Dillema about the method of delivery for the fetus in breech presentation

The management of preterm and term delivery of fetus in breech presentation is one of the most disputable issues in modern obstetric practice. Several years ago, one of the biggest randomized controlled studies in obstetrics, Term Breech Trial (TBT), tried to set up guidelines and resolve the question of the best method to deliver the fetus at term in breech presentation. The results of this study have shown that the policy of planned cesarean section reduces the risk of short-term adverse perinatal outcome, compared with the policy of planned vaginal birth. Many perinatal centers have accepted the recommendations from this study and different obstetric associations have implemented these results in their guidelines. On the other hand, TBT had some limitations, especially those connected with the impossibility of regular and objective comparison of these two methods of delivery. In addition, the same group of authors did not find differences in long-term outcomes between the planned cesarean section and vaginal delivery. Although the rate of planned cesarean section has increased following the publication of TBT, selective vaginal breech delivery is still very successfully used in the centers where doctors have the possibility to obtain experience in vaginal breech deliveries. The most common method of reduce the noncephalic presentation is external cephalic version at term. It reduces the incidence of noncephalic presentations at labor, thus reducing the number of cesarean sections as well. At this moment, there is not enough evidence to support cesarean section as the method of choice for delivery of preterm and term breech, having in mind obstetric indications and criteria. The decision whether to deliver vaginally or by cesarean section should be individual for each pregnant woman.     

Expectant parents' preferences for mode of delivery and trade-offs of outcomes for breech presentation

OBJECTIVE: To assess patients' preferences and trade-offs for mode of delivery in case of breech presentation at term. METHODS: Eighty women (40 with a foetus in breech presentation and 40 with a foetus in cephalic presentation) with a gestational age from 36 weeks onwards were offered scenarios of vaginal and caesarean breech delivery in which 1-month and 2-year neonatal and maternal complication rates were varied; expectant fathers (when present) were interviewed separately. Thresholds for complication rates where patients switch preferences were visualised graphically in trade-off curves. Differences in preference thresholds were tested using the Wilcoxon signed ranks test. RESULTS: Caesarean delivery was the preferred mode of delivery for breech presentation in 65% of the patients interviewed. The trade-off questions showed that the 2-year neonatal outcome after breech delivery was the most important outcome for the mothers, whereas the fathers were more influenced by the maternal outcome. CONCLUSION: When realistic assumptions for complications are made, most women prefer a caesarean delivery over vaginal delivery for at term breech presentation. In the balance of pros and cons, 2-year neonatal outcome is the most important factor in the decision between caesarean and vaginal delivery. PRACTICE IMPLICATIONS: The results of this study can be used by the clinician to help patients weigh risk, benefit, and potential harm with regard to breech delivery.     

Preterm caesarean section in Nigerian obstetric practice.

A retrospective study of cases of preterm caesarean section was carried out at the University of Nigeria Teaching Hospital between January 1985 and December 1989. A total of 1973 caesarean sections were performed; 167 (8%) of these were preterm sections. Most of the patients were "booked" (133 cases, 80%) while 34 patients (20%) were "unbooked." The most common indications for preterm caesarean sections were preeclampsia, placenta previa, and premature rupture of membranes. The perinatal and maternal mortality were high: 257 per 1000 and 11 per 1000, respectively. Timely hospital admission, better intrapartum care, and vaginal delivery of very low birthweight babies are suggested to reduce the incidence of preterm caesarean section and its attendant complications in our hospital practice.     

Caesarean delivery rate and indications at a secondary healthcare Facility in Ibadan,South Western Nigeria: a five-year review

BackgroundCaesarean delivery is an essential surgical skill within the primary care setting aimed at reducing maternal morbidity and mortality.ObjectivesTo determine the rate and indications for caesarean deliveries with a view to improving on the service delivery in the study area.MethodsA retrospective review of all caesarean deliveries over a five-year period, January 1^st, 2012 to December 31^st, 2016.ResultsA total of 2321 deliveries were recorded during the study duration and 481 of them were through caesarean section (CS) giving a caesarean section rate of 20.4%. The rate was higher in the multigravida 255 (53.1%). The commonest indication for caesarean section was previous caesarean section 131 (27.2%). Emergency caesarean delivery accounted for 278 (57.8%). Only 16 (3.3%) stayed more than five days postoperatively while the rest, 465 (96.7%), stayed less than five days. There was a gradual yearly increase in rate from 12.1% in 2012 to 19.5% in 2016.ConclusionThe rate of CS in this study has shown a gradual yearly increase with emergency CS having a higher percentage. Early diagnosis and referral of high-risk pregnancies from peripheral hospitals could reduce emergency CS among the study population.     

