Max Brinsmead PhD FRANZCOG August 2014

Background  Incidence ○ 20% at 28 weeks ○ 4% at term  Reasons for a breech ○ Uterine abnormalities ○ Placental localisation ○ Excessive or reduced amniotic fluid ○ Fetal abnormalities ○ Fetal attitude – extended legs ○ Just chance

Perinatal mortality is increased because…  Prematurity  Congenital malformations  Birth asphyxia  Birth trauma  “the biggest part of the baby is coming last”  Increased risk of long term “handicap” even when delivered by CS

Current Controversies  Management of term breech Elective Caesarean or vaginal birth  Selection of patients for breech birth  Techniques in vaginal breech delivery  Pre term breech and the twin breech  The detection of breech presentation  The Role of ECV Is it effective Is it safe When should it be performed How is it best achieved

Recent History  By 1990 The practice of ECV had been mostly abandoned Because of reports of intrauterine death But it was done at 33 – 35 weeks And therefore possibly unnecessary  Most Pre term breech delivered by CS Because of concerns about incomplete cervical dilatation But there was no good evidence to support this  Confusion about the Primigravid Breech With the “untried pelvis”  Breech skills were being lost

2000 The Term Breech Trial  RCT in 121 centres in 26 countries & 2088 women  To prove that vaginal breech was safe & to maintain breech skills  Multiparous or nulliparous at term with a singleton breech  Non-footling, EFW <4000g & morphologically normal  Randomised to elective CS or trial of vaginal delivery  Induction & augmentation of labour permitted  Experienced accoucheur to be present  But this trial was stopped prematurely because increased perinatal risk with vaginal breech delivery

Risks to the baby & the mode of delivery…  After exclusion of deaths from congenital malformation the risk of perinatal death or serious morbidity is reduced by elective CS (RR 0.29, CI 0.10 – 0.86)  After excluding cases with: ○ Epidural anaesthesia ○ Prolonged labour ○ Labours induced or augmented ○ Footling breech ○ No experienced accoucheur present  Risk with vaginal birth still 3.3% but 1.3% with elective CS (RR 0.49, CI 0.26 – 0.91)  This data from systematic analysis of the Term Breech Trial plus two smaller prior trials

Risks to the mother & mode of delivery…  Short term morbidity is increased by vaginal delivery (RR 1.29 CI 1.03 – 1.61)  Urinary incontinence  More perineal pain  Long term morbidity from uterine scar needs evaluation  Estimated that for each baby saved by CS there will be one scar rupture in attempted VBAC later  In the Netherlands, in the 4 years after 2000, 8500 CS were done, “saved” 19 babies but 4 maternal deaths occurred  Needs 53 additional CS for each baby saved

Events since the publication of the Term Breech Trial…  Many criticisms of the Trial  Follow up of the Term Breech Trial babies found no long term benefit from CS  A prospective study of 2526 women in France and Belgium analyzed on an intention-to-treat basis found no benefit from elective CS  RCOG, RANZCOG and Canadian guidelines state that trial of vaginal breech delivery is a safe option  All also recommend attempting ECV

Other Major Studies  A prospective study of 2526 women in France and Belgium analyzed on an intention-to-treat basis found no benefit from elective CS  Dutch study of 58,320 term breech Elective CS rose from 24% to 60% PNM fell from 1.3 to 0.7 per 1000 PNM for those having vaginal birth did not change

Problems with the Term Breech Trial…  Most of the patients recruited in developed countries Subgroup analysis suggests that the outcome cannot be extrapolated to resource poor countries  Many of the centres involved had historically low rates of vaginal breech birth Raises questions about the experience of the “skilled accoucheur”  Criteria for patients for trial of vaginal birth were too liberal  Lumping fetal mortality and morbidity was inappropriate for long term outcomes 3 deaths in the vaginal group vs none in the CS group is NS (and one death was a surviving twin)

Two year follow up of babies in the Term Breech Trial…  Was conducted in those Centres thought to achieve 80% follow up  Outcomes measured were perinatal death and neurodevelopmental delay  There were no significant differences (RR 1.09 CI 0.52 – 2.30)  The smaller number of perinatal deaths in the CS group was balanced by a higher number of 2 year- olds with neuro-developmental delay  Calls into question the measures of neonatal morbidity (which were more frequent in the vaginal birth group)

Patients not suitable for vaginal breech birth…  Other obstetric contraindications incl. placenta previa, compromised fetus and previous CS  Footling or kneeling breech  EFW >3800 or <2000g  Hyper extended neck – ultrasound or X-ray  Routine radiological pelvimetry not required but patients with a small pelvis not suitable But maybe a role for CT pelvimetry  Experienced accoucheur not available  Diagnosis of the breech in labour is not a contraindication

