Breech presentation
Hung N. Winn, Frank A. Chervenak, Roberto Romero in Clinical Maternal-Fetal Medicine Online, 2021
Breech presentation is a significant obstetric event associated with dramatic increases in perinatal morbidity and mortality (1,2). The three areas of greatest risk for these infants are the often overlapping problems of preterm delivery, congenital anomalies, and birth trauma. More than one quarter of breech-presenting fetuses are premature. Concomitantly, severe or lethal anomalies further complicate up to 20% of such preterm deliveries and fully 6% to 7% of term breech deliveries (a relative risk of three- to fivefold), depending on gestational age. The outcome of vaginal breech delivery has always been noted to be associated with a higher risk of neonatal injury with both short-term and long-term morbidity as well as an increased risk of neonatal death. These risks have led to numerous attempts to evaluate the risk of vaginal breech delivery versus that of elective cesarean delivery for the persistent breech at term. The results of studies published prior to the Term Breech Trial (TBT) (3) in 2000 were inconclusive with some showing no increased risk of vaginal breech delivery and some showing an increased risk of fetal injury and death in those infants delivered vaginally. These studies were, for the most part, small and retrospective, which left room for error in their conclusions. In 2000 the publication of the TBT, a randomized, multinational multi-center trial that incorporated all levels of care in both advanced and developing countries, demonstrated a clear benefit to the delivery of the term fetus in a breech presentation by elective cesarean.
Pre-conceptual and antenatal care
Helen Baston in Midwifery, 2020
As the pregnancy progresses the woman and the midwife may need to change the original plans to accommodate a change in need. The midwife may detect, during an antenatal check-up, that the fetus is no longer presenting head first but is presenting by the breech. The midwife would then need to explain the options available to the woman so that a new plan can be put in place. For example, women who have straightforward pregnancies but a breech presentation should be offered the option of having the baby turned, a procedure known as ‘External Cephalic Version’ (ECV). Performed at the maternity unit by a skilled practitioner, this should only be performed under scan guidance to prevent cord entanglement and to confirm that a cephalic presentation is not inadvertently turned to become a breech. There is also a small chance of bleeding or fetal distress so this should only be performed when the pregnancy is at full term and with the option of having an emergency caesarean section urgently should any complication arise. The woman would also need to know what would happen if ECV was not successful and in what circumstances a vaginal breech birth might be possible. Changes to the plan of care might need to be accommodated such as changing from a home birth to a planned caesarean section if a vaginal breech is contraindicated for some reason.
Assisted Vaginal Breech Delivery
Sanjeewa Padumadasa, Malik Goonewardene in Obstetric Emergencies, 2021
In breech presentation, the buttocks or one foot or both feet of the fetus instead of the head are present at the maternal pelvis. It is the most common malpresentation, with an incidence of 3–4% of all the deliveries at term. External cephalic version is recommended after 36 weeks of gestation in order to reduce the number of breech presentations at term (discussed in Chapter 27). Since the publication of the ‘Term Breech Trial’ back in the dawn of the 21st century, many obstetricians worldwide have opted to deliver ‘breech babies’ using the scalpel rather than trusting their skills and choosing to vaginally deliver these babies instead. This has deskilled the modern-day obstetrician to such an extent that he/she may be incapable of performing even the most straightforward assisted vaginal breech delivery (AVBD), if and when the need arises. There has been concern regarding the conduct, interpretation and applicability of the ‘Term Breech Trial’, and in addition, there is evidence that supports AVBD as a safe method in delivering certain ‘breech babies’ after careful selection of cases. Therefore, AVBD continues to be performed safely and frequently in many centres around the world. Furthermore, due to poor antenatal clinic attendance or rarely even misdiagnosis as a cephalic presentation antenatally, a woman in advanced labour may be detected to have a previously undiagnosed breech presentation, at which point it may be too late and risky to perform a caesarean delivery. In addition, some women, especially multigravida, make an informed choice to deliver their ‘breech babies’ vaginally. Therefore, the skill of performing an AVBD is an essential one to possess.
