Breech Presentation Version: 1 Derived from: Breech Presentation - PDF document

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 Breech presentation September 2016 page 1 of 9 V1.0

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 Breech presentation September 2016 page 2 of 9 V1.0

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 Netherlands 7 estimated that, in the four years following publication of the Term Breech Trial 5 , 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. Breech presentation September 2016 page 3 of 9 V1.0

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 obstetrician. 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. Breech presentation September 2016 page 4 of 9 V1.0