Lessons to be learnt in managing the breech presentation at term: An 11-year single-centre retrospective study

"I had no choice": A mixed-methods study on access to care for vaginal breech birth

INTRODUCTION

Although current recommendations support vaginal breech birth as a reasonable option, access to breech birth in US hospitals is limited. This study explored the experiences of decision-making and perceptions of access to care in people who transferred out of the hospital system to pursue home breech birth.

METHODS

We conducted a mixed methods study of people with a singleton, term breech fetus who transferred out of the US hospital system to pursue home breech birth. Twenty-five people completed an online demographic and psychosocial survey, and 23 (92%) participated in semi-structured interviews. We used an interpretive description approach informed by situational analysis to analyze qualitative data about participants' experiences and perceived access to care.

RESULTS

Of 25 individuals who left the hospital system to pursue a home breech birth, most felt denied informed choice (64%) and threatened or coerced into cesarean (68%). The majority reported low or very low autonomy in decision-making (n = 20, 80%) and high decisional satisfaction using validated measures. Many participants felt safer in a hospital setting but were not able to access care for planned vaginal breech hospital birth, despite extensive efforts. Participants felt "backed into a corner" and "forced into homebirth," perceiving a lack of access to safe and respectful care in the hospital system.

CONCLUSION

Some service users believe that home birth is their only option when they cannot access hospital-based care for vaginal breech birth. Current barriers to care for breech birth limit birthing people's autonomy and may be placing them and their infants at increased risk.

Introducing the fragility index-A case study using the Term Breech Trial

The fragility index (FI) is a sensitivity analysis of the statistically significant result of a clinical study. It is the number of hypothetical changes in the primary event of one of the two cohorts in a 1-to-1 comparative trial to render the statistically significant result non-significant (ie, to alter the P-value from ≤0.05 to >0.05). The FI can be compared with the patient drop-out rates and protocol violations, which, if much higher than the FI, may arguably suggest less robustness/stability of the trial's results. To illustrate the concept, we have chosen the Term Breech Trial (TBT) as a case study. The TBT results favor planned cesarean birth, as opposed to planned vaginal delivery, in the term singleton fetus with breech presentation. Our analysis shows that the FI of the TBT is 21, which is small in comparison to the number (hundreds) of protocol violations present. Some experts have suggested the inclusion of the FI in data analysis and subsequent discussion of clinical trial data. Routine use of such a metric may be valuable in encouraging readers to maintain a healthy degree of skepticism, especially when interpreting trial results which may directly influence clinical practice.

Comparing forces on the fetal neck in breech delivery in lithotomy versus all-fours position: a simulation model

PURPOSE

To measure forces applied to the fetal neck, in a simulation model for breech delivery, in both lithotomy versus all-fours position.

METHODS

We used a Laerdal SimMom simulator and a Birthing Baby together with PROMPT Flex Software. The descent of the fetus was accomplished using the Automatic Delivery Module 2. The baby was always in breech position; the SimMom in either all-fours or lithotomy positions. Sensors were located inside the fetal neck region to simulate forces applied to the plexus.

RESULTS

The lowest force on the fetal neck region was recorded for the delivery in all-fours position without further maneuvers (mean force 58.70 Newton, standard deviation 2.54 N). As weight was added to the baby, the force increased (i.e. + 500 g, mean force 71.8 N, SD 3.08 N, p < 0.001). Delivery in lithotomy position resulted in a mean force of 81.56 N (SD 19.55 N). The force significantly increased in case of delivery of the head without assistance from contractions (mean force 127.93 N, SD 23.10 N). In all-fours position, the delivery of the fetal head from pelvic floor level without contractions (Frank's Nudge maneuver) resulted in a mean force of 118.45 N (SD 15.48 N, p = 0.02). Maneuvers for shoulder dystocia (the inverted type that can occur during breech delivery) led to significantly higher mean forces independent from birthing positions.

CONCLUSION

Breech delivery in all-fours position was associated with the lowest force acting on the fetal neck in our simulation model.

Maternal and fetal risks of planned vaginal breech delivery vs planned caesarean section for term breech birth: A systematic review and meta-analysis

Background

Breech presentation delivery approach is a controversial issue in obstetrics. How to cope with breech delivery (vaginal or C-section) has been discussed to find the safest in terms of morbidity. The aim of this study was to assess the risks of foetal and maternal mortality and perinatal morbidity associated with vaginal delivery against elective caesarean in breech presentations, as reported in observational studies.

