• New Zealand Guidelines Group (NZGG). Care of women with breech presentation or previous caesarean birth. Wellington (NZ): New Zealand Guidelines Group (NZGG); 2004 Nov. 80 p. [168 references]

This is the current release of the guideline.

Definitions for the Levels of Evidence and Grades of Recommendation (A-C, I, and Good Practice Points [GPP]) are given at the end of the "Major Recommendations" field. Where no evidence is available, best practice recommendations are made based on the experience of the Guideline Development Team.

Informed Decision Making

GPP - Evidence-based information on the risks and benefits of caesarean and vaginal birth should be provided to women prior to birth so that they can make informed decisions and choices about their care.

Mäori Perspectives

GPP - A cultural care plan for the whänau should be offered to Mäori women.

GPP - Cultural awareness training programmes should be made available in each District Health Board (DHB) to ensure that Mäori women are able to access culturally appropriate birthing services.

Pacific Perspectives

GPP - Hard or vigorous traditional massage of the baby in utero is not recommended.

GPP - Cultural awareness training programmes should be made available in DHBs to ensure Pacific women are able to access culturally appropriate birthing services.

Antenatal Management

B - Women with uncomplicated (extended or flexed leg) breech presentation at term should be offered a caesarean after full discussion of the risks and benefits. (The evidence for this recommendation may not be applicable to all women with breech presentation. The study population was highly selected and not all the study clinicians had optimal experience with vaginal breech birth.)

A - Women with uncomplicated breech at 37 to 40 weeks should be offered external cephalic version (ECV) to increase the likelihood of cephalic presentation and vaginal birth.

I - There is currently insufficient information to adequately assess the risks of ECV. Low complication rates have been reported.

I - There is currently insufficient information to recommend ECV prior to 37 weeks.

B - Women with uncomplicated breech at 37 to 40 weeks may be offered tocolysis (with betamimetic drugs) to increase the success of ECV.

I - There is insufficient evidence to make specific recommendations about type of tocolytic treatment or dose.

I - There is insufficient evidence to recommend the use of spinal or epidural analgesia to facilitate ECV with the goal of increasing the likelihood of cephalic presentation or reducing the caesarean rate.

I - There is insufficient evidence to recommend routine and/or specific antenatal positioning exercises.

B - Moxibustion may be offered to women with breech presentation from 33 weeks of pregnancy to facilitate the change from breech to cephalic presentation.

I - There is insufficient evidence to recommend ultrasound estimation of foetal weight in women with breech presentation planning vaginal birth.

B - Pelvimetry, including magnetic resonance imaging (MRI), for women with breech presentation is not recommended.

I - There is insufficient evidence to recommend routine caesarean for women with the second twin presenting as breech.

I - There is insufficient evidence to recommend caesarean or vaginal breech birth for pre-term breech.

GPP - Breech presentation should be identified antenatally and arrangements made for the woman to give birth in an appropriate facility, where possible.

GPP - Before and after ECV, electronic foetal monitoring (EFM) is recommended.

A Practical Guide for Caring for Women in Labour with Breech Presentation

GPP - When a breech presentation is identified, the informed choice and consent process should be clearly documented.

GPP - Continuity of care should be maintained wherever possible.

GPP - Women who elect to have vaginal birth should have immediate access to obstetricians/paediatricians and caesarean facilities.

GPP - In active labour with uncomplicated flexed or extended legs breech presentation at term, it is recommended that:

• Amniotomy may be performed, with caution, when clinically indicated
• The infant's heart rate monitoring is done by either intermittent auscultation every 15 to 30 minutes in active labour 1st stage and after each contraction in 2nd stage or by continuous EFM
• The essential elements of vaginal breech birth are to prevent trauma and delay (with associated hypoxia/asphyxia). Therefore:
  • Total breech extraction should not be performed.
  • Active labour positions that facilitate the birth of the infant's body and head should be encouraged.
  • Spontaneous birth of the infant's body including the thorax should occur by maternal effort where possible.
  • No traction (which may extend arms and cause trauma) should be applied to the infant's body.
  • During the delivery of the buttocks and thorax, the birth attendant is recommended to keep the infant's back in the anterior position.
  • The Lovsett manoeuvre, using gentle traction, should be used to deliver extended or nuchal arms or may be used during assisted birth.
  • Controlled birth of the after-coming infant's head is achieved by:
    • Mauriceau-Smellie-Veit (MSV) grip or forceps in a prone position
    • Adapted MSV grip, maternal effort, and/or support of the baby in active birth positions

There should be immediate access to obstetricians/paediatricians and caesarean facilities.

