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International Journal of Gynecology and Obstetrics 107 (2009) 169176

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International Journal of Gynecology and Obstetrics


j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / i j g o

SOGC CLINICAL PRACTICE GUIDELINE

Vaginal delivery of breech presentation


No. 226, June 2009
This guideline has been reviewed by
the
Maternal Fetal Medicine Committee and
approved by the Executive and Council
of the Society of Obstetricians and
Gynaecologists of Canada.
PRINCIPAL AUTHORS
Andrew Kotaska, MD, Yellowknife NT
Savas Menticoglou, MD, Winnipeg MB
Robert Gagnon, MD, Montreal QC
MATERNAL
FETAL
MEDICINE
COMMITTEE Robert Gagnon (Chair), MD,
Montreal QC Dan Farine, MD, Toronto
ON
Melanie Basso, RN, Vancouver BC
Hayley Bos, MD, London ON
Marie-France Delisle, MD, Vancouver BC
Kirsten Grabowska, MD, Vancouver BC
Lynda Hudon, MD, Montreal QC
Savas Menticoglou, MD, Winnipeg MB
William Mundle, MD, Windsor ON
Lynn Murphy-Kaulbeck, MD, Allison NB
Annie Ouellet, MD, Sherbrooke QC
Tracy Pressey, MD, Vancouver BC
Anne Roggensack, MD, Calgary AB

a b s t r a c t
Objectives: To review the physiology of breech birth; to discern the risks and benets of a trial of
labour versus planned Caesarean section; and to recommend to obstetricians, family physicians,
midwives, obstetrical nurses, anaesthesiologists, pediatricians, and other health care providers
selection criteria, intrapartum management parameters, and delivery techniques for a trial of vaginal
breech birth. Options: Trial of labour in an appropriate setting or delivery by pre-emptive Caesarean
section for women with a singleton breech fetus at term. Outcomes: Reduced perinatal mortality, short-term
neonatal morbidity, long- term infant morbidity, and short- and long-term maternal morbidity and
mortality. Evidence: Medline was searched for randomized trials, prospective cohort studies, and
selected retrospective cohort studies comparing planned Caesarean section with a planned trial of
labour; selected epidemiological studies comparing delivery by Caesarean section with vaginal breech
delivery; and studies comparing long-term outcomes in breech infants born vaginally or by Caesarean
section. Additional articles were identied through bibliography tracing up to June 1, 2008. Values:
The evidence collected was reviewed by the Maternal Fetal Medicine Committee of the Society of
Obstetricians and Gynaecologists of Canada (SOGC) and quantied using the criteria and classications of
the Canadian Task Force on Preventive Health Care. Vali- dation: This guideline was compared with the
2006 American College of Obstetrician's Committee Opinion on the mode of term singleton breech
delivery and with the 2006 Royal College of Obstetrician and Gynaecologists Green Top Guideline: The
Management of Breech Presentation. The document was reviewed by Canadian and International clinicians
with particular expertise in breech vaginal delivery. Sponsors: The Society of Obstetricians and
Gynaecologists of Canada.

Summary statements
Disclosure statements have been received
from all members of the committee.
J Obstet Gynaecol Can 2009;31(6):
557566

1. Vaginal breech birth can be associated with a higher risk of perinatal mortality and short-term
neonatal morbidity than elective Caesarean section. (I)
2. Careful case selection and labour management in a modern obstetrical setting may achieve a
level of safety similar to elective Caesarean section. (II-1)

This document reects emerging clinical and scientic advances on the date issued and is subject to change. The information should not be construed as dictating
an exclusive course of treatment or procedure to be followed. Local institutions can dictate amendments to these opinions. They should be well documented if modied
at the local level.
Abbreviations: ACOG, American College of Obstetricians and Gynecologists; CS, Caesarean section; CEFM, continuous electronic fetal monitoring; RCOG, Royal College
of
Obstetricians and Gynaecologists; TBT, Term Breech Trial; TOL, trial of
labour.
doi:10.1016/j.ijgo.20 09.07.0 02

170

SOGC CLINICAL PRACTICE


GUIDELINE

Keywords
Breech presentation
Labour
Caesarean section
Term gestation
External validity

Key to evidence statements and grading of recommendations, using the ranking of the Canadian Task Force on Preventive
Health Care.
Quality of Evidence Assessment

Classication of Recommendations

I:

A. There is good evidence to recommend the clinical


preventive action
B. There is fair evidence to recommend the
clinical preventive action
C. The existing evidence is conicting and does not
allow to make a recommendation for or against use of
the clinical preventive action; however, other factors
may inuence decision-making
D. There is fair evidence to recommend against the
clinical preventive action
E. There is good evidence to recommend against the
clinical preventive action
L. There is insufcient evidence (in quantity or quality) to
make a recommendation; however, other factors may
inuence decision-making

Evidence obtained from at least one properly randomized


controlled trial
II-1: Evidence from well-designed controlled trials
without randomization
II-2: Evidence from well-designed cohort (prospective or
retrospective) or case-control studies, preferably from
more than one centre or research group
II-3: Evidence obtained from comparisons between times
or places with or without the intervention. Dramatic
results in uncontrolled experiments (such as the results of
treatment with penicillin in the 1940s) could also be
included in this category
III:
Opinions of respected authorities, based on
clinical experience, descriptive studies, or reports of
expert committees

The quality of evidence reported in these guidelines has been adapted from The Evaluation of Evidence criteria
The quality
described
in theof Canadian
evidence reported
Task Forcein on
these
Preventive
guidelines
Health
has been
Care adapted
[62].
from The Evaluation of Evidence criteria

described
in the Canadian
Task in
Force
on guidelines
Preventive have
Health
Careadapted
[62]. from the Classication of Recommendations criteria
Recommendations
included
these
been
described in the The Canadian Task Force on Preventive Health Care [62].

3. Planned vaginal delivery is reasonable in selected women with a


term singleton breech fetus. (I)
4. With careful case selection and labour management, perinatal
mortality occurs in approximately 2 per 1000 births and
serious short-term neonatal morbidity in approximately 2% of
breech infants. Many recent retrospective and prospective reports
of vagi- nal breech delivery that follow specic protocols have
noted ex- cellent neonatal outcomes. (II-1)
5. Long-term neurological infant outcomes do not differ by planned
mode of delivery even in the presence of serious short-term neonatal morbidity. (I)

7. Induction of labour is not recommended for breech presentation.


(II-3B) Oxytocin augmentation is acceptable in the presence of
uterine dystocia. (II-1A)
8. A passive second stage without active pushing may last up to
90 minutes, allowing the breech to descend well into the pelvis.
Once active pushing commences, if delivery is not imminent after
60 minutes, Caesarean section is recommended. (I-A)
9. The active second stage of labour should take place in or near an
operating room with equipment and personnel available to
perform a timely Caesarean section if necessary. (III-A)
10. A health care professional skilled in neonatal resuscitation should
be in attendance at the time of delivery. (III-A)

Recommendations
Labour selection criteria
1. For a woman with suspected breech presentation, pre- or early
labour ultrasound should be performed to assess type of
breech presentation, fetal growth and estimated weight, and
attitude of fetal head. If ultrasound is not available, Caesarean
section is recommended. (II-1A)
2. Contraindications to labour include
a. Cord presentation (II-3A)
b. Fetal growth restriction or macrosomia (I-A)
c. Any presentation other than a frank or complete breech with a
exed or neutral head attitude (III-B)
d. Clinically inadequate maternal pelvis (III-B)
e. Fetal anomaly incompatible with vaginal delivery (III-B)
3. Vaginal breech delivery can be offered when the estimated fetal
weight is between 2500 g and 4000 g. (II-2B)
Labour management
4.

Clinical pelvic examination should be performed to rule out


patho- logical 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. (III-B)
5. Continuous electronic fetal heart monitoring is preferable in the
rst stage and mandatory in the second stage of labour. (I-A)
When membranes rupture, immediate vaginal examination is
recom- mended to rule out prolapsed cord. (III-B)
6. In the absence of adequate progress in labour, Caesarean section is
advised. (II-1A)

Delivery technique
11. The health care provider for a planned vaginal breech delivery
needs to possess the requisite skills and experience. (II-1A)
12. An experienced obstetrician-gynaecologist comfortable in the
performance of vaginal breech delivery should be present at the
delivery to supervise other health care providers, including a
trainee. (I-A)
13. The requirements for emergency Caesarean section, including
availability of the hospital operating room team and the approximate 30-minute timeline to commence a laparotomy, must be
in accordance with the recommendations of the SOGC Policy
Statement, Attendance at Labour and Delivery (CPG No. 89; update in press, 2009). (III-A)
14. The health care provider should have rehearsed a plan of action
and should be prepared to act promptly in the rare circumstance of a trapped after-coming head or irreducible nuchal
arms: symphysiotomy or emergency abdominal rescue can be
life saving. (III-B)
15. Total breech extraction is inappropriate for term singleton breech
delivery. (II-2A)
16. Effective maternal pushing efforts are essential to safe delivery
and should be encouraged. (II-1A)
17. At the time of delivery of the after-coming head, an assistant
should be present to apply suprapubic pressure to favour exion
and engagement of the fetal head. (II-3B)
18. Spontaneous or assisted breech delivery is acceptable. Fetal traction should be avoided, and fetal manipulation must be applied
only after spontaneous delivery to the level of the umbilicus.
(III-A)

19.