Methods

Studies assessing perinatal morbidity and mortality associated with breech presentations births. Cochrane, Medline, Scopus, Embase, Web of Science, and Cuiden databases were consulted. This protocol was registered in PROSPERO CRD42020197598. Selection criteria were: years between 2010 and 2020, in English language, and full-term gestation (37-42 weeks). The methodological quality of the eligible articles was assessed according to the Newcastle-Ottawa scale. Meta-analyses were performed to study each parameter related to neonatal mortality and maternal morbidity.

Results

The meta-analysis included 94 285 births with breech presentation. The relative risk of perinatal mortality was 5.48 (95% confidence interval (CI) = 2.61-11.51) times higher in the vaginal delivery group, 4.12 (95% CI = 2.46-6.89) for birth trauma and 3.33 (95% CI = 1.95-5.67) for Apgar results. Maternal morbidity showed a relative risk 0.30 (95% CI = 0.13-0.67) times higher in the planned caesarean group.

Conclusions

An increment in the risk of perinatal mortality, birth trauma, and Apgar lower than 7 was identified in planned vaginal delivery. However, the risk of severe maternal morbidity because of complications of a planned caesarean was slightly higher.

Delivery in breech presentation: Perinatal outcome and neurodevelopmental evaluation at 18 months of life

OBJECTIVES

To compare maternal and perinatal outcomes, including neurodevelopmental results at 18 months of life, between term breech and cephalic deliveries.

STUDY DESIGN

In this longitudinal retrospective study of mothers seen at the Maternity and Paediatric University Hospital of the Canary Islands delivery unit from November 1, 2011, to October 31, 2012, we compared maternal and perinatal outcomes associated with breech or cephalic presentation of the foetus. A second analysis was performed to compare breech births, differentiating between whether a vaginal delivery attempt was made or if caesarean section (C-section) without labour had been directly scheduled. The psychomotor development of children 18 months after birth was assessed using the Haizea-Llevant scale.

RESULTS

A total of 130 breech deliveries were matched with 130 cephalic deliveries. No perinatal mortality occurred in either group. The C-section percentage was greater in the breech presentation group compared with the cephalic delivery group (72.3 % vs. 14.6 %; p < 0.001). Children in the breech presentation had a threefold increased risk for Apgar scores <7 at 1 min (OR 3.2; 95 % CI: 1.2-8.4; p = 0.016) compared with cephalic presentation. These differences disappeared 5 min after birth. No differences were observed in moderate to severe neonatal morbidity between the breech and cephalic presentation groups. There were no differences between groups in neurodevelopmental outcomes. Of 130 pregnancies with breech presentation, 79 (60.8 %) made a vaginal delivery attempt, and 51 (39.2 %) were planned C-sections. Women who attempted vaginal breech delivery were younger and had a history of previous pregnancy. Apgar scores <7 at 1 min were more frequent in the vaginal delivery attempt group (27.9 % vs. 5.9 %; p = 0.002). A high percentage of type III resuscitation (36.5 % vs. 14.3 %; p = 0.007) and Neonatology admission (22.8 % vs. 5.9 %; p = 0.013) was observed in the vaginal delivery attempt group. Except for Apgar scores <7 at 1 min, none of these associations was significant after adjusting for nulliparity and maternal age. The mode of delivery was not associated with moderate to severe perinatal outcomes.

CONCLUSION

The implementation of a specific protocol for selecting pregnant women with breech presentation as candidates for vaginal delivery achieved perinatal outcomes similar to births in cephalic presentation.

Vaginal breech delivery of pregnancy before and after the estimated due date-A prospective cohort study

INTRODUCTION

3-4% of pregnant women present with a fetal breech position at term. National societies regard vaginal breech delivery as a safe option, but only for a specific and thoroughly counseled group of patients. To avoid adverse outcome, many practitioners recommend elective cesarean section once their patients go past the estimated due date. Since encompassing evidence is missing, the evaluation on this common clinical practice is needed.

OBJECTIVE

This study compares the short-term maternal and fetal outcome in intended vaginally breech deliveries before the estimated due date (until 40 0/7 weeks of gestation) to the outcome of deliveries carried out past the estimated due date (later than 40 0/7 weeks of gestation).

METHODS

This prospective cohort study includes 827 women who presented for an intended vaginal breech delivery of a singleton at our perinatal center between January 2010 and December 2016.

RESULTS

447 patients (54%) delivered before or at their estimated due date, 380 (46%) of pregnancies continued after the estimated due date. Comparing both groups, no significant difference in maternal and neonatal short-term mortality and morbidity was found. The rate of caesarian sections was increased in the group of patients, who delivered later than 40 1/7 weeks of gestation. Here, the likelihood for delivery maneuvers was also increased.

