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Women and Birth : Journal of the... May 2022Clinical practice guidelines are designed to guide clinicians and consumers of maternity services in clinical decision making, but recommendations are often consensus... (Review)
Review
PROBLEM
Clinical practice guidelines are designed to guide clinicians and consumers of maternity services in clinical decision making, but recommendations are often consensus based and differ greatly between leading organisations.
BACKGROUND
Breech birth is a divisive clinical issue, however vaginal breech births continue to occur despite a globally high caesarean section rate for breech presenting fetuses. Inconsistencies are known to exist between clinical practice guidelines relating to the management of breech presentation.
AIM
The aim of this review was to critically evaluate and compare leading obstetric clinical practice guidelines related to the management of breech presenting fetuses.
METHODS
Leading obstetric guidelines were purposively obtained for review. Analysis was conducted using the International Centre for Allied Health Evidence (iCAHE) Guideline Quality Checklist and reviewing the content of each guideline.
FINDINGS
Antenatal care recommendations and indications for Caesarean Section were relatively consistent between clinical guidelines. However, several inconsistencies were found among the other recommendations in terms of birth mode counselling, intrapartum management and the basis for recommendations.
DISCUSSION
Inconsistencies noted in the clinical practice guidelines have the potential to cause issues related to valid consent and create confusion among clinicians and maternity consumers.
CONCLUSION
Clinical practice guidelines, which focus on the risks of a Vaginal Breech Birth without also discussing the risks of a Caesarean Section when a breech presentation is diagnosed, has the potential to sway clinician attitudes and impact birth mode decision-making in maternity consumers. To respect pregnant women's autonomy and fulfil the legal requirements of consent, clinicians should provide balanced counselling.
Topics: Breech Presentation; Cesarean Section; Counseling; Delivery, Obstetric; Female; Humans; Parturition; Practice Guidelines as Topic; Pregnancy
PubMed: 34253466
DOI: 10.1016/j.wombi.2021.06.011 -
The Cochrane Database of Systematic... May 2023Breech presentation at term can cause complications during birth and increase the chance of caesarean section. Moxibustion (a type of Chinese medicine which involves... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Breech presentation at term can cause complications during birth and increase the chance of caesarean section. Moxibustion (a type of Chinese medicine which involves burning a herb close to the skin) at the acupuncture point Bladder 67 (BL67) (Chinese name Zhiyin), located at the tip of the fifth toe, has been proposed as a way of changing breech presentation to cephalic presentation. This is an update of a review first published in 2005 and last published in 2012.
OBJECTIVES
To examine the effectiveness and safety of moxibustion on changing the presentation of an unborn baby in the breech position, the need for external cephalic version (ECV), mode of birth, and perinatal morbidity and mortality.
SEARCH METHODS
For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register (which includes trials from CENTRAL, MEDLINE, Embase, CINAHL, and conference proceedings), ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform (ICTRP) (4 November 2021). We also searched MEDLINE, CINAHL, AMED, Embase and MIDIRS (inception to 3 November 2021), and the reference lists of retrieved studies.
SELECTION CRITERIA
The inclusion criteria were published and unpublished randomised or quasi-randomised controlled trials comparing moxibustion either alone or in combination with other techniques (e.g. acupuncture or postural techniques) with a control group (no moxibustion) or other methods (e.g. acupuncture, postural techniques) in women with a singleton breech presentation.