分娩方式对妊娠合并重型肝炎产妇预后的影响

目的 探讨不同分娩方式对妊娠合并重型肝炎产妇预后的影响。方法 回顾1994—2007年间60例妊娠合并重型肝炎病例的资料，按分娩方式分为阴道分娩组、剖宫产组以及剖宫产加子宫切除组，其中阴道分娩组22例，剖宫产组20例，剖宫产加子宫切除组18例，对比三组患者分娩前、分娩后的情况及病死率。统计方法采用方差分析，卡方检验、Fisher’s精确概率法和秩和检验。结果 三组患者分娩前血清胆红素、血清胆固醇、凝血酶原活动度、血清肌酐、血清胆碱酯酶、肝性脑病及肝肾综合征发生情况差别无显著性；分娩后血清胆固醇、血清胆碱酯酶及肝性脑病在各组间差别无显著性；分娩后阴道分娩组与剖宫产组的血清胆红素、凝血酶原活动度、血清肌酐、肝肾综合征、产后出血、产褥感染、病死率差异无显著性，而阴道分娩组或剖宫产组与剖宫产加子宫切除组相比，上述指标差异均有显著性。结论 妊娠合并重型肝炎产妇采用剖宫产加子宫切除预后较好。     

Chorioamnionitis caused by gram-negative bacteria as an etiologic factor in preterm birth

The role and microbiological causes of infection and inflammation of the chorioamnion were studied in 85 patients with spontaneous preterm deliveries (< 37 weeks) and in 85 control patients with full term deliveries. Microorganisms were isolated from the freshly separated chorioamnion in 55% of preterm and 26% of term deliveries (p<0.001). Isolation rates of gram-negative enteric bacteria were significantly higher in preterm deliveries than in term deliveries (p<0.001), whereas differences in the isolation of other bacterial species were not significant. Histological chorioamnionitis was noted in 49% of preterm and 14% of term deliveries (p<0.001), and was strongly associated with a positive chorioamniotic culture in both groups (p<0.001). Histological chorioamnionitis was noted in 94%, 54%, and 4% of membranes with gram-negative rods, other microbial species and negative cultures, respectively (p<0.001). Preterm deliveries were also associated with significantly higher rates of bacterial vaginosis (38% vs. 14%) and isolation of vaginal pathogens (85% vs. 65%). In the case of the majority (88%) of chorioamniotic isolates the same species was isolated in the vagina. The findings suggest that gram-negative enteric rods are important placental pathogens responsible for subclinical chorioamnionitis and possibly preterm birth. The findings support the concept that microorganisms ascending from the lower genital tract produce local inflammation, which may result in preterm labour and delivery.     

Pregnancy outcome in immigrant women in the Rotunda Hospital

In recent years the numbers of immigrants attending maternity hospitals has risen. The amount of antenatal care these women receive varies widely. Analysis was performed of deliveries to immigrant women in the Rotunda Hospital in 2002. Women were sub-divided depending on antenatal care received in Ireland. Women who received no antenatal care were 'unbooked', those who attended the hospital two to 28 days before delivery were 'late bookers'. The remaining women were 'booked'. There were 1,954 deliveries to immigrant women; 1,1 73 (60%) 'booked', 391 (20%) 'late bookers' and 390 (20%) 'unbooked'. 'Unbooked' women had a higher rate of spontaneous vertex delivery (63%) (p < 0.01). 'Late bookers' had a higher rate of caesarean section (27.6%) (p < 0.01). The 'late bookers' infants were more likely to be preterm, low birth weight and had a higher rate of neonatal ICU (NICU) admissions (p < 0.01). This study has identified 'late booker' immigrants as a high-risk group.     

