Prepared by Helen Cooke February 2009

2. 1 Goals Discuss the incidence and causes of breech How to diagnose and manage antenatally Discuss the Term Breech Trial Discuss the risks and benefits of ECV How to diagnose and manage a breech birth

3. 2 Incidence At term the incidence of breech is 3%. In 2005 in NSW the vaginal breech birth rate was for all gestation was 0.4% (about 322 births)At term the incidence of breech is 3%. In 2005 in NSW the vaginal breech birth rate was for all gestation was 0.4% (about 322 births)

4. 3 Presentation Two breech presentations. The frank breech will birth vaginally with greater ease and with less complications as there is a firm well applied presenting part (the buttocks). The footling breech is associated with many more complications such as cord prolapseTwo breech presentations. The frank breech will birth vaginally with greater ease and with less complications as there is a firm well applied presenting part (the buttocks). The footling breech is associated with many more complications such as cord prolapse

5. 4 The causes Prematurity High parity Uterine anomalies Placenta praevia Multiple pregnancy Pelvic anomalies Fetal anomalies Absolute CPD Previous breech Unknown A breech presentation is associated with situations where there is a mismatch between the fetus and the maternal pelvis � things such as CPD, anomalies � pelvic/uterine and fetal. A breech presentation is associated with situations where there is a mismatch between the fetus and the maternal pelvis � things such as CPD, anomalies � pelvic/uterine and fetal.

6. 5 Diagnosis Abdominal palpation (Leopold�s Manouevre) Vaginal examination Ultrasound On abdominal palpation the fetal head is palpable under the mothers rib and the buttocks hopefully sitting just above the pelvic brim. On VE the breech has three points. 2 sacral prominences and an anus/triangle. Ultrasound provides the definitive diagnosis. On abdominal palpation the fetal head is palpable under the mothers rib and the buttocks hopefully sitting just above the pelvic brim. On VE the breech has three points. 2 sacral prominences and an anus/triangle. Ultrasound provides the definitive diagnosis.

7. 6 Antenatal Management Identification - palpation Diagnosis - ultrasound Management plan for birth developed Helpful to identify a breech early so that a diagnosis and management plan can be put in place. In determining the management plan women need to be made aware of their birth options and provided with all the information to make the most appropriate choices. ECV should be offered to women from 34 weeks (Hutton et al Am J Obstet Gynaecol. 2003;189:245-540. The early ECV trial has now completed recruitment, so hopefully there will be an answer soon regarding the most appropriate gestation to offer the procedure.Helpful to identify a breech early so that a diagnosis and management plan can be put in place. In determining the management plan women need to be made aware of their birth options and provided with all the information to make the most appropriate choices. ECV should be offered to women from 34 weeks (Hutton et al Am J Obstet Gynaecol. 2003;189:245-540. The early ECV trial has now completed recruitment, so hopefully there will be an answer soon regarding the most appropriate gestation to offer the procedure.

8. 7 Term Breech Trial-Conclusions Planned CS is safer than planned vaginal birth delivery for the singleton fetus in breech presentation at term. A policy of planned CS is not associated with a higher risk of serious maternal morbidity in the first 6 weeks post-partum. RANZCOG (2005): informed women who choose vaginal breech birth should be supported with decision There has been some very cogent criticism of the TBT that is worth reading. Glezerman M. Five years to the term breech trial: The rise and fall of a randomized controlled trial. Am J Obstet Gynecol 2006;194:20-5 Objective: On the basis of the end points of neonatal morbidity and death, the authors of the term breech trial concluded unequivocally that cesarean delivery was safer for breech babies. Study design: Analysis of the original and new data gives rise to serious concerns as far as study design, methods, and conclusions are concerned. In a substantial number of cases, there was a lack of adherence to the inclusion criteria. There was a large interinstitutional variation of standard of care; inadequate methods of antepartum and intrapartum fetal assessment were used, and a large proportion of women were recruited during active labor. In many instances of planned vaginal delivery, there was no attendance of a clinician with adequate expertise. Results: Most cases of neonatal death and morbidity in the term breech trial cannot be attributed to the mode of delivery. Moreover, analysis of outcome after 2 years has shown no difference between vaginal and abdominal deliveries of breech babies. Conclusion: The original term breech trial recommendations should be withdrawn.There has been some very cogent criticism of the TBT that is worth reading. Glezerman M. Five years to the term breech trial: The rise and fall of a randomized controlled trial. Am J Obstet Gynecol 2006;194:20-5 Objective: On the basis of the end points of neonatal morbidity and death, the authors of the term breech trial concluded unequivocally that cesarean delivery was safer for breech babies. Study design: Analysis of the original and new data gives rise to serious concerns as far as study design, methods, and conclusions are concerned. In a substantial number of cases, there was a lack of adherence to the inclusion criteria. There was a large interinstitutional variation of standard of care; inadequate methods of antepartum and intrapartum fetal assessment were used, and a large proportion of women were recruited during active labor. In many instances of planned vaginal delivery, there was no attendance of a clinician with adequate expertise. Results: Most cases of neonatal death and morbidity in the term breech trial cannot be attributed to the mode of delivery. Moreover, analysis of outcome after 2 years has shown no difference between vaginal and abdominal deliveries of breech babies. Conclusion: The original term breech trial recommendations should be withdrawn.

