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PubMed1998

Variations in the management of singleton breech presentation throughout Scotland.

Breech presentation occurs in 3-5% of deliveries and can be managed by either a trial of vaginal breech delivery (TOVBD), external cephalic version (ECV) or Caesarean section. A postal questionnaire was completed by 82% of Scottish consultant obstetricians and revealed wide variations in practice. Eighteen percent never offered ECV. Among those who did consensus was lacking on some contraindications. One-quarter sometimes performed ECV before 37 weeks gestations despite the possibility of spontaneous version. Only 70% restricted ECV to one or more designated operators thereby maintaining levels of expertise. Variations were demonstrated in the use of tocolytics, and pre and post procedure investigations. Following failed ECV 28% considered a repeat attempt and 56% a TOVBD. TOVBD was not offered as first line management by one-fifth of respondents. Those who did varied in the pre-procedure investigations performed. Guidelines are required to ensure safe, consistent practice and avoid unnecessary Caesarean sections.

Breech Presentation↗
PubMed1993

[External cephalic version of breech presentation].

External cephalic version of the breech presentation has long traditions. Earlier this was practised to improve the baby's prognosis. Today most breech presentations are delivered by Caesarean section, and external cephalic version of the breech presentation is done to reduce the number of Caesarean sections. External cephalic version of breech presentation reduces the total rate of Caesarean sections by 1-2%. If the breech deliveries are carefully selected at term, they become comparable with cephalic presentation, both in terms of mortality and morbidity. Although the complications associated with external cephalic version of the breech presentation are considered minimal they cannot be ruled out. Therefore systematic external cephalic version of the breech presentation should not be encouraged.

Breech Presentation↗
PubMed2004

Interventions to help external cephalic version for breech presentation at term.

BACKGROUND: Breech presentation places a fetus at increased risk. The outcome for the baby is improved by planned caesarean section compared with planned vaginal delivery. External cephalic version attempts to reduce the chances of breech presentation at birth, but is not always successful. Tocolytic drugs to relax the uterus as well as other methods have been used in an attempt to facilitate external cephalic version at term. OBJECTIVES: To assess the effects of routine tocolysis, fetal acoustic stimulation, epidural or spinal analgesia and transabdominal amnioinfusion for external cephalic version at term on successful version and measures of pregnancy outcome. SEARCH STRATEGY: The Cochrane Pregnancy and Childbirth Group trials register (September 2003) and the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 3, 2003) were searched. SELECTION CRITERIA: Randomised and quasi-randomised trials comparing routine versus selective or no tocolysis; fetal acoustic stimulation in midline fetal spine positions versus dummy or no stimulation; epidural or spinal analgesia versus no regional analgesia; or transabdominal amnioinfusion versus no amnioinfusion for external cephalic version at term. DATA COLLECTION AND ANALYSIS: The reviewer assessed eligibility and trial quality. MAIN RESULTS: In six trials, routine tocolysis with beta-stimulants was associated with fewer failures of external cephalic version (relative risk (RR) 0.74, 95% confidence interval (CI) 0.64 to 0.87). The reduction in non-cephalic presentations at birth was not statistically significant. Caesarean sections were reduced (RR 0.85, 95% CI 0.72 to 0.99). In four small trials, sublingual nitroglycerine used as a tocolytic was associated with significant side-effects, and was not found to be effective. Fetal acoustic stimulation in midline fetal spine positions was associated with fewer failures of external cephalic version at term (RR 0.17, 95% CI 0.05 to 0.60). With epidural or spinal analgesia, external cephalic version failure, non-cephalic births and caesarean sections were reduced in two trials but not the other. The overall differences were not statistically significant. No randomised trials of transabdominal amnioinfusion for external cephalic version at term were located. REVIEWER'S CONCLUSIONS: Routine tocolysis appears to reduce the failure rate of external cephalic version at term. There is not enough evidence to evaluate the use of fetal acoustic stimulation in midline fetal spine positions, nor of epidural or spinal analgesia. Large volume intravenous preloading may have contributed to the effectiveness demonstrated in two of the latter trials.

Analgesia, Obstetrical↗
PubMed2004

A simple patient-initiated intervention to increase antenatal detection of breech presentation at term.

