Evaluation of a protocol for selecting fetuses in breech presentation for vaginal delivery or cesarean section

Trial and error - Outcome of breech presentation depending on birth mode and root cause analysis of severe adverse events

OBJECTIVES

The debate about the safest birth mode for breech presentation at term remains unresolved. The comparison of a vaginal breech birth (VBB) with an elective caesarean section (CS) regarding fetal outcomes favors the CS. However, the question of whether attempting a VBB is associated with poorer fetal outcomes is examined in this study. Additionally, the study evaluates factors contributing to a successful VBB and illustrates possible errors in VBB management.

STUDY DESIGN

We performed a retrospective analysis of term breech births over 15 years in a Perinatal Center Level I regarding fetal, maternal, and obstetric outcomes by comparing successful with unsuccessful VBB attempt and all attempted VBB vs. CS including a multivariate analysis of predictors for a successful VBB. A root cause analysis of severe adverse events (SAE) was conducted to evaluate factors leading to poorer fetal outcomes in VBB.

RESULTS

Of 863 breech cases, in 78 % a CS was performed and in 22 % a VBB was attempted, with 57 % succeeding. Comparing successful with unsuccessful VBB attempts, successful VBB showed significantly lower maternal blood loss (p < 0.001) but poorer umbilical arterial pH (UApH) (p < 0.001), while other fetal outcome parameters showed no significant differences. Predictive factors for a successful VBB attempt were a body mass index (BMI) below 30.0 kg/m2 (p = 0.010) and multiparity (p = 0.003). Comparing all attempted VBB to CS, maternal blood loss was significantly higher in CS (p < 0.001), while fetal outcomes were significantly worse in VBB attempts, included poorer Apgar scores (p < 0.001), poorer UApH values (p < 0.001), higher transfer rate to the Neonatal Intensive Care Unit (NICU) (p < 0.001) and higher rate of respiratory support in the first 24 h (p = 0.003).

CONCLUSION

The failed attempt of VBB indicates significantly worse UApH without lower Apgar scores or higher transfer rate to the NICU. The likelihood of a successful VBB is 9% lower with obesity and 2.5 times higher in multiparous women. Attempting a VBB should include detailed pre-labor counseling, regarding predictive success factors, an experienced team, and consistent management during birth.

[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.

Comparison of Apgar scores in breech presentations between vaginal and cesarean delivery

OBJECTIVE

The mode of delivery in breech presentation (BP) is controversial. Several studies have reported the advantages and disadvantages of delivery mode in BP. The aim of this study was to compare the Apgar scores in BPs between vaginal and cesarean delivery.

MATERIALS AND METHODS

A retrospective study was conducted at Dr. Zainoel Abidin General Hospital from January 2010 to December 2012. Data on the mode of delivery and Apgar scores at 1 and 5 min for infants with a BP were extracted from the medical records. Logistic regression was employed to assess the correlation between mode of delivery and Apgar scores. In addition, a meta-analysis was conducted to summarize findings from other regions.

RESULTS

A total of 205 (3.9%) BPs among 5252 deliveries between January 2010 and December 2012 were analyzed for this study. There were 26% (52 cases) vaginal and 74% (153 cases) cesarean deliveries. The mode of delivery for BP had a significant association with Apgar score at 1 min (odds ratio [OR] 95% confidence interval [CI] = 6.462 [2.476-16.870], P = 0.0001) and 5 min (OR 95% CI = 7.727 [1.416-42.175], P = 0.018). Our meta-analysis showed that the delivery mode had a significant association with Apgar score in BP (OR: 3.69; 95% CI: 2.18-6.26, P = 0.0001).

CONCLUSIONS

There was a significant association between Apgar scores in BPs and mode of delivery. Our results suggest better outcomes for cesarean than vaginal delivery in BPs.

