No. 384-Management of Breech Presentation at Term

SOGC CLINICAL PRACTICE GUIDELINE It is SOGC policy to review the content 5 years after publication, at which time the document may be re-affirmed or revised to reflect emergent new evidence and changes in practice.

No. 384, August 2019 (Replaces No. 226, June 2009) This guideline is the fourth in a 4-part series on labour and delivery.

No. 384-Management of Breech Presentation at Term This guideline has been prepared by the authors, reviewed by the Society of Obstetricians and Gynaecologists of Canada (SOGC)’s Maternal Fetal Medicine; Clinical Practice Obstetrics; and Guideline Management and Oversight Committees and approved by the Board of the SOGC. Andrew Kotaska, MD, Yellowknife, NT Savas Menticoglou, MD, Winnipeg, MB

Clinical Practice Obstetrics Committee: Hussam Azzam, MD, Charlottetown, PE Jon Barrett, MD, Toronto, ON; Melanie Basso, RN, Vancouver, BC; Hayley Bos, MD, Victoria, BC; Kim Campbell, RM, Vancouver, BC; Krista Cassell (Co-Chair), MD, Charlottetown, PE; Sheryl Choo, MD, London, ON; Gina Colbourne, MD, St. John’s NL; Kirsten Duckitt, MD, Campbell River, BC; Ellen Giesbrecht (Co-Chair), MD, Vancouver, BC; Michael Helewa, MD, Winnipeg, MB; Amy Metcalfe, PhD, Calgary, AB; Barbara Parish, MD, Halifax, NS; J. Larry Reynolds, MD, Winnipeg, MB; Yvonne Vasilie, MD, Pointe Claire, QC Disclosure statements have been received from all authors and no conflicts were declared. Key Words: Breech presentation, labour, Caesarean section, term gestation, guideline

J Obstet Gynaecol Can 2019;41(8):1193−1205 https://doi.org/10.1016/j.jogc.2018.12.018 © 2019 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.

CHANGE IN PRACTICE/INFORMATION 1. Evidence that perinatal mortality risk is between 0.8 and 1.7/ 1000 with planned vaginal breech birth and 0 and 0.8/1000 for planned Caesarean section. 2. Cerebral palsy rates and long-term neurological outcomes are similar with planned vaginal breech birth and planned Caesarean section. 3. There is modest evidence that home breech birth is associated with approximately 10-fold higher risk of perinatal mortality than well-supported planned vaginal breech birth in hospital. 4. There is modest evidence that careful induction of labour may involve similar level of risk as planned vaginal breech birth. 5. Changed to GRADE evidence ratings.

KEY MESSAGES 1. In the absence of a contraindication to vaginal delivery, a woman with a breech presentation should be informed of the risks and benefits of a planned vaginal breech birth and planned Caesarean section, and informed consent should be obtained. A woman’s choice of delivery mode should be respected. 2. Long-term neurological infant outcomes including cerebral palsy do not differ by planned mode of delivery, even in the presence of serious short-term neonatal morbidity. 3. The risk of planned vaginal breech birth is acceptable to some women with a term singleton breech fetus. 4. Women with a contraindication to a trial of labour should be advised to have a Caesarean section. Women choosing to labour despite this recommendation have a right to do so and should be provided the best possible in-hospital care. 5. Women will continue to ask for planned vaginal breech birth, and unplanned vaginal breech birth will occur in various settings; therefore, vaginal breech birth should remain a part of core and continuing obstetrical training/education. 6. Appendix added: sample Patient Information Sheet and Consent Form

This document reflects clinical and scientific consensus on the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. Local institutions can dictate amendments to these opinions. They should be well-documented if modified at the local level. None of these contents may be reproduced in any form without prior written permission of the publisher. All people have the right and responsibility to make informed decisions about their care in partnership with their health care providers. In order to facilitate informed choice, patients should be provided with information and support that is evidence-based, culturally appropriate, and tailored to their needs. This guideline was written using language that places women at the centre of care. That said, the SOGC is committed to respecting the rights of all people − including transgender, gender non-binary, and intersex people − for whom the guideline may apply. We encourage health care providers to engage in respectful conversation with patients regarding their gender identity and their preferred gender pronouns to be used as a critical part of providing safe and appropriate care. The values, beliefs, and individual needs of each patient and their family should be sought and the final decision about the care and treatment options chosen by the patient should be respected.

^ T 2019 AUGUST JOGC AOU



1193

SOGC CLINICAL PRACTICE GUIDELINE

Abstract Objectives: To discern the risks and benefits of planned vaginal breech birth versus planned Caesarean section and to recommend selection criteria, intrapartum management parameters, and delivery techniques for vaginal breech birth. Options: Planned vaginal breech birth or planned Caesarean section for women with a singleton breech fetus at term. Outcomes: Perinatal mortality, short- and long-term neonatal/infant morbidity, maternal mortality, and short- and long-term maternal morbidity. Evidence: Medline was searched up to April, 2018 for randomized trials and cohort studies comparing outcomes after planned vaginal breech birth and planned Caesarean section and for cohort studies comparing vaginal breech birth techniques. Additional articles were identified through bibliography tracing. Validation: This guideline was peer reviewed by international clinicians with expertise in vaginal breech birth and compared with the 2017 Royal College of Obstetricians and Gynaecologists Green Top Guideline 20b: Management of Breech Presentation. The content and recommendations were drafted and agreed upon by the principal authors. The Board of the Society of Obstetricians and Gynaecologists of Canada approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology framework. Sponsors: The Society of Obstetricians and Gynaecologists of Canada. SUMMARY STATEMENTS: 1. External cephalic version is recommended to reduce the likelihood of Caesarean section. If unsuccessful, options include planned vaginal breech birth or planned Caesarean section (high). 2. In appropriately selected women in hospitals with obstetricians skilled in vaginal breech birth, perinatal mortality is between 0.8 and 1.7/1000 for planned vaginal breech birth and between 0 and 0.8/1000 for planned Caesarean section (moderate). 3. In appropriately selected women, planned vaginal breech birth is associated with greater short- but not long-term neonatal neurological morbidity. Regardless of planned mode of birth, cerebral palsy occurs in approximately 1.5/1000 breech births, and any abnormal neurological development occurs in approximately 3/100 (moderate). 4. During planned vaginal breech birth, a clinician experienced in vaginal breech birth should supervise the first stage of labour and be present for the active second stage of labour and delivery (IA). Staff required for rapid Caesarean section and skilled neonatal resuscitation should be in-hospital during the active second stage of labour (low). 5. Vaginal breech birth requires a high degree of skill and support. To avoid the increased risk of out-of-hospital vaginal breech birth, women who choose planned vaginal breech birth should be accommodated in-hospital. To facilitate this, referral to more experienced centres, back-up on-call arrangements, and continuing medical training in vaginal breech birth skills should be promoted (very low). RECOMMENDATIONS: Labour Selection Criteria 1. For a woman with breech presentation near term, pre- or earlylabour ultrasound should be performed to assess type of breech presentation, flexion of the fetal head, and fetal growth. If a woman presents in labour and ultrasound is unavailable and has not

