Induced labour at term and breech presentation: Experience of a level IIB French maternity

Neonatal morbidity and mortality for preterm in breech presentation regarding the onset mode of labor

PURPOSE

To assess severe neonatal morbidity and mortality in induced labor in preterm breech deliveries, compared to spontaneous labor.

METHODS

This is a retrospective study conducted in a tertiary university center in France. Women with single live breech pregnancy between 28 + 0 and 36 + 6 weeks gestation were included. We excluded situations with medical contraindication to vaginal delivery and fetal malformations. We compared women with an unfavorable cervix, who had an indication for deliver and could receive cervical ripening to induce labor, to women in spontaneous labor. The primary outcome was a composite criterion of severe neonatal morbidity and mortality including perinatal death, traumatic event during delivery, Apgar score at 5-min < 4, moderate or severe encephalopathy, seizures within the first 24 h, Intra-Ventricular Hemorrhage grade 3 or 4, necrotizing enterocolitis grade 2 or 3.

RESULTS

We included 212 patients: 64 in the induced labor group and 136 in the spontaneous labor group. In the induced labor group, 45.3% of patients delivered vaginally, and 86% in spontaneous labor group. The neonatal morbidity and mortality rate were similar in both groups: 4.7% in the induced labor group, and 5.2% in the spontaneous labor group, p = 0.889, aOR = 1.5 (0.28-8.28).

CONCLUSION

Nearly half of the patient who received induction of labor delivered vaginally. The onset mode of labor does not appear to have an effect on severe neonatal morbidity and mortality in preterm breech fetuses. Induction of labor could be an option for patients in this setting.

Breech presentation induction compared to cephalic presentation: Effectiveness and characteristics

INTRODUCTION

The objective of our study was to compare the effectiveness of induction in cephalic presentations to that of breech presentations as well as the characteristics of the latter and the maternal-fetal morbidity and mortality.

MATERIAL AND METHODS

This was a single-center retrospective study carried out at the Lille University Hospital in the Jeanne de Flandre Maternity Hospital including all patients with a breech fetus for whom an induction was indicated beyond 37 weeks of gestation between January 2014 and December 2020. A matching was performed to include 2 cephalic presentations for one breech presentation. The primary outcome was successful induction defined by two things: passage into the active phase (cervical dilatation > 5 cm) and vaginal delivery.

RESULTS

101 inductions of breech presentations were included and matched to 202 cephalic presentations. After adjustment by BISHOP score, there was no significant difference in the caesarean section rate between the two groups (25.7% in cephalic vs 33.7% in breech, OR 0.67 [CI95% 0.38-1.18]) or in the rate of transition to active phase (80.7% in cephalic vs 82.2% in breech, OR 1.26 [CI95% 0.65-2.44]). Post-partum blood loss was not significantly different between the two groups (14.4% in cephalic vs 12.9% in breech, OR 1.22 [CI95% 0.57-2.57]). Moderate neonatal acidosis was more frequent in the breech group (6,4% in cephalic vs 15,8% in breech, OR 3.04 [CI95% 1.38-6.71]).

CONCLUSION

Induction of breech births beyond 37 weeks of gestation appeared to be as effective as induction of cephalic presentations. There was no difference in the rate of caesarean section and transition to active labor. Maternal morbidity was not increased.

Neonatal Morbidity after Cervical Ripening with a Singleton Fetus in a Breech Presentation at Term

Vaginal delivery in women with a breech presentation is part of common practice in France despite much debate, and the induction of labor (IOL) with a fetus in a breech presentation at term remains uncommon. Little is known about the effectiveness of cervical ripening and its neonatal and maternal safety in these women. We present a retrospective study of 362 women who gave birth to a live singleton fetus in a breech presentation at term. The objective was to compare severe maternal and neonatal morbidity according to the planned mode of labor (spontaneous labor or the induction of labor (IOL) with a favorable cervix, cervical ripening, or elective cesarean delivery) and, specifically, to compare cervical ripening to the other modes of labor. The rate of severe neonatal morbidity was 3.0% and was significantly higher after the IOL compared to elective cesarean delivery (p = 0.02), and the severe maternal morbidity rates were similar. Multivariable logistic regression analysis found no significant association between cervical ripening and either composite severe neonatal (adjusted odds ratio [aOR] 2.80, 95% confidence interval [CI] 0.10-43.6) or maternal morbidity (aOR 1.29, 95% CI 0.05-11.5). Our results support a policy of offering cervical ripening to the appropriately selected candidates with a singleton fetus in a breech presentation at term without increasing the incidence of severe maternal and neonatal morbidity.

