Breech Birth Synthethis

Research gaps from Cochrane Reviews

(Cochrane Library Issue 3, 2006)

The faces indicate the direction of findings in each review:

J Likely to be effective
K Benefits and risks balanced
? Uncertain or limited effect
L Likely to be ineffective or potentially harmful

? Thus, important research implications are more likely to arise from reviews with uncertain findings.

J If a review shows an intervention to be beneficial,

K  or that the risks and benefits are reasonably balanced, there may be less need for further research (at least for the major review question).

? If a review indicates that the intervention is likely to be ineffective or potentially harmful, or has been superseded, then this will often indicate that these research questions are of lower importance. 

Methods to change presentation of a breech fetus

? Moxibustion for correcting a breech presentation (Coyle 2005)

• Need more trials of moxibustion (with and without acupuncture), and safety and women’s views need to be addressed

• Need to determine optimal timing, frequency and duration of moxibustion

• Need to compare moxibustion with external cephalic version/postural management

? Postural management for correcting a breech presentation (Hofmeyr 2000)

• Need to determine optimal timing, frequency and duration of postural management

• Need larger trials that measure mothers’ views

? Policy of expedited (rapid delivery from umbilicus to head) breech birth (Hofmeyr 1996a)

No trials able to be included – any future study should measure perinatal morbidity and mortality as well as maternal trauma and satisfaction with birth

JExternal cephalic version (ECV) for correcting a breech presentation at term (Hofmeyr 1996b)

• ECV at term effective. Need to refine selection of women (e.g. previous caesarean), and role of ECV during labour, in non-longitudinal lies

• Need to assess maternal views and satisfaction with ECV

? External cephalic version (ECV) for correcting a breech presentation before term (Hutton 2006)

Need larger RCTs that measure neonatal morbidity and mortality and rates of preterm birth - a large international trial is in progress 

Additional interventions to help external cephalic version

J Tocolysis  (Hofmeyr 2004)

• Scope for further RCTs of routine tocolysis for external cephalic version at term, particularly looking at reduction of force required for successful ECV, and the possible risks of maternal cardiovascular side-effects

• Need further RCTs of routine versus selective use of tocolysis, including longterm outcomes

L Nitroglycerine (Hofmeyr 2004)

• Further RCTs of nitroglycerine are not encouraged

? Fetal acoustic stimulation (Hofmeyr 2004)

• Further RCTs of fetal acoustic stimulation in midline fetal spine positions are justified

? Amnioinfusion (Hofmeyr 2004)         

• No trials of amnioinfusion were located

? Regional anaesthesia (Hofmeyr 2004)

• Need further RCTs of epidural or spinal analgesia, assessing vaginal displacement of the presenting part (ensuring similar amounts of fluid in the regional analgesia and control groups)

• The possible effect of intravenous hydration prior to ECV attempt, to increase amniotic fluid volume, should be investigated as a separate intervention.  

J Planned caesarean for term breech (Hofmeyr 2003)

• Need further RCTs that address longterm benefits and risk of planned caesarean sections for term breech births

References

1. Coyle ME, Smith CA, Peat B. Cephalic version by moxibustion for breech presentation. Cochrane Database of Systematic Reviews 2005, Issue 2

2. Hofmeyr GJ, Kulier R. Cephalic version by postural management for breech presentation. Cochrane Database of Systematic Reviews 2000, Issue 3

3. Hofmeyr GJ, Kulier R. Expedited versus conservative approaches for vaginal delivery in breech presentation. Cochrane Database of Systematic Reviews 1996, Issue 1 (Hofmeyr 1996a)

4. Hofmeyr GJ, Kulier R. External cephalic version for breech presentation at term. Cochrane Database of Systematic Reviews 1996, Issue 1 (Hofmeyr 1996b)

5. Hofmeyr GJ, Gyte G. Interventions to help external cephalic version for breech presentation at term. Cochrane Database of Systematic Reviews 2004, Issue 1

6. Hofmeyr GJ, Hannah ME. Planned caesarean section for term breech delivery. Cochrane Database of Systematic Reviews 2003, Issue 2

7. Hutton EK, Hofmeyr GJ. External cephalic version for breech presentation before term. Cochrane Database of Systematic Reviews 2006, Issue 1