Spontaneous cephalic version of breech presentation in the last trimester

Summary. A prospective longitudinal investigation of spontaneous cephalic version from breech presentation in the last trimester is reported. All pregnancies were assessed with ultrasound in the 32nd week of gestation, and were thereafter checked weekly. Of the 310 singleton breech presentations identified at 32 weeks, spontaneous cephalic version occurred in 177 (57%) while breech presentation persisted in 133 patients (43%). Of 140 patients with a breech presentation at delivery 95% were already presenting by the breech in the 32nd week. Spontaneous cephalic version was less likely in pregnancies with extended fetal legs, low birth-weight, short umbilical cord and primiparity.     

Spontaneous cephalic version of breech presentation in the last trimester

A prospective longitudinal investigation of spontaneous cephalic version from breech presentation in the last trimester is reported. All pregnancies were assessed with ultrasound in the 32nd week of gestation, and were thereafter checked weekly. Of the 310 singleton breech presentations identified at 32 weeks, spontaneous cephalic version occurred in 177 (57%) while breech presentation persisted in 133 patients (43%). Of 140 patients with a breech presentation at delivery 95% were already presenting by the breech in the 32nd week. Spontaneous cephalic version was less likely in pregnancies with extended fetal legs, low birth-weight, short umbilical cord and primiparity.     

Does Advice to Assume the Knee-Chest Position Reduce the Incidence of Breech Presentation at Delivery? A Randomized Clinical Trial

ABSTRACT: A randomized clinical trial of 76 women with a persistent singleton breech presentation at 37 weeks’ or more gestation tested the value of advising women to assume the knee-chest position for 15 minutes three times a day in reducing the incidence of breech presentation at delivery. In the 39 women advised to perform the procedure, 16 (41.0%) fetuses underwent rotation and remained cephalic at delivery compared to 12 (32.4%) of the 37 women in the control group in whom spontaneous version to cephalic occurred. The procedure warrants further evaluation in other obstetric populations, at or in the thirty-seventh week of gestation, and in a larger study group.     

Spontaneous version following preterm premature rupture of membranes

Our objective was to determine the rate of spontaneous version following preterm premature rupture of membranes (PPROM). Medical charts over a 4-year period were reviewed. All women with PPROM and singleton gestation between 24 and 34 weeks gestation were included; 65 patients met the inclusion criteria. By ultrasound on admission, 48 were cephalic 16 were breech, and one was transverse lie. Mean amniotic fluid index on admission was 5.1 +/- 4.8 cm (standard deviation) and was not associated with fetal presentation at delivery. Spontaneous version from cephalic presentation at admission to noncephalic presentation at delivery occurred in one pregnancy (2.2%). Spontaneous version from noncephalic presentation at admission to cephalic presentation at delivery occurred in three pregnancies (17.6%; p = 0.05). Among women with noncephalic presentation at delivery (n = 15), 73.3% had a cesarean, compared with 23.4% of those with cephalic presentation at delivery (p < 0.05). Spontaneous version, particularly from cephalic to noncephalic presentation, is unlikely following PPROM.     

Maternal and fetal factors in breech presentation

The authors used ultrasound examination in an attempt to identify fetal and environmental differences between breech and vertex presentations. During a period of 13 months, 228 pregnancies with the fetus in breech position were found by routine ultrasound screening in the 33rd gestational week. Before delivery, 132 fetuses (58%) turned to vertex presentation and 96 (42%) remained in breech presentation. Fetal growth, posture, position, placental site, and amniotic fluid volume in the 33rd, 35th, and 38th gestational weeks were studied. In contrast to earlier proposed theories, no difference between the two groups (breech and vertex) was found regarding the frequency of extended fetal legs and cornual-fundal placental implantation. However, the neonates born in breech presentation had a shorter gestational age by ten days at delivery, and preterm delivery was more common. At birth, the breech neonates weighed 4.9% less than their vertex controls in relation to gestational age. In the breech group, there was an increased frequency of oligohydramnios, contracted pelvis, and uterine and fetal malformations. These conditions occurred only in 15% of the breech pregnancies; in the remaining 85%, no single cause of the breech presentation could be identified.     

