Breech presentation in the new millennium

The best management of the singleton breech presentation at term has changed. Despite being widely under-used, external cephalic version (ECV) is appropriate in most pregnancies and reduces the incidence of breech presentation at delivery. The procedure is safe although it can be uncomfortable, and is successful in more than 40–80% of cases. Success is better with tocolysis.Breech presentation is associated with increased fetal, neonatal and long-term risk. This is not entirely a result of its association with fetal abnormalities, or the effect of vaginal breech birth. Nevertheless, there is good evidence that planned elective Caesarean section lowers perinatal mortality and morbidity in the first 6 weeks, without increasing maternal morbidity. The beneficial effects are most in countries with a low existing perinatal mortality rate and remain, even with highly experienced operators, or when labour is neither induced nor augmented.The incidence of vaginal breech delivery will decrease further. Yet the new evidence does not apply to vaginal delivery of second twins, labours presenting in advanced second stage or preterm breeches. Since essential skills will be gradually lost, these ‘unpredictable’ breech deliveries and those in women still choosing vaginal birth may become less safe.     

Impact of the International Term Breech Trial on Clinical Practice and Concerns: A Survey of Centre Collaborators

Objective: The purpose of this study was to determine what impact the International Term Breech Trial had had in different settings and to elicit any concerns among collaborators regarding the implementation of a policy of planned Caesarean section for term breech babies.Methods: We mailed a questionnaire to all Term Breech Trial collaborators. The questionnaire asked 3 open-ended questions about the impact of the trial, about concerns with implementing planned Caesarean section for term breech babies, and about whether information as to the relative costs of planned Caesarean section versus planned vaginal birth would be helpful. Frequencies of responses were calculated for centres in countries classified as having a low or a high national perinatal mortality rate (≤ 20/1000 vs. > 20/1000, respectively) according to the figures published by the World Health Organization in 1996.Results: We received responses from 80 centres in 23 countries. Most centres (92.5%) stated that clinical practice had changed to planned Caesarean section for most or all term breech babies. The majority of centres 66.3 had no difficulties or concerns with implementing a policy of planned Caesarean section for term breech babies. Most centres (85.0) indicated that an analysis of relative costs would not affect clinical practice in their setting.Conclusion: Clinical practice has changed to planned Caesarean section in most collaborating centres, given the results of the Term Breech Trial.     

The management of breech pregnancies in Australia and New Zealand

AIM: To assess current obstetric practice in the management of singleton breech pregnancies in Australia and New Zealand. METHODOLOGY: Survey mailed to all members and fellows of the Royal Australian and New Zealand College of Obstetrics and Gynaecology. RESULTS: Of 1284 surveyed, 956 (74%) responded of whom 696 (73%) were practicing obstetrics. Prior to the Term Breech Trial (TBT), 72% of obstetricians reported that they routinely offered vaginal breech birth for uncomplicated singleton breech pregnancies. After the TBT publication this rate declined to 20%. External cephalic version (ECV) was usually recommended by 67% of obstetricians and only 53% use tocolytics. Common practices for which safety has yet to be demonstrated included 28% of obstetricians carrying out ECV outside hospitals and 42% carrying out ECV before 37 weeks' gestation. CONCLUSIONS: While the majority of obstetricians recommend ECV and/or planned Caesarean section for breech presentation, barriers to the promotion of ECV and the use of tocolysis for ECV need to be identified if the rates of this effective manoeuvre are to be increased.     

Outcomes of a Breech Birth Program in Canada,Quality Assurance Project

ObjectiveTo report antenatal, intrapartum, and postnatal factors associated with breech birth from our Breech Program at South Health Campus, Calgary.MethodsWe reviewed all maternal and neonatal patient records where breech birth was documented from 2013 to 2018. Neonatal blood gas values, Apgar scores, birth weight, admissions to NICU, antenatal ultrasound reports, inpatient electronic medical records, and operative and delivery reports, were reviewed. Any indices known as indications, contraindications, or outcomes associated with breech birth were recorded and summarized.ResultsAmong the 499 breech births that occurred over the study period, there were109 attempted external cephalic versions, 411 planned and 39 unplanned cesarean deliveries, and 49 vaginal deliveries. Unplanned cesarean delivery was performed for newly diagnosed breech presentation in labour (14), footling presentation in labour (9), abnormal fetal heart rate (4), labour dystocia (8), ultrasound findings of low fluid (2) or unfavourable fetal position (1), and worsening maternal hypertension (1).ConclusionDespite the absence of reported contraindications in the majority of patients and the presence of a program that supported vaginal breech delivery, cesarean delivery was more common. Mothers who chose to labour were highly successful in achieving vaginal birth with excellent maternal and neonatal outcomes.     

