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Nothelfer A, Friedl TWP, Dayan D, Beer F, Janni W, Reister F, Kraft K, Huener B. Trial and error - Outcome of breech presentation depending on birth mode and root cause analysis of severe adverse events. Eur J Obstet Gynecol Reprod Biol 2024; 299:309-316. [PMID: 38950454 DOI: 10.1016/j.ejogrb.2024.06.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Revised: 06/16/2024] [Accepted: 06/25/2024] [Indexed: 07/03/2024]
Abstract
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.
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Affiliation(s)
- Anika Nothelfer
- University Hospital Ulm, Department of Gynecology and Obstetrics, Prittwitzstraße 43, 89075 Ulm, Germany.
| | - Thomas W P Friedl
- University Hospital Ulm, Department of Gynecology and Obstetrics, Prittwitzstraße 43, 89075 Ulm, Germany.
| | - Davut Dayan
- University Hospital Ulm, Department of Gynecology and Obstetrics, Prittwitzstraße 43, 89075 Ulm, Germany.
| | - Franziska Beer
- University Hospital Ulm, Department of Gynecology and Obstetrics, Prittwitzstraße 43, 89075 Ulm, Germany.
| | - Wolfgang Janni
- University Hospital Ulm, Department of Gynecology and Obstetrics, Prittwitzstraße 43, 89075 Ulm, Germany.
| | - Frank Reister
- University Hospital Ulm, Department of Gynecology and Obstetrics, Prittwitzstraße 43, 89075 Ulm, Germany.
| | - Katrina Kraft
- University Hospital Schleswig-Holstein, Department of Gynecology and Obstetrics, Campus Lübeck, Germany.
| | - Beate Huener
- University Hospital Ulm, Department of Gynecology and Obstetrics, Prittwitzstraße 43, 89075 Ulm, Germany.
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Morris JM, Bertotti AM. Protocol versus practice: Deviations from guidelines in low-risk twin deliveries in the United States. Birth 2022; 49:147-158. [PMID: 34549453 DOI: 10.1111/birt.12587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 08/27/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Medical guidelines recommend vaginal delivery for low-risk twin pregnancies because cesareans increase the probability of maternal morbidity and mortality. Yet, vaginal delivery rates for twins are considerably lower than for comparable singletons. One explanation for this disparity argues that greater risk associated with twins warrants increased surgical intervention. An alternative explanation is that twin deliveries are more likely to deviate from protocols that advise vaginal birth. METHODS Using the 2017 Natality Detail File (N = 3,197,401), we measured alignment of vaginal birth and trial of labor (TOL) with the American College of Obstetricians and Gynecologists' guidelines for twin and singleton no-indicated-risk births. We calculated predicted probabilities for the population and by maternal race/ethnicity to assess whether low rates of vaginal births among twins are explained by associated risk factors, or by deviations from recommended delivery methods. RESULTS Overall, 31.2% of twins were born vaginally compared with 79.4% of singletons. Controlling for indicated risks, the predicted probability of vaginal birth for twins was 0.49 and 0.85 for singletons. The predicted probability of TOL for twins was 0.18 and 0.47 for singletons. Maternal race/ethnicity was only weakly associated with mode of delivery. These findings indicate that no-indicated-risk twin pregnancies, across maternal racial/ethnic categories, have lower probabilities of vaginal birth and TOL than would be expected with widespread adherence to current guidelines. CONCLUSIONS Given the life-threatening consequences that may result from unnecessary surgical procedures, our findings highlight the need for further research to illuminate medical and nonmedical mechanisms driving nonadherence to clinical guidelines for twin births.
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Mattiolo S, Spillane E, Walker S. Physiological breech birth training: An evaluation of clinical practice changes after a one-day training program. Birth 2021; 48:558-565. [PMID: 34160107 DOI: 10.1111/birt.12562] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 05/22/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND The "physiological breech birth" one-day training program is based on evidence about the physiology of breech births and how clinicians learn breech skills. Previous evaluations have demonstrated positive effects on confidence and knowledge, but the training's effect on clinical practice and outcomes is unknown. METHODS A mixed-methods evaluation was conducted in eight National Health Service hospitals in England and Northern Ireland. Changes in confidence and knowledge were assessed using pretraining and post-training surveys. Mode of birth and maternal birth positions were evaluated using audit data covering one year before the training and one year after, for all singleton vaginal breech births at term. FINDINGS A total of 263 participants completed the surveys. Confidence in managing breech births in both upright and supine positions significantly increased, as did participant knowledge. Audited data for 1402 women were collected. Overall vaginal birth rates remained similar in both periods. Among singleton vaginal breech births >37 weeks, the use of upright birthing positions increased significantly (P = .002). The study was not powered to detect differences in other outcomes, but pilot data were collected to inform the design of future studies. CONCLUSIONS Increase in use of upright birthing positions suggests that physiological breech birth training is likely to lead to clinical practice changes, which may help support maternal choice in line with current guidance. However, provision of a one-day training program did not change overall vaginal breech birth rates. Adequately powered research is needed to determine effects of clinical practice changes on clinical outcomes.