Implementation of a breech program in a Belgian obstetric team

OBJECTIVE

To stimulate obstetric centers to start training in breech counseling and selection and performing vaginal breech deliveries.

METHODS

The different steps that were needed to roll out a breech program, are described: the "walking" epidural (PIEB protocol), the breech consultation with a structured counseling tool, and training of the whole team (gynecologists, midwives, anesthesiologists, and pediatricians). We describe below the results of 111 women who were counseled at the breech consultation, in the period May 2019 to August 2021.

RESULTS

In all, 86.5% of patients (n= 96) with a singleton term breech met the criteria for a vaginal breech delivery; 77% of this group (n= 74) accepted a planned vaginal breech delivery. Of this group, 54% (n=40) had a successful vaginal breech delivery, 27% (n=20) ended up in a secondary cesarean section, and 19% (n=14) had a planned cesarean section.

CONCLUSION

We were able to roll out a successful breech program, including vaginal breech delivery, in a safe way. The breech consultation is the most essential part of the process. Training of the whole team is mandatory. The results of the first 2 years are encouraging to continue this program.

Cervical ripening for a singleton fetus in breech prensentation at term: Comparison between mechanical and pharmaceutical methods

Although various international professional societies currently recommend trial of vaginal delivery of term fetuses in breech presentation, the question of the method of cervical ripening, when necessary, remains open.

OBJECTIVE

To compare the effectiveness of two methods of cervical ripening for delivery of a singleton fetus in breech presentation at term: a mechanical method (balloon catheter) and a pharmaceutical method (prostaglandins).

STUDY DESIGN

This two-center retrospective study reviewed records from 2014 through 2019 in two French maternity units with two different cervical ripening methods for fetuses in breech presentation. The study included all women with cervical ripening for a medical indication with a live singleton fetus in breech presentation ≥ 37 weeks, with an unfavorable cervix. The group treated with a mechanical method was compared with the group receiving a pharmaceutical method. The cesarean delivery rate was the principal outcome, and maternal and neonatal morbidity the secondary outcomes.

RESULTS

We included 74 women, 19 with mechanical cervical ripening, and 55 with pharmaceutical treatment. The cesarean rate was 57.9% in the balloon catheter group and 40% in the prostaglandin group (P = 0.097) (crude OR =2.06, 95% CI [0.72 - 5.94]; adjusted OR = 2.88, 95% confidence interval [0.52-15.96]), and the postpartum hemorrhage rates 21.1% and 1.8% respectively (P = 0.008). Neonatal morbidity did not differ significantly.

CONCLUSION

Although the cesarean rate and neonatal morbidity and mortality did not differ significantly between these two methods of cervical ripening, our study lacked power.

Comparison of maternal and fetal complications in pregnant women with breech presentation undergoing spontaneous or induced vaginal delivery, or cesarean delivery

OBJECTIVE

Breech presentation is the most common form of malpresentation, and associated with perinatal asphyxia and mortality, and maternal morbidity. Data associated with labor induction in breech presentation are limited. The aim of this study was to compare maternal and fetal complication rates in induced and spontaneous vaginal, and cesarean delivery with breech presentation.

MATERIALS AND METHODS

Pregnant women with breech presentation were grouped: spontaneous vaginal delivery (Group 1, n = 72) induced or augmented vaginal delivery (Group 2, n = 32), and cesarean delivery (Group 3, n = 253). Fetal complications were as follows: clavicle fracture, femur fracture, humerus fracture, brachial plexus injury, cephalic hematoma, pneumothorax, need for intensive care unit (ICU), and 5th minute APGAR <7. Maternal complications were as follows: vaginal hematoma, deep vaginal laceration, perineal injury (≥3rd degree), decline in hemoglobin level (>2 g/dL), and postpartum endometritis. Data were collected and analyzed retrospectively.

RESULTS

The highest fetal complication rate was in Group 2, and the lowest in Group 3 (p = 0.001). Clavicle fracture was significantly less in Group 3 compared with the other groups (p = 0.024). The rate of lower APGAR scores at the 5th minute was similar in all groups. Maternal complications were significantly higher in Group 2 compared with the other groups (p = 0.001). Fetal complications were 5.66-fold higher in Group 1 than in Group 3 (p = 0.002). Fetal and maternal complications were 9.48-fold and 7.48-fold higher, respectively, in Group 2 than in Group 3 (p < 0.001).

CONCLUSION

This study is the first in literature to have investigated and analyzed neonatal complications in breech delivery according to different delivery modes including induced vaginal delivery. Due to possible complications, the risks and benefits of a specific type of delivery should be considered in breech presentation.

