Maternal and neonatal outcome of 846 term singleton breech deliveries: seven-year experience at a single center

Conceptual and ethical problems underpinning calls to abandon vaginal breech birth

The view that vaginal breech birth is unjustifiable due to neonatal safety concerns has resulted in continued calls for breech pregnancies to be managed via a policy of planned caesarean birth. Vaginal breech birth has of course always occurred, but women with term breech pregnancies who seek to have a vaginal birth often face coercive pressures to have a caesarean birth instead. In this paper I argue that even if there is population level evidence that vaginal birth is relatively riskier for the breech presenting fetus, implementing a policy of planned caesarean birth would essentially be an unjustified attempt at forced medical intervention upon women. Advocates of a policy of planned caesarean birth often conflate the acceptability of allocating participants to a treatment group (policy) within the context of a randomized controlled trial with the justifiability of doing that as part of individual health care. Calls for obstetricians to "abandon vaginal breech birth" mistakenly position vaginal breech birth itself as a form of medical intervention that can simply be removed as an option for women by obstetricians. In reality, abandoning vaginal breech birth would entail abandoning women by denying them access to healthcare options that are otherwise available to any woman having a vaginal birth.

Association between planned mode of delivery and severe maternal morbidity in women with breech presentations: A secondary analysis of the PREMODA prospective general population study

BACKGROUND

Neonatal morbidity among fetuses in breech presentation is not associated with planned mode of delivery in France. Data about consequences to these mothers are sparse.

METHODS

The prospective PREMODA study took place in France and Belgium (2001-2002) in 138 maternity units and included all women with a singleton fetus in breech presentation ≥ 37 weeks of gestation (n=8105). We excluded women with more than one previous cesarean delivery, an in utero fetal death, or for whom cesarean delivery or induction of labor was planned due to maternal disease. The composite variable "severe acute maternal morbidity" (SAMM) grouped severe events. Associations between planned modes of delivery and SAMM were estimated from multivariable Poisson regression models adjusted for potential confounders. A control group with fetuses in cephalic presentation enabled us to compare maternal complications by fetal presentation.

RESULTS

Among the 7564 women included in the analysis, 5098 (67.4%) had a planned cesarean and 2466 (32.6%) a planned vaginal delivery; their SAMM rates did not differ: 48/8098 (0.9%) versus 17/2466 (0.7%), respectively, with an adjusted risk ratio (aRR) of 1.60, 95% confidence interval (95% CI) 0.81-3.15. The SAMM rate was significantly higher in the planned vaginal breech group than in the planned vaginal cephalic group: 17/2466 (0.7%) versus 39/10156 (0.4%) (aRR 2.10, 95% CI 1.18-3.74).

CONCLUSION

In women with a fetus in breech presentation at term, the short-term risk of severe maternal morbidity did not differ significantly according to planned mode of delivery.

[Breech Presentation: CNGOF Guidelines for Clinical Practice - Maternal Benefits and Risks of Planned Cesarean Delivery compared to Planned Vaginal Delivery]

OBJECTIVE

To evaluate maternal risks and benefits associated with planned mode of delivery in case of breech presentation at term.

METHODS

MedLine and Cochrane Library databases search and review of the main foreign guidelines.

RESULTS

To analyze maternal complications according to the planned mode of delivery for breech singleton at term, only one study of high quality is available, a randomized controlled trial- the Term Breech Trial, having found a similar maternal morbidity rate with planned cesarean delivery compared to planned vaginal delivery (LE2). This trial found at 3 months postpartum a decreased risk of urinary incontinence and perineal pain, and an increased risk of abdominal pain in case of planned cesarean delivery compared to planned vaginal delivery (LE2). This trial found at 2 years postpartum, a similar rate of maternal morbidity according to planned mode of delivery, in the absence of subsequent pregnancy (LE2). In studies with fetus in cephalic presentation, previous cesarean delivery exposes women in subsequent pregnancies at serious risk of uterine rupture, abnormalities of placental insertion and hysterectomy (LE2).