Is vaginal breech delivery outdated for all singletons and twins? The current kaleidoscope of obstetric thinking

The best practice for the delivery of a term breech in singleton and twin pregnancies is still controversial. We sought the opinions of obstetricians working in Ireland. A questionnaire was used to address the management of the obstetrician's "own hypothetical pregnancy" in three different scenarios. We also inquired about factors which might influence the decision on mode of delivery. The response rate was 104/174 (60%). In the scenario of a singleton fetus presenting by the breech in a nulliparous woman, 15/84 (18%) of obstetricians would chose a spontaneous vaginal delivery compared to 40/80 (50%) for a multiparous woman (p < 0.01). In the scenario of a second twin in breech presentation (nulliparous and multiparous), 75/93 (81%) would choose a spontaneous vaginal delivery. When asked about a singleton cephalic presentation, 85/91 (93%) would choose a spontaneous vaginal delivery. These decisions were influenced by concerns about perinatal morbidity [91/100 (91%)], published evidence [73/98 (75%)], the delivery doctor's inexperience [56/94 (60%)], but not by gender. Our study indicates that obstetricians in Ireland consider that there is a role for vaginal breech delivery in selected scenarios.     

剖宫产与阴道分娩产妇血催乳素水平与泌乳关系的探讨

通过对1996年6～8月在我院分娩的63例产妇,其中择期部宫产30例(剖宫产组),自然分娩33例(阴道分娩组),测定其产前、产时、产后24小时和72小时血催乳素(PRL)水平,观察其与产后泌乳始动时间以及产后1～4天泌乳情况的关系.结果显示:两组产前、产后24小时和72小时血PRL差异无显著性,但两组产时PRL均下降.剖宫产组明显低于阴道分娩组(P<0.05);部宫产组泌乳始动时间显著延迟(P<0.01);产后1～4天剖官产用泌乳不足率依次为90%、36.67%、13.33%、10%,而阴道分娩组依次为39.39%,3.33%、0%、0%.提示不仅从产科质量考虑而且从母乳喂养考虑.也应严格掌握部宫产指征.     

Erect lateral pelvimetry and the outcome of labor in Lagos.

The erect lateral radiograph pelvimetry measurements was related to the outcome of labor in 173 patients. The most common indication for pelvimetry was one previous caesarean section in 90 (52%) patients. Sixty-nine (39.9%) pelvimetry measurements were performed because of suspected cephalopelvic disproportion, while 20 (11.6%) were done because of breech presentation. In patients with a cephalic presentation at delivery, the mean +/- standard deviation (SD) obstetric conjugate for the 87 women who delivered vaginally (group 1) was 11.42 +/- 1.5 cm, while that of the 45 women who had emergency caesarean section (group 2) was 10.77 +/- 1.5 cm. The mean +/- SD anteroposterior outlet diameter for groups 1 and 2 were 12.24 +/- 1.9 cm and 11.84 +/- 1.7 cm respectively. Both differences were found to be statistically significant (p < 0.001 and p < 0.05 respectively). The mean +/- SD birthweight of the babies in groups 1 and 2 were 3.34 +/- 0.79 kg and 3.42 +/- 0.86 kg respectively. There was no statistically significant difference between the two groups (p < 0.05). The critical obstetric conjugate for safe vaginal delivery was 9.88 cm while the corresponding value for the anteroposterior pelvic outlet diameter was 10.24 cm.     