Evolving Evidence Since the Term Breech Trial: Canadian Response,European Dissent,and Potential Solutions

ObjectivesWe wished to gain insight into Canadian hospital policy changes between 2000 and 2007 in response to (1) the initial results of the Term Breech Trial suggesting delivery by Caesarean section was preferable for term breech presentation, and (2) the trial’s two-year follow-up and other research and commentary suggesting that risks associated with vaginal breech delivery and delivery by Caesarean section were similar. We also wished to determine the availability of vaginal breech delivery and the feasibility of establishing breech clinics and on-call squads, and whether these could include midwives.MethodsIn 2006, we sent surveys to the 30 largest maternity centres in Canada asking about their changes in practice in response to results of the initial Term Breech Trial and the subsequent two-year follow-up and the possibility of establishing breech clinics and on-call delivery squads and whether they could include midwives.ResultsOf the 30 surveys sent, responses were received from 20 maternity centres in six provinces. Hospitals were almost five times more likely to adopt a policy of requiring Caesarean section for breech delivery when current evidence suggested that it decreased risk for the neonate than they were to reintroduce the option of vaginal breech delivery when it did not. A breech clinic was considered possible, feasible, and desirable by only one centre, and forming a breech squad was similarly regarded by only two hospitals; 70% of respondents, however, did not entirely dismiss either possibility.ConclusionsThe weight of epidemiologic evidence does not support the practice developed in Canadian hospitals since the Term Breech Trial that recommends delivery by Caesarean section for all breech presentations. Obstetric and midwifery bodies will require creative strategies to make clinical practice consistent with current national and international evidence.     

Breech delivery

Fetuses that present by the breech are at increased risk of trauma and hypoxia during delivery. The threshold for Caesarean section for breech presentation had been low for several years. The result of the term breech trial confirms that planned Caesarean section is the best method of delivering the singleton frank or complete breech at term. The best mode of delivery for the pre-term breech is less clear. Vaginal breech delivery will be unavoidable in certain circumstances and it is therefore important to be adept with the techniques of vaginal breech delivery. The atraumatic technique of delivery of the baby presenting by the breech at times of Caesarean section is similar to that of assisted vaginal breech delivery. The number of vaginal breech deliveries is falling, and regular teaching using video clips or practising with mannequins will be necessary to preserve the skills of vaginal breech delivery.     

Singleton Breech at Term: Two Continents Two Approaches

Breech presentation is a complication in 3% to 4% of singleton pregnancies at term. On the strength of a large study published in the early 2000s, the American College of Obstetricians and Gynecologists (ACOG) recommended Caesarean section be routinely performed in such cases. However, French gynaecologists continue to perform vaginal breech deliveries. Through various observational studies, they have shown that their management approach, although different from the one used in North America, is safe. In 2006, the ACOG declared that vaginal delivery of a breech presentation may be acceptable under specific circumstances. In this analysis, we compare North American and French practices and present a protocol of care for the management of term breech presentation based on French recommendations.     

