Breech Labor Research Articles

Maternal and neonatal outcomes associated with breech presentation in planned community (home and birth center) births in the United States: A prospective observational cohort study.

Investigate maternal and neonatal outcomes associated with breech presentation in planned community births in the United States, including outcomes associated with types of breech presentation (i.e., frank, complete, footling/kneeling). Secondary analysis of prospective cohort data from a national perinatal data registry (MANA Stats). Planned community birth (homes and birth centers), United States. Individuals with a term, singleton gestation (N = 71,943) planning community birth at labor onset. Descriptive statistics to calculate associations between types of breech presentation and maternal and neonatal outcomes. Maternal: intrapartum/postpartum transfer, hospitalization, cesarean, hemorrhage, severe perineal laceration, duration of labor stages and membrane rupture Neonatal: transfer, hospitalization, NICU admission, congenital anomalies, umbilical cord prolapse, birth injury, intrapartum/neonatal death. One percent (n = 695) of individuals experienced breech birth (n = 401, 57.6% vaginally). Most fetuses presented frank breech (57%), with 19% complete, 18% footling/kneeling, and 5% unknown type of breech presentation. Among all breech labors, there were high rates of intrapartum transfer and cesarean birth compared to cephalic presentation (OR 9.0, 95% CI 7.7-10.4 and OR 18.6, 95% CI 15.9-21.7, respectively), with no substantive difference based on parity, planned site of birth, or level of care integration into the health system. For all types of breech presentations, there was increased risk for nearly all assessed neonatal outcomes including hospital transfer, NICU admission, birth injury, and umbilical cord prolapse. Breech presentation was also associated with increased risk of intrapartum/neonatal death (OR 8.5, 95% CI 4.4-16.3), even after congenital anomalies were excluded. All types of breech presentations in community birth settings are associated with increased risk of adverse neonatal outcomes. These research findings contribute to informed decision-making and reinforce the need for breech training and research and an increase in accessible, high-quality care for planned vaginal breech birth in US hospitals.

Effect of the Presence of Nuchal Cords on Vaginal Breech Labor.

Breech delivery has been reported to be associated with a high incidence of abnormal fetal heart rate pattern leading to neonatal asphyxia. In this study, we examined the effect of the presence of nuchal cords on perinatal outcomes of vaginal breech labor. We reviewed the obstetric records of all singleton breech labor cases at the Japanese Red Cross Katsushika Maternity Hospital between 1999 and 2011. Of the 266 breech labor cases in singleton pregnancies, the presence of nuchal cords was recognized in 50 cases (18.8%) on neonatal findings at birth. We compared the clinical characteristics and perinatal outcomes between the breech labor cases with and without nuchal cords. A chi-square test was used for categorical data, and a p-value <0.05 was considered significant. It was found that the incidence of fetal heart rate abnormality during breech labor or neonatal asphyxia in the deliveries with nuchal cords was not significantly different from that in those without nuchal cords. Also,there was no significant difference in the rate of emergent caesarean delivery between the two labors with and without nuchal cords. The current results suggest that the presence of nuchal cords may not be associated withperinatal outcomes. Our results may become one of several pieces of evidence leading to the alleviation of anxiety in pregnant women with breech presentation and fetal nuchal cords.

Prenatal hydrometrocolpos as an unusual finding in Fraser syndrome. Case report

Abstract Objectives Fraser syndrome is a rare congenital malformation characterized by cryptophthalmos, syndactyly and urogenital tract malformations. The association with hydrometrocolpos is infrequent, with only a few cases reported in the literature. Case presentation A 19-year-old primigravida presenting at 35 weeks of gestation, with prenatal finding of hydrometrocolpos associated with hypotelorism and microphthalmia. Pre-term cesarean delivery was performed due to breech labor and perinatal death. The autopsy confirmed hydrometrocolpos secondary to vaginal atresia and imperforate hymen, associated with cryptophthalmos, syndactyly, nasal and pinna malformations, confirming the diagnosis of Fraser syndrome. Conclusions Fraser syndrome is usually a postnatal diagnosis. The association with genital abnormalities explains the finding of hydrometrocolpos, which could be considered a diagnostic criterion for this syndrome.

