Comparison of maternal and fetal complications in pregnant women with breech presentation undergoing spontaneous or induced vaginal delivery,or cesarean delivery

ObjectiveBreech presentation is the most common form of malpresentation, and associated with perinatal asphyxia and mortality, and maternal morbidity. Data associated with labor induction in breech presentation are limited. The aim of this study was to compare maternal and fetal complication rates in induced and spontaneous vaginal, and cesarean delivery with breech presentation.Materials and MethodsPregnant women with breech presentation were grouped: spontaneous vaginal delivery (Group 1, n = 72) induced or augmented vaginal delivery (Group 2, n = 32), and cesarean delivery (Group 3, n = 253). Fetal complications were as follows: clavicle fracture, femur fracture, humerus fracture, brachial plexus injury, cephalic hematoma, pneumothorax, need for intensive care unit (ICU), and 5th minute APGAR <7. Maternal complications were as follows: vaginal hematoma, deep vaginal laceration, perineal injury (≥3rd degree), decline in hemoglobin level (>2 g/dL), and postpartum endometritis. Data were collected and analyzed retrospectively.ResultsThe highest fetal complication rate was in Group 2, and the lowest in Group 3 (p = 0.001). Clavicle fracture was significantly less in Group 3 compared with the other groups (p = 0.024). The rate of lower APGAR scores at the 5th minute was similar in all groups. Maternal complications were significantly higher in Group 2 compared with the other groups (p = 0.001). Fetal complications were 5.66-fold higher in Group 1 than in Group 3 (p = 0.002). Fetal and maternal complications were 9.48-fold and 7.48-fold higher, respectively, in Group 2 than in Group 3 (p < 0.001).ConclusionThis study is the first in literature to have investigated and analyzed neonatal complications in breech delivery according to different delivery modes including induced vaginal delivery. Due to possible complications, the risks and benefits of a specific type of delivery should be considered in breech presentation.     

Objective Structured Assessment of Technical Skills (OSATS) evaluation of theoretical versus hands-on training of vaginal breech delivery management: a randomized trial

Objective

To compare the skills of performing a vaginal breech (VB) delivery after hands-on training versus demonstration.

Study design

We randomized medical students to a 30-min demonstration (group 1) or a 30-min hands-on (group 2) training session using a standardized VB management algorithm on a pelvic training model. Subjects were tested with a 25 item Objective Structured Assessment of Technical Skills (OSATS) scoring system immediately after training and 72 h thereafter. OSATS scores were the primary outcome. Performance time (PT), self assessment (SA), confidence (CON), and global rating scale (GRS) were the secondary outcomes. Statistics were performed using the Mann–Whitney U-test, chi-square test, and multiple linear regression analysis.

Results

172 subjects were randomized. OSATS scores (primary outcome) were significantly higher in group 2 (n = 88) compared to group 1 (n = 84) (21.18 ± 2.29 vs. 20.19 ± 2.37, respectively; p = 0.006). The secondary outcomes GRS (10.31 ± 2.28 vs. 9.17 ± 2.21; p = 0.001), PT (214.60 ± 57.97 s vs. 246.98 ± 59.34 s; p < 0.0001), and CON (3.14 ± 0.89 vs. 2.85 ± 0.90; p = 0.04) were also significantly different between groups, favoring group 2. After 72 h, primary and secondary outcomes were not significantly different between groups. In a multiple linear regression analysis, group assignment (odds ratio [OR] 1.60; 95% confidence interval [CI] 1.14–2.05; p < 0.0001) and gender (OR 2.91; 95% CI 2.45–3.38; p < 0.0001) independently influenced OSATS scores.

Conclusion

Hands-on training leads to a significant improvement of VB management in a pelvic training model, but this effect was only seen in the short term.     

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.     

Retrospective study of outcome on vaginal and abdominal delivery in twin pregnancy in which twin 1 is presenting by the breech

We retrospectively reviewed the perinatal outcome of twin pregnancies cohere the first baby was presenting by the breech. 21 were delivered vaginally and 37 abdominally. Differences in perinatal outcome, as measured by Apgar score and mortality, were not apparently different. Received: 24 March 1997 / Accepted: 4 September 1997     

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.     

