Is the breech presentation and delivery normal or pathological?

The authors share their opinion, comparing their personal experience with the data in the world literature.     

Registrar experience in vaginal breech delivery. How much is occurring?

The debate surrounding the safety of vaginal breech delivery compared to Caesarean delivery may be close to resolution, with a large randomized trial underway. However, trends in the management of vaginal breech delivery over recent years have led to suggestions that training in the technique of such deliveries may be inadequate. We have attempted to quantify the level of training in vaginal breech delivery available to registrars. This was accomplished by surveying obstetric training schemes in comparable regions of England and South Australia. Our findings suggest that registrar exposure to this important obstetric skill may be insufficient to guarantee expertise.     

What to do when it is breech? A state-of-the-art review on management of breech presentation

Any non-cephalic presentation in a fetus is regarded as malpresentation. The most common malpresentation, breech, contributes to 3%-5% of term pregnancies and is a leading indication for cesarean delivery. Identification of risk factors and a proper physical examination are beneficial; however, ultrasound is the gold standard for the diagnosis of malpresentations. External cephalic version (ECV) refers to a procedure aimed to convert a non-cephalic presenting fetus to cephalic presentation. This procedure is performed manually through the mother’s abdomen by a trained health care provider, to reduce the likelihood of a cesarean section. Studies have reported a version success rate of above 50% by ECV. The main objective of this review is to present a broad perspective on fetal malpresentation, ECV, and delivery of a breech fetus. The focus is to elaborate all clinical scenarios of breech and to provide an evidence-based clinical approach for them. After discussing breech prevalence, risk factors, diagnosis, and management, an updated review of ECV is presented. Moreover, ECV indications/contraindications, alternatives, clinical techniques on how to perform ECV and breech vaginal delivery, and obstetrical considerations for the delivery of malpresentations are thoroughly discussed.     

Vaginal delivery or cesarean section at term breech delivery – chance or risk?

Aim: The aim of the study was to examine maternal age, parity, and estimated neonatal birth weight (BW) depending on the mode of a full-term breech presentation (BP) birth delivery and neonatal outcomes.

Material and methods: One hundred and forty-six singleton term breech presentation pregnancies were included in a retrospective study conducted at the Department of Gynecology/Obstetrics, Clinical Center of Serbia in Belgrade in 2013. Statistical analysis: Student's-t test, χ² likelihood ratio, and the Fisher's exact test. The level of statistical significance was set at p?<0.05.

Results: An ECS was the most common mode of delivery in (81.2%) nulliparous older than 35 years and most of the neonates (66.67%) with an estimated birth weight (BW) above 3500 grams were delivered by elective cesarean section (ECS). Perinatal asphyxia remained increased in the successful vaginal delivery (SVD) group (23.8%) compared with the urgent CS (UCS) group (13.3%) (p?=?0.035). Birth asphyxia was the most common in neonates were delivered by SVD (23.8%). There were no cases of perinatal deaths.

Conclusion: ECS remained the recommended mode of breech term delivery in nulliparous women older than 35 years, as well as in neonates with an estimated BW above 3500 grams.     

Vaginal breech delivery: is it still an option?

OBJECTIVE: To provide local data on term breech delivery for future guidance. STUDY DESIGN: Retrospective, 'intended-mode-of-delivery' analysis of 711 antenatally uncomplicated singleton breech deliveries at >or=37 weeks: 445 (63%) planned for vaginal delivery (VD) (no fetal growth restriction, fetal weight 2000-4000 g, adequate pelvic size, maternal consent) and 266 for cesarean section (CS). OUTCOME MEASURES: Apgar score, cord blood acid-base status, childhood deaths and disability. RESULTS: Perinatal mortality was nil in both groups. Low 1-min Apgar scores and low arterial cord blood pH were significantly more frequent in planned VD, but not low Apgar scores at 5 or 10 min or low venous pH. Metabolic acidosis, neonatal intensive care, neonatal seizures, birth trauma, childhood death (CS=1), and neurodevelopmental handicaps (CS=2, VD=1) were equally common. CONCLUSION: Our results do not disqualify selective vaginal breech delivery at term and beyond as an option.     

Signal quality of non-invasive fetal electrocardiogram in vaginal breech delivery: a case–controlled study

Objective

Recently, a non-invasive fetal electrocardiogram monitor has been approved for clinical usage in labour and delivery. To determine the fetal signal quality of vaginal breech deliveries in comparison with a case–controlled cephalic group during labour.

Study design

This case–control study was carried out at the Department of Obstetrics and Gynecology of the University Hospital Frankfurt between 1st July 2012 and 30th September 2012. A total of seven breech deliveries were evaluated. A case–controlled cephalic group with same gestational age and parity were selected from a previous trial.

Results

During first stage of labour, vaginal breech and cephalic delivery had no significant different fetal signal success rates (mean 87.8 vs. 85.7 %; p > 0.05). There was a trend of higher fetal signal success rates in the vaginal breech delivery group during second stage of labour (78.4 vs. 55.4 %; p = 0.08).