1194



^ T 2019 AUGUST JOGC AOU

recently been performed, Caesarean section is recommended (strong; moderate). 2. Contraindications to planned vaginal breech birth include: a. Cord presentation (strong; very low) b. Fetal growth restriction (strong; moderate) c. Fetal macrosomia (estimated fetal weight >4000 g) (weak; low) d. Footling breech presentation (1 or both hip[s] extended) (strong; moderate) e. Clinically inadequate maternal pelvis (weak; very low) f. Fetal anomaly likely to interfere with vaginal delivery (strong; low) g. Hyperextended fetal head (weak; low) 3. For planned vaginal breech birth at term, care should be taken to rule out growth restriction. Estimated fetal weight should be between 2800 and 4000 g (strong; moderate). 4. The maternal pelvis should be clinically assessed to be adequate. Radiologic pelvimetry is not necessary for planned vaginal breech birth. Provided fetal growth is normal, good progress in labour is an indicator of adequate fetal-pelvic proportions (weak; low). Labour Management 5. Upon admission in labour and immediately prior to planned Caesarean section, breech presentation should be (re)confirmed with ultrasound (strong; low). 6. During planned vaginal breech birth, continuous electronic fetal monitoring is recommended in labour. When membranes rupture, immediate vaginal examination is recommended to rule out prolapsed cord (strong; moderate). 7. Oxytocin augmentation is acceptable to correct weak uterine contractions. If progress in labour is poor despite adequate contractions, Caesarean section is recommended (strong; moderate). 8. Although data are limited, induction of labour with breech presentation does not appear to be associated with poorer outcomes than spontaneous labour (weak; low). 9. A passive second stage of up to 90 minutes before active pushing is acceptable to allow the breech to descend well into the pelvis. Once active pushing commences, delivery should be accomplished or imminent within 60 minutes; otherwise, Caesarean section is recommended (strong; moderate). 10. Planned vaginal breech birth should only occur in hospitals with Caesarean section capability. During the first stage of labour, Caesarean section should be available within a time frame similar to cephalic birth. This may vary according to geographical and other factors (strong; low). 11. During the active second stage of labour, anaesthesia, pediatric, and operating room personnel should be in-hospital, available for rapid Caesarean section if necessary (strong; low).

Delivery Technique 12. An obstetrician skilled in vaginal breech birth should be present during the active second stage and breech delivery (strong; low). 13. Effective maternal and uterine power is essential to safe delivery. When vaginal delivery is imminent, oxytocin infusion may be helpful to ensure strong uterine contractions between delivery of the body and the head (weak; low). 14. Fetal traction during vaginal breech birth should be avoided if possible. Any fetal manipulation should only be applied after spontaneous delivery to the level of the umbilicus (strong; moderate). 15. For expulsive delay after the breech has “crowned,” power from above is very likely safer than traction from below. Techniques to

No. 384-Management of Breech Presentation at Term

maximize power from above include effective maternal effort, hands and knees posture, the Bracht manoeuvre, and oxytocin augmentation (strong; low). 16. Nuchal arms may be reduced by the Løvset or Bickenbach manoeuvres (strong; low). 17. The fetal head may deliver spontaneously, with the assistance of suprapubic pressure, by Mauriceau-Smellie-Veit manoeuvre, or with the assistance of Piper forceps. It is recommended that an assistant be available to assist with any necessary procedures (strong; low). 18. The obstetrical team should have rehearsed a plan of action for the rare trapped after-coming head or irreducible nuchal arms: symphysiotomy or Zavanelli manoeuvre can be life-saving (weak; very low).

20.

21.

22.

23.

Setting and Consent 24. 19. In the absence of a contraindication to vaginal delivery, a woman with a breech fetus should be informed of the risks and benefits of planned Caesarean section and planned vaginal breech birth. A

woman’s choice of delivery mode should be respected and consent obtained (strong; very low). The consent discussion and chosen plan should be well documented and communicated to labour-room staff. A sample consent form can be found in the Appendix (strong; very low). Hospitals offering planned vaginal breech birth should have a written protocol for selection and intrapartum management. Experienced obstetricians willing to back up junior colleagues will maximize a hospital’s ability to offer vaginal breech birth (strong; very low). Hospitals without obstetricians skilled in vaginal breech birth should readily refer women desiring vaginal breech birth to a centre that has colleagues with those skills (strong; very low). Caesarean section should be recommended to women with a contraindication to vaginal breech birth. Women who decline this recommendation should be provided the best possible in-hospital care (strong; low). Theoretical and simulated hands-on vaginal breech birth training should be a part of basic obstetrical curricula and post-graduate skills training programs such as ALARM, ALSO, and MOREOB (strong; very low).

^ T 2019 AUGUST JOGC AOU



1195

SOGC CLINICAL PRACTICE GUIDELINE

Table 1. Key to Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Strength of the recommendation

Definition

Strong

Highly confident of the balance between desirable and undesirable consequences (i.e., desirable consequences outweigh the undesirable consequences; or undesirable consequences outweigh the desirable consequences).

Conditional (weak)a

Less confident of the balance between desirable and undesirable consequences.

Quality level of a body of evidence

Definition

Highj++++

We are very confident that the true effect lies close to that of the estimate of the effect.

Moderatej+++0

We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.

Lowj++00

Our confidence in the effect estimate is limited. The true effect may be substantially different from the estimate of the effect.

Very lowj+000

We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect.

a €nemann H, Brozek J, Guyatt G, Conditional (weak) recommendations should not be misinterpreted as weak evidence or uncertainty of the recommendation.From Schu et al.1

Table 2. Judgement and interpretation of strong and conditional recommendations Judgement/interpretation

Strong recommendation “We recommend. . ...”

Conditional recommendation “We suggest. . ..”

Judgement by guideline panel

It is clear to the panel that the net desirable consequences of a strategy outweighed the consequences of the alternative strategy.

It is less clear to the panel whether the net desirable consequences of a strategy outweighed the alternative strategy.

Implications for patients

Most individuals in this situation would want the recommended course of action, and only a small proportion would not.

Most individuals in this situation would want the suggested course of action, but many would not.

Implications for clinicians

Most individuals should receive the intervention. Adherence to this recommendation according to the guideline could be used as a quality criterion or performance indicator.

Clinicians should recognize that different choices will be appropriate for each individual and that clinicians must help each individual to arrive at a management decision consistent with his or her values and preferences.