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Affiliation(s)
- Stella Mattiolo
- Women's and Children's Health, Epsom and St Helier University Hospitals, Epsom, UK
| | - Emma Spillane
- Kingston Hospital NHS Foundation Trust, Kingston, UK
| | - Shawn Walker
- Women and Children's Health, King's College London, London, UK.,Chelsea and Westminster Hospitals NHS Foundation Trust, London, UK
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Derisbourg S, Costa E, De Luca L, Amirgholami S, Bogne Kamdem V, Vercoutere A, Zhang WH, Alexander S, Buekens PM, Englert Y, Pintiaux A, Daelemans C. Impact of implementation of a breech clinic in a tertiary hospital. BMC Pregnancy Childbirth 2020; 20:435. [PMID: 32727421 PMCID: PMC7391516 DOI: 10.1186/s12884-020-03122-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Accepted: 07/21/2020] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND The incidence of breech presentation in single pregnancies at term is between three to 5 %. In order to support eligible women in their choice of mode of delivery, a dedicated breech clinic with a care pathway was developed in December 2015 in a tertiary referral centre in Brussels. The primary objective of this study was to evaluate the vaginal birth rate before and after the introduction of a dedicated breech clinic. The secondary objective was to compare the early neonatal outcomes before and after the breech clinic was introduced. METHODS This was a single centre retrospective and prospective study. The inclusion criteria were term (from 37 weeks), singleton fetus and breech presentation at delivery. The exclusion criteria were suspected intrauterine growth restriction, severe fetal malformations and intrauterine fetal demise. We used a composite outcome as an indicator of neonatal morbidity and mortality. RESULTS After the introduction of the breech clinic, we observed a significant increase in planned vaginal delivery from 7.4% (12/162) to 53.0% (61/115) (OR: 13.5; 95% CI: 6.7-27.0). The effective vaginal breech delivery rate (planned and unexpected) significantly increased from 4.3% (7/162) pre-implementation of breech clinic to 43.5% (50/115) post-implementation (OR: 17.0; 95% CI: 7.3-39.6). Neonatal outcomes were not statistically different between the before and after periods. CONCLUSION The introduction of a dedicated breech clinic has led to an increase in vaginal deliveries for breech babies without adversely affecting neonatal outcomes.
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Affiliation(s)
- S Derisbourg
- Department of Obstetrics and Gynecology, Cliniques Universitaires de Bruxelles, Hôpital Erasme, Université Libre de Bruxelles (ULB), 808 route de Lennik, B-1070, Bruxelles, Belgium.