CONCLUSION

This study provides evidence, that an elective cesarean section for breech presentations at term is not obligatory when the estimated due date has passed in singleton pregnancy.

[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.

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 - 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 - 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).

[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.

Breech birth at home: outcomes of 60 breech and 109 cephalic planned home and birth center births

Background

Research on outcomes of out-of-hospital breech birth is scarce. This study evaluates the outcomes of singleton term breech and cephalic births in a home or birth center setting.

Methods

This is a retrospective observational cohort study of 60 breech and 109 cephalic planned out-of-hospital term singleton births during a 6 year period with a single obstetrician. Outcomes measured included mode of delivery; birth weights; 1 & 5-min Apgar scores; ante-, intra-, and post-partum transports; perineal integrity; and other maternal and neonatal morbidity.

Results

50 breech and 102 cephalic presentations were still in the obstetrician’s care at the onset of labor; of those, 10 breech and 11 cephalic mothers required transport during labor. 76% of breech and 92.2% of cephalic births were planned to occur at home, with the remainder at a freestanding birth center. When compared to the cephalic group, the breech group had a higher rate of antepartum and in-labor transfer of care and cesarean section. Among completed out-of-hospital births, the breech group had a significantly higher rate of 1-min Apgar scores < 7 but no significant difference at 5 min. Rates of vaginal birth for both groups were high, with 84% of breech and 97.1% of cephalic mothers giving birth vaginally in this series. Compared to primiparas, multiparas in both groups had less perineal trauma and higher rates of out-of-hospital birth, vaginal birth, and spontaneous vaginal birth. No breech infant or mother required postpartum hospital transport, while one cephalic infant and one cephalic mother required postpartum transport. Of the babies born out-of-hospital, there was one short-term and one longer-term birth injury among the breech group and one short-term brachial plexus injury in the cephalic group.

Conclusions

A home or birth center setting leads to high rates of vaginal birth and good maternal outcomes for both breech and cephalic term singleton presentations. Out-of-hospital vaginal breech birth under specific protocol guidelines and with a skilled provider may be a reasonable choice for women wishing to avoid a cesarean section—especially when there is no option of a hospital breech birth. However, this study is underpowered to calculate uncommon adverse neonatal outcomes.

Maternal and neonatal outcome after vaginal breech delivery at term of children weighing more or less than 3.8 kg: A FRABAT prospective cohort study

INTRODUCTION

The clinical management of breech presentations at term is still a controversially discussed issue among clinicians. Clear predictive criteria for planned vaginal breech deliveries are desperately needed to prevent adverse fetal and maternal outcomes and to reduce elective cesarean section rates. The green-top guideline considers an estimated birth weight of 3.8 kg or more an indication to plan a cesarean section despite the lack of respective evidence.

OBJECTIVE

To compare maternal and neonatal outcome of vaginal intended breech deliveries of births with children with a birth weight of 2.5 kg- 3.79 kg and children with a birth weight of 3.8 kg and more.

DESIGN

Prospective cohort study.

SAMPLE

All vaginal intended deliveries out of a breech position of newborns weighing between 2.5 kg and 4.5 kg at the Obstetrics department at Goethe University Hospital Frankfurt from January 2004 until December 2016.

METHODS

Neonatal and maternal outcome of a light weight group (LWG) (< 3.8 kg) was compared to and a high weight group (HWG) (≥ 3.8 kg) using Pearson's Chi Square test and Fishers exact test. A logistic regression analysis was performed to detect an association between cesarean section rates, fetal outcome and the birth weight.

RESULTS

No difference in neonatal morbidity was detected between the HWG (1.8%, n = 166) and the LWG (2.6%, n = 888). Cesarean section rate was significantly higher in the HWG with 45.2% in comparison to 28.8% in the LWG with an odds ratio of 1.57 (95% CI 1.29-1.91, p<0.0001). In vaginal deliveries, a high birth weight was not associated with an increased risk of maternal birth injuries (LWG in vaginal deliveries: 74.3%, HWG in vaginal deliveries: 73.6%; p = 0.887; OR = 1.9 (95% CI 0.9-1.1)).