[Breech Presentation: CNGOF Guidelines for Clinical Practice - Labour and Induction]

OBJECTIVES

To issue guidelines on management of labour induction and breech vaginal delivery.

MATERIALS AND METHODS

Bibliographic search restricted to French and English languages using Medline database®, Cochrane Library and international guidelines of medical societies.

RESULTS

Breech delivery must take place in a maternity ward, in the presence of an obstetrician and gynaecologist and with the immediate availability of an anesthesiologist and a pediatrician during active second stage (Professional consensus). Term breech is not a contraindication to labour induction when the criteria for acceptance of vaginal delivery are met (Grade C). In this case, oxytocin or prostaglandins can be used (Grade C). Epidural analgesia with low concentrations of local anesthetics should be encouraged in case of vaginal delivery attempt (Professional consensus). It is recommended to use continuous monitoring of the CTG (Professional consensus). The use of second-line fetal monitoring is not recommended (Professional consensus). The administration of oxytocin is possible for labour augmentation (Professional consensus). It is better to start the expulsive efforts when the presentation is engaged as low as possible in the pelvic excavation (Professional consensus). Breech presentation is not an indication of episiotomy (Professional consensus). Due to insufficient data, it was not possible to make recommendations on specificities of preterm breech delivery.

CONCLUSION

In case of planned vaginal delivery, labour induction is possible for term breech fetuses, even with unfarable cervix. Guidelines for labour and vaginal delivery management have a low level of evidence.

[Comparison of obstetric prognosis of attempts of breech delivery: Spontaneous labor versus induced labor]

OBJECTIVES

Delivery mode in breech presentation (BP) is often controversial. Spontaneous labor, when vaginal birth seems safe, allows to better estimate uterus contractility, fetus' accommodation to maternal pelvis and optimize monitoring with a partograph. Induced labor in BP was usually contra-indicated. Lack of strong scientific evidence on this matter has permitted a progressive and careful evolution in obstetrical management, with the introduction of induced labor in BP. The aim of our study is to compare vaginal birth rates when labor is induced versus when spontaneous in BP. Maternal and fetal morbidity and mortality parameters were also evaluated.

METHODS

In this retrospective study were included 206 patients carrying fetuses in BP, between June 2012 and June 2017. 182 of them had spontaneous labor and 24 experienced induced labor. Inclusion criteria were singleton pregnancy, BP after 34 weeks of gestation and vaginal delivery authorized by a senior obstetrician. Multiple pregnancy, birth before 34 weeks of gestation, uterine scar, planned caesarian section for BP, intra-uterine fetal death and medical termination of pregnancy were excluded. Induction of labor was performed for medical reason on a favorable cervix.

RESULTS

There was no significant difference in cesarean section rates between the two "induced" and "spontaneous" labor groups in BP (OR=1.69 [CI95%: 0.71-4.04]). We observed no difference between the two groups in neither perineum trauma nor post-partum hemorrhage. No difference was found between the two groups in rates of Apgar score<7 5minutes after birth, neonatal transfer, fetal trauma and pH at birth.

CONCLUSION

Despite our small population, it seems acceptable to propose induced labor for medical reason if cervix is favorable in BP if a protocol is available stating acceptability criteria for vaginal birth. It can avoid unnecessary caesarian section and allow better obstetrical outcome. It would be interesting to study fetal and maternal morbidity and mortality criteria in induced labor versus planned cesarean section when patients could be eligible for induced labor in BP.

Comparison of outcomes between induction of labor and spontaneous labor for term breech - A systemic review and meta analysis

OBJECTIVES

Few studies have assessed the impact of induction of labor on breech presentation. This study aims to summarize the effect of induction of labor of breech presentation on perinatal morbidity.

METHODS

Literature review was done in Medline, Embase, Web of science and Cochrane Library up to 20 October 2017. Randomized control studies, cohort studies, and case control publishing studies comparing induction of labor versus spontaneous labor of singleton live breech birth were included. Perinatal morbidity was calculated by RevMan 5 and presented by pooled odds ratio with 95% confidence intervals.

RESULTS

Cesarean section rate and neonatal intensive care unit admission were increased in induction of breech labor as compared with spontaneous breech labor. No significant difference in umbilical cord blood base excess ≤ -12 mmol/L, Apgar 5 min < 7, Apgar 5 min < 4, umbilical cord blood PH < 7, neonatology unit admission, maternal fever, and intrapartum stillbirth between the two groups was found.

CONCLUSIONS

Induction of breech labor has higher cesarean section rate and NICU perinatal morbidity compared to spontaneous breech labor. The neonatal outcomes were otherwise similar across both groups. Eligibility for induction of breech labor needs to be assessed carefully according to individual situation.