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Breech Presentation

Version: 1 Derived from: Breech Presentation (FPH) and LW 12: Multiple pregnancy and birth, breech and malpresentation (WPH) Name of authors Lynne Sheene (Midwife FPH) Ratified by (Committee): Obstetric and Gynaecology Clinical Governance Date ratified: 27/09/2016 Date implemented: October 2016 Review date: August 2019 Key words: Breech, malpresentation

This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date

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Contents

Incidence of breech .......................................................................................... 3 Antenatal management .................................................................................... 3 Factors regarded as unfavourable for vaginal breech birth .............................. 3 Twins ............................................................................................................... 4 Intrapartum management ................................................................................. 4 Mechanisms for Birth ....................................................................................... 5 Procedure for Vaginal Breech Deliveries ......................................................... 6 Paediatric follow up .......................................................................................... 7 Documentation ................................................................................................. 7 Auditable standards ......................................................................................... 7 Monitoring ........................................................................................................ 7 Communication ................................................................................................ 7 Equality Impact Assessment ............................................................................ 7 References ...................................................................................................... 8

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Incidence of breech

The incidence of breech presentation decreases from about 20% at 28 weeks of gestation to 3-4% at term, as most babies turn spontaneously to the cephalic presentation.1

Antenatal management

This guideline should be read in conjunction with the guideline for external cephalic version (ECV). If ECV has failed, was contraindicated or declined, women should be informed of the benefits and risks, both for the current and future pregnancies of planned Caesarean section versus planned vaginal delivery for breech presentation at term to make an informed choice.1 All women with breech presentation at term must be offered a Caesarean section. Planned Caesarean section carries a reduced perinatal mortality and early neonatal morbidity for babies with a breech presentation at term, compared with planned vaginal

• birth. However, there is no evidence that the long term health of babies with a breech

presentation delivered at term is influenced by how the baby is born. 1,2,3,4,5,6. Women should be advised that planned Caesarean section for breech presentation carries a small increase in serious immediate complications for them, compared to planned vaginal birth, but that it does not carry any additional risk to long term health outside

• pregnancy. However, the long term effects on future pregnancy outcome for them and

their babies are uncertain. A study from the Netherlands7 estimated that, in the four years following publication of the Term Breech Trial5, the increase of approximately 8500 elective Caesarean sections probably prevented 19 perinatal deaths. However, it also resulted in four maternal deaths that may have been avoidable. It is estimated that, in future pregnancies, nine perinatal deaths can be expected as a result of the uterine scar and 140 women will have potentially life threatening complications from the uterine scar.1,7,8,9,14. Women should be assessed carefully before selection for vaginal breech birth. Women with unfavourable clinical features should be specifically advised of the increased risk to them and their babies of attempting vaginal breech birth. 1

Factors regarded as unfavourable for vaginal breech birth include:1, 10

• Other contraindications to vaginal birth (e.g., placenta praevia, compromised fetal

condition).

• Clinically inadequate pelvis.
• Footling or kneeling breech presentation.
• Estimated fetal weight <2000g or >3800g
• Hyperextended fetal neck in labour (diagnosed with ultrasound scan )
• Lack of presence of a clinician trained in vaginal breech delivery.
• Uterine scar or abnormality.

Routine radiological pelvimetry is not necessary. 1,22. In the absence of good evidence that a preterm baby needs to be delivered by Caesarean section, the decision about the mode of delivery should be discussed on an individual basis with the parents. 1,18.

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Twins

When the first twin is breech presentation at term the women should be informed of the benefits, including reduced perinatal mortality, and risks, both for the current and for the future pregnancies, of planned Caesarean section for breech presentation. Routine Caesarean section for twin pregnancy with breech presentation of the second tw (where the first twin is cephalic) should not be performed. 20,21. Diagnosis of breech presentation for the first time during labour should not be a contradiction for vaginal breech birth. 1,12 Some women with breech presentation choose to deliver vaginally 13 and some women for whom a Caesarean section is planned, labour too quickly for the operation to be undertaken.1,3,14. It therefore remains important that clinicians and hospitals are prepared for vaginal breech delivery. 1,3,14. A practitioner skilled in the conduct of labour with breech presentation and vaginal breech birth should be present at all vaginal breech births. Practitioners supervising labour with a breech presentation or carrying out vaginal breech birth must have appropriate training, which should include simulated training. 15

Intrapartum management

Vaginal breech birth should take place in the hospital where there are facilities for emergency Caesarean section. Vaginal breech birth can take place on Labour Ward or in theatres at the discretion of the

• bstetrician. If the delivery is on Labour Ward an anaesthetist and theatres must be
• informed. A paediatrician should be present for all vaginal breech births.

