Breech delivery at term: do the perinatal results justify a trial of labour?

This is a retrospective study conducted at Princess Badee'a Teaching Hospital in North Jordan to compare neonatal loss and morbidity in term singleton breech infants delivered either vaginally or by caesarean section. In this study, all singleton term breech presentation at 37 completed weeks' gestation were reviewed. Three hundred and eight singleton term babies, presenting by the breech were studied. Intrapartum deaths, neonatal deaths and Apgar scores in vaginal and caesarean delivery were compared. After exclusion of infants with lethal congenital malformations and antenatal stillbirths, the incidence of intrapartum and neonatal deaths associated with vaginal births was 3.5% compared with 1.3% in infants born abdominally. The number of low Apgar scores were similar in both groups. We concluded that caesarean section for term singleton breech presentation is associated with good neonatal outcome and this may influence the decision of obstetricians about the mode of delivery.     

Once cesarean section--always cesarean section?

Between 1975 and 1985 from 522 patients, who had undergone caesarean section during their previous delivery or deliveries, per cent 63 have been delivered vaginally and 37 per cent with a caesarean section (52.8% primary, 47.2% secondary). The rate of spontaneous labour was higher, if patient had a spontaneous delivery before caesarean section or the first caesarean section has been performed because of a placenta praevia, a breech presentation or a fetal distress syndrome. Cephalopelvic disproportion went on in 67.2 per cent with a caesarean section. Rupture of the scare occurred in 2.9 per cent. Expectative management of delivery is justified following previous caesarean section. Oxytocin infusions are possible in cases if internal tocography will be done.     

Critical notes on delivery and perinatal mortality in single breech presentation deliveries]

This report deals with 432 single breech presentation deliveries. Caesarean section frequency was 12,3%. As to the vaginal route of delivery, the simple Bracht manoeuvre had been prefered; in recent times, however, the assisted spontaneous delivery with oxytocin-infusion has been introduced. The corrected perinatal mortality was 4,9%. The rate of prematurely born infants amounted to 14,6%. The corrected perinatal mortality of infants up to 2500 g was 3,3%; of full term infants it was 1,4%. The importance of breech presentation delivery as a high risk delivery is being emphasized. Fetal monitoring and blood gas analysis were required. Indications of caesarean section and suggestions for the management of breech presentations were established. Generally caesarean section of primiparae is not recommended. The diminished rate of prematurely born infants is considered to be of great importance for the decrease of perinatal mortality of breech presentation infants. Intensive pregnancy care, widely used uterotocolysis, and cervix-cerclage in cases of breech presentation are recommended.     

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.     

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.     

Is term breech presentation in primigravida an absolute indication for cesarean section?

Excessive perinatal loss is associated with breech presentation, this loss being accounted for by prematurity, congenital anomalies and birth trauma. In the endeavor to exert an effect on two of these problems, cesarean section has been resorted to increasingly. We have compared two management regimes of primigravida term breech presentation corresponding to two 4-yr periods. During the first period every case was evaluated carefully and, if no other pathology was found, a trial vaginal delivery was allowed. During the second period all the cases were delivered by elective cesarean section. Of the 108 cases of the first period, 46 delivered vaginally and 62 underwent cesarean section. 119 cases were scheduled for abdominal delivery during the second period. Immediate infant outcome for each group was determined by the 1 and 5 min Apgar scores. Analysis of 5 min Apgar scores demonstrated no significant differences in immediate outcome between infants delivered vaginally and by cesarean section. Fetal morbidity related to birth trauma was higher in the vaginal delivery group but there were no perinatal deaths. Maternal morbidity was observed only in the cesarean section groups. This study suggests that properly selected primigravid term breech infants could be delivered vaginally without increased perinatal mortality and with immediate outcomes comparable to those found with cesarean section.     

Perinatal mortality and route of delivery in term breech presentations

Objective To compare intrapartum related infant mortality in term (> 34 weeks) breech presentations in relation to vaginal delivery or delivery by caesarean section.
Design Register based nationwide study.
Setting Sweden from 1991 to 1992.
Participants 6542 singleton fetuses born in the breech presentation.
Main outcome measures Intrapartum and early neonatal deaths, stillbirths and congenital malformations, low Apgar score < 7 at 5 min, mode of delivery.
Results After exclusion of antepartum stillbirths and congenital malformation, the intrapartum and early neonatal mortality rate was 2/2248 (0.09%) in the group delivered vaginally and 2/4029 (0.05%) in the group delivered by caesarean section. The relative risk was 1.81 (95% CI 0.26–12.84). Thus the difference was not statistically significant. This result was further supported after reviewing individual cases.
Conclusions The intrapartum related mortality in the group delivered vaginally was low and the result could not verify an increased mortality in term breech presentations delivered vaginally compared with those delivered by caesarean section.     