The benefit of external cephalic version with tocolysis as a routine procedure in late pregnancy.

The effectiveness of external cephalic version with tocolysis when routinely used in the 37th week of gestation is reported. The procedure had earlier been ruled out in our department, was found effective in a prospective study, and afterwards settled as a routine. Among 1038 women with single breech presentation, 882 could be offered an attempt of external cephalic version during the period 1982-1988. Attempt of version was carried out in 316 women resulting in a vertex presentation at delivery in 100. The success rate on average was 35%. The estimated reduction of breech deliveries was 100/1038 = 9.6%. As the mean caesarean section rate in women with breech presentation was 81% during the period studied, the estimated reduction in the number of caesarean sections during those seven years was 81. Thus the total caesarean section rate (11.3%) was estimated to be reduced by 0.4%. No immediate serious complications were associated with the procedure. Two cases of intra-uterine fetal death occurred 2 and 5 weeks, respectively, after successful, uncomplicated version to vertex presentation. No obvious connection with the external cephalic version could be demonstrated. The effectiveness of version as a routine procedure is less than expected from reports of prospective trials of external cephalic version carried out by a few investigators, but the results may realistically illustrate what is achieved in the long term.     

The nonlaboring transverse lie. A management dilemma

During a one-year period, 29 patients at 37 weeks' gestation or later were referred to the breech version clinic at Los Angeles County/University of Southern California Medical Center and found to have sonographic evidence of a transverse lie. Because of the relative instability of the lie and the high probability of spontaneous conversion, the patients were not considered candidates for version and were returned to their referral agencies for subsequent prenatal care. The subsequent outcomes in these patients were reviewed. Twenty-four (83%) spontaneously converted to a longitudinal lie and presented in labor with either a vertex (15 [52%]) or breech (9 [31%]) presentation. The five (17%) remaining patients presented in labor with a persistent transverse lie. Overall, the cesarean section rate was 13 of 29, or 45%. The indications for cesarean section were breech presentation, eight (62%), and transverse lie, five (38%). Major complications included two prolapsed cords, one spontaneous uterine rupture and one neonatal death. Based on a review of our experience, it appears reasonable to consider external version in any patient with a persistent transverse lie around 39 weeks. The high rate of subsequent cesarean section and major morbidity associated with expectant management of these patients suggests that if version is unsuccessful, strong consideration should be given to elective cesarean section.     

Placental implantation as the cause of breech presentation

The ultrasonographic study of 5294 singleton pregnancies between the 16 and 41 gestational weeks and 47 breech presentations at term revealed the following: The placenta was found in the mid-anterior or mid-posterior region of the uterus in 60.9 to 74.0%. In 12.8 to 18.7% of cases, the placenta was implanted in the fundal region before gestational week 28, but thereafter it was found in the cornual region in 13.8 to 19.1%. Of 47 cases with breech presentation at term, the placenta was implanted in the cornual region in 28, in the fundus in 7, in the lateral in 6, and in the mid-anterior or mid-posterior in another 6. In gestational weeks from 16 to 19, the breech presentation was found in 38% when the placenta was implanted in the cornual region, in 50% when it was implanted in the lateral region, 52.8% in the fundus, and 47.2% in the middle, with no significant difference in the incidence of occurrence. However in gestational weeks from 36 to 41, the incidence was 20.2, 6.4, 9.0 and 1.1% respectively and the spontaneous version rate was significantly higher when the placenta was implanted in the middle region than in others (p less than 0.01). The author has concluded that the breech presentation in single pregnancy is caused by the placental position; when it markedly indents and changes the inverted pear shape of the amniotic cavity, the spontaneous fetal cephalic version is inhibited.(ABSTRACT TRUNCATED AT 250 WORDS)     

Antepartum detection of cord presentation by transvaginal ultrasonography for term breech presentation: potential prediction and prevention of cord prolapse