Nuchal arms may be reduced by the Lvset or Bickenbach


manoeu- vres. (III-B)
20. The fetal head may deliver spontaneously, with the assistance of
suprapubic pressure, by Mauriceau-Smellie-Veit manoeuvre, or
with the assistance of Piper forceps. (III-B)

Setting and consent


21.

22.
23.
24.

25.

26.

In the absence of a contraindication to vaginal delivery, a


woman with a breech presentation should be informed of the
risks and benets of a trial of labour and elective Caesarean
section, and informed consent should be obtained. A woman's
choice of delivery mode should be respected. (III-A)
The consent discussion and chosen plan should be well
docu- mented and communicated to labour-room staff. (III-B)
Hospitals offering a trial of labour should have a written protocol
for eligibility and intrapartum management. (III-B)
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. (III-A)
The Society of Obstetricians and Gynaecologists of Canada
(SOGC), in collaboration with the Association of Professors
of Obstetrics and Gynaecology (APOG), The College of Family
Physicians of Canada (CFPC), and The Canadian Association
of Midwives (CAM) should revise the training requirements at
the undergraduate and postgraduate levels. SOGC will continue
to promote training of current health care providers through
the MOREOB, ALARM (Advances in Labour
and
Risk
Management), and other courses. (III-A)
Theoretical and hands-on breech birth training simulation should
be part of basic obstetrical skills training programs such as ALARM,
ALSO (Advanced Life Support Training in Obstetrics), and
MOREOB to prepare health care providers for unexpected
vaginal breech births. (III-B)

Background
Compared with a fetus with cephalic presentation, a breech fetus
faces increased risk during labour and delivery of asphyxia from cord
compression and of traumatic injury during delivery of the shoulders
and head. Pre-emptive Caesarean section avoids most of this risk. Prior
to 1940, despite breech perinatal mortality rates of 5%, CS involved
too much maternal risk to be used routinely to lower fetal risk [1].
Im- proved safety with antibiotics, blood transfusion, and Kerr's
lower segment incision prompted consideration of routine CS for
breech presentation [2]. Concurrently, improvements in vaginal
breech delivery technique markedly lowered the risk of a trial of
labour in experienced hands, and
breech perinatal mortality
continued to fall,
despite stabilization of the CS rate [1,38]. The debate surrounding the
optimal mode of delivery for the breech fetus focuses on a single
clinical question: what is the magnitude of risk to the fetus of a TOL
and how should we balance it against the increased immediate and
future risk of CS to the mother and her future children?
Term breech trial
Published in 2000, the Term Breech Trial was a large, multicentre
randomized controlled trial designed to determine the safest mode of
delivery for a term breech fetus [9]. In countries with a low perinatal
mortality rate, the trial showed no difference in perinatal
mortality between a planned CS and a TOL but a striking difference in
serious short-term neonatal morbidity: 0.4% versus 5.1%. No
difference in
maternal mortality or serious morbidity was measured, leading most
experts to recommend planned CS for breech presentation at
term

[10,11]. An abrupt shift in clinical practice ensued, and term breech CS


rates increased around the world.
The pool of expertise in
vaginal breech birth has shrunk rapidly since, and many
obstetrician- gynaecologists now graduate with little
or no
experience with vaginal breech delivery. In many regions of the
world, women with a breech fetus no longer have the option of a
medically attended vaginal breech birth [12,13].
The TBT is the largest randomized clinical trial ever undertaken on
term breech mode of delivery, and it has provided a wealth of information about breech birth. Despite its strengths, however, a number of
weaknesses have been identied since its publication [1420]. Based on
the information available at the time, its ndings may have been misinterpreted and may have led to premature changes in clinical practice.
A
comprehensive analysis is beyond the scope of this guideline;
however, an examination of the TBT's major limitations is critical to
estimating the true risk of labour to a breech fetus. They can be
grouped as fol- lows:
(1) inadequate case
selection and
intrapartum management; (2) maternity units with markedly different
skill levels grouped together; and (3) short-term morbidity used as a
surrogate marker for long-term neurological impairment.
TBT: Case selection and labour management
Pre- or early labour ultrasound was not required, which may have
allowed fetuses with growth restriction due to placental insufciency
to go undetected. At least seven of the trial's 16 perinatal deaths were
in growth-restricted fetuses [9,16,19,21]. To what extent undetected
fetal macrosomia and deexed head position contributed to morbidity
and mortality is unknown. Continuous electronic fetal monitoring was
also not required, and only one third of fetuses received it. The trial
protocol allowed labour progress to be as slow as 0.5 cm/hr in the rst
stage and up to 3.5 hours for the second stage [21]. Although they are
acceptable for cephalic fetuses, few experienced practitioners consider these limits acceptable for a breech fetus, and the 5% of fetuses
born
after
an active second stage longer than 60 minutes
encountered increased morbidity and mortality [22]. Therefore it
can be learned from the TBT that the following strategies may
increase
the safety of term
breech deliveries: ultrasound
estimation of fetal weight to detect abnormal fetal growth, fetal
head attitude, and type of breech presentation, and close attention
to progress in the second stage of labour.
Although a practitioner experienced in vaginal breech birth was
expected at every delivery, a licensed obstetrician was not present at
13% of births in the planned vaginal birth group versus 2% in the
planned Caesarean section group, and there was a high degree
of crossover in the trial: 10% of women randomized to planned
CS delivered vaginally. Three percent of fetuses were cephalic at
delivery, highlighting the need for routine ultrasound for suspected
breech in labour or prior to elective CS.
TBT:
Surrogate
outcome

short-term

Short-term morbidity in vaginally born breech fetuses is often


increased because of the cord compression that commonly occurs
during the second stage and fetal expulsion. In countries like Canada
with low perinatal mortality, the absolute difference in serious shortterm morbidity between the arms of the TBT was 5%. However, one
half of the sample was followed beyond two years, at which time
there was no difference in the combined perinatal death and
abnormal neurological outcome: 3.1% in the planned CS group, and
2.8% in the TOL group [23]. Of the 18 infants with serious neonatal
morbidity that were followed, 17 were neurologically normal at two
years of age. The remaining infant died of congenital subglottic
stenosis, considered unlikely to be related to mode of delivery.
This demonstrates the systematic failure, also shown by other
studies, of short-term
morbidity to predict long-term outcome in breech infants [2428].

At two years of age, the only signicant difference in infant outcome was fewer medical problems in the past several months in the
TOL group (15% vs. 21%; P = 0.02). The neonatal immune system
is activated during labour, and associations between labour and
reduced incidence of pediatric allergic and auto-immune disease may
be causal [2932].
With the limitations in the TBT, women had a 97% chance of
having a neurologically normal two-year old, regardless of planned
mode of birth. Those randomized to a trial of labour had a 6%
absolute lower chance (or 30% relative risk reduction) of having a
two-year-old child with unspecied medical problems, suggesting
some lasting benet of labour to the newborn immune system.
Premoda study
Numerous retrospective series comparing a TOL with planned
CS have been published [26,27,3337]. Many were large enough to
dem- onstrate acceptable safety of breech birth in individual units;
however, data were collected retrospectively and
were not
necessarily general- izable beyond those experienced units. In 2006, in
response to the TBT, Gofnet et al. published the PREMODA study: a
multicentre descriptive
study four times larger than the TBT [38]. Prospective data were collected from 8105 women in 174 centres in France and Belgium, using
the same short-term combined outcome of perinatal mortality or
serious neonatal morbidity as the TBT. Contemporary practice in
France and Belgium involves a cautious, consistent level of care,
which was not altered by the investigators.
The PREMODA study was descriptive, and the percentage of
women attempting vaginal birth varied between centres (47.889.0%).
Overall, CS was planned in 69% and a TOL undertaken in 31%,
consistent with non-randomization. Of 2526 women having a TOL,
1796 (71%) de- livered vaginally for an overall vaginal birth rate
of 22.5%. Pre- or early labour ultrasound and CEFM in labour were
universal. Contrary to standard practice in many countries, including
Canada, radiologic pelvimetry was employed in 82%. Failure to
progress for more than two
hours in the rst stage of labour occurred in 3.8% of labours, and an
active second stage longer than 60 minutes occurred in only 0.2% of
cases. Only 0.6% of women planning CS eventually delivered vaginally,
and all fetuses were breech at delivery.
Although not strictly comparable, the PREMODA outcomes contrast with those of the TBT. There was no difference in perinatal
mortality (0.08% vs. 0.15%) or serious neonatal morbidity (1.6%
vs.
1.45%) between a TOL and planned CS. The only difference in outcome
was a 0.16% incidence of ve-minute Apgar score b 4 in the TOL
group versus 0.02% in the planned CS group. Eight times larger than
the low- perinatal-mortality subset of the TBT, the PREMODA study
provides a robust estimate of the risk of a cautious breech TOL in a
modern, well- supported obstetrical unit.

