Uterine anomalies
Preterm
Congenital anomalies

Question 7

Factors that mean CS should be recommended

Answer 7

• Hyperextended neck
• EFW >3.8kg or <10th centile
• Footling breech
• Antenatal compromise

Question 8

Management of breech presenting in labour

Answer 8

If at or close to second stage, CS should not routinely be recommended.
If time allows then scan and counsel as for antenatal breech presentation.

Question 9

Management of labour in breech presentation

Answer 9

• Not for IOL
• Augmentation only if <4:10 contractions in presence of epidural
• Slow progress —> offer CS
• Passive second stage until buttocks on perineum and then can start active pushing
• Hands off approach
• Intervention if: fetal compromise, delay >5min from buttocks to head or >3min from umbilicus to head

Question 10

Techniques for breech delivery

Answer 10

Lovett Maneouvre for delivery of unchallenged arms once scapula visible.
Mauriceau-Smelie-Veit manoeuvre for delivery of head.
Bracht manoeuvre - once umbilicus delivered, keep fetal legs flexed on to abdomen and without traction bring baby up against symphysis pubis with suprapubic pressure.

Question 11

Risk of head entrapment in preterm vaginal breech liveries

Answer 11

14%

Question 12

In what percentage of twin pregnancies is the second twin non-vertex at the time of delivery

Answer 12

40%

Question 13

Success rate for ECV

Answer 13

40% primip, 60% multip

Question 14

Percentage of babies that revert to breech after successful ECV

Answer 14

3%

Question 15

Percentage of babies that spontaneously vert after unsuccessful ECV

Answer 15

3-7%

Question 16

Benefits of ECV

Answer 16

• Reduces risk of CS

- Labour after ECV may be associated with slightly increased rate of CS or instrumental delivery

Question 17

Factors which improve chance of success of ECV

Answer 17

Multiparity
Complete breech
AFI >10
Tocolysis
Posterior placenta
Breech not engaged and head palpable
Maternal weight < 65kg

Question 18

Timing of ECV

Answer 18

From 36 primip and 37 multip

Question 19

Contraindications to ECV

Answer 19

Placental abruption
Severe PET
Abnormal CTG
CS otherwise indicated
Ruptured membranes
Vaginal bleeding last 7 days
Multiple pregnancy (except after delivery first twin)

Caution with oligohydramnios or hypertension.

Question 20

Risk of CS within 24 hours of ECV

Answer 20

0.5%

Question 21

Sensitivity of abdominal palpating for detecting breech presentation

Answer 21

70%

Question 22

Moxibustion

Answer 22

May promote spontaneous version 33-35 weeks.