Guideline for the Management of Breech Presentation

INITIATED BY:

Obstetrics, Gynaecology & Sexual Health

APPROVED BY:

Integrated Business, Obstetrics, Gynaecology, Sexual Health & Quality And Safety Group (pending)

DATE APPROVED: VERSION:

Three

OPERATIONAL DATE:

18th April 2016

DATE FOR REVIEW:

3 years from date of approval or if any legislative or operational changes require

DISTRIBUTION:

Medical & Maternity Staff Cwm Taf University Health Board

FREEDOM OF INFORMATION STATUS:

i Author Dr Mike Hardway

Open

Guidelines Definition Clinical guidelines are systemically developed statements that assist clinicians and patients in making decisions about appropriate treatments for specific conditions. They allow deviation from a prescribed pathway according to the individual circumstances and where reasons can be clearly demonstrated and documented.

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Contents Definition…………………………………………………………….……………..…………..2 Rationale………………………………………………………………….…………..………..2 Antenatal Management…………..……………………….……….……………..…..2 External Cephalic Version………………………………….…….………………..….2 Planning Vaginal Birth…………………………………………………………………….3 Unexpected Breech presentation on Obstetric Unit..………………….4 Unexpected Breech Presentation in Community Setting.……..……4 Management of Vaginal Birth…………………………………………….…..…5-6 Birth by Elective Caesarean Section………………………………………..….7 Preterm Breech Birth……………………..…………………………………………….8 Training Requirements………………….……………………….…………..………..8 Auditable Standards………………………….…………………..…………..…………8 References……………………………………………………………………………….…...9 Appendix One: Vaginal Breech Birth Pro forma…………………….….10 1

Definition Breech presentation is when the baby’s buttocks, foot or feet present instead of its head. Breech presentation although sometimes associated with uterine, placental, or fetal abnormalities, is often simply an error of orientation that places the mother and healthy baby at risk. The incidence of breech presentation decreases from approximately 20% at 28 weeks gestation to between 3-4% at term. Spontaneous changes from breech to cephalic presentation occur with decreasing frequency as gestational age advances in the third trimester. Breech presentations are more likely to occur at all gestational ages in women who have previously given birth. Rationale It has been widely recognised that there is higher perinatal mortality and morbidity with breech presentation due principally to prematurity, congenital malformations and birth asphyxia or trauma. Breech presentation, whatever the mode of birth, is a signal for potential fetal handicap and this should inform antenatal, intrapartum and neonatal management. Caesarean section for breech presentation has been suggested as a way of reducing the associated fetal problems. Antenatal Management Breech presentation does not become clinically significant until 36 weeks gestation. Women with confirmed breech presentation at or over 36 weeks gestation should be seen by their named Consultant to plan the mode of birth. Such management plans regarding birth should be discussed with the woman, enabling informed choice. The RCOG information leaflet should be given and this should be recorded in the notes. Consent should be given at all stages for all interventions. Risks and benefits should be discussed and clearly documented. Ultrasound scans are useful to exclude fetal anomaly, determine type of breech (frank, complete, footling) and to assess fetal size and liquor volume. External Cephalic Version The option of external cephalic version (ECV) should be offered to all women with an uncomplicated breech presentation at 37-42 weeks gestation, unless a contraindication exists. Referral is made to an appropriately trained senior obstetrician usually via Labour Ward. The procedure should be carried out:

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By an appropriately trained and skilled professional, preferably practising at Consultant level, or under appropriate supervision. Where facilities for immediate delivery are available. Following fetal cardiotocograph monitoring. Where ultrasound guidance is available. Cardiotocograph should be performed following the procedure. Tocolysis has been shown to be effective when used routinely and selectively. Anti D should be administered to women who are Rhesus negative

The EIDO ECV Patient Information Leaflet should be offered to all women considering ECV and can be found at the EIDO Download Centre by following this link. http://dc.eidohealthcare.com/processform.php?form=login&usernam e=NGL&password=consent11&terms=accepted Planning Vaginal Birth Any woman considering a vaginal breech birth should be referred to an Obstetric consultant after 36 weeks gestation for confirmation of presentation and a full discussion of the risks and benefits. A plan of care for labour should be clearly documented. The woman should be informed that; •

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Planned caesarean section carries a reduced perinatal mortality and early neonatal morbidity for babies with a breech presentation at term compared with planned vaginal birth. There is no evidence that the long term health of babies with a breech presentation delivered at term is influenced by how the baby is born Planned caesarean section for breech presentation carries a small increase in serious immediate complications for them compared with planned vaginal birth. Planned caesarean section for breech presentation does not carry any additional risk to long-term health outside pregnancy. The long-term effects of planned caesarean section for term breech presentation on future pregnancy outcomes for them and their babies is uncertain (RCOG) Vaginal breech birth should take place in a hospital with facilities for emergency caesarean section.

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Labour induction for breech presentation may be considered if individual circumstances are favourable. Labour augmentation is not recommended.

