Breech Management at Term

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BACKGROUND

The incidence of breech presentation at term is between three to four percent, althougha widespread policy of external cephalic version close to term might be expected to lowerthis incidence. Associated with this malpresentation is an increased frequency of perinatalmortality and morbidity, due principally to prematurity, congenital anomalies and birth

trauma/asphyxia. Numerous authors have suggested that a policy of elective Caesareansection (CS) for the breech at term would minimize perinatal mortality and morbidity, whileconceding an inevitable increase in morbidity for the mother.*

The evidence for this recommendation is based largely on the results of imperfect data,seriously compromised by selection bias. Hospital audits, which reveal the outcomes forvaginal breech deliveries and those delivered by CS, rather than comparing a policy ofelective CS with a policy of selective, planned vaginal birth, have been used to bolsterthe case for elective CS.3 Those studies which show higher rates of perinatal mortalityand morbidity with vaginal delivery do not emphasize, or completely ignore, the cruciallyimportant issues of judicious selection of patients, the appropriate intrapartum

management, and the skill, experience and judgment of the obstetric attendant.* In theonly randomized trials comparing elective CS and planned vaginal delivery, there was nodifference in mortality between the two groups, no difference in low Apgar scores, but anincrease in short term neonatal morbidity in those delivered vaginally.4 These trials were,however, much too small to provide a definitive answer to the question of which policyis associated with a lower incidence of perinatal mortality and morbidity, although it isclear that a policy of elective CS is associated with increased maternal morbidity.

It is evident, therefore, that this important question cannot be properly answered withouta well-designed randomized controlled trial comparing these two policies, with a samplesize of sufficient magnitude that a significant difference in morbidity and mortality, if it

exists, will be detected. The question is deemed to be important because it affects threeto four percent of all pregnant women reaching term (in Canada, this is approximately11,000 to 14,000 women per year); the policies being compared include the issues ofmajor abdominal surgery versus vaginal birth; the survival of the infant free from injuryand neurologic deficit, a matter of primary concern to the parents, the child, the physicianand society; and an answer to the question will have an important influence on clinicalpractice and postgraduate training programmes in obstetrics in this country andelsewhere. Because there has been a gradual trend in many centres towards the use ofelective CS for breech presentation at term, the number of physicians who possess orhave retained the skills to perform vaginal breech deliveries is diminishing, and it isinevitable that within a relatively short time, with fewer and fewer trainees having the

opportunity to acquire these skills, they will be lost forever, and women will be denied theoption of a vaginal birth if their fetus presents by the breech.


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Prior to any serious consideration of developing a proposal for a large, randomizedcontrolled trial comparing these two policies, an essential prerequisite is the developmentof a strong consensus on the important issues associated with the management ofpatients with a breech presentation at term in whom a planned vaginal birth is beingconsidered. There is no evidence that any such consensus exists.

Accordingly, plans for the organization of an International Workshop to develop such aconsensus were begun in the late summer of 1993 by a Steering Committee formed atthe University of Toronto for that purpose - (Walter Hannah, Mary Hannah, Knox Ritchie,Kofi Amankwah, Mary Cheng, Paula Penkin and Sheila Hewson . Twelve obstetriciansfrom across Canada, the United Kingdom, and Ireland were invited to participate, alongwith the members of the Steering Committee, in the Workshop whose principal objectivewas to develop a protocol for the selection and intrapartum management of women atterm with a breech presentation, in whom a planned vaginal birth would be considered.

A secondary objective was to consider the feasibility of a large, international randomized,controlled trial, comparing a policy of elective CS with a policy of planned vaginal birth

in term breech presentation. All those who were invited were known by members of theSteering Committee to have a keen interest in this problem, and all of them respondedpositively to the invitation to participate.

The Workshop was planned for January 15/l 6, 1994 in Toronto, and in preparation forthis event, the participants were provided with the following information to facilitate thediscussions that would take place:

1. The objectives of the Workshop

2. Summaries of a comprehensive literature review prepared by members of

the Steering Committee

3. A questionnaire designed to determine their position on a number of issuesconcerning the selection and intrapartum management of term breechpresentations which would be discussed at the Workshop

4. A list of Workshop participants

Funding to support the costs of the Workshop was provided from three granting agencies-Medical Research Council of Canada; Institute for Clinical Evaluative Sciences; and theFoundation of the Hospital for Sick Children, and this support is gratefully acknowledged.


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THE WORKSHOP PROCEEDINGS

There was general agreement at the outset that the objective of developing a realistic,workable protocol for the selection and intrapartum management of women at term withbreech presentation could best be met by extensive reliance on the findings from thescientific literature, together with the substantial collective experience of the Workshopparticipants themselves. Further, it was recognized that the protocol must be acceptableto all practisingclinicians. For this reason, we must err on the side of caution on thoseissues where research evidence was either lacking or equivocal.

It was also agreed that consensus was not necessarily synonymous with unanimity, butelements of the proposed protocol did require overwhelming support before they wouldbe endorsed by the Workshop participants.