Sex ratio at birth in Zaria, Nigeria

AIM: The objectives of this study were to determine the sex ratio at birth in Ahmadu Bello University Teaching Hospital, Zaria, Nigeria and its relationship with certain pathologies including breech presentation, twin delivery, major degree placenta praevia and abruptio placentae. METHODOLOGY: A retrospective analysis of records of all deliveries in the hospital between 1 January 1991 and 31 December 2002 (10 years) was carried out. To minimize bias, breech presentation included singletons only and placenta praevia included only major degrees confirmed at Caesarean section. RESULTS: The total number of deliveries during the study period was 12 845. The male:female ratio was 1.12. Sex ratio at birth was not significantly associated with any of the conditions studied, although there was a slight male preponderance with placenta praevia (57.3% in babies born to mothers with major degree placenta praevia compared to 52.7% in babies born to mothers without placenta praevia) and first twins (56.3% compared to 52.7% among singletons), and a slight female preponderance with singleton breech presentation (50.9% compared to 47.2% among non-breech deliveries). CONCLUSION: The findings in this study may reflect racial, dietary or environmental variations or a combination of these factors. They may also be as a result of bias from hospital data, emphasizing the need for accurate population-based records of births and other vital statistics.     

Perinatal outcome in unbooked women at the Rotunda Hospital

To determine the incidence and outcome of unbooked pregnancies in women at the Rotunda Hospital Retrospective case control study. All unbooked deliveries in the Rotunda Hospital over a two year period were identified and matched with a control. Control patients were selected as the next delivery after each case and were regular antenatal attenders. Demographic and obstetric data was collected from each case and control and compared using the Chi-square test. There were 101 unbooked women in the study, during this time there were 11522 deliveries giving an incidence of unbooked pregnancies of 0.88%. Unbooked women were found to be young, multiparous, unemployed and unmarried. They were more likely to deliver by spontaneous vaginal delivery to preterm, low birth weight infants and were at greater risk of a stillbirth and neonatal death. Unbooked pregnancies account for a small proportion of our antenatal population. However, perinatal outcome is significantly worse in unbooked patients compared to those who are regular antenatal attenders.     

Mode of delivery is not associated with asthma or atopy in childhood

BACKGROUND: Caesarean-section delivery has been associated with the subsequent development of atopy and wheezing in childhood. OBJECTIVE: To examine the association between mode of delivery (vaginal vs. caesarean section) and development of atopy, asthma and wheezing disorders in a population-based cohort of children. METHODS: The Avon Longitudinal Study of Parents and Children is a longitudinal birth cohort of children born 1 April 1991 to 31 December 1992. Mode of delivery was categorized as vaginal (including forceps and ventouse extractions) or caesarean section (elective and emergency). Primary outcomes were parental report of asthma or wheezing between 69 and 81 months of age, physician-diagnosed asthma (PDA) at 91 months of age and atopy at 7 years by skin prick testing. Possible confounding factors were considered in a multivariable logistic regression model. RESULTS: Total livebirths were 14,062, from which were selected 12 367 born to mothers resident in a defined area and delivered in one of two major obstetric hospitals. Of these infants, 10,980 (88.8%) were delivered vaginally and 1387 (11.2%) by caesarean section. Outcome data were available for 7495 (61%) subjects (asthma 69-81 months); 7389 (60%) (wheeze 69-81 months); 7196 (58%) (PDA 91 months) and 5916 (48%) (atopy 7 years). Adjusted odds ratios [95%confidence interval] for caesarean section compared with vaginal delivery were not statistically significant for any outcome we considered: asthma 69-81 months 1.16 [0.9, 1.5]; wheeze 69-81 months 0.95 [0.7, 1.3]; PDA 1.14 [0.9, 1.4]; atopy 1.04 [0.8, 1.3]. CONCLUSION: Delivery by caesarean section was not associated with the subsequent development of asthma, wheezing or atopy in later childhood in this population.     

Immunohistochemical Localization of Endothelin-1 in Placenta and Fetal Membranes in Term and Preterm Human Pregnancy

PROBLEM : The aim of the study was to determine the ET-1 localization on human placenta and fetal membranes and to compare its distribution between term and preterm pregnancies in laboring and non-laboring tissues. METHODS : Tissues obtained from nine term elective cesarean section, eight spontaneous vaginal term delivery, and 13 preterm delivery from both cesarean section (N = 6) and vaginal delivery (N = 7) were studied by immunohistochemistry. RESULTS : Immunoreactive ET-1 (IR-ET-1) was detected in villous and nonvillous trophoblast in all groups, although laboring tissues showed strong staining in the syncytiotrophoblast of the villi. ET-1 immunostaining of endothelial cells was observed in all placental villous vessels with a considerable variability within groups. In the fetal membranes, intensive immunopositive staining was observed in the chorionic trophoblast following vaginal deliveries in term and preterm tissues. CONCLUSIONS : This is the first study to report the localization of IR-ET-1 in human fetal membranes and placenta, and suggests that amnion and trophoblast represents a source of ET-1 production or, alternatively, a site for ET-1 binding.     