Implications for policy makers

The recommendation can be adopted as policy in most situations

Policy making will require substantial debate and involvement of various stakeholders

€nemann H, Brozek J, Guyatt G, et al.1 From Schu

his quality of evidence in this guideline was rated using the criteria described in the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology framework (Tables 1 and 2).1

T

BACKGROUND

Compared with a fetus in cephalic presentation, a breech fetus faces increased risk of asphyxia from cord compression during delivery of the shoulders and head. Planned Caesarean section (CS) avoids most of this risk. (Tables 1 and 2 describe grading and interpretation of evidence.1) Prior to 1940, despite a breech perinatal mortality (PNM) rate of 5%, maternal surgical risks prevented routine use of CS to lower fetal risk. Improved safety with antibiotics, blood transfusion, and lower-segment CS prompted increased use of planned CS for breech presentation.2−4 More recently, improvements

1196



^ T 2019 AUGUST JOGC AOU

in vaginal breech delivery technique lowered the risk of a trial of labour (TOL) in experienced hands, despite stabilization of the CS rate.5−10 The debate surrounding mode of delivery for the breech fetus focuses on 1 main question: compared with planned CS, what is the fetal risk of planned vaginal breech birth (VBB), and how can it be balanced against the immediate and subsequent risks of CS to the mother and her future children? TERM BREECH TRIAL

Published in 2000, the Term Breech Trial (TBT) was a large, multicentre randomized controlled trial designed to determine the safest mode of delivery for a term breech fetus.11 Approximately half of the births in the TBT occurred in countries with high PNM and lack external validity in a Canadian setting. In low-PNM countries, the

No. 384-Management of Breech Presentation at Term

trial showed no difference in PNM in singleton breech births between planned CS and planned VBB (0% vs. 0.4%) but a striking difference in “serious” short-term neonatal morbidity: 0.4% versus 5.1%. There was no difference in maternal mortality or serious morbidity in the first 4 postpartum weeks, leading many experts to recommend planned CS for breech presentation at term.12,13 An abrupt shift in clinical practice ensued, and term breech CS rates increased around the world. The pool of expertise in VBB has shrunken, and many obstetricians now graduate with little or no experience with VBB. In many regions of the world, women with a breech fetus no longer have the option of a medically attended vaginal breech birth.14,15 A large randomized clinical trial, the TBT provided a wealth of information about breech birth.16−22 A comprehensive analysis is beyond the scope of this guideline; however, some limitations provide guidance on the safety of planned VBB. Lack of routine ultrasound appears to have allowed growth-restricted fetuses to go undetected: at least 7 of the trial’s 16 perinatal deaths were in growth-restricted fetuses. The trial protocol allowed slow labour progress: 0.5 cm/hour in the first stage and 3.5 hours for the second stage.11 Babies born after an active second stage longer than 60 minutes experience greater morbidity and mortality.23 The TBT provides evidence that fetal growth restriction is a contraindication to planned VBB and that careful attention to labour progress is important to safety. Short-term morbidity in vaginally born breech fetuses is often increased because of cord compression that commonly occurs during the fetal expulsion. In low-PNM countries, the difference in serious short-term morbidity between the arms of the TBT was 5%. However, one half of neonates were followed beyond 2 years of age, at which time there was no difference in the combined outcome of PNM and abnormal long-term neurological outcome: 3.1% in the planned CS group and 2.8% in the planned VBB group.24 Of 18 infants with serious neonatal shortterm morbidity who were followed, 17 were neurologically normal at age 2. The remaining infant died of congenital subglottic stenosis, considered unlikely to be related to mode of delivery. This demonstrates a failure, also found in other studies, of short-term morbidity to predict longterm outcome in breech infants.25−29 At 2 years of age, the only significant difference in infant outcome was fewer “medical problems in the past several months” in the planned VBB group (15% vs. 21%; P = 0.02). Despite the limitations of the TBT, 97% of children were neurologically normal, regardless of planned mode of birth. It is not clear why children randomized to planned CS had an absolute increase in unspecified medical problems of 6%; however,

observational evidence is mounting of a positive effect of labour on activation of the fetal immune system.30 PREMODA STUDY

Apart from the TBT, there have been no significant experimental studies on the safety of planned VBB. The most comprehensive observational series (PREMODA) prospectively collected data on 8105 consecutive women with a breech fetus who were delivered at 174 centres in France and Belgium during a 1-year period.31 PREMODA was not a randomized controlled trial and was not designed to compare planned delivery modes on equivalent groups of women, but rather to evaluate the safety of a widespread system of care that selected low-risk women for VBB and monitored them carefully in labour. France and Belgium have a low PNM rate, and their approach to VBB involves a consistent level of care, which was not altered by investigators. Planned mode of delivery was carefully ascertained. Thirty-one percent of women planned a VBB, and 69% planned a CS. Of 2526 women planning VBB, 1796 (71%) were delivered vaginally, for an overall VBB rate of 22.5%. In contrast to the TBT, ultrasound and continuous electronic fetal monitoring (CEFM) were used universally. Radiologic pelvimetry was employed in 82%. Failure to progress for more than 2 hours in the first stage of labour occurred in only 3.8% of women, and an active second stage longer than 60 minutes occurred in only 0.2%. The PREMODA results showed no difference in PNM between planned VBB and planned CS (0.8/1000 vs. 1.5/ 1000) or in the combined outcome of PNM or serious short-term neonatal morbidity (1.6% vs. 1.45%). An Apgar score less than 4 was more common with planned VBB than with planned CS (0.2 vs. 1.6/1000). Four times larger than the TBT, PREMODA demonstrated that a cautious approach to planned VBB in modern, well-supported obstetrical units can achieve a level of safety that is acceptable to many women.32 PERINATAL MORTALITY

Both PREMODA and the low-PNM arm of the TBT showed no difference in PNM between planned VBB and planned CS. However, both studies were underpowered to detect a small difference. The best estimates of PNM in a well-supported system come from selected Scandinavian studies that reliably ascertained planned mode of birth. Studies that base planned mode of birth on International Statistical Classification of Diseases and Related Health Problems-10th revision (ICD-10) codes cannot reliably distinguish among planned VBB in hospital, planned CS in

^ T 2019 AUGUST JOGC AOU



1197

SOGC CLINICAL PRACTICE GUIDELINE

labour, precipitous VBB, or home VBB. They do not provide reliable estimates of the risk of planned VBB in a well-supported hospital setting.33,34 Since publication of the TBT, Scandinavian and Dutch registries have demonstrated an increase in PNM with planned VBB compared with planned CS. The magnitude is compatible with the results of the TBT and PREMODA. In Norway, of 16 700 singleton breech term fetuses, CS was planned in 53% and vaginal delivery in 47%. Of 7917 planned vaginal births, 5581 (70%) were delivered vaginally, for an overall VBB rate of 33.4%.35 In the planned VBB group, there were 7 intrapartum and 8 neonatal deaths: PNM = 1.9/1,000. In the planned CS group there were 7 neonatal deaths: PNM = 0.8/1,000. In Finland, PNM was 0.8/1000 for planned VBB and 0/1000 for planned CS; in Denmark, 1.7/ 1000 and 0.1/1000; and in the Netherlands, 1.6/1000 and 0/1000.36−38 Collectively, these estimates demonstrate a PNM risk of between 0.8 and 1.7/1000 with planned VBB and between 0 and 0.8/1000 with planned CS. LONG-TERM NEUROLOGICAL OUTCOME

The TBT found no difference in long-term neurological outcome between planned CS and planned VBB. The 2-year follow-up data provide the best prospective evidence of the poor correlation between short-term neonatal morbidity and long-term neurological outcome. However, the trial was too small to detect a small difference in cerebral palsy. Again, national registries that verify planned mode of birth provide the best estimates of long-term neurological outcome. In Norway, Finland, and Australia, the cerebral palsy rate in children was the same whether born by planned VBB or planned CS: 1.4/1000 in Norway, 1.3/1000 in Finland, and 0.9/1000 in Australia.35,36,39 Data on other long-term neurological outcomes are limited. In Finland, the incidence of any adverse neurodevelopment was similar to that found in the TBT: 3.4% and 3.2% for planned VBB and planned CS. NEONATAL TRAUMA