A. SUMMARY OF THE BREECH QUESTIONNAIRE RESPONSES

Prior to the Workshop, the participants were asked to respond to a series of questionsdirectly related to those matters which influence selection and management of termbreech patients, and which would be discussed at the Workshop. The purpose of thisquestionnaire was to determine those areas where considerable agreement alreadyexisted and those where it did not, acknowledging that the responses represented theparticipants initial position and that they might change as a result of the consensus-building process itself.

A summary of the questionnaire responses was presented at the start of the Workshop,and as expected, some issues were characterized by almost universal agreement whileothers showed considerable divergence. This knowledge allowed for an increasedallocation of time to the more controversial matters and reduced discussion time to thosematters which already enjoyed a strong consensus, although as might be expected, thisdid not always happen.

B. DEVELOPMENT OF THE PROTOCOL

In coming to grips with the principal objective of the Workshop, it was agreed that wewould subdivide the protocol elements into two separate categories:

a) Selection Criteria

b) lntrapartum Management

We would then deal with the items in each of those categories on an individual basis,continuing the discussion until consensus was reached. For each item, Dr. Mary Cheng,who had assumed responsibility, along with Drs. Paula Penkin and Mary Hannah, forproviding the participants with a comprehensive review of the literature, summarized theevidence on that particular item. The item was then open for general discussion, and thisincluded the opportunity for participants to provide the group with data from their own


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units which might have a bearing on the matter at hand. In those circumstances wherethe questionnaire responses had revealed a divergence of views, debate was lively butconstructive. On those issues where the literature was persuasive, consensus was mostoften reached early, but when that was not the case and particularly in those situationswhere there appeared to be no difference between two different approaches, theparticipants agreed to avoid imposing a single approach.

The following paragraphs outline the conclusions reached by the participants, on thebasis of the published scientific literature, their own clinical experience and that of theircolleagues, and as a result of the thoughtful exchange of ideas made possible by theWorkshop forum. A brief summary of the issues discussed will be included to assist thereader in understanding how the conclusions were reached.

a) SELECTION CRITERIA

I. Type of Breech Presentation

The literature showed a significantly increased perinatal mortality/morbidity in footlingbreech, due principally to an increased incidence of cord prolapse, and entrapment of theaftercoming head by an incompletely dilated

cervix.53

This was in accord with the clinicalexperience of the participants.

It was agreed that complete breech should be defined asflexion

of hips and knees, butthat the feet should not lie below the fetal buttocks.

CONCLUSION: ONLY THOSE WOMEN WHOSE BREECH IS EITHER FRANK ORCOMPLETE SHOULD UNDERGO A TRIAL OF L BOUR IN ANTICIPATION

OF A VAGINAL DELIVERY.

2. Influence of Parity

There was virtual unanimity that parity should not influence a decision for planned vaginalbirth, and this was supported by the

Iiterature.7 12 142g

It was pointed out, however, by oneparticipant that, in his unit, over a twenty-year period (1972 to 1991), perinatal mortalitywas higher in primigravid breech presentation delivered vaginally, than in multiparas,although these figures included breech presentation at all gestational ages. Thus, parityshould be considered as a separate factor in the analysis of vaginal breech outcome.

CONCLUSION: IT IS REASONABLE TO ALLOW A TRIAL OF LABOUR IN BREECH

PRESENTATION AT TERM IN BOTH NULLIPARAS AND MULTIPARAS.


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3. Maternal Age

A careful review of the literature failed to show any relationship between adverse perinataloutcome and maternal age, in the absence of other risk factors, which, by themselves,might lead to increased perinatal mortality/morbidity.0~2P26~30 It was acknowledged that the

conventional view that elderly gravidas, especially primigravidas, should likely be bestdelivered abdominally is based more on anecdotal and emotional grounds than onscientific evidence. In fact, it was felt by most to be a reflection of the widespread beliefthat a breech presentation, in association with any perceived risk factor, should promptserious consideration for CS, when this view would not necessarily apply in the case ofcephalic presentation. After thoughtful refectionof this matter, there was agreement thatthere was simply no evidence for this position, unless the risk factor was likely to lead tomechanical problems at delivery.

CONCLUSION: IN THE ABSENCE OF ANY OTHER RISK FACTORS, MATERNAL

AGE ALONE SHOULD NOT PRECLUDE PLANNED VAGINAL BIRTH.

4. Pelvlmetry

The research literature revealed that X-ray pelvimetry figured prominently in protocols forplanned vaginal birth, and often included lower limits for pelvic dimensions. Nevertheless,none of these studies was able to confirm the value of this examination in selecting thosewomen who are more likely to succeed in a trial of labour nor has it been shown to haveany effect on perinatal outcome.12~2g 3~4 Concern was expressed about womens anxietyabout radiologic exposure, as well as the reduced level of expertise in performing thisexamination in most Canadian centres. Documentation of pelvic adequacy by clinicalassessment was felt to be important, but a part of normal obstetric practice.

