Management of Breech Presentation

Question 1

What information should be given to women with breech presentation at term?

Answer 1

• offer ECV unless absolute contraindication.
• risks and benefits
• implications for mode of delivery.
• unsuccessful or declined offer: counsell on risks & benefits of planned vaginal breech delivery VS planned CS..

Question 2

What information about the baby should be given to women with breech presentation at term regarding mode of delivery?

Answer 2

• planned CS leads to a small reduction in perinatal mortality VS planned vaginal breech delivery.
• decision CS needs to be balanced against potential adverse consequences from this.
• inform that reduced risk is due to three factors:
  1 - avoidance of stillbirth > 39 wks
  2 - avoidance of intrapartum risks
  3 - risks of vaginal breech birth, only unique to breech

perinatal mortality

• 0.5/1000 with CS > 39+0 wks ,
• 2.0/1000 with planned vaginal breech birth.
• 1.0/1000 with planned cephalic birth.

Selection of appropriate & skilled intrapartum care may allow planned vaginal breech birth to be nearly as safe as planned vaginal cephalic birth.

• planned vaginal breech birth: increase risk low Apgar & serious short-term complications, but not increase risk of long-term morbidity.
• counsel unbiased way: proper understanding of absolute / relative risks of their different options.

Question 3

What information should women having breech births be given about their own immediate and future health?

Answer 3

• planned CS for breech at term: small increase in immediate complications for mother VS planned vaginal - Maternal complications least with successful vaginal birth; planned CS carries a higher risk, but risk is highest with Em CS (40% of planning vaginal breech)
• CS increase risk of complications in future pregnancy, including risks of opting for vaginal birth after CS, increased risk of complications at repeat CS & risk of an abnormally invasive placenta.
• individualised assessment of long-term risks of CS based on individual risk profile & reproductive intentions, and counselled accordingly.

Question 4

What information should women having breech births be given about the health of their future babies?

Answer 4

• CS associated with small increase in risk of stillbirth for subsequent babies although this may not be causal.

Question 5

What factors affect the safety of vaginal breech delivery?

Antenatal assessment

Answer 5

• Diagnosis of persistent breech: assess for risk factors for poorer outcome in planned vaginal breech birth.
• If any risk factor is identified, counselled that planned vaginal birth is likely to be associated with increased perinatal risk & delivery by CS is recommended.
• higher risk planned vaginal breech birth is expected if independent indications CS and following circumstances:
  Hyperextended neck on ultrasound.
  High estimated fetal weight (more than 3.8 kg).
  Low estimated weight (less than tenth centile).
  Footling presentation.
  Evidence of antenatal fetal compromise.
• role of pelvimetry is unclear.

Question 6

What factors affect the safety of vaginal breech delivery?Skill and experience of birth attendant

Answer 6

• skilled birth attendant is essential for safe vaginal breech birth.
  Units with limited access to experienced personnel inform greater risk & antenatal referral to unit (greater skill levels & experience).

Question 7

What factors affect the safety of vaginal breech delivery?

Intrapartum assessment and management of women presenting unplanned with breech presentation in labour

Answer 7

Unplanned vaginal breech labour,

• MX depend on stage of labour,
• factors associated with increased complications
• availability of appropriate clinical expertise and
• informed consent.

Women near or in active second stage of labour

• should not be routinely offered CS.
• Where time and circumstances permit, the position of fetal neck & legs, & fetal weight should be estimated using ultrasound, and woman counselled as with planned vaginal breech birth.

All maternity units

• must skilled supervision for vaginal breech (advanced labour)
• protocols developed.

Question 8

What is appropriate intrapartum management of the term breech?
Are induction and augmentation appropriate?
.

Answer 8

• induction of labour is not usually recommended.
• Consider Augmentation of slow progress with oxytocin only If contraction frequency is low in presence of epidural analgesia

Question 9

What is appropriate intrapartum management of the term breech?
What is the role of epidural analgesia?