Antenatal detection of breech presentations at 35-37 weeks is necessary to allow adequate time for decision making about external cephalic version (ECV) and/or caesarean section. This study aimed to increase antenatal detection of breech presentation and referral for ECV using an inexpensive patient prompt (a simple brochure encouraging pregnant women to ask how their baby is presenting) and posters reminding clinicians to assess presentation. The interventions were evaluated using a before-after (single time series) study design. The records of women who had a breech presentation in late pregnancy were audited for 12 months before (n = 122) and 12 months after (n = 129) the introduction and implementation of the intervention. There was a statistically significant increase in women with a breech presentation who were assessed antenatally for ECV eligibility, from 75 (61%) before the intervention to 100 (78%) after the intervention. In the before-intervention period, 55 (60%) were identified as eligible for ECV and of these 32 (58%) had an ECV. After the intervention, 80 (75%) were identified as eligible for ECV and 46 (58%) had an ECV. A number of unanticipated events occurred during the study period, so although there was better identification of women eligible for ECV during the after-intervention phase we cannot be sure whether this is an intervention effect or attributable to other reasons. Further, there was no increase in the uptake of ECV nor a reduction in caesarean sections for breech presentation. The difficulties associated with before-after studies are highlighted.

Adult↗
PubMed2002

Outcomes at 3 months after planned cesarean vs planned vaginal delivery for breech presentation at term: the international randomized Term Breech Trial.

CONTEXT: The Term Breech Trial found a significant reduction in adverse perinatal outcomes without an increased risk of immediate maternal morbidity with planned cesarean delivery compared with planned vaginal birth. No randomized controlled trial of planned cesarean delivery has measured benefits and risks of postpartum outcomes months after the birth. OBJECTIVE: To compare maternal outcomes of planned cesarean delivery and planned vaginal birth at 3 months post partum. DESIGN: Follow-up study to the Term Breech Trial, a randomized controlled trial conducted between January 9, 1997, and April 21, 2000. SETTING AND PARTICIPANTS: A total of 1596 of 1940 women from 110 centers worldwide who had a singleton fetus in breech presentation at term responded to a follow-up questionnaire at 3 months post partum. MAIN OUTCOME MEASURES: Breastfeeding; infant health; ease of caring for infant and adjusting to being a new mother; sexual relations and relationship with husband/partner; pain; urinary, flatal, and fecal incontinence; depression; and views regarding childbirth experience and study participation. RESULTS: Baseline information was similar for both the cesarean and vaginal delivery groups. Women in the planned cesarean delivery group were less likely to report urinary incontinence than those in the planned vaginal birth group (36/798 [4.5%] vs 58/797 [7.3%]; relative risk, 0.62; 95% confidence interval, 0.41-0.93). Incontinence of flatus was not different between groups but was less of a problem in the planned cesarean delivery group when it occurred (P =.006). There were no differences between groups in other outcomes. CONCLUSIONS: Planned cesarean delivery for pregnancies with breech presentation at term may result in a lower risk of incontinence and is not associated with an increased risk of other problems for women at 3 months post partum, although the effect on longer-term outcomes is uncertain.

Breast Feeding↗
PubMed1989

Delivery of breech presentation infants at term. An analysis of 304 breech-deliveries.

304 breech presentation infants greater than or equal to 2.500 g were delivered at the University Women's Clinic, Kiel, between 1984 and 1987. Only 2 of the vaginally delivered infants died; both had severe malformations sonographically diagnosed prior to delivery. The umbilical cord arterial PH was found to be significantly (p less than 0.001) higher in infants delivered per Caesarean Section as compared to those vaginally delivered. The same ratio was found in a control group of vaginally delivered infants compared to sectioned infants in the vertex presentation. In 13.3% of cases post primary section and in 14.4% of cases post vaginal delivery from breech presentation we found an apgar of less than or equal to 7 one minute post-partum. The transfer rate to a paediatric unit of vaginally delivered infants (7.2%) appeared to be double that of the infants delivered per Caesarean Section (3.6%). However, the indication for transferral is principally independent of the mode of delivery. Taking the 3-12fold increased maternal mortality rate post section as compared to vaginal delivery into consideration, a vaginal delivery of a breech presentation infant at term appears to be justifiable under certain presuppositions: exclusion of cranio-pelvic disproportion, and normal progression of labour. The indication for secondary Caesarean Section should be generously applied in cases of a suspicious C.T.G. and a slow progression of labour.

Breech Presentation↗
PubMed2001

Induction of labor in breech presentation.