Care of Women Having Vaginal Birth After Caesarean (VBAC)

B - Women with a previous caesarean with no additional risk factors should be offered VBAC. The risks and benefits of VBAC for individual women should be discussed and an informed decision made.

C- Women with a previous caesarean where the uterine incision is vertical should be advised there is an increased risk of uterine rupture and offered caesarean.

C - Women with a history of previous uterine rupture should be advised there is an increased risk of further uterine rupture and offered caesarean.

B - In pregnant women with previous caesarean requiring delivery, induction of labour may be offered if indicated. Women need to be advised of the potential risks and benefits of this procedure.

C - In women with previous caesarean in labour with poor uterine activity, the careful use of Syntocinon may be considered.

C - All women who have had a previous caesarean must be referred for consultation with an obstetrician during the antenatal period, preferably prior to 36 weeks.

C - Pregnant women with previous caesarean may be offered an epidural although there is no evidence that this will improve the chance of successful vaginal birth.

C - The possible benefits and risks of continuous EFM should be discussed with women with previous caesarean. Abnormalities in the foetal heart rate may precede uterine rupture and specialist consultation should be sought immediately.

B - X-ray pelvimetry in women with previous caesarean is not recommended.

C - Pregnant women with two previous caesarean births and no additional risk factors for vaginal birth may be offered planned vaginal birth after discussing the risks and benefits.

GPP - Women with previous caesarean should be offered continuity of midwifery care during pregnancy, labour, and birth.

GPP - Full and unbiased information on choosing VBAC should be discussed on a case-by-case basis with the pregnant woman with previous caesarean to enable her to make an informed decision about her birth choices.

GPP - There should be immediate access to obstetricians/paediatricians and caesarean facilities.

Definitions:

Levels of Evidence

+ Strong study where all or most of the validity criteria are met

~ Fair study where not all the validity criteria are met, but the results of the study are not likely to be influenced by bias

x Weak study where very few of the validity criteria are met and there is a high risk of bias

Grades of Recommendations

A - The recommendation is supported by good evidence (where there is a number of studies that are valid, consistent, applicable, and clinically relevant).

B - The recommendation is supported by fair evidence (based on studies that are valid, but there are some concerns about the volume, consistency, applicability, and clinical relevance of the evidence that may cause some uncertainty but are not likely to be overturned by other evidence).

C - The recommendation is supported by international expert opinion.

I - No recommendation can be made because the evidence is insufficient (either evidence is lacking, of poor quality, conflicting, or the balance of benefits and harms cannot be determined).

GPP - Where no evidence is available, best practice recommendations are made based on the experience of the Guideline Development Team.

Clinical algorithms are provided for:

• Antenatal Care of Women With Breech Presentation
• Breech Labour and Birth
• Vaginal Birth After Caesarean (VBAC)

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

The literature searches concentrated on finding high grade evidence to answer the identified clinical questions, such as systematic reviews, randomised controlled trials and, where these were not available, observational studies such as well-designed cohort and case control studies. Only these types of study design were graded (see "Major Recommendations").Where these types of studies were not available, less rigorous study designs such as cross sectional studies and case studies were considered but were not formally graded.

The advice on caesarean section given in the guideline is based on epidemiological and other research evidence, supplemented where necessary by the consensus opinion of the expert development team based on their own experience.

• New Zealand Guidelines Group (NZGG). Care of women with breech presentation or previous caesarean birth. Wellington (NZ): New Zealand Guidelines Group (NZGG); 2004 Nov. 80 p. [168 references]

Not applicable: The guideline was not adapted from another source.