AIM: We evaluated the efficacy of antepartum screening for cord presentation by trans-vaginal ultrasonography (TVS) on predicting and preventing umbilical cord prolapse (UCP) in term breech delivery. METHODS: We investigated every woman with a breech-presenting fetus for cord presentation by weekly TVS after 36 weeks of gestation since 1995. If the cord was found in advance of fetal presenting parts, we recommended her to undergo elective cesarean section to avoid UCP. We studied the incidence of cord presentation by TVS and the clinical courses of the cases with it for 198 women who delivered breech after 36 weeks from 1995 to 2005 (group A). Further, the incidence of UCP was compared between group A and another 230 women who delivered breech at term from 1983 to 1994 (group B). RESULTS: Cord presentation was detected by TVS at least once in eight (4%) group A patients. Seven of them underwent elective cesarean section and, in six of these (86%), cord presentation was still found at the time of operation. The eighth patient became free of cord presentation at the later examinations and delivered vaginally without UCP. A hundred and twenty-one (61%) women in group A and 159 (69%) women in group B delivered vaginally. No UCP occurred in group A, while it occurred in 10 (4%) cases of group B (P < 0.01), and one baby died of it. CONCLUSIONS: Detection of cord presentation by TVS has a potential to predict and reduce UCP in breech delivery at term.     

Low concentrations of maternal thyroxin during early gestation: a risk factor of breech presentation?

OBJECTIVE: To evaluate the relation between breech position at term (>37 weeks of gestation) and low maternal fT4 levels during gestation in women not suffering from overt thyroid dysfunction. DESIGN: A prospective cohort study of pregnant women. SETTING: Community-based study. POPULATION/SAMPLE: At random selected pregnant women of the general population. METHODS: At antenatal booking, based on thyroid function assessed at 12 weeks of gestation in a large cohort of pregnant women, two groups of participants were defined: women with low fT4 levels-below the 10th centile (n= 135) and women with fT4-between the 50th and 90th centiles at 12 weeks of gestation (n= 135). Women with clinical thyroid dysfunction (fT4 and TSH outside reference range) at 12 weeks of gestation were excluded. Maternal thyroid function (fT4 and TSH) was subsequently assessed at 24 and 32 weeks of gestation. Analysis refers to 204 women who met the inclusion and exclusion criteria and in whom all thyroid parameters were assessed. MAIN OUTCOME MEASURES: Fetal presentation (cephalic-breech) at delivery in women with term gestation (>37 weeks of gestation) in relation to maternal thyroid function at 12, 24 and 34 weeks of gestation. RESULTS: Breech presentation at term delivery was independently related to fT4 levels <10th centile at 12 weeks of gestation (OR = 4.7, 95% CI 1.1-19 [but not to an fT4 level below the 10th centile at 24 and 32 weeks of gestation]) as well as primiparity (OR = 4.7, 95% CI 1.3-15). CONCLUSIONS: Women with hypothyroxinaemia (fT4 level at the lowest 10th centile) during early gestation but without overt thyroid function are at risk for fetal breech presentation at term (>37 weeks of gestation).     

Unsuccessful Acupuncture Conversion of Breech Presentation

A case is presented of fetal oblique position with compound presentation, where acupuncture conversion of breech presentation failed due to the umbilical being wrapped three times around the fetus with a knot in the umbilical cord, so that delivery was terminated by cesarean section. Conversion of the fetal breech presentation was induced by manual acupuncture stimulation of the UB 67 acupoint with simultaneous CTG control in the 35th week of pregnancy. During the first acupuncture stimulation, CTG showed protracted uterine contraction with subsequent regular low amplitude contractions with intensified fetal activity and CTG curve reactivity. In the 39th week of gestation, the patient felt regular contractions verified by CTG records showing reactive curves. Obstetrical examination revealed a cervical dilatation of 4 cm, a compound presentation involving both legs and the umbilical cord, and oblique position. Therefore, a cesarean section according to a modified Misgav-Ladach method was performed and the patient gave birth to a healthy male neonate (3330 g, 49 cm, Apgar 10/10, pH 7.334). The obstetrician should warn the patient of the potential risks and complications associated with any method of breech presentation conversion.Key words: Breech presentation, acupuncture     

