CHHS17/262

Canberra Hospital and Health ServicesClinical GuidelineBreech Presentation (Maternity)Contents

Contents................................................................................................................................... 1

Guideline Statement.................................................................................................................3

Definitions............................................................................................................................ 3

Key Objectives...................................................................................................................... 3

Scope........................................................................................................................................ 3

Section 1 – Breech Presentation...............................................................................................4

Pre-disposing factors and causes..........................................................................................4

Antenatal Management........................................................................................................4

Section 2 – External Cephalic Version.......................................................................................4

Contraindications................................................................................................................. 5

Absolute............................................................................................................................... 5

Relative.................................................................................................................................5

Management:.......................................................................................................................5

In Birthing.............................................................................................................................5

Planned LUSCS......................................................................................................................6

Preterm breech.................................................................................................................... 7

Criteria recommended for a planned vaginal, singleton breech term birth.........................7

Intrapartum management....................................................................................................7

Preparation and consent......................................................................................................7

Considerations......................................................................................................................8

First Stage.............................................................................................................................8

Second stage:....................................................................................................................... 8

Forceps to aftercoming head................................................................................................8

Entrapment of the Head.......................................................................................................9

Neonatal wellbeing following breech birth..........................................................................9

Implementation........................................................................................................................9

Related Policies, Procedures, Guidelines and Legislation.........................................................9

References..............................................................................................................................10

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Definition of Terms.................................................................................................................10

Search Terms..........................................................................................................................11

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Guideline Statement

This document provides details of clinical management of women who have a diagnosis of a singleton breech presentation during pregnancy or intrapartum.

The incidence of breech presentation at term is between 3–4%. Breech presentation is a normal finding in preterm pregnancies and should not be considered abnormal until late pregnancy. Twenty-five percent of breech presentations will still undergo spontaneous version after 35 weeks gestation. Spontaneous version occurs with decreasing frequency as gestational age advances.

Definitions The definition of breech presentation is when the buttocks, foot or feet are presenting instead of the head. There are 3 classifications of breech: Frank breech where the hips are flexed and legs extended complete breech where the hips and knees are flexed and the feet are not below the

level of the fetal buttocks footling breech where one or both feet are presenting as the lowest part of the fetus

Key ObjectivesThis guideline outlines the decision and management process required for: External Cephalic Version (ECV) planning for an elective lower uterine segment caesarean section (LUSCS) for a

singleton breech decision making in preterm singleton breech birth planning for a singleton vaginal breech birth managing a singleton vaginal breech birth neonatal management of the breech baby

The guiding principles of this procedure are informed consent and care by clinicians with suitable preparation and experience in vaginal breech birth.

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Scope

This document applies to: Medical Officers Midwives who are working within their scope of practice (Refer to Scope of Practice for

Nurses and Midwives Policy) Student Midwives under direct supervision

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Section 1 – Breech Presentation

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Pre-disposing factors and causesMaternal factors Fetal factors

Polyhydraminos Uterine anomalies (bicornuate, septate) Space occupying lesions (e.g. fibroids) Placental abnormalities (praevia) Multiparity (in particular grand

multiparas)

Prematurity Fetal anomalies (e.g. neurological

hydrocephalus, anencephaly) Multiple pregnancy Fetal death Short umbilical cord

Antenatal ManagementManagement options include: ECV Elective LUSCS Planned breech vaginal birth

Any woman who is found to have a breech presentation at 35-36 weeks gestation should be referred for obstetric review and counselling prior to 37 weeks gestation. An ultrasound should be performed to assess for fetal or maternal causes of the malpresentation and fetal position, size and wellbeing.

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Section 2 – External Cephalic Version

External cephalic version (ECV) from 36 weeks has been shown to decrease the incidence of breech presentation at term and consequently reduce the elective LUSCS rate. It is seen as a relatively safe procedure provided it is performed in a setting where LUSCS can occur if necessary.

Performing an external cephalic version (ECV) has been shown to reduce the rate of noncephalic presentations at term thereby reducing the number of LUSCS for breech birth at term. This procedure provides the 3-4% of women who present with a baby in the breech position at term, a safe alternative to LUSCS or planned vaginal breech.

All women with a singleton breech presentation with no contra-indications to the procedure should be offered an ECV from 37 weeks gestation. Success rates for ECV are approximately 40% in nulliparous women and 60% in multiparous women. Successful ECV has a less than 5% risk for reversion to the breech presentations. Approximately 0.35%-0.5% of women will require an emergency LUSCS from ECV complications

ECV should be offered after 37 weeks gestation. Tocolysis can be used to relax uterine muscles and may increase the success rate of an

ECV

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Women who are RhD negative will be offered Anti-D administration following ECV as recommended by the National Health and Medical Research Council (NHMRC)

ContraindicationsAbsoluteThese situations or conditions are associated with increased mortality and morbidity Severe Intra-uterine growth restriction (IUGR) multiple gestation (except birth of second twin) fetal or maternal compromise placenta Praevia maternal refusal antepartum haemorrhage (APH) within last week major uterine anomaly e.g. large fibroids Rhesus isoimmunisation abnormal cardiotocograph (CTG) ruptured Membranes