fetus and some 175 additional CS to prevent one perinatal death;


however, the results imply that increased caution resulted in a lower
vaginal breech birth rate and improved safety. The improved
outcome was largely due to the increase in planned CS, but the
outcome was also better after emergency CS and vaginal delivery,
suggesting that in carefully selected pregnant women, vaginal
breech delivery may be a safe option. In contrast to the TBT, the
new practice has resulted in a small increase in CS-related
maternal morbidity and mortality, sparking debate about the
balance between maternal and
fetal risk [4044].
Summary statements
1. Vaginal breech birth can be associated with a higher risk of perinatal mortality and short-term neonatal morbidity than elective
Caesarean section. (I)
2. Careful case selection and labour management in a modern obstetrical setting may achieve a level of safety similar to
elective Caesarean section. (II-1)
3. Planned vaginal delivery is reasonable in selected women with a
term singleton breech fetus. (I)
4. With careful case selection and labour management, perinatal mortality occurs in approximately 2 per 1000 births and serious shortterm neonatal morbidity in approximately 2% of breech infants. Many
recent retrospective and prospective reports of vaginal breech
delivery that follow specic protocols have noted excellent
neonatal outcomes. (II-1)
5. Long-term neurological infant outcomes do not differ by planned
mode of delivery even in the presence of serious short-term neonatal morbidity. (I)
Recommendations
Vaginal breech birth is a complex phenomenon. Selection criteria,
intrapartum management parameters, and delivery techniques are
difcult to isolate and study, and there is little rigorous evidence to
support or refute them individually. The criteria outlined here are
based upon the physiology of breech birth, the results of the TBT and
cohort studies with demonstrated safety, and the opinions of experts
in breech birth. Clinical judgement and the experience of the
obstetrical team are essential components of safe breech birth.
Besides an obstetrician-gynaecologist, the health care providers
involved in the team may also include a family practitioner or
midwife.
The recommendations were developed using the
guidelines
developed by the Canadian Task Force on Preventive Health Care
(Table).
Labour selection criteria

Epidemiology
Epidemiological comparisons of breech infants born vaginally or by
CS are typically hampered by their large and retrospective design: the
ultimate mode of delivery does not take into account the
planned mode of delivery or quality of care provided. One study in
particular bears mentioning, however. From
a large, wellmaintained national database, Reitberg et al. studied the change
in obstetrical breech practice in the Netherlands before and after
publication of the
TBT [39]. They detected an abrupt drop
immediately after publication in overall vaginal breech birth rate
from 50% to 20%, accompanied by a drop in perinatal mortality
from 0.35% to 0.18% and in fetal trauma from 0.29% to 0.08%.
Although perinatal mortality had previously continued to decline
in the Netherlands despite a stabilization of the CS rate, the clear
further decrease with the sudden increase in CS rate strongly implies
causality [8]. The magnitude of the drop was small, requiring altered
management in some 600 women with a breech

1. For a woman with suspected breech presentation, pre- or early


labour ultrasound should be performed to assess type of
breech presentation, fetal growth and estimated weight, and
attitude of fetal head. If ultrasound is not available, Caesarean
section is recommended. (II-1A)
2. Contraindications to labour include
a. Cord presentation (II-3A)
b. Fetal growth restriction or macrosomia (I-A)
c. Any presentation other than a frank or complete breech with a
exed or neutral head attitude (III-B)
d. Clinically inadequate maternal pelvis (III-B)
e. Fetal anomaly incompatible with vaginal delivery (III-B)
3. Vaginal breech delivery can be offered when the estimated fetal
weight is between 2500 g and 4000 g. (II-2B)

When a woman is admitted for a planned vaginal breech birth,


having been followed by a family practitioner or a midwife,
a consultation with an obstetrician-gynaecologist should be obtained.
Pre- or early-labour ultrasound assessment is essential to
determine type of breech presentation, assess fetal growth, and
detect the rare extended fetal neck at increased risk of
entrapment [45,46]. To be eligible for a TOL, estimated fetal
weight should be between 2500 g and 4000 g. The lower margin is
intended to exclude growth-restricted fetuses, the upper margin
to avoid
fetal-pelvic disproportion. Clinical pelvic examination
should be performed to rule out pathological pelvic contraction.
Although used in 82% of labours in the
PREMODA study,
radiological pelvimetry remains controversial, and many centres
have demonstrated safety
without it [26,34,35,37]. The best
indication of adequate fetalpelvic proportions is good progress in
labour.
A breech fetus has a higher chance of cord presentation. Persistent
cord presentation is an indication for CS to prevent cord prolapse [47].
A breech fetus also has a higher risk of cord prolapse in labour than a
cephalic fetus. This risk varies from less than 1% for frank breech to
perhaps 10% for footling breech presentation [48]. For a woman
to be eligible for a TOL, her fetus must be in a frank or complete
breech presentation. A footling breech, dened as having at least
one ex- tended fetal hip, is a contraindication to labour, and a CS
should be performed unless delivery is imminent. A fetus with feet
presenting but exed hips and knees is a complete breech, therefore
eligible for a TOL.
Labour management
4.

5.

6.
7.

8.
to

Clinical pelvic examination should be performed to rule out


path- ological pelvic contraction. Radiologic pelvimetry is not
necessary for a safe trial of labour; good progress in labour is the
best indi- cator of adequate fetal-pelvic proportions. (III-B)
Continuous electronic fetal heart monitoring is preferable in the
rst stage and mandatory in the second stage of labour. (I-A)
When membranes rupture, immediate vaginal examination is
recom- mended to rule out prolapsed cord. (III-B)
In the absence of adequate progress in labour, Caesarean section is
advised. (II-1A)
Induction of labour is not recommended for breech presentation.
(II-3B) Oxytocin augmentation is acceptable in the presence of
uterine dystocia. (II-1A)
A passive second stage without active pushing may last up

90 minutes, allowing the breech to descend well into the


pelvis. Once active pushing commences, if delivery is not
imminent after
60 minutes, Caesarean section is recommended. (I-A)
9. The active second stage of labour should take place in or near an
operating room with equipment and personnel available to perform a timely Caesarean section if necessary. (III-A)
10. A health care professional skilled in neonatal resuscitation should
be in attendance at the time of delivery. (III-A)
During breech labour, CEFM is recommended because of the
increased risk of cord prolapse. Detection of cord prolapse in hospital
with timely access to CS is usually associated with good fetal
outcome [27,49]. Prior to deep engagement in labour, membranes
should be ruptured articially only with a clear indication and careful
monitor- ing. When membranes rupture, immediate vaginal
examination is indicated to rule out prolapsed cord. If membranes
rupture at home, a woman with a known breech presentation
should be
advised to present immediately to hospital for
assessment. During the second stage of labour, descent of the
breech and entry of the umbilical insertion into the pelvis are
commonly associated with an increased incidence
of
cord
compression and
variable decelerations. CEFM is universally
required in the second stage. A fetal scalp ECG electrode may be

inserted into the buttock for CEFM, and one small study

supports the validity of capillary blood gas samples drawn from the
fetal buttocks to assess fetal well-being [50].
Progress in labour is an important factor in breech labour management. In the absence of data to the contrary, the TBT protocol
allowed a minimum of 0.5 cm/hr progress in the rst stage and up
to 3.5 hours for the second stage. The trial did not analyze results
according to labour progress in the rst stage, but post hoc analysis
showed increased perinatal morbidity in the 5% of women with an
active second stage N 60 minutes [21]. Comparatively, only 0.2% of
labouring women in the PREMODA study had an active second stage
N 60 minutes. There was failure to progress for two hours or more in
the rst stage in only 3.8% of labours, and dilation from 5 to 10 cm
took more than 7 hours in only 1.4%. It would seem prudent to
expect cervical dilation from 5 to 10 cm to take a maximum of 7
hours.
The use of oxytocin during breech labour is controversial. Oxytocin
augmentation was used in 74% of labours in PREMODA, and 9% of
women were induced. Although small series have also supported its
safety, induction of labour with a breech fetus is not recommended
[51]. Decreased uterine contractions (uterine dystocia) due to epidural
analgesia may be appropriately treated with oxytocin augmentation;
however, in spontaneous labour without epidural analgesia, oxytocin
augmentation is not recommended [22,38,52]. Failure to progress for
two hours despite adequate uterine contractions is an indication for
CS. Of note, the revised ACOG committee opinion indicated that some
of the recently published studies describing good perinatal outcome
did not offer oxytocin induction or augmentation as part of their
protocol [11].
Assessing full dilatation in breech presentation is more difcult than
in cephalic presentation because the fully dilated cervix does not
disappear behind the cephalic crown. Instead, the cervix remains
palpable as the fetal trunk descends through it. An experienced clinician
should make the assessment of full dilatation, as its timing is critical to
evaluating labour progress. Cord compression during descent in
the second stage is common and of unpredictable severity: active
pushing should take place in or near an operating room with
equipment and personnel available to perform an immediate CS if
necessary. An experienced obstetrician-gynaecologist with the
requisite skills should be available for a planned vaginal birth,
although it is recognized that complications at birth may occur even
under the best possible circumstances.
The second stage of labour can be divided into a passive phase,
prior to active pushing, and an active pushing phase. The passive
phase was N 60 minutes in 18% of labouring women in
PREMODA. Active pushing lasted for N 60 minutes in only 0.2%. A
prudent limit for the overall duration of the second stage, therefore,
would be 2.5 hours. If delivery is not imminent after 60 minutes of
active pushing, CS is indicated, even if the buttocks are on the
perineum. Breech infants often have lower Apgar scores at birth;
a health care professional skilled in neonatal resuscitation should be
in attendance at the time of delivery.
Delivery technique
11. The health care provider for a planned vaginal breech delivery
needs to possess the requisite skills and experience (II-1A)
12. An experienced obstetrician-gynaecologist comfortable in the performance of vaginal breech delivery should be present at the delivery to supervise other health care providers, including a trainee.
(I-A)
13. The requirements for emergency Caesarean section, including
availability of the hospital operating room team and the approximate 30-minute timeline to commence a laparotomy, must
be in accordance with the recommendations of the SOGC
Policy Statement, Attendance at Labour and Delivery (CPG
No. 89; update in press, 2009). (III-A)