DATA COLLECTION AND ANALYSIS
Two review authors independently determined trial eligibility, assessed trial quality, and extracted data. Outcome measures were baby's presentation at birth, need for ECV, mode of birth, perinatal morbidity and mortality, maternal complications and maternal satisfaction, and adverse events. We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS: This updated review includes 13 studies (2181 women), of which six trials are new. Most studies used adequate methods for random sequence generation and allocation concealment. Blinding of participants and personnel is challenging with a manual therapy intervention; however, the use of objective outcomes meant that the lack of blinding was unlikely to affect the results. Most studies reported little or no loss to follow-up, and few trial protocols were available. One study that was terminated early was judged as high risk for other sources of bias. Meta-analysis showed that compared to usual care alone, the combination of moxibustion plus usual care probably reduces the chance of non-cephalic presentation at birth (7 trials, 1152 women; risk ratio (RR) 0.87, 95% confidence interval (CI) 0.78 to 0.99, I = 38%; moderate-certainty evidence), but the evidence is very uncertain about the effect of moxibustion plus usual care on the need for ECV (4 trials, 692 women; RR 0.62, 95% CI 0.32 to 1.21, I = 78%; low-certainty evidence) because the CIs included both appreciable benefit and moderate harm. Adding moxibustion to usual care probably has little to no effect on the chance of caesarean section (6 trials, 1030 women; RR 0.94, 95% CI 0.83 to 1.05, I = 0%; moderate-certainty evidence). The evidence is very uncertain about the effect of moxibustion plus usual care on the the chance of premature rupture of membranes (3 trials, 402 women; RR 1.31, 95% CI 0.17 to 10.21, I = 59%; low-certainty evidence) because there were very few data. Moxibustion plus usual care probably reduces the use of oxytocin (1 trial, 260 women; RR 0.28, 95% CI 0.13 to 0.60; moderate-certainty evidence). The evidence is very uncertain about the chance of cord blood pH less than 7.1 (1 trial, 212 women; RR 3.00, 95% CI 0.32 to 28.38; low-certainty evidence) because there were very few data. We are very uncertain whether the combination of moxibustion plus usual care increases the chance of adverse events (including nausea, unpleasant odour, abdominal pain and uterine contractions; intervention: 27/65, control: 0/57), as only one study presented data in a way that could be reanalysed (122 women; RR 48.33, 95% CI 3.01 to 774.86; very low-certainty evidence). When moxibustion plus usual care was compared with sham moxibustion plus usual care, we found that moxibustion probably reduces the chance of non-cephalic presentation at birth (1 trial, 272 women; RR 0.74, 95% CI 0.58 to 0.95; moderate-certainty evidence) and probably results in little to no effect on the rate of caesarean section (1 trial, 272 women; RR 0.84, 95% CI 0.68 to 1.04; moderate-certainty evidence). No study that compared moxibustion plus usual care with sham moxibustion plus usual care reported on the clinically important outcomes of need for ECV, premature rupture of membranes, use of oxytocin, and cord blood pH less than 7.1, and one trial that reported adverse events reported data for the whole sample. When moxibustion was combined with acupuncture and usual care, there was very little evidence about the effect of the combination on non-cephalic presentation at birth (1 trial, 226 women; RR 0.73, 95% CI 0.57 to 0.94) and at the end of treatment (2 trials, 254 women; RR 0.73, 95% CI 0.57 to 0.93), and on the need for ECV (1 trial, 14 women; RR 0.45, 95% CI 0.07 to 3.01). There was very little evidence about whether moxibustion plus acupuncture plus usual care reduced the chance of caesarean section (2 trials, 240 women; RR 0.80, 95% CI 0.65 to 0.99) or pre-eclampsia (1 trial, 14 women; RR 5.00, 95% CI 0.24 to 104.15). The certainty of the evidence for this comparison was not assessed.
AUTHORS' CONCLUSIONS
We found moderate-certainty evidence that moxibustion plus usual care probably reduces the chance of non-cephalic presentation at birth, but uncertain evidence about the need for ECV. Moderate-certainty evidence from one study shows that moxibustion plus usual care probably reduces the use of oxytocin before or during labour. However, moxibustion plus usual care probably results in little to no difference in the rate of caesarean section, and we are uncertain about its effects on the chance of premature rupture of membranes and cord blood pH less than 7.1. Adverse events were inadequately reported in most trials.
Topics: Female; Humans; Infant, Newborn; Pregnancy; Breech Presentation; Cesarean Section; Moxibustion; Oxytocin; Parturition; Premature Birth
PubMed: 37158339
DOI: 10.1002/14651858.CD003928.pub4 -
Journal of Gynecology Obstetrics and... Nov 2020Although its role in the prognosis for delivery remains controversial, the type of breech is sometimes taken into account in the decision about mode of delivery.... (Comparative Study)
Comparative Study
BACKGROUND
Although its role in the prognosis for delivery remains controversial, the type of breech is sometimes taken into account in the decision about mode of delivery. Objective of our study was to compare maternal and neonatal morbidity for trial of vaginal delivery according to the type of breech (complete or frank).
MATERIAL AND METHOD
Single-center retrospective study of women with trials of vaginal delivery of a singleton fetus in breech presentation at of after 37 weeks of gestation. Neonatal status was assessed by the composite variable of the Term Breech Trial, first considered alone, and then with the addition of a 5-min Apgar score < 7 or a neonatal arterial pH<7.0.
