Outcome of small for gestational age-fetuses in breech presentation at term according to mode of delivery: a nationwide, population-based record linkage study

Term breech presentation-Intended cesarean section versus intended vaginal delivery-A systematic review and meta-analysis

INTRODUCTION

Three per cent of all infants are born in breech presentation, still the preferred way to deliver them remains controversial. The objective of this systematic review was to assess the safety for the mother and child depending on intended mode of delivery when the baby is in breech position at term.

MATERIAL AND METHODS

The population (P) was pregnant women with a child in breech presentation, from gestational week 34⁺⁰ . The intervention (I) was the intention to deliver by cesarean section, the comparison (C) was the intention to deliver vaginally. Outcomes (O) were perinatal mortality, perinatal morbidity, maternal mortality, maternal morbidity, conversion of delivery mode, and the mother's experience. Systematic literature searches were performed. We included randomized trials, cohort studies with more than 500 women/group and case series for more than 15 000 women published between 1990 and October 2021, written in English or the Nordic languages. The certainty of evidence was assessed using the GRADE approach and data were pooled in meta-analyses. PROSPERO registration number: CRD42020209546.

RESULTS

Thirty-two articles were included (with 530 604 women). The certainty of evidence was moderate or low because the study designs were mostly retrospective cohort studies. The only randomized trial showed reduced risk of perinatal mortality for planned cesarean section, risk ratio (RR) 0.27 (95% confidence interval [CI] 0.08-0.97, 2078 women, low certainty of evidence), stillbirths excluded. A meta-analysis of cohort studies resulted in a similar estimate, RR 0.36 (95% CI 0.25-0.51, 21 studies, 388 714 women, low certainty of evidence). We also found reduced risk for outcomes representing perinatal morbidity 0-28 days: 5-min Apgar score less than 7 in one randomized controlled trial: RR 0.27 (95% CI 0.12-0.58, 2033 women, moderate certainty of evidence), and in a meta-analysis: RR 0.1 (95% CI 0.14-0.26, 18 studies, 217 024 women, moderate certainty of evidence); APGAR score less than 4 at 5 min: RR 0.39 (95% CI 0.19-0.81, five studies, 44 498 women, low certainty of evidence); and pH less than 7.0: RR 0.23 (95% CI 0.12-0.43, four studies, 13 440 women, low certainty of evidence). Outcomes for the mother were similar in the groups except for reduced risk for experience of urinary incontinence in the group of planned cesarean section: RR 0.62 (95% CI 0.41-0.93, one study, 1940 women, low certainty of evidence). The conversion rate from planned vaginal delivery to emergency cesarean section ranged from 16% to 51% (median 41.8%, 10 studies, 50 763 women, moderate certainty of evidence).

CONCLUSIONS

Intended cesarean section may reduce the risk of perinatal mortality and perinatal as well as some maternal morbidity compared with intended vaginal delivery. It is uncertain whether there is any difference in maternal mortality. The conversion rate from intended vaginal delivery to emergency cesarean section is high.

Neonatal outcome in vaginal breech labor at 32 + 0-36 + 0 weeks of gestation: a nationwide, population-based record linkage study

Background

In many countries, vaginal breech labor at term is an option in selected cases. However, the safety of vaginal breech labor in preterm is still unclear. Therefore our study aimed to evaluate the safety of vaginal breech labor in late preterm deliveries.

Design

A retrospective register-based study.

Setting

Maternity hospitals in Finland, 2004–2017.

Participants

The study population included 762 preterm breech deliveries at 32 + 0—36 + 6 gestational weeks according to the mode of delivery, 535 (70.2%) of them were born vaginally in breech presentation, and 227 (29.8%) were delivered by non-urgent cesarean section.

Methods

The study compared short-term neonatal adverse outcomes of singleton vaginal breech deliveries with non-urgent cesarean deliveries at 32 + 0 to 36 + 6 weeks of gestation. An odd ratio with 95% confidence intervals was calculated to estimate the relative risk of adverse outcomes.

Outcome measures

Neonatal death, an arterial umbilical pH below seven, a five-minute Apgar score below four and seven, admission to neonatal intensive care unit, neonatal intubation, neonatal antibiotic therapy, neonatal birth trauma, respiratory distress syndrome, neonatal convulsions, cerebral ischemia, hypoxic-ischemic encephalopathy, congenital hypotonia, and a composite of severe adverse outcomes.

Results

A five-minute Apgar scores below seven were increased in vaginal breech labor at 32 + 0 to 36 + 6 weeks of gestation compared to non-urgent cesarean sections (aOR 2.48, 95% CI 1.08–5.59). Neonatal antibiotic therapy, the admission to neonatal intensive care unit, and neonatal respiratory distress syndrome were decreased after vaginal breech labor compared to the outcomes of non-urgent cesarean section (neonatal antibiotic therapy aOR 0.60, 95% CI 0.40–0.89; neonatal NICU admission aOR 0.47, 95% CI 0.33–0.68; respiratory distress syndrome aOR 0.30, 95% CI 0.19–0.48).

Conclusion

Vaginal breech labor at 32 + 0—36 + 6 gestational weeks does not increase severe neonatal short-term morbidity or mortality compared to cesarean section.

What is the main factor in predicting the morbidity and mortality in patients with gastroschisis: delivery time, delivery mode, closure method, or the type of gastroschisis (simple or complex)?

Background/aim

There are numerous debates in the management of gastroschisis (GS). The current study aimed to evaluate perinatal outcomes and surgical and clinical characteristics among GS patients based on their type of GS, abdominal wall closure method, and delivery timing.

