Are Intrapartum and Neonatal Deaths in Breech Delivery at Term Potentially Avoidable? – A Blinded Controlled Audit

Abstract

This case-control study of breech deliveries blinded assessors to the outcome to objectively evaluate the quality of care during pregnancy. The goal was to determine whether improved prenatal care can prevent deaths in term breech deliveries. Each of 12 intrapartum or early neonatal deaths of singleton infants in breech presentation, born in Denmark in the years 1982 through 1992, and lacking congenital malformation was matched with two control infants. These were the two subsequent breech deliveries in the database who were delivered at the same hospital using the same planned mode of delivery. Eleven obstetricians reviewed narratives and answered a structured questionnaire focusing on suboptimal care during pregnancy and delivery. A majority of the auditors believed that 5 of the 12 case infants (42%) and 9% of control infants died intrapartum or early in the neonatal period. Antenatal care was judged as definitely or possibly suboptimal in 17% of case infants and 4% of control infants. Intrapartum care was considered suboptimal in about one fourth of each group. In 58% of case infants and 17% of control infants, death (presumed death) was found to potentially be avoidable. The obstetricians made significantly more comments about antenatal care and delivery for case infants than for control infants. Themes associated with cases judged to have a poor outcome included undiagnosed intrauterine growth restriction, inadequate observation and intervention when preeclampsia was present, placental abruption, and postmaturity. Also of concern was an excessive interval between decision-making and cesarean delivery. Issues not cited more often in cases with a poor outcome included undiagnosed breech presentation during pregnancy or on admission to the labor ward, inadequate fetal monitoring, and an inadequate reaction to prolonged labor or fetopelvic disproportion. The findings of this controlled audit imply that most perinatal deaths in breech presentation at term might be avoided by improved care.