Cesarean delivery versus vaginal delivery: impact on survival and morbidity for the breech fetus at the threshold of viability

Objective.?To determine if cesarean delivery is associated with improved survival and morbidity in the breech fetus at the threshold of viability.

Study design.?The Missouri maternally linked cohort data files covering the period 1989 through 2005 were utilized for analysis. All pregnancies with singleton fetuses in the breech presentation delivered between 23⁰ and 24⁶ weeks gestation and birth weights between 400 and 750 g were included. Logistic regression was used to compare cesarean to vaginal delivery after controlling for maternal demographics and pregnancy complications.

Results.?A total of 325 breech singletons were analyzed; cesarean deliveries accounted for 46.1% (150) and vaginal deliveries accounted for 53.9% (175). Cesarean delivery was associated with a survival benefit across all birth weights. Morbidity was higher in cesarean compared to vaginal delivery.

Conclusion.?Although cesarean delivery appears to be associated with an increase in survival at the threshold of viability for the breech fetus, there is a concomitant increase in morbidity. Any benefit that cesarean delivery conveys on survival at the threshold of viability should be weighed against the increased maternal morbidity and high overall neonatal morbidity.     

492例臀位分娩临床分析

目的探讨臀位分娩的合理方式。方法回顾分析笔者所在医院2005年1月～2008年1月492例臀位分娩情况。结果 310例臀位阴道分娩与182例剖宫产新生儿窒息率和新生儿骨折率相比较差异无统计学意义（x2=0.23,P〉0.05）,两种分娩方式的产后出血率相比较差异有统计学意义（x2=4.73,P〈0.05）。结论臀位分娩有选择性的行阴道臀牵引助产分娩,并不会增加母儿的并发症,可以降低剖宫产率。     

Pulmonary complications following endotracheal intubation for anesthesia in breech extraction

A 28-year-old, healthy pregnant patient developed bilateral pneumothorax, subcutaneous emphysema, pneumomediastinum, pneumoretroperitoneum and pneumoperitoneum following endotracheal intubation and manual ventilation during general anesthesia for breech extraction. It is likely that positive-pressure ventilation was the cause for this very rare combination of complications. Early recognition and treatment may prevent such a catastrophe.     

Ultrasound diagnosis of the hyperextended head in breech presentation.

Hyperextension of the fetal head in the breech presentation can be diagnosed by ultrasound. Straightening of the fetal spine and the widest diameter of the skull posterior to the long axis of the spine is diagnostic. Face presentation should also be diagnosable by these criteria.     

Determinants of pain perception after external cephalic version in pregnant women

ObjectiveA considerable proportion of pregnant women with a fetus in breech position refuses external cephalic version (ECV), with fear of pain as important barrier. As a consequence, they are at high risk for caesarean section at term. The current study investigated determinants of pain perception during ECV, with special attention to maternal mental state such as depression and fear of ECV.DesignProspective study of 249 third-trimester pregnant women with breech position with a request for an ECV attempt.SettingDepartment of Obstetrics and Gynaecology in a large teaching hospital in the Netherlands.MethodsPrior to the ECV attempts, obstetric factors were registered, participants fulfilled the Edinburgh Depression Scale (EDS) and reported fear of ECV on a 10-point visual analog scale. Perception of pain intensity was measured with a 10-point visual analog scale, immediately after ECV.FindingsMultivariate linear regression analyses showed success of ECV to be the strongest predictor of pain perception. Furthermore, scores on the depression questionnaire and degree of fear of ECV independently explained pain perception, which was not the case for obstetrical or ECV related factors.ConclusionApart from ECV outcome, psychological factors like depression and fear of ECV were independently related to pain perception of an ECV attempt.Implication for practiceMaternal mood state should be taken into account when offering an ECV attempt to women with a fetus in breech position. Due to the painful experience and the importance of successful outcome, ECV should only be attempted in institutions with experienced practitioners and with careful attention to maternal mood and the way a woman is coping with the ECV attempt.     