CONCLUSION

For breech singleton at term, short and long term maternal complications appear similar in case of planned vaginal delivery compared to planned cesarean delivery without subsequent pregnancy. In subsequent pregnancies, women with previous cesarean section are at risk for serious complications (uterine rupture, abnormalities of placental insertion).

[Breech Presentation: CNGOF Guidelines for Clinical Practice - Case Selection for Trial of Labour]

OBJECTIVE

The objective of this chapter is to examine on the basis of the knowledge currently available the criteria available before labour for selecting women who would be eligible for trial of vaginal delivery.

METHODOLOGY

Bibliographical research in French and English using the Medline and Cochrane databases between 1980 and 2019 and the recommendations of international societies.

RESULTS

It is recommended to offer women who wish to attempt a vaginal delivery at term a pelvimetry to decide with them on their mode of delivery (Grade C). The pelvimetric standards used at the time of the PREMODA study were anteroposterior diameter of inlet≥105mm, a transverse diameter of inlet≥120mm, a transverse interspinous diameter≥100mm. However, since there is no evidence about which pelvic measures to use, nor any evidence to set decision-making thresholds other than those set in published studies, the selected decision-making thresholds can be adjusted according to gestational age at delivery or fetal biometrics (Professional consensus). There is no argument for recommending the practice of pelvimetry in the case of delivery before 37 weeks gestational age (Professional consensus) and in the case of breech presentation discovered at the time of beginning of labour, the absence of pelvimetry alone does not contraindicate the attempt of vaginal delivery (Professional consensus). There is insufficient data to recommend the systematic use of fetal weight estimation and/or biparietal diameter measurement as acceptance criteria for a vaginal delivery attempt. In the event of a known fetal weight estimation before birth greater than 3800g, a cesarean section is to be preferred (Professional consensus). The breech presentation is not in itself a contraindication to an attempt of vaginal delivery for a small fetus for gestational age (Professional consensus). The presentation of the non-frank breech is not in itself a contraindication to an attempt of vaginal delivery (Professional consensus). In the case of premature breech delivery, current data do not allow to recommend one delivery route over another (Professional consensus). It is recommended to check the absence of hyperextension of the fetal head by ultrasound before an attempt of vaginal delivery (Professional consensus) and to prefer a cesarean section if such a position is found (Professional consensus). It is not recommended to propose a caesarean section with the sole reason of nulliparity (Grade C). The history of cesarean section is not in itself a contraindication to an attempt of vaginal delivery in the case of fetal breech presentation (Professional consensus). Premature rupture of the membranes is not in itself a contraindication to an attempt of vaginal delivery (Professional consensus).

CONCLUSION

A number of the factors analyzed in this chapter are to be incorporated into the decision-making process in order to choose with the woman whose fetus is in breech presentation the delivery route.

Planned vaginal delivery of fetuses in breech presentation at term: Prenatal determinants predictive of elevated risk of cesarean delivery during labor

OBJECTIVE

Identify the prenatal determinants associated with cesarean delivery during labor of term breech presentation for which vaginal delivery is planned.

STUDY DESIGN

Prospective study of 174 French and Belgian maternity units. Relations between cesarean and prenatal determinants were estimated with a multilevel logistic model and expressed as adjusted ORs. A prediction score for cesarean section was proposed and diagnostic values were estimated for different cutoff values.

RESULTS

Of 2,478 women meeting the inclusion criteria, 705 (28.5%) had cesarean deliveries. Nulliparity, complete breech, rupture of membranes before labor, fetal weight > or = 3800 g, biparietal diameter > 95 mm and university and public non-teaching hospital maternity units were significantly associated with cesarean delivery during labor. The rate of cesarean during labor was significantly higher in establishments where more than 80% of women had planned cesareans and in cases where mode of delivery had not been decided before labor. The prediction score values ranged from 9 to 21.4 (10th, 50th and 90th percentiles corresponded to 10.1, 12.2 and 14.7). The cesarean rate was 43% in women whose score was greater than the cutoff point of 12.9, and 15% for women whose score was below this value.