The mechanics of VBB pose a greater risk of perinatal trauma than CS; however, short-term trauma often resolves, and reliable estimates of permanent damage are lacking. Brachial plexus injury, one of the most significant non-neurological traumas, may occur in approximately 1/1000 planned VBBs.38 Permanent genital injuries are rare and associated with prolonged labour.40 RISKS AND BENEFITS OF CAESAREAN SECTION

Planned CS avoids the small risk of perinatal death associated with VBB. The small magnitude of this benefit means

1198



^ T 2019 AUGUST JOGC AOU

that several hundred CSs are necessary to prevent 1 perinatal death.35,37,41 Although the risk is low, planned CS increases the risk of maternal death, and maternal deaths have resulted from complications of CS performed solely for breech presentation.42−44 Planned CS also increases maternal morbidity and abnormal placentation in future pregnancies.45−47 These risks must be balanced against the reduction in PNM with planned CS. Clinical factors and women’s values influence decision making. A young woman planning a large family may be motivated to accept the increased perinatal risk of planned VBB in order to avoid the immediate and future risks of CS, whereas a nulliparous woman planning to have 1 child may prefer to accept the increase in maternal risk of CS in order to avoid the risk of PNM associated with VBB. A more comprehensive discussion of the benefits and risks of CS on maternal request is available in a 2018 guideline.48

Summary Statements

1. External cephalic version is recommended to reduce the likelihood of Caesarean section. If unsuccessful, options include planned vaginal breech birth or planned Caesarean section (high). 2. In appropriately selected women in hospitals with obstetricians skilled in vaginal breech birth, perinatal mortality is between 0.8 and 1.7/1000 for planned vaginal breech birth and between 0 and 0.8/1000 for planned Caesarean section (moderate). 3. In appropriately selected women, planned vaginal breech birth is associated with greater short- but not long-term neonatal neurological morbidity. Regardless of planned mode of birth, cerebral palsy occurs in approximately 1.5/1000 breech births, and any abnormal neurological development occurs in approximately 3/100 (moderate). 4. During planned vaginal breech birth, a clinician experienced in vaginal breech birth should supervise the first stage of labour and be present for the active second stage of labour and delivery (IA). Staff required for rapid Caesarean section and skilled neonatal resuscitation should be in-hospital during the active second stage of labour (low). 5. Vaginal breech birth requires a high degree of skill and support. To avoid the increased risk of out-ofhospital vaginal breech birth, women who choose planned VBB should be accommodated in-hospital. To facilitate this, referral to more experienced centres, back-up on-call arrangements, and continuing medical training in vaginal breech birth skills should be promoted (very low).

No. 384-Management of Breech Presentation at Term

Approach to Vaginal Breech Birth

Vaginal breech birth is a complex phenomenon. Selection criteria, intrapartum management parameters, and delivery techniques are difficult to isolate and study independently. There is little rigorous evidence to support or refute them individually. The approach outlined here is based on the physiology of breech birth, the protocols and findings of the TBT and cohort studies with demonstrated safety, and the opinions of experts in breech birth. An experienced obstetrical team and careful clinical judgement are important to safety. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology framework (Tables 1 and 2).

Recommendations

When VBB is planned, an obstetrician should be consulted. Ante- or intrapartum ultrasound assessment is recommended to determine type of breech presentation, assess fetal growth, and detect the rare extended fetal neck at increased risk of entrapment. Estimated fetal weight should be between 2800 and 4000 g. The lower margin is intended to exclude growth-restricted fetuses and the upper margin to avoid fetal-pelvic disproportion. Routine assessment of fetal head attitude prior to vaginal breech birth has been recommended but has not been well studied.49 If a woman presents in labour with an undiagnosed breech fetus, an obstetrician should be consulted. Ultrasound assessment should be performed if possible. If ultrasound is unavailable, a TOL is reasonable if normal growth and frank or complete breech presentation can be confirmed clinically. Otherwise, CS is recommended. Women presenting in advanced labour do not appear to have increased perinatal risk.50,51

Labour selection criteria

1. For a woman with breech presentation near term, pre- or early-labour ultrasound should be performed to assess type of breech presentation, flexion of the fetal head, and fetal growth. If a woman presents in labour and ultrasound is unavailable and has not recently been performed, Caesarean section is recommended (strong; moderate). 2. Contraindications to planned vaginal breech birth include: a. Cord presentation (strong; very low) b. Fetal growth restriction (strong; moderate) c. Fetal macrosomia (estimated fetal weight >4000 g) (weak; low) d. Footling breech presentation (1 or both hip[s] extended) (strong; moderate) e. Clinically inadequate maternal pelvis (weak; very low) f. Fetal anomaly likely to interfere with vaginal delivery (strong; low) g. Hyperextended fetal head (weak; low) 3. For planned vaginal breech birth at term, care should be taken to rule out growth restriction. Estimated fetal weight should be between 2800 and 4000 g (strong; moderate). 4. The maternal pelvis should be clinically assessed to be adequate. Radiologic pelvimetry is not necessary for planned vaginal breech birth. Provided fetal growth is normal, good progress in labour is an indicator of adequate fetal-pelvic proportions (weak; low).

Clinical examination should evaluate the adequacy of the pelvis. Although commonly used in the PREMODA study, radiologic pelvimetry remains controversial, and many centres have demonstrated safety without it. Satisfactory labour progress is a good indicator of adequate fetal-pelvic proportions. For a normally grown fetus in frank or complete breech presentation, the circumference of the abdomen and legs is greater than the head circumference: progressive labour and descent of the breech through the pelvis predicts an adequate pelvis for passage of the fetal head. Nonetheless, magnetic resonance imaging pelvimetry is used in some settings to facilitate decision making, particularly in nulliparous women.52 A breech fetus has a higher chance of cord presentation. External cephalic version may resolve this; however, persistent cord presentation is an indication for CS to avoid cord prolapse.53 A breech fetus also has a higher risk of cord prolapse during labour than a cephalic fetus. This risk varies from less than 1% for frank breech to perhaps 10% for footling breech presentation.54 For a woman to be eligible for planned VBB, her fetus must not be in footling breech presentation. The feet of a complete breech will often be palpable just below the buttocks; however, if 1 or both hips are extended, the diagnosis is footling breech and CS is recommended unless delivery is imminent. A fetus with feet presenting but flexed hips and flexed knees is a complete breech. An incomplete breech has flexed hips, 1 flexed knee, and 1 extended knee. Both are eligible for VBB.55

^ T 2019 AUGUST JOGC AOU



1199

SOGC CLINICAL PRACTICE GUIDELINE

Recommendations

Labour management

5. Upon admission in labour and immediately prior to planned Caesarean section, breech presentation should be (re)confirmed with ultrasound (strong; low). 6. During planned vaginal breech birth, continuous electronic fetal monitoring is recommended in labour. When membranes rupture, immediate vaginal examination is recommended to rule out prolapsed cord (strong; moderate). 7. Oxytocin augmentation is acceptable to correct weak uterine contractions. If progress in labour is poor despite adequate contractions, Caesarean section is recommended (strong; moderate). 8. Although data are limited, induction of labour with breech presentation does not appear to be associated with poorer outcomes than spontaneous labour (weak; low). 9. A passive second stage of up to 90 minutes before active pushing is acceptable to allow the breech to descend well into the pelvis. Once active pushing commences, delivery should be accomplished or imminent within 60 minutes; otherwise, Caesarean section is recommended (strong; moderate). 10. Planned vaginal breech birth should only occur in hospitals with Caesarean section capability. During the first stage of labour, Caesarean section should be available within a time frame similar to cephalic birth. This may vary according to geographical and other factors (strong; low). 11. During the active second stage of labour, anaesthesia, pediatric, and operating room personnel should be in-hospital, available for rapid Caesarean section if necessary (strong; low).