2004 Nov

New Zealand Guidelines Group - Private Nonprofit Organization

New Zealand Guidelines Group

Caesarean Birth Guideline Development Team

Team Members: Cindy Farquhar (Chair) Professor and Postgraduate Chair of Obstetrics and Gynaecology, NWH, Auckland; Anne Lethaby (Project Manager) NZGG, EPIQ, Department of Community Health, University of Auckland, Auckland; Karen Guilliland, Midwife, CEO, NZ College of Midwives, Christchurch, Nominated by the NZ College of Midwives; Sharron Cole, Consumer representative, National President of Parents Centres New Zealand, Nominated by the Parents Centre National Organisation

Breech Sub-Group: Joanne Rama, Mäori Midwife, Auckland, Nominated by Nga Maia Midwives Collective; Bridget-Mary McGown, Consumer, Invercargill, Nominated by the Invercargill Parents Centre; Maggie Banks, Midwife, NZ College of Midwives, Waikato, Nominated by the NZ College of Midwives; Nimisha Waller, Midwife, Auckland University of Technology, Auckland, Nominated by the NZ College of Midwives; Don Simmers, General Practitioner, Queenstown Medical Centre, Queenstown, Nominated by The Royal New Zealand College of General Practitioners; Colin Conaghan, Consultant in Obstetrics and Gynaecology, Hyatt Chambers, Christchurch, Representing The Royal Australian and New Zealand College of Obstetricians and Gynaecologists; Mahesh Harillal, Consultant in Obstetrics and Gynaecology, NWH, Auckland, Nominated by The Royal Australian and New Zealand College of Obstetricians and Gynaecologists; Marion Heeney, General Manager of Womens Health, Counties-Manukau Health, Auckland, Nominated by the Health Funds Association of New Zealand Inc.

VBAC Sub-Group: Lynda Croft, Consultant in Obstetrics and Gynaecology, Hyatt Chambers, Christchurch; Rob Buist, Consultant in Obstetrics and Gynaecology, NWH, Auckland, Nominated by The Royal Australian and New Zealand College of Obstetricians and Gynaecologists; Maralyn Foureur, Professor of Midwifery and Women's Health, Wellington Women's Hospital, Wellington; Celia Butler, Maternity Manager, Nelson Hospital, Nelson, Nominated by DHB and Health Service Managers; Joanne Rama, Mäori Midwife, Auckland, Nominated by Nga Maia Midwives Collective; Brenda Hinton, Consumer, Maternity Services Consumer Council, Auckland; Philippa Peck, Consumer, Palmerston North; Ann Yates, Clinical Leader of Midwifery, Auckland DHB, Auckland, Nominated by NZ College of Midwives; Tim Cookson, General Practitioner, Wellington; Alec Ekeroma, Consultant in Obstetrics and Gynaecology, Middlemore Hospital, Auckland and Vice President, Pacifika Medical Association. Nominated by Pacifika Medical Association

Declarations of competing interests within the guideline development team:

Cindy Farquhar

• Reimbursement for conference travel and fees for speaking, examining and consulting from the New Zealand Guideline Group (NZGG), Royal Australian and New Zealand College of Obstetrics and Gynaecology, and conference organizers

Karen Guilliland

• Director, PHARMAC
• Reimbursement for conference travel and fees for speaking and consulting from a number of professional bodies

Sharron Cole

• Hutt Valley District Health Board member
• Reimbursement for travel from the Chinese University of Hong Kong

There were no other conflicts of interest.

New Zealand College of Midwives Inc. - Medical Specialty Society
Paediatric Society of New Zealand - Medical Specialty Society
Parents Centres of New Zealand - Professional Association
Pasifika Medical Association - Professional Association
Perinatal Society of New Zealand Inc. - Medical Specialty Society

This is the current release of the guideline.

None available

This NGC summary was completed by ECRI on February 8, 2005. The information was verified by the guideline developer on March 16, 2005.

These guidelines are copyrighted by the New Zealand Guidelines Group. They may be downloaded and printed for personal use or for producing local protocols in New Zealand. Re-publication or adaptation of these guidelines in any form requires specific permission from the Executive Director of the New Zealand Guidelines Group.