OBJECTIVE: Induction of labor in breech presentation, although not contraindicated, has rarely been reported. We have undertaken to evaluate the safety and outcome of this practice in two Israeli institutions along with a literature review of this controversial subject. METHOD: The research design was a retrospective case control study covering the years: 1980-1999. We have studied 53 term (>37 weeks) breech deliveries induced for various medical and obstetrical reasons, in two major regional hospitals in Israel. Induction was performed with prostaglandin E(2) for the unripe cervix and with oxytocin for induction or augmentation when the cervix was ripe. Six women were induced by nipple stimulation. Controls were 53 women with spontaneous labor in breech presentation that had a trial of vaginal delivery, and 54 women with breech presentation who delivered by elective cesarean section. RESULT: No significant difference in the various maternal and fetal outcomes was observed. CS rate was comparable in both study and control groups (34% vs. 32%) and two-thirds gave birth vaginally. CONCLUSIONS: In properly selected and carefully managed cases of breech presentation, induction of labor seems a safe and reasonable option.

Adult↗
PubMed2000

External cephalic version for breech presentation before term.

BACKGROUND: Management of breech presentation is controversial, both in regard to manipulation of the position of the fetus and the method of delivery. External cephalic version may reduce the number of breech presentations and caesarean sections, but there also have been reports of increased perinatal mortality with the procedure. OBJECTIVES: The objective of this review was to assess the effects of external cephalic version for breech presentation before term on measures of pregnancy outcome. SEARCH STRATEGY: The Cochrane Pregnancy and Childbirth Group trials register and the Cochrane Controlled Trials Register were searched. Date of last search: October 1997. SELECTION CRITERIA: Randomised and quasi-randomised trials of external cephalic version before term (37 weeks gestation) compared with a control group in women with breech presentation before term. DATA COLLECTION AND ANALYSIS: Eligibility and trial quality were assessed by the reviewer. MAIN RESULTS: Three studies involving 889 women were included. There was no significant effect of external cephalic version before term on the following: non-cephalic presentation (relative risk 1.02, 95% confidence interval 0.89 to 1.17); caesarean section (relative risk 1.10, 95% confidence interval 0.78 to 1.54); low Apgar scores (relative risk 0.81, 95% confidence interval 0.44 to 1.49); perinatal mortality (relative risk 1.19, 95% confidence interval 0.46 to 3.05). REVIEWER'S CONCLUSIONS: External cephalic version before term does not appear to improve pregnancy outcomes.

Breech Presentation↗
PubMed1997

Increased incidence of fetal growth restriction in association with breech presentation in preterm deliveries < 32 weeks.

Breech presentation and fetal growth restriction (FGR) are each related independently with preterm delivery. This study was designed to assess the possible relationship between breech presentation and FGR in deliveries at < 32 weeks' gestation. From an established database of 465 consecutive deliveries at < 32 weeks of nonhypertensive, nondiabetic patients with singleton nonanomalous fetuses, those in whom birth weight, body length, fetal presentation (vertex or breech), and amniotic fluid volume (AFV) had been assessed were studied. Fetal growth restriction (defined as symmetric if both birth weight and body length were < 10th percentile and asymmetric if only the birth weight was < 10th percentile) was studied in relation to maternal age, parity, tobacco use, fetal presentation, AFV, membrane status, and gestational age at delivery. Statistical analyses included contingency tables and analysis of variance, with p < 0.05 considered significant. Two hundred ninety-eight patients met the inclusion criteria. In these patients 85 (28.5%) fetuses were breech and 213 (71.5%) cephalic. A total of 56 (19%) fetuses were growth restricted. Of these, 31 (10.4%) were symmetrically and 25 (8.3%) asymmetrically growth restricted. The incidence of symmetric growth restriction in the breech-presenting fetuses was 16% (n = 14) versus 8% (n = 17) in the cephalic-presenting fetuses, and of asymmetric growth restriction 12% (n = 10) versus 7% (n = 15), (overall p = 0.03). Fetal growth restriction was not associated with significant differences in maternal age, parity, smoking, AFV, membrane status, or gestational age at delivery (each p > 0.10). In preterm deliveries at < 32 weeks' gestation, breech presentation is associated with an increased incidence of intrauterine growth restriction, independent of clinical confounders.

Amniotic Fluid↗
PubMed1985

Fetal motor activity in breech presentation.

Intrauterine motor activity was studied in breech presenting but otherwise normal fetuses. In the first part of the study, 48 fetuses were examined in the 33rd gestational week with an objective method using four piezo-electric crystals attached to the maternal abdomen for recording fetal movements. Of the 48 fetuses, 25 remained in breech presentation until delivery, while 23 assumed the vertex presentation before birth. In the second part of the study, 63 pregnant women with breech-presenting fetuses in the 33rd gestational week subjectively recorded perceptible movements every evening. Spontaneous cephalic version occurred in 40 cases, and 23 fetuses persisted in the breech presentation until delivery. Neither in the objective nor in the subjective study were any quantitative differences in motor activity found between fetuses subsequently born in breech presentation and these born in vertex presentation.

