Professional Recommendations: Delivery of Breech Presentation at Term
Learning Objectives and CME/Disclosure Information
This activity is intended for healthcare providers delivering care to women and their families.
After completing this activity, the participant should be better able to:
1. Discuss the change in the ACOG practice recommendations for singleton breech delivery at term 2. Apply the new guidance to obstetrical care
Estimated time to complete activity: 0.25 hours
Susan J. Gross, MD, FRCSC, FACOG, FACMG President and CEO, The ObG Project
Disclosure of Conflicts of Interest
Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity. All identified COI are thoroughly vetted and resolved according to PIM policy. PIM is committed to providing its learners with high quality CME activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.
Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.
Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.
Method of Participation and Request for Credit
Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from August 7 2018 through August 7 2020, participants must read the learning objectives and faculty disclosures and study the educational activity.
If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.
For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.
Joint Accreditation Statement
In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Physician Continuing Medical Education
Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Continuing Nursing Education
The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.
Designated for 0.2 contact hours of pharmacotherapy credit for Advance Practice Registered Nurses.
ACOG guidance addresses the trend in the United States to deliver term singleton fetuses in breech presentation by cesarean section and the concomitant decrease in the number of practitioners with the skills and experience to perform vaginal breech deliveries. In 2001, the ACOG committee on Obstetric Practice recommended that planned vaginal delivery of a singleton breech was no longer appropriate but due to additional publications since that time, the recommendations have been updated.
Vaginal delivery of a term singleton breech fetus
Planning a vaginal deliver for term singleton breech fetus may be a reasonable option under hospital-specific protocol guidelines that address eligibility and labor management
Consider patient’s wishes and the experience of the health care provider
Criteria based on retrospective studies have resulted in “excellent” neonatal outcomes, using protocols similar to the following
> 37 weeks gestational age
Frank or complete breech presentation
No fetal anomalies on ultrasound examination
Adequate maternal pelvis
EFW between 2,500 g and 4,000 g
One study also included
Fetal head flexion
AFV ≥3 cm vertical pocket
No oxytocin induction or augmentation
Strict criteria for normal labor progress
If vaginal breech delivery is planned, a detailed informed consent should be documented that include risks and benefits
Short term risk/benefit
Term Breech Trial (2000) demonstrated that perinatal mortality, neonatal mortality, and serious neonatal morbidity were significantly lower in the planned cesarean delivery group (1.6%) vs planned vaginal delivery group (5%) with no difference in maternal morbidity or mortality
Follow-up at 3 months: Risk of urinary incontinence was lower for women in the planned cesarean delivery group but no difference at 2 years
Long term risk/benefit (2 years)
No differences for risk of death or neurodevelopmental delay, although there may be multiple reasons to explain this discrepancy, described in the ACOG Committee Opinion (see ‘Learn More – Primary Sources’ below)
No difference for most maternal parameters, such as breastfeeding, pain, depression, or upsetting memories of the birth experience in 79.1% of women
ACOG states that
Current evidence demonstrates short-term benefits in neonatal and maternal morbidity and mortality from planned cesarean delivery of the term fetus with a breech presentation. Long-term benefits of planned cesarean delivery for these infants and women are less clear.
The SOGC guidelines (2019; see ‘Learn More – Primary Sources’ below) address both oxytocin augmentation and induction as follows
Oxytocin augmentation is acceptable to correct weak uterine contractions. If progress in labour is poor despite adequate contractions, Caesarean section is recommended (strong recommendation; moderate quality evidence)
Although data are limited, induction of labour with breech presentation does not appear to be associated with poorer outcomes than spontaneous labour (weak recommendation; low quality evidence)
RCOG recommendations (2017; see Learn More – Primary Sources’ below) also address augmentation and induction and advises caution (D Grade Recommendation)
Women should be informed that induction of labour is not usually recommended.
Augmentation of slow progress with oxytocin should only be considered if the contraction frequency is low in the presence of epidural analgesia.
External cephalic version
Offer as an alternative to planned cesarean delivery if the patient desires planned vaginal delivery of a vertex-presenting fetus and has no contraindications
Only attempt external cephalic version in a setting where cesarean delivery services are readily available
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Disclosure of Unlabeled Use
This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.
The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
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