Singleton vaginal breech delivery at term: still a safe option

How do physicians respond to new medical research?

What happens when the findings of a prominent medical study are overturned? Using a medical trial on breech births, we estimate the effect of the reversal of such a medical study on physician choices and infant health outcomes. Using the United States Birth Certificate Records from 1995 to 2010, we employ a difference-in-differences estimator for C-sections, low Apgar, and low birth weight measures. We find that the reversal of a multi-site, high profile, randomized control trial on the appropriate delivery of term breech births, the Term Breech Trial, led to a 15%-23% decline in C-sections for such births at a time when the overall trend in C-sections was rising. We find our largest estimated effects amongst traditionally disadvantaged groups (i.e., non-white, and minimal education). However, we do not find that such a change in practice had significant impacts on infant health. Contrary to prior studies, we find that physicians updated their beliefs quickly, and do indeed adjust to new medical research, particularly young physicians, prior to mandatory policy or professional guidelines.

Mechanics of vaginal breech birth: Factors influencing obstetric maneuver rate, duration of active second stage of labor, and neonatal outcome

BACKGROUND

We investigated possible parameters that could predict the need for obstetric maneuvers, the duration of the active second stage of labor (i.e., the duration of active pushing), and short-term neonatal outcome in vaginal breech births.

MATERIALS AND METHODS

We performed a retrospective analysis of 268 successful singleton vaginal breech births in women without previous vaginal births from January 2015 to August 2022. Multivariable regression was used to investigate associations between maternal and fetal characteristics (including antepartum magnetic resonance (MR) pelvimetry) with obstetric maneuvers, the duration of active second stage of labor, pH values, and admission to the neonatal unit. Models for the prediction of obstetric maneuvers were built and internally validated.

RESULTS

Obstetric maneuvers were performed in a total of 130 women (48.5%). A total of 32 neonates (11.9%) had to be admitted to the neonatal unit. The intertuberous distance (ITD) (p < 0.001), epidural analgesia (p < 0.001), and birthweight (p = 0.026) were associated with the duration of active second stage of labor. ITD (p = 0.028) and birthweight (p = 0.011) were also independently associated with admission to the neonatal unit, while pH values below 7.10 dropped significantly (p = 0.0034) if ITD was ≥13 cm. Furthermore, ITD (p < 0.001) and biparietal diameter (p = 0.002) were independent predictors for obstetric maneuvers.

CONCLUSIONS

ITD is independently associated with the duration of active second stage of labor. Thus, it can predict suboptimal birth mechanics in the last stage of birth, which may lead to the need for obstetric maneuvers, lower arterial pH values, and admission to the neonatal unit. Consequently, MR pelvimetry gives additional information for practitioners and birthing people preferring a vaginal breech birth.

Contraindications in national guidelines for vaginal breech delivery at term: Comparison, consensus, and controversy

INTRODUCTION

The optimal mode of delivery for vaginal breech presentation remains a clinical dilemma. Planned vaginal delivery offers maternal advantages because it avoids major abdominal surgery and has no consequences for following pregnancies, while elective cesarean delivery proves advantageous for the neonate because adverse outcomes are less frequent. Patient selection for vaginal breech delivery is important based on the individual risk balance. A lack of consensus exists regarding the specific contraindications for vaginal breech delivery, largely due to limited scientific evidence. This systematic review aims to give an overview of contraindications for vaginal breech delivery, as presented in guidelines, analyze relevant literature, and offer evidence-based recommendations for the contraindications stated in the guidelines.

MATERIAL AND METHODS

To identify national guidelines PubMed, the Cochrane Central Register of Controlled Trials, EMBASE, NICE, UpToDate, and ClinicalKey were searched using two keywords: "breech presentation" and "vaginal delivery." We systematically reviewed the literature for existing evidence for contraindications for term vaginal breech delivery. The following databases were searched: PubMed (April 2024), the Cochrane Central Register of Controlled Trials, and EMBASE (1947 to 2024).

RESULTS

Our search identified eight guidelines that stated a total of 11 contraindications for vaginal breech delivery. Among these guidelines, agreement was limited, with the sole consensus in all guidelines on the contraindication of footling breech. Our comprehensive literature search yielded 43 articles discussing 14 potential contraindications. We found supportive evidence for 7 of 11 contraindications from the guidelines, with only substantial and satisfactory evidence for two contraindications.