CONCLUSION

Our findings indicate that once vaginal delivery has been decided upon, the risk of cesarean delivery during labor for breech presentation at term depends not only on the progress of labor, but also on prenatal determinants both maternal and obstetrical. It also depends on some characteristics of the maternity units. Obstetricians should either plan cesarean delivery or define stringent rules for indications of cesarean during labor.

Changes in the rates of caesarean delivery before labour for breech presentation at term in France: 1972–2003

OBJECTIVE

To describe the changes in the rate of caesarean deliveries before labour among women with term breech presentations in France and to identify the factors associated with this change over two periods: 1972-1995/1998 and 1995/1998-2003.

POPULATION

The study population consisted of 1479 women with a foetus in a breech presentation at term and without any previous caesarean delivery, from the population of births in the 1972, 1995, 1998 and 2003 national perinatal surveys (N=53136). Data from the 1995 and 1998 surveys were pooled.

METHODS

The principal endpoint was caesarean delivery before labour. Associations between the factors studied and caesarean before labour were estimated by odds ratios, both crude and adjusted with a logistic regression model.

RESULTS

Between 1972 and 2003, the rate of caesareans before labour for women with term breech presentations rose sharply (from 14.5% in 1972 to 42.6% in 1995/1998 and to 74.5% in 2003). Between 1972 and 1995/1998, this increase was especially marked among the nulliparous women (16.7% versus 52.9%). From 1995/1998 to 2003, the increase was greatest for multiparas: in 2003 this rate among women with children was close to that for women who had never given birth (64.5% and 79.5%, respectively). After adjustment, the factors associated with a high rate of caesarean before labour were nulliparity, birth between 38 and 40 weeks' gestation, birth weight > or =3800g, delivery in the private sector and year of delivery. The rate of caesareans before labour was significantly higher in 2003 (ORa=19.04 [12.06-30.06]) and in 1995-1998 (ORa=4.30 [2.87-6.47]) than in 1972.

CONCLUSION

The increase in the rate of caesarean deliveries before labour in women with term breech presentations was associated principally with changes in obstetrical practices.

Outcomes associated with cesarean section versus vaginal breech delivery at a university hospital

OBJECTIVE

To determine whether vaginal breech delivery is associated with increased morbidity in term breech singletons using strict selection criteria. This study encompasses our previous studies (in 1987 and 1995) and extends our experience to 21 years.

STUDY DESIGN

Retrospective cohort study from 1980 to 2001 including term, non-anomalous singleton breech deliveries selected by strict criteria. Univariable and multivariable analyses were performed for neonatal and maternal outcomes.

RESULTS

Five hundred and eleven women underwent cesarean section and 214 a trial of labor. We found greater overall maternal morbidity in the cesarean section group (odds ratio (OR) 1.89, 95% confidence interval (CI)=1.34-2.65). In the vaginal delivery group, neonates were more likely to have had >1 day of mechanical ventilation (OR 10.0, 95% CI=1.56-63.9). No maternal deaths occurred and no neonatal deaths or seizures occurred.

CONCLUSION

Given our findings, offering a trial of vaginal breech delivery to well-counseled strictly selected patients remains an appropriate option.

Birth weight and neurodevelopmental outcome of children at 2 years of age after planned vaginal delivery for breech presentation at term

OBJECTIVE

The purpose of this prospective cohort study was to determine whether planned vaginal delivery for the term singleton baby in breech position increases the risk of abnormal neurodevelopment at 2 years of age and to assess whether the effect is modified by birth weight.

STUDY DESIGN

At 2 years of age, all nonrandomized children born in breech position during our participation in the Term Breech Trial were screened for abnormal neurodevelopment with the Ages and Stages Questionnaire.