Due to the increased risk of cord prolapse, CEFM is recommended during labour. Additionally, prior to deep engagement of the breech, membranes should be ruptured artificially only with a clear indication and careful monitoring. When membranes rupture, immediate vaginal examination is indicated to rule out prolapsed cord. Detection of cord prolapse in the hospital with timely access to CS has a high likelihood of good fetal outcome.56 If membranes rupture at home, a woman with a known breech presentation should be advised to present immediately to the hospital for assessment. During the second stage of labour, descent of the breech and entry of the umbilicus into the pelvis are commonly

1200



^ T 2019 AUGUST JOGC AOU

associated with cord compression and variable decelerations. CEFM is universally required in the second stage. A fetal electrocardiographic electrode may be inserted into the buttock for CEFM. Progress in labour is an important factor in breech labour management. In the absence of data to the contrary, the TBT protocol allowed a minimum of 0.5 cm/hour progress in the first stage and up to 3.5 hours for the second stage. The trial did not analyze results according to labour progress in the first stage but found increased perinatal risk in women with an active second stage >60 minutes.23 Another series corroborated this finding.57 In the PREMODA study, only 0.2% of labouring women had an active second stage >60 minutes, and there was failure to progress for 2 hours in the first stage in only 3.8%. Dilation from 5 to 10 cm took more than 7 hours in only 1.4%. It would seem prudent to expect cervical dilation from 5 to 10 cm to take a maximum of 7 hours. The use of oxytocin during breech labour is controversial. Oxytocin augmentation was used in 74% of labours in PREMODA, and 9% of women were induced. Induction of labour has not been well studied; however, several case series suggest safety for the well-selected woman and breech fetus.31,58-61 Infrequent or weak uterine contractions may be appropriately treated with oxytocin augmentation. When contractions are adequate, oxytocin augmentation is not recommended. Failure to progress for 2 hours despite adequate uterine contractions is an indication for CS.31 Uterine inertia is more common when epidural analgesia is used. It can be confirmed using an intrauterine pressure catheter (IUPC), if necessary, and corrected with oxytocin.62 In cephalic labour, epidural analgesia increases the need for oxytocin augmentation, impairs maternal pushing efforts, prolongs the second stage, and increases the need for assisted vaginal birth.63 Accordingly, potential implications for the use of epidural analgesia in breech labour include increased likelihood of CS for prolonged second stage and increased need for manoeuvres for expulsive delay during delivery. Assessing full dilatation is more difficult with breech than cephalic presentation because the cervix does not disappear behind the cephalic crown. Instead, the cervix remains palpable as the fetal trunk descends through it. Accordingly, the diagnosis is more subjective and related to descent of the breech than disappearance of the cervix. An experienced clinician should make the assessment of full dilatation, as timing is critical to evaluating labour progress in the second stage. Cord compression during descent is common and of unpredictable severity: active pushing

No. 384-Management of Breech Presentation at Term

should take place near an operating room with equipment and personnel available to perform rapid CS if necessary. The second stage of labour can be divided into a passive phase, prior to active pushing, and an active pushing phase. The passive phase lasted more than 60 minutes in 18% of labouring women in PREMODA. Active pushing lasted for more than 60 minutes in only 0.2%. A prudent limit for the overall duration of the second stage would be 2.5 hours. If delivery is not imminent after 60 minutes of active pushing, CS is recommended, even if the buttocks have reached the pelvic floor. Breech infants are often depressed at birth due to respiratory acidosis secondary to cord compression during expulsion. A health care professional skilled in neonatal resuscitation should be in attendance at the time of delivery.

Recommendations

Delivery technique

12. An obstetrician skilled in vaginal breech birth should be present during the active second stage and breech delivery (strong; low). 13. Effective maternal and uterine power is essential to safe delivery. When vaginal delivery is imminent, oxytocin infusion may be helpful to ensure strong uterine contractions between delivery of the body and the head (weak; low). 14. Fetal traction during vaginal breech birth should be avoided if possible. Any fetal manipulation should only be applied after spontaneous delivery to the level of the umbilicus (strong; moderate). 15. For expulsive delay after the breech has “crowned,” power from above is very likely safer than traction from below. Techniques to maximize power from above include effective maternal effort, hands and knees posture, the Bracht manoeuvre, and oxytocin augmentation (strong; low). 16. Nuchal arms may be reduced by the Løvset or Bickenbach manoeuvres (strong; low). 17. The fetal head may deliver spontaneously, with the assistance of suprapubic pressure, by MauriceauSmellie-Veit manoeuvre, or with the assistance of Piper forceps. It is recommended that an assistant be available to assist with any necessary procedures (strong; low). 18. The obstetrical team should have rehearsed a plan of action for the rare trapped after-coming head or irreducible nuchal arms: symphysiotomy or Zavanelli manoeuvre can be life-saving (weak; very low).

As a breech fetus transits the pelvis, normal fetal tone and uterine compression keep its head and arms flexed. Fetal manipulation prior to entrance of the elbows and chin into the pelvic inlet can induce extension of fetal limbs and head (Moro reflex), resulting in trapped after-coming fetal parts. Spontaneous birth helps minimize this risk, and many breech infants deliver spontaneously in a timely fashion with maternal expulsive efforts alone. When expulsive delay occurs with the fetus partially delivered, preferential use of power from above rather than fetal traction from below minimizes tactile stimulation of the fetus and reduces the likelihood of head or arm extension. Whether used routinely or only if spontaneous birth is not forthcoming, fetal manoeuvres should be employed only after spontaneous delivery to the umbilicus, and traction should be minimized. In 1936, Bracht published a study that had a great impact on PNM.64 The prevalent method of delivery in Europe and North America at the time was partial or complete breech extraction under maternal sedation, and breech PNM was approximately 5%. Bracht radically altered his practice: avoiding maternal sedation, encouraging maternal effort in the second stage, avoiding traction from below, and using fundal pressure to prevent expulsive delay. PNM dropped from a baseline of 3.2% to 0%. This is compelling evidence that power from above is safer than traction from below.64−67 After the breech crowns, fetal expulsion is invariably accompanied by cord compression and fetal bradycardia. A normally grown fetus enters this phase well-oxygenated without acidemia. It can tolerate several minutes of delay while developing primarily a respiratory acidosis, easily reversed once ventilation is established. However, a growth-restricted fetus has a high likelihood of metabolic acidemia in labour due to placental insufficiency. This reduces fetal tolerance to cord compression during expulsion: an early metabolic acidosis can rapidly worsen and cause fetal damage. Accordingly, fetal growth restriction is a contraindication to planned VBB. Significant cord compression beyond several minutes will eventually lead to severe metabolic acidosis even in a normal fetus, and prevention and treatment of expulsive delay are critical components of delivery technique. Mechanisms that maximize power from above are associated with lower risk of trapped after-coming fetal parts than manoeuvres that involve fetal traction.65,68,69 Maternal cooperation is essential. To maximize expulsive efforts, heavy sedation or dense epidural analgesia should be avoided.62,64 When vaginal delivery is thought to be imminent, oxytocin infusion may be helpful to ensure adequate uterine activity between

