"I had no choice": A mixed-methods study on access to care for vaginal breech birth

INTRODUCTION

Although current recommendations support vaginal breech birth as a reasonable option, access to breech birth in US hospitals is limited. This study explored the experiences of decision-making and perceptions of access to care in people who transferred out of the hospital system to pursue home breech birth.

METHODS

We conducted a mixed methods study of people with a singleton, term breech fetus who transferred out of the US hospital system to pursue home breech birth. Twenty-five people completed an online demographic and psychosocial survey, and 23 (92%) participated in semi-structured interviews. We used an interpretive description approach informed by situational analysis to analyze qualitative data about participants' experiences and perceived access to care.

RESULTS

Of 25 individuals who left the hospital system to pursue a home breech birth, most felt denied informed choice (64%) and threatened or coerced into cesarean (68%). The majority reported low or very low autonomy in decision-making (n = 20, 80%) and high decisional satisfaction using validated measures. Many participants felt safer in a hospital setting but were not able to access care for planned vaginal breech hospital birth, despite extensive efforts. Participants felt "backed into a corner" and "forced into homebirth," perceiving a lack of access to safe and respectful care in the hospital system.

CONCLUSION

Some service users believe that home birth is their only option when they cannot access hospital-based care for vaginal breech birth. Current barriers to care for breech birth limit birthing people's autonomy and may be placing them and their infants at increased risk.

Consensus-based recommendations for the care of women with a breech presenting fetus

OBJECTIVE

To establish consensus related to aspects of breech presentation and care.

DESIGN

A multinational, three round e-Delphi study.

PARTICIPANTS

A panel of 15 midwives, four obstetricians and an academic with knowledge and/or experience of caring for women with a breech presenting fetus.

METHODS

An initial survey of 45 open-ended questions. Answers were coded and amalgamated to form 448 statements in the second round and three additional statements in the third round. Panellists were asked to provide their level of agreement for each statement using a 5-point Likert scale. Consensus was deemed met if 70% of panellists responded with strongly agree to somewhat agree, or strongly disagree to somewhat disagree after the second round.

FINDINGS

Results led to the development of a consensus-based care pathway for women with a breech presenting fetus and a skills development framework for clinicians.

KEY CONCLUSIONS

A cultural shift is beginning to occur through the provision of physiological breech workshops offered by various organisations and may result in greater access to skilled and experienced clinicians for women desiring a vaginal breech birth, ultimately improving the safety of breech birth.

IMPLICATIONS FOR PRACTICES

The care pathway and skills development framework can be used by services wishing to make changes to their current practices related to breech presentation and increase the level of skill in their workforce.

OptiBreech collaborative care versus standard care for women with a breech-presenting fetus at term: A pilot parallel group randomised trial to evaluate the feasibility of a randomised trial nested within a cohort

OptiBreech collaborative care is a multi-disciplinary care pathway for breech presentation at term, with continuity from a breech specialist midwife, including where chosen, for vaginal breech birth (VBB). Pilot randomised trial using unblinded 1:1 parallel group allocation to OptiBreech versus standard care, within a cohort. Participants were women with a breech-presenting fetus > 33 weeks, at four sites in England, January-June 2022. A two-stage consent process was used. Participants consented to undergo random selection to be offered a 'new care process', with a choice to accept it, or not. Primary objectives were to identify recruitment, acceptance, and attrition rates. Randomisation procedures and potential primary outcomes for a substantive study were also feasibility-tested. 68 women were randomised between January-June 2022. The consent process was acceptable to participants, but randomisation was unacceptable to women who specifically sought OptiBreech care. Two women withdrew due to concerns about sharing personal information. More women planned a VBB when randomised to OptiBreech Care (23.5% vs 0, p = .002, 95% CI = 9.3%,37.8%). Women randomised to OptiBreech care had: lower rates of cephalic presentation at birth (38.2% vs 54.5%), higher rates of vaginal birth (32.4% vs 24.2%), lower rates of in-labour caesarean birth (20.6% vs 36.4%), lower rates of neonatal intensive care (5.9% vs 9.1%), and lower rates of severe neonatal morbidity (2.9% vs 9.1%). Randomisation was stopped on the advice of the steering committee before the planned sample of 104, as lack of access to VBB within standard care prohibited comparison of outcomes. Demand for VBB is sufficient for a cohort study, but comparison of outcomes by 1:1 randomisation is not feasible. OptiBreech care would be best evaluated using stepped wedge cluster randomisation. Funded by the United Kingdom National Institute for Health and Care Research (NIHR300582). Clinical trial registration: ISRCTN 14521381.

Remifentanil for External Cephalic Version: A Systematic Review and Meta-Analysis

The purpose of this study was to examine the efficacy of remifentanil on external cephalic version (ECV) in breech presentation. An extensive search was conducted using PubMed, Cochrane Library, and other grey literature. Only randomized controlled trials using remifentanil for ECV were included. Risk ratio (RR) and mean difference (MD) were used to estimate outcomes and quality of evidence was assessed using the Risk of Bias and GRADE system. Five studies consisting of 602 patients were analyzed. Remifentanil resulted in a moderate increase in ECV success rate (RR, 1.19; 95% CI, 1.00 to 1.43; P = .05), a large reduction of pain score (MD, -2.02; 95% CI, -2.32 to -1.72; P < .00001) with fewer transient fetal bradycardia (RR, 0.40; 95% CI, 0.19 to 0.85; P = .02). However, remifentanil did not affect cesarean section rates, (RR, 0.97; 95% CI, 0.49 to 1.93; P = .93) instrumental delivery (RR, 0.94; 95% CI, 0.41 to 2.15; P = 0.89), and spontaneous delivery rate (RR, 1.02; 95% CI, 0.78 to 1.35; P = 0.87). Mothers treated with remifentanil have a higher patient satisfaction score. The use of remifentanil may be a good strategy for ECV. However, extrapolation of this finding to clinical settings must consider the study limitations.

Factors influencing the effect of external cephalic version: a retrospective nationwide cohort analysis

OBJECTIVE

This study aims to assess the factors associated with the success and failure rate of the external cephalic version (ECV) in breech fetuses. Secondary outcomes were fetal presentation in labor and mode of delivery.

METHODS

This cross-sectional study examined the live birth certificates from 2003 through 2020 from US states and territories that implemented the 2003 revision. A total of 149,671 singleton pregnancies with information about ECV success or failure were included. The outcome was ECV success/failure, while the exposures were possible factors associated with the outcome.

RESULTS

The successful ECV procedures were 96,137 (64.23%). Among the successful ECV procedures, the prevalence of spontaneous vaginal delivery was 71.63%. Among the failed ECV procedures, 24.74% had a cephalic presentation at delivery, but 63.11% of these pregnancies were delivered by cesarean section. Nulliparity, female sex, low fetal weight centile, high pre-pregnancy BMI, high BMI at delivery, and high maternal weight gain during pregnancy were associated with an increased ECV failure (p < 0.001). African American, American Indian and Alaska Native race categories were significant protective factors against ECV failure (p < 0.001). Maternal age had a U-shape risk profile, whereas younger maternal age (< 25 years) and old maternal age (> 40 years) were significant protective factors against ECV failure (p < 0.001).

CONCLUSIONS

A high prevalence of successful ECV procedures and subsequent spontaneous vaginal delivery were found. The present results found nulliparity, maternal race, maternal age, female fetal sex, low fetal weight, and maternal anthropometric features correlated to ECV results. These findings can potentially improve the knowledge about the factors involved in ECV, allowing more informed counseling to the women undergoing this procedure.

Impact of full vs empty urinary bladder on external cephalic version success: a randomized controlled trial

BACKGROUND

External cephalic version is a procedure used to turn a fetus from a breech position to a cephalic position before delivery. The success rate of the external cephalic version can be affected by various factors; however, the effect of bladder volume on the success rate of the external cephalic version remains controversial.

OBJECTIVE

This study aimed to determine the effect of urinary bladder status (full or empty) on the success rate of the external cephalic version through a prospective randomized study.

