The Society of Obstetrics & Gynaecologists (SOGP) Pakistan in accordance with Clinical Governance Guideline 1d of Royal College of Obstetricians & Gynaecologists (RCOG), U.K, has adapted Green Top guideline No 20b on “The Management of Breech Presentation” in January 2011. Initial Recommendations were made in meeting of an expert group comprised of the following

PRINCIPAL AUTHOR

Prof. Dr Syeda Batool Mazhar

CLINICAL PRACTICE OBSTETRICS COMMITTEE

Prof. Dr Fahmeeda Shaheen+

Associate Prof. Dr Farhat Parveen Malik*

Assistant Prof. Dr Arfa Tabassum*

Assistant Prof. Dr Kausar Bangash*

Post graduate Resident. Dr Azmat Riaz*

Post graduate Resident. Dr Majida Zafar*

NURSE MIDWIFE

Nasreen*

NEONATOLOGIST:

Asso Prof. Dr Haider Shirazi*

ANAESTHESIOLOGIST:

Dr Safdar*

purpose and scope

The aim of this guideline is to provide up to date information on methods of delivery for women with breech presentation in the Pakistani context. The scope is confined to decision making regarding the route of delivery and choice of various techniques used during delivery. It does not include antenatal or postnatal care. External cephalic version is the topic of a separate RCOG Green Top Guideline No 20 a : “ECV and Reducing the incidence of Breech Presentation” which has also been adapted by this group for SOGP. The levels of evidence supporting the recommendations can be confirmed from Green Top Guideline on The Management of Breech Presentation number 20 b. The adaptations added or removed in the Pakistani context are highlighted and are recommended best practices based on the clinical experience of the guideline adaptation committee referred to above.

Background

The incidence of breech presentation decreases from about 20% at 28 weeks of gestation to 3–4% at term, as most babies turn spontaneously to the cephalic presentation. This appears to be an active process whereby a normally formed and active baby adopts the position of ‘best fit’ in a normal intrauterine space. Persistent breech presentation may be associated with abnormalities of the baby, the amniotic fluid volume, the placental localisation or the uterus. It may be due to an otherwise insignificant factor such as cornual placental position or it may apparently be due to chance.

There is higher perinatal mortality and morbidity with breech than cephalic presentation, due principally to prematurity, congenital malformations and birth asphyxia or trauma. Caesarean section for breech presentation has been suggested as a way of reducing the associated perinatal problems and in many countries in Northern Europe and North America caesarean section has become the normal mode of breech delivery. However, breech presentation, whatever the mode of delivery, is associated with increased risk of subsequent handicap. This suggests that failure to adopt the cephalic presentation may in some cases be a marker for fetal impairment.

Local data

Recommendations:

II. What factors affect the safety of vaginal breech delivery?

1. Women should be assessed carefully before selection for vaginal breech birth.
2. Women with unfavourable clinical features should be specifically advised of the increased risk to them and their babies of attempting vaginal breech birth.
3. Routine radiological pelvimetry is not necessary.
4. Diagnosis of breech presentation for the first time during labour should not be a contraindication For vaginal breech birth.
5. 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
• 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 delivery
• Previous caesarean section.

III Intrapartum management

1 Where should vaginal breech birth take place?

Vaginal breech birth should take place in a hospital with facilities for emergency caesarean section.

2 What is the place of labour induction, labour augmentation and epidural analgesia in breech labour?

??Labour induction for breech presentation may be considered if individual circumstances are favourable.( This may be a point for a consensus )

Labour augmentation is not recommended.

Epidural analgesia should not be routinely advised; women should have a choice of analgesia during breech labour and birth.

3 What is the place of fetal monitoring during breech labour?

Continuous electronic fetal heart rate (EFM) monitoring should be offered to women with a breech presentation in labour, where facilities are available.

In absence of EFM, standard intermittent monitoring with Doppler sonicaid or pinnard should be done.

1^st stage :

Intermittent auscultation of the fetal heart after a contraction should be undertaken for 1 minute, every 15 to 30 minutes, and the rate should be recorded as an average. The maternal pulse should be palpated if a FHR abnormality is detected to differentiate the two heart rates.