CONCLUSION: X-RAY PELVIMETRY SHOULD NOT BE A PREREQUISITE FOR

PLANNED VAGINAL BIRTH.

5. Ultrasonography (U/S)

Because ultrasonography provides a wealth of important information in term breechpresentation (congenital anomalies, type of breech, hyperextension of fetal head, cordposition, estimated fetal weight (EFW), and amniotic fluid volume), it was felt that thisexamination should be performed before making a decision for planned vaginal birth.42 43It is recognized, however, that predicting EFW by ultrasonography is imprecise and hasnot been shown to be of any greater value in the term fetus than clinical assessment,especially in suspected macrosomia.30 Nevertheless, because there is evidence that abirthweight greater than 4,000 gms may be associated with increased perinatalmortality/morbidity due to mechanical difficulties at delivery, it was felt that plannedvaginal birth should be restricted to those cases where the EFW, by U/S or clinicalassessment, is less than 4,000 gms10 27 37 44 47. If the diagnosis of breech presentation ismade for the first time in labour and the estimate of fetal weight, by clinical examinationor U/S, is greater than 4,000 gms, delivery by CS is recommended. Hyperextension of


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the fetal head is associated with significant perinatal mortality and neonatal neurologicmorbidity when vaginal delivery is undertaken.348-53

CONCLUSION: WHEN BREECH PRESENTATION IS DIAGNOSED ATTERMBEFORELABOUR, ULTRASONOGRAPHY IS RECOMMENDED. TRIAL OF LABOUR IS

REASONABLE IF EFW, BY CLINICAL OR U/S ASSESSMENT, IS JUDGED TO BELESS THAN 4,000 GRAMS, AND IF THERE IS NO HYPEREXTENSION OF THEFETAL HEAD. FOR THE BREECH DIAGNOSED IN LABOUR FETAL ATTITUDE CANBE ASSESSED CLINICALLY, BY U/S OR BY X-RAY. BREECH PRESENTATION, IN

WHICH HYPEREXTENSION OF THE FETAL HEAD IS DIAGNOSED, SHOULD BE

DELIVERED BY CS.

6. Medlcal/Obstetrlcal Complications

As indicated earlier, there is no scientific evidence to support the belief that breechpresentation in association with another risk factor such as mild pre-eclampsia, post-termpregnancy etc. should preclude a trial of labour unless that risk factor is likely to beassociated with mechanical difficulties at delivery.0V27V37V44 47

CONCLUSION: THE PRESENCE OF MEDICAL OR OBSTETRIC COMPLICATIONSSHOULD NOT PRECLUDE A TRIAL OF L BOUR UNLESS THE COMPLICATION IS

LIKELY TO LEAD TO MECHANICAL DIFFICULTIES AT DELIVERY.

B) INTRAPARTUM MANAGEMENT

7. Induction of Labour

Nowhere in the literature was there any evidence to justify a prohibition of induction oflabour in term breech when there was a medical or obstetric indication to doso.

2017 2g 3g 53-56 Conversely, breech presentation, by itself, is not an indication for induction.The usual precautions advised for vaginal breech delivery and for induction of labourshould be observed.

CONCLUSION: BREECH PRESENTATION ALONE IS NOT A CONTRA-INDICATIONTO MEDICALLY INDICATED INDUCTION OF LABOUR

8. Augmentation of Labour

There are no scientific data to preclude the judicious use of oxytocin augmentation to

correct inadequate uterine activity.5 i792102g 34 3g045V54V55 57 5g Because there was concernamong some of the participants about the possible relationship between a reduction inuterine activity and feto-pelvic disproportion, especially in the multiparous woman, everyeffort should be made to exclude such disproportion before resorting to augmentation.

Although it must be said that such disproportion, in the case of cephalic presentation, ismost appropriately recognised by failure of dilatation of the cervix or descent of thepresenting part in the presence of adequate contractions, there was a strong feeling


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among some of the participants that this was not necessarily the case with breechpresentation. Unlike cephalic presentation, oxytocin should not be used to overcomerelative feto-pelvic disproportion.

CONCLUSION: CAREFUL OXYTOCINAUGMENTATION OF LABOURTO CORRECT

INADEQUATE UTERINE ACTIVITY IS REASONABLE PRACTICE, PROVIDED THATCAUTION IS EXERCISEDTO EXCLUDE FETO-PELVIC DISPROPORTION THlS IS OF

PARTICULAR IMPORTANCE IN THE MULTIPAROUS WOMAN.

9. Limits to Duration of Labour

On the basis of the published literature, and the collective experience of the participants,it was not felt that there should be a limit to the duration of the first stage of labourprovided that there is continued progress of at least 0.5 cm./hour in cervical dilatationafter reaching 3 cm dilatation. Unlike labour in cephalic presentation, progress slowerthan this was felt to be a sign of potential feto-pelvic disproportion. These views are

based on those studies which show an increase in adverse perinatal outcome whereactive labour is prolonged beyond 20 hours.0~2~28~3g~40~41~60

As in cephalic presentation, active pushing should not be encouraged until the breech hasdescended to the pelvic floor. If the breech has not descended to the pelvic floor after twohours in the second stage without active pushing, or if vaginal delivery is not imminentafter one hour of active pushing, CS is recommended. This admonition is based on thecollective view of the participants that abnormal prolongation of the second stage of labour in a breech presentation is a strong indication of potential feto-pelvic disproportion.