Transvaginal assessment of fetal anatomy at 11 to 16 weeks of gestation in relation to fetal position

OBJECTIVE: To investigate the ability of the high-frequency transvaginal scanning technique to assess embryo-fetal anatomy in early pregnancy in relation to fetal position and in comparison with transabdominal scan. METHODS: A study population of 1,402 pregnant women were examined by transvaginal ultrasonography performed at 10(+1) to 16(+0) weeks of pregnancy. At 14(+1) to 16(+0) weeks of gestation, an ultrasonographic examination was performed in 247 pregnant women by transvaginal and transabdominal route. The criteria necessary for an adequate visualization of fetal organs and structures were met. RESULTS: The visualization rate of complete fetal anatomy increased with increase in menstrual age and fetal position affected this possibility. A detailed brain anatomy was more easily viewed with the fetus in the cephalic or transverse position than in the breech position, whereas the thoracic and abdominal anatomy were viewed more easily with the transverse position compared to the cephalic or breech position. Complete surveys of fetal anatomy were possible in 50% and 62% of women with transabdominal scan and in 85% and 85% with transvaginal one at 15 and 16 weeks' gestation, respectively (p < 0.001). CONCLUSION: A detailed assessment of fetal structures was possible in most cases at 13 weeks of gestation. Fetal position can influence this capability. At 14(+1) to 15(+0) weeks' gestation more anatomical surveys were completed with a transvaginal scan compared to a transabdominal one and this was influenced by fetal position.     

A randomised controlled trial of moxibustion for breech presentation

OBJECTIVES: To evaluate the efficacy of moxibustion for the correction of fetal breech presentation in a non-Chinese population. DESIGN: Single-blind randomised controlled trial (RCT). SETTING: Six obstetric departments in Italy. SAMPLE: Healthy non-Chinese nulliparous pregnant women at 32-33 weeks + 3 days of gestational age with the fetus in breech presentation. METHODS: Random assignment to treatment or observation. Treatment consisted of moxibustion (stimulation with heat from a stick of Artemisia vulgaris) at the BL 67 acupuncture point (Zhiyin) for one or two weeks. Two weeks after recruitment, each participant was subjected to an ultrasonic examination of the fetal presentation. MAIN OUTCOME MEASURE: Number of participants with cephalic presentation in the 35th week. RESULTS: The study was interrupted when 123 participants had been recruited (46% of the planned sample). Intermediate data monitoring revealed a high number of treatment interruptions. At this point no difference was found in cephalic presentation in the 35th week (treatment group: 22/65, 34%; control group: 21/58, 36%; RR 0.95; 99% CI 0.59-1.5). CONCLUSIONS: The results underline the methodological problems evaluating of a traditional treatment transferred from a different cultural context. They do not support either the effectiveness or the ineffectiveness of moxibustion in correcting fetal breech presentation.     

Congenital high airway obstruction syndrome in the breech presentation managed by ex utero intrapartum treatment procedure after intraoperative external cephalic version

Congenital high airway obstruction syndrome (CHAOS) caused by laryngeal atresia was diagnosed by prenatal ultrasound in a male fetus at 26 weeks of gestation. Findings included massive ascites, subcutaneous edema, enlarged hyperechogenic lungs with diaphragmatic inversion, dilated trachea, polyhydramnios, and breech presentation. Those findings of CHAOS spontaneously returned to normal by 33 weeks of gestation. However, the placenta was localized to the anterior uterine wall. In addition, the fetal position had been breech until delivery. At 36 weeks of gestation, a planned ex utero intrapartum treatment (EXIT) procedure was performed following intraoperative external cephalic version (ECV) in which the fetus was approached from the posterior wall of the uterus. Laryngoscopy revealed the predicted laryngeal obstruction, and tracheostomy was placed. Intraoperative ECV may be a useful technique in breech presentation before EXIT procedure.     