STUDY DESIGN

This was a prospective randomized controlled trial conducted at a tertiary care obstetrical center. Overall, 70 women with a singleton breech presentation at term undergoing external cephalic version were randomly allocated into 2 groups: external cephalic version with an empty bladder and external cephalic version with a full bladder. The external cephalic version procedure was performed by experienced obstetricians under ultrasound guidance. The primary outcome was the success rate of the external cephalic version.

RESULTS

The success rate of the external cephalic version was 67.56% (25/37) in the full bladder group and 54.54% (18/33) in the empty bladder group, with no statistically significant difference between the groups (P=.26). In addition, the relative risk of successful external cephalic version was 1.23 (95% confidence interval, 0.84-1.81), indicating no significant difference.

CONCLUSION

This randomized controlled trial demonstrated that the presence of a full or empty urinary bladder does not significantly affect the success rate of the external cephalic version in women with singleton breech presentation at term. Our findings suggest that women undergoing an external cephalic version do not need to have a full bladder to improve the success rate of the procedure.

Evaluating the effectiveness of lateral postural management for breech presentation: study protocol for a randomized controlled trial (BRLT study)

BACKGROUND

Breech presentation is observed in 3-4% at term of pregnancy and is one of the leading causes of cesarean section. There is no established treatment for breech presentation before 36 weeks. A retrospective cohort study was conducted to demonstrate that the lateral position is effective for breech presentation. However, there are no randomized controlled trials evaluating lateral position management for breech presentation. Here, we described the methodology of a randomized controlled trial of a cephalic version for breech presentation in the third trimester by lateral postural management (BRLT study).

METHODS

The BRLT study is an open-label, randomized controlled trial with two parallel groups allocated in a 1:1 ratio to examine the lateral position management for breech presentation, as compared with expectant management care. An academic hospital in Japan will enroll 200 patients diagnosed with a breech presentation by ultrasonography between 28 + 0 weeks and 30 + 0 weeks. Participants in the intervention group will be instructed to lie on their right sides for 15 min three times per day if the fetal back was on the left side or lie on their left sides if the fetal back was on the right side. The instruction will be given every 2 weeks after confirmation of fetal position, and the lateral position will be instructed until the cephalic version, and after the cephalic version, the reverse lateral position will be instructed until delivery. The primary outcome is cephalic presentation at term. The secondary outcomes are cesarean delivery, cephalic presentation 2, 4, and 6 weeks after the instruction, and at delivery, recurrent breech presentation after cephalic version, and adverse effects.

DISCUSSION

This trial will answer whether the lateral positioning technique is effective in treating breech presentation and, depending on the results, may provide a very simple, less painful, and safe option for treating breech presentation before 36 weeks, and it may impact breech presentation treatment.

TRIAL REGISTRATION

UMIN Clinical Trials Registry UMIN000043613. Registered on 15 March 2021 https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000049800 .

Cephalic version by moxibustion for breech presentation

BACKGROUND

Breech presentation at term can cause complications during birth and increase the chance of caesarean section. Moxibustion (a type of Chinese medicine which involves burning a herb close to the skin) at the acupuncture point Bladder 67 (BL67) (Chinese name Zhiyin), located at the tip of the fifth toe, has been proposed as a way of changing breech presentation to cephalic presentation. This is an update of a review first published in 2005 and last published in 2012.

OBJECTIVES

To examine the effectiveness and safety of moxibustion on changing the presentation of an unborn baby in the breech position, the need for external cephalic version (ECV), mode of birth, and perinatal morbidity and mortality.

SEARCH METHODS

For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register (which includes trials from CENTRAL, MEDLINE, Embase, CINAHL, and conference proceedings), ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform (ICTRP) (4 November 2021). We also searched MEDLINE, CINAHL, AMED, Embase and MIDIRS (inception to 3 November 2021), and the reference lists of retrieved studies.

SELECTION CRITERIA

The inclusion criteria were published and unpublished randomised or quasi-randomised controlled trials comparing moxibustion either alone or in combination with other techniques (e.g. acupuncture or postural techniques) with a control group (no moxibustion) or other methods (e.g. acupuncture, postural techniques) in women with a singleton breech presentation.

DATA COLLECTION AND ANALYSIS

Two review authors independently determined trial eligibility, assessed trial quality, and extracted data. Outcome measures were baby's presentation at birth, need for ECV, mode of birth, perinatal morbidity and mortality, maternal complications and maternal satisfaction, and adverse events. We assessed the certainty of the evidence using the GRADE approach.   MAIN RESULTS: This updated review includes 13 studies (2181 women), of which six trials are new. Most studies used adequate methods for random sequence generation and allocation concealment. Blinding of participants and personnel is challenging with a manual therapy intervention; however, the use of objective outcomes meant that the lack of blinding was unlikely to affect the results. Most studies reported little or no loss to follow-up, and few trial protocols were available. One study that was terminated early was judged as high risk for other sources of bias. Meta-analysis showed that compared to usual care alone, the combination of moxibustion plus usual care probably reduces the chance of non-cephalic presentation at birth (7 trials, 1152 women; risk ratio (RR) 0.87, 95% confidence interval (CI) 0.78 to 0.99, I2 = 38%; moderate-certainty evidence), but the evidence is very uncertain about the effect of moxibustion plus usual care on the need for ECV (4 trials, 692 women; RR 0.62, 95% CI 0.32 to 1.21, I2 = 78%; low-certainty evidence) because the CIs included both appreciable benefit and moderate harm. Adding moxibustion to usual care probably has little to no effect on the chance of caesarean section (6 trials, 1030 women; RR 0.94, 95% CI 0.83 to 1.05, I2 = 0%; moderate-certainty evidence). The evidence is very uncertain about the effect of moxibustion plus usual care on the the chance of premature rupture of membranes (3 trials, 402 women; RR 1.31, 95% CI 0.17 to 10.21, I2 = 59%; low-certainty evidence) because there were very few data. Moxibustion plus usual care probably reduces the use of oxytocin (1 trial, 260 women; RR 0.28, 95% CI 0.13 to 0.60; moderate-certainty evidence). The evidence is very uncertain about the chance of cord blood pH less than 7.1 (1 trial, 212 women; RR 3.00, 95% CI 0.32 to 28.38; low-certainty evidence) because there were very few data. We are very uncertain whether the combination of moxibustion plus usual care increases the chance of adverse events (including nausea, unpleasant odour, abdominal pain and uterine contractions; intervention: 27/65, control: 0/57), as only one study presented data in a way that could be reanalysed (122 women; RR 48.33, 95% CI 3.01 to 774.86; very low-certainty evidence). When moxibustion plus usual care was compared with sham moxibustion plus usual care, we found that moxibustion probably reduces the chance of non-cephalic presentation at birth (1 trial, 272 women; RR 0.74, 95% CI 0.58 to 0.95; moderate-certainty evidence) and probably results in little to no effect on the rate of caesarean section (1 trial, 272 women; RR 0.84, 95% CI 0.68 to 1.04; moderate-certainty evidence). No study that compared moxibustion plus usual care with sham moxibustion plus usual care reported on the clinically important outcomes of need for ECV, premature rupture of membranes, use of oxytocin, and cord blood pH less than 7.1, and one trial that reported adverse events reported data for the whole sample. When moxibustion was combined with acupuncture and usual care, there was very little evidence about the effect of the combination on non-cephalic presentation at birth (1 trial, 226 women; RR 0.73, 95% CI 0.57 to 0.94) and at the end of treatment (2 trials, 254 women; RR 0.73, 95% CI 0.57 to 0.93), and on the need for ECV (1 trial, 14 women; RR 0.45, 95% CI 0.07 to 3.01). There was very little evidence about whether moxibustion plus acupuncture plus usual care reduced the chance of caesarean section (2 trials, 240 women; RR 0.80, 95% CI 0.65 to 0.99) or pre-eclampsia (1 trial, 14 women; RR 5.00, 95% CI 0.24 to 104.15). The certainty of the evidence for this comparison was not assessed.