^ T 2019 AUGUST JOGC AOU



1201

SOGC CLINICAL PRACTICE GUIDELINE

delivery of the body and the head.69 Although none have been well studied independently, other methods of increasing power from above once the buttocks have crowned include maximizing maternal pushing efforts, upright or all-fours posture, and fundal pressure.67−72 The application of fundal pressure after crowning maintains flexion of the fetal head and facilitates its engagement.64−66 After spontaneous delivery to the fetal umbilicus, expulsive delay despite power from above may require manoeuvres involving fetal manipulation. Løvset’s and Bickenbach’s are the best described manoeuvres for reducing nuchal arms.54,70−73 Only the bony fetal pelvis and legs should be grasped to avoid damage to intra-abdominal fetal organs. Traction should be minimized to avoid trapped after-coming fetal parts. The fetal head may deliver spontaneously, by Mauriceau-Smellie-Veit manoeuvre, with the assistance of suprapubic pressure, or with the assistance of Piper’s forceps. If the fetal head is trapped at the pelvic inlet in a direct anterior/posterior position, manual intravaginal rotation to a transverse position can facilitate flexion and entry into the pelvis. If the occiput remains posterior, the Prague manoeuvre may be helpful.54 If unsuccessful, symphysiotomy performed under local anaesthesia or Zavanelli manoeuvre can be life-saving.74−76

Recommendations

Setting and consent

19. In the absence of a contraindication to vaginal delivery, a woman with a breech fetus should be informed of the risks and benefits of planned Caesarean section and planned vaginal breech birth. A woman’s choice of delivery mode should be respected and consent obtained (strong; very low). 20. The consent discussion and chosen plan should be well documented and communicated to labourroom staff. A sample consent form can be found in the Appendix (strong; very low). 21. Hospitals offering planned vaginal breech birth should have a written protocol for selection and intrapartum management. Experienced obstetricians willing to back up junior colleagues will maximize a hospital’s ability to offer vaginal breech birth (strong; very low). 22. Hospitals without obstetricians skilled in vaginal breech birth should readily refer women desiring

1202



^ T 2019 AUGUST JOGC AOU

vaginal breech birth to a centre that has colleagues with those skills (strong; very low). 23. CS should be recommended to women with a contraindication to vaginal breech birth. Women who decline this recommendation should be provided the best possible in-hospital care (strong; low). 24. Theoretical and simulated hands-on vaginal breech birth training should be a part of basic obstetrical curricula and post-graduate skills training programs such as ALARM, ALSO, and MOREOB (strong; very low).

An obstetrician should assess women presenting with a singleton breech fetus near term. Unless there is a contraindication to labour, external cephalic version should generally be recommended. If unsuccessful or declined, suitability for planned VBB should be assessed. If conditions are not suitable for vaginal birth, planned CS should be recommended. Women who are suitable candidates for VBB should be informed that compared with planned CS, planned VBB is associated with a small increase in PNM, a modest increase in short-term morbidity, and no difference in long-term neurological outcome, including cerebral palsy. They should be informed of the increased immediate and future maternal and fetal risks of CS compared with vaginal delivery and that the likelihood of CS in labour with a breech fetus is higher (approximately 40% to 50%) than with a fetus in a cephalic presentation. For those who choose planned VBB, every effort should be made to enable this choice in a hospital setting. The 2001 American College of Obstetricians and Gynecologists and Royal College of Obstetricians and Gynaecologists breech guidelines left little room for parturient autonomy.12,13 After their publication, it became routine practice in many jurisdictions for obstetricians to refuse women a breech TOL in hospital and the volume of breech home births increased. Planned home VBB attended by midwives is associated with 10fold higher PNM (16.8/1000) than planned VBB in hospital.77 Unattended homebirth is likely less safe.78,79 Newer Royal College of Obstetricians and Gynaecologists and American College of Obstetricians and Gynecologists guidelines are supportive of parturient choice and selected VBB.80,81 Women who are poor candidates for planned VBB should be advised to deliver by CS. If a woman chooses planned VBB despite this

No. 384-Management of Breech Presentation at Term

recommendation, she should be cared for in a hospital. A patient has a right to decline a recommended medical procedure or treatment and still receive medical care. VBB in a modern hospital obstetrical setting is safer than breech homebirth, and a woman must not be abandoned if she does not take medical advice. By maintaining a therapeutic alliance with her, better decisions may later be reached if labour does not progress well or the fetal heart rate becomes abnormal.82 Hospitals offering VBB should have a written protocol for eligibility and intrapartum management. The consent discussion regarding risks and benefits of mode of delivery and plans for delivery should be well documented in the chart and available in the birthing unit. A sample information and consent form can be found in the Appendix. Upon admission in labour, breech presentation should be re-confirmed with ultrasound and an experienced obstetrician responsible for labour and birth should be notified. Many newly qualified obstetricians do not have the experience necessary to supervise a breech TOL. Mentoring by more senior colleagues will be necessary if they are to attain these skills. As women will continue to request planned VBB and precipitous breech births occur in all settings, theoretical and hands-on breech birth training using models should remain part of basic obstetrical and midwifery training and of training programs such as ALARM, ALSO, and MOREOB. Acknowledgements

The authors would like to thank the following people for peer review of this guideline: Suzanne Albrechtsen, Norway; Sophie Alexander, Belgium; Andrew Bisits, Australia; Emmanuel Bujold, Canada; Francois Goffinet, France; Michael Krause, Germany; Georg Macharey, Finland; and Jos van Roosmalen, the Netherlands.

