breech

Question 1

What are the relative and absolute contraindications to ECV

Answer 1

Absolute - ECV what will be associated with increased morbidity or mortality

 where caesarean delivery is required
 antepartum haemorrhage within the last 7 days
 abnormal cardiotocography
 major uterine anomaly
 ruptured membranes
 multiple pregnancy (except delivery of second twin).

Relative contraindications where ECV might be more complicated:
 small-for-gestational-age fetus with abnormal Doppler parameters
 proteinuric pre-eclampsia
 oligohydramnios
 major fetal anomalies
 scarred uterus
 unstable lie

Question 2

How to consent for an EVC

Answer 2

Risk for EMLSCS 1/200 - serious adverse outcome such as placental abruption, cord prolapse, or acute fetal compromise

Minor complications (transient CTG abnormalities,
rupture of membranes and small antepartum haemorrhage) were reported to occur in 4.3%
patients undergoing ECV

Success 40% primips 60% multips

5% high pain scores

Question 3

If breech in T3 why do you need a formal USS?

Answer 3

Praevia
Uterine anomalies 
fetal abnormalities 
hyperextended neck
footling presentation
liquor volume and EFW 
cord presentation

Question 4

Where should an ECV be performed

Answer 4

ECV should only be performed by suitably trained health professionals where there is facility for emergency caesarean section if needed and according to appropriate institutional protocols that define the place of cardiotocography, ultrasound, and tocolysis.

Question 5

Contraindications to vaginal breech delivery include:

Answer 5

 Cord presentation
 Fetal growth restriction or macrosomia
 Any presentation other than frank or complete breech
 Extension of the fetal head
 Clinically inadequate maternal pelvis
 Fetal anomaly incompatible with vaginal delivery

Question 6

Where should vagina breech deliveries occur?

Answer 6

Planned vaginal breech delivery must take place in a facility where appropriate
experience and infrastructure are available: :
 Continuous fetal heart monitoring in labour.
 Immediate availability of caesarean facilities.
 Availability of a suitably experienced obstetrician to manage the delivery, with arrangements in place to manage shift changes and fatigue arrangements.

Question 7

Incidence of breech at 37 weeks

Answer 7

3-4 %

Question 8

Evidence
Term breech trial
Pub 2000
Hannah et all

Answer 8

P Published in 2000, this trial compared a policy of planned vaginal delivery with
planned caesarean section for selected breech presentations. It reported that perinatal mortality and serious
neonatal morbidity were significantly lower in the planned caesarean section group (1.6 per cent) compared
to the planned vaginal birth group (5 per cent) (RR 0.33, p<0.0001). Perinatal death occurred in 0.3 per
cent of planned caesarean births and 1.3 per cent of all planned vaginal births (RR 0.23, p=0.01), while
serious neonatal morbidity occurred in 1.4 per cent of planned caesarean births versus 3.8 per cent of
planned vaginal births (RR 0.36, p=0.0003). Serious maternal morbidity showed no difference between the
two groups. Subsequent follow-up data on a subset of survivors failed to show long-term differences in
death and neurodevelopmental delay between the two groups at 2 years of age.P
4
P However, because of the
small number of patients involved, those long term outcomes are not suitable endpoints.

Question 9

How to manage breech dx in labour

Answer 9

When breech presentation is first recognised in labour, the obstetrician should discuss the options of emergency caesarean section or proceeding with
attempted vaginal breech birth with the woman, explaining the respective risks and benefits of each option according to her individual circumstances.
Wherever practicable, point-of-care ultrasound should be performed when breech presentation is first diagnosed in labour

Increased fetal risks of vaginal breech delivery exist where there is a possibility of undiagnosed
congenital abnormalities or undiagnosed hyperextension of the fetal head.

The obstetrician should discuss the options for mode of
birth with the woman, explaining the balance of the fetal and maternal risks and benefits for that woman’s
individual circumstances. The fundamental principles of informed consent should be observed.

Question 10

When to perform ECV

Answer 10

36 primip

37 multip

Question 11

Counselling breech VD vs LSCS

Answer 11

RCOG says woman should be informed
‘small reduction in perinatal mortality with LSCS compared to breech VB’ this is due to a avoidance of SB after 39 weeks, avoid intrapartum risks, and avoid risk of a breech VD.

Mortality risk is 0.5/1000 LSCS
2/1000 Planned breech VD
1/1000 Cephalic birth

clinicians should counsel in an unbiased way to communicate absolute and relative risks

Breech Vaginal birth increases the risk of low apgar scores and serious short term complications but not long term morbidity