Question: A 41 y.o. Primip presented in preterm labour at 25- weeks. After short course of Atisoban she was found to be 5cm dilated with a footling breech presentation. What is the preferred mode of delivery?
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Answer: The RCOG green-top guideline on the management of breech presentation says:
"Routine caesarean section for the delivery of preterm breech presentation should not be advised.
The mode of delivery of the preterm breech presentation should be discussed on an individual basis with a woman and her partner.
Factors regarded as unfavourable for vaginal breech birth include footling presentation"
(Evidence level IV)
The clinical practice guideline form the Royal Women's Hospital, Australia notes;
"•The optimal mode of delivery for preterm breech has not been fully evaluated in clinical trials and the relative risks for the preterm infant and mother remain unclear. Overall, decisions regarding mode of delivery will need to be made on an individual basis however with the evidence available to us at this time, Royal Women's Hospital recommended practice is to perform emergency caesarean section for any woman presenting in preterm labour with breech presentation except where;
•vaginal delivery is imminent
•The medical circumstances are such that survival (and least morbidity) of the fetus is assessed to be unchanged by mode of delivery (eg extremely premature infants-24-25 weeks, or lethal condition) and/or the maternal morbidity of caesarean section is judged to be too great for the relative potential fetal disadvantages. "
Two more recent comparative studies of very preterm breech delivery were identified, with differing conclusions about the risk of infant death:
- Kayem et al compared neonatal death rates in preterm singleton breech deliveries from 26 weeks to 29 weeks 6 days of gestation in centers with either a policy of planned vaginal delivery (PVD) or planned cesarean delivery (PCD). The study included 84 women in the PVD group and 85 women in the PCD group. Incidence of neonatal death was similar in both (10.7% vs 7.1%; P = .40). Footling breech was found not to be an independent risk factor for neonatal death.
- Hogberg et al analysed the Swedish Medical Birth Register (MBR) data from 1990 to 2002, to examine the 2,094 live births of infants at 23+0 to 27+6 weeks gestation. Vaginal delivery was associated with a significantly increased risk for infant death in breech presentations, although footling breech is not specifically mentioned.
(Evidence level III)
References:
- Hogberg U. Holmgren PA. Infant mortality of very preterm infants by mode of delivery, institutional policies and maternal diagnosis. Acta Obstetricia et Gynecologica Scandinavica. 86(6):693-700, 2007 Abstract. Full text available to Fellows, Members and Trainees.
- Kayem G. Baumann R. Goffinet F. El Abiad S. Ville Y. Cabrol D. Haddad B. Early preterm breech delivery: is a policy of planned vaginal delivery associated with increased risk of neonatal death? American Journal of Obstetrics & Gynecology. 198(3):289.e1-6, 2008 Mar. Abstract
- RCOG. The management of breech presentation. Green-top guideline 20b, 2006.
- Royal Women's Hospital, Australia. Breech: management of breech presentation.
Search date: March 2011
Classification of evidence levels
Ia Evidence obtained from meta-analysis of randomised controlled trials.
Ib Evidence obtained from at least one randomised controlled trial.
IIa Evidence obtained from at least one well-designed controlled study without randomisation.
IIb Evidence obtained from at least one other type of well-designed quasi-experimental study.
III Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case studies.
IV Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities.
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