Max Brinsmead PhD FRANZCOGAugust 2014

Background

Incidence○ 20% at 28 weeks○ 4% at term

Reasons for a breech○ Uterine abnormalities○ Placental localisation○ Excessive or reduced amniotic fluid○ Fetal abnormalities○ Fetal attitude – extended legs○ Just chance

Perinatal mortality is increased because…

Prematurity Congenital malformations Birth asphyxia Birth trauma “the biggest part of the baby is coming

last” Increased risk of long term “handicap”

even when delivered by CS

Current Controversies Management of term breech

Elective Caesarean or vaginal birth

Selection of patients for breech birth Techniques in vaginal breech delivery Pre term breech and the twin breech The detection of breech presentation The Role of ECV

Is it effectiveIs it safeWhen should it be performedHow is it best achieved

Recent History By 1990

The practice of ECV had been mostly abandonedBecause of reports of intrauterine deathBut it was done at 33 – 35 weeksAnd therefore possibly unnecessary

Most Pre term breech delivered by CSBecause of concerns about incomplete cervical

dilatationBut there was no good evidence to support this

Confusion about the Primigravid BreechWith the “untried pelvis”

Breech skills were being lost

2000 The Term Breech Trial RCT in 121 centres in 26 countries & 2088 women To prove that vaginal breech was safe & to maintain

breech skills Multiparous or nulliparous at term with a singleton

breech Non-footling, EFW <4000g & morphologically

normal Randomised to elective CS or trial of vaginal

delivery Induction & augmentation of labour permitted Experienced accoucheur to be present But this trial was stopped prematurely because

increased perinatal risk with vaginal breech delivery

Risks to the baby & the mode of delivery… After exclusion of deaths from congenital

malformation the risk of perinatal death or serious morbidity is reduced by elective CS (RR 0.29, CI 0.10 – 0.86)

After excluding cases with:○ Epidural anaesthesia○ Prolonged labour○ Labours induced or augmented○ Footling breech○ No experienced accoucheur present

Risk with vaginal birth still 3.3% but 1.3% with elective CS (RR 0.49, CI 0.26 – 0.91)

This data from systematic analysis of the Term Breech Trial plus two smaller prior trials

Risks to the mother & mode of delivery…

Short term morbidity is increased by vaginal delivery (RR 1.29 CI 1.03 – 1.61)

Urinary incontinence More perineal pain

Long term morbidity from uterine scar needs evaluation

Estimated that for each baby saved by CS there will be one scar rupture in attempted VBAC later

In the Netherlands, in the 4 years after 2000, 8500 CS were done, “saved” 19 babies but 4 maternal deaths occurred

Needs 53 additional CS for each baby saved

Events since the publication of the Term Breech Trial… Many criticisms of the Trial Follow up of the Term Breech Trial babies

found no long term benefit from CS A prospective study of 2526 women in

France and Belgium analyzed on an intention-to-treat basis found no benefit from elective CS

RCOG, RANZCOG and Canadian guidelines state that trial of vaginal breech delivery is a safe option

All also recommend attempting ECV

Other Major Studies

A prospective study of 2526 women in France and Belgium analyzed on an intention-to-treat basis found no benefit from elective CS

Dutch study of 58,320 term breech 1999-2007Elective CS rose from 24% to 60%PNM fell from 1.3 to 0.7 per 1000PNM for those having vaginal birth did not

change

Problems with the Term Breech Trial… Most of the patients recruited in developed

countriesSubgroup analysis suggests that the outcome cannot

be extrapolated to resource poor countries

Many of the centres involved had historically low rates of vaginal breech birthRaises questions about the experience of the “skilled

accoucheur”

Criteria for patients for trial of vaginal birth were too liberal

Lumping fetal mortality and morbidity was inappropriate for long term outcomes3 deaths in the vaginal group vs none in the CS group

is NS (and one death was a surviving twin)

Two year follow up of babies in the Term Breech Trial…

Was conducted in those Centres thought to achieve 80% follow up

Outcomes measured were perinatal death and neurodevelopmental delay

There were no significant differences (RR 1.09 CI 0.52 – 2.30)

The smaller number of perinatal deaths in the CS group was balanced by a higher number of 2 year-olds with neuro-developmental delay

Calls into question the measures of neonatal morbidity (which were more frequent in the vaginal birth group)

Patients not suitable for vaginal breech birth…

Other obstetric contraindications incl. placenta previa, compromised fetus and previous CS