2^nd STAGE

Intermittent auscultation of the fetal heart should be performed after a contraction for 1 minute and at least every 5 minutes. The maternal pulse should be palpated if there is suspected fetal heart rate abnormality

(NICE clinical guideline 55 – Intrapartum care 30 September 2007 )

Where facilities are available, fetal blood sampling from the buttocks during labour is not advisable

4. How should delayed second stage of labour with breech presentation be managed?

Caesarean section should be considered if there is delay in the descent of the breech at any stage in the second stage of labour.

5. What maternal position should be used for breech delivery?

Women should be advised that, as most experience with vaginal breech birth is in the dorsal or lithotomy position, that this position is advised.

6. Should routine episiotomy be performed?

Episiotomy should be performed selectively when indicated to facilitate delivery.

7. Should breech extraction be performed routinely?

Breech extraction should not be used routinely.

8. How should delayed delivery of the arms be managed?

The arms should be delivered by sweeping them across the baby’s face and downwards or by the Lovset’s manoeuvre (rotation of the baby to facilitate delivery of the arms).

9. How should delayed engagement in the pelvis of the aftercoming head be managed?

Suprapubic pressure by an assistant should be used to assist flexion of the head. There is no experimental evidence to indicate which is the best method of assisting engagement of head in the pelvis.

10. How should the aftercoming head be delivered?

The aftercoming head may be delivered with forceps, the Mariceau-Smellie-Veit manoeuvre or the Burns-Marshall method.

11. How should obstructed delivery of the aftercoming head be managed?

If conservative methods fail, symphysiotomy or caesarean section should be performed. (do we recommend symphysiotomy in Pakistan??we would first have to learn how to do it)

IV. Management of the preterm breech and twin breech

1. How should preterm babies in breech presentation be delivered?

Routine caesarean section for the delivery of preterm breech presentation should not be advised. POG : cut off for Pakistan

The mode of delivery of the preterm breech presentation should be discussed on an individual basis with a woman and her husband.

Where there is head entrapment during a preterm breech delivery, lateral incisions of the cervix should be considered. Duhrssen’s cervical incisions initially at 2 and 10 o clock positions are advised and if necessary a third incision at 6 o clock position may also be given.

2. How should a first twin in breech presentation at term be delivered?

Women should be informed of the benefits, including reduced perinatal mortality, and risks, both for the current and for future pregnancies, of planned caesarean section for breech presentation.

Women should be advised that planned caesarean section for breech presentation carries a very small increase in serious immediate complications for them compared with planned vaginal birth.

3. How should a second twin in breech presentation be delivered?

Routine caesarean section for twin pregnancy with breech presentation of the second twin should not be performed.

V. Training: skill, experience and judgement of the intrapartum attendant

1. What part does the skill of the attendant play in vaginal breech delivery?

A practitioner skilled in the conduct of labour with breech presentation and vaginal breech birth should be present at all vaginal breech births.Trainees should perform Vaginal breech deliveries under supervision

If a unit is unable to offer the choice of a planned vaginal breech birth, women who wish to choose this option should be referred to a unit where this option is available.

Practitioners supervising labour with a breech presentation or carrying out vaginal breech birth should have appropriate training, which may include simulated training.

Alternative methods of training need to be introduced (such as videos, models and scenario teaching). Simulation training has been shown to improve performance in the management of a simulated vaginal breech delivery.

A video-recorded teaching aid on vaginal breech delivery and symphysiotomy is available in the World Health Organization Reproductive Health Library (available from rhl@who.int; www.rhlibrary.com).

VI. Documentation

What is the place of documentation?

All details of care should be clearly documented, including details of counselling and the identity of all those involved in the procedures.

A culture of documentation and the regular recording of times of intervention should be in inculcated in all facilities, both government and private.

VII. Auditable standards
What standards may be used to evaluate care of women with breech presentation during delivery?

1. Discussion with woman regarding mode of delivery documented in the notes.
2. Review with the mother of the birth documented in the notes.
3. Proportion of planned vaginal deliveries that take place vaginally.
4. Proportion of planned caesarean sections that deliver by caesarean section.
5. Rate of experienced attendant being present during breech labour.
6. Rate of experienced attendant being present during vaginal breech birth.
7. Rate of birth trauma during breech delivery.
8. Rate of perinatal death related to breech birth.
9. Rate of perinatal death or severe morbidity related to breech birth.
10. Rate of neonatal encephalopathy related to breech birth.
11. Training program in place for improving vaginal breech delivery skills.

