Safely increase vaginal breech rates with a written protocol

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A 2011 study at a tertiary hospital in France found that implementing a written consensus protocol for breech increased the rates of vaginal breech birth without compromising safety. From 2000-2004, before the protocol was implemented, the vaginal breech birth rate was 24% (planned rate 30%). Once the protocol was adopted in 2004, vaginal breech rates began rising. The rate averaged 38.5% (planned rate 44.5%). The study included 1133 breech presentations at term over the 8-year period. After the study ended in 2008, the vaginal breech rate continued to rise, exceeding 50% in 2009.

Here are more specifics on the written protocol:

Before 2003, the authors’ department had no written protocolfor breech delivery, except for the general French recommendationsfor radiographic assessment of maternal pelvimetry andultrasonographic evaluation of fetal size. The authors’ team set upa working group to develop a protocol to decide the type ofdelivery for breech presentations as an institutional change ofpractice. The staff approved the final protocol by consensus in June2004. It was based on practices followed locally by obstetricians,but not previously described or discussed in writing. The protocolindicated that external cephalic version should be proposedbefore 36 weeks of gestation, and X-ray pelvimetry should beoffered around 36–37 weeks of gestation to women whose fetusremained in breech presentation. A fetal ultrasound was alsoplanned to measure biparietal diameter, estimate fetal weight,and verify that the head was not hyperextended (a contraindicationto attempted vaginal delivery in the protocol). Thisultrasound was to take place in the delivery room unless aprevious ultrasound had been taken within the last 7 days. Thebiparietal diameter was compared with the results of the pelvicmeasurements. Regardless of whether the breech presentationwas frank or complete, vaginal delivery was considered appropriatewhen three conditions were met: (1) obstetric conjugate–biparietal diameter 15 mm; (2) median transverse diameter–biparietal diameter 25 mm; and (3) interspinous diameter–biparietal diameter 0 mm. In all other situations, vaginaldelivery was considered inappropriate. A further condition forvaginal delivery was an estimated fetal weight 3800 g innulliparous women (there was no cut-off for parous women). Awoman arriving in labour without any previous pelvimetry couldonly have a vaginal delivery if the fetal weight, estimated byultrasound, was <2500 g or if she had previously had a vaginal delivery of an infant weighing >3800 g. A previous caesareansection and uterine malformations were not contra-indications tovaginal delivery. All women had continuous electronic fetalmonitoring during labour. All breech deliveries were performedwith an anaesthetist and an obstetrician experienced in thenecessary manoeuvres present in the delivery room. In all cases,this information was given to the woman and discussed with herwhen the measurements were compared.

The authors discussed their findings in relation to the Hannah Term Breech Trial and the more recent PREMODA study from centers in France and Belgium:

These results confirm the findings of recent studies [7–11] thatvaginal delivery of breech presentations is not accompanied byincreased neonatal morbidity and mortality, as reported byHannah et al. [1]. The difference in results can be explained bythe differences in levels of experience and selection criteria. Forexample, pelvimetry was only performed in 10% of cases in thestudy by Hannah et al.; this percentage reached 82.5% for theplanned vaginal deliveries in the PREMODA study [7] and 95.3% inthe present study. Moreover, 21.4% of the vaginal breech deliveriesin the study by Hannah et al. were performed by obstetricians intraining or inexperienced midwives. In the present study, ananaesthetist and an obstetrician with at least 5 years of experiencewere present in the delivery room. The PREMODA study found thatspecific manoeuvres were necessary in 34.4% of breech deliveries,including 13.4% for retention of the aftercoming head [7]. In thepresent study, 11.3% of deliveries required forceps and there wereno cases of cervical head entrapment.