3. Trolle D. Considerations on breech presentation as an indication for caesarean section. Dan Med Bull 1960;7:117–20. 4. Kubli F, Ruttgers H, Meyer-Menk M. [Danger of fetal acidosis in vaginal delivery from breech presentation (author’s transl)]. Z Geburtshilfe Perinatol 1975;179:1–16. [in German]. 5. Albrechtsen S, Rasmussen S, Irgens LM. Secular trends in peri- and neonatal mortality in breech presentation; Norway 1967-1994. Acta Obstet Gynecol Scand 2000;79:508–12. 6. Roman J, Bakos O, Cnattingius S. Pregnancy outcomes by mode of delivery among term breech births: Swedish experience 1987-1993. Obstet Gynecol 1998;92:945–50. 7. Krebs L, Langhoff-Roos J. Breech delivery at term in Denmark, 1982-92: a population-based case-control study. Paediatr Perinat Epidemiol 1999;13:431–41. 8. Rietberg CC, Elferink-Stinkens PM, Brand R, et al. Term breech presentation in the Netherlands from 1995 to 1999: mortality and morbidity in relation to the mode of delivery of 33824 infants. BJOG 2003;110:604–9. 9. Vendittelli F, Riviere O, Pons JC, et al. [Breech presentation at term: evolution of French practices and an analysis of neonatal results in regards to obstetrical management of breech presentation, from AUDIPOG Database]. J Gynecol Obstet Biol Reprod (Paris) 2002;31:261–72. [in French]. 10. Ulander VM, Gissler M, Nuutila M, et al. Are health expectations of term breech infants unrealistically high? Acta Obstet Gynecol Scand 2004;83:180–6. 11. Hannah ME, Hannah WJ, Hewson SA, et al. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group. Lancet 2000;356:1375–83. 12. Royal College of Obstetricians and Gynaecologists (RCOG). RCOG green-top guidelines: the management of breech presentation. London: RCOG; 2001. 13. American College of Obstetricians and Gynecologists. ACOG committee opinion no. 265. Mode of term singleton breech delivery. Obstet Gynecol 2001;98:1189–90. 14. Phipps H, Roberts CL, Nassar N, et al. The management of breech pregnancies in Australia and New Zealand. Aust N Z J Obstet Gynaecol 2003;43:294–7. ; discussion 61. 15. Hogle KL, Kilburn L, Hewson S, et al. Impact of the international term breech trial on clinical practice and concerns: a survey of centre collaborators. J Obstet Gynaecol Can 2003;25:14–6.

SUPPLEMENTARY MATERIAL

16. Goffinet F, Blondel B, Breart G. [Breech presentation: questions raised by the controlled trial by Hannah et al. on systematic use of Cesarean section for breach presentations]. J Gynecol Obstet Biol Reprod (Paris) 2001;30:187–90. [in French].

Supplementary material related to this article can be found online at https://doi.org/10.1016/j.jogc.2018.12.018.

17. Hauth JC, Cunningham FG. Vaginal breech delivery is still justified. Obstet Gynecol 2002;99:1115–6. 18. Van Roosmalen J, Rosendaal F. There is still room for disagreement about vaginal delivery of breech infants at term. BJOG 2002;109:967–9.

REFERENCES 1. Sch€unemann H, Bro_zek J, Guyatt G, eds. The GRADE handbook, Grade Working Group; 2013. Available at: http://gdt.guidelinedevelopment.org/ app/handbook/handbook.html. Accessed February 4, 2019. 2. Wright RC. Reduction of perinatal mortality and morbidity in breech delivery through routine use of cesarean section. Obstet Gynecol 1959;14:758–63.

19. Kotaska A. Inappropriate use of randomised trials to evaluate complex phenomena: case study of vaginal breech delivery. BMJ 2004;329:1039– 42. 20. Keirse MJ. Evidence-based childbirth only for breech babies? Birth 2002;29:55–9. 21. Menticoglou SM. Why vaginal breech delivery should still be offered. J Obstet Gynaecol Can 2006;28:380–5; discussion 6−9.

^ T 2019 AUGUST JOGC AOU



1203

SOGC CLINICAL PRACTICE GUIDELINE

22. Glezerman M. Five years to the term breech trial: the rise and fall of a randomized controlled trial. Am J Obstet Gynecol 2006;194:20–5. 23. Su M, McLeod L, Ross S, et al. Factors associated with adverse perinatal outcome in the Term Breech Trial. Am J Obstet Gynecol 2003;189:740–5. 24. Whyte H, Hannah ME, Saigal S, et al. Outcomes of children at 2 years after planned Cesarean birth versus planned vaginal birth for breech presentation at term: the International Randomized Term Breech Trial. Am J Obstet Gynecol 2004;191:864–71.

41. Swedish Collaborative Breech Study Group. Term breech delivery in Sweden: mortality relative to fetal presentation and planned mode of delivery. Acta Obstet Gynecol Scand 2005;84:593–601. 42. Schutte JM, Steegers EA, Santema JG, et al. Maternal deaths after elective Cesarean section for breech presentation in the Netherlands. Acta Obstet Gynecol Scand 2007;86:240–3. 43. Verhoeven AT, de Leeuw JP, Bruinse HW. [Breech presentation at term: elective caesarean section is the wrong choice as a standard treatment because of too high risks for the mother and her future children]. Ned Tijdschr Geneeskd 2005;149:2207–10. [in Dutch].

25. Danelian PJ Wang J, Hall MH. Long term outcome by method of delivery of fetuses in breech presentation at term: population based follow-up. BMJ 1996;312:1453−3.

44. Lawson GW. Report of a breech Cesarean section maternal death. Birth 2011;38:159–61.

26. Pradhan P, Mohajer M, Deshpande S. Outcome of term breech births: 10-year experience at a district general hospital. BJOG 2005;112: 218–22.

45. Getahun D, Oyelese Y, Salihu HM, et al. Previous Cesarean delivery and risks of placenta previa and placental abruption. Obstet Gynecol 2006;107:771–8.

27. Giuliani A, Scholl WM, Basver A, et al. Mode of delivery and outcome of 699 term singleton breech deliveries at a single center. Am J Obstet Gynecol 2002;187:1694–8. 28. Hellsten C, Lindqvist PG, Olofsson P. Vaginal breech delivery: is it still an option? Eur J Obstet Gynecol Reprod Biol 2003;111:122–8. 29. Munstedt K, von Georgi R, Reucher S. Term breech and long-term morbidity − Cesarean section versus vaginal breech delivery. Eur J Obstet Gynecol Reprod Biol 2001;96:163–7. 30. Blustein J, Liu J. Time to consider the risks of caesarean delivery for long term child health. BMJ 2015;350:h2410. 31. Goffinet F, Carayol M, Foidart JM, et al. Is planned vaginal delivery for breech presentation at term still an option? Results of an observational prospective survey in France and Belgium. Am J Obstet Gynecol 2006;194:1002–11. 32. Lansac J, Crenn-Hebert C, Riviere O, et al. How singleton breech babies at term are born in France: a survey of data from the AUDIPOG network. Eur J Obstet Gynecol Reprod Biol 2015;188:79–82. 33. Lyons J, Pressey T, Bartholomew S, et al. Delivery of breech presentation at term gestation in Canada, 2003-2011. Obstet Gynecol 2015;125:1153–61. 34. Ekeus C, Norman M, Aberg K, et al. Vaginal breech delivery at term and neonatal morbidity and mortality - a population-based cohort study in Sweden. J Matern Fetal Neonatal Med 2017: 1–6. 35. Bjellmo S, Andersen GL, Martinussen MP, et al. Is vaginal breech delivery associated with higher risk for perinatal death and cerebral palsy compared with vaginal cephalic birth? Registry-based cohort study in Norway. BMJ Open 2017;7:e014979.