Relative Previous LUSCS uterine contractions pre-eclampsia small for gestational age fetus with abnormal Doppler studies major fetal anomalies oligohydramnios if the deepest pool is less than 2cm multiple loops of cord round neck on ultrasound. Management:Ensure the woman has read the information sheet, and that she has been counseled about the risks and benefits of an ECV and that consent is obtained. Determine that there are no contra-indications to performing an ECV an ultrasound is performed to ensure that the baby is still presenting by breech and that

there is no evidence of congenital anomalies that preclude vaginal birth give the women the written information on external cephalic version document that the procedure and risks of ECV are discussed obtain the woman’s written consent organise an appointment for the woman to have the ECV performed in Birthing unit

under ultrasound surveillance.

In Birthing ECV appointments are made for the morning, the woman to have a light breakfast then

fast from breakfast – she may have fluids only, and present to Birthing fasted perform an abdominal palpation, Blood Pressure, Pulse, Respirations and CTG before

and on completion of the procedure complete a portable ultrasound prior to commencing preparation for ECV to ensure that

the fetus is still in the breech presentation

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obtain / confirm consent (Ideally written consent) offer a uterine relaxant 15-30 mins prior to procedure, a maximum effect is achieved in

about 15 - 30 minutes position the women on the bed with no pillow under her head and place a pillow under

her buttocks, ensure a left tilt practitioner turns the baby by pushing the presenting part upwards and the fetal head is

pushed in the opposite direction towards the pelvis

AlertThe total time spent in manipulation of the baby during any one attempt should not exceed 5 minutes. No more than 4 attempts are advised at any one visit. The maximum overall duration of hands on attempts should not usually exceed 10 minutes.

ultrasound to confirm presentation.

AlertThe ECV will be discontinued if it is not easily accomplished, the FHR is non- reassuring or if the woman reports significant pain or requests the procedure be abandoned.

if the woman’s blood group is negative, test for fetomaternal haemorrhage and offer Anti D and document

if fetomaternal haemorrhage test positive ensure adequate anti D has been administered and if significantly positive, offer further fetal surveillance.

document monitor the woman for complications identify and manage complications appropriately

If the ECV has been unsuccessful the practitioner will: Offer a repeat ECV in one week discuss a plan for vaginal birth or LUSCS document the plan of care in her clinical record and antenatal card.

Planned LUSCSPlanned LUSCS is associated with lower risks of neonatal morbidity than vaginal birth in women classified as eligible for vaginal breech birth. Vaginal breech birth may be offered provided the woman is appropriately counselled and skilled clinicians are available for the birth.

If a woman is intending to have an elective LUSCS then this should be booked to occur after 39 weeks gestation to help reduce neonatal morbidity.

Preterm breechThe mode of birth for preterm breech presentation is based on individual clinical situations, and the decision is made after discussion with the woman and consultant.

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Section 3: Vaginal Breech Birth

Criteria recommended for a planned vaginal, singleton breech term birth The woman has given consent, after counselling regarding risks and outcomes of a

breech birth compared to an Elective LUSCS availability of an experienced obstetrician trained in vaginal breech birth for the labour

process frank or complete breech neck is not hyperextended (as seen on ultrasound) estimated fetal weight is between 2500g and 3800g immediate theatre facilities should be available for caesarean section if required no previous caesarean section no contraindication to vaginal birth (e.g. placenta praevia, compromised fetus, fetal

anomaly incompatible with vaginal birth).Diagnosis of breech during labour is not a contraindication for vaginal breech birth.

Intrapartum managementUndiagnosed breech presenting in labour The decision regarding mode of birth will depend on various factors including: gestation, stage and progress of labour, maternal and fetal risks and maternal wishes after consultation with the obstetric team. An intrapartum ultrasound should be performed if possible.If the woman elects to proceed with a vaginal breech birth, continuous CTG monitoring is recommended.

Diagnosed breech booked for Elective LUSCS presenting in labour The management plan may be adjusted depending on the gestation, clinical situation and consultation with the woman and her obstetric team. If breech presentation is verified and the woman confirms her request for this mode of birth then it is usual to proceed to a caesarean section, however circumstances may be that a vaginal birth occurs.

Preparation and consent The woman should be informed of the benefits and risks for both current and future

pregnancies, of planned caesarean birth versus planned vaginal breech birth at term The woman should be given sufficient information on the risks and benefits to make an

informed decision. Planned caesarean has a reduced risk of perinatal mortality and early morbidity compared with vaginal birth.

Considerations induction of labour - opinion varies. Induction of labour is not often recommended, it is

preferable that labour be spontaneous. Individual cases must be discussed with a specialist obstetrician

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augmentation of labour – opinion varies. Augmentation of labour should be done with caution and only after assessment by a specialist obstetrician

epidural analgesia is not routinely recommended; women have the same choice of analgesia as those having a cephalic birth

continuous CTG monitoring is required, a scalp electrode can be applied to the breech being cautious to avoid fetal genitalia

fetal blood sampling may be performed if indicated only after discussion with the specialist obstetrician

caesarean section should be considered if there is delay in descent in second stage episiotomy may be considered to facilitate birth when indicated. There is no clear

evidence that selective episiotomy should differ from cephalic birth breech extraction should not be routinely used.