CONCLUSIONS

The findings of this study underscore the lack of consensus among national guidelines regarding contraindications for term vaginal breech delivery. Furthermore, we found a notable lack of substantial scientific evidence to support these contraindications. In light of these findings, we suggest a reduced list of contraindications in vaginal breech deliveries.

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.

Neonatal outcomes of planned vaginal delivery versus planned cesarean section for breech presentation at term: Population-based study on 546,842 breech births across the United States between 2008 and 2017

INTRODUCTION

Over the last several decades, cesarean delivery has been recommended as the safest mode of delivery for breech presentations. The purpose of this study was to evaluate the outcomes of planned vaginal births with planned cesarean births in breech presenting fetuses.

METHODS

This retrospective population-based cohort study utilized data from the United States' Period Linked Birth-Infant Death Public Use Files from 2008 to 2017. All term singleton breech deliveries of a live baby without congenital anomalies were identified (n = 546,842) and divided into two cohorts: women who had a planned vaginal birth (n = 116,828), and women who had a planned cesarean section (n = 430,014). Multivariate logistic regression models, adjusted for maternal baseline characteristics, examined the associations between the planned delivery method and neonatal outcomes.

RESULTS

It was observed that 26.14 % of the planned vaginal birth cohort had a vaginal delivery. In adjusted analyses, undergoing a planned vaginal birth for breech delivery was associated with an increased risk of adverse neonatal outcomes including infant death, OR 1.32, 95 % CI 1.16-1.52, admission to NICU,1.23, 1.19-1.27, ventilation support at 〈 6 h of life, 1.47, 1.42-1.52, ventilation support at 〉 6 h of life, 1.19, 1.08-1.31, and Apgar score of ≤3 at 5 min, 2.27, 2.06-2.50.

CONCLUSION

In women carrying fetuses in breech presentation, having a planned vaginal birth had a low success rate and was associated with increased risk of neonatal morbidity and mortality. Women should be carefully counselled on the risks associated with breech vaginal delivery as well as the low success rate of vaginal delivery.

FIGO best practice guidance in surgical consent

Obtaining medical consent preoperatively is one of the key steps in preparing for surgery, and is an important step in informed decision making with the patient. According to good medical practice guidelines, doctors are required to have the knowledge and skills to treat patients as well as inform them, respect their wishes, and establish trust between themselves and their patients. Valid consent includes elements of competence, disclosure, understanding, and voluntariness. Documentation of these elements is also very important. The International Federation of Gynecology and Obstetrics (FIGO) Education Communication and Advocacy Consortium (ECAC) has realized that the quality of consent varies considerably across the world and has developed simple guidelines regarding consent and procedure-specific checklists for the most common obstetric and gynecological procedures.

Novel Three-Dimensional Body Scan Anthropometry versus MR-Pelvimetry for Vaginal Breech Delivery Assessment

In this prospective, monocentric study, we investigated the potency of a novel three-dimensional (3D) body scanner for external pelvic assessment in birth planning for intended vaginal breech delivery. Between April 2021 and June 2022, 73 singleton pregnancies with intended vaginal birth from breech presentation (>36.0 weeks of gestation) were measured using a pelvimeter by Martin, a three-dimensional body scanner, and MR-pelvimetry. Measures were related to vaginal birth and intrapartum cesarean section. A total of 26 outer pelvic dimensions and 7 inner pelvic measurements were determined. The rate of successful vaginal breech delivery was 56.9%. The AUC (area under the curve) of the obstetric conjugate (OC) measured by MRI for predicting the primary outcome was 0.62 (OR 0.63; p = 0.22), adjusted for neonatal birth weight 0.66 (OR 0.60; p = 0.19). Of the 22 measured 3D body scanner values, the ratio of waist girth to maternal height showed the best prediction (AUC = 0.71; OR 1.27; p = 0.015). The best predictive pelvimeter value was the distantia spinarum with an AUC of 0.65 (OR = 0.80). The 3D body scanner technique is at least equal to predict successful vaginal breech delivery compared to MRI diagnostics. Further large-scale, prospective studies are needed to verify these results.

