To Breech, or not to Breech. That is sometimes the question…

This story is stolen from my big Dutch mate:

It is 6 AM, you get a call from the labour ward from the night midwife.  “Hey, I am looking after a primip and she has been progressing well, and I just did a VE – not sure if she is fully yet, it felt a bit odd – can you come and give a second opinion?”   So you wonder into the ward and don the latex…. after a quick feel you have made the following observation:

“Not sure if she is fully, but it is definitely a boy!”   AHH ! The undiagnosed breech rears its head (or bum) again.

If you are like me this is one of the scary moments in O&G.  I have only seen 3 breech births and they all were less than fun.  Breech vaginal birth was dealt a ‘final blow’by the Term Breech Trial Collaborative Group in Lancet 2000.  So I thought I would look at the evidence and ask the following questions:

Well, yes and no. The incidence of short-term poor neonatal outcomes is higher. However, this does not translate into more longer term neurological problems. So is a bad Apgar or a dodgy cord blood a good end-point to measure? The maternal stats were worse for CS as opposed to vaginal birth – basically having a big operation is bad, having a vaginal birth – not so bad for major problems – infection, bleeding, VTE etc All of this data comes from ëxperienced operators” ie. not people like me who have read a few textbooks and gone to a course about breech delivery. Mauriceau-Smellie-Veit: if you don’t know what I mean then don’t attempt a vaginal breech at home. (Hint- it isn’t a French guy with a bit of tinea) Review article here.

Hmmm… no good evidence it seems. The risk of vaginal birth is probably overblown in our minds. I think this depends on the situation and the operator a bit. Doing a CS late in the 2nd stage can be tricky, and you have already exposed the fetus to all the risk of labour, than the mother to the risk of CS. I am going to be pragmatic and say – once the breech is below the spines in 2nd stage it is probably too late to back out from a risk POV. This is really just my opinion. I decided to ask my local Expert – Dr Wendy Hughes -O&G of the Kimberley for her opinion

The bottom line is that 1 in 20 vaginal breech deliveries will have serious consequences for the baby – death or injury. The rest will be okay – completely okay. Unfortunately it’s the “rest that are okay” that sometimes leads us to be rather complacent about missing the diagnosis of breech both antenatally and in labour until it’s too late to do anything about it – until we experience a bad vaginal breech delivery. The second concern is avoiding unnecessary damage to mother from undertaking a C/S where the uterus is damaged by trying to drag the baby back up and out. Thankfully I haven’t personally been involved in a difficult C/S breech “retrieval” but I have heard horror stories from colleagues – I think one woman ended up with hysterectomy. If the baby is crowning this is definitely a case for vaginal delivery. I believe late first stage with rapid progression in labour is ditto. Early first stage (when many are diagnosed – you know SROM with niggles – oops, it’s bum first) I offer mum the choice and they almost always elect C/S. My belief is the best guide to proceeding with vaginal delivery is how quickly labour is progressing, both dilatation and descent. And the best way to avoiding the situation is to always question whether you have definitely felt the head – both abdominally and vaginally – and have a low threshold to resort to a quick scan – and ditto at antenatal clinic, particularly beyond 36 weeks – most breeches haven’t “just turned” but been that way unrecognized all along.

OK, it is too late to do ECV once labour is upon us! But it is worth doing. See this Cochrane review of ECV at 37/40. Another study by Dr Hannah (busy lady) looked at doing breech earlier – 34 – 36 weeks, with some success, though maybe a few more preterm labours

Go to an ALSO (Advanced Life Support in Obstetrics) course. This is a really fun and educational course, loads of evidence and a lot of practical skills to learn. Go to the ALSO website to check out courses near you

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