List of Consultants involved in 2nd review process of guidelines on ECV and Breech Management

• Brig. Nadra Sultana, Prof. of Obst/Gynae, FUMC Rawalpindi. FCPS-1977
• Prof. Rahat-un-Nisa, Prof&H.O.D of Obs/Gynae, Women Medical College, Abbottabad. FCPS-1982
• Prof. Roshan Ara Qazi, Prof. Obst/Gynae, LUMHS, Jamshoro, FCPS-1990
• Prof. Abeera Choudhary, Prof. & Classified Gynaecologist, CMH Rawalpindi, FCPS-1991, MRCOG-1998
• Dr. Tahira Batool,H.O Gynae Dept.,KRL Hospital, Islamabad,MRCOG-1991,
• Prof. Arif Tajamul,Prof. Obst.&Gynae,AIMC, Lahore,,MRCOG-1991
• Prof. Rizwana Chaudhri,Prof. Obst & Gynae,R.M.C Rawalpindi,FCPS-1992,
• Prof.Syeda Batool Mazhar,Prof. of Obst & Gynae,MCH, PIMS, Islamabad,MRCOG-1992, FRCOG-2005, FCPS-2010,
• Prof. Tanvir Jamal,Prof. of Obs/Gynae, Incharge Gynae B Unit, Khyber Teaching Hospital, Peshawar FCPS-1993, DGO-1985
• Lt.Col.Dr.Shehla M.Baqai,Consultant Gyneacologist,P.N.S Shifa Hospital, Karachi FCPS-1993
• Dr. Muhammad Ikramullah Khan,Associate Prof. of Gynae,K.E.M.U., Lahore,FCPS-1994
• Dr. Neelofur Babar, Clinical Head, Dept. of Gynae,A.K.U.H for women, Karachi,FCPS-1994
• Dr. Shehla Noor,Associate Prof. Of,Obst/Gynae,A.M.C AbbottabadDGO-1995, FCPS-1998
• Dr. Maimoona Ashraf,Assistant Prof. of obst/Gynae,P.G.M.I/L.G.H, Lahore,FCPS-1995,
• Dr. Azra Saeed Awan,Prof. of Obst & GynaeIslamic international Medical Complex/Railway Hospital, Rawalpindi,FCPS-1996
• Maj. Dr. Aliya Islam,Associate Prof. of Obs/Gynae,International Medical College, Abbotabbad FCPS-1996
• Dr. Nabeela Waheed,Asstt. Prof. of Obst/Gynae,R.M.C/Holy Family Hospital,Rawalpindi FCPS-1998
• Dr. Raheel Sikandar,Associate Prof of Obst/Gynae,L.U.H.S Hyderabad,FCPS-1998
• Dr. Nudrat Sohail,Asstt. Prof. Gynae,Allama Iqbal Medical College, Lahore,FCPS-1999
• Dr. Farhat Perveen,Associate Prof.of Obst/Gynae,MCH, PIMS, Islamabad FCPS-1999,
• Dr. Mahreen Mahmood,Associate prof. of Obs/Gyne,Islamabad medical & Dental collage, Islamabad FCPS-1999
• Dr. Razia Mustafa Abbasi,Assoc Prof. of Obs/Gynae,L.U.M.H.S Jamshoro,,FCPS-2000
• Dr. Naeema Utman,Associate Prof. Obst & Gynae,PGMI/Lady Reading Hospital, Peshawar FCPS-1997
• Dr. Naila Tahir,Classified Gynaecologist,CMH, Peshawar,FCPS-1999
• Dr. Ruqqia Sultana,Asstt. Prof. of Obst/Gynae,Ayub Medical College, Abbotabad,FCPS-1999,
• Prof Fehmida Shaheen,Prof. Obst & Gynae,R.M.C Rawalpindi,
• Dr Arfa Tabassum,Assistant Prof.of Obst/Gynae,MCH, PIMS, Islamabad