Factors associated with preterm delivery in mothers of children with Beckwith-Wiedemann syndrome: a case cohort study from the BWS registry

Pregnancy that results in a child with Beckwith-Wiedemann syndrome (BWS) is associated with preterm delivery. Based on previous case series, we hypothesized that preterm delivery of a child with BWS was due to known risk factors for preterm delivery such as polyhydramnios and gestational hypertension. A case cohort study using the BWS Registry at Washington University School of Medicine was undertaken. Cases were pregnancies that resulted in the birth of a child with BWS, controls were pregnancies resulting in the birth of siblings without BWS. Univariate analyses of maternal complications and logistic regression to predict preterm delivery were used. Children with BWS (n = 304) were delivered preterm at a significantly higher rate than their siblings (n = 269) odds ratio 19.1 (95% CI 9.1-40.2). Polyhydramnios, gestational hypertension, and vaginal bleeding also occurred at high rates in the BWS group with odds ratios of 31.6 (95% CI 12.6-79.1), 2.4 (95% CI 1.4-4.1), and 3.9 (95% CI 2.3-6.4), respectively. In a multivariate logistic regression model within the BWS group, polyhydramnios, vaginal bleeding, and gestational hypertension were significant predictors of preterm delivery, odds ratios of 2.9 (95% CI 1.6-5.4), 2.6 (95% CI 1.3-5.0), and 5.3 (2.3-12.0), respectively. However, a significant proportion, 6.5% (18 of 277), of patients in the BWS group delivered preterm without known risk factors. Preterm delivery of a child with BWS is associated with an increased frequency of polyhydramnios, gestational hypertension, and vaginal bleeding in the mother. However, preterm delivery also occurs in the absence of these risk factors.     

Short ReportSex ratio at birth in Zaria,Nigeria

Aim: The objectives of this study were to determine the sex ratio at birth in Ahmadu Bello University Teaching Hospital, Zaria, Nigeria and its relationship with certain pathologies including breech presentation, twin delivery, major degree placenta praevia and abruptio placentae.

Methodology: A retrospective analysis of records of all deliveries in the hospital between 1 January 1991 and 31 December 2002 (10 years) was carried out. To minimize bias, breech presentation included singletons only and placenta praevia included only major degrees confirmed at Caesarean section.

Results: The total number of deliveries during the study period was 12?845. The male:female ratio was 1.12. Sex ratio at birth was not significantly associated with any of the conditions studied, although there was a slight male preponderance with placenta praevia (57.3% in babies born to mothers with major degree placenta praevia compared to 52.7% in babies born to mothers without placenta praevia) and first twins (56.3% compared to 52.7% among singletons), and a slight female preponderance with singleton breech presentation (50.9% compared to 47.2% among non-breech deliveries).

Conclusion: The findings in this study may reflect racial, dietary or environmental variations or a combination of these factors. They may also be as a result of bias from hospital data, emphasizing the need for accurate population-based records of births and other vital statistics.     

Chlamydia trachomatis seropositivity is associated both with stillbirth and preterm delivery

The cause of stillbirth and preterm delivery is often unknown. We studied the prevalence of Chlamydia trachomatis antibodies in mothers with stillbirth and preterm labor. Serum specimens from 72 mothers with stillbirth after the 21st gestational week, and from 48 mothers with preterm delivery between gestational weeks 23 and 29, both from the greater Helsinki area, and cord blood from 96 consecutive liveborn deliveries at the Department of Obstetrics and Gynecology, the University of Helsinki, were studied for antibodies to C. trachomatis immunotypes CJHI, GFK and BED by microimmunofluorescence test. The prevalence of C. trachomatis antibodies was highest, 33.3%, in mothers with stillbirth, 18.8% in mothers with preterm delivery, and 10.4% in cord blood. The IgM seropositivity rate was high among mothers with preterm delivery (8.3%). We conclude that C. trachomatis IgG antibodies are frequently detected in sera from mothers with stillbirth, suggesting past infection, while mothers with preterm delivery often have serum IgM antibodies, suggesting of acute infection.     

