Factors associated with adverse perinatal outcome in the Term Breech Trial

BACKGROUND: In the Term Breech Trial, the risk of adverse perinatal outcome was lower with planned cesarean section versus planned vaginal birth. We undertook secondary analyses to determine factors associated with adverse perinatal outcome. STUDY DESIGN: By using multiple logistic regression analyses, we determined the effect of prelabor cesarean section, cesarean section during early labor, cesarean section during active labor versus vaginal birth, and other factors, on adverse perinatal outcome. For 1384 fetuses delivered after labor, we determined the effect of variables associated with labor on adverse perinatal outcome. RESULTS: The risk of adverse perinatal outcome was lowest with prelabor cesarean section (odds ratio [OR]=0.13) and highest with vaginal birth. For those delivered after labor, labor augmentation (P=.007), birth weight less than 2.8 kg (P=.003), and longer time between pushing and delivery (P<.001) increased the risk, whereas the presence of an experienced clinician at delivery (P=.004) reduced the risk of adverse perinatal outcome. CONCLUSION: Breech infants at term are best delivered by prelabor cesarean section.     

Retention of Vaginal Breech Delivery Skills Taught in Simulation

Objective

The optimal frequency of conducting simulation training for high-acuity, low-frequency events in obstetrics and gynaecology residency programs is unknown. This study evaluated retention over time of vaginal breech delivery skills taught in simulation, by comparing junior and senior residents. In addition, the residents' subjective comfort level to perform this skill clinically was assessed.

Report of a Breech Cesarean Section Maternal Death

In Australia in 2007, a woman with two previous normal vaginal deliveries underwent an emergency cesarean section at full dilatation of the cervix with a breech presentation. The woman died after a severe hemorrhage. The official Coroner’s Report attributed the cause of death to postpartum hemorrhage, whereas the breech presentation was barely mentioned, suggesting that complications with breech cesarean deliveries are under‐appreciated and under‐reported. (BIRTH 38:2 June 2011)     

Care for Women Desiring Vaginal Birth After Cesarean

Women with a history of a prior cesarean birth may receive conflicting information regarding options in future pregnancies related to the choice of a trial of labor after a cesarean (TOLAC) or having an elective repeat cesarean delivery (ERCD). The National Institutes of Health Consensus Development Conference on Vaginal Birth After Cesarean (VBAC) addressed questions related to safety and outcomes of having a VBAC compared to ERCD. Summary recommendations included increasing access to health care providers and facilities that care for women who desire a TOLAC yet factors were raised in determining what constitutes best practices. The purpose of this clinical bulletin by the American College of Nurse‐Midwives is to offer evidence‐based guidelines for midwives who are caring for women who have had a prior cesarean birth. Risk assessment, counseling, and education to support informed choices including considerations related to site of birth are provided.     

瘢痕子宫再次妊娠阴道分娩相关问题

文章结合国际临床指南和研究阐述了瘢痕子宫再次妊娠阴道分娩的可行性、指征、风险、产程处理和引产问题。要注重产前评估及产程中的监测。     

剖宫产后阴道分娩相关问题

剖宫产后再次妊娠的分娩方式始终是一个具有争议的产科问题。随着我国全面实施“二孩”政策,剖宫产后阴道分娩问题越来越受到关注。目前,多个妇产科学术机构已达成共识：计划性剖宫产后阴道分娩对于大多数一次子宫下段剖宫产史的产妇是一种安全的选择。文章就剖宫产后阴道分娩的相关循证医学证据进行讨论,并为有剖宫产后阴道试产意愿的产妇制定产前、产时管理方案。     

Breech delivery: Review of a consecutive series of 285 cases

In a consecutive series of 285 breech deliveries (3.2%), the overall perinatal mortality rate was 8.0%, but the corrected perinatal mortality rate was 1.2% (primiparae 1.5% — multiparae 1.0%). The incidence of cesarean operation was 11.9%. Of the factors leading to a cesarean operation, unfavorable sociocultural factors (lack of cooperation, inadequate preparation, etc.) are more important than the classical feto-pelvic disproportion. Emphasis is placed on the liberal use of cesarean section, and on more frequent application of forceps on the aftercoming head (FACH) in vaginal deliveries. In any case, the abdominal route is to be preferred to difficult vaginal deliveries. The role of intrapartum fetal monitoring in case of breech delivery is outlined.     