Factors regarded as unfavourable for vaginal breech birth include the following; ● Other contraindications to vaginal birth (e.g. placenta praevia, compromised fetal condition) ● Clinically inadequate pelvis (pelvimetry is not necessary) ● Footling or kneeling breech presentation ● Large baby (usually defined as larger than 3800 g) ● Growth-restricted baby (usually defined as smaller than 2000 g) ● Hyperextended fetal neck in labour (diagnosed with ultrasound or X-ray where ultrasound is not available) ● Lack of presence of a clinician trained in vaginal breech birth ● Previous caesarean section. A trial of labour should be precluded in the presence of medical or obstetric complications which are likely to be associated with mechanical difficulties at birth. This discussion should be clearly documented in the notes. Unexpected Breech Presentation on Obstetric Unit If a breech presentation is diagnosed unexpectedly on admission to labour ward the midwife must inform the Senior Obstetrician on call immediately to discuss mode of birth and formulate a plan of care. The woman should be supported to make an informed choice regarding mode of birth. Unexpected Breech Presentation in the Community Setting When labour commences, a risk assessment must take place as per the All Wales Midwifery Led Care Guidelines. In the event of a breech presentation being diagnosed at home, the midwife must:•

Activate the transfer policy immediately, and if time permits the woman should be transferred to an obstetric unit. The risks/benefits when considering transfer should be assessed bearing in mind the likelihood of birth during the transfer.

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Call for assistance if second midwife not in attendance (may need to call in other midwives to support transfer)

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Inform the Senior Midwife on the Labour Ward

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If birth is imminent, follow the steps outlined in management of vaginal birth section (remember many complications associated with vaginal breech deliveries can be attributed to operator interference).

A midwife should remain with the woman throughout the transfer process, including transfer by ambulance. It is unacceptable for the midwife responsible for providing care to a woman in labour to follow the ambulance in her car. If there is no space in the ambulance, the baby’s father / birth partner has to travel to the consultant-led unit in his/her own car or in a taxi. All midwives must ensure they maintain their skills in emergency breech birth. A clinical incident form should be completed following all undiagnosed breech presentations. Management of Vaginal Birth • A senior obstetrician must be informed of admission. • On admission an assessment CTG should be performed. • A plan of care will be recorded following explanation, agreement and consent from the woman. • If presenting with ruptured membranes or in labour a vaginal examination should be undertaken to check for cord and confirmation of labour. If footling presentation, proceed to CS (high risk of cord prolapse/ head entrapment). • Allow to progress and manage as high-risk labour. ie continuous external CTG, close observation by midwife • An intravenous cannula, (16g) Venflon should be sited. • Bloods should be taken and sent, for FBC and group and save. • Epidural analgesia should not be routinely advised; women should have a choice of analgesia during breech labour and birth. • Induction or augmentation is always a consultant decision. Oxytocin may be used with caution in cases where there is delay in the progress of labour • Caesarean section should be considered if there is delay in the descent of the breech at any stage in the second stage of labour. • Fetal blood sampling from the buttocks is not advised • Senior obstetrician, obstetric anaesthetist and paediatrician should be present on labour ward for birth (the most experienced practitioner should be available). 5

The principles of a breech birth are: 9 Warm room and ensure resuscitation equipment is prepared 9 Assist birth, if able to on a bed with lithotomy poles, if not – at end or side of bed, semi upright or kneeling. In community settings the ‘English Prayer or All fours position may be more appropriate. 9 Confirm cervix is fully dilated and catheterise to empty bladder. 9 Consideration of episiotomy manipulations as required.

is

recommended,

to

allow

9 Allow the woman to push at her own rate facilitating a steady descent. As buttocks distend the perineum, the anterior & posterior buttocks follow quite quickly. Meconium is not unusual at this stage 9 Allow to deliver to thorax, with NO interference – Hands off the breech. Traction may cause head extension and displacement of the arms above the head. 9 Allow legs to deliver spontaneously, or gently insert a finger behind the knee to enable knee flexion and thigh abduction. 9 The arms will normally escape one by one, but gentle downward traction can be applied to the baby 9 Only grasp baby around the pelvis. Only if necessary apply traction at a downward 45 degree angle. Baby’s back to face upwards if woman is semi-recumbent, to allow head to enter the pelvis occipito anterior- if the woman is in an all-fours position, the baby’s chest will be visible 9 Rotate body into the oblique until tip of scapula appears 9 Sweep the anterior arm down across the chest and out 9 Reverse manoeuvre for the other arm 9 Allow the breech to hang until the nape of the neck or nose is visible. Do not attempt delivery of the head before this is visible. 9 Birth of head – by modified Mauriceau Smellie Veit manoeuvre

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9 Support the baby’s body over the birth attendants arm 9 One hand with one finger in the vagina placed on the occiput and one finger on each of the shoulders 9 Other hand beneath the baby with 2 fingers on the maxillae – not in the baby’s mouth 9 Head is flexed through the pelvis by the occipito finger applying flexing pressure on the occiput, and the fingers on the maxillae applying pressure on the lower face 9 The body is raised upwards in a large arc 9 The rest of the head can be born slowly and placed on mother’s abdomen 9 Where there is head entrapment during a preterm breech delivery, lateral incisions of the cervix should be considered by an experienced obstetrician. 9 An experienced paediatrician should be asked to attend 9 Cord blood gases are mandatory irrespective of mode of birth 9 All breech babies will require a hip scan

Birth by Elective Caesarean section Women with breech presentations will be given a full explanation of the plan of events. Women will be scanned on the day of the planned caesarean section. If the fetus has changed position to cephalic presentation, the plan will be reviewed and if all is well the women will be advised to await normal labour. See guideline for elective caesarean section. It is important to note that around 10% of women who plan elective caesarean section will end up having a vaginal birth.

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Preterm Breech Birth There is much debate as to the appropriate mode of birth for preterm breech presentations