Defining a Cesarean Delivery Rate for Optimizing Maternal and Neonatal Outcomes

After the global cesarean delivery rate nearly doubled between 2000 and 2015, cesarean deliveries now account for nearly one third of births in the United States. Although rates have plateaued, the high national cesarean delivery rate has garnered criticism from both lay and academic communities because it has not been associated with improvements in maternal or neonatal outcomes. Efforts are underway to lower the cesarean delivery rate through implementation of hospital-level and national guidelines. However, the cesarean delivery rate that optimizes maternal and neonatal outcomes is not known. Defining a cesarean delivery rate that optimizes perinatal outcomes and reduces morbidity seems simple. However, there are a host of challenges to such a task, including determining the outcomes that are most meaningful to use, deciding the population that should define the rate, and incorporating person-centered decision making, given that people place different value on different outcomes. Rather than a "call" for cesarean delivery rate reductions of a specific and arbitrary magnitude, we need further attention to defining an evidence-based optimal target. This commentary summarizes current national and international cesarean delivery rate targets, discusses the challenges of identifying an evidence-based national cesarean delivery rate target, and explores future considerations for best defining a cesarean delivery rate target.

[Impact of a service protocol on the practice of vaginal delivery of breech presentations at term]

OBJECTIVES

The delivery of breech presentations remains controversial. Our study analysed the impact of a service protocol on the proportion of planned vaginal delivery and its success. Immediate neonatal morbidity and factors that may influence the success of vaginal delivery were studied.

METHODS

Retrospective study, between 2009 and 2020 at the CHRU of Limoges, type 3 maternity hospital, on patients with a breech foetus at term. The proportion of planned vaginal delivery and the rate of effective vaginal delivery were compared before/after 2015. Neonatal morbidity was compared for planned vaginal delivery and planned cesarean delivery groups.

RESULTS

We included 923 patients. The rate of planned vaginal delivery was significantly higher after 2015 from 5.2% to 19% (P<0.001), with a success rate increasing from 60% to 82.1% (P=0.06). The rate of vaginal breech deliveries significantly increased from 3.8% to 17% (P<0.001). We found significantly more newborns with moderate acidosis when a vaginal delivery was attempted (P<0.001). The success of vaginal delivery was correlated to the Magnin index (P=0.044), to gestational age (P=0.037), and to multiparity (OR 3.78 95% CI [1.42-10.03] P=0.006).

CONCLUSION

Our study demonstrates the benefits of setting up a service protocol for the practice of breech vaginal delivery.

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.

Is Vaginal Breech Delivery Still a Safe Option?

OBJECTIVE

 To determine whether there was any difference in neonatal and maternal outcomes between breech vaginal delivery and cephalic vaginal delivery.

METHODS

 A retrospective, case-control study was conducted between January 2015 and December 2017 in a Portuguese hospital. A total of 26 cases of breech vaginal delivery were considered eligible and 52 pregnant women formed the control group.

RESULTS

 Induced labor was more frequent in the breech vaginal delivery group (46% versus 21%, p = 0.022). Episiotomy was more common in the breech vaginal delivery group (80% versus 52%, p = 0.014), and one woman had a 3rd degree perineal laceration. Newborns in the study group had a lower birthweight (2,805 g versus 3,177 g, p < 0.001). There was no significant difference in the neonatal outcomes.

CONCLUSION

 The present study showed that breech vaginal delivery at term compared with cephalic presentation was not associated with significant differences in neonatal and maternal morbidity. It also suggests that breech vaginal delivery remains a safe option under strict selection criteria and in the presence of an experienced obstetrician.

[Comparison of antepartum management of breech versus cephalic presentation]

OBJECTIVES

Delivery mode of term breech presentation is still being discussed. The aim of this study was to compare the labor management of a breech presentation to a vertex presentation during a vaginal delivery attempt.

METHODS

It was a single-center, comparative, descriptive retrospective study from 2014 to 2017. We studied fetal heart rate (FHR) during labor and expulsion, duration of the different stage of labor, mode of delivery and neonatal outcomes for breech and vertex presentations.

RESULTS

Two hundred and thirty-nine patients were included whom 106 (44%) breech presentation. The use of oxytocin was more common in breech group (63,2% versus 48,1%, P=0.020). Average dilatation rate was slower for breech presentation than for vertex presentation (1.9cm/h vs. 2.8cm/h; P=0.005). There was more FHR with high risk of acidosis in the breech presentations (37.2% vs 19.1%, P=0.001) and Melchior's FHR classification were comparable in both groups.