Planned vaginal delivery of fetuses in breech presentation at term: prenatal determinants predictive of elevated risk of cesarean delivery during labor

OBJECTIVE: Identify the prenatal determinants associated with cesarean delivery during labor of term breech presentation for which vaginal delivery is planned. STUDY DESIGN: Prospective study of 174 French and Belgian maternity units. Relations between cesarean and prenatal determinants were estimated with a multilevel logistic model and expressed as adjusted ORs. A prediction score for cesarean section was proposed and diagnostic values were estimated for different cutoff values. RESULTS: Of 2,478 women meeting the inclusion criteria, 705 (28.5%) had cesarean deliveries. Nulliparity, complete breech, rupture of membranes before labor, fetal weight > or = 3800 g, biparietal diameter > 95 mm and university and public non-teaching hospital maternity units were significantly associated with cesarean delivery during labor. The rate of cesarean during labor was significantly higher in establishments where more than 80% of women had planned cesareans and in cases where mode of delivery had not been decided before labor. The prediction score values ranged from 9 to 21.4 (10th, 50th and 90th percentiles corresponded to 10.1, 12.2 and 14.7). The cesarean rate was 43% in women whose score was greater than the cutoff point of 12.9, and 15% for women whose score was below this value. CONCLUSION: Our findings indicate that once vaginal delivery has been decided upon, the risk of cesarean delivery during labor for breech presentation at term depends not only on the progress of labor, but also on prenatal determinants both maternal and obstetrical. It also depends on some characteristics of the maternity units. Obstetricians should either plan cesarean delivery or define stringent rules for indications of cesarean during labor.     

Maternal health outcomes two years after term breech delivery

Objective. To evaluate maternal health outcomes two years after term breech delivery.

Design. This was a non-randomized single-center prospective cohort study. Mothers were asked to fill out questionnaires at two years postpartum to judge their health in the previous three to six months. Outcomes of the planned cesarean section group were compared with outcomes of the planned vaginal delivery group, whether or not a vaginal birth was realized or an emergency cesarean section was performed.

Results. One hundred and eighty-three women completed a follow-up questionnaire at two years postpartum. Outcomes of the planned cesarean section group were compared with her partner were found between the two groups. Also, no differences were found in all investigated maternal health items, or in sexual activity and fertility.

Conclusion. Maternal health outcomes two years after term breech delivery were similar after planned cesarean section and planned vaginal delivery.     

Cesarean delivery versus vaginal delivery: impact on survival and morbidity for the breech fetus at the threshold of viability

Objective.?To determine if cesarean delivery is associated with improved survival and morbidity in the breech fetus at the threshold of viability.

Study design.?The Missouri maternally linked cohort data files covering the period 1989 through 2005 were utilized for analysis. All pregnancies with singleton fetuses in the breech presentation delivered between 23⁰ and 24⁶ weeks gestation and birth weights between 400 and 750 g were included. Logistic regression was used to compare cesarean to vaginal delivery after controlling for maternal demographics and pregnancy complications.

Results.?A total of 325 breech singletons were analyzed; cesarean deliveries accounted for 46.1% (150) and vaginal deliveries accounted for 53.9% (175). Cesarean delivery was associated with a survival benefit across all birth weights. Morbidity was higher in cesarean compared to vaginal delivery.

Conclusion.?Although cesarean delivery appears to be associated with an increase in survival at the threshold of viability for the breech fetus, there is a concomitant increase in morbidity. Any benefit that cesarean delivery conveys on survival at the threshold of viability should be weighed against the increased maternal morbidity and high overall neonatal morbidity.     

Vaginal versus cesarean section oriented approaches in the management of breech delivery

In a 5-year retrospective study, 543 singleton breech presented infants weighing more than 1000 g were reviewed in two obstetric departments. Department "A" actively conducted the labor with lower cesarean section rate (26%). Department "B" attempted a trial of labor with less invasive procedures and performed more cesarean sections (38% P less than 0.05 S). The management of labor, fetal and maternal outcome were compared between the two departments. Both vaginal and abdominal routes of delivery in fetuses weighing more than 1500 g resulted in the same fetal and maternal outcome. For fetuses weighing 1000-1500 g cesarean section is probably the recommended delivery route.     

