Breech presentation occurs in three to five percent of singleton pregnancies after 37 weeks of gestational age (GA) (1). The publication of the Term Breech Trial (TBT) in 2000 (2) had a significant impact on obstetric practice with many countries and international organisations recommending against vaginal birth. However, more recently, and mostly due to concerns surrounding the global rise in caesarean section rates and on-going criticisms about the methodology and the interpretation of the TBT, this option has been re-evaluated. The International Federation of Gynecology and Obstetrics (FIGO) (3), Le Collège National des Gynécologues et Obstétriciens Français (CNGOF) (4), the Royal College of Obstetricians and Gynaecologists (RCOG) (1) and the Society of Obstetricians and Gynaecologists of Canada (SOGC) (5) now support the option of vaginal breech birth (4) (6) (7).
The Cochrane Review of 2015 revealed a lower neonatal morbidity and mortality in the planned C-section group compared with the vaginal delivery group with an Odds Ratio (OR) of 0.3 and a 95% confidence interval (95% CI) of 0.2-0.6. However the TBT contributed to the majority of cases to the meta-analysis (2). Multiple criticisms of this trial have already been published with many suggesting that selection was biased and expertise in breech delivery was suboptimal in some participating centres (8) (9). Perhaps of more significance, was the failure to demonstrate any statistically significant difference in childhood outcomes between the two modes of birth at two years of age (10).
The PREMODA (7) study conducted in Belgium and France used similar outcome criteria as the TBT (2) but the methodology was prospective observational rather than a randomised trial. There was no specific management protocol, but the items used as a basis for deciding the mode of birth were: ultrasound evaluation of fetal size and cephalic flexion, maternal pelvimetry, woman’s desire to attempt a vaginal birth. The elements for managing and monitoring the labour were: the obstetrician’s self-assessed expertise in vaginal breech and continuous electronic fetal monitoring. The outcomes of 2526 planned vaginal breeches were compared to the outcomes of 5579 planned C-sections in 174 units. Neonatal short-term morbidity (five-minute Apgar score under four, injuries and intubation) was more frequent in the planned vaginal group compared to the planned C-section group (OR 8.92 (95% CI 1.0-79.8), 3.90 (2.4-6.34) and 1.82 (1.08-3.06) respectively). No other difference was found (7). However since the publication of the TBT, the C-section rate for breech presentation has drastically increased in Europe (11) (12) (13) (14) and expertise in vaginal breech birth has withered away.
Arguments against the conclusions of the TBT (2), the positive results of the PREMODA study (7), and globally rising C-section rates, have led to a reconsideration of vaginal breech birth by various authorities (1) (4) (5) (6). A secondary analysis of the TBT highlighted the beneficial effect of the presence of an experienced clinician at breech births (15). The recently published guideline by the RCOG (5) on the management of breech presentation suggests that ‘clinicians should counsel women in an unbiased way that ensures a proper understanding of the absolute as well as the relative risks of their different options’ and that ‘the presence of a skilled birth attendant is essential for safe vaginal breech birth’ (1). In Belgium, the French-speaking Belgian guidelines (16) never ceased to recommend “selected vaginal breech” approach. However, compared to other European countries with the same policy, the national rate of vaginal birth in 2015 according to Euro-peristat (17) was low: 10.3% in Belgium, compared to 25.2% in France, a country with very similar guidelines, or 34.5% in Norway (17).
A returned focus on vaginal breech deliveries needs to be well planned. In order to support eligible women in their choice of mode of delivery, and to standardise care and counselling (18), a ‘breech clinic’ with a dedicated care pathway and a vaginal breech protocol were developed in our unit starting from December 2015. In order, to effectively support women and clinicians, a 24-hour on-call specialist team was also established as suggested by Walker et al.(18)(19).
The primary objective of this hybrid retrospective and prospective study was to compare the planned and observed vaginal delivery rates before and after the implementation of the breech clinic. The secondary objective was to compare the early neonatal outcomes.
