Outcome of term breech births: 10-year experience at a district general hospital

OBJECTIVE: To review the short and long term outcomes among singleton infants with breech presentation at term delivered in a geographically defined population over a 10-year period. DESIGN: Retrospective, cohort study. SETTING: District General Hospital. POPULATION: 1433 term breech infants alive at the onset of labour and born between January 1991 and December 2000. METHODS: Data abstracted from birth registers, neonatal discharge summaries and the child health database system were used to compare the short and long term outcomes of singleton term breech infants born by two different modes of delivery (prelabour caesarean section and vaginal or caesarean section in labour). Fisher's exact test was used to compare the categorical variables. MAIN OUTCOME MEASURES: Short term outcomes: perinatal mortality, Apgar scores, admission to the neonatal unit, birth trauma and neonatal convulsions. Long term outcomes: deaths during infancy, cerebral palsy, long term morbidity (development of special needs and special educational needs). RESULTS: Of 1433 singleton term infants in breech presentation at onset of labour, 881 (61.5%) were delivered vaginally or by caesarean section in labour and 552 (38.5%) were born by prelabour caesarean section. There were three (0.3%) non-malformed perinatal deaths among infants born by vaginal delivery or caesarean section in labour compared with none in the prelabour caesarean section cohort. Compared with infants born by prelabour caesarean section, those delivered vaginally or by caesarean section in labour were significantly more likely to have low 5-minute Apgar scores (0.9% vs 5.9%, P < 0.0001) and require admission to the neonatal unit (1.6% vs 4%, P= 0.0119). However, there was no significant difference in the long term morbidity between the two groups (5.3% in the vaginal/caesarean section in labour group vs 3.8% in the prelabour caesarean group, P= 0.26); no difference in rates of cerebral palsy; and none of the eight infant deaths were related to the mode of delivery. CONCLUSIONS: Vaginal breech delivery or caesarean section in labour was associated with a small but unequivocal increase in the short term mortality and morbidity. However, the long term outcome was not influenced by the mode of delivery.     

The management of breech presentation at term.

Three to four percent of singleton pregnancies at term are complicated by breech presentation. The management options are to offer external cephalic version, to perform planned caesarean section or to aim for vaginal birth. There has been an increasing reluctance, in many centres, to allow vaginal birth. The publication of the Term Breech Trial will almost certainly accelerate this trend. For many, the choice now lies between external cephalic version and elective caesarean section. Perhaps the focus should now be on increasing the rate of offering external cephalic version, increasing its uptake and also its success.     

Randomized management of the nonfrank breech presentation at term: a preliminary report

Cesarean section has become the standard management used by many clinicians for breech presentation in labor. Proof of the superiority of routine cesarean section has been largely circumstantial. Concern over rising cesarean section rates has led to renewed interest in possible alternatives. Protocols have been developed to select which patients may be allowed a trial of labor with frank breech presentation at term. We undertook a prospective clinical trial comparing elective cesarean section with a selective management protocol for the nonfrank breech presentation at term. One hundred five patients with nonfrank breech presentations at term in labor were studied. Seventy (67%) were randomized to a trial of labor and 35 (33%) to elective cesarean section. Of the patients allowed a trial of labor, 31 (44%) were delivered vaginally, and 39 (56%) required cesarean section. The largest single cause of a "failed" trial of labor was inadequate pelvic dimensions on x-ray pelvimetry (23 patients, 59%). Neonatal morbidity assessed by Apgar scores, cord gases, birth injury, and hospital stay was not different for those delivered vaginally or by cesarean section. Maternal morbidity in terms of febrile morbidity, blood transfusion, wound infections, and hospital stay was significantly greater among women delivered by cesarean section. Two of three neonatal deaths occurred in infants with major congenital anomalies. The third infant, apparently normal, died after vaginal delivery. Extensive evaluation suggests the death was attributable to inadequate resuscitation. We conclude that the use of a selective management protocol under controlled conditions is a reasonable alternative to elective cesarean section. Approximately one half of patients allowed a trial of labor may be expected to deliver vaginally with neonatal morbidity comparable to that seen with cesarean section.     

The relation of breech presentation at term tocerebral palsy

Objective To examine the relation between breech delivery and cerebral palsy, considering the influence of intrauterine growth, low Apgar score at birth, and mode of delivery.
Design Register-based, case-control study.
Population A cohort of infants with cerebral palsy born between 1979 and 1986 in east Denmark, identified by linkage of the cerebral palsy register with the national birth register. Discharge letters from births of breech infants with cerebral palsy were reviewed.
Main outcome measures Presentation, mode of delivery, gestational age, birthweight, Apgar score, type of cerebral palsy, severity of handicap.
Results Breech presentation at term was associated with a borderline significantly higher risk of cerebral palsy than vertex presentation (OR 1.56; 95% CI 0.9–2.4). Breech presentation infants more often had a lower Apgar score (< 7 at 5 minutes) and were smaller for gestational age (SGA < 2 SD) than were those with vertex presentation; infants with a low Apgar score, or who were small for gestational age, had a higher risk of cerebral palsy. After stratification by being small for gestational age the risk of cerebral palsy was not related to presentation. There were no differences between breech and vertex infants with cerebral palsy in terms of low Apgar score, being small for gestational age, mode of delivery, and severity of the handicap. Breech presentation infants were more often classified as diplegic (77.8% versus 42.3% in cephalic infants).
Conclusion The risk of cerebral palsy among term breech presentation infants does not seem to be related to mode of delivery, but is more likely linked to a higher rate of being small for gestational age in breech infants.     