Breech presentation: evolution of management

From the historical perspective, vaginal delivery of the persistent breech presentation had been the tradition since the 1st century A.D. The external cephalic version was perfected and popularized in the mid-16th century. A variety of instruments and maneuvers had been used in the 19th century, with successful application of forceps to the after-coming head, and in 1924, Edmund Piper developed forceps for application only to the after-coming head. Vaginal delivery of breech cases had been performed primarily for the safety of the mother. As blood banking, antibiotics and safe anesthesia became available and legal and the ethical and social milieu was changing, cesarean breech deliveries were performed more liberally to reduce the increased perinatal morbidity and mortality of infants born of vaginal breech deliveries. Liberalization of cesarean delivery resulted in increased maternal mortality, and increased maternal morbidity created potential hazards in subsequent pregnancies. Renewed interest in revival of the practice of external cephalic version created successful reduction in term breech presentation. Several retrospective, prospective and randomized studies of vaginal deliveries of some types of breech cases were conducted under strict, selective protocols, with results of outcome comparable to those of cesarean sections. The International Term Breech Collaborative Group, after study of a large number of frank and complete breech cases, concluded that planned cesarean delivery is a "substantially better method of delivery for the fetus" and that a policy of planned vaginal birth for term, singleton, breech fetuses should no longer be encouraged.     

Survey of Canadian Obstetricians Regarding the Management of Term Breech Presentation

Objective: the objective of this study was to determine current attitudes and practices of obstetricians in Canada regarding the management of breech presentation at term.Methods: a survey was sent to 307 obstetricians across Canada to determine their views on trial of labour for frank and non-frank breech presentation at term, use of external cephalic version, acquisition of skills by residents, influence of the medico-legal climate, and participation in a randomized controlled trial of Caesarean section versus planned vaginal delivery for breech presentation at term.Results: most obstetricians surveyed were from teaching hospitals and from hospitals in Ontario or the Western provinces. The response rate was 65 percent. Almost all of the respondents (96%) were supportive of a trial of labour for the frank breech, and many were supportive of a trial of labour for the non-frank breech presentation. Most (68%) performed external cephalic version, although 52 percent considered their success rate to be less than 50 percent. Most of the respondents (69%) did not feel that residents were acquiring the necessary skills to manage a trial of labour and vaginal delivery for the frank breech presentation at term. Many (46%) indicated that the medico-legal climate had a major influence on clinical decision making. Most respondents (58%) were willing to ask patients to be entered into a randomized controlled trial of Caesarean section versus planned vaginal delivery, and most (78%) indicated that they would be prepared to change their practice based on the results of such a trial.Conclusions: most obstetricians surveyed would support a trial of labour in selected pregnancies.     

Mode of delivery, postnatal condition and neonatal outcome in preterm infants]

There were under examination 578 preterm infants of two groups--28. up to 31. and 32. up to 36. week of gestation--after birth of vertex as well as breech prevention. Postnatal condition and neonatal outcome were put into relation to the mode of delivery. We compared Apgar-Score (one and five minute value), morbidity on respiratory distress syndrom as well as rate of survival and neonatal mortality in spontaneous delivery with and without episiotomia, with specula delivery, Shute-forceps and vacuum extraction of vertex presentation as well as with breech presentation after vaginal delivery and primary Caesarean section. In respect of the management of the second stage of labour it is our opinion that prophylactic additional measures in preterm delivery of vertex presentation after 32 weeks of gestation are not necessary and that this question should be examined in a larger study of much more cases. But we were able to demonstrate that up to 32. week of gestation well-timed episiotomia of optimal size is necessary. Our good experiences in breech presentation between 31. and 35. week of gestation treated by obligate Caesarean section have to prove true in future.     

Breech deliveries and cesarean section

Breech presentation is the most common malpresentation, with about 3-4% of singleton fetuses presenting breech at delivery. Management of breech presentation has been a contentious issue with a lowering threshold for cesarean section in recent years. Perinatal mortality and morbidity are estimated to be three times that of comparable infants with vertex presentation. Breech presentation is commonly associated with certain adverse maternal and fetal factors which inherently give rise to increased perinatal morbidity and mortality. At present, most obstetricians favor cesarean delivery for uncomplicated pre-term breech. Controlled prospective studies have shown that the outcome of breech fetuses weighing more than 1500 g was not dependent on the mode of delivery. A more recent review from the Cochrane database by Grant does not justify a policy of elective cesarean section for pre-term breech. Vaginal delivery is preferred if the following criteria are met: frank breech only, estimated fetal weight of 2500-3500 g, adequate pelvimetry without hyperextended head, normal progression of labor, no evidence of fetal hypoxia under continuous fetal monitoring, and maternal weight under 90 kg. Vaginal delivery of frank breech at term may be just as safe as cesarean section when careful selection criteria are used. If these criteria are not fulfilled, or fetal monitoring cannot be performed, cesarean section is advisable.     