Conclusion

Similar fetal signal success rates in vaginal breech delivery in comparison to cephalic presentation were demonstrated using the new commercially available non-invasive abdominal fECG device (the Monica AN24^TM).     

Comparison of fetal outcome in premature vaginal or cesarean breech delivery at 24–37 gestational weeks

Purpose

To compare the fetal outcome of preterm breech infants delivered vaginally (VD) or by cesarean section (CS).

Methods

A monocentric, retrospective consecutive case series of preterm breech deliveries between 24–37 gestational weeks over 10 years from 1/2000 to 12/2009 was performed in a perinatal care center (Level 1) at the University Clinic of Salzburg, Austria. Data from hospital database were statistically analyzed and compared regarding birth weight, head circumference, parity, transfer rate to neonatal intensive care unit (NICU), arterial and venous cord blood pH and base excess (BE), arterial cord blood pH ≤ 7.10 and BE ≤ ?11. Special focus was on fetal outcome of elective CS preterm breech deliveries with a non-urgent medical indication compared to VD.

Results

Among 22.115 deliveries, there were 346 live-born preterm singletons and twins in breech presentation (1.56 %), born between 24 + 0 and 37 + 0 gestational weeks. 180 CS and 36 vaginally delivered preterm breech infants were statistically evaluated. On comparing CS vs. VD for premature breech singletons, arterial cord blood pH and BE were lower in the VD group. VD twins had a lower arterial cord blood pH than CS twins. All other parameters were comparable. In preterm breech singletons with non-urgent CS, a statistical analysis was not possible due to small numbers. The VD twin group revealed lower values in birth weight, head circumference, arterial cord blood pH and BE, but no significant difference in venous cord blood pH and BE and transfer rate to NICU.

Conclusions

Although general recommendations regarding a superior mode of delivery for improved fetal outcome of preterm breech infants cannot be given, these data do not support a policy of routine CS.     

Are intrapartum and neonatal deaths in breech delivery at term potentially avoidable?--a blinded controlled audit

The aim of the study was to investigate whether deaths in term breech deliveries could have been avoided with improved care during pregnancy and delivery. All cases of intrapartum/early neonatal death of nonmalformed infants in breech presentation delivered at term in Denmark in the period 1982-92 were studied. For each of the 12 deaths two controls matched by presentation and planned mode of delivery were selected. Eleven obstetricians assessed the care through narratives that ended when the infant was delivered to umbilicus and stated if the infant died, and whether the "possible death" was potentially avoidable. The majority thought that 42% of cases and 9% of the controls had died. Antenatal and intrapartum care was suboptimal respectively in 17% and 25% of cases and 4% and 26% of controls. The assumed death was found to have been potentially avoidable in 58% of cases and 17% of controls. Care in pregnancies with IUGR, pre-eclampsia, placental abruption, post-maturity, the time from decision to performance of cesarean section, and compliance between patient and professionals were more often criticized in cases than in controls. Controlled audit seemed to be a valuable tool for quality improvement and for validation of litigation activities. In conclusion, infant death at term breech delivery was to a large extent potentially avoidable. However, even in controls, suboptimal care was not uncommon.     

Low concentrations of maternal thyroxin during early gestation: a risk factor of breech presentation?

OBJECTIVE: To evaluate the relation between breech position at term (>37 weeks of gestation) and low maternal fT4 levels during gestation in women not suffering from overt thyroid dysfunction. DESIGN: A prospective cohort study of pregnant women. SETTING: Community-based study. POPULATION/SAMPLE: At random selected pregnant women of the general population. METHODS: At antenatal booking, based on thyroid function assessed at 12 weeks of gestation in a large cohort of pregnant women, two groups of participants were defined: women with low fT4 levels-below the 10th centile (n= 135) and women with fT4-between the 50th and 90th centiles at 12 weeks of gestation (n= 135). Women with clinical thyroid dysfunction (fT4 and TSH outside reference range) at 12 weeks of gestation were excluded. Maternal thyroid function (fT4 and TSH) was subsequently assessed at 24 and 32 weeks of gestation. Analysis refers to 204 women who met the inclusion and exclusion criteria and in whom all thyroid parameters were assessed. MAIN OUTCOME MEASURES: Fetal presentation (cephalic-breech) at delivery in women with term gestation (>37 weeks of gestation) in relation to maternal thyroid function at 12, 24 and 34 weeks of gestation. RESULTS: Breech presentation at term delivery was independently related to fT4 levels <10th centile at 12 weeks of gestation (OR = 4.7, 95% CI 1.1-19 [but not to an fT4 level below the 10th centile at 24 and 32 weeks of gestation]) as well as primiparity (OR = 4.7, 95% CI 1.3-15). CONCLUSIONS: Women with hypothyroxinaemia (fT4 level at the lowest 10th centile) during early gestation but without overt thyroid function are at risk for fetal breech presentation at term (>37 weeks of gestation).