Carcinosarcoma of the ovary treated over a 10-year period at the Christie Hospital

Carcinosarcomas (previously termed malignant mixed Müllerian tumors) are highly malignant but rare tumors of the ovary. Most patients have been treated according to a wide variety of protocols for soft tissue sarcoma or for epithelial ovarian carcinoma and as a result the optimal treatment for this neoplasm is unknown. We describe here 20 patients with this ovarian tumor (15 with heterologous sarcomatous elements and five with homologous sarcomatous elements) referred to our institute. Five patients were treated with surgery alone, two patients with chemotherapy alone and 13 patients with a combination of surgery and chemotherapy. A variety of chemotherapeutic regimens were used reflecting the 10-year time span it took to accrue these patients. Forty-five per cent of all patients died within 1 year of initial surgery and there was a median survival of 14 months. Two patients achieved a complete remission following treatment with 10 cycles of intravenous cyclophosphamide and are still alive at 103 and 106 months follow-up. We suggest that a chemotherapy regimen combining cyclophosphamide and a platinum analog may be useful for the management of patients with carcinosarcoma of the ovary requiring further therapy following surgery.     

The relation of breech presentation at term to epilepsy in childhood

OBJECTIVE: To investigate the relation between breech at term and epilepsy in childhood, and identify risk factors for epilepsy in term breech infants. STUDY DESIGN: Register-based study of all (n = 7514) singleton term infants without malformations, born between 1980 and 1994 and hospitalised with epilepsy until year 1996. For each case delivered in breech presentation (n = 290), the two subsequent deliveries of non-malformed, singleton infants delivered in breech presentation at term at the same hospital were selected as controls (n = 580). RESULTS: Breech presentation was a risk factor for epilepsy (OR: 1.2 [95% CI: 1.1, 1.3]). Breech infants with epilepsy were more often small for gestational age (9.7%) than breech infants without epilepsy (4.7%). Vaginal delivery was associated with low Apgar score, but mode of delivery and low Apgar score were not related to epilepsy. CONCLUSION: The increased risk of epilepsy in term breech infants is not related to intrapartum events, but to growth restriction in pregnancy.     

A novel and dedicated multidisciplinary service to manage breech presentation at term; 3 years of experience in a tertiary care maternity unit

Objective: In order to provide uniform and unbiased multidisciplinary counselling on the options available, including vaginal breech delivery (VBD) and external cephalic version (ECV), the latter of which could then be performed, a weekly Breech Clinic was introduced to a tertiary care maternity unit in Northern Ireland in June 2013, replacing the traditional ECV Clinic introduced in June 2012.

Methods: Retrospective data collection was undertaken using clinic proformas, Northern Ireland Maternity System data and case notes of women who attended the clinics (ECV and Breech) from June 2012 to May 2015.

Results: There were 434 referrals to the clinic over the 3-year period; 356 women attended. The proportion of women attending increased from 69% to 85% since the introduction of the Breech Clinic. Two hundred and thirty-two were deemed eligible and 179 of these underwent ECV after counselling. Although the proportion of women undergoing ECV decreased from 69% to 46%, 11 women opted for and achieved VBD during the 2 years of the Breech Clinic, compared with one woman in the year of the ECV Clinic. Seventy-one of the attempted ECVs were successful, with 61 women having a normal vaginal delivery. Notably, the success rate of ECV increased from 33% to 42%. The number of caesarean sections performed solely for breech at term decreased from 199 in the 12 months before the introduction of ECV clinic, to 188 during the ECV clinic, and 154 in the final 12 months of Breech Clinic.

Conclusions: A dedicated service to counsel women on the management of breech presentation can decrease caesarean sections for breech presentation through increased uptake and success of ECV, and encouraging suitable women to opt for VBD when ECV is unsuccessful, contraindicated or declined.     

Changing management of breech presentation in a primipara

The authors investigate the changing management based on a score including the prognostic items in a primiparous woman with a breach presentation. The study involved two series: one from 1970 to 1975, including 185 breach position primiparous women before the score was established, and the other, dating from 1982 to 1988, consisting of 145 breach position primiparous women after this score came into use. The use of the score has tripled the number of cesareans but reduced neonatal morbidity. In contrast, the authors note a slight increase in maternal morbidity, related to the increased cesarean rate.     

The relation of breech presentation at term to cerebral palsy.