Induction of labour may be considered if individual circumstances are favourable but would not normally be recommended. This discussion should take place between the patient and a consultant obstetrician. Labour augmentation is not recommended. 3,5. Epidural analgesia should not be routinely advised; women should have a choice of analgesia during breech labour and birth. 1 Continuous electronic fetal monitoring should be offered to women with a breech presentation in labour. 1,11,15. Fetal blood sampling from the buttocks during labour is not advised 1, 11,15. Caesarean section should be considered if there is delay in cervical dilatation or in the descent of the breech at any stage in the second stage of labour. 1 Women should be advised that, as most experience with vaginal breech birth is in the dorsal or lithotomy position, that is the position advised for breech delivery when manoeuvres are required.1 Episiotomy should be performed when indicated to facilitate delivery.1 Breech extraction should not be used routinely. 1,16.

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Mechanisms for Birth Remember – Hands off the breech unless manoeuvres are required. Do not pull

• The anterior buttock is usually born first, and then the posterior buttock sweeps the

perineum by lateral flexion of the fetal body.

• The baby rotates to sacrum anterior. Ensure the back remains anterior.
• The hips rotate, often from RSA to LSA (or opposite), so appear to twist out.
• The baby flexes its sacrum around the maternal symphysis pubis, which helps

release the legs. N.B. If the legs appear to be delaying progress, assist delivery by inserting a finger into the popliteal fossa, flex and abduct.

• The baby should continue to descend with maternal effort.
• The anterior arm and shoulder are usually released first, and then slight rotation may
• ccur, either way to free the second arm in the oblique. N.B. If the fetal arms are

extended and the fetal axilla can be seen, it will impede progress. Løvset manoeuvre can be used to facilitate delivery. Once the scapula can be seen, grasp the bony pelvis and turn the fetal body into the oblique position. Sweep the arm down across the chest by inserting a finger over the shoulder.

• Once the nape of the neck is visualised, flexion of the head is vital. This can be

achieved by using the Mauriceau–Smellie–Veit manoeuvre: the middle finger of one hand applies pressure on the occiput with the index and ring fingers applying modest traction on the shoulders. The fetal body rests on the other hand with the index and ring fingers applying modest pressure on the maxillae. The aim is to deliver the head by flexion and the baby onto the maternal abdomen. An assistant may apply supra- pubic pressure to encourage flexion of the fetal head. There are often no contractions

• nce the body has delivered and the head is in the pelvis, therefore the delivery of the

head may need to be without a contraction.

• If forceps are required for the after coming head Keillands are easier to apply as they

are straight. Obstetricians who are not familiar with Keillands should use Anderson or Neville Barnes forceps. The baby’s body must be held up by an assistant whilst the

• bstetrician applies the blades. The obstetrician pulls with one hand whilst guarding

the perineum with the other hand while the assistant lightly supports and catches the baby’s body as the head is delivered.

• Where there is head entrapment during a preterm breech delivery, lateral incisions at

10:00 and 02:00 of the cervix should be considered by a suitably qualified practitioner.

• Obstructive delivery of the after-coming head should be managed by symphysiotomy

(by a suitably qualified practitioner) or category 1 Caesarean section.

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Procedure for Vaginal Breech Deliveries

A practitioner skilled in the conduct of labour with breech presentation and vaginal breech birth should be present at all vaginal breech births.

Midwife Obstetrician On admission

• Admission procedure as per labour

ward guidelines including CTG

• Inform obstetric registrar
• Inform anaesthetic registrar if

woman is in established labour and requesting epidural.

• Site 16g cannula/send routine

bloods including full blood count and group & save to the laboratory.

• Ensure the labour room has a

resuscitaire in full working order in situ. On admission

• Review clinical notes, check

findings and decisions re: labour/delivery.

• Full assessment of the mother

including vaginal examination to exclude cord presentation (if not already done so by the midwife).

• Inform consultant on call.
• Discuss plan of care and

document in the woman’s labour

• notes. Good communication

between practitioners is important.

1

First stage of labour

• Commence partogram
• Care as per guideline Care of

women in labour.

• Continuous EFM
• Assess progress during labour

including 4 hourly VE. NB. Rate of progress should be the same as for cephalic presentation. Note both progress in cervical dilatation and descent.

First stage of labour

• Review labour progress with

midwife providing care and labour ward coordinator.

• If progress is sub-optimal, discuss

case with consultant on call. Second stage of labour

• The 2nd stage must be confirmed by

vaginal examination to ensure the cervix is fully dilated. N.B. The woman must be encouraged not to push until full dilatation is confirmed. N.B. Remember that a multiparous patient may be able to push a narrow breech through an incompletely dilated cervix.

• Ensure the bladder is empty.
• Inform the Obstetric Registrar and

agree who will deliver the baby.

• The baby will descend in the birth

canal with maternal effort.

• Inform Paediatric SHO and/or

Registrar who should be present for the birth.

• Ensure a pair of forceps are available

in the room. Check with the

• bstetrician which forceps they prefer.

Second stage of labour

• If a midwife is to deliver the baby, the

registrar must remain in the room throughout the birth.

• Inform consultant obstetrician on call.

Depending on the experience of the registrar, the consultant should be either in the room or on standby in the unit.