Comparison of cesarean versus vaginal delivery of extremely preterm gestations in breech presentation: retrospective cohort study

Objective: As survival increases at earlier gestational ages, the optimal mode of delivery, especially in cases of breech presentation, is of increasing importance. The objective of this study was to compare outcomes of vaginal delivery (VD) and cesarean section (CS) births for infants in breech presentation at borderline viability.

Study design: A retrospective chart review of live breech births between 23?+?0 and 25?+?6 weeks gestation at a tertiary university center from 2003 to 2013 was conducted. Those delivered vaginally were compared with those delivered by CS. Stillbirths and deliveries where no resuscitation was intended were removed from the analysis. Variables were compared using a Student t-test (continuous), Mann–Whitney U test (categorical), or a Chi-squared test (count). Logistic regression analysis was performed to further evaluate the results. Results with p?Results: One hundred seventy-six births were included, 36 VD and 140 CS. Baseline characteristics were similar between groups. Gestational age at delivery was significantly higher in CS deliveries (24.9?±?0.6 versus 24.5?±?0.7, p?=?.0007). The rate of neonatal death (23.6% versus 44.4%, p?=?.0127) was significantly lower in those born by CS. All other neonatal outcomes including Apgar scores at one and 5?min, cord gases, birth weight, length of stay in NICU, incidence of respiratory complications, and incidence of high-grade IVH demonstrated no significant differences. Logistic regression suggested that male sex, lower birth weight, and earlier gestational age are significantly associated with neonatal mortality. Thirty percent of uterine incisions were of the classical, high transverse or inverted-T types. The estimated blood loss was significantly higher in CS births (706.6?±?226.4 versus 327.4?±?174.1?mL, p?Conclusion: CS delivery of breech infants at borderline viability had a protective effect on neonatal mortality compared to VD depending on the regression model utilized. Infant sex, birth weight, and gestational age also contribute significantly to neonatal mortality. A prospective study of planned method of delivery is recommended to further explore this finding.     

Cesarean vs. vaginal birth for term breech presentation in 2 different study periods.

OBJECTIVE: To compare outcomes for fetuses at term in breech presentation during 2 periods when different delivery policies were in effect. METHODS: Outcomes of the 392 planned vaginal deliveries and 1160 elective cesarean sections (CSs) performed from January 1, 1988, through December 31, 2000, were compared with those of the 24 emergency vaginal deliveries, the 403 planned CSs, and 75 emergency CSs performed from January 1, 2001 through December 31, 2004 at Alexandra Hospital, Athens, Greece. RESULTS: A significant difference was found in rates of low 5-minute Apgar score, birth trauma, serious neonatal morbidity, and admission to the neonatal intensive care unit (0% vs. 1.02% [P=0.004], 1.02% vs. 0% [P=0.004], 3.06% vs. 0.43% [P<0.001], and 2.8% vs. 0.43% [P<0.001], respectively) between neonates born by planned vaginal delivery and those born by elective CS during the first period. Only a reduction in rates of admission to the neonatal intermediate care unit was found between the first and second periods. CONCLUSIONS: Planned CS was found to be safer than planned vaginal delivery for fetuses at term in breech presentation. However, the study did not demonstrate that the change in policy improved neonatal outcome.     

The influence of counseling on the mode of breech birth: A single-center observational prospective study in The Netherlands