OBJECTIVE: To examine the relation between breech delivery and cerebral palsy, considering the influence of intrauterine growth, low Apgar score at birth, and mode of delivery. DESIGN: Register-based, case-control study. POPULATION: A cohort of infants with cerebral palsy born between 1979 and 1986 in East Denmark, identified by linkage of the cerebral palsy register with the national birth register. Discharge letters from births of breech infants with cerebral palsy were reviewed. MAIN OUTCOME MEASURES: Presentation, mode of delivery, gestational age, birthweight, Apgar score, type of cerebral palsy, severity of handicap. RESULTS: Breech presentation at term was associated with a borderline significantly higher risk of cerebral palsy than vertex presentation (OR 1.56; 95% CI 0.9-2.4). Breech presentation infants more often had a lower Apgar score (< 7 at 5 minutes) and were smaller for gestational age (SGA < 2 SD) than were those with vertex presentation; infants with a low Apgar score, or who were small for gestational age, had a higher risk of cerebral palsy. After stratification by being small for gestational age the risk of cerebral palsy was not related to presentation. There were no differences between breech and vertex infants with cerebral palsy in terms of low Apgar score, being small for gestational age, mode of delivery, and severity of the handicap. Breech presentation infants were more often classified as diplegic (77.8% versus 42.3% in cephalic infants). CONCLUSION: The risk of cerebral palsy among term breech presentation infants does not seem to be related to mode of delivery, but is more likely linked to a higher rate of being small for gestational age in breech infants.     

Cesarean section in the management of breech presentation

In a retrospective analysis of 275 consecutive deliveries of singleton infants in a breech presentation, the liberal use of cesarean section (58.2 per cent) resulted in a corrected perinatal mortality rate of zero for both vaginal and abdominal deliveries of infants weighing over 2,500 grams although perinatal morbidity was greater for vaginal deliveries (5.6 per cent) compared to cesarean section (0.8 per cent). Comparison of perinatal morbidity for delivery of infants weighing between 1,000 and 2,500 grams in a breech presentation suggests that cesarean section is the method of choice for delivery of infants in this weight range in a breech presentation.     

The intrapartum management of the breech presentation

In many cases of breech presentation, a trial of labor is practical and safe among carefully selected parturients. Anesthesia and full neonatal support should be available. Described is the protocol in use at several large institutions that maintain a Cesarean rate for breech presentation in the 60 to 70 per cent range which is approximately 25 per cent lower than the national rate. The development of this protocol as well as its highlights in clinical application are described and highlighted in this report.     

Gynaecological laparoscopic injuries: a 10-year retrospective review at a District General Hospital NHS Trust

Worldwide, increasingly complex surgery is being performed laparoscopically; thus, laparoscopic complication rates may be increasing. Reported risks from all complications of laparoscopic surgery are between 1 and 12.5/1000 cases and serious complications in 1/1000 cases. Accurate complication rates of surgery are difficult to obtain as most data are from retrospective studies and may be incomplete. This paper is a 10-year retrospective review of gynaecological laparoscopic complications from 1 January 2003 to 31 December 2012. Data sources are SEMAHELIX Hospital Database, Gynaecology Complications Register, Clinical Governance Records, Complaints and Legal Cases. Recorded complications were classified as diagnostic, sterilisations and therapeutic laparoscopies. Further classifications are as follows: major complications and type of injury (bowel, urological, vascular, other), minor complications and failed sterilisations. Twenty-nine complications were identified from 5128 laparoscopies; total complication rate is 5.7/1000 procedures. Major complication rates are as follows: diagnostic, 2.2/1000; sterilisations, 3.3/1000; and therapeutic, 3.1/1000, subcategorised into bowel 1.4/1000, urological 0.2/1000 and vascular 1.2/1000. Our total complication rate lies within published national rates. Compared to published standards of major complications, diagnostic laparoscopy and laparoscopic sterilisation rates were comparable. Conversely, our therapeutic laparoscopy complication rate was much lower. The highest complication rate was in the failed sterilisation group; however, this rate is within published sterilisation failure rates. Bowel and vascular complications were comparable; minor complication rates were low in all groups.     

Delivery of breech presentation infants at term. An analysis of 304 breech-deliveries

304 breech presentation infants greater than or equal to 2.500 g were delivered at the University Women's Clinic, Kiel, between 1984 and 1987. Only 2 of the vaginally delivered infants died; both had severe malformations sonographically diagnosed prior to delivery. The umbilical cord arterial PH was found to be significantly (p less than 0.001) higher in infants delivered per Caesarean Section as compared to those vaginally delivered. The same ratio was found in a control group of vaginally delivered infants compared to sectioned infants in the vertex presentation. In 13.3% of cases post primary section and in 14.4% of cases post vaginal delivery from breech presentation we found an apgar of less than or equal to 7 one minute post-partum. The transfer rate to a paediatric unit of vaginally delivered infants (7.2%) appeared to be double that of the infants delivered per Caesarean Section (3.6%). However, the indication for transferral is principally independent of the mode of delivery. Taking the 3-12fold increased maternal mortality rate post section as compared to vaginal delivery into consideration, a vaginal delivery of a breech presentation infant at term appears to be justifiable under certain presuppositions: exclusion of cranio-pelvic disproportion, and normal progression of labour. The indication for secondary Caesarean Section should be generously applied in cases of a suspicious C.T.G. and a slow progression of labour.