TOG - Management of term breech presentation - Oct 2022

Question 1

How many babies are in breech at term?

Answer 1

5%

Question 2

What is meant by extended or frank breech. what percentage do this roughly account for?

Answer 2

Buttocks present with the fully flexed hips, knees extended and feet by the head.
Accounts for ~2 thirds

Question 3

What is meant by flexed/complete and semi flexed/incomplete.

Answer 3

The buttocks present, though the fetus is in a cross legged position with both hips flexed and one or both knee flexed.
One or both feet are positioned near and present with the buttocks

Question 4

What is meant by standing, footling and kneeling breech

Answer 4

One or both hips are extended with one or both feet leading and the fetal pelvis is non engaged.
These are widely considered a contraindication to vaginal birth as the is no wide presenting part to dilate the cervix and the risk of cord prolapse is high.

Question 5

What are risk factors for breech presentation?

Answer 5

Nulliparity,
Caucasian,
Congenital uterine malformation
Multifibroid uterus
Raised maternal BMI
Oligohydramnios
Polyhydramnios
SGA

Question 6

What was the rate of VBB in 2019-2020 in the UK?

Answer 6

0.3%

Question 7

What was the Term breech trial (study mode and scope)

Answer 7

RCT which randomised over 2000 women at over 120 centres in 26 countries to either planned CS or VBB.

Question 8

What was the difference in perinatal/neonatal mortality and neonatal morbidity between VBB group and LSCS group.

Answer 8

5% in women randomised to VBB vs 1.6% in caesarean birth group with no significant differences in maternal mortality or serious maternal morbidity

Question 9

What are the criticisms of the Term breech trail

Answer 9

• A lack of adherence to inclusion criteria
• Over representation of macrosomia in vaginal birth group
• significant interinstititional variance in standards of care.
• experience of accoucher
• relationship between mod and cause of death
• definition and implications of morbidity

Question 10

Criticism of the term breech trial - in detail - a lack of adherence to the inclusion criteria

Answer 10

Study protocol dictated only live singleton fetuses but among the 16 perinatal deaths were x2 sets of twin, one anencephalic fetus and at least one stillborn infant thought to have died before onset of labour.

Question 11

Criticism of the term breech trial - in detail - Over -representation of macrosomia in the vaginal birth group

Answer 11

Of fetuses randomised to planned vaginal birth, 5.8% weight >4000g
Numerous guidelines considered an EFW >3800g a contraindication to VBB.

Question 12

Criticism of the term breech trial - in detail - significant interinstititional variance in standards of care

Answer 12

Participating centres were deemed to provide either a “high standard of care - LSCS could be within 10min and access to ET intubation” or usual standard
Of the centres included 64.8% provided usual care.

Question 13

Criticism of the term breech trial - in detail - Experience of accoucher

Answer 13

Almost 20% of fetuses in the vaginal breech group were delivered without the oversight of an experienced obstetrician.
Adverse outcomes were over-represented in this cohort.

Question 14

Criticism of the term breech trial - in detail - relationship between MOD and cause of death

Answer 14

There is evidence to suggest that half of all the perinatal deaths in the VBB were wholly unrelated to MOD including several who died from SIDs weeks after an uncomplicated birth.

Question 15

Criticism of the term breech trial - in detail - Definition and implications of “morbidity”

Answer 15

18 infants in the vaginal birth group were identified as having sustained “significant morbidity” on account of isolated hypotonia at birth. In at least 7 cases this resolved spontaneously within 2 hours. In a 2 year follow up it was acknowledged that most with serious neonatal morbidity survive and develop normally.

Question 16

There are greater rates of VBB in Europe as high as 31% in Norway. This may be in part associated with the publication of several studies subsequent to TBT.

Answer 16

They demonstrate a greater safety profile for vaginal breech especially in the setting of stricter selection criteria and mandatory presence of “skilled birth attendant.”

Question 17

a secondary analysis of the TBT, the presence of a practitioner experienced in vaginal breech was found to be…

Answer 17

a protective factor.

Question 18

What was the PREMODA trial?

Answer 18

a large intention-to-treat analysis of over 8000 women in France and Belgium in 2006
of whom over 2500 planned VBB with a 71% success rate.

Question 19

What were the results of the PREMODA study?

Answer 19

Failed to demonstrate significant differences in combined outcomes for fetal/neonatal morbidity and mortality.

