Selective Vaginal Breech Delivery at Term—Still an Option

Abstract

The mode of delivery for breech presentation has long been a subject of debate. Planned cesarean delivery (CD) has become the favored method, but planned vaginal delivery (VD) is still considered an acceptable option in some settings. This study was undertaken to assess the neonatal and maternal outcomes of planned vaginal breech delivery (planned VD), planned breech CD (planned CD), or planned VD in vertex presentation. Only patients with live singleton fetuses at gestation of 37 weeks or more were included. Deliveries planned to be by CD were classified as planned CD, and those planned to be vaginal deliveries were classified as planned VD, regardless of the actual delivery mode. For every planned breech VD, a term, singleton fetus in vertex presentation was selected as an additional control. The final population totaled 1008 deliveries, of which 497 (66.2% of breech deliveries) were in the planned CD group, 254 (33.8% of breech deliveries) were in the planned VD group, and 257 were in the vertex group. From a total of 24,850 deliveries, the incidence of term, singleton breech delivery was 3.1%. The most common indication for planned CD was either the mother’s fear of VD or her expressed desire for an elective CD. The primary end point was neonatal mortality or serious morbidity and serious maternal morbidity. Low Apgar scores (≤6 at 1 or 5 minutes) and an umbilical artery pH less than 7.05 were secondary end points. All statistical analyses were done using SPSS for Windows 14.0. The mode of delivery changed significantly more often and was more often emergency CD in the planned VD group compared with the other 2 groups. Newborns in both the planned CD group and vertex group had Apgar scores of equal to or greater than 7 more often and lower scores less often than in the planned VD group at 1 minute, but no significant differences were noted at 5 minutes. No neonates died. Infants in the planned VD group had an umbilical cord pH of less than 7.05 significantly more often than those in either of the other groups. Infants in the planned VD group had significantly more infections compared with the planned CD group, but the rates for the planned VD and vertex groups were similar. The groups did not differ in the frequency of admission to the neonatal intensive care unit. Rates of severe morbidity were low. One breech infant in the planned CD group, 2 in the planned VD group, and 3 in the vertex group had serious neonatal morbidity, but the groups did not statistically differ in overall morbidity. Two birth traumas occurred in the planned VD group, one in the vertex group, and none in the planned CD group. One mother in the planned CD group died of pulmonary embolism 12 days after an elective CD. Women in the planned CD group had significantly more frequent massive bleeding that required transfusions. The groups did not differ in the frequency of puerperal infections or surgical complications. Severe bleeding (>1500 mL) occurred in 1.1% of vaginal deliveries, 8.0% of elective CDs, and 6.4% of emergency CDs. When nulliparous and multiparous women who actually gave birth vaginally were compared, breech infants of nulliparous mothers had Apgar scores of less than 4 at 1 minute significantly more often (9.3% vs 0%; P = 0.010) than breech infants of multiparous women, but at 5 minutes, no significant differences were noted. Median pH values were 7.22 and 7.31 in the breech infants of nulliparous and multiparous women, respectively. No differences in neonatal intensive care unit admittance or infant morbidity were noted between nulliparous and multiparous breech delivery groups. Based on these results, the dilemma and uncertainty regarding breech delivery are still present. With proper selection of patients for a trial of VD and a low trigger point for change in mode of delivery if signs of asphyxia or poor progress of labor are present, vaginal breech delivery is still an acceptable option.