AUTHORS' CONCLUSIONS

We found moderate-certainty evidence that moxibustion plus usual care probably reduces the chance of non-cephalic presentation at birth, but uncertain evidence about the need for ECV. Moderate-certainty evidence from one study shows that moxibustion plus usual care probably reduces the use of oxytocin before or during labour. However, moxibustion plus usual care probably results in little to no difference in the rate of caesarean section, and we are uncertain about its effects on the chance of premature rupture of membranes and cord blood pH less than 7.1.  Adverse events were inadequately reported in most trials.

[Tocolysis during External Cephalic Version (ECV): A retrospective before/after study in a type III maternity hospital]

OBJECTIVE

On January 2020, the French College of Gynecologists and Obstetricians (CNGOF) issued new Clinical Practice Guidelines (CPG) "Breech Presentation". Since then, it is recommended to use a tocolytic agent to improve the success rate of External Cephalic Version (ECV). The aim of this study, one year after these CPG, is to compare ECV without (before CPG) and with (after CPG) tocolysis in a type III maternity hospital. We intend to assess its effects on immediate success rate of ECV and obstetrical and neonatal outcomes.

MATERIALS AND METHODS

This is a single-center retrospective study conducted in Nantes University Hospital. We collected patient characteristics, immediate success rate, and maternal and neonatal outcomes at delivery of all ECV over two periods: the first one during 2019 (before CPG) and the second one from June 2020 to June 2021 (after CPG).

RESULTS

We included 253 patients: 126 in the first period and 127 in the second period. Immediate success rate of ECV was significantly higher since the use of tocolysis: 38.6 % (period 2) vs 23.8 % (period 1) (P=0.011). However, there was not significant difference found for cephalic presentation at birth, mode of delivery or obstetrical and neonatal outcomes.

CONCLUSION

The immediate success rate is significantly improved with the widespread use of tocolysis during ECV, with no change in obstetrical and neonatal outcomes.

Use of external cephalic version for breech presentation at term: A national survey of Norwegian birth units

INTRODUCTION

International guidelines recommend that external cephalic version (ECV) be offered to all women with single fetuses in breech presentation at term. In Norway, ECV is not offered routinely; the national clinical guidelines advice that birth units capable of offering ECV for breech pregnancies make their own practice decisions. This study was performed to determine the extent to which Norwegian birth units offer ECV to pregnant women with fetuses in breech presentations at term, and to identify factors that might influence the use of ECV.

MATERIAL AND METHODS

A survey of all 39 obstetric birth units providing ECV in Norway was conducted using a self-reporting questionnaire about ECV availability, attitudes, clinical procedures, perceived competence, and outcome expectations.

RESULTS

Chief obstetricians from all birth units responded. Twenty-six (67%) respondents reported that their units offered ECV for breech presentation at term to a large degree. Thirty-one (80%) respondents reported a large degree of competence in performing ECV. Thirty-three (85%) units followed local ECV procedures. Nineteen (49%) units provided standardized information about the procedure to pregnant women. The respondents had different views about who should be offered ECV, and varying knowledge about ECV outcomes.

CONCLUSIONS

The majority of Norwegian birth units offer ECV to pregnant women with fetuses in breech position to a large extent. However, the survey results reveal challenges related to ECV information provision to pregnant women, determination of women's eligibility for ECV attempts, and familiarity and agreement with the knowledge base regarding ECV.

The impact of a routine late third trimester growth scan on the incidence, diagnosis, and management of breech presentation in Oxfordshire, UK: A cohort study

BACKGROUND

Breech presentation at term contributes significantly to cesarean section (CS) rates worldwide. External cephalic version (ECV) is a safe procedure that reduces term breech presentation and associated CS. A principal barrier to ECV is failure to diagnose breech presentation. Failure to diagnose breech presentation also leads to emergency CS or unplanned vaginal breech birth. Recent evidence suggests that undiagnosed breech might be eliminated using a third trimester scan. Our aim was to evaluate the impact of introducing a routine 36-week scan on the incidence of breech presentation and of undiagnosed breech presentation.

METHODS AND FINDINGS

We carried out a population-based cohort study of pregnant women in a single unit covering Oxfordshire, United Kingdom. All women delivering between 37+0 and 42+6 weeks gestational age, with a singleton, nonanomalous fetus over a 4-year period (01 October 2014 to 30 September 2018) were included. The mean maternal age was 31 years, mean BMI 26, 44% were nulliparous, and 21% were of non-white ethnicity. Comparisons between the 2 years before and after introduction of routine 36-week scan were made for 2 primary outcomes of (1) the incidence of breech presentation and (2) undiagnosed breech presentation. Secondary outcomes related to ECV, mode of birth, and perinatal outcomes. Relative risks (RRs) with 95% confidence intervals (CIs) are reported. A total of 27,825 pregnancies were analysed (14,444 before and 13,381 after). A scan after 35+0 weeks was performed in 5,578 (38.6%) before, and 13,251 (99.0%) after (p < 0.001). The incidence of breech presentation at birth did not change significantly (2.6% and 2.7%) (RR 1.02; 95% CI 0.89, 1.18; p = 0.76). The rate of undiagnosed breech before labour reduced, from 22.3% to 4.7% (RR 0.21; 95% CI 0.12, 0.36; p < 0.001). Vaginal breech birth rates fell from 10.3% to 5.3% (RR 0.51; 95% CI 0.30, 0.87; p = 0.01); nonsignificant increases in elective CS rates and decreases in emergency CS rates for breech babies were seen. Neonatal outcomes were not significantly altered. Study limitations include insufficient numbers to detect serious adverse outcomes, that we cannot exclude secular changes over time which may have influenced our results, and that these findings are most applicable where a comprehensive ECV service exists.

CONCLUSIONS

In this study, a universal 36-week scan policy was associated with a reduction in the incidence but not elimination of undiagnosed term breech presentation. There was no reduction in the incidence of breech presentation at birth, despite a comprehensive ECV service.

A Systematic Review and Meta-analysis of Clinical Trials of Neuraxial, Intravenous, and Inhalational Anesthesia for External Cephalic Version

BACKGROUND

External cephalic version (ECV) is a frequently performed obstetric procedure for fetal breech presentation to avoid cesarean delivery. Neuraxial, intravenous, and inhalational anesthetic techniques have been studied to reduce maternal discomfort caused by the forceful manipulation. This study compares the effects of these anesthetic techniques on ECV and incidence of cesarean delivery.

METHODS

We conducted a comprehensive literature search for published randomized controlled trials (RCTs) or well-conducted quasi-randomized trials of ECV performed either without anesthesia or under neuraxial, intravenous, or inhalational anesthesia. Pairwise random-effects meta-analyses and network meta-analyses were performed to compare and rank the perinatal outcomes of the 3 anesthetic interventions and no anesthesia control, including the rate of successful version, cesarean delivery, maternal hypotension, nonreassuring fetal response, and adequacy of maternal pain control/satisfaction.

RESULTS

Eighteen RCTs and 1 quasi-randomized trial involving a total of 2296 term parturients with a noncephalic presenting singleton fetus were included. ECV under neuraxial anesthesia had significantly higher odds of successful fetal version compared to control (odds ratio [OR] = 2.59; 95% confidence interval [CI], 1.88-3.57), compared to intravenous anesthesia (OR = 2.08; 95% CI, 1.36-3.16), and compared to inhalational anesthesia (OR = 2.30; 95% CI, 1.33-4.00). No association was found between anesthesia interventions and rate of cesarean delivery. Neuraxial anesthesia was associated with higher odds of maternal hypotension (OR = 9.33; 95% CI, 3.14-27.68). Intravenous anesthesia was associated with significantly lower odds of nonreassuring fetal response compared to control (OR = 0.36; 95% CI, 0.16-0.82). Patients received neuraxial anesthesia reported significantly lower visual analog scale (VAS) of procedure-related pain (standardized mean difference [SMD] = -1.61; 95% CI, -1.92 to -1.31). The VAS scores of pain were also significantly lower with intravenous (SMD = -1.61; 95% CI, -1.92 to -1.31) and inhalational (SMD = -1.19; 95% CI, -1.58 to -0.8) anesthesia. The VAS of patient satisfaction was significantly higher with intravenous anesthesia (SMD = 1.53; 95% CI, 0.64-2.43).