单胎臀位外倒转术的影响因素分析

目的探讨影响单胎臀位外倒转术成功率的相关因素。 方法对2015年11月至2016年4月就诊于广州医科大学附属第三医院妇产科进行外倒转术的20例单胎孕妇的临床资料进行回顾性分析,患者均为单胎妊娠,孕龄在35～38周之间,不合并绝对剖宫产指征,均愿接受行外倒转术。分析影响外倒转术成功率的相关因素,统计学采用χ²检验。 结果20例外倒转术有14例(70%)完成倒转,其中12例(60%)倒转成功并经阴道分娩。比较单臀位和复合臀位[7/9例与7/11例],初产妇及经产妇[5/8例与9/12例]、胎盘位于前壁、后壁和宫底[5/8例,6/8例与3/4例]、妊娠足月与否[4/6例与10/14例]、羊水量正常与否[12/17例与2/3例]、脐带绕颈与否[2/4例与12/16例]的外倒转成功率,差异无统计学意义(P>0.05)。胎儿窘迫、胎盘早剥和早产的发生率分别为10.0%(2/20)例、5.0%(1/20)例和2/14例。 结论外倒转术能较为安全有效将臀位转为头位,适用于足月或近足月妊娠,可达到降低剖宫产率的目的。     

Experiences with continuous fetal measurements during pregnancy]

Experiences by continuous ultrasonic measurements during pregnancy. The authors have published earlier a diagram for use to evaluate the fetal development. The aptitude in practice has been proved.--To evaluate normal fetal growth the percentiles curves of Lubchenco are less suitable than of the GDR. But also the last show the normal weight 100 to 150 g to small during the 30th to 36th gestation week in comparison to the calculated fetal weight of normal pregnancies. The intrauterine retardation and hypertrophy can well be diagnosed if the beginning of the measures occurs at the end of the first trimenon of the pregnancy. But it is necessary to know the possibilities of apparent "abnormalities" in normal pregnancy, as ceccation of the fetal growth for 3 or 4 weeks, the late flattening of the biparietal diameter in breech presentation etc.--Our effort to simulatae the fetal growth in intrauterine retardation by using beta-stimulating sympathicomimetics, was without of success.     

Epidural analgesia for cephalic version: a randomized trial

OBJECTIVE: To determine if epidural analgesia improves the success rate of external cephalic version. METHODS: Women with singleton fetuses in breech or transverse presentation of at least 37 weeks' gestation were offered enrollment in a randomized trial. Inclusion criteria included maternal age of 18 years or older, nonvertex presentation confirmed by ultrasound, intact membranes, reactive fetal nonstress test, and estimated fetal weight (EFW) between 2000 and 4000 g. Women in the epidural group had lumbar epidural catheters inserted, through which 2% lidocaine and 100 microg of fentanyl were infused. External cephalic version attempts were done with ultrasound guidance in a standard fashion for both groups. The primary outcome variable was the successful version of the fetus to a cephalic presentation. RESULTS: There were no statistically significant differences between groups in gestation at time of procedure, placental location, fetal lie, gravity, parity, EFW, or amniotic fluid index. External cephalic version was successful in 32 of 54 women (59%) with epidural anesthesia compared with 18 of 54 (33%) with no anesthesia (relative risk [RR] 1.8, 95% confidence interval [CI] 1.2, 2.8, P <.05). Vaginal delivery occurred in 29 of 54 women (54%) in the epidural group and 16 of 54 women (30%) in the control group (RR 1.9, 95% CI 1.2, 2.9, P <.05). CONCLUSION: Epidural analgesia increased the success rate of external cephalic version and the likelihood of subsequent vaginal delivery.     

External cephalic version under tocolysis.