9. 8 However TBT does not apply to: Preterm breech presentation. Breech presenting in advanced second stage Has changed the way we manage breech presentation at term.

10. 9 External Cephalic Version Parity Complete or Frank breech Normal or increased amniotic fluid Relaxed uterus with Tocolysis Gestational age < 37 weeks Each unit should have a medical officer who can perform ECV. Alternatively women should be offered the opportunity to travel to a centre where it is offered Multiparity has a greater success. Remember to give Anti D to women who are Rh -veMultiparity has a greater success. Remember to give Anti D to women who are Rh -ve

11. 10 Contraindications to ECV Multiple pregnancy Utero-placental insufficiency Non-reassuring FHR pattern Uterine anomalies Placenta praevia Unexplained bleeding Previous C/S No immediate access to theatres Important that ECV is offered to women who want to achieve vaginal birth or where a vaginal birth option is possibleImportant that ECV is offered to women who want to achieve vaginal birth or where a vaginal birth option is possible

12. 11 Complications of ECV Fetal bradycardia, decelerations (5% transient, 0.4% pathological) Abruption (0.1%) Fetal haemorrhage (1.5%) Maternal haemorrhage (0.5%) Knotted or entangled cord (0%) Fetal mortality (0.16%) Amniotic fluid embolus, maternal death (0%) LSCS (0.4%) It should be noted that these complications are extremely rare (44 studies of 7377 women) Hofmeyr & Kulier � Cochrane library 2005 Nasser et al. Paed Perinatal Epidemiology. 2006;20:163-7 It should be noted that these complications are extremely rare (44 studies of 7377 women) Hofmeyr & Kulier � Cochrane library 2005 Nasser et al. Paed Perinatal Epidemiology. 2006;20:163-7

13. 12 Vaginal Breech Contraindications Proven CPD Macrosomia > 3.8kg IUGR, placental insufficiency Footling breech Hyperextension of fetal head, nuchal arm Fetal anomalies non-progressive labour Lack of birth attendant skills If a woman request a vaginal breech birth, one of the most important factors is that there is someone available to assist at the birth. It is important to rule out any condition that is going to cause a complication and decrease the chance of success.If a woman request a vaginal breech birth, one of the most important factors is that there is someone available to assist at the birth. It is important to rule out any condition that is going to cause a complication and decrease the chance of success.

14. 13 Breech Birth The head of a breech presents with the same diameters as a cephalic presentation Mechanism of labour same as for cephalic HANDS OFF THE BREECH � NO Pulling\ Call for HELP Need efficient and effective uterine action maternal effort to push KEEP THE BACK UP and hands gently supporting the breech One of the most important points to remember if to keep your hands off the breech and don�t pull. Tugging at the breech will cause abnormal descent and stop the normal rotation causing the head to extend or the arms to get caught behind the neck (Nuchal) CHO BUSH FLEE C contractions HO hands off BU back up SH shoulders FL flexion E extension E One of the most important points to remember if to keep your hands off the breech and don�t pull. Tugging at the breech will cause abnormal descent and stop the normal rotation causing the head to extend or the arms to get caught behind the neck (Nuchal) CHO BUSH FLEE C contractions HO hands off BU back up SH shoulders FL flexion E extension E

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16. 15 Breech birth Just let the breech birth May need to help the legs deliver � flex the knees at the popliteal fossa and gently release Keep the back anterior If the back requires rotation � place your hands gently around the baby�s hips with your fingers on bone not soft tissue and gently rotate the baby to keep the back uppermost If the legs are fully extended over the abdomen you may need to assist them to deliver. The flexion action of the knees is similar to getting off a bike or stepping out of a sports car. Always keep the back anterior as it encourages the head to flex for birthIf the legs are fully extended over the abdomen you may need to assist them to deliver. The flexion action of the knees is similar to getting off a bike or stepping out of a sports car. Always keep the back anterior as it encourages the head to flex for birth

17. 16 Breech birth Do not pull or cut the cord Let the baby hang until the scapula can be seen or the arms are birthing. If the arms need some assistance, sweep them gently down the baby�s front until they are free Continue to let the baby hang until the nape of the neck is visible

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19. 18 L�vset Manoeuvre (1937) Used when assistance is required to birth the arms or where there is a nuchal arm. rotation of the fetal body from anterior to oblique to encourage the arms to release under the pubic arch the arm may be gently guided out if not released completely repeat this in the opposite direction to birth the second arm rotate the baby back to the original position with back anterior

20. 19 Breech Birth Mauriceau Smellie Veit manoeuvre is used to help flex and birth the baby�s head place the second and fourth finger of one hand on the baby�s shoulders the middle finger is placed on the baby�s occiput the second and third fingers of the other hand are placed on the mallar prominences flex the baby�s head to assist the birth at the same time lifting the baby�s body over on to the mother�s chest birth slowly to avoid tentorial tears

21. 20 Practice Points Detect breech presentation after 36 weeks or in labour ECV at term is an easy, safe and effective way of reducing the incidence of breech birth at term Expertise in vaginal breech birth remains important, and training schemes should be implemented as experience potentially decreases.