CONCLUSIONS

Compared to control, ECV with neuraxial anesthesia had a significantly higher successful rate; however, the odds of maternal hypotension increased significantly. All anesthesia interventions provided significant reduction of procedure-related pain. Intravenous anesthesia had significantly higher score in patient satisfaction and lower odds of nonreassuring fetal response. No evidence indicated that anesthesia interventions were associated with significant decrease in the incidence of cesarean delivery compared to control.

Impact of implementation of a breech clinic in a tertiary hospital

BACKGROUND

The incidence of breech presentation in single pregnancies at term is between three to 5 %. In order to support eligible women in their choice of mode of delivery, a dedicated breech clinic with a care pathway was developed in December 2015 in a tertiary referral centre in Brussels. The primary objective of this study was to evaluate the vaginal birth rate before and after the introduction of a dedicated breech clinic. The secondary objective was to compare the early neonatal outcomes before and after the breech clinic was introduced.

METHODS

This was a single centre retrospective and prospective study. The inclusion criteria were term (from 37 weeks), singleton fetus and breech presentation at delivery. The exclusion criteria were suspected intrauterine growth restriction, severe fetal malformations and intrauterine fetal demise. We used a composite outcome as an indicator of neonatal morbidity and mortality.

RESULTS

After the introduction of the breech clinic, we observed a significant increase in planned vaginal delivery from 7.4% (12/162) to 53.0% (61/115) (OR: 13.5; 95% CI: 6.7-27.0). The effective vaginal breech delivery rate (planned and unexpected) significantly increased from 4.3% (7/162) pre-implementation of breech clinic to 43.5% (50/115) post-implementation (OR: 17.0; 95% CI: 7.3-39.6). Neonatal outcomes were not statistically different between the before and after periods.

CONCLUSION

The introduction of a dedicated breech clinic has led to an increase in vaginal deliveries for breech babies without adversely affecting neonatal outcomes.

[Breech Presentation: CNGOF Guidelines for Clinical Practice - Epidemiology, Risk Factors and Complications]

OBJECTIVES

To study the frequency, the risk factors and the mode of delivery of breech presentation. To analyze the perinatal morbidity and mortality associated with breech presentation in comparison to cephalic presentation from all mode of delivery.

METHODS

MedLine and Cochrane Library databases search in French and English and review of the main foreign guidelines between 1980 and 2019.

RESULTS

Three modes of breech presentation exist according to fetal lower limbs position: frank in 2/3 of cases, complete in 1/3 of cases or, more rarely, incomplete (LE3). About 5% of women gave birth in breech presentation in France (LE3). As the frequency of breech presentation decreases with increasing gestational age, this incidence is lower after 37 WG and represents only 3% of term deliveries (LE3). Congenital uterine malformation (LE3) and fibroma (LE3), prematurity (LE3), oligoamnios (LE3), some fetal congenital malformations (LE3) and low birthweight for gestational age (LE3) are the main risk factors with breech presentation. In France, one-third of women with a term fetus in breech presentation attempt a vaginal delivery (LE3), which is successful in 70% of cases (LE3). Neonatal outcome is not associated with type of breech presentation (frank or complete) in case of vaginal delivery attempt after 37 WG (LE3). Overall, perinatal morbidity and mortality after 37 WG of breech presentation appear to be greater than in cephalic presentation from all mode of delivery (LE3). The risk of traumatic injury in breech delivery is estimated under 1% (LE3). The most common injuries are collarbone fractures, hematomas or contusions, and brachial plexus injury (LE3). Breech presentation is associated with an increased risk of hip dysplasia (LE3) and cesarean delivery does not seem to be a protective factor (LE3). Breech presentation does not appear to be associated with an increased risk of cerebral palsy compared to cephalic presentation after exclusion of fetuses with congenital malformations (LE3).

CONCLUSION

Worldwide, mode of delivery of breech presentation has undergone profound changes since the publication of the TBT (Term Breech Trial). There are intrinsic factors associated with breech presentation, which should not be overlooked when interpreting the increased perinatal morbidity and mortality observed in case of breech presentation.

[Breech delivery 'on all fours']

Since the publication of the results of the Term Breech Trial (TBT) in 2000 the number of planned Caesarean sections for breech presentation has increased dramatically, at the expense of vaginal breech deliveries. The favourable effect of a planned Caesarean section for breech presentation on perinatal outcomes described in the TBT could not, however, be reproduced in later trials. A planned Caesarean section does carry an increased risk of maternal complications; furthermore, a previous Caesarean section leads to higher risks for both mother and child in any subsequent pregnancy. A recent prospective study advocates vaginal breech delivery 'on all fours', a position in which the mother leans on her hands and knees during delivery. A vaginal breech delivery in this position seems to be just as safe for the child as a planned Caesarean section, while a vaginal delivery is safer for the mother than a Caesarean section. This article describes two uncomplicated vaginal breech deliveries in the all fours position.

Mode of delivery of twin pregnancies with the first twin in breech position after the introduction of a policy of planned caesarean delivery for nulliparous women

INTRODUCTION

To evaluate the impact of the mode of delivery of twin pregnancies with the first twin in breech position for all parities combined after introduction of a policy of planned caesarean section in 38 weeks' gestation in nulliparas.

MATERIAL AND METHODS

A retrospective study of the mode of delivery of twin pregnancies with the first twin in breech position was conducted from January 2007 to December 2015 after the implementation of a planned caesarean section in 38 weeks' gestation in nulliparas. Maternal and neonatal outcomes were compared according to the decision of attempted vaginal or planned caesarean delivery.

RESULTS

Among the 134 women included, an attempted vaginal delivery was decided for 30.6% women (n = 41), with 95% (n = 39) who delivered vaginally and 5% (n = 2) by caesarean section during labour. Among the 69.4% women (n = 93) with a planned caesarean section, 64.5% (n = 60) and 11.8% (n = 11) delivered by caesarean before labour and during labour, respectively, and 23.7% (n = 22) delivered vaginally. The overall vaginal delivery rate was 45.5%, and the overall rate of caesarean section was 54.5% for all parities combined. In nulliparous women, the rate of caesarean section during labour was 33%. There were no significant differences in maternal mortality or morbidity between the two groups.

CONCLUSION

A selective policy of attempted vaginal delivery based on parity for twin pregnancies with the first twin in breech position can lead to a reduction in the overall rate of caesarean section in this population.

Comparison of outcomes between induction of labor and spontaneous labor for term breech - A systemic review and meta analysis

OBJECTIVES

Few studies have assessed the impact of induction of labor on breech presentation. This study aims to summarize the effect of induction of labor of breech presentation on perinatal morbidity.

METHODS

Literature review was done in Medline, Embase, Web of science and Cochrane Library up to 20 October 2017. Randomized control studies, cohort studies, and case control publishing studies comparing induction of labor versus spontaneous labor of singleton live breech birth were included. Perinatal morbidity was calculated by RevMan 5 and presented by pooled odds ratio with 95% confidence intervals.

RESULTS

Cesarean section rate and neonatal intensive care unit admission were increased in induction of breech labor as compared with spontaneous breech labor. No significant difference in umbilical cord blood base excess ≤ -12 mmol/L, Apgar 5 min < 7, Apgar 5 min < 4, umbilical cord blood PH < 7, neonatology unit admission, maternal fever, and intrapartum stillbirth between the two groups was found.

CONCLUSIONS

Induction of breech labor has higher cesarean section rate and NICU perinatal morbidity compared to spontaneous breech labor. The neonatal outcomes were otherwise similar across both groups. Eligibility for induction of breech labor needs to be assessed carefully according to individual situation.

Applying the Newman-Peacock Prognostic System to a Portuguese Obstetrical Population - A Useful Tool?