RESULTS
Of the 495 trials of vaginal delivery during the study period, approximately one third of them were complete breech (35.8 %) and two thirds frank (64.2 %). The frequency of cesareans during labor was similar regardless of the type of breech (16.4 for complete vs 12.6 % for frank, p=0.24), nor did neonatal morbidity differ (1.7 for complete vs 4.1 % for frank, p=0.15). On the other hand, cord prolapse occurred almost exclusively in complete breech presentations (4.5 vs 0.3 %, p<0.01), and prognosis was good in all cases. Complete breech presentations were also associated with more frequent use of forceps to the after-coming head (16.2 vs 9.7 %, p<0.05). Finally, there were non significant difference between the two types of breech concerning severe acidosis but it seemed to have it more in frank breech (2.3 vs 1.2 %, p=0.34).
CONCLUSION
Among women eligible for vaginal delivery, the type of breech presentation (complete or frank) has little influence on delivery maternal and neonatal morbidity. The type of breech need not be taken into account in deciding the route of delivery.
Topics: Adult; Body Mass Index; Breech Presentation; Cesarean Section; Delivery, Obstetric; Female; Gestational Age; Humans; Infant, Newborn; Pregnancy; Pregnancy Outcome; Prognosis; Retrospective Studies
PubMed: 32574703
DOI: 10.1016/j.jogoh.2020.101832 -
Gynecologie, Obstetrique, Fertilite &... Jan 2020To study the frequency, the risk factors and the mode of delivery of breech presentation. To analyze the perinatal morbidity and mortality associated with breech... (Review)
Review
OBJECTIVES
To study the frequency, the risk factors and the mode of delivery of breech presentation. To analyze the perinatal morbidity and mortality associated with breech presentation in comparison to cephalic presentation from all mode of delivery.
METHODS
MedLine and Cochrane Library databases search in French and English and review of the main foreign guidelines between 1980 and 2019.
RESULTS
Three modes of breech presentation exist according to fetal lower limbs position: frank in 2/3 of cases, complete in 1/3 of cases or, more rarely, incomplete (LE3). About 5% of women gave birth in breech presentation in France (LE3). As the frequency of breech presentation decreases with increasing gestational age, this incidence is lower after 37 WG and represents only 3% of term deliveries (LE3). Congenital uterine malformation (LE3) and fibroma (LE3), prematurity (LE3), oligoamnios (LE3), some fetal congenital malformations (LE3) and low birthweight for gestational age (LE3) are the main risk factors with breech presentation. In France, one-third of women with a term fetus in breech presentation attempt a vaginal delivery (LE3), which is successful in 70% of cases (LE3). Neonatal outcome is not associated with type of breech presentation (frank or complete) in case of vaginal delivery attempt after 37 WG (LE3). Overall, perinatal morbidity and mortality after 37 WG of breech presentation appear to be greater than in cephalic presentation from all mode of delivery (LE3). The risk of traumatic injury in breech delivery is estimated under 1% (LE3). The most common injuries are collarbone fractures, hematomas or contusions, and brachial plexus injury (LE3). Breech presentation is associated with an increased risk of hip dysplasia (LE3) and cesarean delivery does not seem to be a protective factor (LE3). Breech presentation does not appear to be associated with an increased risk of cerebral palsy compared to cephalic presentation after exclusion of fetuses with congenital malformations (LE3).
CONCLUSION
Worldwide, mode of delivery of breech presentation has undergone profound changes since the publication of the TBT (Term Breech Trial). There are intrinsic factors associated with breech presentation, which should not be overlooked when interpreting the increased perinatal morbidity and mortality observed in case of breech presentation.
Topics: Adult; Birth Injuries; Breech Presentation; Cesarean Section; Delivery, Obstetric; Female; France; Gestational Age; Humans; Infant, Newborn; MEDLINE; Pregnancy; Pregnancy Complications; Pregnancy Outcome; Risk Factors
PubMed: 31682966
DOI: 10.1016/j.gofs.2019.10.027 -
Journal of Midwifery & Women's Health May 2018Moxibustion, a form of traditional Chinese medicine (TCM), is the burning of the herb moxa (Folium Artemisiae argyi or mugwort) over acupuncture points. It is often used... (Review)
Review
Moxibustion, a form of traditional Chinese medicine (TCM), is the burning of the herb moxa (Folium Artemisiae argyi or mugwort) over acupuncture points. It is often used in China to facilitate cephalic version of breech presentation. This article reviews the history, philosophy, therapeutic use, possible mechanisms of action, and literature pertaining to its use for this indication. For moxibustion, moxa can be rolled into stick form, placed directly on the skin, or placed on an acupuncture needle and ignited to warm acupuncture points. Studies have demonstrated that moxibustion may promote cephalic version of breech presentation and may facilitate external cephalic version. However, there is currently a paucity of research on the effects of moxibustion on cephalic version of breech presentation, and thus there is a need for further studies. Areas needing more investigation include efficacy, safety, optimal technique, and best protocol for cephalic version of breech presentation.