RESULTS

An Ages and Stages Questionnaire at 2 years of age was obtained in 183 of 203 children (90.1%). Twenty-eight percent of these children showed 1 or more abnormal Ages and Stages Questionnaire domains. There were no differences in the risk of having abnormal Ages and Stages Questionnaire domains between planned vaginal delivery and planned cesarean section (P = .99). There was, however, evidence of interaction between mode of delivery and birth weight, with significantly higher risk in neurodevelopmental delay in children with birth weight greater than 3500 g with planned vaginal birth (adjusted odds ratio for interaction term 3.37; 95% confidence interval 1.14 to 9.95).

CONCLUSION

Based on the Ages and Stages Questionnaire results at 2 years of age, planned vaginal delivery is associated with an increased risk of neurodevelopmental delay at 2 years of age in term breech children with a birth weight greater than 3500 g.

Inappropriate use of randomised trials to evaluate complex phenomena: case study of vaginal breech delivery

As randomised trials continue to ascend in the evolution of evidence based medicine, we must recognise and respect their limitations when examining complex phenomena in heterogeneous populations

Are health expectations of term breech infants unrealistically high?

BACKGROUND

The aim of this study was to compare the effect of fetal presentation and mode of delivery on infant outcome in a nation-wide study.

METHODS

In a retrospective observational cohort study, we compared, with the help of Finnish Medical Birth Register and other nation-wide registers, the short-term and long-term outcome of infants born by breech vaginal (n = 1270) or by vertex vaginal delivery (n = 128,683) or through planned cesarean section (CS) in breech (n = 1640) or vertex (n = 4997); the pregnancies were otherwise entirely normal.

RESULTS

One perinatal death occurred in the breech vaginal group and 23 deaths in the vertex vaginal group (p = 0.112), but none in either CS group. Breech vaginal delivery was associated with increased risk of Apgar scores 6 or less at age 1 min (OR 7.65, CI 6.41-9.12) and at age 5 min (OR 6.42, CI 4.36-9.45) as compared with vertex vaginal delivery. These odd ratios were also elevated (OR 4.59, CI 3.48-7.08 and OR 7.58, CI 3.09-18.66, respectively) when compared with breech planned CS. Yet the risk for birth trauma of infants in the breech vaginal group was smaller (OR 0.70, CI 0.51-0.96) than that in the vertex vaginal group but this risk was smallest in the planned CS groups. A number of other neonatal complications occurred equally commonly in each group. Breech infants born vaginally needed fewer admissions (OR 0.58, 0.47-0.72) to out-patient departments and the cumulative incidence of long-term morbidity in the breech vaginal group was smaller (OR 0.47, CI 0.28-0.80) to the age of 7 years than that in the breech planned CS. The maturity for starting school and school performance during the first two school years showed no dependence on mode of delivery.

CONCLUSION

Apart from Apgar suppression, elective vaginal delivery of a full-term breech fetus in highly selected pregnancies does not cause additional neonatal hazards as compared with full-term vertex deliveries. The immediate outcome was best for breech or vertex infants born through elective CSs.

Six hundred and ten breech versus 12,405 cephalic deliveries at term: is there any difference in the neonatal outcome?

OBJECTIVES

To compare neonatal morbidity of breech and cephalic deliveries at term.

STUDY DESIGN

Cohort study of 610 consecutive singleton breech presentations and 12,405 consecutive singleton cephalic presentations in term between 1992-1998. Five hundred and fourteen breech and 11,989 cephalic presentations were candidates for vaginal delivery, of which 407 (79%) breeches and 11,265 (94%) cephalic delivered vaginally.

RESULTS

Neonatal intensive care admissions were significantly greater for breech than cephalic vaginal deliveries (2.7% versus 0.25%, P = 0.000), but newborn intensive care admission and mortality were equally distributed between the two groups.