BACKGROUND

 External cephalic version (ECV) is a maneuver that enables the rotation of the non-cephalic fetus to a cephalic presentation. The Newman-Peacock (NP) index, which was proposed by Newman et al. in a study published in 1993, was described as a prediction tool of the success of this procedure; it was validated in a North-American population, and three prognostic groups were identified.

PURPOSE

 To evaluate the value of the NP score for the prediction of a successful ECV in a Portuguese obstetrical population, and to evaluate maternal and fetal safety.

METHODS

 We present an observational study conducted from 1997-2016 with pregnant women at 36-38 weeks of pregnancy who were candidates for external cephalic version in our department. Demographic and obstetrical data were collected, including the parameters included in the NP index (parity, cervical dilatation, estimated fetal weight, placental location and fetal station). The calculation of the NP score was performed, and the percentages of success were compared among the three prognostic groups and with the original study by Newman et al. The performance of the score was determined using the Student t-test, the Chi-squared test, and a receiver operating characteristic (ROC) curve.

RESULTS

 In total, 337 women were included. The overall success rate was of 43.6%. The univariate analysis revealed that multiparity, posterior placentation and a less engaged fetus were factors that favored a successful maneuver (p < 0.05). Moreover, a higher amniotic fluid index was also a relevant predictive factor (p < 0.05). The Newman-Peacock score had a poorer performance in our population compared with that of the sample of the original study, but we still found a positive relationship between higher scores and higher prediction of success (p < 0.001). No fetal or maternal morbidities were registered.

CONCLUSIONS

 The Newman-Peacock score had a poorer performance among our population compared to its performance in the original study, but the results suggest that this score is still a useful tool to guide our clinical practice and counsel the candidate regarding ECV.

The impact of physiological peripartal stress on the lifelong health of newborn

In the last decades the exponential increase in frequency of Caesarean sections is being observed. At the same time, there is growing amount of epidemiologic data showing higher lifetime risk of incidence of several diseases in offspring who do not experience natural labour. These findings lead to investigation of mechanisms which are responsible for maladaptation of several organ systems. Authors of this article describe these mechanisms, focusing especially on epigenetic programming, production of microbiome and positive effect of peripartal stress on successful beginning of extrauterine life.The best prevention strategy is following the strict indications of elective Caesarean sections. The current trend worldwide is to prepare the chronically ill patient for vaginal birth instead of indicating elective Caesarean section. From obstetric point of view it is possible to offer the external version of the foetus in breech presentation, the possibility of vaginal birth after Caesarean section and leave out controversial indications. The inevitable elective Caesarean sections should be planned close to term or after the beginning of spontaneous labour. The composition of intestinal microbiome could be partially influenced by application of vaginal secretion on newborn born by Caesarean section but there is not enough data proving long term positive outcomes (Ref. 48).

Breech Presentation: Vaginal Versus Cesarean Delivery, Which Intervention Leads to the Best Outcomes?

INTRODUCTION

The best route of delivery for the term breech fetus is still controversial. We aim to compare maternal and neonatal outcomes between vaginal and cesarean term breech deliveries.

MATERIAL AND METHODS

Multicentric retrospective cohort study of singleton term breech fetuses delivered vaginally or by elective cesarean section from January 2012 - October 2014. Primary outcomes were maternal and neonatal morbidity or mortality.

RESULTS

Sixty five breech fetuses delivered vaginally were compared to 1262 delivered by elective cesarean. Nulliparous women were more common in the elective cesarean group (69.3% vs 24.6%; p < 0.0001). Gestational age at birth was significantly lower in the vaginal delivery group (38 ± 1 weeks vs 39 ± 0.8 weeks; p = 0.0029) as was birth weight (2928 ± 48.4 g vs 3168 ± 11.3 g; p < 0.0001). Apgar scores below seven on the first and fifth minutes were more likely in the vaginal delivery group (1st minute: 18.5% vs 5.9%; p = 0.0006; OR 3.6 [1.9 - 7.0]; 5th minute: 3.1% vs 0.2%; p = 0.0133; OR 20.0 [2.8 - 144.4]), as was fetal trauma (3.1% vs 0.3%: p = 0.031; OR 9.9 [1.8-55.6]). Neither group had cases of fetal acidemia. Admission to the Neonatal Intensive Care Unit, maternal postpartum hemorrhage and the incidence of other obstetric complications were similar between groups.

DISCUSSION

Although vaginal breech delivery was associated with lower Apgar scores and higher incidence of fetal trauma, overall rates of such events were low. Admission to the neonatal intensive care unit and maternal outcomes were similar.

CONCLUSION

Both delivery routes seem equally valid, neither posing high maternal or neonatal complications' incidence.

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

OBJECTIVE

This paper aims to study if vaginal breech delivery is associated with increased risk for neonatal mortality (NNM) or cerebral palsy (CP) in Norway where vaginal delivery accounts for 1/3 of all breech deliveries.

DESIGN

Cohort study using information from the national Medical BirthRegister and Cerebral Palsy Register.

SETTING

Births in Norway 1999-2009.

PARTICIPANTS

520 047 term-born singletons without congenital malformations.

MAIN OUTCOME MEASURES

NNM, CP and a composite outcome of these and death during birth.

RESULTS

Compared with cephalic births, breech births had substantially increased risk for NNM but not for CP. Vaginal delivery was planned for 7917 of 16 700 fetuses in breech, while 5561 actually delivered vaginally. Among these, NNM was 0.9 per 1000 compared with 0.3 per 1000 in vaginal cephalic delivery, and 0.8 per 1000 in those actually born by caesarean delivery (CD) in breech. Compared with planned cephalic delivery, planned vaginal delivery was associated with excess risk for NNM (OR 2.4; 95% CI 1.2 to 4.9), while the OR associated with planned breech CD was 1.6 (95% CI 0.7 to 3.7). These risks were attenuated when NNM was substituted by the composite outcome. Vaginal breech delivery was not associated with excess risk for CP compared with vaginal cephalic delivery.

CONCLUSION

Vaginal breech delivery, regardless of whether planned or actual, and actual breech CD were associated with excess risk for NNM compared with vaginal cephalic delivery, but not with CP. The risk for NNM and CP in planned breech CD did not differ significantly from planned vaginal cephalic delivery. However, the absolute risk for these outcomes was low, and taking into consideration potential long-term adverse consequences of CD for the child and later deliveries, we therefore conclude that vaginal breech delivery may be recommended, provided competent obstetric care and strict criteria for selection to vaginal delivery.

Moxibustion did not have an effect in a randomised clinical trial for version of breech position

INTRODUCTION

In Chinese traditional medicine, the stimulation of acupuncture point no. 67 - the bladder meridian - is recommended to favour cephalic version in case of foetal breech presentation. The point can be stimulated by an acupuncture needle, ginger application, fingertip pressure, laser or moxibustion; moxibustion is heat generated by a burning stick containing the herb Artemisia vulgaris. A Cochrane review concluded that more research on the effectiveness of moxibustion is needed. This study aimed to estimate the effectiveness of moxibustion for version of breech presentation.

METHODS

We included 200 women in gestational week 33 who had a singleton foetus in breech position. They were randomised to moxibustion treatment daily for two weeks or control without moxibustion. The randomisation was performed for nulliparous and parous women separately.

RESULTS

After the trial, which lasted on average 16 days, the breech position was confirmed in 68 of the 92 nulliparous and in 50 of the 108 parous women (74% versus 46%, p < 0.01); furthermore, cephalic position was verified in 76 women and other positions in six women. No significant difference regarding the incidence of breech position was found in the moxibustion group compared with the control group (risk ratio (RR) = 1.05, 95% confidence interval (CI): 0.8-1.38); nor in nulliparous (RR = 1.17, 95% CI: 0.77-1.76) or in parous women (RR = 1.0, 95% CI: 0.69-1.46); an RR > 1 favours moxibustion).

CONCLUSIONS

No significant effects of moxibustion were found in correcting the breech position in primiparous and parous women after their 33rd gestational week.

