«City Research Online Original citation: Walker, S. (2013). Undiagnosed Breech: towards a woman-centred approach. British Journal of Midwifery, 21(5), ...»
Walker, S. (2013). Undiagnosed Breech: towards a woman-centred approach. British Journal of
Midwifery, 21(5), pp. 316-322. doi: 10.12968/bjom.2013.21.5.316
City Research Online
Original citation: Walker, S. (2013). Undiagnosed Breech: towards a woman-centred approach.
British Journal of Midwifery, 21(5), pp. 316-322. doi: 10.12968/bjom.2013.21.5.316
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Undiagnosed Breech: towards a woman-centred approach Shawn Walker, RM Breech Specialist Midwife James Paget University Hospital NHS Foundation Trust Lowestoft Road, Gorleston, Great Yarmouth, NR31 6LA Correspondence: (updated June 2014) School of Health Sciences, City University London;
Shawn.Walker.email@example.com Abstract The unexpected diagnosis of breech presentation upon admission in labour affects approximately 1:100 women and presents an ethical dilemma for health professionals involved, particularly when this occurs in the context of midwifery-led care. This article critically examines current guidelines recommending caesarean section on the basis of available evidence, outlines factors which must be considered in order to provide safe care, makes recommendations for women-centred counselling, and explores the role of the midwife in this situation.
Conflict of Interest None known Undiagnosed Breech: towards a woman-centred approach Background The prevalence of breech presentation is approximately 3-4% at term (3-4 women in 100 at 37 weeks) (Hickock et al 1992 and Albrechtsen et al 1998).
Currently, standard care involves antenatal screening to identify babies who are presenting breech after 36 weeks, with subsequent referral for ultrasound confirmation and counselling regarding treatment options. However, this screening process is not highly effective, commonly resulting in a 25-33% rate of breech presentation diagnosed for the first time in labour (Nwosu et al, 1993, Jackson and Tuffnell, 1994, Nassar et al, 2006). Thus, the experience of an unexpected diagnosis of breech presentation in labour affects approximately 1 in 100 women.
NICE Guidelines The National Institute for Health and Care Excellence (NICE) clinical guideline on caesarean section (2011) recommends that pregnant women with a singleton breech presentation at term, for whom external cephalic version is contraindicated or has been unsuccessful, should be offered CS because it reduces perinatal mortality and neonatal morbidity (NICE, 2011:10). This is based mostly on the primary report of the Term Breech Trial (Hannah et al, 2000) – a large, randomised controlled trial (RCT), which has Undiagnosed Breech: towards a woman-centred approach attracted much criticism, even among medical contributors to the trial (Glezerman 2006). The Term Breech Trial included women who were randomised in labour, but did not report outcomes according to the stage of labour in which this decision was made. NICE also recommends further research into the outcomes where breech presentation is diagnosed in the second stage of labour. It suggests that an appropriately powered RCT should include at least 4230 women, which would make it approximately twice the size of the Term Breech Trial.
One secondary analysis of the Term Breech Trial data did in fact compare outcomes for those babies actually born by caesarean section in active labour (defined as contractions 5 minutes or less apart and the cervix 3 cm or greater dilated or 80% effaced) or vaginally (Su et al, 2003). For these babies, even when the definition of ‘active’ was more conservative than current intrapartum guidelines, the difference in mortality/morbidity was not statistically significant [OR 0.57, 95% CI 0.32-1.02, p value.06], a finding to which Su et al (2003) make no reference. The Term Breech Trial team concluded, based multiple secondary analyses, that a planned pre-labour caesarean section was the preferred course of action for breech-presenting
Undiagnosed Breech: towards a woman-centred approach “... [F]rom a baby’s perspective, a prelabour caesarean or a caesarean during early labour are better approaches to delivery if there is a singleton fetus in breech presentation at term. These findings are consistent with the findings of observational studies which have found better outcomes for the singleton fetus in breech presentation at term following elective caesarean, compared with emergency caesarean” (Su et al 2004:1073).
Thus, we have no conclusive evidence of the benefit of caesarean section performed in active labour (3 cm), without evidence of fetal compromise.
In line with other studies, including one from the UK (Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI), 2000), the Term Breech Trial found more adverse outcomes due to causes related to labour than to the delivery itself (Su et al, 2004). The two-year follow-up to the Term Breech Trial, which found no difference in long-term adverse outcomes between the planned caesarean section and planned vaginal birth groups, suggests an explanation (Whyte et al, 2004). Whyte et al (2004) were surprised to find that increased numbers of children with neurodevelopmental delay in the planned caesarean section group (14 adverse outcomes, of which 2 were deaths, sample of 457) balanced the increased numbers of deaths (13 adverse outcomes, of which 6 were deaths, sample of 463) in the planned vaginal birth group. This is likely Undiagnosed Breech: towards a woman-centred approach due to the fact that morphological and functional disorders associated with breech presentation often predate delivery (Albrechtsen et al, 2000), resulting in already compromised babies, less able to cope with the stresses of labour and birth. A policy of pre-labour caesarean section may prevent these babies from dying, but has not been shown to lessen the number of babies who at two years of age are severely delayed or have died. A caesarean section in active and progressive labour (3 cm) for a breech baby who is coping well is not supported by evidence of improvement in long-term outcomes.