46. Smith GC, Pell JP, Dobbie R. Caesarean section and risk of unexplained stillbirth in subsequent pregnancy. Lancet 2003;362:1779–84. 47. Huang X, Lei J, Tan H, et al. Cesarean delivery for first pregnancy and neonatal morbidity and mortality in second pregnancy. Eur J Obstet Gynecol Reprod Biol 2011;158:204–8. 48. Alsayegh E, Bos H, Campbell K, et al. No. 362-Caesarean delivery on maternal request. J Obst Gynaecol Can 2018;40:967–71. 49. Westgren M, Grundsell H, Ingemarsson I, et al. Hyperextension of the fetal head in breech presentation. A study with long-term follow-up. Br J Obstet Gynaecol 1981;88:101–4. 50. Nwosu EC, Walkinshaw S, Chia P, et al. Undiagnosed breech. Br J Obstet Gynaecol 1993;100:531–5. 51. Faivre M, Mottet N, Bourtembourg A, et al. [Obstetrical prognosis of breech presentation admitted in advanced first stage of labour]. J Gynecol Obstet Biol Reprod (Paris) 2016;45:585–91. [in French]. 52. Hoffmann J, Thomassen K, Stumpp P, et al. New MRI criteria for successful vaginal breech delivery in primiparae. PLoS One 2016;11: e0161028. 53. Kinugasa M, Sato T, Tamura M, et al. Antepartum detection of cord presentation by transvaginal ultrasonography for term breech presentation: potential prediction and prevention of cord prolapse. J Obstet Gynaecol Res 2007;33:612–8. 54. Cunningham FG, Leveno KJ, Bloom SL, eds. Williams Obstetrics, 22nd ed, New York: McGraw-Hill; 2005. 55. Feige A, Krause M. Beckenendlage [Breech]. Munich, Germany: Urban & Schwarzenberg; 1998.

36. Macharey G, Vaisanen-Tommiska M, Gissler M, et al. Neurodevelopmental outcome at the age of 4 years according to the planned mode of delivery in term breech presentation: a nationwide, population-based record linkage study. J Perinat Med 2018;46:323–31.

56. Murphy DJ, MacKenzie IZ. The mortality and morbidity associated with umbilical cord prolapse. Br J Obstet Gynaecol 1995;102:826–30.

37. Hartnack Tharin JE, Rasmussen S, Krebs L. Consequences of the term breech trial in Denmark. Acta Obstet Gynecol Scand 2011;90:767–71.

57. Macharey G, Ulander VM, Heinonen S, et al. Risk factors and outcomes in “well-selected” vaginal breech deliveries: a retrospective observational study. J Perinat Med 2017;45:291–7.

38. Vlemmix F, Bergenhenegouwen L, Schaaf JM, et al. Term breech deliveries in the Netherlands: did the increased cesarean rate affect neonatal outcome? A population-based cohort study. Acta Obstet Gynecol Scand 2014;93:888–96.

58. Macharey G, Ulander VM, Heinonen S, et al. Induction of labor in breech presentations at term: a retrospective observational study. Arch Gynecol Obstet 2016;293:549–55.

39. Bin YS, Ford JB, Nicholl MC, et al. Long-term childhood outcomes of breech presentation by intended mode of delivery: a population record linkage study. Acta Obstet Gynecol Scand 2017;96:342–51. 40. Saroha M, Batra P, Dewan P, et al. Genital injuries in neonates following breech presentation. J Neonatal Perinatal Med 2015;8:421–5.

1204



^ T 2019 AUGUST JOGC AOU

59. Bleu G, Demetz J, Michel S, et al. Effectiveness and safety of induction of labor for term breech presentations. J Gynecol Obstet Hum Reprod 2017;46:29–34. 60. Burgos J, Arana I, Garitano I, et al. Induction of labor in breech presentation at term: a retrospective cohort study. J Perinat Med 2017;45:299–303.

No. 384-Management of Breech Presentation at Term

61. Marzouk P, Arnaud E, Oury JF, et al. [Induction of labour and breech presentation: experience of a French maternity ward]. J Gynecol Obstet Biol Reprod (Paris) 2011;40:668–74. [in French]. 62. Chadha YC, Mahmood TA, Dick MJ, et al. Breech delivery and epidural analgesia. Br J Obstet Gynaecol 1992;99:96–100. 63. Anim-Somuah M, Smyth RM, Jones L. Epidural versus non-epidural or no analgesia in labour. Cochrane Database Syst Rev 2011(12): CD000331.

72. Hollstein K. [Experience with Lovset's method of shoulder delivery in breech presentation]. Geburtshilfe Frauenheilkd 1954;14:1018–24. [in German]. 73. Løvset J. Shoulder delivery by breech presentation. J Obstet Gynaecol Br Emp 1937;44:696–704. 74. Menticoglou SM. Symphysiotomy for the trapped aftercoming parts of the breech: a review of the literature and a plea for its use. Aust N Z J Obstet Gynaecol 1990;30:1–9.

64. Bracht E. Zur manualhilfe bei beckendlage. Z Geburtshilfe Gynakol 1936;112:271. [in German].

75. Pust RE, Hirschler RA, Lennox CE. Emergency symphysiotomy for the trapped head in breech delivery: indications, limitations and method. Trop Doct 1992;22:71–5.

65. Plentl AA, Stone RE. The Bracht maneuver. Obstet Gynecol Surv 1953;8:313–25.

76. Sandberg EC. The Zavanelli maneuver: 12 years of recorded experience. Obstet Gynecol 1999;93:312–7.

66. Jotkowitz MW, Picton FC. An appraisal of an anatomically and physiologically correct method of breech delivery: the Bracht manoeuvre. Aust N Z J Obstet Gynaecol 1970;10:151–9.

77. Bovbjerg ML, Cheyney M, Brown J, et al. Perspectives on risk: Assessment of risk profiles and outcomes among women planning community birth in the United States. Birth 2017;44:209–21.

67. Bracht E. Zur Behandlung der Steisslage. Zentralbl Gynakol 1938;62:1735. [in German].

78. Coroner’s judgement of inquiry, case no. 2005:225:0211. Burnaby, BC: 2005.

68. Thiessen P. [Spontaneous labor, education and manual aid in breech presentation]. Zentralbl Gynakol 1952;74:1969–76. [in German]. 69. Thiessen P. [The author’s own obstetrical method in breech presentation and its comparison with accepted textbook methods. (New diagnostic, etiologic and therapeutic principles)]. Geburtshilfe Frauenheilkd 1964;24:661–82. [in German]. 70. Krause M, Feige A. [Techniques for vaginal breech delivery]. Geburtsh Frauenheilk 2008;68:25–48. [in German]. 71. Evans J. Understanding physiological breech birth. Essentially MIDIRS 2012;3:17–21.

79. Kotaska A. Commentary: routine Cesarean section for breech: the unmeasured cost. Birth 2011;38:162–4. 80. ACOG Committee on Obstetric Practice. ACOG committee opinion no. 340. Mode of term singleton breech delivery. Obstet Gynecol 2006;108:235–7. 81. Royal College of Obstetricians and Gynaecologists (RCOG). RCOG green top guidelines: the management of breech presentation. London: RCOG; 2006. 82. Kotaska A. Informed consent and refusal in obstetrics: a practical ethical guide. Birth 2017;44:195–9.

^ T 2019 AUGUST JOGC AOU



1205