FUNDING

none.

TRIAL REGISTRATION

This trial was registered with ClinicalTrials.gov as NCT02251886.

Flemish obstetricians' personal preference regarding induction of labor and mode of delivery in term births

INTRODUCTION

In a 2002 survey, 2% of Flemish gynecologists preferred elective cesarean section for themselves or their partner. This study aims to determine actual preference regarding induction of labor and mode of delivery in term cephalic or breech births for gy- necologists or their partners.

MATERIALS AND METHODS

An anonymous postal questionnaire was sent to all gynecologists and trainees in Flanders.

RESULTS

Response rate was 28.2 % (241/852). In case of an uncomplicated cephalic singleton pregnancy, 39 gynecologists (16.2%) preferred cesarean section. Most (n=134, 66.5%) chose induction at 41 weeks, 26 (13%) at 40 weeks, 37 (18%) at 42 weeks, 26 (13%) at 40 weeks, three (1.5%) preferred induction before 40 weeks and two (1%) would wait until after 42 weeks. Concerning term breech, 30% (n=72) opted for vaginal delivery and 70% (n = 169) for planned cesarean section. Ninety-nine (41%) gynecologists pre- ferred to attempt external version first. Only 115 (47.7 %) gynecologists felt professionally capable to assist vaginal breech delivery them- selves; about one-third (n=96; 38%) had performed less than ten vaginal breech deliveries in their career.

CONCLUSIONS

Flemish gynecologists are still in favor of vaginal delivery for themselves in terms of cephalic position, but an increasing number favor planned cesarean section. Most Flemish gynecologists opt for cesarean section for themselves or their partners in case of term breech and state that they do not feel capable in assisting vaginal breech delivery for their patients.

Breech delivery in the all fours position: a prospective observational comparative study with classic assistance

OBJECTIVE

Vaginal delivery of fetal breech presentation is considered to be a challenge for obstetricians. The purpose of this study was to show that vaginal delivery in all fours position is feasible and safe for mother and child compared with vaginal breech and classic support.

METHODS

A single-center prospective observational case series of breech delivery (n=41) in all fours position was compared to a retrospective cohort of breech deliveries in the form of a matched-pair analysis.

RESULTS

Deliveries in the all fours position successfully took place without obstetric intervention in 70.7% of deliveries (n=29/41), and those including intervention in 90.2% (n=37/41). The rate of maternal perineal injuries was reduced (14.6% vs. 58.5%, P<0.001). Newborns delivered in all fours position had increased prenatal hypoxic stress with a pH of 7.19 [95% confidence interval (CI) 7.16-7.22] vs. a pH of 7.24 (95% CI 7.21-7.27; P=0.016). With n=24 vs. n=16, a higher number of newborns had a pH of <7.20 (P=0.03) and decreased base excess of -7.2 mmol/L (95% CI -8.2-6.2) vs. -4.8 mmol/L (95% CI -5.7-4.0; P<0.001). However, this had no clinical consequences for the newborns (5 min Apgar score <9: n=5 vs. n=4, not significant; transfer rate to neonatal intensive care unit n=7 vs. n=6, not significant).

CONCLUSION

This is the first clinical evaluation of breech delivery in the all fours position. It is a feasible non-interventional obstetric delivery method. It seems to be safe for the fetus with reduced maternal morbidity. Vaginal delivery of fetal breech presentation, even in the all fours position, creates stress for the newborn.

[Training achieves an internal version and a total breech extraction at birth of second twin]

OBJECTIVES

To evaluate French residents in obstetrics and gynaecology's training to internal version and breech extraction during vaginal delivery of the second twin.

METHODS

A national descriptive survey conducted among 1064 residents between July and October 2014. Respondents were invited by email to specify the type of theoretical and practical training they had received, their university hospital obstetrical practices and the number of vaginal internal version and breech extraction of the second twin they had seen and performed.

RESULTS

Response rate was 38.7% (n=412). Regarding the type of theoretical training, 39.8% of residents (n=164) had received the obstetrical mechanics and techniques degree; 47.6% (n=196) had got a teaching during special education classes and 29.4% (n=121) a training on mannequin. There were important differences between regions. At the end of residency, 45.6% of residents (n=36) had practiced more than five vaginal internal version and breech extraction of the second twin.

CONCLUSION

Internal version and breech extraction are difficult but essential maneuvers for the management of twin delivery. The French residents in obstetrics and gynaecology's training for these maneuvers seems to be insufficient. It is necessary to improve their teaching, this teaching must also be equivalent between regions.

Informed consent to breech birth in New Zealand

The authors note significant room for improvement in facilitating informed consent in the management of breech presentation. New Zealand maternity care providers, including midwives, general practitioners and specialist obstetricians, have legal duties to provide full and unbiased information about risks and benefits of all relevant treatment options. In the case of breech presentation, such options include the interventions of external cephalic version or planned caesarean section, as well as the option to decline intervention and proceed with a planned vaginal breech birth. Information should be presented in a balanced and accessible way and not limited to the provider's personal preferences. Women have legal rights to make an informed choice, to give or refuse consent, to a second opinion and to co-operation among providers. The right of competent persons to refuse medical treatment, including the right to refuse caesarean section, is well established. Clinical policies therefore should include appropriate and non-coercive care for women who choose to birth their breech-presenting baby vaginally, compliance with such policies should be the norm, and consideration should be given to any institutional reforms or educational priorities needed to achieve this.

Genital injuries in neonates following breech presentation

Breech presentation is seen in 3-4% of babies born. Delivering a breech baby through vaginal route is difficult and carries a much higher complication rate than cesarean sections. Breech born babies carry an overall increased risk of maternal morbidity, neonatal mortality, birth asphyxia and birth injuries. Various types of birth injuries to the babies have been reported following breech delivery, but genital injuries are less commonly reported and thus, less anticipated. We report series of five babies with spectrum of genital injuries following breech delivery. These injuries led to significant short and long term morbidity in these babies. Keeping high index of suspicion, an early cesarean section can be an aide in preventing these complications. Once the baby is born, careful examination and early intervention should be done to prevent long term complications.

Effect of maternal intravenous fluid therapy on external cephalic version at term: a prospective cohort study

OBJECTIVE

We sought to analyze whether maternal intravenous fluid therapy prior to external cephalic version (ECV) increases the amount of amniotic fluid and the success rate of the procedure.

STUDY DESIGN

This was a prospective single-center cohort study of 200 women with a consecutive cohort of 100 pregnant women with a breech presentation at term who were administered intravenous fluid therapy with 2 L of hypotonic saline before the version attempt, compared to a control cohort of 100 pregnant women not given hydration treatment.

RESULTS

The mean increase in the amniotic fluid index (AFI) after intravenous maternal hydration was 3.75 ± 2.71 cm. The amount of fluid before hydration was the only variable found to be associated with increases in amniotic fluid levels, both in absolute and relative terms (odds ratio, -0.21; 95% confidence interval, -0.37 to -0.05 and odds ratio, -4.62; 95% confidence interval, -6.17 to -3.06; P < .01, respectively). We did not observe any severe complications secondary to the intravenous fluid therapy. The ECV success rate was 43% in the study group compared to 47% in the control group (P = .67). The success rate was significantly lower the larger the relative increase in the AFI, although no correlation was found in absolute terms (χ(2) for linear trend = 0.03 and 0.34, respectively).

CONCLUSION

Maternal intravenous fluid therapy with 2 L of hypotonic saline prior to ECV is an effective and safe technique for increasing the AFI. However, its use in ECV does not increase the success rate of the procedure.

Talcum powder or aqueous gel to aid external cephalic version: a randomised controlled trial

BACKGROUND

External cephalic version (ECV) is offered to reduce the number of Caesarean delivery indicated by breech presentation which occurs in 3-4% of term pregnancies. ECV is commonly performed aided by the application of aqueous gel or talcum powder to the maternal abdomen. We sought to compare gel with powder during ECV on achieving successful version and increasing tolerability.