Optimal intrapartum management…  Induction of labour is okay  But augmentation of labour not recommended  Epidural according to the mother’s wishes  Continuous CTG is recommended  CS should be performed for failure to progress on the 1 st stage and failure of the breech to descend in the second stage  40 – 50% of patients attempting vaginal birth will require Caesarean  And, because both baby and maternal outcomes are worse with emergency CS, this is why I prefer elective CS

The breech delivery…  Episiotomy when clinically indicated  Routine breech extraction not recommended (But delivery should not be unduly delayed)  Delivery of the arms Sweep them down or… Lovset’s maneuvre  Delayed engagement of the head Suprapubic pressure or… Mauriceau-Smellie-Veit with or without rotation  Delivery of the head Burns-Marshall or… Mauriceau-Smellie-Veit  Symphysiotomy and forceps for trapped head

Pre term Breech  Retrospective studies suggest that delivery by CS confers advantage to the baby  Especially for the very pre term  But the data is biased  And maternal risk needs to be taken into account  So the best option is to make individual decisions With the involvement of the patient  Incomplete dilation is a problem Cervical incisions recommended

Twins and Breech  Many clinicians recommend CS when the leading twin is breech But data is lacking to confirm this trend And locked twins are very rare  Routine CS for a second twin that is breech is not recommended But is sometimes required Some RCT’s have been performed and CS not shown to confer any benefit More studies are underway  Breech extraction of the second twin is an option

Detection of breech presentation…  Antenatal diagnosis is inconsequential before 35 weeks  But detection in labour is too late because… Maternal counseling is compromised Place of labour may be inappropriate Risks to mother and baby both increased regardless of the mode of delivery In a study of 1633 women attending the antenatal clinic of a tertiary Sydney hospital 30% of breech presentations were missed Conclusion: Ultrasound for presentation at 36 – 37 weeks should be a component of routine antenatal care

Because breech delivery is a preventable condition that meets all the criteria for a screening procedure The Role of External Cephalic Version

ECV is Effective RCT’s of external version at or near term (5 trials and 433 women) Reduce the rate of breech presentation in labour (RR 0.38, CI 0.18 – 0.80) Reduce the rate of CS (RR 0.55, CI 0.33 – 0.91) Overall success rate is: 60% in multipara 40% in primipara Lower when the legs are extended Or the breech is deeply engaged

Risks with ECV  Cord entanglement Post procedure monitoring by CTG Transient decelerations common with a known nuchal cord  Premature labour and PROM Not a problem if it is deferred until >37w  Antepartum haemorrhage Anti-D for those patients who are Rh Neg  Maternal pain Limits continuation with the attempt in ~ 5%  Fetal reversion to breech Overall less than 5% and is usually predictable

ECV is Safe  No differences in any measure of baby or maternal outcome in the RCT’s  Has a low rate of complications in large observational studies O.5% rate of emergency CS in 805 consecutive cases in Oxford One Term PROM in a personal series of >200 attempted ECV’s over 15 years No documented case of procedure-related perinatal loss in the large trials And few in the literature overall

An attempt at ECV is not contraindicated by…  Advanced gestation  A uterine scar  History of prior APH  Maternal hypertension  Oligohydramnios  A nuchal cord And is usually limited only by the maternal willingness to consider and continue the procedure Which in turn is usually proportional to the counseling that is initially and subsequently provided

ECV is not successively achieved by…  Maternal posturing 5 trials 392 women  Moxibustion with or without acupuncture 3 trials 597 women The need for ECV was reduced in one study  But ECV is facilitated by… Tocolysis with IV or SC betamimetic agents Betamimetics better than oral Nifedipine & sublingual nitroglycerine is not recommended Epidural but not spinal anaesthesia Fetal acoustic stimulation

Unanswered Questions about ECV  When it should be attempted Beginning earlier at 34 – 36w may be okay  Should attempts be repeated How many times How often  Role in the fetus who has an unstable lie  Role with amnioreduction and amnioinfusion  Teaching and maintaining skills

The Early ECV Trial  1543 ♀ in 21 countries randomised to: ECV at 34 – 36 weeks or >37 weeks  Fewer breeches at term from early ECV RR 0.84 CI 0.75 – 0.94 (41% vs 48%)  But rate of Caesarean not reduced Inexplicable  Early ECV appears safe No difference in fetal/neonatal morbidity But a meta analysis suggests increased risk of preterm labour  Discuss benefits and risks and choose