Breech Presentation

Key Points

• Read in conjunction with the guideline for external cephalic version (ECV) • Delivery by should be specifically advised for women with unfavourable clinical features • The obstetrician and the anaesthetist are informed of all vaginal breech deliveries • A Consultant Obstetrician 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 • Documentation of discussion regarding mode of delivery

Version: 2.0 Sarah Coxon, Consultant midwife WPH Guidelines Lead(s): Balvinder Sagoo, Consultant Obstetrician WPH Nicky Galdeano, Practice Contributors: development midwife FPH Lead Director/ Chief of Service: Anne Deans Obstetrics and Gynaecology Ratified at: Clinical Governance Committee, 30th September 2020 Date Issued: 18th November 2020 Review Date: September 2023 Pharmaceutical dosing advice and Ruhena Ahmed, 10.06.2020 formulary compliance checked by: 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. This guideline is for use in Frimley Health Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

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Version Control Sheet

Version Date Guideline Lead(s) Status Comment 1.0 27/09/2016 Lynne Sheen Final Approved at Obstetric and Gynaecology Clinical Governance 2.0 September Sarah Coxon Final Updated and approved at 2020 OGCGC with amendments on page 9 and 10. Amended and approved by chair Miss A. Deans November.2020

Related Documents

Document Document Name Type Guideline Guideline for external cephalic version (ECV) Guideline Care of women in labour

Abbreviations

CTG Cardiotocograph ECV External cephalic version EFM Electronic fetal monitoring LSA Left sacral anterior PPH Postpartum haemorrhage RSA Right sacral anterior USS Ultrasound scan VE Vaginal examination

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Contents Incidence of breech ...... 4 Antenatal management ...... 4 Clinical Factors regarded as unfavourable for vaginal ...... 4 Twins ...... 4 Intrapartum management ...... 5 Mechanisms for Birth ...... 6 Procedure for Vaginal Breech Deliveries ...... 8 Paediatric follow up ...... 9 Documentation ...... 9 Auditable Topics ...... 9 Monitoring ...... 9 Communication ...... 10 Equality Impact Assessment ...... 10 References ...... 10

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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.

Antenatal management

This guideline should be read in conjunction with the guideline for external cephalic version (ECV). Women with a breech presentation should be offered an ECV unless there is an absolute contraindication.

Risks and benefits of a planned caesarean section versus planned vaginal birth should be discussed with women if an ECV has failed, contraindicated or declined. This will enable an informed choice to be made.

Women should be assessed carefully before selection for vaginal breech birth. Planned caesarean section leads to a small reduction in perinatal mortality compared with planned vaginal breech birth. A discussion should take place about the potential adverse consequences that may result from this.

The avoidance of stillbirth after 39 weeks of gestation, avoidance of intrapartum risks factors and the risks of vaginal breech birth, the last is unique to a breech baby. These are the three factors which reduce the risk.

Delivery by caesarean section should be specifically advised for women with unfavourable clinical features as planned vaginal breech birth is likely to be associated with increased perinatal risk.

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

• Footling presentation. • Estimated fetal weight more than 3.8kg • Low estimated weight less than the tenth centile • Hyperextended fetal neck in labour (diagnosed with ultrasound scan) • Evidence of antenatal fetal compromise

The role of pelvimetry is unclear.

Twins When the first twin is presenting breech at term, the woman should be informed of the benefits and risks, both for the current and for the future , especially reduced perinatal mortality and planned Caesarean section for breech presentation.

Routine Caesarean section for twin with breech presentation of the second twin (where the first twin is cephalic) should not be performed. 20,21.

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Diagnosis of breech presentation for the first time during labour should not be a contradiction for vaginal breech birth. 1,12

If diagnosed in labour a 2222 call should be put out to summon emergency assistance from the obstetric team and obstetric consultant on call should be made aware.

A practitioner skilled in the conduct of labour with breech presentation and vaginal breech birth should be present at all vaginal breech births. A consultant obstetrician must also be present in supervising labour with a breech presentation or carrying out vaginal breech birth. All practitioners must have appropriate training, which should include simulated training.

Intrapartum management

Deliveries should not take place in the midwifery led unit.

Where a woman presents with an unplanned vaginal breech labour, management should depend on the stage of labour, whether factors associated with increased complications are found, availability of appropriate clinical expertise and informed consent.

When a woman presents near or in the active second stage of labour, a caesarean section should not be routinely offered. A discussion should be had with the woman about versus caesarean section risks at this stage, and this should be clearly documented.

Women who are planning a vaginal breech birth and where time permits with unplanned vaginal breech birth the position of the fetal neck, legs and the fetal weight should be estimated using ultrasound.

Vaginal breech birth can take place on Labour Ward or in theatres at the discretion of the obstetrician. If the delivery is on Labour Ward an anaesthetist and theatres must be informed. Birth in an operating theatre is not routinely recommended.

A member of the neonatal team should be present for all vaginal breech births.

The effect of epidural analgesia on the success of vaginal breech birth is unclear, but that is likely to increase the risk of intervention. An epidural also restricts women from being able to birth on all fours, which is the position that leads to less need for additional manoeuvres.

Continuous electronic fetal monitoring should be offered to women with a breech presentation in labour.

Induction of labour is not usually recommended. Augmentation of slow progress with oxytocin should only be considered if the contraction frequency is low in the presence of epidural analgesia. Multiparous women who have gone into spontaneous labour, use oxytocin with caution, consider descent as well as cervical dilatation.

Women should be informed that adherence to a protocol for management reduces the chance of early neonatal morbidity.