First Stage All maternal and fetal observations, including diagnosis of labour and proactive planning apply as guided by the Clinical Guideline: Labour: 1st, 2nd and third stage care.

Second stage: confirm full dilatation and position of breech Continue monitoring fetal heart rate Inform appropriate staff. (midwifery, obstetric, neonatal) up to 60 minutes passive second stage, as defined by full dilatation without

spontaneous urge to push is appropriate providing that the CTG is reassuring active pushing is not encouraged until presenting part is distending the perineum spontaneous birth of the trunk and limbs by maternal effort should be awaited active second stage, ½ hour for multigravida and 1 hour for primipara consultant obstetrician should be present for the birth a neonatologist should be present at the birth an anaesthetist should be available for the birth

Forceps to aftercoming head if forceps are to be used, an assistant will usually be asked to slightly elevate the body

of the baby to allow sufficient space below the baby to apply the forceps, this is usually achieved by placing a cloth beneath the baby’s body to act as a sling.

the left blade is applied to the right side of the head the right blade is applied An episiotomy may be performed. the head is delivered with traction

Entrapment of the HeadThis is an extreme emergency which may occur where there is poor selection of cases for vaginal breech birth or where a woman presents with a partially born baby. A vaginal examination should be undertaken to determine if a rim of cervix is still present which may prevent the head from descent or birth.

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If cervix is not fully dilated (especially if preterm) Duhrssen incision at 2, 10 and 6

o’clock may be indicated. Consider using tocolytic. if unsuccessful, symphisiotomy may be performed by an experienced clinician, however

is not without potential morbidity a caesarean section may be performed in operating theatre if the baby is still alive.

Neonatal wellbeing following breech birth Cord blood sampling for gas analysis is recommended after any breech birth baseline set of post-birth observations routine observations must be taken and documented as per the NEWS chart observe neonate for signs of jaundice, infection and any concerns about tissue or nerve

related injury ultrasound of the hips to be performed at 6 weeks.

Post birth care as per usual care as per MEWS and Maternity Care Plan

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Implementation

This guideline will be implemented and education will be provided at multidisciplinary education opportunities. It will be available electronically via the ACT Health Intranet under Policy and Clinical Guidance.

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Related Policies, Procedures, Guidelines and Legislation

ACT Health: Consent and Treatment Policy Clinical Guideline Fetal surveillance Clinical Guideline: Labour: first, second and third stage care.

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References

1. Bin, Y., Roberts, c., Ford, J., and Nicholl M (2016) Australian and new Zealand Journal of Obstetrics and Gynaecology; 56:453-459: Outcomes of breech birth by mode of delivery: a population linkage study

2. South Australian Health (2014) Perinatal Practice Guidelines – breech presentation 3. Government of Western Australia, Department of Health, KEMH (2015) 4. Complications of pregnancy abnormalities of lie/presentation-Breech Presentation5. National Health and Medical Research Council (NH&MRC), (1999) Guidelines on the

prophylactic use of Rh D immunoglobulin (anti-D) in obstetrics.6. National Institute for Health and Clinical Excellence (2012) Quality Standard: 7. The Royal Australian and New Zealand College of Obstetricians and Gynaecologist (2013)

College Statement: Management of Breech Presentation at Term

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Definition of Terms

Bicornuate uterus: a type of congenital septate uterine malformation in which the uterus is heart-shaped. A bicornuate uterus have two conjoined cavities)

Duhrssen incision: three surgical incisions of an incompletely dilated cervix, corresponding roughly to 2-, 6-, and 10-o'clock, used as a means of effecting immediate birth of the fetus when there is an entrapped head during a breech birth

Fibroids: Uterine fibroids are benign smooth muscle tumors of the uterus Grand multipara: a woman who has given birth to ≥5 live births and stillbirths ≥20

weeks of gestation Placenta praevia: an obstetric complication in which the placenta is embedded partially

or wholly in the lower uterine segment, partially or wholly covering the cervix) Polyhydraminos: the presence of excess amniotic fluid in the uterus. Polyhydramnios is

diagnosed if the deepest vertical pool is more than 8 cm or amniotic fluid index (AFI) is more than 95th percentile for the corresponding gestational age

Septate uterus: a type of uterine duplication anomaly. It results from partial or complete failure of resorption of the uterovaginal septum after fusion of the paramesonephric ducts. The septum is usually fibrous

Symphysiotomy: a surgical procedure in which the cartilage of the pubic symphysis is divided to widen the pelvis allowing childbirth when there is a mechanical problem.

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Search Terms

Breech, Breech birth, Breech extraction, Footling, Complete breech, Frank breech, ECV, External cephalic version

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Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Policy Team ONLY to complete the following:Date Amended Section Amended Divisional Approval Final Approval 01/11/2017 Full Revision DON WY&C CHHS Policy

Committee

This document supersedes the following: Document Number Document Name2.13 Maternity - External Cephalic Version

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