CONCLUSION

A fetal weight above 3.79 kg does not predict increased maternal or infant morbidity after delivery from breech presentation at term. Neither the literature nor our analyses document evidence for threshold of estimated birth weight that is associated with maternal and/or infant morbidity. However, patients should be informed about an increased likelihood of cesarean sections during labor when attempting vaginal birth from breech position at term in order to reach an informed shared decision concerning the birth strategy. Further investigations in multi center settings are needed to advance international guidelines on vaginal breech deliveries in the context of estimated birth weight and its impact on perinatal outcome.

Media Representations of Breech Birth: A Prospective Analysis of Web-Based News Reports

INTRODUCTION

Recent research has demonstrated that the media presentation of childbirth is highly medicalized, often portraying birth as risky and dramatic. Media representation of breech presentation and birth is unexplored in this context. This study aimed to explore the content and tone of news media reports relating to breech presentation and breech birth.

METHODS

Google alerts were created using the terms breech and breech birth in online English-language news sites over a 3-year period from January 1, 2013, to December 31, 2015. Alerts were received daily and filed for analysis, and data were analyzed to generate themes.

RESULTS

A total of 138 web-based news reports were gathered from 9 countries. Five themes that arose from the data included the problem of breech presentation, the high drama of vaginal breech birth, the safe option of cesarean birth versus dangers of vaginal breech birth, the defiant mother versus the saintly mother, and vaginal breech birth and medical misadventure.

DISCUSSION

Media reports in this study predominantly demonstrated negative views toward breech presentation and vaginal breech birth. Cesarean birth was portrayed as the safe option for breech birth, while vaginal breech birth was associated with poor outcomes. Media presentations may impact decision making about mode of birth for pregnant women with a breech fetus. Health care providers can play an important role in balancing the media depiction of planned vaginal breech birth by providing nonjudgmental, evidence-based information to such women to facilitate informed decision making for birth.

Principles of physiological breech birth practice: A Delphi study

OBJECTIVE

to establish a multi-professional consensus on shared principles underlying the practice of physiological breech birth.

DESIGN

three-round Delphi e-survey.

SETTING

multi-national.

PARTICIPANTS

a panel of thirteen obstetricians and thirteen midwives, experienced in facilitating physiological breech births in varied settings, and involving varied maternal birthing positions, and two service user representatives.

METHODS

an initial survey contained open-ended questions. Answers were coded and amalgamated into 60 statements in Round 1 and a further 6 statements in Round 2. Participants considered statements in the following categories: first principles (14), maternal positioning (12), birth environment (18), fetal positions (14), safe progress (8). The panel indicated the extent of their agreement using a 5-point Likert scale. The pre-determined level of consensus was 70% of respondents indicating 4 or 5 on the Likert scale (agreement or strong agreement).

FINDINGS

the panel indicated consensus on 37 of 66 proposed statements concerning 'Principles of Practice.' Negative data (29/66 statements) are also reported, highlighting areas of divergent opinions. The findings suggest a paradigm shift away from risk management strategies based on prediction and control, and towards facilitation strategies based on relationship and response. Upright positions are a tool and not a rule of physiological breech birth.

CONCLUSION

the parameters of 'normal for breech' require further exploration to support professionals working within a paradigm of complex normality. The principles articulated in this research can be used to design further research exploring the influence of physiological breech practices on neonatal and maternal outcomes, including women's experiences of maternity care.

Women's experiences of planning a vaginal breech birth in Australia

Background

In many countries, planned vaginal breech birth (VBB) is a rare event. After the Term Breech Trial in 2000, VBB reduced and caesarean section for breech presentation increased. Despite this, women still request VBB. The objective of this study was to explore the experiences and decision-making processes of women who had sought a VBB.

Methods

A qualitative study using descriptive exploratory design was undertaken. Twenty-two (n = 22) women who planned a VBB, regardless of eventual mode of birth were recruited. The women had given birth at one of two maternity hospitals in Australia that supported VBB. In-depth, semi-structured interviews using an interview guide were conducted. Interviews were analysed thematically.

Results

Twenty two women were interviewed; three quarters were primiparous (n = 16; 73%). Nine (41%) were already attending a hospital that supported VBB with the remaining women moving hospitals. All women actively sought a vaginal breech birth because the baby remained breech after an external cephalic version – 12 had a vaginal birth (55%) and 10 (45%) a caesarean section after labour commenced. There were four main themes: Reacting to a loss of choice and control, Wanting information that was trustworthy, Fighting the system and seeking support for VBB and The importance of ‘having a go’ at VBB.

Conclusions

Women seeking a VBB value clear, consistent and relevant information in deciding about mode of birth. Women desire autonomy to choose vaginal breech birth and to be supported in their choice with high quality care.