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• Complete Breech (5% - 10%) = hips flexed, knees flexed (foot may be adjacent to or just below buttocks)

• Footling or Incomplete (10% - 30%) = one or both hips extended, foot or knee presenting

• Frank Breech (50% - 70%) = hips flexed, knees extended

22nd Edition 2015

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A 2009 study by Andersen indicated that breech presentation alone is a risk factor for cerebral palsy (independent of mode of delivery) when compared with cephalic presentation

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When deciding the timing, the pros/cons should be discussed with the patient.

1022nd Edition 2015

• Although the success rate of ECV declines as gestational age advances, may be attempted up until labour

• ECV may be attempted in early labour if membranes are intact and the uterus remains relaxed long enough between contractions

1122nd Edition 2015

Emphasis all of these contraindications, placing importance on the absolute ones

1222nd Edition 2015

The relative contraindications listed above negatively impact on the likelihood of ECV being successful and need to be considered when planning whether or not to attempt ECV. It has also been shown that ECV is somewhat less likely to be successful with an anterior placenta, although this is not statistically significant.

External cephalic version appears to be safe after one CS with a low transverse uterine incision. There are very limited data on the safety of ECV after two or more CS.

May attempt in early labour if uterus is relaxed between contractions.

1322nd Edition 2015

Emphasize importance of having delivery capabilities close by and available. Reemphasize importance of waiting till mature fetus to attempt for this reason.

Risk of fetal bradycardia is low but real

Know the blood group of the woman

Risks are less than vaginal delivery

1422nd Edition 2015

The patient should be informed that:

• Successful ECV will reduce the chance of a CS (success varies widely from 30% - 80%)

• Sedation and tocolysis may be used

• The procedure may be uncomfortable

• There are risks to the procedure (see above)

1522nd Edition 2015

ECV Procedure

• Dislodge buttocks from the pelvis, pushing upwards and then laterally

• Grasp the head and direct it downwards

• Slowly rotate the baby by pushing upwards and to the side of the fetal back with the hand holding the buttocks, at the same time guiding the head downwards and to the opposite side

• When the head reaches a lower level than the buttocks, manoeuvre the head over the pelvic inlet

• If the forward roll attempt fails, may attempt backward roll

• An assistant may be helpful to facilitate the ECV

1622nd Edition 2015

Most atypical and abnormal FHR patterns will resolve. If the FHR doesn’t recover with intrauterine resuscitation, an emergency C/S must be done.

Administer Rh immunoglobulin 300 micrograms to unsensitized Rh-negative women. Routine assessment with the Kleihauer-Betke test for the possibility and degree of fetomaternal bleed is not necessary since it has been shown that only 0.08% of bleeds with ECV will be greater than 30 ml (300 micrograms of Rh immunoglobulin will cover up to a 30 ml bleed)

1722nd Edition 2015

Tocolytics – 2012 Cochrane Review – Beta-mimetic drugs (not available in Canada) superior to placebo, nifedipine and nitroglycerine, but effectiveness needs to be weighed against adverse maternal effects. No benefit of nifedipine or nitroglycerine over placebo. Authors concluded there was enough evidence on nitroglycerine to recommend against its use.

The trial on using regional analgesia also showed a trend toward fewer CS (48% vs 59%)

Moxibustion is a traditional medicine technique involving the burning of sticks or cones of the herb moxa close to the pressure point on the 5th toe in order to induce a warming sensation that in turn has been suggested to promote turning of the baby to cephalic position.

1822nd Edition 2015

This data will all be further discussed in the slide on the term breech trial revisited

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Reference paper – point #2

2122nd Edition 2015

7 of 16 perinatal deaths were growth restricted infants

1/3 of infants were monitored with EFM

Prolonged labour for 1st and 2nd stage

No ultrasound required

13% did not have an experienced caregiver

2222nd Edition 2015

• Prospective data from 8105 women in 174 centers in France and Belgium

• Provides estimate of the risk of a cautious breech TOL in a modern, well-supported obstetrical unit.

Goffinet F, Carayol M, Foidart JM, Alexander S, Uzan S, Subtil D, et al. Is

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However, the short-term neonatal morbidity nearly always resolves and any increase in perinatal mortality is small. Although perinatal mortality in developed countries was not significantly different between the arms of the Term Breech trial, two delivery-related perinatal deaths occurred in 511 labours versus none in the planned CS group: a point estimate of 1/250. In the PREMODA study, there was no delivery-related perinatal deaths in 2502 labours.

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2522nd Edition 2015

Consider having a vaginal breech protocol in your unit

Clinical pelvic examination should be performed to rule out significant pelvic contraction. Radiologic pelvimetry is not necessary for a safe trial of labour; good progress in labour is the best indicator of adequate fetal-pelvic proportions.

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• Team needs to be available

• Skilled personnel in attendance

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Avoid hyperextension of fetal head

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