Birth Weight↗
PubMed1980

[Breech Presentation--a problem of prematurity? (author's transl)].

The single breech deliveries at the Universitäts-Frauenklinik Insbruck from 1973 to 1977 have been reviewed. Related to a total number of 10.693 deliveries 390 children (3.6%) were born in breech presentation. The unselected perinatal mortality rate of infants in breech presentation was 7.0% which is 4 times higher than the total infant mortality (1.6%). This seems to be due to the higher prematurity rate with breech presentation compared to all deliveries (22.6% versus 8%). In 1977 only premature breeches have been lost. The perinatal mortality rate of premature infants with breech presentation is higher than those of premature babies with vertex presentation (26.3% versus 9.8%). Therefore, more care is needed for the prevention of premature labour in breech presentation. The Caesarean section rate because of breech presentation increased from 18% (1973) to 40% (1977); nevertheless the perinatal mortality rate couldn't be reduced. Up to the present we have been afraid of deliver large series of premature breeches by Caesarean section. Maybe that therefore the perinatal mortality rate couldn't be reduced. However, according to our results routinely performed Caesarean section with mature breeches is not justified. In our opinion a decrease of perinatal morbidity and mortality only can be obtained by reducing the premature breeches.

Acidosis↗
PubMed1998

Factors influencing delivery method in breech presentation.

BACKGROUND: To study factors influencing delivery method in breech presentation. METHODS: Population based cohort study from The Medical Birth Registry of Norway, comprising all singleton deliveries in Norway, 1967-1994, 1,592,064 deliveries of which 45,921 (2.9%) were in breech presentation. RESULTS: The proportion of cesarean section in breech presentation increased from 3.6 per 100 in 1969 to 58.8 in 1994. The relative risk for delivery by cesarean section in breech presentation compared to the nonbreech population increased from 2.0 (95% CI 1.5-2.7) in 1967 to 5.9 (95% CI 5.6-6.2) in 1994. It declined by maternal age, increased by gestational age and was lowest among mothers with urban residence. A negative association was observed between the annual number of births at the delivery department and the cesarean section proportion. However, during the observation period, the centralization of breech deliveries to the largest departments was reduced. CONCLUSIONS: Vaginal delivery in breech presentation was particularly observed in large delivery departments and among mothers with urban residence. Since experience and practical competence are prerequisites for successful vaginal delivery, this centralization seems justified. Further centralization of all breech presentation births should be pursued. However, preparedness as to vaginal delivery should be established also at the smaller units, e.g. by a routine providing periodical centralized training for obstetricians working in smaller institutions.

Adult↗
PubMed1996

A population-based case-control study of risk factors for breech presentation.

OBJECTIVE: We evaluated relationships between breech presentation and infant, maternal, and pregnancy characteristics of singleton births. STUDY DESIGN: A population-based case-control study (3588 breech cases, 8183 controls) was conducted with data from the 1987 to 1988 Washington State birth certificate. RESULTS: Low birth weight, short gestational age, primiparity, and older maternal age were associated with increased risk of breech birth, and after we controlled for these factors, the following were also associated with breech birth: hydrocephalus, established maternal diabetes, congenital malformation of the infant, smoking during pregnancy, and late or no prenatal care. In addition, black and Filipino women had decreased risk of breech presentation compared with white women. CONCLUSION: Several different maternal and infant characteristics appear to increase risk of breech birth, suggesting that there may be several different biologic mechanisms leading to breech presentation.

Adult↗
PubMed1995

Sonographic assessment of birth weight among breech presentations.

The objective in this study was to determine whether there was a difference in the accuracy of sonographically determined birth weight estimate in fetuses presenting by the breech as compared to the vertex. Prospectively, 104 consecutive singleton fetuses presented by the breech presentation were identified who also had a sonographic estimate of birth weight within 72 h of delivery. The control group (n = 104) consisted of fetuses presenting by the vertex of women who had the following hospital number and who were of similar demographic characteristics; the birth weight estimate in the control group had to be within 100 g of that of the women with the breech fetus. The estimate of the birth weight was derived for both groups using seven published models. Prediction limits were calculated for an estimated vs. actual birth weight for parturients with breech presentation. Among the study group, the mean standardized absolute error was similar for the seven models (range 120 +/- 104 to 138 +/- 118 g/kg; p = 0.08). For six of the models, the mean standardized absolute error was significantly higher for fetuses in the breech presentation than for fetuses in vertex presentation (range 80 +/- 63 to 112 +/- 95 g/kg; p = 0.02 to < 0.0001). Prediction limit calculations indicate that 99% of the time the actual birth weight was between 1500 and 3999 g if the estimate of birth weight was 2400-2900 g. We conclude that, for fetuses in a breech presentation, the error with most models is significantly higher than for a singleton in the vertex position.