METHOD

We enrolled 95 women (≥ 36 weeks gestation) on their attendance for planned ECV. All participants received terbutaline tocolysis. Regional anaesthesia was not used. ECV was performed in the standard fashion after the application of the allocated aid. If the first round (maximum of 2 attempts) of ECV failed, crossover to the opposing aid was permitted.

RESULTS

48 women were randomised to powder and 47 to gel. Self-reported procedure related median [interquartile range] pain scores (using a 10-point visual numerical rating scale VNRS; low score more pain) were 6 [5-9] vs. 8 [7-9] P = 0.03 in favor of gel. ECV was successful in 21/48 (43.8%) vs. 26/47 (55.3%) RR 0.6 95% CI 0.3-1.4 P = 0.3 for powder and gel arms respectively. Crossover to the opposing aid and a second round of ECV was performed in 13/27 (48.1%) following initial failure with powder and 4/21 (19%) after failure with gel (RR 3.9 95% CI 1.0-15 P = 0.07). ECV success rate was 5/13 (38.5%) vs. 1/4 (25%) P = 0.99 after crossover use of gel or powder respectively. Operators reported higher satisfaction score with the use of gel (high score, greater satisfaction) VNRS scores 6 [4.25-8] vs 8 [7-9] P = 0.01.

CONCLUSION

Women find gel use to be associated with less pain. The ECV success rate is not significantly different.

TRIAL REGISTRATION

The trial is registered with ISRCTN (identifier ISRCTN87231556).

Nitrous oxide for analgesia in external cephalic version at term: prospective comparative study

OBJECTIVE

The objective of this study was to analyze the effect of using inhaled nitrous oxide (N2O) for analgesia in external cephalic version (ECV) at term on the success rate of the procedure, on pain, and on obstetric and perinatal outcomes.

METHODS

A prospective comparative cohort study among 300 women with singleton pregnancy in breech presentation at term undergoing an ECV with inhaled N2O in a 50:50 mix with oxygen for analgesia and 150 ECVs with no analgesia.

RESULTS

The success rate was 52.3% in the N2O cohort and 52.7% in the controls (P=0.94), whereas the median level of pain was statistically lower in women given N2O (median, 6; range, 4-7, vs. median, 7; range, 5-8; P<0.01). This improvement is mainly from a 49% decrease in severe pain. There were no significant differences in the rate of complications associated with the ECV, in the rate of cesarean sections, or in perinatal outcomes. Furthermore, there were no severe complications secondary to N2O inhalation.

CONCLUSIONS

N2O inhalation at a concentration of 50% for analgesia during ECV decreases the level of severe pain experienced by women, appears to be safe both for mother and child, and has no influence on the success rate of ECV or the perinatal outcomes.

[Delivery in breech presentation: what way should we choose?]

BACKGROUND

The breech delivery is considered dangerous because of the higher rates of perinatal mortality and morbidity which become attached to it, consequences of obstetric traumas bound to the obstetric operations. What way of delivery is it necessary to privilege? What are the arguments which we have to support our choice?

AIM

To assess the maternal and fetal outcome according to the way of delivery.

METHODS

In this retrospective study, 194 women with a singleton pregnancy in a breech presentation delivered at term in our maternity unit in Ariana's Hospital from January 2007 to December 2009.

RESULTS

Breech presentation was noticed in 2, 59%. The main factors favoring this presentation are: the primipara, the uterine deformations, the pathological ponds, the abnormalities of the amniotic liquid, the fetal weight and the fetal deformations. Vaginal delivery was accepted in 57,7% of women and 75% from them delivered in natural way. The rate of caesarians was 56,7 %. Among these patients, 74, 5 % were indications in a cold caesarian (scar womb, pathological pond, RPM > 12 hours, estimated (esteemed) fetal weight > 3800g). The Apgar's score was superior to seven in 97.6% of cases. There was no significant difference in fetal morbidity, Apgar's score or in the need of transfer in intensive care unit.

CONCLUSION

When the acceptance conditions of the vaginal delivery are combined and when the surveillance of the labour is rigorous, it seems that there is no excess of neonatal risk by the natural ways.

Cephalic version by moxibustion for breech presentation

BACKGROUND

Moxibustion (a type of Chinese medicine which involves burning a herb close to the skin) to the acupuncture point Bladder 67 (BL67) (Chinese name Zhiyin), located at the tip of the fifth toe, has been proposed as a way of correcting breech presentation.

OBJECTIVES

To examine the effectiveness and safety of moxibustion on changing the presentation of an unborn baby in the breech position, the need for external cephalic version (ECV), mode of birth, and perinatal morbidity and mortality for breech presentation.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (26 March 2012), MEDLINE (1966 to 1 August 2011), EMBASE (1980 to August 2011), CINAHL (1982 to 1 August 2011), MIDIRS (1982 to 1 August 2011) and AMED (1985 to 1 August 2011) and searched bibliographies of relevant papers.

SELECTION CRITERIA

The inclusion criteria were published and unpublished randomised controlled trials comparing moxibustion (either alone or in combination with acupuncture or postural techniques) with a control group (no moxibustion), or other methods (e.g. external cephalic version, acupuncture, postural techniques) in women with a singleton breech presentation.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility and trial quality and extracted data. The outcome measures were baby's presentation at birth, need for external cephalic version, mode of birth, perinatal morbidity and mortality, maternal complications and maternal satisfaction, and adverse events.

MAIN RESULTS

Six new trials have been added to this updated review. One trial has been moved to studies awaiting classification while further data are being requested. This updated review now includes a total of eight trials (involving 1346 women). Meta-analyses were undertaken (where possible) for the main and secondary outcomes. Moxibustion was not found to reduce the number of non-cephalic presentations at birth compared with no treatment (P = 0.45). Moxibustion resulted in decreased use of oxytocin before or during labour for women who had vaginal deliveries compared with no treatment (risk ratio (RR) 0.28, 95% confidence interval (CI) 0.13 to 0.60). Moxibustion was found to result in fewer non-cephalic presentations at birth compared with acupuncture (RR 0.25, 95% CI 0.09 to 0.72). When combined with acupuncture, moxibustion resulted in fewer non-cephalic presentations at birth (RR 0.73, 95% CI 0.57 to 0.94), and fewer births by caesarean section (RR 0.79, 95% CI 0.64 to 0.98) compared with no treatment. When combined with a postural technique, moxibustion was found to result in fewer non-cephalic presentations at birth compared with the postural technique alone (RR 0.26, 95% CI 0.12 to 0.56).

AUTHORS' CONCLUSIONS

This review found limited evidence to support the use of moxibustion for correcting breech presentation. There is some evidence to suggest that the use of moxibustion may reduce the need for oxytocin. When combined with acupuncture, moxibustion may result in fewer births by caesarean section; and when combined with postural management techniques may reduce the number of non-cephalic presentations at birth, however, there is a need for well-designed randomised controlled trials to evaluate moxibustion for breech presentation which report on clinically relevant outcomes as well as the safety of the intervention.

Effects of Three Different Stimulations (Acupuncture, Moxibustion, Acupuncture Plus Moxibustion) of BL.67 Acupoint at Small Toe on Fetal Behavior of Breech Presentation

The aim of the study was to evaluate cardiovascular effects and fetal behavior during moxibustion, acupuncture or acupuncture plus moxibustion applied on the BL.67 acupoint of women (beside the outer corner of the 5th toenail) in fetal breech presentation. During the acupoint stimulation (20 min, two times a week), the women were submitted to computerized non-stress test. Fourteen cases were treated by both acupuncture and moxibustion, 15 cases by moxibustion and 10 cases by acupuncture. In 56% of cases, fetal position was converted from breech position to cephalic one; the success share was 80% for moxibustion, 28% for acupuncture, 57% for acupuncture plus moxibustion; the conversion, on average, was achieved after 3 sessions. Statistical analysis indicated that acupuncture plus moxibustion was able to reduce fetal heart rate during the application of stimuli while acupuncture and moxibustion separately did not affect such parameter. Moreover, moxibustion and acupuncture with moxibustion reduced fetal movements while acupuncture only appears ineffective. The present study suggests that fetal movements were reduced by both acupuncture plus moxibustion and moxibustion and that fetal heart rate was reduced just by acupuncture plus moxibustion. The mechanisms leading the effect on fetal heart rate and fetal movements remain to be clarified. Even though further studies are needed, such preliminar report mainly investigated the impact of different stimula on the BL.67 acupoint. Unfortunately these small series of data do not allow us to draw any conclusion about the effectiveness of the different treatments.

