Maternal outcomes of term breech presentation delivery: impact of successful external cephalic version in a nationwide sample of delivery admissions in the United States.

Carolyn F Weiniger,Deirdre J Lyell,Lawrence C Tsen,Brian T Bateman,Alexander J Butwick,Batzion Shachar,Andreea A Creanga,William M Callaghan

doi:10.1186/s12884-016-0941-9

Abstract

BackgroundWe aimed to define the frequency and predictors of successful external cephalic version in a nationally-representative cohort of women with breech presentations and to compare maternal outcomes associated with successful external cephalic version versus persistent breech presentation.MethodsUsing the Nationwide Inpatient Sample, a United States healthcare utilization database, we identified delivery admissions between 1998 and 2011 for women who had successful external cephalic version or persistent breech presentation (including unsuccessful or no external cephalic version attempt) at term. Multivariable logistic regression identified patient and hospital-level factors associated with successful external cephalic version. Maternal outcomes were compared between women who had successful external cephalic version versus persistent breech.ResultsOur study cohort comprised 1,079,576 delivery admissions with breech presentation; 56,409 (5.2 %) women underwent successful external cephalic version and 1,023,167 (94.8 %) women had persistent breech presentation at the time of delivery. The rate of cesarean delivery was lower among women who had successful external cephalic version compared to those with persistent breech (20.2 % vs. 94.9 %; p < 0.001). Compared to women with persistent breech at the time of delivery, women with successful external cephalic version were also less likely to experience several measures of significant maternal morbidity including endometritis (adjusted Odds Ratio (aOR) = 0.36, 95 % Confidence Interval (CI) 0.24–0.52), sepsis (aOR = 0.35, 95 % CI 0.24–0.51) and length of stay > 7 days (aOR = 0.53, 95 % CI 0.40–0.70), but had a higher risk of chorioamnionitis (aOR = 1.83, 95 % CI 1.54–2.17).ConclusionsOverall a low proportion of women with breech presentation undergo successful external cephalic version, and it is associated with significant reduction in the frequency of cesarean delivery and a number of measures of maternal morbidity. Increased external cephalic version use may be an important approach to mitigate the high rate of cesarean delivery observed in the United States.

Highlights

We aimed to define the frequency and predictors of successful external cephalic version in a nationally-representative cohort of women with breech presentations and to compare maternal outcomes associated with successful external cephalic version versus persistent breech presentation
Hospitals are selected for inclusion in order to create a sample that is maximally representative of all types of health facilities in United States admissions
Cohort We identified women admitted for delivery who had a breech presentation or a successful External cephalic version (ECV) during pregnancy using ICD-9-CM codes, using the Nationwide Inpatient Sample (NIS) database during 1998–2011, as has been utilized previously [17, 18]

Summary

Introduction

We aimed to define the frequency and predictors of successful external cephalic version in a nationally-representative cohort of women with breech presentations and to compare maternal outcomes associated with successful external cephalic version versus persistent breech presentation. The last two decades have seen a rise in the frequency of cesarean delivery (CD) in the United States, primarily due to a rise in the rate of primary CD [1]. This trend in CD frequency has been associated with an increase in the rate of maternal morbidity, which is at least partly attributable to the increased risk for adherent placenta in subsequent deliveries, uterine rupture, and maternal hemorrhage [2,3,4]. In the developed world, increased breech CD rates have been reported in the United States, New Zealand, and Europe [1, 9, 10]. In 2010, 16 of 21 European countries reported breech presentation CD rates of greater than 80 %; Norway had the lowest breech presentation CD rate, at 69 % [9]

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