Materials and methods

This study was a retrospective analysis of prospectively collected data of 29 fetuses with GS that were prenatally diagnosed, delivered, and managed between June 2015 and December 2019 at the Obstetrics and Pediatric Surgery Clinics of Kanuni Sultan Süleyman Training and Research Hospital.

Results

Twenty-three of the patients had simple GS, and six of them had complex GS. The reoperation requirement, number of operations, duration of mechanical ventilation, time to initiate feeding, time to full enteral feeding, total parenteral nutrition (TPN) duration, TPN-associated cholestasis, wound infection, sepsis, and necrotizing enterocolitis were significantly lower in the simple GS group than in the complex GS group. The mean hospital length of stay was 3.5 times longer in the complex GS group (121.50 ± 24.42 days) than in the simple GS group (33.91 ± 4.13 days, p = 0.009). There were no cases of death in the simple GS group. However, two deaths occurred in the complex GS group.

Conclusion

This study indicated that simple GS, compared with complex GS, was associated with improved neonatal outcomes. We suggest that the main factor affecting the patients’ outcomes is whether the patient is a simple or complex GS rather than the abdominal wall closure method.

Could Subtle Obstetrical Brachial Plexus Palsy Be Related to Unilateral B Glenoid Osteoarthritis?

Background: Several factors associated with B glenoid are also linked with obstetrical brachial plexus palsy (OBPP). The purpose of this observational study was to determine the incidence of OBPP risk factors in type B patients. Methods: A cohort of 154 patients (68% men, 187 shoulders) aged 63 ± 17 years with type B glenoids completed a questionnaire comprising history of perinatal characteristics related to OBPP. A literature review was performed following the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) to estimate the incidence of OBPP risk factors in the general population. Results: Twenty-seven patients (18%) reported one or more perinatal OBPP risk factors, including shoulder dystocia (n = 4, 2.6%), macrosomia >4 kg (n = 5, 3.2%), breech delivery (n = 6, 3.9%), fetal distress (n = 8, 5.2%), maternal diabetes (n = 2, 1.3%), clavicular fracture (n = 2, 1.3%), and forceps delivery (n = 4, 2.6%). The comparison with the recent literature suggested that most perinatal OBPP risk factors were within the normal range, although the incidence of shoulder dystocia, forceps and vaginal breech deliveries exceeded the average rates. Conclusion: Perinatal factors related to OBPP did not occur in a higher frequency in patients with Walch type B OA compared to the general population, although some of them were in the high normal range.

Term cesarean breech delivery in the first pregnancy is associated with an increased risk for maternal and neonatal morbidity in the subsequent delivery: a national cohort study

Purpose

To determine whether there is an association between term cesarean breech delivery in the first pregnancy and maternal and neonatal morbidities in the subsequent pregnancy and delivery.

Methods

We conducted a retrospective, nationwide Finnish population-based cohort study, including all deliveries from January 2000 to December 2017. We included all women with the first two consecutive singleton deliveries of which the first one was a breech delivery regardless of mode of delivery (n = 11,953), and constructed a data set in which the first two deliveries for these women were connected. The outcomes of the second delivery of the women with a first pregnancy that resulted in cesarean breech delivery at term were compared with women whose first pregnancy resulted in a vaginal breech delivery at term. P-value, odds ratio, and adjusted odds ratio were calculated.

Results

Neonates of a subsequent delivery after cesarean breech delivery had an increased risk for arterial umbilical cord pH below seven, a higher rate of a 5 min APGAR score < 7 and a higher rate of neonatal intensive care unit admission. The women with a history of cesarean section with the fetus in breech presentation were more often in need of a blood transfusion and suffered more often a uterus rupture. In this group, the second delivery was more often a planned cesarean section, an emergency cesarean section, or an instrumental vaginal delivery.

Conclusions

Primary cesarean breech section in the first pregnancy is associated with adverse neonatal and maternal outcomes in the subsequent delivery.

A comparison of risk factors for breech presentation in preterm and term labor: a nationwide, population-based case-control study

PURPOSE

To determine if the common risks for breech presentation at term labor are also eligible in preterm labor.

METHODS

A Finnish cross-sectional study included 737,788 singleton births (24-42 gestational weeks) during 2004-2014. A multivariable logistic regression analysis was used to calculate the risks of breech presentation.

RESULTS

The incidence of breech presentation at delivery decreased from 23.5% in pregnancy weeks 24-27 to 2.5% in term pregnancies. In gestational weeks 24-27, preterm premature rupture of membranes was associated with breech presentation. In 28-31 gestational weeks, breech presentation was associated with maternal pre-eclampsia/hypertension, preterm premature rupture of membranes, and fetal birth weight below the tenth percentile. In gestational weeks 32-36, the risks were advanced maternal age, nulliparity, previous cesarean section, preterm premature rupture of membranes, oligohydramnios, birth weight below the tenth percentile, female sex, and congenital anomaly. In term pregnancies, breech presentation was associated with advanced maternal age, nulliparity, maternal hypothyroidism, pre-gestational diabetes, placenta praevia, premature rupture of membranes, oligohydramnios, congenital anomaly, female sex, and birth weight below the tenth percentile.

CONCLUSION

Breech presentation in preterm labor is associated with obstetric risk factors compared to cephalic presentation. These risks decrease linearly with the gestational age. In moderate to late preterm delivery, breech presentation is a high-risk state and some obstetric risk factors are yet visible in early preterm delivery. Breech presentation in extremely preterm deliveries has, with the exception of preterm premature rupture of membranes, similar clinical risk profiles as in cephalic presentation.