CONCLUSION: THERE SHOULD BE NO LIMIT TO THE DURATION OF THE FIRSTSTAGE OF LABOURAS LONG AS CERVICAL DILATATION IS PROCEEDING AT A

RATE OF AT LEAST 0.5 CM/HOUR AFTER THREE CM DILATATION. CAESAREAN

SECTION IS RECOMMENDED IF THE BREECH HAS NOT DESCENDED TO THE

PERINEUM IN THE SECOND STAGE OFL BOUR

AFTER TWO HOURS, IN THE

ABSENCE OF ACTIVE PUSHING, OR IF VAGINAL DELIVERY IS NOT IMMINENT

AFTER ONE HOUR OF ACTIVE PUSHING.

10. lntrapartum Fetal Monitoring

In view of the extensive literature, of excellent quality, casting doubt on the superiority ofcontinuous electronic fetal monitoring (EFM) over properly performed intermittentauscultation (IA) in both low-risk and high-risk labouring women, there was general

agreement that breech presentation, by itself, was not an indication for continuous EFM-66.In those units where this form of monitoring is used for patients at risk, it can be usedfor the same indications as for cephalic presentation. The point was made that continuousEFM might detect cord prolapse earlier than IA, leading to the second part of therecommendation incorporated in the following conclusion.


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CONCLUSION: BREECH PRESENTATION, BY ITSELF, IS NOT AN INDICATION FORCONTINUOUS EFM, WHICH MAY BE USED FOR THE SAME INDICATIONS AS FORCEPHALIC PRESENTATIONS. VAGINAL EXAMINATION SHOULD BE PERFORMEDAS SOON AS POSSIBLE AFTER SPONTANEOUS RUPTURE OF MEMBRANES TOEXCLUDECORDPROLAPSE.

11. Analgesla/Anaesthesla

While epidural analgesia/anaesthesia is a favourite choice of all the participants, there isno convincing evidence that it offers any unique advantages for term breech presentation,and it may be associated with some prolongation of the second stage.7~30~31~53~67~71

CONCLUSION: THE TYPE OF PAIN RELIEF SHOULD BE INDIVIDUALIZED AFTER

DISCUSSION WITH THE PREGNANT WOMAN. BREECH PRESENTATION, BYITSELF, IS NOT AN INDICATION FOR, OR GROUNDS FOR WITHHOLDINGEPIDURAL ANAESTHESIA.

12. Amnlotomy

A policy of deliberate amniotomy versus membrane preservation in established labourdoes not appear to influence perinatal outcome.6,72-74

CONCLUSION: AMNIOTOMY MAY BE PERFORMED FOR THE SAME INDICATIONSAS IN CEPHALIC PRESENTATION.

13. Delivery Technique

The published literature and the collective experience of the participants leave no roomfor doubt that total breech extraction has no place as a method of delivery in the term,singleton breech. Perinatal mortality and morbidity are significantly increased when this liv ry

m tho is

u~ed.Q~~0~~2~~5~~7~22 26 2Q 75 79 Assisted breech delivery is the preferredmethod, although spontaneous delivery is acceptable as long as control of theaftercoming head is maintained. The important elements of assisted breech delivery are:no intervention until there has been spontaneous exit of the infant to the umbilicus;minimum intervention thereafter with no traction on the body, and controlled delivery ofthe aftercoming head, either with the use of forceps or the Mauriceau-Smellie-Veitmanoeuvre.

CONCLUSION: ASSISTED BREECH DELIVERY IS STRONGLY RECOMMENDED ASTHE DELIVERY METHOD OF CHOICE, IN ASSOCIATION WITH THE USE OFFORCEPS OR MAURICEAU-SMELLIE-VEIT MANOEUVRE FORTHE AFTERCOMING

HEAD. TOTAL BREECH EXTRACTION SHOULD NOT BE PERFORMED AS A

DELIVERY METHOD IN THE SINGLETON BREECH.


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14. intrapartum Consultation

Extensive discussion took place concerning the desirability and feasibility of providing aback-up system in obstetric units whereby a second obstetrician could be available in theobstetric unit for the second stage and delivery of a term breech. This was thought bymany of the participants to be of particular value in those circumstances where theattending obstetrician might appreciate the presence of additional expertise from acolleague, especially when that individual is more experienced in vaginal breechmanagement. While there was general acknowledgment of the value of such anarrangement, it was equally recognized that, for many smaller units, this may not befeasible. Nevertheless, the value of intrapartum consultation with an experiencedcolleague cannot be denied and should be encouraged.