A comparison of risk factors for breech presentation in preterm and term labor: a nationwide,population-based case–control study

To determine if the common risks for breech presentation at term labor are also eligible in preterm labor. A Finnish cross-sectional study included 737,788 singleton births (24–42 gestational weeks) during 2004–2014. A multivariable logistic regression analysis was used to calculate the risks of breech presentation. The incidence of breech presentation at delivery decreased from 23.5% in pregnancy weeks 24–27 to 2.5% in term pregnancies. In gestational weeks 24–27, preterm premature rupture of membranes was associated with breech presentation. In 28–31 gestational weeks, breech presentation was associated with maternal pre-eclampsia/hypertension, preterm premature rupture of membranes, and fetal birth weight below the tenth percentile. In gestational weeks 32–36, the risks were advanced maternal age, nulliparity, previous cesarean section, preterm premature rupture of membranes, oligohydramnios, birth weight below the tenth percentile, female sex, and congenital anomaly. In term pregnancies, breech presentation was associated with advanced maternal age, nulliparity, maternal hypothyroidism, pre-gestational diabetes, placenta praevia, premature rupture of membranes, oligohydramnios, congenital anomaly, female sex, and birth weight below the tenth percentile. Breech presentation in preterm labor is associated with obstetric risk factors compared to cephalic presentation. These risks decrease linearly with the gestational age. In moderate to late preterm delivery, breech presentation is a high-risk state and some obstetric risk factors are yet visible in early preterm delivery. Breech presentation in extremely preterm deliveries has, with the exception of preterm premature rupture of membranes, similar clinical risk profiles as in cephalic presentation.     

臀位阴道分娩

臀先露是最常见的胎位异常,阴道分娩风险高。产科医生和助产士应对臀先露的产妇进行充分评估及沟通,选择适宜的病例阴道分娩,同时加强产时监护,以确保臀位阴道分娩的母婴安全。本文围绕臀先露的病因、臀位阴道分娩的适应证、禁忌证、注意事项及可能的风险进行阐述。     

Breech vaginal delivery at or near term

Three percent to 4% of term fetuses will be breech at delivery. Evidence from randomized controlled trials has found a policy of planned cesarean section to be significantly better for the singleton fetus in breech presentation at term compared to a policy of planned vaginal birth. However, some women may wish to avoid cesarean section and for others, cesarean section may not be possible. We undertook this review to identify factors associated with higher and lower risk of adverse fetal or neonatal outcome at term during vaginal breech delivery. We searched MEDLINE from 1966 to 2002 using the search terms vaginal breech delivery and breech presentation and retrieved all relevant articles. We also reviewed personal references and reference lists of articles retrieved. Women who are older or who have a fetus that is either in footling presentation, has a hyperextended head or is estimated to weigh <2500 g or >4000 g may be at higher risk of adverse fetal outcome. Prolonged labor or not having an experienced clinician at vaginal breech birth may also increase the risk. Women with a fetus in breech presentation at term should be offered the option of delivery by planned cesarean section and should be informed that this will reduce their risk of adverse fetal or neonatal outcome. Practitioners should develop and maintain skills at vaginal breech delivery for those women not wishing or not able to be delivered by cesarean section.     

Planned caesarean section decreases the risk of adverse perinatal outcome due to both labour and delivery complications in the Term Breech Trial