Effect of mode of delivery on perinatal results in singleton breech presentation weighing >/= 1500 g.

The object of this retrospective study was to evaluate the mode of delivery and perinatal outcome of singleton fetuses with breech presentation weighing >/= 1500 g. Consecutive cases of all singleton pregnancies at the Princess Badeea Teaching Hospital in North Jordan in the years 1994 and 1995 were compared for crude and corrected perinatal mortality and effect of mode of delivery by weight after correction for non-preventable causes. There were no differences in the 1 and 5 minutes Apgar scores and corrected perinatal mortality between those delivered vaginally and abdominally. It is concluded that poor perinatal outcome are primarily related to factors other than breech presentation. The mode of delivery for infants weighing >/= 1500 g does not influence neonatal outcome and therefore caesarean section for breech presentation in this group is not justified.     

Correlation of fetal outcome with mode of delivery for breech presentation.

The objective of this retrospective analysis of 344 singleton pregnancies of gestational ages greater than 24 weeks conducted at a tertiary hospital was to determine the fetal outcome in relation to the mode of delivery of the fetus with a breech presentation. Caesarean section was performed in 157 mothers, and 187 babies were delivered vaginally. There was no statistical difference in the perinatal outcome for breech fetuses delivered either abdominally or vaginally. Cord prolapse and arrest of the after-coming head were responsible for five fetal losses, four of which were delivered vaginally. Neonatal morbidity comprising nerve injury, birth asphyxia and seizures occurred in 11 newborns, nine of whom were delivered vaginally. One mother sustained a massive intra-operative haemorrhage during a caesarean section which necessitated an emergency hysterectomy. We conclude that a policy of planned vaginal birth for selected breech fetuses with a low threshold to proceed to caesarean section may be in the best interests of both mother and child.     

Mortality in relation to method of delivery in breech infants

To study the relation of method of delivery to perinatal mortality, we examined information from the deliveries of 1593 breech infants weighing 1000 g or more born in 1976 and 1977. In none of the birthweight groups 1000 g or more was neonatal mortality significantly different between infants delivered vaginally compared with those delivered by cesarean section, although the number of deaths was small. In all the birthweight groups, perinatal mortality was higher in breeches delivered vaginally, but the differences were because all of the infants who died before labor were delivered vaginally. Total mortality (intrapartum plus neonatal deaths) in infants who survived to labor was not significantly different in breech infants delivered by one or the other method at any birthweight. These data suggest that routine cesarean delivery for infants 1000 g or more who are in the breech presentation may not be justified from the standpoint of mortality.     

Has pelvimetry a role in current obstetric practice?

Radiological pelvimetry is still requested in some centres before planned vaginal delivery for breech presentation or following a previous caesarean section. In a retrospective review of the utilisation of pelvimetry in 167 cases in our department, 103 (62%) and 64 (38%) had pelvimetry in the postnatal and antenatal periods respectively. Antero-posterior inlet and outlet diameters were inadequate in 19.2% and 16.2% respectively. Of those who had postnatal pelvimetry, only 36 (35%) returned to our unit for further confinement and the caesarean section rate in this group was 75%. The main indications for antenatal pelvimetry were breech presentation (28), previous caesarean section (23) and anticipated cephalopelvic disproportion (13). The caesarean section rates in these groups were 82%, 70% and 45% respectively. However, the emergency caesarean section rate in the breech presentation group was 28%. Nine patients (32%) of those who had breech presentation and delivered by elective caesarean section had normal pelvic measurements. Pelvimetry should only be performed if its results will influence the mode of delivery. Pelvimetry may be useful in selecting fetuses with breech presentation for vaginal delivery or elective caesarean section. However it would increase the likelihood of caesarean section in cephalic presentation.     