[Breech vaginal delivery: a study of maternal and neonatal morbidity and mortality]

Le but de cette étude était de déterminer la fréquence de l'accouchement en présentation du siège aux Cliniques Universitaires de Lubumbashi, décrire les caractéristiques sociodémographiques et obstétricales en rapport avec les accouchées et évaluer la morbi-mortalité maternelle et néonatale liée à l'accouchement du siège par voie basse en comparaison avec l'accouchement du sommet par la même voie. Il s'agissait d'une étude rétrospective descriptive et analytique portant sur 31 accouchements par voie basse (VB), avec f'tus en présentation du siège, des grossesses monofoetales d’âge gestationnel supérieur à 35 semaines aménorrhées, réalisés au cours de la période allant du 1^er janvier 2010 au 30 juin 2011 à la maternité des Cliniques Universitaires de Lubumbashi en RD Congo. Les paramètres sociodémographiques, l'environnement obstétrical et l'issue maternelle et néonatale ont été analysés en comparaison avec ceux des 99 couples Mère-Enfant issus des accouchées eutociques (VB) au cours de la même période. Le seuil de signification a été fixé à p<,05. La fréquence de la présentation du siège est de 2,5% et le siège décomplété est la variété la plus retrouvée (60%). L’âge moyen, la parité moyenne, l’âge gestationnel moyen ainsi que le poids de naissance moyen sont comparables dans les 2 groupes (p=0,3308, p=0,6897, p=0,4420 et p=0,8240). La morbidité maternelle est caractérisée par un taux de 19,3% de lésions des parties molles parmi les accouchées avec foetus en présentation du siège contre 6,1% parmi les accouchées avec foetus en présentation du sommet (p=0,1197). La morbidité périnatale est représentée par un taux de dépression néonatale à la fin de la 1ère minute plus élevé chez les nouveau-nés en présentation du siège (38,7%) que ceux nés en présentation du sommet (5,1%) (p=0,0000) signifiant un risque de dépression néonatale multiplié par près de 12 (OR=11,87 3,35-44,51). A partir de la 5ème minute, le risque de dépression néonatale n'est pas différent quelque soit la présentation foetale considérée. S'agissant des déperditions néonatales, si aucun décès n'a été enregistré parmi les nouveau-nés en présentation du sommet, il a été déploré 2 décès parmi ceux nés en présentation du siège (6,5%; p=0,0554). Le séjour hospitalier moyen des accouchées ainsi que celui de leurs nouveau-nés sont comparables dans les deux groupes. La morbidité maternelle et néonatale observée dans l'accouchement du siège, matérialisée par un taux élevé des lésions périnéales et la dépression néonatale à la 1ère minute, est vraisemblablement le reflet du niveau des accoucheurs quant à la maîtrise des techniques dans la direction d'un accouchement du siège par VB. Il s'agit d'une morbidité non imputable à la seule présentation et donc totalement évitable.

Factors associated with adverse perinatal outcomes for term breech fetuses with planned vaginal delivery

OBJECTIVE

We sought to identify factors associated with adverse perinatal outcomes (APO) among term breech neonates with planned vaginal deliveries.

STUDY DESIGN

We conducted univariable and multilevel multivariable analysis of the data collected in the multicenter prospective observational study PREsentation et MODe d'Accouchement (PREMODA) in women with planned vaginal delivery giving birth to singleton term breech babies. The end point was a composite set of APO.

RESULTS

Of 2502 women with planned vaginal delivery recruited in the 174 participating centers, 1772 (71%) delivered vaginally. Adverse outcomes were observed in 165 cases (6.59%). After adjustment, the factors associated with them were geographic origin, gestational age <39 weeks at birth, birthweight <10th percentile, and annual number of maternity unit births <1500.

CONCLUSION

When strict conditions governed the selection of delivery route and management of labor was rigorous, APO were not associated with any prenatal or peripartum obstetric factors.

Undiagnosed breech in Zaria, Nigeria

There is no certainty about the best way of dealing with a breech presentation first diagnosed in labour. In our unit, the decision to allow a trial of vaginal delivery rested on the clinical assessment of the size of the baby and the maternal pelvis, and the progress of labour. We compared the outcome of 32 cases where a breech presentation was first diagnosed in labour with 65 women where the malpresentation was diagnosed antenatally where a full assessment including ultrasound and radiological pelvimetry could be made. There was no significant difference in the mode of delivery and fetal outcome. We continue to favour careful case selection for vaginal delivery even where the breech is first diagnosed in labour.