OBJECTIVE: To determine if the decreased risk of adverse perinatal outcome, with a policy of planned caesarean, in the Term Breech Trial, was due to a reduction of problems of labour, problems of delivery or unrelated problems. DESIGN: Secondary analysis of data from the Term Breech Trial, a randomised controlled trial of planned caesarean versus planned vaginal birth for the singleton fetus in frank or complete breech presentation at term. SETTING: Women were recruited from 121 centres in 26 countries. POPULATION: Women who were enrolled in the Term Breech Trial. METHODS: Adverse perinatal outcome was classified as due to labour, due to delivery, due to neither labour nor delivery or unexplained by an experienced obstetrician who was masked to allocation group. The risk of an adverse outcome in each category was compared according to intention to treat and also by actual method of delivery. MAIN OUTCOME MEASURES: Adverse perinatal outcome (excluding lethal congenital anomalies) that was due to labour, due to delivery, due to neither labour nor delivery or unexplained. RESULTS: Planned caesarean was associated with a lower risk of adverse outcome due to both labour (RR 0.14, 95% CI 0.04-0.45, P < 0.001) and delivery (RR 0.37, 95% CI 0.16-0.87, P= 0.03), compared with planned vaginal birth. Prelabour caesarean and caesarean during early labour were associated with the lowest risk and vaginal birth was associated with the highest risk of adverse outcome due to both labour (0%, 0.4% and 2.2%, respectively) and delivery (0.2%, 0% and 3.1%, respectively). CONCLUSIONS: Planned caesarean decreases the risk of adverse perinatal outcome due to both problems of labour and problems of delivery for the singleton fetus in breech presentation at term, compared with planned vaginal birth.     

The effect of the Term Breech Trial on medical intervention behaviour and neonatal outcome in The Netherlands: an analysis of 35,453 term breech infants

OBJECTIVE: To examine the effects of the Term Breech Trial on the medical behaviour of Dutch obstetricians and on neonatal outcomes. DESIGN: Retrospective observational study. SETTING: The Netherlands. POPULATION: Infants born at term in breech presentation in the Netherlands between 1998 and 2002, with birthweights < or =4000 g (n= 33,024) and >4000 g (n= 2429), respectively. Multiple pregnancies, antenatal death and major congenital malformations were excluded. METHODS: Data derived from the Dutch Perinatal Database were used to compare modes of delivery and neonatal outcome of infants born in breech position in the 33 months preceding publication of the Term Breech Trial and in the 25 months thereafter. MAIN OUTCOME MEASURES: Incidence of planned and emergency caesarean section, vaginal breech delivery, perinatal death, 5-minute Apgar score and birth trauma. RESULTS: Within two months after publication of the Term Breech Trial, the overall caesarean rate increased from 50% to 80% and has remained stable thereafter. In the group of infants < or =4000 g, this was associated with a significant decrease of perinatal mortality from 0.35% to 0.18%, a decrease of the incidence of a 5-minute Apgar score <7 from 2.4% to 1.1% and a decrease of birth trauma from 0.29% to 0.08%. In the (small) group of infants >4000 g, a similar trend was observed. CONCLUSIONS: The Term Breech Trial has resulted in an exceptionally rapid change in medical behaviour by Dutch obstetricians. This change was followed by improved neonatal outcome.     

Are health expectations of term breech infants unrealistically high?

BACKGROUND: The aim of this study was to compare the effect of fetal presentation and mode of delivery on infant outcome in a nation-wide study. METHODS: In a retrospective observational cohort study, we compared, with the help of Finnish Medical Birth Register and other nation-wide registers, the short-term and long-term outcome of infants born by breech vaginal (n = 1270) or by vertex vaginal delivery (n = 128,683) or through planned cesarean section (CS) in breech (n = 1640) or vertex (n = 4997); the pregnancies were otherwise entirely normal. RESULTS: One perinatal death occurred in the breech vaginal group and 23 deaths in the vertex vaginal group (p = 0.112), but none in either CS group. Breech vaginal delivery was associated with increased risk of Apgar scores 6 or less at age 1 min (OR 7.65, CI 6.41-9.12) and at age 5 min (OR 6.42, CI 4.36-9.45) as compared with vertex vaginal delivery. These odd ratios were also elevated (OR 4.59, CI 3.48-7.08 and OR 7.58, CI 3.09-18.66, respectively) when compared with breech planned CS. Yet the risk for birth trauma of infants in the breech vaginal group was smaller (OR 0.70, CI 0.51-0.96) than that in the vertex vaginal group but this risk was smallest in the planned CS groups. A number of other neonatal complications occurred equally commonly in each group. Breech infants born vaginally needed fewer admissions (OR 0.58, 0.47-0.72) to out-patient departments and the cumulative incidence of long-term morbidity in the breech vaginal group was smaller (OR 0.47, CI 0.28-0.80) to the age of 7 years than that in the breech planned CS. The maturity for starting school and school performance during the first two school years showed no dependence on mode of delivery. CONCLUSION: Apart from Apgar suppression, elective vaginal delivery of a full-term breech fetus in highly selected pregnancies does not cause additional neonatal hazards as compared with full-term vertex deliveries. The immediate outcome was best for breech or vertex infants born through elective CSs.     