CONCLUSIONS

The per-partum management of a fetus in breech presentation differs from a fetus in cephalic presentation. It must be known and anticipated for an optimal management in the delivery room.

[Breech Presentation: CNGOF Guidelines for Clinical Practice - Benefits and Risks for the Neonate and Child of Planned Vaginal Delivery versus Elective Cesarean Section]

OBJECTIVE

To provide guidelines regarding the benefits and risks for the neonate and the child of planning vaginal delivery versus planning elective cesarean section in case of term breech presentation.

METHODS

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

RESULTS

In case of term breech presentation, planned vaginal delivery might be associated with an increased composite risk of perinatal mortality or occurrence of a combined outcome of serious neonatal morbidity in comparison to elective cesarean section (LE2). In case of planned vaginal delivery of term breech presentation, the risk of perinatal mortality is around 1‰ (LE3). It is potentially less but still exists in case of elective cesarean section (LE2). Risks of neonatal trauma - especially fracture of clavicle and breech hematoma -, Apgar score lower than 7 at 5minutes, and need for neonatal intubation and ventilation, are increased in case of planned vaginal delivery (LE2) and are around 1% (LE3). However, no difference has been demonstrated between planned vaginal and planned cesarean delivery regarding neurodevelopmental outcomes at 2 years (LE2), cognitive and psychomotor outcomes between 5 and 8 years (LE3), and adult intellectual performances (LE4).

CONCLUSIONS

In case of term breech presentation, risks of severe complications for neonate and child are low in case of planned vaginal delivery or elective cesarean section. Short-term benefit/risk balance for the neonate might favor elective cesarean section but long-term morbidity seems to be similar whatever the delivery route (Professional consensus).

[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.

An alternative to cesarean: a description of external cephalic version in noncephalic presenting twin

Objective: External cephalic version (ECV) is utilized in breech presenting singleton gestations but ECV of the noncephalic presenting twin has been considered technically unfeasible. We have successfully performed ECVs of the noncephalic presenting twin. Our objective is to describe our experience with this technique.Study design: This is a descriptive case series of our attempted ECVs in twin pregnancies and their outcomes.Results: Of 19 twin A ECV attempts, 10 cases were successful. The overall vaginal delivery rate was 42% (8/19 cases). There were no emergent cesarean deliveries required, and no neonatal injuries were observed.Conclusions: ECV can be achieved in pregnancies complicated by a noncephalic presenting twin. Further study is necessary to assess the safety and generalizability of our finding.

Is induction of labor a reasonable option for breech presentation?

INTRODUCTION

Whereas spontaneous onset of labor and vaginal delivery for breech presentation is considered to be a safe and effective option in selected cases, the safety of induction of labor is not established yet. The objectives of this study were to describe the outcomes of pregnancy in women induced with a fetus in breech presentation and compare the outcomes with those undergoing planned cesarean delivery.

MATERIAL AND METHODS

We performed a secondary analysis of the observational prospective multicenter PREMODA study, including all singleton breech deliveries after 37 weeks in 174 centers in France and Belgium. We excluded women with spontaneous onset of labor, scarred uterus or intrauterine fetal death. Our study population consisted of women with either induction of labor or planned cesarean delivery. The primary outcome was the composite criteria of neonatal mortality and serious morbidity used in the Term Breech Trial and in the PREMODA prospective cohort.

RESULTS

Our study population consisted of 4138 women, 218 with induction of labor and 3920 with planned cesarean. Two-thirds (67.4%) of the women in the induction of labor group delivered vaginally. There was no significant difference between the groups for the primary outcome (48 [1.2%] in the planned cesarean group vs 3 [1.4%] in the induction of labor group, P = 0.75). Moreover, none of the criteria of the composite primary outcome was significantly more frequent in the induction of labor group.

CONCLUSIONS

Induction of labor for breech presentation does not seem to increase neonatal mortality or severe neonatal morbidity compared with planned cesarean delivery.

[Per-partum risk factors of neonatal acidemia in planned vaginal delivery for fetuses in breech presentation]

OBJECTIVES

Delivery mode of term breech presentation is debated because of higher rate of neonatal acidosis (pH<7.15) in planned vaginal delivery than in planned caesarean section. The objective was to evaluate per-partum risk factors of neonatal acidosis in vaginal delivery for podalic fetuses.