Vaginal birth in breech presentation in morbidly obese woman
Published in Journal of Obstetrics and Gynaecology, 2018
Milan Stefanović, Bojan Lukic, Ranko Kutlešić, Predrag Vukomanović
Breech presentation at term occurs in about 3–4% of pregnant women (Walker 2013). From the literature to-date, we could only identify one case‐control study of the effectiveness of the all‐fours position for vaginal breech birth (Bogner et al. 2015). This study showed that vaginal breech birth in the all‐fours position was accomplished spontaneously in 70.7%. In 19.5% assisting manoeuvres were deemed necessary. Severe perineal injury was reported less often in women who gave birth on all-fours (14.6%) when compared to the matched control group of women who gave birth in lithotomy position (58.5%). However, this study does not refer to morbidly obese women. Keeping in mind the risks, being aware of the safety of both the woman and the infant and having the woman’s consent, we judged to the best of our professional ability that the all-fours position would be the safest way of delivery, although the continuous CTG monitoring could not be done and vaginal examination was unusual due to obesity. Our decision is consistent with the latest RCOG guidelines (Impey et al. 2017).
Hypoplasia of the Corpus Callosum: A Single Center Experience and a Concise Literature Review
Published in Fetal and Pediatric Pathology, 2021
Valentina D'Ambrosio, Chiara Boccherini, Lucia Manganaro, Pierluigi Benedetti Panici, Raffaella Cellitti, Flaminia Vena, Cristina Pajno, Sara Corno, Roberto Brunelli, Antonella Giancotti
A 32-years old woman G2P1 was admitted to our high-risk pregnancy unit at 35 weeks of gestation. Her past medical history was unremarkable. The first-trimester US screening and the mid-trimester anomaly scan were normal. The US scan performed at 35 weeks of gestation highlighted a unilateral borderline ventriculomegaly, a thin CC and elevated amniotic fluid levels (CC width: 4.8 mm). Genetic counseling was offered, but she refused amniocentesis and therefore no fetal karyotype was obtained. For a better evaluation a fetal brain MRI was also performed at 36 weeks of gestation. US findings were confirmed and a pachygyria was also described. A cesarean section at 39 weeks of gestation was performed due to breech presentation. A live boy in good general condition was delivered (the weight was 2798 gr, Apgar 9-10 at 1 and 5 minutes, respectively). The postnatal US and MRI evaluation confirmed the antenatal diagnosis. The six months neurological examination was normal although the ultrasound and clinical follow-up highlighted a head circumference smaller than expected (Figure 2). At 1 year, the child did not reach the developmental milestones expected for age: he does not sit or stand unassisted and does not walk with assistance.
Utilization of epidural volume extension technique for external cephalic version
Published in Baylor University Medical Center Proceedings, 2021
Hanna Hussey, James Damron, Mark F. Powell, Michelle Tubinis
Repeat ultrasound demonstrated breech presentation, normal amniotic fluid volume, and fetal head toward the maternal left abdomen. After 0.25 mg of intramuscular terbutaline injection, a forward roll was initiated by applying pressure from behind the fetal head toward the maternal left. Continuous progress was made and bedside ultrasound showed cephalic presentation. Immediately after successful ECV, the fetal heart rate was 70 beats/min but returned to baseline with conservative measures. Motor blockade regressed after approximately 1.5 hours. After 4 hours of fetal heart rate monitoring and tocometry, the patient was deemed stable for discharge. Follow-up discussion with the patient via phone call on postprocedure day 1 confirmed that she was not experiencing pain or concerning symptoms for neuraxial complications. She returned to the labor and delivery unit at 40 weeks’ gestation for elective induction of labor and had a successful vaginal delivery.
Related Knowledge Centers
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- Stillbirth
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- Caesarean Section
- Vaginal Delivery
- Midwife
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- Smith–Lemli–Opitz Syndrome
- Fetal Alcohol Spectrum Disorder