The most fascinating part of the article came at the end of the discussion section, where the authors hypothesize that increased patient and care provider confidence in the safety of vaginal breech birth explain the rise in vaginal breech birth rates. Emphasis mine:

This study found an increase in the percentage of successfulvaginal delivery of breech presentations from 24% in 2000 to 38% in2008. This increase cannot be related to more favourable pelvic-tobiparietalcomparisons, as this rate was similar before (77%) andafter (72%) implementation of the protocol. Given that there wereno changes in practice for breech deliveries except for implementationof this protocol, it is hypothesized that the reduction in thecaesarean rate from 76% in 2000–2004 to 61.5% in 2004–2008 wasdue to practitioners’ increasing confidence in the safety of vaginaldelivery. Moreover, the confidence of both practitioners andwomen appears to be bolstered by the systematic checking of‘objective margins of security’ related to fetal biparietal diameterbefore allowing vaginal delivery. Finally, the reduction in thecaesarean rate for breech delivery was part of an overall decreasein the caesarean rate in the authors’ department during this period(from 22% in 2000 to 17% in 2008).It was not possible to determine which aspects of the protocolwere essential to increase the number of vaginal deliveries withoutincreasing neonatal complications.The rate of refusal of vaginal delivery by women decreased from19.3% in 2005 to 4.8% in 2008 (data not shown). This indicates thatacceptance of the protocol also reassured the women, probablymediated by the physicians’ increased confidence. The trend since2004 was confirmed in 2009, when more than 50% of breechpresentations at the hospital were delivered vaginally.

The French hospital's protocol is similar to the 2009 SOGC guidelines on vaginal breech birth. Here is a summary of the Canadian guidelines for vaginal breech birth:

• Baby is frank or complete with a flexed or neutral head attitude
• No cord presentation, pelvic abnormalities, fetal growth restriction, or macrosomia
• Baby's EFW is between 2500-4000g; EFW should be done within 10 days of onset of labor
• Continuous electronic fetal heart monitoring is preferable in the first stage and mandatory in the second stage of labor
• The HCP must be experienced in vaginal breech birth; an experienced OB should also be present to supervise other HCPs. HCP skilled in neonatal resuscitation should also be present at time of birth
• Passive 2nd stage of up to 90 minutes, followed by an active 2nd stage of 60 minutes

Interestingly, the SOGC does not recommend radiographic pelvimetry. The guidelines note: "Clinical pelvic examination should be performed to rule out pathological pelvic contraction. Radiologic pelvimetry is not necessary for a safe trial of labour; good progress in labour is the
best indicator of adequate fetal-pelvic proportions."

The SOGC also rigorously supporis a woman's right to informed consent & refusal: "Women with a contraindication to a trial of labour should be advised to have a Caesarean section. Women choosing to labour despite this recommendation have a right to do so and should not be abandoned. They should be provided the best possible in-hospital care." 

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Citation:
S. Michel, A. Drain, E. Closset, P. Deruelle, A. Ego, D. Subtil. Evaluation of a decision protocol for type of delivery of infants in breech presentation at term. European Journal of Obstetrics &amp; Gynecology and Reproductive Biology. 158 (2011) 194–198.

Relevant references: 
[1] Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR. Plannedcaesarean section versus planned vaginal birth for breech presentation atterm: a randomised multicentre trial. Term Breech Trial Collaborative Group.Lancet 2000;356:1375–83.
[7] Goffinet F, Carayol M, Foidart JM, et al. Is planned vaginal delivery for breechpresentation at term still an option? Results of an observational prospectivesurvey in France and Belgium. Am J Obstet Gynecol 2006;194:1002–11.
[8] Uotila J, Tuimala R, Kirkinen P. Good perinatal outcome in selective vaginalbreech delivery at term. Acta Obstet Gynecol Scand 2005;84:578–83.
[9] Krupitz H, Arzt W, Ebner T, Sommergruber M, Steininger E, Tews G. Assistedvaginal delivery versus caesarean section in breech presentation. Acta ObstetGynecol Scand 2005;84:588–92.
[10] Alarab M, Regan C, O’Connell MP, Keane DP, O’Herlihy C, Foley ME. Singletonvaginal breech delivery at term: still a safe option. Obstet Gynecol 2004;103:407–12.
[11] Vendittelli F, Pons JC, Lemery D, Mamelle N. The term breech presentation:neonatal results and obstetric practices in France. Eur J Obstet Gynecol ReprodBiol 2006;125:176–84.