METHODS

It was a single-centre, case-control retrospective study that included planned vaginal delivery in singleton term breech presentation between 2012 and 2016. The "case" group defined by neonatal pH≤7.10 and the "control" group defined by neonatal pH≥7.20 were matched. The maternal, labor, and neonatal characteristics were noted.

RESULTS

One hundred and thirty-two patients were included: each of 44 patients in "case" group, has been matched according to breech type (legs position) to 2 patients in the "control" group, so 88. In multivariate analysis, significant risk factors identified were oxytocin use [ORa=5.663 (95% CI=1.844-17.397)], "high risk" fetal heart rate (FHR) abnormalities according to FIGO classification [ORa=10.997 (95% CI=1.864-64.866)] and FHR abnormalities during expulsion, Melchior 2 [ORa=8.088 (95% CI=1.192-54.875)] and Melchior 4 [ORa=12.705 (95% CI=1.157-139.541)].

CONCLUSIONS

These risk factors of neonatal acidemia have to be known to improve the labor management in case of breech planned vaginal delivery.

MRI-based pelvimetric measurements as predictors for a successful vaginal breech delivery in the Frankfurt Breech at term cohort (FRABAT)

OBJECTIVES

The purpose of this study was to investigate the role of the maternal pelvis, assessed by MRI pelvimetry in nulliparous women expecting a term fetus in breech presentation, to predict a successful and safe vaginal birth.

STUDY DESIGN

In this monocentric and anonymized cohort study, we enrolled 367 nulliparous women with breech presentation at 39⁺⁰ to 41⁺⁰ weeks of gestation during a period of 8 years at the University Women's Hospital in Frankfurt/Main. Pelvic measurements were obtained by standard MRI imaging. We correlated the obstetric conjugate, the pubic angle and the distance between the ischial tuberosities (intertuberous distance) with the maternal and fetal outcomes of vaginally intended breech births. The data was evaluated using logistic regression analysis.

RESULTS

241 of 367 participants (65.7%) experienced a successful vaginal delivery whereas 126 patients (34.3%) were subjected to secondary cesarean section. An increasing obstetric conjugate was significantly associated with an increasing rate of successful vaginal deliveries. No significant correlation of the intertuberous distance and the pubic angle with the mode of delivery could be shown. Although statistically not significant, we were able to define cut-off values of 10.9 cm in the intertuberous distance and 70° in the pubic angle; below these values, no successful vaginal delivery was recorded. No significant differences in the short-term outcomes were seen between the neonates of the vaginal delivery and the cesarean section groups. Inter- and intraobserver variability showed excellent reproducibility for all MRI parameters.

CONCLUSION

The obstetric conjugate correlates with the rate of vaginal deliveries in nulliparous women at term and can be used as a useful criterion for pre-selection and counseling of women with breech presentation and the desire for a vaginal delivery.

Influence of mode of delivery on outcomes in preterm breech infants presenting in labor

Objective: Rates of vaginal breech delivery at term have fallen significantly. We sought to examine rates of preterm vaginal breech delivery and outcomes associated with delivery route.Methods: This retrospective cohort study was carried out at a large tertiary referral center serving an urban population, from 2001 to 2011. The primary objective was to compare outcomes of breech presenting preterm infants according to mode of delivery. The incidence of preterm breech delivery was examined as well as maternal and neonatal outcomes associated with vaginal and abdominal delivery of preterm breech infants.Results: A total of 15% (413/2759) of breech presenting infants delivered prior to 37-week gestation. In extreme prematurity (<28 weeks) the majority (88%; 37/42) of those who presented in labor delivered vaginally, this rate fell to 47% (63/134) after 28 weeks. Infants delivered vaginally after 28 weeks were more likely to have an Apgar <7 at 5 min, than those who had a cesarean delivery (22.5% [16/71] versus 9% [25/278], p = .002; numbers needed to treat (NNT) = 4). Maternal blood loss >500 ml was more likely in those patients delivered by cesarean section (24.2% [74/305] versus 3.7% [4/108]; p < .0001; NNT =2).Conclusion: These results demonstrate that vaginal delivery of a preterm breech - presenting infant is a necessary skill for all birth attendants in contemporary practice, particularly prior to 28-week gestation.