Mode of delivery and neonatal death in 17,587 infants presenting by the breech

OBJECTIVE--To study the effects of caesarean section on neonatal mortality in infants presenting by the breech. DESIGN--Population-based non-experimental comparison of infants presenting by the breech born vaginally with those born by caesarean section. Neonatal mortality rates were calculated for 250 g birthweight intervals. Weight-specific relative risks (RRs) were further adjusted for birthweight in 50 g categories. SETTING--New York City, 1978-1983. Data came from the Department of Health's computerized vital records on livebirths and infant deaths. SUBJECTS--17,587 singleton breech livebirths greater than or equal to 500 g birthweight, with congenital anomaly deaths excluded. 6178 were born vaginally and 11409 were born by caesarean section. MAIN OUTCOME MEASURES--Birthweight-specific and birthweight-adjusted neonatal mortality. RESULTS--At birthweights of 501 to 1750 g, the risk of neonatal death for breech infants born vaginally was significantly higher than the risk for those born by caesarean section (weight-adjusted RR = 1.7). For breech infants with birthweights over 3000 g, the weight-adjusted risk was 5.6 times greater for a vaginal birth compared with caesarean section. The addition of 16 additional control variables in multiple logistic regression analyses did not change these RRs. CONCLUSION--Population-based studies indicate that an increase in the caesarean section rate among breech singletons may be associated with increased neonatal survival, but a large multicentre randomized trial of management of breech presentation would answer the question much more definitively.     

Neonatal mortality and morbidity associated with preterm breech presentation

A retrospective study was performed on 88 live-born preterm infants with breech presentation. The neonatal mortality (NNM) was 18.2%, and 13.3% after correction for congenital malformations incompatible with life. 62.5% were delivered vaginally, and 37.5% by cesarean section (CS). In spite of the fact that most CSs were done for indications associated with increased fetal and neonatal morbidity and mortality, overall morbidity was comparable in the two groups. Mortality was higher in the vaginal group. Entrapment of the fetal head (7.3% of vaginal deliveries) and prolapse of the cord (4.5%) were major complications of preterm breech delivery. They resulted in two cases of neonatal death (NND) and three cases of neonatal asphyxia. Prolapse of the cord was in all cases associated with footling presentation. The authors consider these results in favor of routine CS in preterm breech presentation.     

Vaginal delivery for the selected frank breech infant at term

A retrospective analysis of 254 term breech deliveries was done, with term breech presentations managed by a protocol in which cesarean section was done for nonfrank breech presentation, or estimated fetal weight in excess of 4000 g. Patients with frank breech presentation were assigned to one of three groups based on x-ray pelvimetry and estimated fetal weight. Of 70 group 1 patients (adequate pelvis with estimated fetal weight less than 3600 g), 79% had a vaginal delivery. Of 21 group 2 patients (borderline pelvis or estimated fetal weight of 3600 to 4000 g), 67% delivered vaginally. In group 3 (contracted pelvis or estimated fetal weight greater than 4000 g), all patients were delivered by cesarean section. The overall cesarean section rate for frank breech infants was 36%. Apgar scores were not significantly different for infants delivered vaginally or abdominally. The crude perinatal mortality rate was 11.8; the corrected perinatal mortality rate was 0. These findings further substantiate the safety of these criteria in management of term breech presentations.     

Breech presentation after cesarean section: always a section?

A retrospective review of 71 breech deliveries after previous cesarean was done to determine the need for repeat cesarean section. Twenty-four (33.8%) women were allocated to the elective repeat cesarean section group and forty-seven (66.2%) patients were allocated to a trial of labor group. Thirty-seven (78.7%) were delivered of their infants vaginally. A total of 37 of the 71 women (52.1%) had successful vaginal deliveries. Neonatal morbidity did not differ for women who were delivered vaginally or by cesarean section. Maternal febrile morbidity was significantly higher in the cesarean section group than in the vaginal delivery group (p less than 0.001). On the basis of these data, a trial of labor seems reasonable in carefully selected cases of breech presentation after a previous cesarean section.     

Evaluation of a feto-pelvic scoring system in the management of breech presentations

A feto-pelvic scoring system comprising maternal pelvimetric data, estimated fetal weight, type of breech presentation and previous obstetric history was used in selecting patients for cesarean section of vaginal delivery. A maximum score of 20 points was possible. Twelve points or less indicated cesarean section. During 1973-1975 224 singleton breech deliveries were evaluated. In 29.5% cesarean section was performed and in 83% of these it could be planned in advance. In 70.5% of cases, patients were allowed to deliver vaginally under continuous electronic monitoring of the fetal heart rate. There was one intrapartum death and only one early neonatal death of a small premature child. In two cases intrauterine death had occurred already in the antepartum period. The uncorrected perinatal mortality was 17.9 per 1000 but not significantly different from the uncorrected perinatal mortality of 8.0 per 1000 for all patients delivered at the Danderyd's Hospital during the period 1972-1975 (12832 births). The corrected mortality resulting from breech presentation was 8.9 per 1000. The infants exhibited similar and excellent 5 min Apgar scores whether delivered vaginally or by cesarean section or matched with a randomized control series of 1000 cephalic presentations.     