Topics: Acupuncture Points; Acupuncture Therapy; Breech Presentation; Female; Humans; Medicine, Chinese Traditional; Midwifery; Moxibustion; Pregnancy; Pregnancy Outcome; Pregnancy Trimester, Third; Version, Fetal
PubMed: 29775226
DOI: 10.1111/jmwh.12752 -
Zeitschrift Fur Geburtshilfe Und... Apr 2022To evaluate the moxibustion for turning fetuses from breech to vertex presentation.
OBJECTIVE
To evaluate the moxibustion for turning fetuses from breech to vertex presentation.
MATERIALS AND METHODS
This was a single-center prospective study. All pregnant women carrying a fetus in breech presentation between the 32 and 35 gestational weeks were offered moxibustion application. The primary outcomes were vertex presentation at 37 weeks of gestation, vertex presentation at birth, and vaginal birth rates. A secondary analysis was performed to understand the effect of parity, type of breech presentation, body mass index (BMI), placental location, gender, and fetal birth weight on the presentation at birth.
RESULTS
There were 63 cases in the study group and 245 cases in the control group. The rate of vertex presentation at term was found to be higher in the moxibustion group compared to controls (66.7 vs. 48.2%, p=0.022). There were 45 (71.4%) and 131 (53.5%) fetuses with vertex presentation at birth in the study and control groups, respectively (p=0.020). Overall, vaginal delivery rate was higher in the study group (50.8 vs. 37.1%, p=0.048). Multiparity and higher birth weight were associated with increased rates of vertex presentation in the moxibustion and control groups.
CONCLUSION
Moxibustion application increased the rate of vertex presentation at birth and also vaginal delivery rate compared with expectant management. Offering moxibustion between the 32nd and 36th week of gestation may provide women with a singleton fetus in breech presentation an opportunity for a vaginal birth.
Topics: Birth Weight; Breech Presentation; Female; Humans; Infant, Newborn; Moxibustion; Placenta; Pregnancy; Prospective Studies; Version, Fetal
PubMed: 34528235
DOI: 10.1055/a-1579-1436 -
European Journal of Obstetrics,... Mar 2022Success rates of external cephalic version (ECV) are heterogenous in the published literature. Some individual factors are already known to be associated with ECV... (Review)
Review
INTRODUCTION
Success rates of external cephalic version (ECV) are heterogenous in the published literature. Some individual factors are already known to be associated with ECV success but probably do not fully explain the differences. The objective of this review is to assess the association between hospitals' cesarean delivery rates for breech presentations after ECV failure and their ECV success rates.
MATERIAL AND METHODS
We performed a review of the literature using the Medline and Cochrane Library computer databases and by searching on clinicaltrials.gov, from 1985 through 2020. This analysis included all studies reporting ECV success rates and cesarean delivery rates for breech presentations. The prognostic factors for successful ECV, such as rates of nulliparity, gestational age at ECV, BMI, and tocolysis use, were also collected and analyzed. Median ECV success rates from the included studies were compared according to these factors. The cesarean rate for persistent breech presentation after ECV failure reported in these studies was considered a proxy indicator of the unit's policy for breech presentations. The correlation between ECV success rates and cesarean delivery rates was analyzed and is presented as a scatter plot.
RESULTS
This analysis included 22 studies reporting rates of both successful ECV and cesarean deliveries for persistent breech presentation after ECV failure. The ECV success rates ranged from 16.3% to 82.5% with a median of 48.8% (interquartile range: 36.9-62.9). The median ECV success rate was higher in the studies that used tocolysis than in those that did not (51.3% versus 22.0%, P = .001) and in the studies with the highest cesarean rates for breech presentations than in those with the lowest cesarean rates (57.9% versus 36.2%, P = .006). The ECV success rates were significantly correlated with cesarean delivery rates for persistent breech presentations (R = 0.67; P = .001).
CONCLUSION
The likelihood of successful ECV appears higher in hospitals with policies that generally result in cesarean delivery for persistent breech presentation.