Planned vaginal delivery of term breech remains an option – result of eight years experience at a single centre

In order to compare the short term outcome of vaginal and abdominal delivery of babies with breech presentation at term at a single centre, a retrospective study of 299 women presenting with singleton normal breech fetuses at term between 1st January 1996 and 31st December 2003, at a tertiary referral centre, was conducted. The rates of perinatal mortality, neonatal mortality, serious neonatal morbidity and low Apgar scores of neonates delivered after either planned vaginal or planned abdominal delivery were compared. Among 299 women with singleton normal breech at term, 32.1% delivered vaginally and 67.9% had C/S. Successful planned vaginal delivery rate was 97.9%. There was no perinatal or neonatal death in either group and no significant difference in the rates of serious perinatal morbidity between the two groups. We concluded that planned vaginal delivery is associated with no significant adverse perinatal outcome and remains an option for selected term breech presentation.

Has pelvimetry a role in current obstetric practice?

Radiological pelvimetry is still requested in some centres before planned vaginal delivery for breech presentation or following a previous caesarean section. In a retrospective review of the utilisation of pelvimetry in 167 cases in our department, 103 (62%) and 64 (38%) had pelvimetry in the postnatal and antenatal periods respectively. Antero-posterior inlet and outlet diameters were inadequate in 19.2% and 16.2% respectively. Of those who had postnatal pelvimetry, only 36 (35%) returned to our unit for further confinement and the caesarean section rate in this group was 75%. The main indications for antenatal pelvimetry were breech presentation (28), previous caesarean section (23) and anticipated cephalopelvic disproportion (13). The caesarean section rates in these groups were 82%, 70% and 45% respectively. However, the emergency caesarean section rate in the breech presentation group was 28%. Nine patients (32%) of those who had breech presentation and delivered by elective caesarean section had normal pelvic measurements. Pelvimetry should only be performed if its results will influence the mode of delivery. Pelvimetry may be useful in selecting fetuses with breech presentation for vaginal delivery or elective caesarean section. However it would increase the likelihood of caesarean section in cephalic presentation.

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.

Term breech delivery in Sweden: mortality relative to fetal presentation and planned mode of delivery

OBJECTIVES

To compare perinatal and infant mortality in breech and cephalic presentations and between planned vaginal and cesarean section (CS) breech deliveries in Sweden.

METHODS

The study comprised two parts. Study A is a national cohort study for the period 1991-2001, including 22 549 breech presentations and 875 249 cephalic presentations born at > or =38 completed weeks. Study B is a case-control study, including all 164 breech deliveries with perinatal or 1-year infant death (during 1991-1999 in Sweden) and controls.

RESULTS

Study A: Among non-malformed infants, the total mortality rate was 0.46% in breech and 0.28% in cephalic presentations [adjusted odds ratio (OR) 1.6; 95% confidence interval 1.3-1.9]. Non-malformed breech babies were at an increased risk of antenatal death (breech versus cephalic hazard ratio: 2.7, 2.1-3.6). The infant mortality among non-malformed breech deliveries was higher in vaginal birth than in delivery by CS before labor (OR 2.5, 1.2-5.3). The perinatal + infant mortality among non-malformed breech babies was higher at delivery after 39 completed weeks than at CS delivery at 38 weeks (0.53% versus 0.14%; OR 3.5, 1.9-6.4). The estimated needed number of CS to avoid one death was 400. Study B: In breech presentations without malformations, OR for perinatal or infant death was 3.1 (1.7-5.8) at planned vaginal delivery compared with planned CS delivery, and when breech presentations not diagnosed at 37 gestational weeks were excluded, OR was 3.7 (1.6-9.2).

CONCLUSIONS

These large population-based and case-control studies both show a significant reduction of perinatal and infant mortality with planned CS in term breech pregnancy.

Assisted vaginal delivery versus caesarean section in breech presentation

BACKGROUND

The Term Breech Trial (TBT), a well-known study conducted by Hannah and published in the Lancet, revealed a better outcome for neonates after primary caesarean section compared with attempted vaginal delivery. The aim of the present study was to determine whether the results of TBT have to be taken into account when counseling pregnant women in central Europe.

METHODS

We investigated 882 women who had delivered infants in breech presentation over a period of 11 years. The neonates had a birthweight of >2500 g and no malformations. We compared mortality and serious neonatal morbidity after attempted vaginal delivery and after primary caesarean section.

