Learning Breech Birth in an Upright Position Is Influenced by Preexisting Experience-A FRABAT Prospective Cohort Study

If the first child is breech, overall outcomes for families with two children are similar regardless of the mode of the first birth

Cesarean section for breech presentation is often recommended. However, cesarean section affects future reproduction. The aim of this study was to assess the effect of mode of the first birth in breech on outcomes of the second birth and the two births together. This is a register-based nationwide cohort study including 23 062 women with a first singleton birth in breech ≥ 34 gestational weeks and a subsequent singleton birth in Sweden 2000-2019. Exposure was mode of first delivery. Main maternal outcome was a composite of fourth-degree perineal injury, postpartum hemorrhage requiring blood transfusion, hysterectomy, or death. Main infant outcome was a composite of stillbirth, extremely preterm birth (< 28 weeks), moderate to severe hypoxic ischemic encephalopathy, therapeutic hypothermia, or death. Outcomes were analyzed using multivariable logistic regression. In the first birth, the infant composite outcome affected < 1% in both groups but the risk was higher in the vaginal breech group (13/1525), compared with the breech CS group (27/21 537), aOR 7.06, 95% CI 2.91-17.1. In the second birth, the infant composite outcome affected < 1% in both groups but the risk was lower for the first vaginal breech group (3/1525) compared with the first breech CS group (152/21 537), aOR 0.26, 95% CI 0.08-0.84. There was no significant difference between the groups in risk of composite infant outcome in the two births assessed together, or in risk of composite maternal outcome. In total, the chance of a two-children family without maternal or infant severe adverse composite outcome was high and similar regardless mode of the breech first birth.

Sonographic examination at the beginning of the second stage of labor predicts birth outcome in vaginally intended breech deliveries: a blinded prospective study

PURPOSE

In order to spread competence in vaginal breech deliveries, it is necessary to develop new and easily applicable tools for birth progression and safety evaluation. Ultrasound is a useful and ubiquitously available tool with already documented value for birth progression observation. In deliveries out of breech presentation, an established ultrasound examination is missing. We determined the descent of the fetal buttocks in relation to the maternal pelvic inlet using intrapartum ultrasound. We evaluated these results in comparison to the clinical vaginal examination with the aim to establish an easily applicable method for birth outcome prediction. Therefore, we analyzed the predictive value of our examinations on birth outcome parameters, such as cesarean section rate, as well as fetal and maternal outcome parameters.

METHODS

We performed a prospective blinded study on 106 mothers with vaginally intended breech delivery. At beginning of stage two in labor, the descent of the fetal buttocks into the mother's pelvic inlet was detected with transabdominal ultrasound and vaginal examination by different observers.

PRIMARY OUTCOME VARIABLE

Cesarean section rate. Secondary outcome variables: rate of manual assistance in vaginal deliveries, birth duration, 5' APGAR score, umbilical arterial pH, maternal blood loss, and perineal injury. For non-parametric values, Wilcoxon's χ2 test was performed. In order to analyze the predictive value of our examination, lack-of-fit analysis was conducted. Reliability evaluation of the sonographic examination was done with a matched-pair analysis.

RESULTS

Women with positive intrapartum ultrasound breech engagement sign (+ IPUBES) had a significantly lower rate of cesarean section in comparison with those with negative IPUBES (5/67; 7.5% vs. 18/39; 46.2%; p < 0.0001). The area under the ROC curve for the prediction of CS for negative IPUBES was 0.765 with a sensitivity of 78.3% and a specificity of 74.7%. Sonographic examination showed an excellent reliability in a matched-pair analysis comparing vaginal and sonographic examinations with a mean difference of 0.012 (SD ± 0.027, 95% CI - 0.014 to 0.065). Mean birth duration was significantly longer in deliveries with negative IPUBES (533 min vs. 440 min; p = 0.0011). Fetal and maternal outcome parameters were not significantly different between deliveries with positive and negative IPUBES.

CONCLUSIONS

Sonographic evaluation of the fetal descent in relation to the mother's pelvic inlet screens reliably for emergency cesarean section. This newly presented method for birth progression observation might be a powerful tool for distribution of expertise in vaginal breech delivery and is able to give reference for clinical vaginal examination by obstetricians in training.

TRAIL REGISTRY

Clinical trial. Date of registration: 13.03.2019; Date of initial participant enrollment: 20.03.2019; DRKS00016885; https://www.drks.de ; German clinical trials register.

Combined Assessment of the Obstetrical Conjugate and Fetal Birth Weight Predicts Birth Mode Outcome in Vaginally Intended Breech Deliveries of Primiparous Women-A Frabat Study

(1) Background: Guidelines on vaginal breech delivery require birth weight restrictions and neglect the impact of pelvic measurements despite contradicting evidence. There is a great need for more evidence on delivery outcome predicting factors for patients counselling. (2) Methods: We performed a prospective cohort study on 748 primiparous women intending vaginal breech birth and analyzed combined influence of fetal birth weight (BW) and the obstetric conjugate (conjugate vera obstetrica, CVO) on delivery outcome. (3) Results: We generated a BW/CVO ratio and devided our study cohort at median (257.8 g/cm) into a low ratio group (LR, with low birth weight and wide obstetric conjugate) and a high ratio group (HR, high birth weight and narrow obstetric conjugate). Cesarean section (CS) rate was significantly higher in HR (50.3%) as compared to LR (28.3%, p < 0.0001). Fetal morbidity was not different. In vaginally completed deliveries duration of birth was significantly longer in vHR (557 min) as in vLR (414 min, p < 0.001). Manual assistance to deliver the arms (‘Louwen maneuver’) positively correlated with birth weight (r2 = 0.215; p = 0.005) and the BW/CVO ratio (r2 = 0.0147; p = 0.02). (4) Conclusions: A high fetal birth weight combined with a tiny CVO predicts higher cesarean section probability, longer birth duration and the necessity to perform arm delivery assistance. Birth weight and pelvic measurements should be topics of great importance in patients counselling.