Management of term breech presentation: A protocl of external cephalic version and selective trial of labor

Objective: The results of a program of external version and selective trial of labor for term breech presentation are reviewed. This is a follow-up to our 1987 report describing management of singleton, term breech presentations and expands our 16-year experience to 1180 cases.Study design: All term breech presentations cared for in 1985 through 1992 are reviewed and outcome contrasted with those predicted in our earlier report. During these 8 years a trial of external version was offered if a breech presentation was identified after 36 completed weeks' gestation and before active labor. The criteria for allowing a trial of labor are detailed.Results: Four hundred sixty-four breech presentations were identified for review. Three hundred eighty-two (82%) were diagnosed before active labor. Of these, 344 (90%) underwent an attempt at external version, of which 174 (51%) were successful. The 290 breech presentations where version either was not attempted or was unsuccessful were stratified into three groups: cesarean section without labor (147), trial of labor with cesarean section (90), and trial of labor with vaginal delivery (53). The 174 cases where version was successful were stratified into two additional groups on the basis of the eventual route of delivery. Careful review of maternal and fetal variables indicates that a trial of labor in selected patients resulted in vaginal delivery in only 37% but was achieved without an increase in fetal or maternal mortality or morbidity. Surprisingly, 54 of the 174 cases where version was successful were ultimately delivered by cesarean section. This 31% rate of cesarean delivery is significantly higher than the 15% rate observed for all cases of term, singleton vertex presentation. A higher prevalence of cases complicated by failed progress in labor and failed induction contributed to the excess.Conclusion: External version is successful in 51% of cases of term breech presentation. With careful selection, cases where version has failed can be allowed to labor and be delivered vaginally. The incidence of cesarean section (31%) for those cases where a version had been successful was surprisingly high, largely because of an increase in labor abnomalities and failed labor inductions.     

Use of External Cephalic Version for Breech Pregnancy and Mode of Delivery for Breech and Twin Pregnancy: A Survey of Canadian Practitioners

Objectives: (1) To understand how external cephalic version (ECV) is used in the management of breech pregnancies; (2) to determine if Canadian practitioners have changed their recommendations regarding the mode of breech delivery since becoming aware of the findings of the Term Breech Trial; and (3) to establish a baseline of how twins are being delivered in Canada.Methods: In March 2001, a survey was mailed to 920 obstetrician/gynaecologists, 409 family physicians, and 62 midwives from the membership list of the Society of Obstetricians and Gynaecologists of Canada.Results: The response rate was 52% (476/920) for obstetrician/gynaecologists, 22% (90/409) for family physicians, and 53% (32/62) for midwives. Eighty-nine percent of practitioners routinely offered women ECV. The median self-estimated ECV success rate for nulliparous women was 30%, and for multiparous women, it was 58%. Forty-seven percent of practitioners used tocolytics 9% used analgesics, and 14% recommended repeat ECV when initial attempts failed. Eighty-four percent of practitioners recommended vaginal breech birth before learning the results of the Term Breech Trial, and 14% afterwards. When both twins present as vertex, most respondents planned vaginal delivery (100% for term, 95% for preterm > 32 weeks, and 73% for preterm ≤ 32 weeks). Vaginal birth was recommended for Twin A vertex, Twin B breech at term by 92% of practitioners for frank, 92% for complete, and 88% for footling breech at Preterm > 32 weeks by 84% of practitioners for frank, 81% for complete, and 78% for footling breech; and at preterm ≤ 32 weeks by 43% of practitioners for frank, 42% for complete, and 39% for footling breech pregnancies. When Twin A was non-footling breech and Twin B vertex 7%, 5% and 2% of practitioners recommended vaginal birth for term, preterm > 32 weeks, and preterm ≤ 32 weeks pregnancies, respectively. Sixty-four percent of respondents on twin births were interested in a randomized controlled trial to compare planned Caesarean section with planned vaginal birth for twin pregnancies.Conclusion: Although the use of ECV is high in Canada, the success rate is low. Increasing the use of tocolytics, considering epidural analgesic, and repeating the procedure when the initial attempt fails may increase success and decrease Caesarean section rates. The survey results reflect a dramatic shift toward recommending Caesarean section for management of term breech pregnancies. Vaginal birth is the method of delivery of choice for most twin pregnancies of 32 weeks’ gestation, especially for vertex/vertex presentations.     