Footling or kneeling breech EFW >3800 or <2000g Hyper extended neck – ultrasound or X-ray Routine radiological pelvimetry not required but

patients with a small pelvis not suitableBut maybe a role for CT pelvimetry

Experienced accoucheur not available Diagnosis of the breech in labour is not a

contraindication

Optimal intrapartum management… Induction of labour is okay But augmentation of labour not recommended Epidural according to the mother’s wishes Continuous CTG is recommended CS should be performed for failure to progress on

the 1st stage and failure of the breech to descend in the second stage

40 – 50% of patients attempting vaginal birth will require Caesarean

And, because both baby and maternal outcomes are worse with emergency CS, this is why I prefer elective CS

The breech delivery…

Episiotomy when clinically indicated Routine breech extraction not recommended

(But delivery should not be unduly delayed)

Delivery of the armsSweep them down or…Lovset’s maneuvre

Delayed engagement of the headSuprapubic pressure or…Mauriceau-Smellie-Veit with or without rotation

Delivery of the headBurns-Marshall or…Mauriceau-Smellie-Veit

Symphysiotomy and forceps for trapped head

Pre term Breech Retrospective studies suggest that delivery

by CS confers advantage to the baby Especially for the very pre term But the data is biased And maternal risk needs to be taken into

account So the best option is to make individual

decisionsWith the involvement of the patient

Incomplete dilation is a problemCervical incisions recommended

Twins and Breech Many clinicians recommend CS when the

leading twin is breechBut data is lacking to confirm this trendAnd locked twins are very rare

Routine CS for a second twin that is breech is not recommendedBut is sometimes requiredSome RCT’s have been performed and CS

not shown to confer any benefitMore studies are underway

Breech extraction of the second twin is an option

Detection of breech presentation…

Antenatal diagnosis is inconsequential before 35 weeks

But detection in labour is too late because…Maternal counseling is compromisedPlace of labour may be inappropriateRisks to mother and baby both increased regardless of the

mode of delivery

In a study of 1633 women attending the antenatal clinic of a tertiary Sydney hospital30% of breech presentations were missed

Conclusion:Ultrasound for presentation at 36 – 37 weeks

should be a component of routine antenatal care

Because breech delivery is a preventable condition that meets all the criteria for a screening procedure

The Role of External Cephalic Version

ECV is EffectiveRCT’s of external version at or near term (5

trials and 433 women)Reduce the rate of breech presentation in

labour (RR 0.38, CI 0.18 – 0.80)Reduce the rate of CS (RR 0.55, CI 0.33 –

0.91)

Overall success rate is:60% in multipara40% in primiparaLower when the legs are extendedOr the breech is deeply engaged

Risks with ECV Cord entanglement

Post procedure monitoring by CTGTransient decelerations common with a known nuchal cord

Premature labour and PROMNot a problem if it is deferred until >37w

Antepartum haemorrhageAnti-D for those patients who are Rh Neg

Maternal painLimits continuation with the attempt in ~ 5%

Fetal reversion to breechOverall less than 5% and is usually predictable

ECV is Safe No differences in any measure of baby or

maternal outcome in the RCT’s Has a low rate of complications in large

observational studiesO.5% rate of emergency CS in 805

consecutive cases in OxfordOne Term PROM in a personal series of >200

attempted ECV’s over 15 yearsNo documented case of procedure-related

perinatal loss in the large trialsAnd few in the literature overall

An attempt at ECV is not contraindicated by…

Advanced gestation A uterine scar History of prior APH Maternal hypertension Oligohydramnios A nuchal cord

And is usually limited only by the maternal willingness to consider and continue the procedure

Which in turn is usually proportional to the counseling that is initially and subsequently provided

ECV is not successively achieved by…

Maternal posturing5 trials 392 women

Moxibustion with or without acupuncture 3 trials 597 womenThe need for ECV was reduced in one study

But ECV is facilitated by…Tocolysis with IV or SC betamimetic agentsBetamimetics better than oral Nifedipine &

sublingual nitroglycerine is not recommendedEpidural but not spinal anaesthesiaFetal acoustic stimulation

Unanswered Questions about ECV

When it should be attemptedBeginning earlier at 34 – 36w may be okay

Should attempts be repeatedHow many timesHow often

Role in the fetus who has an unstable lie Role with amnioreduction and

amnioinfusion Teaching and maintaining skills

The Early ECV Trial 1543 ♀ in 21 countries randomised to:

ECV at 34 – 36 weeks or>37 weeks

Fewer breeches at term from early ECVRR 0.84 CI 0.75 – 0.94 (41% vs 48%)

But rate of Caesarean not reducedInexplicable

Early ECV appears safeNo difference in fetal/neonatal morbidityBut a meta analysis suggests increased risk

of preterm labour

Discuss benefits and risks and choose