CONCLUSIONS

A low caesarean rate is possible (21% beech and 6% cephalic). Neonatal morbidity was equal in the two populations. Admission to neonatal intensive care was significantly more frequent for caesarean section than for vaginal delivery in the cephalic group and equal in the breech group. This study justifies our obstetrical policy and the realisation of a trial in several centres similar in terms of perinatal management.

Breech vaginal delivery at or near term

Three percent to 4% of term fetuses will be breech at delivery. Evidence from randomized controlled trials has found a policy of planned cesarean section to be significantly better for the singleton fetus in breech presentation at term compared to a policy of planned vaginal birth. However, some women may wish to avoid cesarean section and for others, cesarean section may not be possible. We undertook this review to identify factors associated with higher and lower risk of adverse fetal or neonatal outcome at term during vaginal breech delivery. We searched MEDLINE from 1966 to 2002 using the search terms vaginal breech delivery and breech presentation and retrieved all relevant articles. We also reviewed personal references and reference lists of articles retrieved. Women who are older or who have a fetus that is either in footling presentation, has a hyperextended head or is estimated to weigh <2500 g or >4000 g may be at higher risk of adverse fetal outcome. Prolonged labor or not having an experienced clinician at vaginal breech birth may also increase the risk. Women with a fetus in breech presentation at term should be offered the option of delivery by planned cesarean section and should be informed that this will reduce their risk of adverse fetal or neonatal outcome. Practitioners should develop and maintain skills at vaginal breech delivery for those women not wishing or not able to be delivered by cesarean section.

Mode of delivery and outcome of 699 term singleton breech deliveries at a single center

OBJECTIVE

Elective cesarean delivery has been postulated to improve the outcome of term fetuses in breech presentation. We retrospectively compared the short- and long-term outcomes of term infants who were delivered from a breech presentation at a single center.

STUDY DESIGN

We reviewed 699 consecutive term breech presentations according to the intended mode of delivery at a single center between January 1993 and December 1999. The short-term outcome measures were perinatal death, neonatal death, or serious neonatal morbidity; the long-term outcome measures were developmental delay and spasticity.

RESULTS

The rate of serious perinatal morbidity in the trial-of-labor and cesarean delivery groups was 2.3% and 0.5%, respectively (P =.12). There was no perinatal or neonatal death in either group. With a median follow-up period of 57 months (range, 13-100 months), the rate of developmental delay was 1.9% and 0.5%, respectively (P =.29). Spasticity was not noted in any of the children.

CONCLUSION

Our data suggest that planned vaginal delivery remains an option for selected term breech presentations.

The Webster Technique: a chiropractic technique with obstetric implications

OBJECTIVE

To survey members of the International Chiropractic Pediatric Association (ICPA); regarding the use of the Webster Technique for managing the musculoskeletal causes of intrauterine constraint, which may necessitate cesarean section.

METHODS

Surveys were mailed to 1047 US and Canadian members of the ICPA.

RESULTS

One hundred eighty-seven surveys were returned from 1047 ICPA members, constituting a return rate of 17.86%. Seventy-five responses did not meet the study inclusion criteria and were excluded; 112 surveys (11%) provided the data. Of these 112 surveys, 102 (92%) resulted in resolution of the breech presentation, while 10 (9%) remained unresolved.

CONCLUSION

The surveyed doctors reported a high rate of success (82%) in relieving the musculoskeletal causes of intrauterine constraint using the Webster Technique. Although the sample size was small, the results suggest that it may be beneficial to perform the Webster Technique in month 8 of pregnancy, when breech presentation is unlikely to spontaneously convert to cephalic presentation and when external cephalic version is not an effective technique. When successful, the Webster Technique avoids the costs and/or risks of external cephalic version, cesarean section, or vaginal trial of breech.In view of these findings, the Webster Technique deserves serious consideration in the health care management of expectant mothers exhibiting adverse fetal presentation.