RESULTS

No infant or maternal mortality was registered in either group. Serious neonatal morbidity was higher (0.5%; n = 2) for attempted vaginal delivery than for primary caesarean section; in the latter group, no child fulfilled the criteria for serious neonatal morbidity. However, the difference was not statistically significant. As expected, after attempted vaginal delivery, the base excess, and 5-min APGAR scores were indicative of more markedly depressed children.

CONCLUSION

After careful exclusion of risk factors and informing the patient in detail about the risks and possible complications, vaginal delivery from breech presentation is still warrantable.

Good perinatal outcome in selective vaginal breech delivery at term

BACKGROUND AND AIM

To compare perinatal outcome in groups of planned vaginal breech delivery, elective cesarean section with the fetus in breech presentation, and planned vaginal delivery with the fetus in cephalic presentation in a university hospital with a tradition of managing breech deliveries by the vaginal route.

METHODS

A cohort study from a 7-year period 1995-2002, including 590 planned vaginal deliveries with a term (> 37 weeks) singleton fetus in breech presentation, 396 elective cesarean sections with a term singleton fetus in breech presentation, and 590 control women intending vaginal delivery with a singleton term fetus in cephalic presentation.

RESULTS

The Apgar scores were lower in the group of planned vaginal breech delivery, but in other outcome measures there were no significant intergroup differences. The overall neonatal morbidity was small (1.2% vs. 0.5% vs. 0.3% in the respective study groups) if compared to a recently published randomized multicenter study.

CONCLUSIONS

Selective vaginal breech deliveries may be safely undertaken in units having a tradition of vaginal breech deliveries.

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.

Vaginal breech delivery: is it still an option?

OBJECTIVE

To provide local data on term breech delivery for future guidance.

STUDY DESIGN

Retrospective, 'intended-mode-of-delivery' analysis of 711 antenatally uncomplicated singleton breech deliveries at >or=37 weeks: 445 (63%) planned for vaginal delivery (VD) (no fetal growth restriction, fetal weight 2000-4000 g, adequate pelvic size, maternal consent) and 266 for cesarean section (CS).

OUTCOME MEASURES

Apgar score, cord blood acid-base status, childhood deaths and disability.

RESULTS

Perinatal mortality was nil in both groups. Low 1-min Apgar scores and low arterial cord blood pH were significantly more frequent in planned VD, but not low Apgar scores at 5 or 10 min or low venous pH. Metabolic acidosis, neonatal intensive care, neonatal seizures, birth trauma, childhood death (CS=1), and neurodevelopmental handicaps (CS=2, VD=1) were equally common.

CONCLUSION

Our results do not disqualify selective vaginal breech delivery at term and beyond as an option.

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 term breech presentation. A retrospective study with regard to the planned mode of delivery

BACKGROUND

To analyze retrospectively a large group of term breech and vertex deliveries, with regard to the influence of the mode of delivery on the frequency of fetal and maternal complications.

METHODS

All singleton breech deliveries after completed 36 weeks of pregnancy, with a live fetus, delivered at Rogaland Central Hospital, from September 1 1996 to the May 10 2001 were included (n = 575). Correspondingly as a control group, 582 cases in vertex presentation were analyzed.

RESULTS

Planned vaginal delivery (VD) for the fetus in breech presentation (n = 448) in comparison with elective caesarean section (CS) (n = 127) increased early neonatal morbidity (3.6% vs. 0%). The frequency of Apgar scores < 7 at 5 min also increased (4.2% vs. 0.8%), as well as umbilical artery pH < 7.0 (4.4% vs. 0%), and referrals to the neonatal intensive care unit (NICU) (15.8% vs. 6.3%). Corresponding figures for planned VD of the fetus in vertex presentation were: 0.5% neonatal morbidity, 0.2% Apgar scores < 7 at 5 min, 8.1% admissions to NICU and 1.5% pH < 7.0 in umbilical arteries. Results comparing maternal morbidity in the different breech groups were inconclusive, but there were more maternal complications in the breech group planned for VD than in the corresponding vertex group (5.1% vs. 1.9%).

CONCLUSIONS

Elective CS for breech presentation will significantly decrease the risks for the fetus in comparison with planned VD.

Mode of delivery in breech presentation at term: increased neonatal morbidity with vaginal delivery

OBJECTIVE

To compare the neonatal outcome in planned vaginal delivery and planned cesarean section in term singleton pregnancies with breech presentation in a Scandinavian clinic with a high rate of vaginal breech delivery.