Objectivewomen in the Netherlands, with a fetus in breech presentation, are thoroughly counseled to make an informed choice for the mode of delivery. The aim of this study was to assess the influence of counseling techniques on women's choices for the mode of delivery and subsequently to compare fetal and maternal outcomes of vaginal breech birth versus planned caesarean section.Study designwe performed an observational prospective study. Data on breech deliveries were prospectively collected. We used ANOVA to identify variables influencing women's choice for the mode of delivery.Settingthe obstetric department of the Red Cross Hospital in Beverwijk, the Netherlands.Participantswomen with a singleton gestation (>37 + 0 weeks) and a fetus in breech presentation were included.Measurements and findingsbetween January 2007 and December 2015 364 women were included. Counseling technique (p =<0.001) and maternal education (p = 0.046) were significantly associated with the choice of mode of delivery. Of all included women 33% (N = 119) opted for a vaginal breech delivery and 52% (N = 190) opted for a planned cesarean section. 15% (N = 55) were unexpected breeches. Of the planned vaginal delivery group 66% (N = 79) delivered vaginal, whereas 99.5% (N = 189) of the women in the planned cesarean section group underwent a planned cesarean section. There were no significant differences in maternal and neonatal outcomes.Key conclusionswomen's choice on the mode of delivery and the eventual modus partus of fetuses in breech presentation is strongly influenced by the counseling technique. Vaginal breech birth in low-risk women is a safe option without long term morbidity in neonates.Implications for practicecounselors should be aware of their influence on women's choice for mode of delivery in breech presentation. Counseling should be done using evidence based information.     

Cesarean delivery after successful external cephalic version of breech presentation at term: a comparative study

OBJECTIVE: The purpose of this study was to evaluate the rate and indications of cesarean delivery after a successful external cephalic version. STUDY DESIGN: A case-control study was performed from patients who were delivered in a tertiary care center between 1987 and 2000. Each patient who underwent a successful external cephalic version (study group) was compared with the next woman with the same parity, who was delivered at term (control group). Nulliparous and multiparous women were analyzed separately. Chi-squared, Mann-Whitney, and Student t tests were used for statistical analysis. Multivariate logistic regression analysis was performed where appropriate. RESULTS: A total of 602 patients were included in this study. The rates of cesarean delivery in nulliparous women (29.8% vs 15.9%; P<.001) and in multiparous women (15.9% vs 4.7%; P<.001) were significantly higher when compared with the control group. Patients with successful external cephalic version were more likely to have a cesarean delivery for dystocia (nulliparous, 22.5% vs 11.9%; P=.01; multiparous, 10.9% vs 1.3%; P<.01). After an adjustment for confounding variables, a successful external cephalic version was associated with an increased rate of cesarean delivery at term (nulliparous: odds ratio, 2.04; 95% CI, 1.13-3.68; multiparous: odds ratio, 4.30; 95% CI, 1.76-10.54). CONCLUSION: The rate of cesarean delivery for dystocia is increased after a successful trial of external cephalic version in both nulliparous and multiparous women.     

A novel and dedicated multidisciplinary service to manage breech presentation at term; 3 years of experience in a tertiary care maternity unit

Objective: In order to provide uniform and unbiased multidisciplinary counselling on the options available, including vaginal breech delivery (VBD) and external cephalic version (ECV), the latter of which could then be performed, a weekly Breech Clinic was introduced to a tertiary care maternity unit in Northern Ireland in June 2013, replacing the traditional ECV Clinic introduced in June 2012.

Methods: Retrospective data collection was undertaken using clinic proformas, Northern Ireland Maternity System data and case notes of women who attended the clinics (ECV and Breech) from June 2012 to May 2015.

Results: There were 434 referrals to the clinic over the 3-year period; 356 women attended. The proportion of women attending increased from 69% to 85% since the introduction of the Breech Clinic. Two hundred and thirty-two were deemed eligible and 179 of these underwent ECV after counselling. Although the proportion of women undergoing ECV decreased from 69% to 46%, 11 women opted for and achieved VBD during the 2 years of the Breech Clinic, compared with one woman in the year of the ECV Clinic. Seventy-one of the attempted ECVs were successful, with 61 women having a normal vaginal delivery. Notably, the success rate of ECV increased from 33% to 42%. The number of caesarean sections performed solely for breech at term decreased from 199 in the 12 months before the introduction of ECV clinic, to 188 during the ECV clinic, and 154 in the final 12 months of Breech Clinic.

Conclusions: A dedicated service to counsel women on the management of breech presentation can decrease caesarean sections for breech presentation through increased uptake and success of ECV, and encouraging suitable women to opt for VBD when ECV is unsuccessful, contraindicated or declined.