14. The health care provider should have rehearsed a plan of


action and should be prepared to act promptly in the rare
cir- cumstance of a trapped after-coming head or irreducible
nuchal arms: symphysiotomy or emergency abdominal rescue
can be life saving. (III-B)
15. Total breech extraction is inappropriate for term singleton breech
delivery. (II-2A)
16. Effective maternal pushing efforts are essential to safe delivery
and should be encouraged. (II-1A)
17. At the time of delivery of the after-coming head, an
assistant should be present to apply suprapubic pressure to
favour exion and engagement of the fetal head. (II-3B)
18. Spontaneous or assisted breech delivery is acceptable. Fetal traction should be avoided, and fetal manipulation must be applied
only after spontaneous delivery to the level of the umbilicus.
(III-A)
19. Nuchal
arms may
be
reduced by the
Lvset or
Bickenbach manoeuvres. (III-B)
20. The fetal head may deliver spontaneously, with the assistance of
suprapubic pressure, by Mauriceau-Smellie-Veit manoeuvre, or
with the assistance of Piper forceps. (III-B)
In 1938, Bracht published a study that had a great impact
on perinatal mortality. The prevalent method of delivery at the time
was partial or complete breech extraction under maternal sedation.
By encouraging maternal effort in the second stage without
sedation, abandoning traction efforts from below, and using fundal
pressure to prevent a prolonged expulsion phase, Bracht reduced
perinatal mortality from a baseline of 3.2% to 0% [3].
As a breech fetus transits the pelvis, normal fetal tone and uterine
compression keep its head and arms exed. Fetal manipulation prior
to entrance of the elbows and chin into the pelvic inlet can
induce extension of fetal limbs and head (Moro reex) resulting in
trapped after-coming fetal parts. Spontaneous birth helps minimize
this risk, and many breech infants deliver spontaneously in a
timely fashion with maternal expulsive efforts alone. Whether used
routinely or only if spontaneous birth is not forthcoming, fetal
manoeuvres should be employed only after spontaneous delivery
to the umbilicus, and traction should be minimized [53].
After the breech crowns, fetal expulsion is invariably accompanied
by cord compression and fetal bradycardia. The normally grown fetus
enters this phase well oxygenated without acidemia. It may tolerate a
number of minutes of delay with extrinsic cord compression,
resulting in a respiratory acidosis, easily reversed once ventilation
is estab- lished. A growth-restricted fetus, however, has a high
likelihood of metabolic acidemia in labour due to pre-existing
compromise in placental function, which reduces its tolerance to
cord compression during expulsion. Therefore, fetal
growth
restriction is a contra- indication to labour.
Signicant cord compression beyond several minutes will eventually lead to severe acidosis even in a normal fetus, and prevention
and treatment of expulsive delay are critical components of delivery
technique. Mechanisms that maximize power from above may be
associated with lower risk of trapped after-coming fetal parts
than manoeuvres that involve fetal traction [1,36]. Maternal
cooperation is essential, and heavy sedation or dense epidural
analgesia should be avoided to maximize expulsive efforts [52].
Methods of increasing
power from above once the buttocks have crowned include maximizing maternal pushing efforts, upright posture, and suprapubic
pressure [5,6]. None have been well studied independently. Maximizing maternal pushing is considered safe, and the use of an assistant to
apply suprapubic pressure after crowning to maintain exion of the
fetal head and facilitate its engagement may be helpful (Bracht
manoeuvre) [1,3].
After spontaneous delivery to the fetal umbilicus, expulsive delay
despite power from above, with or without nuchal arms may require

manoeuvres involving fetal manipulation. The Lvset and Bickenbach


manoeuvres are the best described [7,54]. Only the bony fetal pelvis
and legs should be grasped to avoid damage to the fetal
adrenal glands, which are disproportionately large. Traction on
the fetus should be minimized to avoid trapped after-coming fetal
parts. Total breech extraction is inappropriate for term singleton
breech delivery in a modern hospital with ready access to CS. The
fetal head may deliver spontaneously, by Mauriceau-Smellie-Veit
manoeuvre, with the assistance of suprapubic pressure (Bracht
manoeuvre), or with the
assistance of Piper's forceps.
Symphysiotomy performed under local anaesthesia or abdominal
rescue can be a life-saving procedure in the
event of a trapped fetal head [5557].
Setting and consent
21. In the absence of a contraindication to vaginal delivery, a woman
with a breech presentation should be informed of the risks and
benets of a trial of labour and elective Caesarean section, and
informed consent should be obtained. A woman's choice of
delivery mode should be respected. (III-A)
22. The consent discussion and chosen plan should be well
docu- mented and communicated to labour-room staff. (III-B)
23. Hospitals offering a trial of labour should have a written protocol
for eligibility and intrapartum management. (III-B)
24. 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 inhospital care. (III-A)
25. The Society of Obstetricians and Gynaecologists of Canada
(SOGC), in collaboration with the Association of Professors of
Obstetrics and Gynaecology (APOG), The College of Family
Physicians of Canada (CFPC), and The Canadian Association of
Midwives (CAM) should revise the training requirements at the
undergraduate and postgraduate levels. SOGC will continue to
promote training of current health care providers through the
MOREOB, ALARM (Advances in Labour and Risk Management),
and other courses. (III-A)
26. Theoretical and hands-on breech birth training simulation should
be part of basic obstetrical skills training programs such as
ALARM, ALSO (Advanced Life Support Training in Obstetrics),
and MOREOB to prepare health care providers for unexpected
vaginal breech births. (III-B)

In light of recent publications that further clarify the lack of longterm newborn risk of vaginal breech delivery and the many cohort
reports noting excellent neonatal outcomes in settings with specic
protocols, it is acceptable for hospitals to offer vaginal breech delivery. Hospitals offering vaginal breech birth should have a written
protocol for eligibility and intrapartum management, including notication of the most responsible health care provider upon admission
in labour.
Faced with a parturient requesting a TOL, the health care provider
must evaluate his or her own system of breech selection, intrapartum
management, delivery technique, and clinical experience. Women
should be informed that the
risk
of short-term neonatal
morbidity maybe higher for a planned vaginal delivery than for a
planned CS but that long-term infant neurological outcome is not
different. In the low-perinatal-mortality-country arm of the TBT and
the PREMODA study, perinatal mortality was not different between
the planned vaginal delivery and planned CS groups. When vaginal
breech delivery is planned, the consent discussion regarding risks
and benets of mode of delivery and plans for delivery should be
well documented in the chart and available in the birthing centre.

The potential risk of coercion


The 2001 ACOG and RCOG breech guidelines left little room
for parturient autonomy [10,11]. Since their publication, it has
been routine practice in many jurisdictions for obstetriciangynaecologists to refuse women a breech TOL in hospital. On
occasion, women so denied have given birth unattended at home,
and perinatal deaths have resulted [58]. Also, the volume of
midwife-attended breech home births appears to have increased.
Even with the quality of care limitations of the TBT, the long-term
outcome was equivalent in the planned vaginal birth and planned
CS groups, and
parturient auto- nomy takes precedence over
practitioner concerns about small levels of fetal risk. Women should
be informed of the safety of a TOL in a setting with experienced
care providers.
Women who have a contraindication to labour or who are considered poor candidates for a TOL should be advised to deliver by CS.
However, it is the patient's right to decline any recommended
medical procedure or treatment. If a woman chooses to labour
despite this recommendation, she should be cared for in hospital.
In-hospital breech birth in a modern obstetrical setting is almost
certainly safer than home birth,
and a woman must not be
abandoned if she does not take medical advice [59].

System factors
In 2006, the Royal College of Obstetricians and Gynaecologists and
the American College of Obstetrics and Gynecology replaced their
restrictive 2001 breech guidelines with new versions supportive of
selected vaginal breech birth [60,61]. The 2006 RCOG Green Top
Guideline on breech birth outlines the obstetrical community's
responsibility to the individual parturient: If a unit is unable
to offer the choice of a planned vaginal breech birth, women who wish
to choose this option should be referred to a unit where this option
is available.
Many newly qualied obstetrician-gynaecologists do not have the
experience necessary to supervise a breech TOL, and mentoring by
more senior colleagues will be necessary if they are to attain
these skills. As precipitous breech births will occur in all settings,
theoretical and hands-on breech birth training using models
should be part of basic obstetrical and midwifery training and of
OB
training programs such as ALARM, ALSO, and MORE .