External cephalic version as a possible treatment of breech presentation

BACKGROUND: Breech presentation shows 3-4% incidence on every foetal presentation at the time of delivery and is more correlated than vertex presentation to a foetal risk of perinatal mortality (with a frequency from 2 to 5 times higher) and to foetal malformations, low weight at birth and prematurity. On the other hand, without a careful case selection, breech delivery has a higher risk of perinatal morbidity and mortality in comparison to cephalic presentation. It is estimated that perinatal mortality for breech presentation at term is about 4-5% for vaginal delivery and about 2-4% for caesarean section. In addition caesarean section has a higher maternal morbidity and a small but significant risk of perinatal mortality, therefore, external cephalic version (ECV) can be a good choice to increase physiological deliveries. The aim of the present study is to evaluate the real efficacy of this obstetric manoeuvre to decrease the frequency of breech presentation at delivery. METHODS: The study group included 67 patients (age 29.5 +/- 3.8) with foetal breech presentation at gestational age 35.8 +/- 1.9 weeks, recruited at the Department of Obstetrics and Gynaecology of the Pavia University. Every patient underwent ECV. The same physician has performed every ECV attempt using the forward roll technique, with previous tocolysis in 50 cases (rithodrine vs isoxsuprine). The following variables have been taken into consideration: amount of amniotic fluid, gestational age, kind of tocolysis, placental location, foetal back position, parity, breech variety and foetal adnexial complication at birth. RESULTS: ECV succeeded in 77.6% (n = 52) and failed in 22.4% (n = 15) of cases. No maternal or foetal complications, side effects and spontaneous breech version occurred and in 74.6% of cases (n = 50) a vaginal delivery was performed. In 25.4% of cases (n = 17) a caesarean section was performed (15 breech presentation, 1 foetal distress in labour and 1 cervical dystocia). Among variables examined related to successful ECV, it has been observed that the amount of amniotic fluid (chi 2 = 15.33; p < 0.0000), the kind of tocolysis (chi 2 = 10.04; p < 0.007) and the umbilical cord rounds (chi 2 = 3.98; p < 0.045) were distributed in a significantly different way, whereas gestational age (p < 0.045) was significantly higher in unsuccessful ECV. CONCLUSIONS: The results obtained suggest that ECV may be a good therapeutic approach for decreasing the percentage of breech presentation at delivery.     

Attitudes Among Toronto Obstetricians Towards Vaginal Breech Delivery

ObjectiveThe recent SOGC guidelines allow for selective vaginal delivery of breech presentations, following an eight-year period during which vaginal breech delivery was discouraged based on the results of the Term Breech Trial (TBT). We sought to determine the effect of publication of this guideline on the acceptance of vaginal breech delivery by obstetricians and to correlate obstetricians’ attitudes with actual practice.MethodsA survey was sent to all obstetricians practising in five teaching hospitals in Toronto exploring their attitudes towards, and comfort with, vaginal breech delivery in various clinical situations. We correlated these with their graduation year in relation to the publication of the TBT. We also reviewed the obstetrical database of the largest teaching hospital in Toronto to see if these attitudes correlated with actual practice.ResultsThe vaginal breech delivery rate, which was declining prior to publication of the TBT, plummeted after it. Our survey found that most practitioners (50% to 80%) would be willing to provide vaginal breech delivery in defined conditions, with more experienced obstetricians being more comfortable with offering vaginal breech delivery. However, despite these attitudes, the vaginal breech delivery rate during the period surveyed was only 3% (6/195).ConclusionsIn the eight years between publication of the TBT and the new guidelines, very few vaginal breech deliveries were performed. Our survey indicates that most obstetricians have accepted the new guidelines; however, it seems that actual practice is lagging behind. The recent SOGC guidelines seem to have changed attitudes, but without changes in training and practical support, it seems unlikely that the trend for very few vaginal breech deliveries to be performed will be reversed.