CONCLUSION: RECOGNIZING THAT THE TRAINING EXPERIENCE OF MANYPRACTISING OBSTETRICIANS IN VAGINAL BREECH DELIVERY MAY BEVARIABLE, INTRAPARTUM COt lSULT TiON W I T H A C O L L E A G U E I SENCOURAGED. MEDICAL PERSONNEL TO PROVIDE ANAESTHESIA AND

IMMEDIATE NEONATAL CARE SHOULD BE AVAILABLE AT THE TIME OF VAGINALBREECH DELIVERY, AS IN CEPHALIC PRESENTATION.

15 . External Cephalic Version (ECV)

Although the issue of external cephalic version, strictly speaking, does not properlybelong to a protocol defining the selection of women and their intrapartum managementwho present at term with a breech presentation, and for whom a trial of labour andvaginal delivery is planned, the Workshop participants felt that their work would beincomplete if they did not discuss this matter and reach a conclusion about its properplace in contemporary obstetric practice.

The research evidence in support of the efficacy of external cephalic version at term toreduce the number of breech presentations entering labour as well as the number ofCSs, is the most powerful and persuasive in all the published breech literature, becausethe findings are based on well designed randomized, controlled trials.*-B6The rates ofsuccess are variable and appear to be related to experience. There is no evidence thattocolysis increases the success rate, though as might be expected, this rate is higher inthe multiparous woman. Although the published studies do not refer to the type of breechpresentation, there was agreement that it might be expected that the success rate will behigher in non-frank presentations. It is evident that the studies are not large enough toprovide a precise estimate of perinatal risk. For this reason, it was felt that ECV should

be performed in the labour/delivery suite, or clinic area.

CONCLUSION: EXTERNAL CEPHALIC VERSION IS ENCOURAGED FOR THOSE BREECHPRESENTATIONS IN WHICH NO CONTRA-INDICATION EXISTS (CLASSICAL CS SCAR,PLACENTA PRAEVIA ETC.). THIS SHOULD BE DONE AT OR AFTER 37 WEEKS, AND IN

THE LABOUR/DELIVERY SUITE, OR CLINICAREA. TRAINING OF OBSTETRIC PERSONNELIN THIS PROCEDURE SHOULD BE ENCOURAGED.

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CLOSING REMARKS

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conclusion, it must be said that all participants were sensitive to the potential forcriticism from their colleagues across the country and abroad for presuming to establisha clinical protocol in this controversial area. Nevertheless, there was a strong feeling that

thi needed to be done, and done soon, to allow the members of our discipline to workwith guidelines that have been formulated by peer discussion, based on the best literatureavailable and the extensive, collective experience of a representative group of concernedand experienced obstetricians. There was unanimity among the Workshop participantsthat the skills and judgment required for selecting and managing women who reach termwith a breech presentation are rapidly being lost, and the practice of vaginal breechdelivery is in grave danger of disappearing by default, without any of us ever beingcertain that this will lead to more good than harm. The definitive answer to this question,it was agreed, is to compare a policy of elective CS with a policy of selective vaginaldelivery by an appropriately-sized randomized trial. The difficulties in establishing sucha trial are obvious to everyone, but the answer will not be found without it, and there was

strong support from the participants for further exploration of the feasibility of such a trial.

It is hoped that the development of this protocol will assist all obstetricians to becomemore comfortable with the principle of carefully selected vaginal breech delivery, andacquire or renew their skills in its performance.

The Steering Committee expresses its gratitude to all the participants for theircommitment of time and energy in the fulfilment of the Workshop objectives.


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REFERENCES:

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

Pritchard JA, MacDonald PC. Dystocia caused by abnormalities in presentation, position, ordevelopment of the fetus. In: Williams Obstetrics Sixteenth Edition. Appleton-Century-Crofts 1980:787-96.

Cheng M, Hannah ME. Breech delivery at term a critical review of the literature. Obstet Gynecol1993;82:605-618.

Thorpe-Beeston JG,Banfield

PJ, Saunders NJ. Outcome of breech delivery at term. Br-Med J1992;305:746-7

Hofmeyr GJ. Planned elective caesarean section for term breech presentation. In: Pregnancy andChildbirth Module (eds.

Enkin

MW, Keirse MJNC, Renfrew MJ,Neilson

JP), Cochrane Databaseof Systematic Reviews: Review No 05287,24 March 1993. Published through Cochrane Updateson Disk, Oxford: Update Software, Spring 1993.

Barlov K, Larsson G. Results of a five-year prospective study using a fete-pelvic scoring systemfor term singleton breech delivery after uncomplicated pregnancy. Acta Obstet Gynecol Stand

1986;65:315 9.

Benson WL, Boyce DC, Vaughn DL. Breech delivery in the primigravida. Obstet Gynecol1972;40

417 28.

Bistoletti P, Nisel H, Palme C, Lagercrantz H. Term breech delivery: Early and late complications.Acta Obstet Gynecol

Stand

1981;60:165-71.

Bowes WA, Taylor ES, OBrien M, Bowes C. Breech delivery: Evaluation of the method of deliveryon perinatal results and maternal morbidity. Am J Obstet Gynecol

1979;135:965-73.