Setting up the breech clinic
The breech clinic was developed in Cliniques Universitaires de Bruxelles ‘Hôpital Erasme’ a tertiary referral centre and the academic hospital of the ‘Université Libre de Bruxelles’ (ULB) in Brussels, Belgium. The breech clinic was not developed following formal program theory techniques ante hoc. The model aimed to remediate poor adherence to Belgian breech guidelines and included: new skills development, a dedicated team and clinic, and a rota of on-call breech specialists. This type of intervention has already been reported for external cephalic version (ECV) in breech (20), but also for vaginal birth after C-section, including a trial (21), or management of early pregnancy bleeding (22). Belgian breech guidelines (16), as in some Nordic countries, consider the appropriate pathway includes timely recognition and routine consideration of ECV. And in case of unsuccessful ECV a discussion with the parents should lead to a partnership decision of the most appropriate mode of delivery. Our philosophy is to promote physiological labour and delivery with as few medical interventions as is safely possible. The maternity has around 2000 deliveries per year and since 2014 has also developed the first alongside midwifery unit in Belgium ‘the Cocoon’ (23).
Prior to the introduction of the breech clinic, no structured pathway of care for women with a breech presentation existed. In December 2015, such a care pathway was developed with dedicated appointments and an information leaflet for women (Supplementary material 1) explaining the ECV, the different modes of delivery and our antenatal education program. Since May 2016, each component of the service has been fully functional.
Six obstetricians and two midwives are dedicated to the breech clinic. Four of the obstetricians are experienced but two of the younger obstetricians still need direct supervision (19). Two of the six are responsible for in-depth counselling, perform the ECV and select eligible women. One is regularly involved in the teaching of midwives, obstetric trainees and other colleagues (19). The two midwives are responsible for the more physical aspects of a planned vaginal birth: training in pushing, maternal positions and pain management. For the delivery, one or two of the six “breech” obstetricians are always present and all support each other (24). All members must have a training update in breech delivery at least once every year (local or international training, simulation, local or international congress and local review of cases with birth videos and/or medical records).
If the fetus is in breech position at the routine ultrasound around 32 weeks of GA, the woman is referred to the breech clinic. An appointment is scheduled at around 35-36 weeks of GA to explain the ECV procedure, including the risks and benefits. If a woman opts for an ECV, this takes place at between 36-37 weeks of GA (Figure 1). One to three ECV are scheduled per week. In order to concentrate practice two of the obstetricians of the breech clinic perform it (25). If the ECV is unsuccessful, in order to comply with the French-speaking Belgian college guidelines, a pelvimetry by computerized tomography (CT) scan is performed for all women (16) even though there is minimal evidence to support its use. As MRI-pelvimetry is less accessible in our service, most pelvimetries were performed using a CT-scan. Following the pelvimetry, an appointment is scheduled with one of the obstetricians from the breech clinic team to discuss the options for delivery, their relative risks and benefits and the management of labour, in case of a vaginal delivery attempt. Finally, if the woman opts for a vaginal delivery, we organise several sessions with a midwife in order to adequately prepare the woman for the labour and the delivery. All the women are offered the Erasme breech clinic leaflet (Supplementary material 1) containing information about ECV and breech delivery (vaginal delivery and C-section). The obstetricians work in accordance with the local guidelines and are comfortable and skilled at breech deliveries.
Eligibility criteria for a breech delivery attempt:
- Motivated expectant woman
- Estimated fetal weight above 2500 grams
- GA more than 37 weeks
- CT-pelvimetry deemed adequate
- No cephalo-pelvimetric disproportion
- No other indication for C-section (two or more previous C-sections, placenta praevia, etc.)
- No hyperextension of the fetal head
Management of labour and delivery
An ultrasound is performed at the time of the admission to the delivery suite to confirm the presentation and to exclude hyperextension of the fetal head. If indicated, induction of labour is performed ideally with favourable cervix (Bishop score >6-7). Continuous electronic fetal monitoring is mandatory during the labour and if necessary, oxytocin and/or artificial rupture of membranes are/is used for augmentation. Epidural analgesia is available and used based on maternal request rather than systematically. During the birth, physiological techniques are preferred: no unnecessary manoeuvre is performed and the woman make their own decisions regarding birthing positions including, but not restricted to, upright or ‘on all fours’ positions (26). Episiotomy is individualised and not performed systematically.