| | - E Costa
- Department of Obstetrics and Gynecology, Cliniques Universitaires de Bruxelles, Hôpital Erasme, Université Libre de Bruxelles (ULB), 808 route de Lennik, B-1070, Bruxelles, Belgium
| | - L De Luca
- Department of Obstetrics and Gynecology, Cliniques Universitaires de Bruxelles, Hôpital Erasme, Université Libre de Bruxelles (ULB), 808 route de Lennik, B-1070, Bruxelles, Belgium
| | - S Amirgholami
- Department of Obstetrics and Gynecology, Cliniques Universitaires de Bruxelles, Hôpital Erasme, Université Libre de Bruxelles (ULB), 808 route de Lennik, B-1070, Bruxelles, Belgium
| | - V Bogne Kamdem
- Department of Obstetrics and Gynecology, Cliniques Universitaires de Bruxelles, Hôpital Erasme, Université Libre de Bruxelles (ULB), 808 route de Lennik, B-1070, Bruxelles, Belgium
| | - A Vercoutere
- Department of Obstetrics and Gynecology, Cliniques Universitaires de Bruxelles, Hôpital Erasme, Université Libre de Bruxelles (ULB), 808 route de Lennik, B-1070, Bruxelles, Belgium
| | - W H Zhang
- Research Laboratory for Human Reproduction, Faculty of Medicine, Université Libre de Bruxelles (ULB), 808 route de Lennik, CP 597, B-1070, Bruxelles, Belgium
| | - S Alexander
- Perinatal Epidemiology and Reproductive Health Unit, Epidemiology, Biostatistics and Clinical Research Centre, Ecole de Santé Publique, Université Libre de Bruxelles (ULB), Bruxelles, Belgium
| | - P M Buekens
- Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana, USA
| | - Y Englert
- Department of Obstetrics and Gynecology, Cliniques Universitaires de Bruxelles, Hôpital Erasme, Université Libre de Bruxelles (ULB), 808 route de Lennik, B-1070, Bruxelles, Belgium
- Research Laboratory for Human Reproduction, Faculty of Medicine, Université Libre de Bruxelles (ULB), 808 route de Lennik, CP 597, B-1070, Bruxelles, Belgium
| | - A Pintiaux
- Department of Obstetrics and Gynecology, Cliniques Universitaires de Bruxelles, Hôpital Erasme, Université Libre de Bruxelles (ULB), 808 route de Lennik, B-1070, Bruxelles, Belgium
| | - C Daelemans
- Department of Obstetrics and Gynecology, Cliniques Universitaires de Bruxelles, Hôpital Erasme, Université Libre de Bruxelles (ULB), 808 route de Lennik, B-1070, Bruxelles, Belgium
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Fischbein SJ, Freeze R. Breech birth at home: outcomes of 60 breech and 109 cephalic planned home and birth center births. BMC Pregnancy Childbirth 2018; 18:397. [PMID: 30305050 PMCID: PMC6180643 DOI: 10.1186/s12884-018-2033-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 09/27/2018] [Indexed: 01/17/2023] Open
Abstract
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.
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Affiliation(s)
| | - Rixa Freeze
- Wabash College, 211 Center Hall, Crawfordsville, IN, 47933, USA.
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Walker S, Parker P, Scamell M. Expertise in physiological breech birth: A mixed-methods study. Birth 2018; 45:202-209. [PMID: 29205469 DOI: 10.1111/birt.12326] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 10/21/2017] [Accepted: 10/21/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND The safety of vaginal breech birth depends on the expertise of birth attendants, yet the meaning of "expertise" remains unclear and subjectively defined. The objective of this study was to define expertise and the roles experts may play in expanding access to this service. METHODS We performed an integrative analysis of two strands of data concerning expertise in physiological breech birth, including the following: survey data from a Delphi study involving 26 very experienced clinicians (mean experience = 135 breech births) and 2 service user representatives, and interviews from a grounded theory study of 14 clinicians more moderately experienced with physiological methods (5-30 upright breech births). Data were pooled and analyzed using constant comparative methods. RESULTS Expertise is defined by its ongoing function, the generation of comparatively good outcomes, and confidence and competence among colleagues. Although clinical experience is important, expertise is developed and expressed in social clinical roles, which expand as experience grows: clinician, mentor, specialist, and expert. To develop expertise within a service, clinicians who have an interest in breech birth should be supported to perform these roles within specialist teams. CONCLUSIONS Specialist breech teams may facilitate the development of expertise within maternity care settings. Evaluation of expertise based on enablement of women and colleagues, as well as outcomes, will potentially avoid the pitfalls of alienation produced by some forms of specialist authority.
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Affiliation(s)
- Shawn Walker
- Florence Nightingale Faculty of Nursing and Midwifery, King's College London, London, UK
| | - Pam Parker
- Department for Learning Enhancement and Development, City, University of London, Northampton Square, London, UK
| | - Mandie Scamell
- Centre for Maternal and Child Health Research, City, University of London, Northampton Square, London, UK
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Nel S, Geraghty S. Are midwifery students adequately prepared for vaginal breech birth in clinical practice? ACTA ACUST UNITED AC 2018. [DOI: 10.12968/bjom.2018.26.3.145] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Steffne Nel
- Midwifery student, Edith Cowan University, Perth
| | - Sadie Geraghty
- Coordinator, Master of Midwifery Practice, Edith Cowan University, Perth
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