Breech presentation at term: morbidity and mortality according to the type of delivery at Port Royal Maternity hospital from 1993 through 1999

OBJECTIVE

To compare neonatal morbidity and mortality at Port Royal Maternity between 1993 and 1999 for infants with a singleton breech presentation born after 37 weeks, according to planned mode of delivery.

STUDY DESIGN

Retrospective study of 501 patients of whom vaginal delivery was planned in 322 (64%) or/and cesarean in 179 (36%).

RESULTS

Severe neonatal morbidity was similar in the two groups (13/322, 4.0% versus 8/179, 4.5%; P=0.82); severe trauma morbidity was not significantly higher in the "planned vaginal delivery" group (3/322, 0.9% versus 1/179, 0.06%; P=0.16); there were no long-term sequelae. Mortality was not higher when vaginal delivery was planned.

CONCLUSION

We have not found in this series any excess of morbidity or mortality attributable to vaginal delivery of breech presentations. This work does not indicate that we should change our obstetrical practice in the light of other recently-published studies.

Caesarean section delivery in Kerala, India: evidence from a National Family Health Survey

Ensuring safe pregnancy and motherhood occupies a pivotal role and has been considered as one of the key issues in the framework of reproductive and child health programmes. Evidence from research studies indicate that there is a growing tendency for caesarean section deliveries especially during complications confronted at the time of pregnancy and delivery. The present study focuses on the demographic, antenatal care, spatial and socio-economic variables associated with caesarean section delivery in Kerala, India. The data from the National Family Health Survey has been utilised for this purpose. The results from logistic regression models indicate that maternal age, birth order, current age, births in health institutions and spatial differences were significantly associated with caesarean section deliveries in Kerala. The older cohorts of mothers were found at higher risk to have caesarean section when compared to their younger counterparts. When controlled for demographic variables, the odds for caesarean section was about 1.7 times more likely to occur in private health institutions. The inclusion of spatial and socio-economic variables has neither influenced the demographic and antenatal care variables nor showed any significant association with caesarean section delivery in the state. The present study calls for that a detailed investigation on behavioural aspects of both the physician and the patient with regard to type of delivery in the state. Information related to pregnancy and health related aspects needs to be monitored more accurately, both in the public and private hospitals, to understand the determinants associated with caesarean section.

Comparison of vaginal and cesarean section delivery for fetuses in breech presentation

OBJECTIVES

Our purpose was to evaluate the perinatal mortality and morbidity of deliveries with fetuses presenting by the breech comparing outcomes of two groups according to mode of delivery: vaginal and cesarean section.

RESULTS

Of 756 fetuses studied, 271 were delivered vaginally and 485 by cesarean section. In infants weighing > or = 1500 grams, "further corrected" mortality and morbidity rates were low and similar for both delivery routes: one neonatal death (NNM) in each. Among very low birth weight (VLBW) infants (< 1500 grams) the "further corrected" mortality rate was higher in the vaginal group: 57.4%, and 18.0% in abdominal deliveries (odds ratio [OR] = 6.1, 95% CI: 3.1 to 12.1). Likewise, rate of depression at five minutes were higher in the vaginal group (p < 0.001). However, the average fetal weight among the vaginal deliveries VLBW (787 grams) was 250 grams less than in the cesarean section group (1040 grams). After adjustment for fetal weight, gestational age, and other prognostic variables the odds ratio for neonatal death was no longer statistically significant (adjusted OR = 2.1, 95% CI: 0.9 to 5.2, p = 0.105). Comparison of planned vaginal delivery with elective cesarean section yielded smaller differences (adjusted OR for neonatal death = 1.3, 95% CI: 0.6 to 2.9, p = 0.525).

CONCLUSION

The poor perinatal outcomes of breech delivered infants are due primarily to VLBW, congenital malformations, and premature labor. Although abdominal delivery had a lower NNM rate than vaginal delivery, the difference was not significant after adjustment for confounding factors. The results confirm the findings of a previously analyzed similar series delivered at our institution between 1980 and 1987. They suggest that, with appropriate technique, abdominal delivery is not mandatory in breech presentation.