A multicentre randomised controlled trial comparing elective and selective caesarean section for the delivery of the preterm breech infant

Objective To determine the optimum mode of delivery for women in preterm breech labour at a gestational age of 26 to 32 weeks.
Design A multicentre randomised controlled trial. Setting Twenty-six hospitals in England, UK.
Participants Women with a singleton breech fetus in spontaneous preterm labour between 26 and 32 completed weeks of gestation, with no clear indication for a caesarean section or vaginal breech delivery.
Intervention Random allocation to either 'intention to delivery vaginally' or 'intention to deliver by caesarean section'.
Main outcome measures Perinatal mortality, neonatal morbidity, maternal morbidity and gestation at delivery.
Results The trial was closed after 17 months because of low recruitment, by which time substantial numbers of women had been in the eligible gestation period. Thirteen women from six hospitals were recruited. One infant, randomised to and delivered vaginally, was stillborn. Three fetal presentations were cephalic at delivery despite a diagnosis of breech presentation at trial entry. No formal statistical analysis was performed due to the small numbers.
Conclusions No conclusions about the optimum mode of delivery for women in preterm labour with a fetus presenting by the breech can be drawn from this trial. The low accrual rate was due to clinicians' reluctance to randomise eligible women, reflecting the circumstances and nature of the trial.     

Influence of presentation on neonatal outcome of vaginally delivered low birthweight infants. A matched pair analysis

Neonatal outcome of 30 low birthweight (800 to 2000 g) breech infants delivered vaginally was compared with a matched sample of vaginally delivered vertex infants. Using a multiple regression analysis, presentation was found to be significantly related only to the Apgar score at 1 minute. No effect of presentation was found on Apgar score at 5 minutes, length of stay in the nursery, need for ventilatory support, or incidence of neonatal death, seizures, or intracranial hemorrhage. Thus, vaginal delivery of low birthweight breech fetuses was associated with short-term infant outcomes comparable to those of similar fetuses delivered vaginally from vertex presentations. The findings suggest that prevailing assumptions about the risks of premature breech vaginal delivery need to be evaluated critically.     

Vaginal breech delivery of selected infants weighing more than 2000 grams. A retrospective analysis of seven years' experience

This retrospective study analyzes 580 term and near-term singleton pregnancies complicated by breech presentation from 1976 through 1982. Vaginal delivery was achieved in 174 patients (30%), 135 of which were selectively allowed a trial of labor. Six infant deaths occurred (1%); all were neonatal deaths directly related to lethal congenital anomalies, for a corrected neonatal mortality rate of 0%. No significant difference was found in the incidence of low Apgar scores, traumatic birth injury, or requirement for neonatal resuscitation between those infants delivered by cesarean section and those delivered vaginally. Although no maternal deaths occurred, cesarean section was associated with a 38-fold increase in significant maternal morbidity. These data suggest that with careful patient selection and fetal monitoring, vaginal delivery of the term or near-term breech infant remains a real alternative to routine cesarean delivery of all breech infants. A selection and management protocol is proposed.     

The mode of delivery and neonatal outcome in breech presentations less than 32 weeks' of gestation

This study was undertaken to determine the effect of the delivery method on neonatal outcome in fetal breech presentation, and the following results were obtained. The rate of cesarean section for breech presentations was 70.7% (104/147). 1) There were 18 neonatal deaths (41.9%) in 43 vaginal breech deliveries compared to 8 (7.7%) in 104 cesarean breech deliveries. Neonatal deaths were significantly higher in vaginal breech deliveries than cesarean breech deliveries (p less than 0.001). 2) In breech presentations, intracranial hemorrhages were more common among vaginally born infants (44.2% vs. 25.0%; p less than 0.02), but the incidence of idiopathic respiratory distress syndrome (39.5% vs. 28.8%) did not differ significantly between vaginal and cesarean infants. 3) In singletons delivered vaginally, fetal distress was more common among breech presentations than vertex presentations (83.3% vs. 46.3%; p less than 0.02). 4) In vaginally delivered breech singletons, there was no neonatal death among infants with more than 4 one minute Apgar scores, and there was no significant difference between neonatal death and the no neonatal death groups with regard to gestational weeks and birth weight.