Dunn LJ, Voorhis LV, Napier J. Term breech presentation: A report of 499 consecutive cases.Obstet Gynecol

1965;25:170-6.

Fianu S. Fetal mortality and morbidity following breech delivery. ActaObstet GynecolStand

Suppl1976;56:1-59.

Fortney JA, Higgins JE, Kennedy KI, Laufe LE, Wilkens L. Delivery type and neonatal mortalityamong 10,749 breeches. Am J Pub Health

1986;76:980-5.

Kauppila 0. The perinatal mortality in breech deliveries and observations on affecting factors: Aretrospective study on 2,227 cases. Acta Obstet Gynecol

Stand

Suppl1975;39:1-79.

Svenningsen NW, Westgren M, lngemarsson I. Modern strategy for the term breech delivery-Astudy with a 4-year follow-up of the infants. J Perinat Med 1985;13:117-26.

Potter MG, Heaton CE, Douglas GW. Intrinsic fetal risk in breech delivery. Obstet Gynecol1960;15:158-62.

De la Fuente P, Escalante JM, Hernandez-Garcia JM. Perinatal mortality in breech presentations.Contr Gynecol Obstet 1977;3:108 12.

De Leeuw JP. Management of breech presentation in two university hospitals: preliminary resultsof a prospective comparative study. Eur J Obstet Gynecol ReprodBiol

1987;24:94-6.


13/16

17.

18.

19.

20.

21.

22. Johnson CE. Breech presentation at term. Am J Obstet Gynecol 1970;108:865-71.

23. Luterkort M, Marsal K. Umbilical cord acid-base state and Apgar score in term breech neonates.

Acta Obstet Gynecol Stand 1987;66:57-60.

24.

25.

28.

27.

28.

29.

30.

31.

32.

33.

34.

35.

Donnai

P, Nicholas ADG. Epidural analgesia, fetal monitor ing and t he condition of the baby at birt hwith breech presentation. Brit J Obstet Gynaecol 1975;82:360-5.

Fehr PE. Management of breech presentation at term: A retrospective 5 year review to testguidelines of a management protocol. Minn Med 1984;67:439-43.

Gauthier D, Lipinski A. Effect of parity on maternal and neonatal outcome in selective vaginalbreech delivery. Am J Obstet Gynecol 1993:166:436.

Green JK, Mclean F, Smith, LP, Usher R. Has an increased caesarean section rate for term breechdelivery reduced the incidence of birth asphyxia, trauma and death? Am J Obstet Gynecol1982;142:643-8.

Hall JE Kohl SG, OBrien F, Ginsberg M. Breech presentation and perinatal mortality: A study of6,044 cases. Am J Obstet Gynecol 1965;91:665-83.

Leeb J. An analysis of 1,082 breech deliveries at Baragwanath Hospital during 1967. SAfr MedJ 1969;43:623-5.

Minogue M. Vaginal breech delivery in multiparae: A review of perinatal mortality- National MaternityHospital, 1967-71. J Irish Med Assoc 1974;67:117.

Morgan HS, Kane SH. An analysis of 16,327 breech births. JAMA 1964;187:108-10.

Neilson

DR. Management of the large breech infant. Am J Obstet Gynecol 1970;107:345-8.

Selvaggi L, Molloca G, Chieppa M, Loizzi P, Bettocchi S. Contr Gynecol Obstet 1977;3:99-107.

Todd WD, Steer CM. Term breech: Review of 1006 term breech deliveries. Obstet Gynecol 1963;22:583-95.

Songane FF, Thobani S Malik H, Bingham P, Lilford RJ. Balancing the risks of planned electivecaesarean section and trial of vaginal delivery for the mature, selected, singleton breechpresentation. J Perinat Med 1987;15:531-4.

Bingham P, Hird V, Lilford RJ. Management of the mature selected breech presentation: Ananalysis based on the intended method of delivery. Br J Obstet Gynaecol 1987;94:746-52.

Biswas A, Johnstone MJ. Term breech delivery: Does X-ray pelvimetry help? Aust NZ J ObstetGynaecol 1993;33:2:150-3.

Capeless EL, Maan LI. A vaginal delivery protocol for the term breech infant using Ball pelvimetry.J Reprod Med 1985;30:545-8.

Confino E lsmajovich B Sherzer A, Peyser RM, David MP. Vaginal versus Caesarean sectionoriented approaches in the management of breech delivery. In t J Gynaecol Obstet 1985;23:1-6.

Joyce DN, Giwa-Osagie F, Stevenson GW. Role of pelvimetry in active management oflabour.

BrMed J 1975;4:505-7.


14/16

36.

37.

38.

39.

40.

41.

42.

43.

44.

45.

46.

47.

48.

49.

50.

51.

52.

53.

Mahmood TA. The influence of maternal height, obstetrical conjugate and foetal birth-weight in themanagement of patients with breech presentation. Aust NZ. J Obstet Gynaecol

1990;30:10-4.

