RANZCOG guideline - BREECH Flashcards
What is the incidence of breech presentation at term?
3-4% beyond 37/40
What was the term breech trial and what was its impact on breech deliveries?
large RCT published in 2000
comparison of vaginal breech delivery vs elective C/S breech delivery
reported that perinatal morbidity and mortality was much higher in vaginal breech group vs C/S breech delivery 5% vs 1.6%
according to the term breech trial what was the rate of perinatal death in the vaginal breech group vs the elective CS breech group?
1.3% vs 0.3%
according to the term breech trial in 2000 what was the rate of serious perinatal morbidity in the elective CS breech delivery group vs vaginal breech delivery group?
1.4% vs 3.8%
What was the ‘fallout’ from the term breech trial
- less vaginal breech deliveries, less expertise and training
- now weigh up risk of CS for future pregnancies with risk of vaginal breech delivery
- methodology of term breech trial questioned
- individual case by case counselling now recommended
Reitberg et al published a paper titled “The effect of the Term breech Trial on medical intervention behaviour and neonatal outcome in the Netherlands: an analysis of 35,453 term breech deliveries”
What was the most significant finding?
- NNT 175
- 175 C/S need to be offered to prevent one fetal death
What were the criticisms of the Term breech trial?
- methodology criticised
- may not be generalisable to appropriately resourced and staffed centres in NZ and Australia
in 2016 Berhan and Haileamlak completed a meta analysis
What was their conclusion regarding the absolute risk of vaginal breech vs C/S breech delivery?
perinatal mortality was calculated to be 1:333 for vaginal breech delivery and 1:2000 for elective CS
what is required if a breech presentation is found late in third trimester?
- an USS by a experienced clinician to determine whether any fetal or maternal reasons for a breech presentation exists
- the USS should also be used to identify contraindications to ECV - amniotic fluid, placental location, hyperextension of fetal head, cord or footling breech
List 6 contraindications to ECV
- Another reason for C/S exists (placenta praaevia)
- APH within last 7 days
- abnormal CTG
- ruptured membranes
- where there is rhesus iso-immunisation
- multiple pregnancy
List 5 relative contraindications to ECV
- oligohydramnios
- SGA with abnormal dopplers
- pre-eclampsia
- major fetal anomalies
- uterine anomalies (ECV may not be successful)
Non ECV methods to help with breech presentation - comments?
- no evidence that postural management alone helps
- no evidence from recent trials that moxibustion is effective for version of breech presentation
what percentage of breech babies at term currently have C/S
90%
what is the recommended timing of elective CS?
39/40
what are the 3 essential components of planned vaginal breech birth?
- appropriate case selection
- management according to a strict protocol
- availability of skilled birth attendants
Where a vaginal delivery of a breech presentation is planned, appropriate infrastructure must include: (3)
- Continuous electronic fetal heart monitoring in labour.
- Immediate availability of skilled anaesthetic staff, facilities for immediate caesarean section, and paediatric resuscitation.
- Availability of a suitably experienced midwife and obstetrician for all of labour with arrangements in place to manage shift changes and fatigue.
List 6 contraindications to vaginal breech delivery?
• Cord presentation
• Fetal growth restriction (estimated fetal weight< 10th%) or macrosomia (estimated fetal weight >
3.8kg)
• Any presentation other than frank (extended) or complete (flexed) breech
• Hyperextension of fetal neck on ultrasound
• Evidence of antenatal fetal compromise (e.g. abnormal CTG)
• Fetal anomaly incompatible with vaginal delivery.
What if a woman requires an IOL for another indication and has a term breech baby?
- should not offer vaginal breech delivery if IOL is required
- augmentation of labour should also be avoided as adequate progress may be the best indicator of adequate fetopelvic proportions
how should 1st stage of labour be managed with a vaginal breech delivery?
- same as with cephalic delivery but with continuous electronic fetal monitoring
- if progress is slow, CS should be offered
- the effect of epidural is unclear (may increase risk of intervention)
how should 2nd stage of labour be managed for vaginal breech delivery?
- passive second stage for 2 hours
- if breech is not present at 2 hours, CS should be recommended
- active pushing should not be encouraged until breech is visible
What should you do if breech presentation first discovered in labour?
- counsel regarding risks and benefits
- offer emergency CS
- POCT USS should be available
how should a woman >25 with a viable fetus presenting in labour be counselled regarding MOD?
- elective CS recommended
For a woman presenting in labour between 22-24:6 with breech presentation, what mode of delivery should be recommended?
- no evidence that CS is beneficial
- perinatal mortality is dependent on factors other than the mode of delivery
- CS should not be routinely recommended (as maternal morbidity therefore outweighs benefit)
how do you deliver a breech baby vaginally?
- discourage active pushing until breech visible
- hands off approach - traction should be avoided
- fetus grasped around pelvic girdle (not soft tissue)
- do NOT hyperextend fetal neck
- selective rather than routine episiotomy recommended