Abdomen↗
PubMed1998

The occurrence of breech presentation in Norway 1967-1994.

BACKGROUND: To study the occurrence of breech presentation and its association with demographic and geographic variables. METHOD: Population based cohort study from the Medical Birth Registry of Norway comprising all singleton deliveries 1967-1994, a total of 1,592,064 deliveries. Of these, 45,921 in breech presentation. RESULTS: From 1967 through 1994, the breech presentation proportion increased from 2.2% (95% CI 2.1-2.3) to 3.4% (95% CI 3.2-3.5). Breech presentation was associated with high maternal age and low birth order, as well as low gestational age and birthweight. The secular trend was mainly due to demographic changes in terms of increasing proportions of births with low birth order and high maternal age. Breech presentation was most frequent in urban areas. CONCLUSIONS: Strong associations were observed between breech presentation and low birth order as well as high maternal age. The findings are compatible with both intrinsic as well as environmental mechanisms. A full understanding of the birth order effect necessitates further studies based on sibship data. Prevention of premature delivery would be an effective measure for reducing the breech presentation proportion.

Adult↗
PubMed1975

[Critical notes on delivery and perinatal mortality in single breech presentation deliveries].

This report deals with 432 single breech presentation deliveries. Caesarean section frequency was 12,3%. As to the vaginal route of delivery, the simple Bracht manoeuvre had been prefered; in recent times, however, the assisted spontaneous delivery with oxytocin-infusion has been introduced. The corrected perinatal mortality was 4,9%. The rate of prematurely born infants amounted to 14,6%. The corrected perinatal mortality of infants up to 2500 g was 3,3%; of full term infants it was 1,4%. The importance of breech presentation delivery as a high risk delivery is being emphasized. Fetal monitoring and blood gas analysis were required. Indications of caesarean section and suggestions for the management of breech presentations were established. Generally caesarean section of primiparae is not recommended. The diminished rate of prematurely born infants is considered to be of great importance for the decrease of perinatal mortality of breech presentation infants. Intensive pregnancy care, widely used uterotocolysis, and cervix-cerclage in cases of breech presentation are recommended.

Birth Weight↗
PubMed2000

External cephalic version for breech presentation at term.

BACKGROUND: Management of breech presentation is controversial, both in regard to manipulation of the position of the fetus and the method of delivery. External cephalic version may reduce the number of breech presentations and caesarean sections, but there also have been reports of increased perinatal mortality with the procedure. OBJECTIVES: The objective of this review was to assess the effects of external cephalic version at term on measures of pregnancy outcome. SEARCH STRATEGY: The Cochrane Pregnancy and Childbirth trials register was searched. Date of last search: October 1997. SELECTION CRITERIA: Randomised trials of external cephalic version at term (with or without tocolysis) compared with no attempt at external cephalic version in women with breech presentation. DATA COLLECTION AND ANALYSIS: Eligibility and trial quality were assessed by GJH and checked by RK. MAIN RESULTS: Six studies were included. External cephalic version at term was associated with a significant reduction in non-cephalic births (relative risk 0.42, 95% confidence interval 0.35 to 0.50) and caesarean section (relative risk 0.52, 95% confidence interval 0.39 to 0.71). There was no significant effect on perinatal mortality (relative risk 0.44, 95% confidence interval 0.07 to 2.92). REVIEWER'S CONCLUSIONS: Attempting cephalic version at term appears to reduce the chance of non-cephalic births and caesarean section. There is not enough evidence to assess any risks of external cephalic version at term.

Breech Presentation↗
PubMed1989

The intrapartum management of the breech presentation.

In many cases of breech presentation, a trial of labor is practical and safe among carefully selected parturients. Anesthesia and full neonatal support should be available. Described is the protocol in use at several large institutions that maintain a Cesarean rate for breech presentation in the 60 to 70 per cent range which is approximately 25 per cent lower than the national rate. The development of this protocol as well as its highlights in clinical application are described and highlighted in this report.

Breech Presentation↗