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laporan ringkasan
SOGC KLINIK PRAKTEK PEDOMAN
Persalinan pervaginam sungsang presentasi

No 226, Juni 2009


Pedoman ini telah ditinjau oleh
bstract
Maternal Fetal Medicine Komite dan
disetujui oleh Eksekutif dan Dewan
Masyarakat of Obstetricians dan
Gynaecologists Kanada.
PENULIS UTAMA
Andrew Kotaska, MD, Yellowknife NT Savas
Menticoglou, MD, Winnipeg MB Robert
Gagnon, MD, Montreal QC
IBU JANIN OBAT KOMITE Robert Gagnon
(Ketua), MD, Montreal QC Dan Farine, MD,
Toronto ON
Melanie Basso, RN, Vancouver BC Hayley Bos,
MD, London ON
Marie-France Delisle, MD, Vancouver BC
Kirsten Grabowska, MD, Vancouver BC Lynda
Hudon, MD, Montreal QC
Savas Menticoglou, MD, Winnipeg MB William
Mundle, MD, Windsor ON
Lynn Murphy-Kaulbeck, MD, Allison NB Annie
Ouellet, MD, Sherbrooke QC
Tracy Pressey, MD, Vancouver BC Anne
Roggensack, MD, Calgary AB
Laporan pengungkapan telah diterima dari
seluruh anggota komite.
J Obstet Gynaecol Can 2009; 31 (6):
557-566
Tujuan: Untuk meninjau fisiologi kelahiran
sungsang; untuk membedakan risiko dan
manfaat dari percobaan kerja dibandingkan
operasi caesar yang direncanakan; dan untuk
merekomendasikan kepada dokter
kandungan, dokter keluarga, bidan, perawat
obstetri, anestesi, dokter anak, dan
perawatan kesehatan kriteria seleksi
penyedia lainnya, parameter manajemen
intrapartum, dan teknik pengiriman untuk
percobaan lahir sungsang vagina. Pilihan:
Pengadilan tenaga kerja dalam pengaturan
yang sesuai atau pengiriman melalui operasi
caesar pre-emptive untuk wanita dengan
sungsang janin tunggal pada jangka panjang.
Hasil: Mengurangi kematian perinatal,
morbiditas neonatal jangka pendek, jangka
panjang morbiditas bayi, dan morbiditas ibu
jangka pendek dan jangka panjang dan
kematian. Bukti: Medline telah mencari
percobaan acak, studi kohort prospektif, dan
dipilih studi kohort retrospektif
membandingkan operasi caesar yang
direncanakan dengan percobaan rencana
kerja; dipilih studi epidemiologi
membandingkan pengiriman melalui operasi
caesar dengan pengiriman sungsang vagina;
dan studi yang membandingkan hasil jangka
panjang pada bayi sungsang lahir melalui
vagina atau melalui operasi caesar. Artikel
tambahan diidentifikasi melalui kepustakaan
melacak sampai dengan 1 Juni 2008. Nilai:
Bukti yang dikumpulkan diperiksa oleh Komite
Kedokteran Maternal Fetal Society of
Obstetricians dan Gynaecologists of Canada
(SOGC) dan quanti fi kasi menggunakan
kriteria dan spesifikasi-klasifikasi Tugas
Kanada Angkatan pada Kesehatan
Pencegahan. Vali- dation: Pedoman ini
dibandingkan dengan 2006 American College
of Committee Opini Obstetri pada modus
pengiriman sungsang tunggal jangka panjang
dan dengan 2006 Royal College of dokter
kandungan dan Gynaecologists Hijau
Pedoman Top: Manajemen Sungsang
Presentasi. Dokumen ini ditinjau oleh Kanada
dan Internasional dokter dengan keahlian
khusus dalam pengiriman vagina sungsang.
Sponsor: The Society of Obstetricians dan
Gynaecologists Kanada.

1. kelahiran sungsang vagina dapat dikaitkan


dengan risiko yang lebih tinggi dari kematian
perinatal dan morbiditas neonatal jangka
pendek dari operasi caesar elektif. (I)
2. seleksi kasus yang cermat dan manajemen
tenaga kerja dalam pengaturan kandungan
yang modern dapat mencapai tingkat
keamanan yang serupa dengan operasi
caesar elektif. (II-1)

Dokumen ini kembali proyek-fl muncul


klinis dan ilmiah kemajuan fi k pada tanggal
dikeluarkan dan dapat berubah. Informasi
tidak dapat dianggap sebagai mendikte
kursus eksklusif pengobatan atau prosedur
yang harus diikuti. Institusi lokal dapat
mendikte perubahan pendapat ini. Mereka
harus didokumentasikan dengan baik jika
dimodifikasi di tingkat lokal.
Singkatan: ACOG, American College of
Obstetricians dan Gynecologists; CS, operasi
caesar; CEFM, pemantauan janin elektronik
terus menerus; RCOG, Royal College of
Obstetricians dan Gynaecologists; TBT, Term
Sungsang Pengadilan; TOL, percobaan tenaga
kerja.
doi: 10,1016 / j.ijgo.2009.07.002
Kata kunci
breech
Buruh
pembedahan perut untuk menolong
melahirkan anak
Kunci laporan bukti dan grading rekomendasi,
menggunakan peringkat Satuan Tugas Kanada
pada Pencegahan
Perawatan Kesehatan.
Kualitas Bukti Assessment Klasifikasi
Rekomendasi
kehamilan jangka
validitas eksternal
I: Bukti yang diperoleh dari setidaknya satu
benar acak uji coba terkontrol
II-1: Bukti dari yang dirancang dengan baik uji
coba terkontrol tanpa pengacakan
II-2: Bukti dari kohort yang dirancang dengan
baik (calon atau retrospektif) atau kasus
kontrol studi, lebih disukai dari lebih dari satu
pusat atau penelitian kelompok
II-3: Bukti diperoleh dari perbandingan antara
waktu atau tempat-tempat dengan atau
tanpa intervensi. Hasil yang dramatis dalam
percobaan terkontrol (seperti hasil
pengobatan dengan penisilin pada 1940-an)
juga dapat dimasukkan dalam kategori ini
III: Pendapat otoritas dihormati, berdasarkan
pengalaman klinis, penelitian deskriptif, atau
laporan komite ahli
A. Ada bukti yang baik untuk
merekomendasikan tindakan pencegahan
klinis
B. Ada bukti yang adil untuk
merekomendasikan tindakan pencegahan
klinis
C. Bukti yang ada saling bertentangan dan
tidak memungkinkan untuk membuat
rekomendasi untuk atau terhadap
penggunaan tindakan pencegahan klinis;
Namun, faktor lain mungkin dalam pengaruh
fl pengambilan keputusan
D. Ada bukti yang adil untuk
merekomendasikan terhadap tindakan
pencegahan klinis
E. Ada bukti yang baik untuk
merekomendasikan terhadap tindakan
pencegahan klinis
L. Ada bukti fi sien insufisiensi (dalam
kuantitas atau kualitas) untuk membuat
rekomendasi; Namun, faktor lain mungkin
pengaruh pengambilan keputusan

Kualitas bukti yang dilaporkan dalam


pedoman ini telah diadaptasi dari The
Evaluasi kriteria Bukti dijelaskan dalam
Satuan Tugas Kanada pada Kesehatan
Pencegahan [62].
Rekomendasi termasuk dalam pedoman ini
telah disesuaikan dari Klasifikasi kriteria
Rekomendasi
dijelaskan dalam The Canadian Task Force on
Kesehatan Pencegahan [62].
3. pengiriman vagina Rencana wajar pada
wanita yang dipilih dengan janin istilah
tunggal sungsang. (I)
4. Dengan pemilihan kasus yang cermat dan
manajemen tenaga kerja, kematian perinatal
terjadi pada sekitar 2 per 1000 kelahiran dan
jangka pendek morbiditas neonatal yang
serius pada sekitar 2% dari bayi sungsang.
Banyak laporan retrospektif dan prospektif
baru-baru ini vagi- pengiriman sungsang nal
yang mengikuti spesifik protokol fi c telah
mencatat hasil neonatal cellent mantan. (II-1)
Hasil bayi neurologis 5. jangka panjang tidak
berbeda dengan modus yang direncanakan
pengiriman bahkan di hadapan jangka pendek
neo morbiditas natal serius. (I)
rekomendasi
Kriteria seleksi Buruh
1. Bagi seorang wanita yang diduga
sungsang, pra atau USG persalinan dini harus
dilakukan untuk menilai jenis sungsang,
pertumbuhan janin dan diperkirakan berat
badan, dan sikap kepala janin. Jika USG tidak
tersedia, operasi caesar dianjurkan. (II-1A)
2. Kontraindikasi tenaga kerja termasuk. Cord
presentasi (II-3A)
b. Pembatasan pertumbuhan janin atau
makrosomia (I-A)
c. Presentasi selain sungsang jujur atau
lengkap dengan
fl Exed atau sikap kepala netral (III-B)
d. Klinis memadai panggul ibu (III-B)
e. Anomali janin tidak sesuai dengan
persalinan pervaginam (III-B)
3. Vagina pengiriman sungsang dapat
ditawarkan ketika diperkirakan berat janin
antara 2500 dan 4000 g g. (II-2B)
manajemen Buruh
4. Pemeriksaan panggul klinis harus dilakukan
untuk menyingkirkan patogenesis kontraksi
panggul logis. Pelvimetri radiologis tidak
diperlukan untuk percobaan aman tenaga
kerja; kemajuan yang baik dalam tenaga kerja
adalah indikator terbaik dari proporsi janinpanggul yang memadai. (III-B)
5. berkelanjutan elektronik pemantauan
jantung janin adalah lebih baik dalam tahap
pertama dan wajib pada tahap kedua
persalinan. (IA) Ketika ketuban pecah,
pemeriksaan vagina langsung yang
direkomendasikan untuk dimakan untuk
menyingkirkan prolaps tali pusat. (III-B)
6. Dengan tidak adanya kemajuan yang
memadai dalam tenaga kerja, operasi caesar
disarankan. (II-1A)
7. Induksi persalinan tidak direkomendasikan
untuk presentasi bokong. (II-3B) Oksitosin
augmentation diterima di hadapan distosia
rahim. (II-1A)
8. Sebuah tahap kedua pasif tanpa aktif
mendorong dapat berlangsung sampai
90 menit, memungkinkan sungsang turun
baik ke panggul. Setelah dimulainya
mendorong aktif, jika pengiriman tidak segera
setelah
60 menit, operasi caesar dianjurkan. (I-A)
9. Tahap kedua aktif tenaga kerja harus
dilakukan di atau dekat ruang operasi dengan
peralatan dan personil yang tersedia untuk
melakukan operasi caesar tepat waktu jika
diperlukan. (III-A)
10. Sebuah perawatan kesehatan profesional
yang terampil dalam resusitasi neonatal harus
hadir pada saat pengiriman. (III-A)
teknik pengiriman