Metronidazole to prevent preterm delivery in pregnant women with asymptomatic bacterial vaginosis. National Institute of Child Health and Human Development Network of Maternal-Fetal Medicine Units

BACKGROUND: Bacterial vaginosis has been associated with preterm birth. In clinical trials, the treatment of bacterial vaginosis in pregnant women who previously had a preterm delivery reduced the risk of recurrence. METHODS: To determine whether treating women in a general obstetrical population who have asymptomatic bacterial vaginosis (as diagnosed on the basis of vaginal Gram's staining and pH) prevents preterm delivery, we randomly assigned 1953 women who were 16 to less than 24 weeks pregnant to receive two 2-g doses of metronidazole or placebo. The diagnostic studies were repeated and a second treatment was administered to all the women at 24 to less than 30 weeks' gestation. The primary outcome was the rate of delivery before 37 weeks' gestation. RESULTS: Bacterial vaginosis resolved in 657 of 845 women who had follow-up Gram's staining in the metronidazole group (77.8 percent) and 321 of 859 women in the placebo group (37.4 percent). Data on the time and characteristics of delivery were available for 953 women in the metronidazole group and 966 in the placebo group. Preterm delivery occurred in 116 women in the metronidazole group (12.2 percent) and 121 women in the placebo group (12.5 percent) (relative risk, 1.0; 95 percent confidence interval, 0.8 to 1.2). Treatment did not prevent preterm deliveries that resulted from spontaneous labor (5.1 percent in the metronidazole group vs. 5.7 percent in the placebo group) or spontaneous rupture of the membranes (4.2 percent vs. 3.7 percent), nor did it prevent delivery before 32 weeks (2.3 percent vs. 2.7 percent). Treatment with metronidazole did not reduce the occurrence of preterm labor, intraamniotic or postpartum infections, neonatal sepsis, or admission of the infant to the neonatal intensive care unit. CONCLUSIONS: The treatment of asymptomatic bacterial vaginosis in pregnant women does not reduce the occurrence of preterm delivery or other adverse perinatal outcomes.     

Mode of delivery and risk of developing allergic disease

The aim of this study was to quantify the relationship between mode of delivery and subsequent incidence of allergic disease. The analysis is based on data derived from a birth cohort of 24,690 children who contributed data to the West Midlands General Practice Research Database. We found no convincing evidence to suggest that babies born by caesarean, forceps, or breech delivery had an increased risk of developing allergic disease.     

Teenage pregnancy in the Rotunda Hospital

The primary aim of this study was to investigate obstetric outcomes in teenagers delivered in the Rotunda Hospital and to identify whether younger teenagers have a poorer obstetric outcome. Delivery record details were recorded from the years 1992-96. These included the number of teenage mothers, maternal age, parity, gestation, mode of delivery, birth weight and Apgar scores. Teenagers were classified into those aged under 17 years and those aged 17 and over. Overall 2,228 teenage mothers were delivered in the Rotunda hospital, representing 17.2% of the total teenage population delivered in Ireland during the study period. Ten percent of mothers were under 17 years; 10.6% were multiparous with 2.6% of these under 17 years. There was a significant difference in the preterm delivery rate when the teenagers were compared as a whole with matched controls aged 20-24 years (p = 0.0411). However this did not translate into a poorer neonatal outcome as on average only 5% of babies were low birth weight and only 3% had Apgar scores < 3. Overall 70.2% of deliveries were spontaneous, 20.2% were instrumental. Less than 10% of deliveries were by caesarean section. However the rate of caesarean section increased with age from 14 (5.7%) to 19 (13.5%) years and this trend was statistically significant (p = 0.013). In conclusion, this study does not support the view that younger teenage mothers have a poorer obstetric and neonatal outcome. It has also been shown that there has been a large increase in the number of multiparous patients in this teenage population.