METHODS

A retrospective study including 1050 term singleton breech pregnancies delivered at a Swedish tertiary referral center during 1988 to 2000. For 699 patients (67%) a vaginal delivery was planned, of whom 603 (86%) were delivered vaginally. In 327 (31%) cases a cesarean section was planned and performed. These two groups were compared regarding rates of acidemia at birth (cord artery pH <7.05), low Apgar scores and neonatal neurological morbidity. Long term sequels among infants with a complicated neonatal course were also identified.

RESULTS

Acidemia at birth, Apgar score below 7 at 5 minutes, and referral to neonatal intensive care unit all occurred at higher rates in planned vaginal delivery (5.3%, 3.6%, and 8.9%, respectively), than in planned cesarean delivery (0, 0, and 4.0%). The rate of neonatal neurological morbidity was 24/699 (3.4%) in planned vaginal delivery (18 cases with cerebral symptoms and six cases of brachial plexus palsy) compared to one case (cerebral symptoms) after a planned cesarean. These differences were all statistically significant (p< or =0.002). Of the neurologically affected neonates, two died and four had cerebral palsy (one delivered by planned cesarean section) at follow up.

CONCLUSION

Neonatal morbidity may be reduced with planned cesarean delivery in breech presentation, also in a Scandinavian setting.

Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group

BACKGROUND

For 3-4% of pregnancies, the fetus will be in the breech presentation at term. For most of these women, the approach to delivery is controversial. We did a randomised trial to compare a policy of planned caesarean section with a policy of planned vaginal birth for selected breech-presentation pregnancies.

METHODS

At 121 centres in 26 countries, 2088 women with a singleton fetus in a frank or complete breech presentation were randomly assigned planned caesarean section or planned vaginal birth. Women having a vaginal breech delivery had an experienced clinician at the birth. Mothers and infants were followed-up to 6 weeks post partum. The primary outcomes were perinatal mortality, neonatal mortality, or serious neonatal morbidity; and maternal mortality or serious maternal morbidity. Analysis was by intention to treat.

FINDINGS

Data were received for 2083 women. Of the 1041 women assigned planned caesarean section, 941 (90.4%) were delivered by caesarean section. Of the 1042 women assigned planned vaginal birth, 591 (56.7%) delivered vaginally. Perinatal mortality, neonatal mortality, or serious neonatal morbidity was significantly lower for the planned caesarean section group than for the planned vaginal birth group (17 of 1039 [1.6%] vs 52 of 1039 [5.0%]; relative risk 0.33 [95% CI 0.19-0.56]; p<0.0001). There were no differences between groups in terms of maternal mortality or serious maternal morbidity (41 of 1041 [3.9%] vs 33 of 1042 [3.2%]; 1.24 [0.79-1.95]; p=0.35).

INTERPRETATION

Planned caesarean section is better than planned vaginal birth for the term fetus in the breech presentation; serious maternal complications are similar between the groups.

Influence of maternal-fetal medicine subspecialization on the frequency of trial of labor in term pregnancies with breech presentation

OBJECTIVE

To investigate the role of subspecialization in maternal-fetal medicine (MFM) on the frequency of a trial of labor in term pregnancies with breech presentation.

METHODS

We conducted a retrospective study of 332 singleton pregnancies > or =37 weeks with nonfootling breech presentation that delivered over a 6-year period (1994-1998) at a university-based, tertiary care hospital. Patients were divided into two groups based on whether the delivery was attended by an MFM or non-MFM obstetrician-gynecologist. Demographic and clinical data were compared between groups and outcome variables included whether the patient had an attempt at vaginal delivery, cesarean delivery after a labor attempt, or vaginal breech delivery.

RESULTS

The frequency of labor attempt (OR 1.4, 95% CI 0.9-2.3), vaginal breech success rate (OR 0.6, 95% CI 0.3-1.5), and overall cesarean rates (OR 0.9, 95% CI 0.5-1.7) were similar between groups. Using discriminant function analysis, only nulliparity (R2 = 1.6%, F = 6.0, P = 0.005) and birthweight (R2 = 2.0% F = 6.4, P = 0.01) were associated with trial of vaginal delivery.

CONCLUSIONS

Subspecialization in MFM had no impact on the frequency of trial of labor in the term pregnancy with a 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.