11. penyedia layanan kesehatan untuk


persalinan sungsang vagina yang
direncanakan perlu memiliki keterampilan
yang diperlukan dan pengalaman. (II-1A)
12. Sebuah mengalami dokter kandungandokter kandungan nyaman dalam kinerja
pengiriman sungsang vagina harus hadir pada
saat persalinan untuk mengawasi penyedia
layanan kesehatan lainnya, termasuk trainee.
(I-A)
13. Persyaratan untuk bagian darurat caesar,
termasuk ketersediaan tim ruang operasi
rumah sakit dan Imate kira-30 menit waktu
untuk memulai laparotomi, harus sesuai
dengan rekomendasi dari Pernyataan
Kebijakan SOGC, "Kehadiran Tenaga Kerja dan
Pengiriman "(CPG Nomor 89, tanggal up di
media, 2009). (III-A)
14. Penyedia layanan kesehatan harus
berlatih rencana aksi dan harus siap untuk
bertindak cepat dalam sikap-keadaan langka
terjebak setelah datang kepala atau lengan
nuchal tereduksi: symphysiotomy atau
darurat penyelamatan perut bisa
menyelamatkan nyawa. (III-B)
15. Jumlah ekstraksi sungsang adalah tidak
pantas untuk pengiriman sungsang tunggal
jangka. (II-2A)
16. Upaya mendorong ibu yang efektif sangat
penting untuk pengiriman aman dan harus
didorong. (II-1A)
17. Pada saat penyerahan kepala setelah
datang, asisten harus hadir untuk
menerapkan tekanan suprapubik untuk
mendukung exion fl dan keterlibatan kepala
janin. (II-3B)
18. Spontan atau dibantu pengiriman
sungsang dapat diterima. Janin tion traksi
harus dihindari, dan manipulasi janin harus
diterapkan hanya setelah melahirkan spontan
dengan tingkat umbilikus. (III-A)
19. lengan Nuchal dapat dikurangi oleh VREs
manoeu- Lvset atau Bickenbach. (III-B)
20. Kepala janin dapat memberikan spontan,
dengan bantuan tekanan suprapubik, oleh
Mauriceau-Smellie-Veit manuver, atau dengan
bantuan Piper forsep. (III-B)
Pengaturan dan persetujuan
21. Dengan tidak adanya kontraindikasi untuk
persalinan pervaginam, seorang wanita
dengan presentasi sungsang harus diberitahu
tentang risiko dan manfaat dari percobaan
kerja dan operasi caesar elektif, dan informed
consent harus diperoleh. Pilihan seorang
wanita dari modus pengiriman harus
dihormati. (III-A)
22. Diskusi persetujuan dan rencana yang
dipilih harus baik didokumentasikan dan
dikomunikasikan kepada staf pekerja-kamar.
(III-B)
23. Rumah Sakit menawarkan percobaan
kerja harus memiliki protokol tertulis untuk
kelayakan dan manajemen intrapartum. (III-B)
24. Wanita dengan kontraindikasi untuk
percobaan kerja harus disarankan untuk
memiliki operasi caesar. Perempuan memilih
untuk bekerja meskipun rekomendasi ini
memiliki hak untuk melakukannya dan tidak
boleh ditinggalkan. Mereka harus disediakan
mungkin perawatan rumah sakit terbaik in.
(III-A)
25. Masyarakat of Obstetricians dan
Gynaecologists of Canada (SOGC), bekerja
sama dengan Asosiasi Profesor Obstetri dan
Ginekologi (APOG), The College of Family
Physicians of Canada (CFPC), dan The
Canadian Asosiasi Bidan (CAM) harus merevisi
persyaratan pelatihan di tingkat sarjana dan
pascasarjana. SOGC akan terus
mempromosikan pelatihan penyedia layanan
kesehatan saat ini melalui MOREOB, ALARM
(Kemajuan dalam Buruh dan Manajemen
Risiko), dan kursus lainnya. (III-A)
26. Teori dan tangan-on simulasi pelatihan
kelahiran sungsang harus menjadi bagian dari
program pelatihan keterampilan kandungan
dasar seperti ALARM, JUGA (Training Life
Support Lanjutan di Obstetri), dan MOREOB
untuk mempersiapkan penyedia layanan
kesehatan untuk tak terduga kelahiran
sungsang vagina. (III-B)
latar belakang

Dibandingkan dengan janin dengan


presentasi kepala, janin sungsang
menghadapi peningkatan risiko selama
persalinan asfiksia dari kompresi tali dan
cedera traumatik selama persalinan bahu dan
kepala. Operasi caesar pre-emptive
menghindari sebagian besar risiko ini.
Sebelum tahun 1940, meskipun angka
kematian perinatal sungsang dari 5%, CS
terlibat terlalu banyak risiko ibu untuk
digunakan secara rutin untuk menurunkan
risiko janin [1]. Im- terbukti aman dengan
antibiotik, transfusi darah, dan bawah
segmen sayatan Kerr diminta pertimbangan
rutin CS untuk posisi sungsang [2]. Secara
bersamaan, perbaikan dalam teknik
penyampaian sungsang vagina nyata
menurunkan risiko percobaan kerja di tangan
berpengalaman, dan sungsang kematian
perinatal terus menurun,
meskipun stabilisasi nilai CS [1,3-8].
Perdebatan seputar
Modus optimal pengiriman untuk janin
sungsang berfokus pada pertanyaan klinis
tunggal: apa besarnya risiko terhadap janin
dari TOL dan bagaimana kita harus
menyeimbangkannya terhadap peningkatan
risiko langsung dan masa depan CS untuk ibu
dan anak-anak masa depannya?
Istilah sungsang sidang
Diterbitkan pada tahun 2000, Jangka
Sungsang Percobaan adalah besar, percobaan
multisenter acak terkontrol yang dirancang
untuk menentukan modus paling aman
pengiriman untuk janin sungsang istilah [9].
Di negara-negara dengan angka kematian
perinatal yang rendah, percobaan
menunjukkan tidak ada perbedaan dalam
kematian perinatal antara CS direncanakan
dan TOL tapi perbedaan yang mencolok
dalam "serius" jangka pendek morbiditas
neonatal: 0,4% dibandingkan 5,1%. Tidak ada
perbedaan
kematian ibu atau morbiditas serius diukur,
sehingga sebagian besar ahli untuk
merekomendasikan direncanakan CS untuk
presentasi sungsang di jangka
[10,11]. Pergeseran tiba-tiba dalam praktek
klinis terjadi, dan sungsang tarif CS jangka
meningkat di seluruh dunia. Kolam renang
keahlian dalam kelahiran sungsang vagina
telah menyusut dengan cepat sejak, dan
banyak ginekolog obstetrician- sekarang lulus
dengan sedikit atau tanpa pengalaman
dengan pengiriman sungsang vagina. Di
banyak daerah di dunia, wanita dengan janin
sungsang tidak lagi memiliki pilihan untuk
kelahiran sungsang dihadiri medis vagina
[12,13].
The TBT adalah uji klinis secara acak terbesar
yang pernah dilakukan pada mode sungsang
jangka pengiriman, dan telah memberikan
banyak informasi mengenai kelahiran
sungsang a. Meskipun kekuatan, namun,
sejumlah kelemahan telah diidentifikasi sejak
publikasi [14-20]. Berdasarkan informasi yang
tersedia pada saat itu, temuan yang mungkin
telah mis-ditafsirkan dan mungkin telah
menyebabkan perubahan dini dalam praktek
klinis. A
analisis yang komprehensif adalah di luar
lingkup pedoman ini; Namun, pemeriksaan
keterbatasan utama TBT adalah penting
untuk memperkirakan risiko sebenarnya dari
tenaga kerja untuk janin sungsang. Mereka
dapat dikelompokkan sebagai terendah fol-:
(1) seleksi kasus yang tidak memadai dan
manajemen intrapartum; (2) unit bersalin
dengan tingkat keterampilan yang sangat
berbeda dikelompokkan bersama; dan (3)
morbiditas jangka pendek yang digunakan
sebagai penanda untuk penurunan neurologis
jangka panjang.
TBT: seleksi kasus dan manajemen tenaga
kerja
Pra atau awal USG tenaga kerja tidak
diperlukan, yang mungkin telah
memungkinkan janin dengan pembatasan
pertumbuhan karena insufisiensi plasenta
defisiensi untuk tidak terdeteksi. Setidaknya
tujuh dari 16 kematian perinatal uji coba
berada di pertumbuhan terbatas janin
[9,16,19,21]. Sejauh mana terdeteksi
makrosomia janin dan fl Exed posisi kepala de