The importance of clinically and ethically fine-tuning decision-making about cesarean delivery

In obstetric practice, each pregnant woman presents with a composite of maternal and fetal characteristics that can alter the risk of significant harm without cesarean intervention. The hospital's availability of resources and the obstetrician's training, experience, and skill level can also alter the risk of significant harm without cesarean intervention. This paper proposes a clinical ethical framework that takes these clinical and organizational factors into account, to promote a deliberative rather than simplistic approach to decision-making and counseling about cesarean delivery. The result is a clinical ethical framework that should guide the obstetrician in fine-tuning his or her evidence-based, beneficence-based analysis of specific clinical and organizational factors that can affect the strength of the beneficence-based clinical judgment about cesarean delivery. We illustrate the clinical application of this framework for three common obstetric conditions: Category II fetal heart rate tracing, prior non-classical cesarean delivery, and breech presentation.

Breech presentation at term and associated obstetric risks factors-a nationwide population based cohort study

PURPOSE

The aim of this study was to estimate whether breech presentation at term was associated with known individual obstetric risk factors for adverse fetal outcome.

METHODS

This was a retrospective, nationwide Finnish population-based cohort study. Obstetric risks in all breech and vertex singleton deliveries at term were compared between the years 2005 and 2014. A multivariable logistic regression model was used to determine significant risk factors.

RESULTS

The breech presentation rate at term for singleton pregnancies was 2.4%. The stillbirth rate in term breech presentation was significantly higher compared to cephalic presentation (0.2 vs 0.1%). The odds ratios (95% CIs) for fetal growth restriction, oligohydramnios, gestational diabetes, a history of cesarean section and congenital fetal abnormalities were 1.19 CI (1.07-1.32), 1.42 CI (1.27-1.57), 1.06 CI (1.00-1.13), 2.13 (1.98-2.29) and 2.01 CI (1.92-2.11).

CONCLUSIONS

The study showed that breech presentation at term on its own was significantly associated with antenatal stillbirth and a number of individual obstetric risk factors for adverse perinatal outcomes. The risk factors included oligohydramnios, fetal growth restriction, gestational diabetes, history of caesarean section and congenital anomalies.

Cardiotocography in breech versus vertex delivery: an examiner-blinded, cross-sectional nested case-control study

BACKGROUND

The safety of vaginal breech delivery has been debated for decades. Although it has been shown to predispose infants to immediate depression, several observational studies have also shown that attempting vaginal breech delivery does not increase perinatal morbidity or low Apgar score at the age of five minutes. Cardiotocography monitoring is recommended during vaginal breech delivery, but comparative data describing differences between cardiotocography tracings in breech and vertex deliveries is scarce. This study aims to evaluate differences in intrapartum cardiotocography tracings between breech and vertex deliveries in the final 60 min of delivery. A secondary goal is to identify risk factors for suboptimal neonatal outcome in the study population.

METHODS

One hundred eight breech and 108 vertex singleton, intended vaginal deliveries at term from a tertiary hospital with 5000 annual deliveries were included. Two experienced obstetricians, blinded to fetal presentation, neonatal outcome and actual mode of delivery, evaluated traces recorded 60 min before delivery. They provided a three-tier classification and evaluated different trace features according to FIGO (1987) guidelines. Factors associated with acidemia and low Apgar scores were identified by univariate and multivariable analyses performed with binary logistic regression. Student's T-test and chi-square test were used, as appropriate.

RESULTS

Late decelerations were seen in 13.9 % of breech and 2.8 % of vertex deliveries (p = 0.003) and decreased variability in 26.9 % of breech and 8.3 % of vertex deliveries (p < 0.001). In multivariable analysis complicated variable decelerations and breech presentation were identified as risk factors for neonatal acidemia and low Apgar score at the age of five minutes. Pathological trace and breech presentation were independent risk factors for low Apgar score at the age of one minute.

CONCLUSIONS

Decreased variability and late decelerations were more prevalent in breech compared to vertex deliveries. Pathological trace predicts immediate neonatal depression and especially complicated variable decelerations may signal more severe distress. Further research is needed to create guidelines for safe management of vaginal breech delivery.

Risk factors for emergency caesarean section in planned vaginal breech delivery

PURPOSE

To identify risk factors for emergency caesarean section in women attempting a vaginal breech delivery at term.