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Management of preterm breech

Women should be informed:

• Routine caesarean section for breech presentation in spontaneous preterm labour is not recommended • The mode of delivery should be individualised based on the stage of labour, type of breech presentation, fetal wellbeing and availability of an operator skilled in vaginal breech birth. An obstetrician should be present / conduct birth. • Planned caesarean section is usually recommended for preterm breech presentation where delivery is planned due to maternal/and or fetal compromise.

Mechanisms for Birth

Remember – Supporting physiological breech manoeuvres are required. Do not pull

Women should either be in a semi-recumbent or all-fours position may be adopted for delivery and should depend on maternal preference and experience of the attendant. If the all-fours position is adopted women should be advised that recourse to the semi-recumbent position may become necessary. When a woman is in all- fours, manoeuvres are less likely to be required.

Assistance, without traction, is required if there is delay from crowning of the anterior buttock,

• Delivery of the buttocks to delivery of the umbilicus should take no longer than 2 minutes • Progress from delivery of the umbilicus to delivery of the head should take no longer than 3 minutes

Delivery should be achieved within 7 minutes, or ASAP in the evidence of poor fetal condition.

All obstetricians and midwives should be familiar with the techniques that can be used to assist vaginal breech birth. The choice of manoeuvres used, if required to assist with delivery of the breech, should depend on the individual experience / preference of the attending doctor or midwife.

• 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 (bum to tum) • 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. Do not however, assist with the legs routinely, as the feet may be stretching the perineum, which can help with the subsequent delivery of the head.

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• The baby should continue to descend with maternal effort. If the woman is pushing in between contractions, do not stop her from doing so • The anterior arm and shoulder are usually released first, and then slight rotation may occur, 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 should be used to facilitate delivery. Once the scapula can be seen, grasp the bony 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 once the body has delivered and the head is in the pelvis, therefore the delivery of the head needs to proceed without waiting for 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 obstetrician applies the blades. The obstetrician pulls with one hand whilst guarding the perineum with the other hand while the assistant either a midwife or another obstetrician 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 or category 1 Caesarean section.

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Procedure for Vaginal Breech Deliveries A consultant obstetrician should be involved in managing labour with breech presentation and should be present at the vaginal breech birth.

Midwife Obstetrician On admission On admission

• Admission procedure as per labour ward guidelines including CTG • Review clinical notes, check findings and decisions re: labour/delivery. • Inform obstetric registrar • Full assessment of the mother including vaginal examination to exclude • Inform anaesthetic registrar if woman is in established labour and cord presentation (if not already done so by the midwife). requesting epidural. • Inform consultant on call after examining the woman but BEFORE • Site 16g cannula/send routine bloods including full blood count and finalising mode of delivery group & save to the laboratory. • Discuss plan of care with woman and document in the woman’s labour • Ensure the labour room has a resuscitaire in full working order in situ. notes. Good communication between practitioners is important. 1

First stage of labour First stage of labour • Commence partogram • Review labour progress with midwife providing care and labour ward • Care as per guideline Care of women in labour. coordinator. • Continuous EFM • To reduce the risk of cord compression, amniotomy is reserved for • Assess progress during labour including 4 hourly VE. NB. Rate of definite clinical indications. progress should be the same as for cephalic presentation. Note both • If progress is sub-optimal, discuss case with consultant on call. progress in cervical dilatation and descent.

Second stage of labour Second stage of labour

• The 2nd stage must be confirmed by vaginal examination to ensure • A consultant must attend all breech births and be present in the the cervix is fully dilated. N.B The woman should never be room although they can have a registrar conducting the delivery encouraged to push until the breech is at the perineum and there is a or a midwife. The consultant should be called in advance of the strong urge to push. If the cervix has been fully dilated for more than second stage if known breech in labour and if presenting fully one hour and the breech is still at or above the spines, a CS delivery dilated they must attend if in the unit/ be called in from home should be considered. Remember that a multiparous patient may be ASAP. able to push a narrow breech through an incompletely dilated cervix. • The obstetric anaesthetist on call for labour ward should be • Ensure the bladder is empty. called. • Inform the obstetric registrar and agree who will deliver the baby. • Adequate descent of the breech in the passive second stage is a pre- • Inform the neonatal team who should be present for the birth. requisite for encouragement of the active second stage. • Ensure a pair of forceps are available in the room. Check with the obstetrician which forceps they prefer. • A scribe should be present for all breech births

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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 following delayed cord clamping • 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 obstetric 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 two 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 Topics The obstetrician and the anaesthetist are informed of all vaginal breech deliveries

A consultant obstetrician 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

Documentation of discussion regarding mode of delivery

Vaginal delivery rates in women planning vaginal breech delivery

Vaginal breech births when diagnosed in labour or prior to planned CS date

Rate of adverse neonatal and maternal outcomes following planned and actual breech birth

Percentage of staff who have undergone training in vaginal breech delivery

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.

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Communication If there are communication issues (e.g. 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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13. Doyle NM, Riggs JW, Ramin SM, Sosa MA, Gilstrap LC 3rd. Outcomes of term vaginal breech delivery. Am J Perinatol 2005;22:325–8. 14. Vendittelli F, Pons JC, Lemery D, Mamelle N; The Obstetricians of the AUDIPOG Sentinel Network. The term breech presentation: Neonatal results and obstetric practices in France. Eur J Obstet Gynecol Reprod Biol 2006 ;125:176–84 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. 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. 21. Rabinovici J, Barkai G, Reichman B, Serr DM, Mashiach S. Randomised management of the second nonvertex twin: vaginal delivery or Caesarean section. Am J Obstet Gynecol 1987;156:52–6. 22. Broche DE, Riethmuller D, Vidal C, Sautiere JL, Schaal JP, Maillet R. Obstetric and perinatal outcomes of a disreputable presentation: the nonfrank breech. J Gynecol Obstet Biol Reprod 2005;34:781-8.

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