kontribusi terhadap morbiditas dan mortalitas


tidak diketahui. Pemantauan janin elektronik
terus menerus juga tidak diperlukan, dan
hanya sepertiga dari janin menerimanya.
Protokol percobaan diperbolehkan kemajuan
persalinan menjadi lambat 0,5 cm / jam
dalam tahap pertama dan sampai 3,5 jam
untuk tahap kedua [21]. Meskipun mereka
diterima untuk janin cephalic, beberapa
praktisi berpengalaman mempertim- bangkan
batas-batas ini dapat diterima untuk janin
sungsang, dan 5% dari janin lahir setelah
tahap kedua yang aktif lebih dari 60 menit
ditemui peningkatan morbiditas dan
mortalitas [22]. Oleh karena itu dapat
dipelajari dari TBT bahwa strategi berikut
dapat meningkatkan keamanan pengiriman
sungsang jangka: estimasi USG berat janin
untuk mendeteksi pertumbuhan abnormal
janin, sikap kepala janin, dan jenis presentasi
bokong, dan perhatian untuk kemajuan di
kedua tahap persalinan.
Meskipun seorang praktisi berpengalaman
dalam melahirkan sungsang vagina
diharapkan pada setiap pengiriman, seorang
dokter kandungan berlisensi tidak hadir di
13% dari kelahiran dalam kelompok kelahiran
direncanakan vagina vs 2% pada kelompok
operasi caesar yang direncanakan, dan ada
tingkat tinggi crossover di persidangan: 10%
perempuan acak direncanakan CS melalui
vagina. Tiga persen dari janin yang cephalic
pada persalinan, menyoroti kebutuhan untuk
USG rutin untuk tersangka sungsang dalam
persalinan atau sebelum elektif CS.
TBT: Hasil jangka pendek pengganti
Morbiditas jangka pendek dalam vagina lahir
janin sungsang sering meningkat karena
kompresi tali yang umum terjadi selama
tahap kedua dan pengusiran janin. Di negaranegara seperti Kanada dengan kematian
perinatal yang rendah, perbedaan mutlak
dalam morbiditas jangka pendek yang serius
antara lengan TBT adalah 5%. Namun, salah
satu setengah dari sampel diikuti lebih dari
dua tahun, pada saat tidak ada perbedaan
dalam kematian perinatal gabungan dan hasil
neurologis yang abnormal: 3,1% dalam
kelompok CS yang direncanakan, dan 2,8%
pada kelompok TOL [23]. Dari 18 bayi dengan
morbiditas neonatal serius yang diikuti, 17
yang neurologis normal pada usia dua tahun.
Bayi yang tersisa meninggal bawaan stenosis
subglotis, dianggap tidak mungkin
berhubungan dengan cara persalinan. Ini
menunjukkan kegagalan sistematis, juga
ditunjukkan oleh penelitian lain, jangka
pendek
morbiditas untuk memprediksi hasil jangka
panjang pada bayi sungsang [24-28].
Pada usia dua tahun, satu-satunya perbedaan
signifikan pada bayi out- datang adalah
sedikit "masalah medis dalam beberapa bulan
terakhir" dalam kelompok TOL (15% vs 21%;
P = 0,02). Sistem kekebalan tubuh neonatal
diaktifkan selama persalinan, dan hubungan
antara tenaga kerja dan mengurangi kejadian
penyakit alergi dan auto-imun anak dapat
kausal [29-32].
Dengan keterbatasan dalam TBT, wanita
memiliki kesempatan 97% memiliki berusia
dua tahun neurologis normal, terlepas dari
modus yang direncanakan lahir. Mereka
secara acak percobaan kerja memiliki 6%
mutlak kesempatan yang lebih rendah (atau
30% pengurangan risiko relatif) memiliki anak
dua tahun dengan masalah medis unspeci fi
kasi, menyarankan beberapa tahan bene fi t
dari tenaga kerja untuk sistem kekebalan
tubuh bayi yang baru lahir.
studi Premoda
Retrospektif seri Banyak membandingkan TOL
dengan direncanakan CS telah diterbitkan
[26,27,33-37]. Banyak yang cukup besar
untuk dem- keselamatan onstrate diterima
lahir sungsang di masing-masing unit;
Namun, data yang dikumpulkan secara
retrospektif dan belum tentu Umum- izable
luar unit-unit yang berpengalaman. Pada
tahun 2006, sebagai tanggapan terhadap
TBT, Gof fi net et al. menerbitkan studi
PREMODA: deskriptif multisenter

belajar empat kali lebih besar dari TBT [38].


Data calon yang col dikumpulkan dari 8105
perempuan di 174 pusat di Perancis dan
Belgia, dengan menggunakan hasil jangka
pendek yang sama gabungan kematian
perinatal atau morbiditas neonatal serius
sebagai TBT. Praktek kontemporer di Perancis
dan Belgia melibatkan, tingkat yang konsisten
berhati-hati perawatan, yang tidak diubah
oleh para peneliti.
Penelitian PREMODA adalah deskriptif, dan
persentase perempuan berusaha kelahiran
normal bervariasi antara pusat (47,8-89,0%).
Secara keseluruhan, CS direncanakan di 69%
dan TOL yang dilakukan di 31%, konsisten
dengan non-pengacakan. Dari 2.526 wanita
yang memiliki TOL, 1796 (71%) de- pengecut
vagina untuk tingkat kelahiran vagina secara
keseluruhan 22,5%. Pra atau awal USG
tenaga kerja dan CEFM tenaga kerja yang
universal. Bertentangan dengan praktek
standar di banyak negara, termasuk Kanada,
pelvimetri radiologis dipekerjakan di 82%.
Kegagalan untuk kemajuan selama lebih dari
dua
jam dalam tahap pertama persalinan terjadi
pada 3,8% dari tenaga kerja, dan tahap kedua
yang aktif lebih dari 60 menit terjadi hanya
0,2% dari kasus. Hanya 0,6% dari perempuan
yang merencanakan CS akhirnya disampaikan
melalui vagina, dan semua janin yang
sungsang saat persalinan.
Meskipun tidak secara tegas sebanding, yang
PREMODA hasil-hasil Contrast con dengan
orang-orang dari TBT. Tidak ada perbedaan
dalam kematian perinatal (0,08% vs 0,15%)
atau morbiditas neonatal yang serius (1,6%
vs
1,45%) antara TOL dan direncanakan CS.
Satu-satunya perbedaan hasil adalah kejadian
0,16% dari lima menit skor Apgar b 4 pada
kelompok TOL dibandingkan 0,02% pada
kelompok CS yang direncanakan. Delapan kali
lebih besar dari subset perinatal-kematian
rendah dari TBT, studi PREMODA memberikan
perkiraan yang kuat dari risiko sungsang TOL
berhati-hati dalam modern, dengan baik
didukung satuan kandungan.
epidemiologi
Perbandingan epidemiologi bayi sungsang
lahir melalui vagina atau dengan CS biasanya
terhambat oleh desain besar dan retrospektif
mereka: modus utama pengiriman tidak
memperhitungkan modus direncanakan
pengiriman atau kualitas perawatan yang
diberikan. Satu studi di beruang tertentu
menyebutkan, namun. Dari besar, basis data
nasional terpelihara dengan baik, Reitberg et
al. mempelajari perubahan dalam praktek
sungsang kandungan di Belanda sebelum dan
sesudah publikasi TBT [39]. Mereka
mendeteksi penurunan tiba-tiba segera
setelah publikasi di tingkat kelahiran
sungsang vagina secara keseluruhan dari
50% menjadi 20%, disertai dengan penurunan
kematian perinatal dari 0,35% menjadi 0,18%
dan trauma janin dari 0,29% menjadi 0,08%.
Meskipun angka kematian perinatal
sebelumnya terus menurun di Belanda
meskipun stabilisasi nilai CS, penurunan lebih
lanjut yang jelas dengan peningkatan
mendadak dalam CS tingkat sangat berarti
kausalitas [8]. Besarnya penurunan itu kecil,
memerlukan manajemen yang berubah di
sekitar 600 wanita dengan sungsang sebuah
janin dan beberapa tambahan 175 CS untuk
mencegah satu kematian perinatal; Namun,
hasil menyiratkan bahwa peningkatan kehatihatian menghasilkan angka kelahiran
sungsang vagina yang lebih rendah dan
peningkatan keamanan. Ditingkatkan Hasil ini
terutama disebabkan oleh peningkatan
direncanakan CS, tapi hasilnya juga lebih baik
setelah darurat CS dan pengiriman vagina,
menunjukkan bahwa pada wanita hamil yang
dipilih dengan hati-hati, pengiriman sungsang
vagina mungkin menjadi pilihan yang aman.
Berbeda dengan TBT, praktek baru telah
mengakibatkan sedikit peningkatan
morbiditas ibu CS-terkait dan kematian,
memicu perdebatan tentang keseimbangan
antara ibu dan
risiko janin [40-44].
laporan ringkasan