METHODS

Data from 1092 breech deliveries performed between 1998 and 2013 at a Swiss cantonal hospital were extracted from an electronic database. Of the 866 women with a singleton, full term pregnancy, 464 planned a vaginal breech delivery. Fifty-seven percent (265/464) were successful in delivering vaginally. Multivariate regression analyses of risk factors were performed, and neonatal and maternal complications were compared.

RESULTS

Risk factors for failed vaginal delivery were peridural anaesthesia (OR 2.05; 95 % CI 1.09-3.84; p = 0.025), nulliparity (OR 2.82; 95 % CI 1.87-4.25; p < 0.001), high birth weight (OR 1.17; 95 % CI 1.04-1.30; p = 0.006) and induction of labour (OR 1.56; 95 % CI 1.003-2.44; p = 0.048). Maternal age, height and weight; gestational age; or newborn length and head circumference were not associated with an unplanned caesarean section. The rate of successful vaginal delivery in the low risk sub-group (multiparous women without induction of labour) was 58-83 %, depending on birth weight category. The likelihood of success for the high risk sub-group (nulliparous women with induction of labour) fell below a third at neonatal birth weights >3250 g. Complication rates were low in the cohort.

CONCLUSIONS

Use of peridural anaesthesia, nulliparity, high birth weight and induction of labour were risk factors for unsuccessful vaginal breech delivery requiring an unplanned caesarean section. Awareness of these risk factors is useful when counselling women who are considering a vaginal breech delivery.

New MRI Criteria for Successful Vaginal Breech Delivery in Primiparae

Background

Even if lower vaginal delivery success rates and impaired neonatal short-term outcomes have been reported for primiparous women with breech presentation, vaginal breech delivery remains an option for carefully selected patients. Because Magnetic resonance imaging (MRI) pelvimetry can provide additional information on maternal pelvic morphology, we sought to identify new MRI parameters that predict successful vaginal breech delivery.

Methods

In this retrospective unicentre study, 240 primiparous women with breech presentation at term underwent MRI pelvimetry. For all patients vaginal delivery was planned, according to German guidelines and if the conjugata vera (CV) was ≥12 cm. The patients with uneventful vaginal deliveries and the patients who underwent a secondary caesarean section were compared according to pelvimetric parameters and outcomes. Regression analyses were performed.

Results

In the vaginal delivery group (n = 162, (67.5%)), the distance between the spinae ischiadicae (interspinous diameter, ISD) was significantly enlarged. The ISD significantly influenced the mode of delivery in the regression analyses. The CV did not significantly differ between the groups. The patients with successful vaginal deliveries were significantly younger than the patients who underwent caesarean section. In the receiver operating characteristic (ROC) analysis, the area under the curve (AUC) for ISD was 67.7% (p<0.001, 95% CI [0.303–0.642]) and was higher considering the mother’s age (AUC = 73.1%, p<0.001, 95% CI [0.662–0.800]). The neonatal short-term outcomes were comparable in both groups.

Conclusion

The additional use of ISD may predict successful vaginal breech delivery and may be superior to the CV, which is more commonly used.

Trial Registration

DRKS00009957

[Can we decrease cesarean rate at a university hospital treating high risk pregnancies?]

OBJECTIVE

To determine which clinical practice changes were responsible for a decrease in cesarean rate from 19.2% in 2003 to 15.5% in 2012 at our university hospital treating high risk pregnancies, while verifying the absence of any increase in neonatal morbidity and death.

MATERIALS AND METHODS

A descriptive retrospective study was undertaken at our labour ward including all patients delivering in 2003 and in 2012. Maternal, obstetrical and neonatal characteristics of the two populations were compared. Cesarean rates were analysed following : (1) Robson classification, (2) some maternal and obstetrical characteristics, and (3) indications for cesarean.

RESULTS

Mean age, BMI and rate of scarred uterus significantly increased in 2012. The two populations remained comparable in terms of other criteria studied. The main cause responsible for decrease in cesarean rate was breech presentations (p<0.05). Furthermore, significantly less cesareans were performed after labour induction (p=0.04). We also significantly decreased our elective cesarean rate by more than 3% without increasing cesarean sections during labour, showing a rise in successful vaginal delivery trials. The impact of in utero transfers on the global rate of cesarean is highly significant since the latter has been divided by half in 10 years in this population considered to be of high risk for cesareans.

