Clinical Research Directory

Discourse on the Mother's Decision Regarding the Mode of Delivery in Cases of Breech Presentation

Breech presentation is a common occurrence in routine practice, occurring in 3-4% of all term pregnancies. Despite its frequency, breech presentation at term remains a subject of considerable controversy within the medical community. This results in differing management approaches depending on the country, the center, and the practitioner. Indeed, from a pathophysiological perspective, during a breech delivery, the fetal head is the last segment to descend into the maternal pelvis. This is the largest fetal segment in terms of volume. Furthermore, the fetal head cannot accommodate itself to the maternal pelvis through plastic deformation. This presentation can therefore lead to specific complications that may be life-threatening for the unborn child. Despite its frequency, breech presentation at term remains a subject of considerable controversy within the medical community regarding the management of labor. In the 2000s, a randomized trial called the TERM BREECH TRIAL found a neonatal benefit of planned cesarean section compared to vaginal delivery of a breech fetus (prevention of perinatal death in 1% of cases). This resulted in a significant increase in the rate of planned cesarean sections for breech presentation worldwide. However, numerous more recent studies (notably PREMODA in France) have highlighted the many biases of the Term Breech Trial, and various literature reviews (including the 2015 Cochrane review) have demonstrated lower perinatal morbidity than that found by Hannah's team. In 2020, the CNGOF (National College of Gynecologists and Obstetricians of France) published new recommendations on the management of breech presentations at the end of pregnancy, proposing vaginal delivery as a possible alternative to a planned cesarean section, provided that the patient receives clear and honest information (benefits and risks of each delivery method). The choice of delivery method must be made in consultation with the patient after a dedicated consultation. Since these recommendations were published, management practices still vary between hospitals despite fairly precise guidelines.

Prediction of Version Outcomes for External Maneuvers of Breech Fetus by Assessment of Breech Progression Angle

Breech presentation complicates about 3-4% of single pregnancies at term. Although vaginal delivery is also possible in breech presentations, this is associated with an increased risk of fetal morbidity and mortality. The cephalic version for external maneuvers is an obstetric procedure that allows conversion of an abnormal presentation/situation (breech or transverse) to a cephalic presentation by applying pressure to the maternal abdomen. Over the years, many authors have analyzed numerous factors that might be associated with an increased likelihood of successful maneuvering. Over time, transperineal ultrasonography has proven to be a valid, objective, and highly reproducible tool for the assessment of fetal head progression during delivery in conjunction with examination. The Angle of Progression (AoP) is the angle between the line passing through the longitudinal axis of the pubic symphysis and the line passing through the inferior border of the pubic symphysis and tangent to the fetal skull. AoP is an accurate and reproducible parameter for the assessment of fetal head descent during labor, with a strong correlation with the mode of delivery. The investigators are not aware of any studies that have established the role of transperineal ultrasound in assessing podietal engagement and its role in predicting the success of the cephalic version maneuver, an aspect the investigators want to explore with this study.

Twin A Breech External Cephalic Version Intervention Trial (TWEXIT)

A prospective study assessing the use of external cephalic version for the management of Twin A breech presentation in twin pregnancy.

An Informative Video Before Planned External Cephalic Version

A randomized control trial to investigate whether an informative video before planned external cephalic version reduces maternal anxiety and improves chances of success.