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Norfolk & Norwich University Hospital NHS Trust O & G DIRECTORATE MEDICAL GUIDELINE

Breech Presentation at term May 2008 Page 1 of 2

[IO7] {review May 2011}

GUIDELINES ON THE MANAGEMENT IN HOSPITAL

OF BREECH PRESENTATION AT TERM

Key words: breech presentation, ECV, term

BACKGROUND

Breech remains the commonest of the malpresentations, with an incidence of 20% at 28

weeks. The majority of these fetuses will turn spontaneously, so that the incidence at termis only 3-4%.

Breech presentation is associated with much higher perinatal mortality and morbidity; duemainly to prematurity, congenital malformations and birth asphyxia or trauma. Breech

presentation is also a risk factor for handicap whatever the mode of delivery.

Caesarean section has been suggested as a way of reducing the risk of fetal problems and

in this country has become the normal mode of delivery in this situation. However,caesarean section remains a major abdominal operation commonly associated withmaternal morbidity, even when done as an elective procedure under regional anaesthesia.

ANTENATAL

When the diagnosis is made before the onset of labour, plans for delivery must be clearly

documented in the patients notes by a senior obstetrician.Normally antenatal evaluation will include a departmental ultrasound examination to exclude

fetal or intrauterine anomalies and placenta praevia, determine the type of breechpresentation, exclude hy per-extension of the fetal head and provide an estimate of fetalweight.

External cephalic version (ECV)All women with an uncomplicated breech pregnancy at term should be offered the option ofexternal cephalic version, provided there are no contraindic ations and the woman is

willing.

Contraindications to ECV include:

y Footling breech

y Oligohydramnios or ruptured membranes

y Suspected fetal compromise or anomaly

y Multiple pregnancy

y Those women in whom there is another indication for CS

Although there is evidence that the use of routine tocolysis increases the success rates of

ECV at term, there is currently insufficient evidence to recommend the use of epidural orspinal anaesthesia.

ECVs at term should only be attempted on the Delivery Suite, where there are appropriatefacilities for continuous fetal heart rate monitoring before and after the procedure and for

ultrasound scanning during it. Facilities for emergency delivery are also nearby.

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Norfolk & Norwich University Hospital NHS Trust O & G DIRECTORATE MEDICAL GUIDELINE

Breech Presentation at term May 2008 Page 2 of 2

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An elective caesarean section should be recommended to those w omen with a term breechfor whom ECV is inappropriate/unsuccessful and for those women who have declined ECV.

DELIVERY SUITE

Undiagnosed or inadequately assessed breech presentations will usually be delivered bycaesarean section - unless the labour is progressing so rapidly that this is not possible. A

trial of labour is also precluded in the presence of medical or obstetric complications that

are likely to be associated with any mechanical difficulties at delivery.

If vaginal breech delivery is proposed the following are advised during the

labour:1. Continuous electronic fetal heart monitoring

2. Four hourly vaginal examinations should be performed by the registrar or seniormidwife looking after the patient.

3. Intravenous access should be e stablished and blood sent for FBC/G & S.

4. There is no evidence that an epidural is essential.5. Administer ranitidine 150 mg 6-hourly orally.

6. Syntocinon should only be used after consultation with a senior obstetrician.

7. The anaesthetist and NICU should be notified when the patient is approachingthe second stage. The paediatrician must be present at the delivery, and theanaesthetist aware and immediately available.

8. Delivery must be directly supervised by, or conducted by, a Senior SpecialistRegistrar (or equivalent).

9. On no account should any attempts be made to deliver the baby by grointraction etc. If the breech does not descend on to the perineum in the

second stage a caesarean section should be performed.

References:

1. Confidential Enquiry into Stillbirths and Deaths in Infancy. 7th

Annual Report. London:

Maternal and Child Health Research Consortium; 2000.2. Danelian PJ, Wang J, Hall MH. Long-term outcome by method of delivery of fetuses inbreech presentation at term: population based follow-up. BMJ1996;312: 1451-1453.

3. Hannah ME, Hannah WJ, Hewson SA et al. Planned caesarean section versus plannedvaginal birth for breech presentation at term: a randomised multicentre trial. Lancet

2000;356:1375-83.

4. Hofmeyr GJ, Kulier R. External cephalic version for breech presentation at term(Cochrane Review). In: The Cochrane Library, Issue 3, 2004. Chichester, UK: John Wiley

& Sons, Ltd.5. Hofmeyr GJ, Gyte G. Interventions to help external cephalic version for breech

presentation at term (Cochrane Review). In: The Cochrane Library, Issue 3, 2004.Chichester, UK: John Wiley & Sons, Ltd.

6. Royal College of Obstetricians and Gynaecologists. The Management of BreechPresentation. London: RCOG Press Dec 2006. Green-top guideline No. 20b.

7. Glezerman M. Five years to the term breech trial:The rise and fall of a randomisedcontrolled trial.American J Obst & Gyne Vol 194, Issue 1, Jan 2006 pp 20-25

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