Mahomed K. Breech delivery: A critical evaluation of the mode of delivery and outcome oflabour.

Int J Gynaecol Obstet 1988;27:1 l-20.

Ridley JW, Jackson P, Stewart JH, Boyle P. Role of antenatal radiography in the management ofbreech deliveries. Br J Obstet Gynaecol1982;89:342-7.

Rovinsky JJ, Miller JA, Kaplan S. Management of breech presentation at term. Am J ObstetGynecol 1973;115:497-513.

Varner MW, Cruikshank DP, Laube DW. X-ray pelvimetry in clinical obstetrics. Obstet Gynecol1980;56:296-300.

Wolter DF. Patterns of management with breech presentation. Am J Obstet Gynecoll976;125:733-9.

Tanos V, Rojansky N, Lewin A, Weinstein D. Evaluation of the breech in labour ultrasonic versus

X-ray method. Am J Obstet Gyaecol 1993;168:347.

Christian SS Brady K, Read JA, Kopelman JN. Vaginal breech delivery: A 5year prospectiveevaluation of a protocol using computed tomographic pelvimetry. Am J Obstet Gynecol1990;163:848-55.

Roumen FJME, Luyben AG. Safety of term vaginal breech delivery. Eur J Obstet Gynaecol ReprodBiol 1991;40:171-7

Bird CC, McElin TW. A six-year prospective study of term breech deliveries uti l izing theZatuchni-Andros prognostic scoring index. Am J Obstet Gynecol

1975;121:551-8.

De Crespigny LJC, Pepperell RJ. Perinatal mortality and morbidity in breech presentation. Obstet

Gynecol 1979;53:141 5.

Kei ly

JL. Mode of delivery and neonatal death in 17,587 infants presenting by the breech. Br JObstet Gynaecol 1991;98:898-904.

Abroms IF, Bresnan MJ, Zuckerman JE, Fischer EG, Strand R. Cerv ical cord in juri es secondar yto hyperextension of the head in breech presentation. Obstet Gynecol

1973;41:369-78.

Ballas

S Taoff R. Hyperextension of the fetal head in breech presentation: Radiological evaluationand significance. Br J Obstet Gynaecol

1976;83:201-4.

Bresnan MJ, Abroms IF. Neonatal spinal cord transection secondary to intrauterine hyperextensionof the neck in breech presentation. J Paediatr

1974;84:734-7.

Caterini H, Langer A,Sama

JC, Devanesan M, Pelosi MA. Fetal risk in hyperextension of the fetalhead in breech presentation. Am J Obstet Gynecol

1975;123:632-6.

Westgren M, Grundsell H, lngemarsson I, Muhlow A, Svenningsen NW. Hyperextension of the fetalhead in breech presentation: A study with long-term follow-up. Br J Obstet

Gynaecol1981;88:101-4.

Breeson AJ, Kovacs GT, Pickles BG, Hill JG. Extradural analgesia-the preferred method of

analgesia for vaginal breech delivery. Br J Anaesth1978;50:1227-30.


15/16

54.

55.

56.

57.

58.

59.

60.

61.

62.

63.

64.

65.

66.

67.

68.

69.

Collea JV, Chein C, Quilligan EJ. The randomised management of term frank breech presentation:A study of 206 cas es. AM J Obs tet Gyneco l 1980;137:235-44.

Gimovsky M, OGrady JP, Keroack E. Immediate neonatal outcome of vaginal breech delivery atterm in oxytocin stimulated

labour.

AM J Obstet Gynecol 1993;166:436

Gimovsky ML, Petrie RH, Todd WD. Neonatal performance of the selected term vaginal breechdelivery. Obstet Gynecol 1960;56:667-91.

Westin B. Evaluation of a fete-pelvic scoring system in the management of breech presentations.Acta Obstet Gynecol Stand 1977;56:505 6.

OLeary JA. Vaginal delivery of the term breech: A preliminary report. Obstet Gynecol1979;53:341-3.

Zatuchni GI, Andros GJ. Prognostic index for vaginal delivery in breech presentation at term. AmJ Obstet Gynecol 1967;98:854-7.

Fischer-Rasmussen W, Trolle D. Abdominal versus vaginal delivery in breech presentation: A

retrospective study comparing 420 breech presentations and 9,291 cephalic presentations forinfants weighing more than 2,500 gms. at birth. Acta Obstet Gynecol Stand Suppl 1967;9:69-76.

Grant AM. EFM alone vs intermittent auscultation inlabour.

In: Pregnancy and Childbirth Module(eds. Enkin MW, Keirse MJNC, Neilson JP), Cochrane Database of Systematic Reviews: ReviewNo. 03296 31 August 1993. Published through Cochrane Updates on Disk, Oxford: UpdateSoftware,l993, Disk Issue 2.

Grant AM EFM + scalp sampling vs intermittent auscultation inlabour.

In: Pregnancy and ChildbirthModule (eds.

Enkin

MW, Keirse, C, Renfrew MJ,Neilson

JP), Cochrane Database of SystematicReviews: Review No. 03297, 31 August 1993. Published through Cochrane Updates on Disk,Oxford: Update Software, 1993, Disk Issue 2.

