Breech delivery and ECV

Question 1

What percentage of SINGLETON pregnancies are breech presentation at term?

Answer 1

3-4%

Question 2

What percentage of singleton breech pregnancies are delivered by LSCS?

Answer 2

97%

Question 3

List maternal predisposing factors to breech presentation

Answer 3

Uterine abnormality e.g. bicornuate uterus, previous surgery. Uterine fibroids.

Question 4

List fetal predisposing factors to breech presentation

Answer 4

Multiple pregnancy. Preterm. Abnormal liquor volume (oligo- and polyhydramnios). Fetal anatomical abnormality e.g. hydrocephalus, anencephaly. Fetal neuromuscular abnormality. Placenta praevia.

Question 5

What important information can you get from performing an ultrasound in a baby that is breech presentation?

Answer 5

Presentation (flexed, extended leg breech; footling breech) Cord: presentation, tight nuchal cord. Placental location including if praevia. Liquor volume (oligo- or polyhydramnios). Hyperextension of fetal head. EFW (IUGR or LGA)

Question 6

When should you offer a NULLIP an ECV?

Answer 6

From 36 weeks gestation.

Question 7

When should you offer a MULTIP an ECV?

Answer 7

From 37 weeks gestation.

Question 8

What serious adverse outcomes can result from an ECV and what is the percentage risk of these occurring?

Answer 8

Serious adverse outcomes: cord presentation, placental abruption, uterine rupture, fetal distress. Risk is 0.5%.

Question 9

What minor complications can result from an ECV, and what is the percentage risk of these occurring?

Answer 9

Minor complications: transient CTG abnormalities, rupture of membranes, bleeding. Risk if 4.3%.

Question 10

What is the overall success rate of ECV? How does being a nullip and multip affect this?

Answer 10

Overall success rate of ECVs is 50%; it is lower (40%) in a nullip and higher (60%) in a multip.

Question 11

List the ABSOLUTE contraindications for performing an ECV

Answer 11

When Caesarean section is otherwise indicated. APH within the last 7 days. Ruptured membranes. Abnormal CTG. Major uterine abnormality. Multiple pregnancy (except during delivery of 2nd twin)

Question 12

List the RELATIVE contraindications for performing an ECV

Answer 12

SGA with abnormal dopplers. Proteinuric preeclampsia. Oligohydramnios. Unstable lie (unless another indication to perform stabilising amniotomy/IOL at same time). Restrictive nuchal cord. Major fetal abnormalities. Scarred uterus (although after one LSCS there is no increased risk).

Question 13

Briefly outline how you would counsel a women regarding ECV

Answer 13

Explain what ECV is and why it is offered. Success rate of ECV and low rates of reversion to breech and spontaneous turning to cephalic. Low risk procedure and list risks. Explain procedure and what to expect, including adjuncts (tocolysis, spinal).

Question 14

A meta-analysis by Kok et al found what predictors were associated with successful ECV?

Answer 14

AFI >10. Maternal body weight <65 kg. Palpable fetal head. Posterior placental location. Non-engagement of the breech. Use of tocolysis. Flexed leg breech.

Question 15

List the steps you’d take in preparing for and performing an ECV

Answer 15

Location of ECV must have:

• ultrasound, CTG
• facilities for Caesarean section.
• Who: must be trained in ECV or be under direct supervision of trained practitioner.
• Pre-ECV CTG.
• Perform ECV: max 4 attempts for max 10 mins overall.
• Post-ECV: immediately check FHR with USS. If normal, complete CTG.
  
  • If abnormal, nurse in left lateral and prepare for Cat 1 LSCS after 6 mins of bradycardia.
• Give Anti-D to Rh negative women.

Question 16

What are the contra-indications to vaginal breech delivery>

Answer 16

F - Fetal growth restriction or macrosomia F - Fetal anomaly incompatible with vaginal breech delivery A - Any presentation other than frank or complete breech C - Cord presentation C - Clinically inadequate maternal pelvis E - Extension of the fetal head + Evidence of antenatal fetal compromise (RCOG GTG)

Question 17

What are the benefits and risks of a planned vaginal breech delivery?

Answer 17

• Benefits:
  
  • Fastery recovery and less pain c.f. CS.
  • Can have another vaginal delivery in future.
  • Avoids risks associated with repeat CS.
• Risks:
  
  • Perinatal mortality risk 2 per 1000 (double that of cephalic vaginal delivery 1 per 1000)
  • Fetal hypoxia, HIE
  • Stillbirth after 39 weeks
  • Vaginal and perineal trauma
  • EmCS following attempted breech vaginal delivery high risk (40%)

Question 18

What are the benefits and risks of a planned CS delivery for breech?

Answer 18

• Benefits:
  
  • Perinatal mortality 0.5 per 1000 (half that of cephalic vaginal delivery)
  • No risk of HIE and fetal hypoxia
  • Avoids late stillbirth risk after 39 weeks.
  • Avoids risk of vaginal and perineal trauma.
• Risks:
  
  • Surgical risks: bleeding, intra-abdominal injury, infection, VTE
  • Small risk of TTN
  • Future pregnancies: placenta praevia, placenta accreta, limitation on number of pregnancies, increased rate of complications with repeat CS.
  • Lower rates of breastfeeding.

Question 19

Describe how you would perform the Mariceau-Smellie-Veit manoeuvre

Answer 19

Position yourself so you are kneeling or lower than the bed.

Place right hand in posterior vagina and palpates fetal malar prominences with the index and middle finger, pressing on malar prominences to flex fetal head. Fetus’ chest should rest on palm of right hand while left hand is placed on back of fetus with middle finger on occiput to assist flexion, and index and ring finger on either side of neck on shoulders. Stand up, maintaining flexion to deliver head.

Question 20

Describe how you would use forceps to deliver the aftercoming head

Answer 20

Ask assistant to hold baby on an angle a little beyond horizontal to allow you space to insert Keillands forceps.

Lock forceps and then rest baby on right palm/arm.

Place left hand at occiput as for MSV manoeuvre and stand up like a J-shape to facilitate birth of head.

Question 21

Is routine CS for breech presentation in PRETERM, spontaenous labour recommended?

Answer 21

No

Question 22

Is elective CS for preterm breech presentation with planned delivery for maternal or fetal compromise recommended?

Answer 22

Yes

Question 23

Is routine CS for twins with leading twin in breech presentation but in established labour recommended?

Answer 23

No.

Depends on:

• Cervical dilatation
• Breech station
• Type of breech
• Fetal wellbeing
• Availability of skiled vaginal breech delivery operator

Question 24

Why did the Term Breech trial stopped recruiting early?

Answer 24

For the planned LSCS grp: Significantly lower risk of combined perinatal or neonatal mortality or serious neonatal morbidity (1.6 vs 5%; p<0.0001). NNT = 14.

Question 25

What were the secondary outcomes and discussion points of the Term Breech trial?

Answer 25

• No difference in maternal morbidity or mortality between planned CS and planned vaginal breech group.
• Significant interaction between treatment group primary outcome and a country’s reported perinatal mortality rate (PMR):
  
  • In counties with HIGH PMR, there appeared to be no difference in perinatal or neonatal mortality between treatment groups (2.3% vs 2.5%)
  • Explanations for phenomenon: detection biase (less baby surveillance, early discharge), real effect where high PMR countries have higher levels of experience with vaginal breech delivery.