The influence of counseling on the mode of breech birth: A single-center observational prospective study in The Netherlands

Objectivewomen in the Netherlands, with a fetus in breech presentation, are thoroughly counseled to make an informed choice for the mode of delivery. The aim of this study was to assess the influence of counseling techniques on women's choices for the mode of delivery and subsequently to compare fetal and maternal outcomes of vaginal breech birth versus planned caesarean section.Study designwe performed an observational prospective study. Data on breech deliveries were prospectively collected. We used ANOVA to identify variables influencing women's choice for the mode of delivery.Settingthe obstetric department of the Red Cross Hospital in Beverwijk, the Netherlands.Participantswomen with a singleton gestation (>37 + 0 weeks) and a fetus in breech presentation were included.Measurements and findingsbetween January 2007 and December 2015 364 women were included. Counseling technique (p =<0.001) and maternal education (p = 0.046) were significantly associated with the choice of mode of delivery. Of all included women 33% (N = 119) opted for a vaginal breech delivery and 52% (N = 190) opted for a planned cesarean section. 15% (N = 55) were unexpected breeches. Of the planned vaginal delivery group 66% (N = 79) delivered vaginal, whereas 99.5% (N = 189) of the women in the planned cesarean section group underwent a planned cesarean section. There were no significant differences in maternal and neonatal outcomes.Key conclusionswomen's choice on the mode of delivery and the eventual modus partus of fetuses in breech presentation is strongly influenced by the counseling technique. Vaginal breech birth in low-risk women is a safe option without long term morbidity in neonates.Implications for practicecounselors should be aware of their influence on women's choice for mode of delivery in breech presentation. Counseling should be done using evidence based information.     

臀位外倒转术的应用研究

臀先露是指分娩时胎儿臀部先出来的情况,是异常胎位的一种。臀位孕妇自然分娩面临较大风险,多采用剖宫产术,但也存在近期和远期并发症。臀位外倒转术（ECV）安全性与成功率高,但孕妇接受程度差异较大,宣传及应用仍有待加强。本文对臀位外倒转术的发展、安全性、影响因素、实施时机等作一综述,为临床治疗提供参考。     

External Cephalic Version (ECV) and the Early ECV Trial

The Caesarean section rate among women with breech pregnancies at term is approximately 70 percent. External cephalic version (ECV) has a recognized role in decreasing the likelihood of Caesarean section in women with breech pregnancies. External cephalic version prior to 37 weeks gestation has been abandoned in favour of initiating ECV at or after 37 weeks, with or without the use of tocolytic medication to facilitate the procedure. In North America and Europe, when the manoeuvre is undertaken at or after 37 weeks gestation, the rate of successful version resulting in a cephalic presentation at the time of delivery has remained low, particularly amongst nulliparous women. There is increasing interest in beginning ECV as early as 34 weeks gestation for selected women, as an approach to decreasing the overall rate of non-cephalic presentations at term. The Early ECV Trial is a multicentred, randomized controlled trial comparing the selective use of ECV beginning at 34 weeks gestation to ECV after 37 weeks. The primary outcome is the rate of non-cephalic presentation at the time of birth. Collaborators in the Early ECV Trial include midwives and obstetricians from Toronto, Scarborough, Mississauga, Calgary, Ottawa, Thunder Bay and Hamilton.     

Linear association between maternal age and spontaneous breech presentation in singleton pregnancies after 32 weeks gestation

Purpose: To investigate the association between maternal age and spontaneous breech presentation.

Material and methods: Fifteen-year observational study over (2001–2015). All consecutive singleton births delivered at the Centre Hospitalier Universitaire Sud Reunion’s maternity. The only single exclusion criterion was uterine malformations (N?=?123) women.

Results: Of the 60,963 singleton births, there was a linear association (χ² for linear trend, p2 for linear trend?=?64, p?p?Conclusion: Maternal age (x) is an independent factor for breech presentation in singleton pregnancies after 32 weeks gestation with a linear association that may be approximated at y?=?0.1x. (y: incidence, percent).