1. kelahiran sungsang vagina dapat dikaitkan


dengan risiko kematian yang lebih tinggi natal
peri dan morbiditas neonatal jangka pendek
dari operasi caesar elektif. (I)
2. seleksi kasus yang cermat dan manajemen
tenaga kerja dalam pengaturan stetrical
diamati modern yang dapat mencapai tingkat
keamanan yang serupa dengan operasi
caesar elektif. (II-1)
3. pengiriman vagina Rencana wajar pada
wanita yang dipilih dengan janin istilah
tunggal sungsang. (I)
4. Dengan pemilihan kasus yang cermat dan
manajemen tenaga kerja, tian perinatal kematerjadi pada sekitar 2 per 1000 kelahiran dan
jangka pendek morbiditas neonatal yang
serius pada sekitar 2% dari bayi sungsang.
Banyak laporan retrospektif dan prospektif
baru-baru ini melahirkan sungsang vagina
yang mengikuti spesifik protokol fi c telah
mencatat hasil neonatal sangat baik. (II-1)
Hasil bayi neurologis 5. jangka panjang tidak
berbeda dengan modus yang direncanakan
pengiriman bahkan di hadapan jangka pendek
neo morbiditas natal serius. (I)
rekomendasi
Kelahiran sungsang vagina adalah fenomena
yang kompleks. Kriteria seleksi, parameter
manajemen intrapartum, dan teknik
pengiriman sulit untuk mengisolasi dan
mempelajari, dan ada bukti ketat sedikit
untuk mendukung atau menolak mereka
secara individu. Kriteria diuraikan di sini
didasarkan pada fisiologi kelahiran sungsang,
hasil TBT dan studi kohort dengan
keselamatan menunjukkan, dan pendapat dari
para ahli dalam kelahiran sungsang. Penilaian
klinis dan pengalaman dari tim kandungan
merupakan komponen penting dari kelahiran
sungsang aman. Selain seorang dokter
kandungan-dokter kandungan, penyedia
layanan kesehatan yang terlibat dalam tim
juga mungkin termasuk dokter keluarga atau
bidan.
Rekomendasi tersebut dikembangkan dengan
menggunakan pedoman yang dikembangkan
oleh Satuan Tugas Kanada pada Kesehatan
Preventif (Tabel).
Kriteria seleksi Buruh
1. Bagi seorang wanita yang diduga
sungsang, pra atau USG persalinan dini harus
dilakukan untuk menilai jenis sungsang,
pertumbuhan janin dan diperkirakan berat
badan, dan sikap kepala janin. Jika USG tidak
tersedia, operasi caesar dianjurkan. (II-1A)
2. Kontraindikasi tenaga kerja termasuk
a. Cord presentasi (II-3A)
b. Pembatasan pertumbuhan janin atau
makrosomia (I-A)
c. Presentasi selain sungsang jujur atau
lengkap dengan
fl Exed atau sikap kepala netral (III-B)
d. Klinis memadai panggul ibu (III-B)
e. Anomali janin tidak sesuai dengan
persalinan pervaginam (III-B)
3. Vagina pengiriman sungsang dapat
ditawarkan ketika diperkirakan berat janin
antara 2500 dan 4000 g g. (II-2B)
Ketika seorang wanita mengaku untuk
kelahiran sungsang vagina yang
direncanakan, yang telah diikuti oleh praktisi
keluarga atau bidan, konsultasi dengan dokter
kandungan-dokter kandungan harus
diperoleh.
Prapenilaian atau USG awal-tenaga kerja
sangat penting untuk menentukan jenis posisi
sungsang, menilai pertumbuhan janin, dan
mendeteksi diperpanjang leher janin langka
pada peningkatan risiko jebakan [45,46]. Agar
memenuhi syarat untuk TOL sebuah,
diperkirakan berat janin harus antara 2500
dan 4000 g g. Margin yang lebih rendah
dimaksudkan untuk mengecualikan janin
pertumbuhan terbatas, margin atas untuk
menghindari ketidakseimbangan janinpanggul. Pemeriksaan panggul klinis harus
dilakukan untuk menyingkirkan kontraksi
panggul patologis. Meskipun digunakan di

82% dari tenaga kerja dalam studi PREMODA,


pelvimetri radiologis masih kontroversial, dan
banyak pusat telah menunjukkan keamanan
tanpa itu [26,34,35,37]. Indikasi terbaik
proporsi fetalpelvic yang memadai adalah
kemajuan yang baik dalam persalinan.
Janin sungsang memiliki kesempatan lebih
tinggi presentasi kabel. Presentasi kabel
Persistent merupakan indikasi untuk CS untuk
mencegah prolaps tali pusat [47]. Janin
sungsang juga memiliki risiko yang lebih
tinggi dari prolaps tali pusat tenaga kerja dari
janin cephalic. Risiko ini bervariasi dari kurang
dari 1% untuk sungsang terus terang
mungkin 10% untuk goblok breech [48]. Bagi
seorang wanita untuk memenuhi persyaratan
untuk TOL sebuah, janinnya harus dalam
presentasi sungsang jujur atau lengkap.
Sebuah sungsang goblok, didefinisikan
sebagai memiliki setidaknya satu mantan
cenderung pinggul janin, merupakan
kontraindikasi untuk tenaga kerja, dan CS
harus dilakukan kecuali pengiriman sudah
dekat. Janin dengan kaki menyajikan tapi
pinggul fl Exed dan lutut adalah sungsang
lengkap, karena itu memenuhi syarat untuk
TOL a.
manajemen Buruh
4. Pemeriksaan panggul klinis harus dilakukan
untuk menyingkirkan path- kontraksi panggul
ological. Pelvimetri radiologis tidak diperlukan
untuk percobaan aman tenaga kerja;
kemajuan yang baik dalam pekerjaan adalah
yang terbaik-individu cator proporsi janinpanggul yang memadai. (III-B)
5. berkelanjutan elektronik pemantauan
jantung janin adalah lebih baik dalam tahap
pertama dan wajib pada tahap kedua
persalinan. (IA) Ketika ketuban pecah,
pemeriksaan vagina langsung yang
direkomendasikan untuk dimakan untuk
menyingkirkan prolaps tali pusat. (III-B)
6. Dengan tidak adanya kemajuan yang
memadai dalam tenaga kerja, operasi caesar
disarankan. (II-1A)
7. Induksi persalinan tidak direkomendasikan
untuk presentasi bokong. (II-3B) Oksitosin
augmentation diterima di hadapan distosia
rahim. (II-1A)
8. Sebuah tahap kedua pasif tanpa aktif
mendorong dapat berlangsung sampai
90 menit, memungkinkan sungsang turun
baik ke panggul. Setelah dimulainya
mendorong aktif, jika pengiriman tidak segera
setelah
60 menit, operasi caesar dianjurkan. (I-A)
9. Tahap kedua aktif tenaga kerja harus
dilakukan di atau dekat ruang operasi dengan
peralatan dan personil yang tersedia untuk
per- membentuk operasi caesar tepat waktu
jika diperlukan. (III-A)
10. Sebuah perawatan kesehatan profesional
yang terampil dalam resusitasi neonatal harus
hadir pada saat pengiriman. (III-A)
Selama persalinan sungsang, CEFM
dianjurkan karena peningkatan risiko prolaps
tali pusat. Deteksi prolaps tali pusat di rumah
sakit dengan akses yang tepat terhadap CS
biasanya dikaitkan dengan baik hasil janin
[27,49]. Sebelum keterlibatan dalam tenaga
kerja, membran harus pecah arti secara resmi
hanya dengan indikasi yang jelas dan hatihati pemantauan yang. Ketika ketuban pecah,
pemeriksaan vagina segera diindikasikan
untuk menyingkirkan prolaps tali pusat. Jika
selaput pecah di rumah, seorang wanita
dengan presentasi sungsang dikenal harus
disarankan untuk menyajikan segera ke
rumah sakit untuk penilaian. Selama tahap
kedua persalinan, keturunan dari sungsang
dan masuknya penyisipan pusar ke dalam
panggul yang umumnya terkait dengan
peningkatan insiden kompresi tali dan
deselerasi variabel. CEFM secara universal
dibutuhkan pada tahap kedua. Sebuah janin
kulit kepala EKG elektroda dapat dimasukkan
ke dalam pantat untuk CEFM, dan satu studi
kecil
mendukung validitas sampel gas darah
kapiler diambil dari pantat janin untuk menilai
kesejahteraan janin [50].
Kemajuan dalam tenaga kerja merupakan
faktor penting dalam persalinan sungsang
pengelolaan. Dengan tidak adanya data yang
bertentangan, protokol TBT diperbolehkan

minimal 0,5 cm / jam kemajuan dalam tahap


pertama dan sampai 3,5 jam untuk tahap
kedua. Sidang tidak menganalisis hasil sesuai
dengan kemajuan kerja dalam tahap pertama,
tetapi post hoc analisis menunjukkan
peningkatan morbiditas perinatal dalam 5%
wanita dengan tahap kedua yang aktif N 60
menit [21]. Relatif, hanya 0,2% dari wanita
bersalin dalam studi PREMODA memiliki aktif
kedua tahap N 60 menit. Ada kegagalan untuk
kemajuan selama dua jam atau lebih dalam
tahap pertama hanya 3,8% dari tenaga kerja,
dan pelebaran dari 5 sampai 10 cm
membutuhkan waktu lebih dari 7 jam hanya
1,4%. Tampaknya bijaksana untuk
mengharapkan pelebaran serviks dari 5
sampai 10 cm untuk mengambil maksimal 7
jam.
Penggunaan oksitosin selama persalinan
sungsang masih kontroversial. Oksitosin
augmentation digunakan di 74% dari tenaga
kerja di PREMODA, dan 9% wanita diinduksi.
Meskipun seri kecil juga telah mendukung
keamanannya, induksi persalinan dengan
janin sungsang tidak dianjurkan [51].
Penurunan kontraksi uterus (rahim distosia)
karena analgesia epidural mungkin tepat
diobati dengan oksitosin augmentasi; Namun,
dalam persalinan spontan tanpa analgesia
epidural, oksitosin augmentasi tidak
dianjurkan [22,38,52].