Mode of delivery in non-cephalic presenting twins: a systematic review

Purpose

This systematic review aims to determine if there are evidence-based recommendations for the optimal mode of delivery for non-cephalic presenting first- and/or second twins. We investigated the impact of the mode of delivery on neonatal outcome for twin deliveries with (1) the first twin (twin A) in non-cephalic presentation, (2) the second (twin B) in non-cephalic presentation and (3) both twins in non-cephalic presentation.

Methods

A computer-aided search of Medline, Embase, Cinahl and Cochrane databases was carried out and quality of the studies was assessed with the Cochrane Collaboration’s tool for assessing risk of bias and the GRADE approach.

Results

One high-quality clinical trial (60 twin pairs) and 16 moderate/low-quality observational studies (3,167 twin pairs) showed no difference in neonatal outcome between vaginal and caesarean delivery in twin A and/or B.

Conclusion

Our results do not suggest benefit of caesarean over vaginal delivery for selected twin gestations with twin A and/or twin B in non-cephalic presentation. However, no final conclusion can be drawn due to the small sample sizes and statistic limitations of the included studies. Randomized studies with sufficient power are required to make a strong recommendation.

[Who limit vaginal birth for breech presentation: medical practice or Law? Discussion between a medical doctor, a lawyer and the head chief of an university hospital]

The mode of delivery of breech presentation still remains a debate in France. Despite the medical arguments, themselves in debate, exists a legal pressure felt by medical practitioners. Our study highlights the different opinions of medical practitioners, lawyers and medical teachers faced with breech presentation.

[Case analysis on problem-based learning of acupuncture: "a turning round before birth"]

"A turning round before birth" is a problem-based learning (PBL) case in Chinese medicine education. It focuses on malposition of fetus, through discussion on a series of questions, types and causative factors of malposition of fetus could be comprehended, diagnostic time and methods are set up, and manipulations of moxibustion at Zhiyin (BL 67) for malposition of fetus can be mastered. Mechanism on position correction is explored, and key points in application are clarified. Therefore, methods of position correction with easy, safe and effective manipulations can be popularized as well as the PBL methods in education of Chinese medicine.

Vaginal breech delivery in very low birth weight (VLBW) neonates: experience of a single center

AIMS

To compare the short-term maternal and neonatal outcomes of very low birth weight (VLBW) breech singletons by mode of delivery.

METHODS

All breech fetuses born from 24-0/7 to 26-6/7 weeks' gestation at our institution between 2000 and 2008 were eligible for the study. Abstracted medical record data included maternal demographics, delivery data, and neonatal outcomes.

RESULTS

There were 26 vaginal and 39 cesarean deliveries. Maternal age did not differ between groups; gestational age was greater in the cesarean group by five days. Short-term neonatal outcomes did not differ between groups. Of the 39 cesarean deliveries, 27 involved classical uterine incisions. Estimated blood loss (732 mL vs. 362 mL) and postpartum infection rate (26% vs. 4%) were greater with cesarean delivery.

CONCLUSION

Neonatal outcome is not improved in VLBW infants born by cesarean section. Given the morbidity of classical cesarean sections, vaginal delivery of the breech VLBW infant may be safely considered.

Perinatal outcomes of singleton term breech deliveries in Basra

This study aimed to assess the perinatal morbidity and mortality in breech deliveries, to study the correlation of parity and birth weight with perinatal mortality by mode of delivery. Of 210 women in labour in Basra maternity and child hospital, 97 underwent vaginal breech deliveries and 113 delivered by caesarean section. Birth trauma was restricted to vaginal deliveries. The perinatal mortality was significantly higher in vaginal deliveries (8.2%) compared with caesarean deliveries (0.9%). A higher perinatal mortality was recorded among infants > 3500-4000 g birth weight in vaginal deliveries. Caesarean section reduced the perinatal mortality in both nulliparous and parous women in term breech infants.

External cephalic version with an amniotic fluid index ⩽10: A systematic review

OBJECTIVE

To review the literature and evaluate the role of the amniotic fluid index (AFI) on the success of an external cephalic version (ECV).

STUDY DESIGN

A computerized search of MEDLINE and Cochrane databases were conducted using 'breech', 'version', 'external cephalic version', 'amniotic fluid', and 'amniotic fluid index'. References from the identified publications were manually searched to identify additional relevant articles. Articles from 1987 to 2004 were included.

RESULTS

Of the initial 33 articles discovered, only three remained after exclusions. These articles used different AFI ranges for 'borderline' or 'low-normal' fluid measurements and therefore could not be combined for analysis. All three studies demonstrated a lower success rate of ECV with lower amniotic fluid volume estimates (AFI 5-8, <10, or <8.6), although none reached statistical significance.

CONCLUSION

Due to limited and dissimilar data, it is impossible to define the lower AFI threshold for an unsuccessful ECV compared with the success of a normal AFI. Although not statistically significant, an AFI <10 may correlate with lower success rates for an ECV.

How useful is external cephalic version in clinical practice?

We reviewed retrospectively all women with a singleton breech presentation after 36 weeks' gestation who were referred for an external cephalic version (ECV) in the 3 years from 2001 - 2003. The number (n = 107) referred was low and the overall success rate of 24.5% was also low. Over the 3 years, our practice of ECV prevented only 15 caesarean sections and thus made little contribution to reducing the hospital's overall caesarean section rate. This audit highlights the need for a review of current practices in our hospital. ECV is recommended by the guidelines of the RCOG and it is a concern that the results achieved by enthusiasts of ECV may not be achieved in everyday obstetric practice.

External cephalic version (ECV): Experience in a sub-Saharan African hospital

External cephalic version (ECV) is not a popular procedure in developing countries such as Nigeria. Over a 3-year period, we prospectively studied women who had ECV in a Nigerian University Teaching hospital. Comparative analysis was made between the successful ECV and the unsuccessful ECV groups. Following adequate counselling, Nigerian women were willing to accept an ECV for the singleton term breech. The ECV success rate was 67%. Favourable factors for success were multiparity (Relative Risk, RR 3.8; 95% confidence interval, CI 1.14 - 12.1), flexed breech (RR 2.4; 95% CI 1.02 - 5.7), unengaged breech (RR 4.8; 95% CI 1.3 - 17.2), normal liquor volume (RR 4.8; 95% CI 1.3 - 17.1) and a posterior placenta (RR 6.8; 95% CI 2.8 - 16). Once turned, 97% of the babies remained cephalic until delivery. The caesarean section rate in each group was higher than the unit rate of 12.7%. There was one fetal death from cord prolapse in the vaginal breech delivery group.

Ultrasound factors to predict the outcome of external cephalic version: a meta-analysis

OBJECTIVE

To systematically review the medical literature reporting on ultrasound factors that can be predictive for the outcome of an attempt at external cephalic version (ECV).

METHODS

MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials were searched. Studies reporting on potential ultrasound prognosticators and ECV success rates that allowed construction of a 2x2 table were selected.

RESULTS

We selected 37 primary articles reporting on 7709 women. Posterior placental location (odds ratio (OR), 1.9; 95% CI, 1.5-2.4), complete breech position (OR, 2.3; 95% CI, 1.9-2.8) and an amniotic fluid index>10 (OR, 1.8; 95% CI, 1.5-2.1) were predictors of successful ECV.

CONCLUSION

Success of an ECV attempt is associated with ultrasound parameters such as fetal position, amniotic fluid and placental location. This knowledge can be used to develop a prognostic model to predict successful ECV.