Vaginal birth after caesarean

Caesarean section (CS) rates continue to evoke worldwide concern because of their steady increase. The national caesarean section (CS) rate in the UK is almost 25%, having increased by 5.7% in the last 10 years. A rising primary CS rate is a significant contributor to this trend. The latest available data show that almost 1 in 5 women in the world now give birth by CS.The World Health Organisation states that, when medically justified, a caesarean section can effectively prevent maternal and perinatal mortality and morbidity. However, there is no evidence showing the benefits of caesarean delivery for women or infants who do not require the procedure. As with any surgery, caesarean sections are associated with short and long-term risk which can extend many years beyond the current delivery and affect the health of the woman, her child, and future pregnancies. These risks are higher in women with limited access to comprehensive obstetric care.There are two standard care pathways for women having childbirth following previous CS – Vaginal Birth After Caesarean (VBAC) or Elective Repeat CS (ERCS). Attempting a VBAC is a safe and appropriate choice that must be offered to most women who have had a prior caesarean delivery. Approximately 70–75% of women who attempt VBAC will have a successful vaginal delivery. Focused antenatal counselling sessions highlighting the risks and benefits of VBAC vs ERCS may impact upon the pathway a woman chooses. Continued counselling and discussion of relative risks versus benefits will also encourage patient choice and help support the woman throughout antenatal and intrapartum periods.     

Neonatal Acidemia with Trial of Labor Among Parturients with Prior Cesarean Delivery: A Case-Control Study

Objective: To determine the risk factors for neonatal acidemia with trial of labor among parturients with a prior cesarean delivery.

Methods: From a prospectively collected database on all parturients attempting a trial of labor, newborns with umbilical arterial pH <7.15 were selected as cases and the controls (1:4) were the next four patients who delivered nonacidotic (pH ≥7.15) neonates. Exclusion criteria were no prior cesarean delivery, anomalous fetus, and nonavailability of umbilical arterial blood gas analysis. Student's t-test, χ², and Fisher's exact tests were utilized and odds ratio (OR) and 95% confidence intervals (CI) were calculated. P < 0.05 was considered significant.

Results: The frequency of neonatal acidemia among patients undergoing trial of labor was 12% (28/234). The cases and controls (n = 112) were similar (P > 0.05) with regards to maternal age, frequency of more than one prior cesarean delivery (11% vs. 8%), gestational age, cervical exam on admission (3.0 ± 1.5 vs. 3.4 ± 1.7 cm), usage of oxytocin, and duration of first or second stage of labor. The mean birthweight was significantly higher among acidotic (3,758 ± 670 g) than nonacidotic (3,470 ± 545 g; P = 0.018) newborns. Compared to the controls, the cases had a significantly higher frequency of unsuccessful trial of labor (19% vs. 50%; OR: 4.09; 95% CI: 1.70, 9.82) and separation of the uterine scar (0.8% vs. 14%; OR: 18.50; 95% CI: 1.98, 173.05).

Conclusions: Acidotic newborns with trial of labor tend to be heavier. Parturients have a failed attempt at vaginal birth after cesarean, and have separation of the uterine scar during labor.     

Primigravid Women's Views of Being Approached to Participate in a Hypothetical Term Cephalic Trial of Planned Vaginal Birth versus Planned Cesarean Birth

Background: Several papers have called for a trial of planned cesarean section versus planned vaginal birth for low‐risk women—a recommendation that is fiercely debated. Although proponents of a trial have voiced their support, evidence suggests that in the United Kingdom few midwives and obstetricians believe such a trial to be feasible, and no studies reporting women's views on the prospect of such a trial have been published. The purpose of this study is to explore women's views of participation in a trial of planned cesarean birth versus planned vaginal birth. Methods: A qualitative study was conducted using in‐depth interviews in a large maternity hospital in the United Kingdom. Sixty‐four women were interviewed 12 months after giving birth. Women were asked “How do you think you would have felt if you had been approached to take part in such a trial during your first pregnancy?” Data were analyzed thematically. Results: Only 3 of the 64 women stated that they would have participated in a trial of planned vaginal birth versus planned cesarean section, had they been asked. However, five other women said that they would have consented to participate if they had been asked during pregnancy, but with hindsight, would have regretted that decision. The remainder of women would not have participated, unless a preference arm was offered. Three main themes were identified: “feeling cheated,”“let nature take its course, ” and “just another trauma that you don't need.” Conclusions: Few women supported a trial and most suggested that it was intuitively wrong. Given the strong views voiced by women, it is unlikely that a trial of planned vaginal delivery versus planned cesarean delivery would be feasible.