Answer 9

• effect of epidural analgesia on success of vaginal breech birth is unclear, but that it is likely to increase risk of intervention.

Question 10

What is appropriate intrapartum management of the term breech?
What fetal monitoring should be recommended?

Answer 10

• evidence is lacking, continuous electronic fetal monitoring may lead to improved neonatal outcomes.

Question 11

What is appropriate intrapartum management of the term breech?
Where should vaginal breech birth take place?

Answer 11

Birth in hospital with facilities for immediate CS should be recommended with planned vaginal breech birth, but birth in operating theatre not routinely recommended.

Question 12

What is appropriate intrapartum management of the term breech?
What guidelines should be in place for the management of breech birth?

Answer 12

Women should be informed that adherence to a protocol for management reduces the chances of early neonatal morbidity.
The essential components of planned vaginal breech birth are appropriate case selection, management according to a strict protocol and the availability of skilled attendants. [New 2017]

Question 13

What is appropriate intrapartum management of the term breech?
Management of the first stage and passive second stage

Answer 13

Adequate descent of the breech in the passive second stage is a prerequisite for encouragement of the active second stage.

Question 14

What is appropriate intrapartum management of the term breech?
What position should the woman be in for delivery during a vaginal breech birth?

Answer 14

Either a semirecumbent or an all-fours position may be adopted for delivery and should depend on maternal preference and the experience of the attendant. If the latter position is used, women should be advised that recourse to the semirecumbent position may become
necessary.

Question 15

What is appropriate intrapartum management of the term breech?
What are the principles for the management of active second stage and vaginal breech birth?

Answer 15

• Assistance, without traction, is required if there is delay or evidence of poor fetal condition.
• All obstetricians and midwives should be familiar with the techniques that can be used to assist vaginal breech birth. The choice of manoeuvres used, if required to assist with delivery of breech, should depend on the individual experience/preference of the attending doctor or midwife.

Question 16

Management of the preterm breech

How should preterm singleton babies in breech presentation be delivered?

Answer 16

• routine caesarean section for breech presentation in spontaneous preterm labour is not recommended.
• mode of delivery individualised based on
  1- stage of labour,
  2- type of breech presentation,
  3- fetal wellbeing &
  4- availability of an operator skilled in vaginal breech .
• CS for breech in spontaneous preterm labour at threshold of viability (22–25+6 wks) not routinely recommended.
• planned CS is recommended for preterm breech presentation where delivery is planned due to maternal and/or fetal compromise.

Question 17

Management of the preterm breech

How should labour with a singleton preterm breech be managed?

Answer 17

Labour with a preterm breech should be managed as with a term breech.
- Where there is head entrapment, incisions in the cervix (vaginal birth) or vertical uterine incision extension (CSn) may be used, with or without tocolysis.

Question 18

Management of the twin pregnancy with a breech presentation

How should a first twin in breech presentation be delivered?

Answer 18

• evidence is limited, but planned CS for twin pregnancy where presenting twin is breech is recommended.
• Routine em CS for breech first twin in spontaneous labour, not recommended.
• mode of delivery individualised based on
  1 - cervical dilatation,
  2 - station of the presenting part,
  3 - type of breech presentation,
  4 - fetal wellbeing and
  5 - availability of operator skilled in vaginal breech

Question 19

How should a second twin in breech presentation be delivered?

Answer 19

Routine CS for breech presentation of second twin is not recommended in either term or preterm deliveries.

Question 20

What organisational and governance arrangements should be in place to support a routine vaginal
breech delivery service?

Answer 20

Simulation equipment should be used to rehearse the skills that are needed during vaginal breech birth by all doctors and midwives. Guidance for the case selection and management of vaginal breech birth should be developed in each department by the healthcare professionals who supervise such births. Adherence to
the guidelines is recommended to reduce the risk of intrapartum complications.

Departments should consider developing a checklist to ensure comprehensive counselling of the woman regarding planned mode of delivery for babies presenting by the breech.