We currently consider the external version of the fetus from a breech to a vertex presentation near term the best solution to the disadvantages of a breech delivery for mother and child. Version at such a late time in gestation is only possible with the aid of the tocolytic relaxation of the uterus as recommended by us. This method offers two important advantages over the conventional method of external version, the performance of which after the 34th week of gestation has been discouraged because of the poor chance for success: 1. Because of the relatively decreased intrauterine space during the last month of pregnancy the fetus will revert less readily to a breech. 2. In the event of a complication during external version the immediate operative delivery of the mature infant near term is possible. After the presentation of the fetus has been diagnosed by ultrasound the mother is given 20-50 micrograms Fenoterol (Partusisten) intravenously simultaneously with an inhalation analgesia. The version itself is effected by positioning the hands of the operator against the fetal forehead and by turning the infant as in a backwards roll. If this fails, the dose of the tocolytic agent may be increased. In cases with extended legs the chances for success appear to be decreased. The completed version should be confirmed with an ultrasound examination and the undisturbed status of the fetus should be documented with a cardiotocogram immediately after the version. The following results were achieved: The external version was successful in 43 of 57 pregnant women (75%). If the material is selected more critically, over 80% of the attempted versions should be successful. We have now delivered 40 infants as vertex presentations after a previously diagnosed breech presentation. The frequency of breech deliveries in our hospital has decreased by 2.6% from 5.4% to 2.9% since the introduction of version. The decrease is statistically significant. Convincing evidence that version has decreased fetal risk from breech delivery is found in a comparison of the newborn status. The decrease in the percentages of clinically depressed and acidotic newborns is also statistically significant. The failure rate does not appear to increase with increasing gestational age. There is no correlation between parity and failure or between maternal age and failure. So far we have seen no serious complications. In 5 of 24 cardiotocograms recorded a transient fetal bradycardia occurred immediately after the version which disappeared after a few minutes of maternal lateral position.     

External Cephalic Version at a Military Teaching Hospital: Predictors of Success

Summary: The purpose of this prospective study was to analyze our experience with external cephalic version under tocolysis. This included an expected (1) high success rate of version, (2) infrequent occurrence of reversion, (3) reduction in the incidence of intrapartum breech presentation, avoiding the need for Caesarean delivery, and (4) predictors of success in our series. The study spanned the period from 1985 to 1993, enrolling 113 subjects who presented to our OB/GYN Department with any type of breech presentation at 37 weeks' gestation or greater and met the following criteria: (1) absence of labour or ruptured membranes, (2) singleton pregnancy, (3) absence of medical or obstetrical complications and amniotic fluid index of greater than 8 cm. After a reassuring fetal assessment, IV terbutaline was given prior to an attempt at version.
The results revealed a 46% (53 or 113) version success rate with a 4% (2 of 53) reversion within a week after procedure. There was a 2% (2 of 113) complication rate, with 1 being a minor incident of fetal bradycardia that responded easily to intrauterine resuscitation. One major complication occurred with placental abruption during the attempt, which required immediate Caesarean delivery.
Predictors of success in our series included: multiparity, fundal/posterior placenta, and fetal head and spine on the corresponding side of the maternal sagittal plane. External cephalic version in a controlled setting can be a safe procedure for residents in training that lowers Caesarean delivery rate for breech presentation.     

Maternal Thyroid Hormones in Early Pregnancy and Risk of Breech Presentation

ObjectiveTo evaluate the relationship between breech presentation at term (≥ 37 weeks of gestation) and maternal thyroid hormone activity in early gestation.MethodsWe conducted a case–control study of thyroid hormone activity in 179 women who delivered a live term infant in breech presentation (cases) and 849 women who delivered a live term infant in cephalic presentation (control subjects). We used serum samples from prenatal screening at 15 to 16 weeks of gestation in 2006 and 2007 in Edmonton, Alberta. Maternal free thyroxin (fT4) and thyroid-stimulating hormone (TSH) were assayed. Logistic regression was used to estimate the odds of breech presentation in relation to the levels of thyroid hormones while controlling for potential confounders.ResultsThere were no significant differences between the breech and cephalic groups when comparing fT4 levels (OR 0.94 per pmol/L; 95% CI 0.88 to 1.00) or TSH levels (OR 1.16 per mU/L; 95% CI 0.97 to 1.38) levels, after adjustment for all potential confounders. Segregating fT4 and TSH into quintiles showed the same pattern. Neither hypothyroidism nor hyperthyroidism was associated with risk of breech presentation.ConclusionOur results provide evidence that maternal thyroid hormone levels at 15 to 16 weeks of gestation are not related to risk of breech presentation at birth in term infants.