Topics: Breech Presentation; Cesarean Section; Female; Hospitals; Humans; Pregnancy; Retrospective Studies; Tocolysis; Version, Fetal
PubMed: 35063899
DOI: 10.1016/j.ejogrb.2022.01.007 -
Lancet (London, England) Aug 1953
Topics: Breech Presentation; Female; Humans; Labor Presentation; Pregnancy
PubMed: 13085792
DOI: No ID Found -
Journal of Gynecology Obstetrics and... Jun 2022Breech presentation at term accounts for around 5% of births. Few studies have evaluated the effectiveness of different induction methods for breech presentations. We...
OBJECTIVE
Breech presentation at term accounts for around 5% of births. Few studies have evaluated the effectiveness of different induction methods for breech presentations. We aim to compare the mode of delivery after induction by intra cervical dilatation balloon compared to prostaglandin (PGE2) in breech presentation. We also evaluated the risk factors associated with a failure of induction.
METHODS
Single-center retrospective study from January 2000 to December 2020 including all women induced from 36 weeks, breech presentation, with a single pregnancy without contraindication to vaginal delivery and with an unfavorable cervix (Bishop<6). The primary endpoint was the mode of delivery. Failure of induction was defined as the need of a cesarean section.
RESULTS
One hundred seventy six patients were included, 96 in the balloon group and 80 in the prostaglandin group. The cesarean section rate in the balloon group was not significantly different from the prostaglandin group (34.4% vs. 26.3%, p= 0.24). Fifty percent of the patients in the balloon group required additional maturation with prostaglandins after the balloon was dropped or removed. In our overall population, the factors associated with induction failure were nulliparity (OR= 3.144; CI95%: (1.496-6.661)) and BMI > 30 kg/m (OR= 3.15 CI95%: (1,374 - 7,224)).
CONCLUSION
Mode of delivery after mechanical methods in breech delivery induction appears similar to prostaglandins. However, it should be noted that in half of the cases, additional maturation with prostaglandin was necessary, calling into question the value of the mechanical methods. Factors associated with cesarean were maternal characteristics (nulliparity and BMI > 30 kg/m) but not induction method.
Topics: Breech Presentation; Cervix Uteri; Cesarean Section; Female; Humans; Oxytocics; Pregnancy; Prostaglandins; Retrospective Studies
PubMed: 35526819
DOI: 10.1016/j.jogoh.2022.102404 -
Obstetrics and Gynecology Feb 2021To evaluate a possible correlation between a new variable-persistent breech presentation-and the success rate of external cephalic version (ECV).
OBJECTIVE
To evaluate a possible correlation between a new variable-persistent breech presentation-and the success rate of external cephalic version (ECV).
METHODS
This was a retrospective study of ECVs performed from January 2008 through January 2019 in an Israeli tertiary care hospital. The study group included all pregnant women who underwent an ECV at or beyond 37 weeks of gestation. Persistent breech presentation was defined as persistent breech presentation during all ultrasound examinations performed between the anatomy scan at mid-pregnancy and the gestational week when ECV was attempted. Women in whom cephalic presentation was documented at least once on these ultrasound examinations were defined as not having persistent breech presentation. The primary outcome was defined as the success rate of ECV, and the secondary outcome was defined as the mode of delivery after a successful ECV.
RESULTS
We identified 1,271 women with breech presentation during the study period. They had undergone median of five (range 2-7) ultrasound examinations. External cephalic version was attempted in 684 women (53.8%), with a success rate of 61.5%. External cephalic version succeeded in 19.6% of those with persistent breech presentation (44/224) compared with 82.0% (377/460) of those without persistent breech presentation (P<.001). Ultimately, women with persistent breech presentation and successful ECV experienced a lower rate of vaginal delivery (27.3% vs 79%, P<.001), and a higher rate of instrumental (29% vs 13%, P<.001) and cesarean deliveries (43% vs 7%, P<.001) compared with the nonpersistent breech presentation group. The rate of noninstrumental vaginal delivery among women with persistent breech presentation, regardless of ECV, was 5.4%.
CONCLUSION
Women with persistent breech presentation experienced a high rate of ECV failure and a low rate of spontaneous vaginal delivery.
Topics: Adult; Breech Presentation; Female; Humans; Pregnancy; Retrospective Studies; Ultrasonography, Prenatal; Version, Fetal; Young Adult
PubMed: 33416280
DOI: 10.1097/AOG.0000000000004231