Question 20

What did the PREMODA study conclude?

Answer 20

in places where planned VBB is common practice and strict selection criteria are met before and during labour, planned vaginal delivery of singleton fetuses in breech presentation at term remains a safe option.

Question 21

How does the French management of vaginal breech birth differ significantly from UK practice as advocated by the RCOG.

Answer 21

IOL is not recommended and augmentation is permissible only in certain circumstances, both form a cornerstone of French practice and by their national college.

Question 22

What are the RCOG relative and absolute contraindications to ECV

Answer 22

Maternal:
-PET/HTN
- APH
Fetal
- Oligo
- growth restriction
- Ruptured membranes
- abnormal CTG
- major congenital anomaly

Question 23

Which factors increase the likelihood of success of ECV

Answer 23

• High provider experience
• multiparity
• increased maternal age
• non engagement of the breech
• pre-procedural tocolysis
• Low maternal BMI
• posterior placenta
• Flexed breech
• AFI >10

Question 24

Factors which decrease the success of ECV

Answer 24

Nulliparity
Maternal obesity
Extended breech
Footling breech

Question 25

What is the absolute risk of EmLSCS in the 24 hours following ECV?

Answer 25

0.5%

Question 26

When is ECV offered in primips and multips?

Answer 26

From 36 weeks in primips
37 week in multips

Question 27

What did a 2015 cochrane review on preterm ECV conclude. 34-35+6

Answer 27

It was associated with decreased rates of noncephalic presentation at term compared with both term ECV and no ECV, however,
It increased the risk of preterm birth with resultant consequences for neonatal morbidity was also demonstrated.

Question 28

Pre and post procedural CTG is recommended.

Answer 28

An immediate, transient fetal bradycardia duration of <3minutes is common and should prompt further monitoring.

Question 29

What should be considered upper limits of attempts at version in a 10 minute period

Answer 29

4 attempts at version

Question 30

Rh D negative women should be offered anti-D within 72 hours unless

Answer 30

the fetus is known to be RhD negative

Question 31

What is the rate of spontaneous reversion to cephalic presentation?

Answer 31

8%
however only 3-7% where ECV has been attempted and unsuccessful

Question 32

What are the rates of reversion to breech following a successful ECV?

Answer 32

~3%

Question 33

Presentation of caesarean section as the default MOD for breech is only advised by RCOG

Answer 33

where a separate indication already exists or in the presence of specific additional risk factors

Question 34

What do the RCOG consider to be additional risk factors for vaginal breech birth.

Answer 34

• Hyperextension of the fetal neck on US
• EFW >3800g
• EFW <10th centile
• Footling breech
• evidence of antenatal fetal compromise

Question 35

Compared to supine positioning, upright breech birth is associated with a significantly reduced need for manoeuvres, neonatal birth injury and shortening of the second stage by over

Answer 35

40%

Question 36

In physiological breech birth how long should it be from:
both buttocks visible on the perineum between contractions to birth of the pelvis?

Answer 36

2 minutes

Question 37

In physiological breech birth how long should it be from:
Birth of the pelvis to
birth of the umbilicus

Answer 37

2 minutes

Question 38

In physiological breech birth how long should it be from:
Birth of the umbilicus to
birth of the head

Answer 38

3 minutes

Question 39

In physiological breech birth how long should it be from:
both buttocks visible on the perinuem between the contractions to
birth of the head

Answer 39

7 minutes

Question 40

In physiological breech birth how long should it be from:
Birth of the pelvis to
Birth of the head

Answer 40

5mins

Question 41

By which mechanism might head entrapment occur.

Answer 41

Unlike cephalic deliveries where the torso distends the cavity after delivery of the head…uterine involution begins following delivery of the torso leading to difficulty in releasing the aftercoming head.

Birth of the head is not driven by myometrial contractility, delay may lead to placental separation before completion of delivery.
The uterus may initiate the 3rd stage before completion of the 2nd.

Question 42

What monitoring is advised?

Answer 42

Continuous monitoring of the fetus during breech labour is recommended in all cases.

Question 43

what is moxibustion

Answer 43

Burning of dried mugwort at specific acupunture point at the tip of the 5th toe.
It is hypothesised that this encourages production of placental estrogens and prostoglandins which in turn stumulate uterine contractility and fetal activity.