DISCUSSION

These significant decreases reflect our experience in allowing vaginal deliveries in breech presentations, and also a better selection of patients for labour induction. Furthermore, it should be noted that increasing vaginal delivery trials in various obstetrical situations participated in this decrease. We clearly found that some indications for elective cesarean can be avoided, such as multiple pregnancies and scarred uterus, thus showing the importance of restricting the first indication for cesarean. Finally, the decrease in cesarean rate had no negative effect on neonatal outcome.

CONCLUSION

Decreasing cesarean rate is possible in a university hospital treating high risk pregnancies. It requires daily obstetrical case by case critical analysis, allowing wide acceptance of vaginal delivery trials, and continuously evaluating clinical practices.

Term breech deliveries in the Netherlands: did the increased cesarean rate affect neonatal outcome? A population-based cohort study

OBJECTIVE

The aim of this study was to evaluate the effect of the increased cesarean rate for term breech presentation on neonatal outcome. We also investigated whether the clinical case selection for vaginal delivery applied by Dutch obstetricians led to an optimization of neonatal outcome, or whether there is still room for improvement in terms of perinatal outcome.

DESIGN

Retrospective cohort.

SETTING

The Netherlands.

POPULATION

Singleton term breech deliveries from 37+0 to 41+6 weeks, excluding fetuses with congenital malformations or antenatal death.

METHOD

We used data from the Dutch national perinatal registry from 1999 up to 2007.

MAIN OUTCOME MEASURES

Perinatal mortality and morbidity.

RESULTS

We studied 58,320 women with a term breech delivery. There was an increase in the elective cesarean rate (from 24 to 60%). As a consequence, overall perinatal mortality decreased [1.3 0/00 vs. 0.7 0/00;odds ratio 0.51 (95% confidence interval 0.28–0.93)], whereas it remained stable in the planned vaginal birth group [1.7 0/00 vs. 1.6 0/00; odds ratio 0.96(95% confidence interval 0.52–1.76)]. The number of cesareans done to prevent one perinatal death was 338.

CONCLUSIONS

Adjustment of the national guidelines after publication of the Term Breech Trial resulted in a shift towards elective cesarean and a decrease of perinatal mortality and morbidity among women delivering a child in breech at term. Still, 40% of these women attempt vaginal birth. The relative safety of an elective cesarean should be weighed against the consequences of a scarred uterus in future pregnancies.

[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.

Changes in vaginal breech delivery rates in a single large metropolitan area

OBJECTIVE

Vaginal breech delivery rates have been accepted widely to be in decline and the Term Breech Trial (TBT) has recommended delivery of a breech-presenting infant by elective cesarean section delivery. Our aim was to examine the rate of vaginal delivery of term breech pregnancies in the 8 years before and after the publication of the TBT.

STUDY DESIGN

We retrospectively examined vaginal delivery rates of breech presentations over a 16-year period in 3 large tertiary maternity hospitals that serve a single large metropolitan population. All 3 hospitals are of similar size and serve a population with similar risk profile. We also examined rates of perinatal mortality in the 3 hospitals over the study period.

RESULTS

During the 16-year study period, there were 344,259 deliveries among the 3 hospitals; 11,913 of which were breech deliveries. There were 5655 breech deliveries in the 8 years before the publication of the TBT, with a cesarean delivery rate of 76.9%. There were 6258 breech deliveries in the 8 years since publication of the TBT, and the cesarean delivery rate increased to 89.7% (P < .0001). During the 8 years since publication, the rate of vaginal delivery in nulliparous women decreased from 15.3-7.2% (P < .0001). The vaginal breech delivery rate in multiparous women decreased from 32.6-14.8% (P < .0001). The rates of corrected perinatal mortality showed a significant decrease in the last 4 years of the study.

CONCLUSION

Our study demonstrates that the results and recommendations of the TBT have contributed to decreasing vaginal breech delivery rates, which were already in decline before its publication.

The term breech trial ten years on: primum non nocere?

In 2000, the Term Breech Trial was published, and its authors recommended cesarean section as the safest mode of delivery for breech-presenting babies. Criticisms of the trial were raised at the time, which the authors dismissed. Since then, maternal deaths have been recorded among women undergoing cesarean sections for breech presentations. Accordingly, those initial criticisms deserve to be revisited.