Haverkamp AD, Thompson HE, McFee JG, Cetrulo C. The evaluation of continuous fetal heart ratemonitoring in high-risk pregnancy. Am Obstet Gynecol 1976;125:310-20.

Haverkamp AD, Orleans M, LangendoerferS

McFee J, Murphy J, Thompson HE. A controlled trialof the differential effects of intrapartum fetal monitoring. Am J Obstet Gynecol 1979;1324:399-412.

MacDonald D, Grant AM, Sheridan-Pereira M, Boylau P, Chalmers I. The Dublin randomisedcontrolled trial of intrapartum fetal heart rate monitoring. Am J Obstet Gynecol 1965;152:524-39.

NeldamS

Osler M, Hansen PK, Min J, Smith SF, Hertel J. lntrapartum fetal heart rate monitoringin a combined low- and high-risk population: A controlled trial. Eur J Obstet Gynecol ReprodBiol1986;23:1-11.

Chadha YC, Mahmood TA, Dick MJ, Smith NC, Campbell DM, Templeton A. Breech delivery andepidural analgesia. Br J Obstet Gynaecol 1992;99:96-100.

Crawford JS. An appraisal of lumbar epidural blockade in patients with a singleton fetus presentingby the breech. J Obstet Gynaecol Br Commw 1974;61:667-72.

Darby S Thornton CA, Hunter DJ. Extradural analgesia inlabour

when the breech presents. Br JObstet Gynaecol 1976;83:35-38.


16/16

70.

71 .

72 .

73.

74 .

75 .

76 .

77.

78 .

79 .

80.

81.

82.

83.

84.

85.

86 .

F lanagan TA, Mulcahey KM, Korenbro t CC, Green JR, Laros RK. Management o f a breech

presentat ion. Am J Obstet Gynecol1987;156:1492-502.

Van Zundert A, Vaes L,Soetens

M, et al. Are breech deliveries an indication for lumbar epiduralanalgesia? Anesth Analg

1991;72:399-403.

A ru lkumar an S, lngemarsson I, Gibb DMF, Ratnam SS. Uterine activity in spontaneous labour with

breech presentation. Aust NZ J Obstet Gynaecol 1988;28:275-8.

Jaffa AJ, Peyser MR, Ballas S, Toaff R. Management of term breech presentation in primigravidae.

Br J Obstet Gynaecol1981;88:721-4.

Stein A. Breech del ivery: A co-operat ive nurse-midwifery medical management approach. J

Nurse-midwifery 1986;31 2 :93-7.

Morley GW Breech presentation- a15-year

review. Obstet Gynecol1967;30:745-51.

Ohlsen H. Outcome of term breech del ivery in pr imigravidae: A fete-pelvic breech index. Acta

Obstet Gynecol Stand 1975;54:141-51.

Patterson SP, Mulliniks RC, Schreier PC. Breech presentation in the primigravida. Am J Obstet

Gy nec o l 1967;98:404-10.

Rubin A, Gr imm G. Res u l t s i n b r eec h p r es en ta t i on : A 7 y ea r s tudy . A m J Obs te t Gy nec o l

1963;86:1048-9.

Sellers JD. Breech presentation in the primigravida at term. J Am Osteopath Assoc 1973;73:144-9.

Brocks V, Philipsen T,Secher

NJ. A randomised trial of external cephalic version with tocolysis in

late pregnancy. Br J Obstet Gynaecol1984;91:653-656.

Van Dorsten JP, Shifrin BS, Wallace RL. Randomised controlled trial of external cephalic version

with tocolysis in late pregnancy. Am J Obstet Gynecol 1981;141:417-427.

Hofmeyr GJ. Effect of external cephalic version in late pregnancy on breech presentation and

Caesarean section rate: a controlled trial. Br J Obstet Gynaecol1983;90:392-9.

Van Veelan AJ, Van Cappellen AW, Flu PK, Straub MJPF, Wallenberg HCS. Effect of external

cephalic version in late pregnancy on presentation at delivery: A randomised controlled tr ial. Br

Obstet Gynaecol 1989;96:916-21.

Mahomed

K,Seeras

R Coulson R. External cephalic version at term: A randomised controlled trial

using tocolysis. Br J Obstet Gynaecol1991;98:8-13.

Roberts on AW, Kopel man JN, Read JA, Duff P, Magelssen DJ Dashow EE. External cephali c

version at term: Is a tocolytic necessary? Obstet Gynecol 1987;70:896-9.

Tan GWT, Jen SW, Tan St, Salmon YM. A prospect ive randomised control led tr ia l of external

cephalic version comparing two methods of uterine tocolysis with a non-tocolysis group. Singapore

Med J 1989;30:155-8.

Reprints and copies can be obtained by writing to Dr. Andre Lalonde, SOGCs Executive Vice-President,

at the following address: 774 Echo Drive, Ottawa, Ontario, l5N8.

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Breech Management at Term

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