Singleton term breech deliveries in nulliparous and multiparous women: a 5-year experience at the University of Miami/Jackson Memorial Hospital

OBJECTIVE

The purpose of this retrospective study was to evaluate the feasibility of planned vaginal delivery, the maternal morbidity and mortality, and the short-term perinatal outcome in selected multiethnic women at term with singleton breech presentations.

STUDY DESIGN

Singleton breech deliveries were identified from the delivery database between January 1, 1989, and December 31, 1993. A retrospective chart review identified 310 nulliparous and 711 multiparous women at term (37-42 weeks) for a total of 1021. Parameters studied included the success rate of planned vaginal deliveries and the incidences of maternal morbidity, perinatal morbidity, and mortality as a whole stratified by parity and mode of delivery. The Student t test, chi(2) test, and Fisher exact test were used for statistical analysis.

RESULTS

Among 1021 women with singleton fetuses in a breech position at term, 191 were candidates for vaginal delivery, and 135 (70.7%) of these deliveries were successful. By parity, 12.3% of 310 nulliparous women and 21.5% of 711 multiparous women were candidates for vaginal delivery; 50% of the former and 75.8% of the latter underwent vaginal delivery. Maternal morbidity was more commonly associated with multiparity and cesarean delivery. Newborn intensive care admissions were equally distributed by parity, and significantly more were for vaginal than cesarean deliveries (17.4% vs 10.8%, P =.036). Premature rupture of the membranes complicated deliveries in 23.9% of the nulliparous women and only 6.5% of the multiparous women (P =.000).

CONCLUSION

In this multiethnic population 70.7% of candidates selected for attempted vaginal breech delivery at term were successful. The remaining 29.3% underwent cesarean delivery for labor disorders or nonreassuring fetal heart rate patterns.

Indications for caesarean section in breech presentation

OBJECTIVE

The study was conducted because of the still considerable controversies about the variation in obstetric management in breech presentation, in combination with the still increasing caesarean section rate for this type of presentation, as well as doubt concerning the assumed improvement in neonatal and maternal morbidity and mortality obtained by increasing section rate in breeches.

STUDY DESIGN

Two hundred and sixty eight consecutive breech presentations in two university hospitals were studied longitudinally and prospectively. In principle, vaginal delivery was attempted in all cases, under expert supervision and electronic monitoring, except in the presence of clear-cut contraindications. X-ray pelvimetry was not used.

RESULTS

The incidence of caesarean section was 34%. The trial of vaginal delivery succeeded in 64% of the nulliparas and in 60% of the non-frank breeches, without statistically significant differences in outcome measures compared with the multiparous women and the frank group, respectively. Hyperextension of the foetal head rarely occurred.

CONCLUSION

Several classic obstetric factors have a lower discriminating value for the route of delivery than is currently assumed. Progress of labour was an important factor in determining the route of delivery.

Planned vaginal delivery versus elective caesarean section: a study of 705 singleton term breech presentations

OBJECTIVE

To compare neonatal mortality and neonatal and maternal morbidity in planned vaginal delivery versus elective caesarean section for breech presentation at term. To identify factors associated with the risk of caesarean section during labour.

DESIGN

Cohort study.

SETTING

University Hospital of Geneva.

POPULATION

Seven hundred and five consecutive singleton term breech presentations: 385 planned vaginal deliveries and 320 elective caesarean sections.

METHODS

Relative risk and risk difference with their 95% confidence intervals (95% CI) were calculated for neonatal and maternal morbidity. Prognostic factors for the risk of intrapartum caesarean section were analysed by multiple logistic regression.

