Breech Presentation External Cephalic Version and Vaginal Breech Delivery Document Control Title Breech Presentation, External Cephalic Version and Vaginal Breech Delivery Guideline Author Author’s job title Obstetric Consultant, LW Lead Obstetric Specialty Doctor Lead Clinical Midwife Directorate Department Womens and Childrens Maternity Services Date Version Status Comment / Changes / Approval Issued 1.0 Sep 2002 Final Original version 1.1 Jun 2012 Revision Updated 1.2 Feb 2013 Revision Revision 1.3 May 2013 Revision Guideline converted to Trust template. 2.0 June Final Revision 2013 3.0 July 2017 Final Revision 3.1 Sept Final Approved for publishing 2020 Main Contact Consultant Obstetrician, Labour Ward Tel: Direct Dial – Lead Tel: Internal – North Devon District Hospital Email: Raleigh Park, Barnstaple, EX31 4JB Lead Director Director of Nursing Superseded Documents Issue Date Review Date Review Cycle September 2020 September2023 Three years Consulted with the following stakeholders: (list all) Obstetricians Midwives Guidelines group stakeholders All users of this document Approval and Review Process Maternity Services Guidelines Group Local Archive Reference Maternity Services Risk Manager Local Path G:\OBSGYNAE\Risk\Archives\Maternity Services Filename Breech Presentation External Cephalic Version and Vaginal Breech Delivery v3.0 May2017 Policy categories for Trust’s internal Tags for Trust’s internal website (Bob) website (Bob) Maternity Services Malpresentation vaginal birth Obs&Gynae Page 1 of 20 Breech Presentation External Cephalic Version and Vaginal Breech Delivery CONTENTS Document Control ............................................................................................................... 1 1. Purpose ........................................................................................................................ 3 2. Definitions .................................................................................................................... 3 Definition ....................................................................................................................... 3 3. Responsibilities ........................................................................................................... 3 4. Management of breech presentation .......................................................................... 4 General Principles ......................................................................................................... 4 Antepartum Breech presentation management. ............................................................. 4 Intra-partum Breech presentation management. ............................................................ 8 5. Monitoring Compliance with and the Effectiveness of the Guideline .................... 15 Standards/ Key Performance Indicators ....................................................................... 15 Process for Implementation and Monitoring Compliance and Effectiveness................. 15 6. References ................................................................................................................. 15 7. Associated Documentation ....................................................................................... 16 Appendix A ........................................................................................................................ 17 Obs&Gynae Page 2 of 20 Breech Presentation External Cephalic Version and Vaginal Breech Delivery 1. Purpose 1.1. The purpose of this document is to detail the process for best practice guidelines for breech presentation management. Although incidence of breech presentation is approximately 20% at 28 weeks, most fetuses turn spontaneously resulting in an incidence of 3- 4% at term. Multiple pregnancy increases the risk of breech presentation. Other influencing factors include pelvic tumours, uterine abnormalities (a septum or uterine fibroid), previous breech, high parity and placenta praevia. Whatever the mode of delivery, breech presentation is a signal for potential fetal morbidity and mortality for varied reasons including prematurity, congenital malformations, birth asphyxia or trauma. Fetal growth restriction may also predispose to breech presentation because the reduction in liquor volume restricts fetal movement and thus the fetus is trapped in the position it adopted in the second trimester. In this case the potential for poor perinatal outcome is further increased. 1.2. This guideline applies to Obstetricians and Midwives. 1.3. Implementation of this guideline will ensure evidence based management of breech presentation. 2. Definitions Definition 2.1. ECV – External Cephalic Version. 3. Responsibilities 3.1. All cases of Breech presentation at 36 weeks and beyond must be referred to the obstetrician. 3.2. All Midwives and Obstetricians are responsible for; Acting as an effective advocate for the woman by providing her with appropriate evidence based information so that she can make an informed choice about mode of delivery. Ensuring that appropriate and prompt referral is made to ensure the woman has every option available in management of the breech presentation. Ensuring that any referrals made are followed up effectively. Ensuring that ECV is undertaken by the appointed skilled clinician in a clinically appropriate location. Ensuring vaginal breech delivery is made available in clinically appropriate situations and conducted with appropriate supervision. Obs&Gynae Page 3 of 20 Breech Presentation External Cephalic Version and Vaginal Breech Delivery 4. Management of breech presentation General Principles If breech presentation is suspected on palpation from 34 - 36 weeks gestation, the mother should be referred to the Unit for a diagnostic ultrasound scan within 1 week. If breech is confirmed on scan, the following features should be assessed: Type of breech presentation Location of fetal back in relation to maternal back Estimated fetal weight Liquor volume Location of placenta Inspection of head / neck 4.1. If breech presentation is confirmed, referral should be made prior to 37wks gestation to a Senior Obstetrician in ANC/DAU for a management plan. There is no evidence for routine recommendation of postural regimes to convert the breech to cephalic (e.g. knee-chest position). However these exercises do no harm and may prove beneficial psychologically. Women may wish to consider the use of moxibustion by a trained practitioner for breech presentation at 33–35 weeks of gestation. Please see Appendix A for ‘Diagnosis of the breech presentation’. Antepartum Breech presentation management. 4.2. ECV – External Cephalic Version. Women with a breech presentation at term should be offered external cephalic version (ECV) unless there is an absolute contraindication. They should be advised on the risks and benefits of ECV and the implications for mode of delivery. Women should be counselled about the success rate (40% for nulliparous and 60% for multiparous). The success of ECV is enhanced by using a tocolytic agent – proven for Salbutamol and Terbutaline, not with Nifedipine or GTN. Women should be counselled that with appropriate precautions, ECV has a very low complication rate. Although case reports of placental abruption and large feto-maternal haemorrhage exist, complications associated with ECV are very rare. The reported risk of emergency caesarean section within 24 hours is approximately 0.5%, with the indication in over 90% being vaginal bleeding or an abnormal CTG following the procedure. Women should be informed that few babies revert to breech after successful ECV. Women should be informed that labour after ECV is associated with a slightly increased rate of caesarean section and instrumental delivery when compared with spontaneous cephalic presentation. Criteria for ECV Obs&Gynae Page 4 of 20 Breech Presentation External Cephalic Version and Vaginal Breech Delivery While there is no general consensus on the eligibility for, or contraindications to, ECV. ECV should be offered at term from 37+0 weeks of gestation. In nulliparous women, ECV may be offered from 36+0 weeks of gestation. Success with ECV has been reported at 42 weeks gestation. ECV can be undertaken in early labour, provided the membranes are intact. Women should be informed that ECV after one caesarean delivery appears to have no greater risk than with an unscarred uterus. At NDDH, women eligible for ECV will be singleton pregnancy, 37 weeks gestation and above. ECV will only be performed on CDS by a senior Obstetrician who has been trained to perform ECV. Contraindications to ECV ECV is contraindicated where an absolute reason for caesarean section already exists (e.g. placenta praevia, severe preeclampsia). Multiple pregnancy (except after delivery of a first twin). Rhesus isoimmunisation Vaginal bleeding (less than 1 week previously) Abnormal electronic fetal monitoring (EFM) Rupture of the membranes Mother declines or is unable to give informed consent. ECV should be performed with additional caution where there is oligohydramnios or hypertension. Please see Appendix A for ‘Diagnosis and Types of breech presentation’. Prerequisites for ECV ECV should only be performed by a trained practitioner or by a trainee working under direct supervision. ECV at NDDH will be undertaken on Central Delivery Suite where ultrasound, CTG and theatre facilities are immediately available if required. Ultrasound examination prior to ECV to exclude causes of breech presentation such