Increased risks for mothers Surprisingly, given the admitted lack of clarity about the benefits of a caesarean section for an uncomplicated breech presentation in active labour, the authors of the NICE Caesarean Section guideline (2011) avoid discussing the known increased risks of emergency caesarean section, especially in advanced labour, for women in the context of breech presentation (2011).
Later in their guideline, they state that compared with women who had a vaginal birth, a higher proportion of women who had “emergency” CS (OR 6.3, 95% CI 2.0 to 20.2) and those who had assisted vaginal birth (OR 4.8, 95% CI 1.5 to 15.2) had post-traumatic stress disorder (PTSD) at 1–2 years after birth, although curiously still recommend that practitioners are to Undiagnosed Breech: towards a woman-centred approach reassure women who have had a CS that they are not at increased risk of PTSD. This risks minimalising what many women will experience as a traumatic change of plans (Ryding et al, 1998), which may also adversely affect their partners (Schytt and Hildingsson 2011).
Although the Term Breech Trial found no difference between mortality and morbidity between women planning a vaginal birth and a caesarean section, again secondary analysis did find a significant difference in maternal outcomes dependent on actual mode of delivery (Su et al, 2007). Su’s team concluded that a CS during active labour (3 cm) carried a three times greater risk of maternal morbidity than a vaginal birth [OR 3.33, 95% CI 1.75p-value 0.001], consistent with other studies (Waterstone et al, 2001).
There was also an increase in maternal morbidity associated with CS performed in early labour, although less significant [OR 2.41, 95% CI 1.07p-value 0.03]. This difference in adverse outcomes for women when caesarean sections are performed before labour, versus during early and late labour, is clearly reflected in the Royal College of Obstetricians and Gynaecologists (RCOG) guidelines on consent for caesarean section (2009).
Without knowing which of the Term Breech Trial caesarean sections in active labour (3) were ‘planned’ CS deliveries and which were compromised ‘planned’ vaginal deliveries, we cannot say for certain whether a caesarean Undiagnosed Breech: towards a woman-centred approach delivery significantly improves neonatal outcomes once women are in active labour, nor whether any noticeable improvement is more than we would expect to see for a vertex-presenting baby born electively by caesarean section rather than vaginally. However, we can be certain that the outcomes for women are three times worse after an emergency caesarean section than a vaginal birth, and a caesarean section greatly increases risks for future pregnancies (Verhoeven et al, 2005). Therefore, counselling a woman with a breech presenting baby at any stage in labour needs to be significantly different than counselling a woman about her options antenatally, as she no longer has the option of a comparatively safe pre-labour caesarean section (Lawson 2012).
Undiagnosed breech research The debate is amplified by studies which have looked at outcomes for undiagnosed breech presenting babies in particular. Several single-site observational studies have observed no difference in outcomes between diagnosed and undiagnosed breech babies, aside from a higher rate of vaginal breech birth (VBB) where breech presentation was undiagnosed, highlighting the clinical uncertainty surrounding the ultimate value of antenatal detection (Nwosu et al, 1993; Leung et al, 1999; Bricker et al, 2008).
Undiagnosed Breech: towards a woman-centred approach Nwosu et al’s 1993 study of 301 breech deliveries (101 elective caesarean sections, 122 planned VBB, 78 diagnosed in labour) at a large hospital in Liverpool found no difference in short term morbidity. The only statistical difference they did find between the groups was an increased rate of vaginal delivery among those diagnosed for the first time in labour. These findings found agreement with similar data from Bradford, presented in a follow-up letter, concerning 165 breech presentations in one year (Jackson and Tuffnell 1994). About one third were undiagnosed until labour, and of these 55% delivered vaginally compared with only 15% of those diagnosed antenatally.
Studies undertaken outside of the UK have produced similar results (Babay et al, 2000; Bako et al, 2000; Leung et al, 1999; Usta et al, 2003, Zahoor et al, 2008). Usta et al (2003) matched 256 Lebanese women whose breech babies were diagnosed prior to the onset of labour with 256 women whose breech babies were undiagnosed. They concluded that antenatal diagnosis of breech presentation decreases the threshold for caesarean delivery (64.1% vs. 50.8%, p = 0.003), and failure to diagnose breech antenatally does not affect neonatal outcome. Zahoor et al (2008) reported a remarkable 80% rate of undiagnosed breech among 203 cases in one unit in Pakistan in 2001, again noting no increase in adverse neonatal outcome, despite a significant increase in vaginal delivery rate (84.1% vs 55%) among those who were Undiagnosed Breech: towards a woman-centred approach undiagnosed, a difference which remained even if the figures for successful vaginal delivery following external cephalic version (ECV) were included (25%). Similarly, in a retrospective analysis of 131 women attending a private obstetric clinic in Hong Kong, Leung et al (1999) found an increased rate of vaginal birth (46%) in the group of women whose babies were undiagnosed, compared to those who were diagnosed antenatally (11%), even where successful ECV’s were included (26%). Again, neonatal outcomes did not differ between the groups.