MAIN OUTCOME MEASURES

1. Neonatal mortality 2. Neonatal morbidity (eg. fracture, haematoma with hyperbilirubinemia, paresis, paralysis, visceral trauma, respiratory distress, umbilical cord arterial pH < 7.0 with 5 minute Apgar score < 7), corrected neonatal morbidity was defined as morbidity after exclusion of major malformations. 3. Maternal morbidity (eg. endometritis, urinary infection, pulmonary infection, surgical complications, hysterectomy, anaemia, pulmonary embolism, cardio-respiratory arrest).

RESULTS

There were significantly fewer maternal complications in the planned vaginal delivery group than in the elective caesarean section group (risk difference 10.5%, 95% CI 3.9 to 17.0). Five neonates with major malformations died. There was no difference in corrected neonatal morbidity between the planned vaginal delivery and the elective caesarean section groups (risk difference 1.9%, 95% CI -1.0 to 4.9). Nulliparity, maternal age > 30 years and a higher body mass index were independently associated with the risk (30%) of intrapartum caesarean section, but it was not possible to construct a predictive model useful for clinical practice.

CONCLUSIONS

There is no firm evidence to recommend systematic elective caesarean section for breech presentation at term. Large unbiased studies are needed to determine whether a potential benefit for the newborns outweighs the increased risk for the mothers associated with elective caesarean section.

Perinatal outcome of singleton term breech deliveries

OBJECTIVE

To assess neonatal morbidity and mortality in singleton term infants delivered in breech presentation and to find a possible correlation between outcome and mode of delivery.

STUDY DESIGN

Case study of 306 singleton, term (37-42 weeks), breech deliveries, that took place between 1989 and 1994 in one perinatal centre.

RESULTS

170 infants were delivered vaginally, 72 by elective and 64 by secondary cesarean section. Even after application of strict selection criteria -- i.e. prior pelvic assessment by staff obstetricians, an estimated birth weight of 2500-4000 g -- and with staff supervision, vaginal delivery turned out to be associated with a significantly higher incidence of low umbilical artery pH values and neonatal care unit admissions as compared to elective cesarean section. Five infants suffered mechanical trauma. One neonatal death occurred in the vaginal delivery group.

CONCLUSION

The results of this retrospective study of 306 singleton term breech deliveries imply that even after strict selection of patients, vaginal delivery is associated with increased neonatal morbidity in comparison to elective cesarean section.

Outcome of 1040 consecutive breech deliveries: clinical experience of a maternity hospital in Turkey

OBJECTIVE

To determine the optimal route of delivery in breech presentation.

METHOD

One-thousand and forty singleton breech deliveries among a total of 41785 deliveries that occurred at Zubeyde Hanim Maternity Hospital between 1990 and 1994 were analyzed.

RESULT

The breech deliveries accounted for 2.4% of all deliveries. Of the patients, 572 (56.3%) were delivered vaginally and 468 (43.7%) were delivered by cesarean section. The mean ages of vaginal and cesarean delivery groups were 25.2 and 24.6 years, respectively. Forty-one (3.9%) of the fetuses had congenital anomaly. The leading congenital anomalies were meningocele in seven and hydrocephalus in six patients. Mullerian anomalies were encountered in 29 (6.1%) patients at cesarean section. Fetal morbidity observed in cesarean deliveries were fracture of the humerus in one and fracture of the femur in one and soft tissue injury in four cases. Fracture of the humerus was observed in two, Erb's paralysis in four, facial paralysis in one and soft tissue injury in 43 fetuses delivered vaginally. The leading causes of puerperal maternal morbidity were genital tract lacerations in vaginal delivery group and wound infection in cesarean delivery group. The overall perinatal mortality of this series was 54.8/1000 (57/1040). The corrected figures for cesarean delivery and vaginal delivery groups were 8.5/1000 (4/467) and 57.9/1000 (32/552), respectively.

CONCLUSION

We favor a selective approach for mode of delivery in patients with breech presentation in order to balance the fetal morbidity associated with vaginal delivery and maternal morbidity and cost associated with cesarean delivery.