Management of term breech presentation

The management of 716 cases of singleton breech presentation occurring at 37 or more weeks of gestational age is reviewed. Beginning in 1980 a trial of external version was offered if the breech was identified before active labor. Only 433 (61%) breeches were identified before active labor. Of these, 171 (44%) underwent an attempt at external version and 83 (48%) were successful. The 623 cases remaining as breech presentation were stratified into three groups: cesarean section without labor (379), trial of labor with cesarean section (69), and trial of labor with vaginal delivery (175). The criteria for allowing a trial of labor are detailed. Careful review of maternal and fetal variables indicates that a trial of labor in selected patients will result in vaginal delivery in 72% and that this can be achieved without an increase in fetal or maternal mortality or morbidity. Furthermore, successful external version followed by a trial of labor in selected cases is highly cost-effective.     

Non-clinical determinants of planned cesarean delivery in cases of term breech presentation in France

BACKGROUND: To explore non-clinical maternal and institutional factors associated with the decision for planned cesarean in cases of breech presentation at term in France, where planned vaginal delivery are recommended by the French College of Gynecologists and Obstetricians (CNGOF) when conditions are optimal. METHODS: The analysis included 6,080 women with a live fetus in breech presentation at term, from the PREMODA prospective survey, in 138 French maternity units between 1 June 2001 and 31 May 2002. Women with previous cesarean sections were excluded. The analysis to identify risk factors for planned cesarean used a multilevel logistic model. RESULTS: The planned cesarean rate was 63.5%. The maternal factors most strongly associated with a decision for planned cesarean were parity (adjusted OR: 2.56 (2.29-2.88)) and maternal age > or =35 years (ORa: 1.38 (1.18-1.61)). No association was found between institutional factors, such as maternity size and level of care, although a centre effect was documented (p<0.001). CONCLUSION: The variation in planned cesarean rates between maternity units was not associated with their structural characteristics, but was related to a characteristic specific to each centre, and, thus, suggests that despite the current guidelines in France, obstetricians have diverse opinions about the best mode of delivery for breech presentations.     

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.     

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.     

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.     

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.     

Changes in the rates of caesarean delivery before labour for breech presentation at term in France: 1972-2003

OBJECTIVE: To describe the changes in the rate of caesarean deliveries before labour among women with term breech presentations in France and to identify the factors associated with this change over two periods: 1972-1995/1998 and 1995/1998-2003. POPULATION: The study population consisted of 1479 women with a foetus in a breech presentation at term and without any previous caesarean delivery, from the population of births in the 1972, 1995, 1998 and 2003 national perinatal surveys (N=53136). Data from the 1995 and 1998 surveys were pooled. METHODS: The principal endpoint was caesarean delivery before labour. Associations between the factors studied and caesarean before labour were estimated by odds ratios, both crude and adjusted with a logistic regression model. RESULTS: Between 1972 and 2003, the rate of caesareans before labour for women with term breech presentations rose sharply (from 14.5% in 1972 to 42.6% in 1995/1998 and to 74.5% in 2003). Between 1972 and 1995/1998, this increase was especially marked among the nulliparous women (16.7% versus 52.9%). From 1995/1998 to 2003, the increase was greatest for multiparas: in 2003 this rate among women with children was close to that for women who had never given birth (64.5% and 79.5%, respectively). After adjustment, the factors associated with a high rate of caesarean before labour were nulliparity, birth between 38 and 40 weeks' gestation, birth weight > or =3800g, delivery in the private sector and year of delivery. The rate of caesareans before labour was significantly higher in 2003 (ORa=19.04 [12.06-30.06]) and in 1995-1998 (ORa=4.30 [2.87-6.47]) than in 1972. CONCLUSION: The increase in the rate of caesarean deliveries before labour in women with term breech presentations was associated principally with changes in obstetrical practices.     

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.     

External version from breech position to head presentation near term

The external version of fetus from breech into a head presentation is one of the methods to avoid maternal and fetal risk by Cesarean section and by vaginal delivery. As a supposition, we see a technique which is undangerous for mother and fetus. Our procedure corresponds in many points with a practice, which is published by B. Westin. The sober patient is positioned head down on the side of fetus small parts. Then an intravenous infusion is given over 30 min with 2 micrograms fenoterol (Partusisten)/min. The version is performed in many single and little steps. It needs time, a soft hand and the readiness of the Cesarean section. In 104 of 242 patients with breech presentation there was the indication with fulfilled suppositions for such a version. The success-rate was nearly 50%. In no case there was a complication. The rate of Cesarean section past turning was clearly reduced in contrary to breach presentation. The fetal outcome was clearly better. The version of breach presentation is recommended.     

The unanticipated breech presentation in labor

In summary, the obstetrician often cannot anticipate the appearance of a woman with a breech fetus in labor, and, in the majority of instances, a woman will be in labor before the diagnosis is made. To obtain the best outcome with both preterm and term breech fetuses, the appropriate data must be obtained rapidly, and a plan of management based on this data must be developed. Management protocols outlined in this article, although not ensuring a good outcome in every instance, most often will result in the delivery of a healthy newborn. We should emphasize again that if the information described above is not available, then the safest course in most instances is delivery by cesarean section.     

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.     

Neonatal fetal death following cesarean section secondary to hyperextended head in breech presentation

There is a general agreement that infants with hyperextension in breech presentation should be delivered by Cesarean section in order to prevent spinal cord injuries and neonatal deaths. The following case report illustrates complete spinal cord transection in a fetus with hyperextended head in breech presentation delivered by Cesarean section who died 8 days after delivery.