• Inform the on-call anaesthetist

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Third Stage of labour

• Third stage management should be as Care of women in labour guideline
• The cord should be double clamped and paired cord blood samples obtained

for all breech babies.

• If requested, women at low risk of PPH may be supported in having a

physiological third stage if, prior to delivery of the head, there has been no

• bstetric or midwifery intervention.

Paediatric follow up

All babies born in the breech position must have an outpatient appointment for ultrasound scan (USS) of the hips within 6 – 8 weeks to exclude congenital hip dislocation. If unstable hips are identified at the NIPE check arrange an urgent USS within 2 weeks.

Documentation

All details of care should be clearly documented, including details of counselling and the identity of all those involved in the procedures. A scribe should be appointed to record details of timings and procedures during the birth.

Auditable standards

The obstetrician and the anaesthetist are informed of all vaginal breech deliveries The obstetric registrar is present for vaginal breech deliveries Paired cord blood samples are obtained for all vaginal breech deliveries Babies born in the breech presentation have an USS of the hips

Monitoring

This guideline will be subject to three yearly audit and results presented to the department clinical audit meeting. Action plans will be monitored at the quarterly department clinical governance meeting. The audit midwife takes responsibility for initiating and reporting the audit.

Communication

If there are communication issues (eg English as a second language, learning difficulties, blindness/partial sightedness, deafness) staff will take appropriate measures to ensure the patient (and her partner, if appropriate) understand the actions and rationale behind them.

Equality Impact Assessment

This policy has been subject to an Equality Impact assessment.

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References

• 1. Hofmeyr G.J and Impey L.W.M (2006) The Management of Breech Presentation

3rd edn, RCOG, London.

• 2. Hofmeyr GJ, Hannah ME. Planned Caesarean section for term breech delivery.

Cochrane Database Syst Rev 2003(2):CD000166.

• 3. Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR, et al.

Planned Caesarean section versus planned vaginal birth for breech presentation at term: a randomized multicentre trial. Lancet 2000;356:1375–83.

• 4. Lumley J. Any room left for disagreement about assisting breech births at term?

Lancet 2000;356:1369–70.

• 5. Su M, McLeod L, Ross S, Willan A, Hannah WJ, Hutton E, et al. Factors

associated with adverse perinatal outcome in the Term Breech Trial. Am J Obstet Gynecol 2003;189:740–5.

• 6. Hodnett ED, Hannah ME, Hewson S, Whyte H, Amankwah K, Cheng M, et al.

Mothers’ views of their childbirth experiences 2 years after planned Caesarean versus planned vaginal birth for breech presentation at term, in the international randomized Term Breech Trial. J Obstet Gynaecol Can 2005;27:224–31.

• 7. Visser GH, Rietberg CC, Oepkes D, Vandenbussche FP. Breech presentation:

infant versus mother. Ned Tijdschr Geneeskd. 2005;149:2211–4.

• 8. Coughlan C, Kearney R, Turner MJ. What are the implications for the next delivery

in primigravidae who have an elective Caesarean section for breech presentation? BJOG 2002;109:624–6.

• 9. Verhoeven AT, de Leeuw JP, Bruinse HW. Breech presentation at term: elective

Caesarean section is the wrong choice as a standard treatment because of too high risks for the mother and her future children. Ned Tijdschr Geneeskd 2005;149:2207–

• 10. National Institute for Clinical Excellence. Caesarean Section Guidelines April

2004

• 11. Society of Obstetricians and Gynaecologists of Canada. Policy Statement: the

Canadian consensus on breech management at term. J Soc Obstet Gynecol Can 1994;16:1839–5

• 12. Nwosu EC, Walkinshaw S, Chia P, Manasse PR, Atlay RD. Undiagnosed

breech.BJOG 1993;100:531–5.

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• 15. Confidential Enquiry into Stillbirths and Deaths in Infancy. 7th Annual Report.

London: Maternal and Child Health Research Consortium; 2000 [www.cemach.org.uk/publications/7th_Report.pdf].

• 16. Hofmeyr GJ, Kulier R. Expedited versus conservative approaches for vaginal

delivery in breech presentation. Cochrane Database Syst Rev. 2000(2):CD000082.

• 17. Penn ZJ, Steer PJ. How obstetricians manage the problem of preterm delivery

with special reference to the preterm breech. BJOG 1991;98:531–4.

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• 18. Bowes WA Jr, Taylor ES, O’Brien M, Bowes C. Breech delivery: evaluation of the

method of delivery on perinatal results and maternal morbidity. Am J Obstet Gynecol 1979;135:965–73.

• 19. Cibils LA, Karrison T, Brown L. Factors influencing neonatal outcomes in the very

low birthweight fetus (< 1500 g) with a breech presentation. Am J Obstet Gynecol 1994;171:35–42.

• 20. Sibony O, Touitou S, Luton D, Oury JF, Blot P. Modes of delivery of first and

second twins as a function of their presentation study of 614 consecutive patients from 1992 to 2000. Eur J Obstet Gynecol Reprod Biol 2006;126:180–5.

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