Neonatal outcome in vaginal breech labor at 32\u2009+\u20090\u201436\u2009+\u20090 weeks of gestation: a nationwide, population-based record linkage study

BackgroundIn many countries, vaginal breech labor at term is an option in selected cases. However, the safety of vaginal breech labor in preterm is still unclear. Therefore our study aimed to evaluate the safety of vaginal breech labor in late preterm deliveries.DesignA retrospective register-based study.SettingMaternity hospitals in Finland, 2004–2017.ParticipantsThe study population included 762 preterm breech deliveries at 32 + 0—36 + 6 gestational weeks according to the mode of delivery, 535 (70.2%) of them were born vaginally in breech presentation, and 227 (29.8%) were delivered by non-urgent cesarean section.MethodsThe study compared short-term neonatal adverse outcomes of singleton vaginal breech deliveries with non-urgent cesarean deliveries at 32 + 0 to 36 + 6 weeks of gestation. An odd ratio with 95% confidence intervals was calculated to estimate the relative risk of adverse outcomes.Outcome measuresNeonatal death, an arterial umbilical pH below seven, a five-minute Apgar score below four and seven, admission to neonatal intensive care unit, neonatal intubation, neonatal antibiotic therapy, neonatal birth trauma, respiratory distress syndrome, neonatal convulsions, cerebral ischemia, hypoxic-ischemic encephalopathy, congenital hypotonia, and a composite of severe adverse outcomes.ResultsA five-minute Apgar scores below seven were increased in vaginal breech labor at 32 + 0 to 36 + 6 weeks of gestation compared to non-urgent cesarean sections (aOR 2.48, 95% CI 1.08–5.59). Neonatal antibiotic therapy, the admission to neonatal intensive care unit, and neonatal respiratory distress syndrome were decreased after vaginal breech labor compared to the outcomes of non-urgent cesarean section (neonatal antibiotic therapy aOR 0.60, 95% CI 0.40–0.89; neonatal NICU admission aOR 0.47, 95% CI 0.33–0.68; respiratory distress syndrome aOR 0.30, 95% CI 0.19–0.48).ConclusionVaginal breech labor at 32 + 0—36 + 6 gestational weeks does not increase severe neonatal short-term morbidity or mortality compared to cesarean section.

Induction of labor in breech presentations - a retrospective cohort study.

There is limited evidence on the safety and outcome of induction of breech labor. In this study, we aimed to compare the outcomes of spontaneous and induced breech deliveries and to describe variations in induction rates. This was a retrospective cohort study comprising 1054 singleton live fetuses in breech presentation at Trondheim University Hospital from 2012 to 2019. The main outcome was intrapartum cesarean section, and secondary outcomes were postpartum hemorrhage, anal sphincter ruptures, Apgar scores, pH in the umbilical artery, and metabolic acidosis. All data were obtained from the hospital birth journal. Induction of labor was performed in 127/606 (21.0%) women with planned vaginal birth. The frequency of intrapartum cesarean section was 48.0% for induced labor vs 45.7% for spontaneous labor (P=.64). We found no differences in the frequency of postpartum hemorrhage or anal sphincter ruptures between induced and spontaneous births. The median pH in the umbilical artery was significantly lower in neonates with induced labor compared with neonates with spontaneous labor (7.22 vs 7.25; P=.02). The frequency of pH <7.05 was 7.0% for induced labor vs 2.9% (P=.05) for spontaneous labor, but the frequency of pH <7.0 was not significantly different: 2.6% vs 0.8% (P=.14), respectively. Three neonates with planned vaginal birth had metabolic acidosis: two with spontaneous labors and one with induced labor. Three fetuses with planned vaginal birth died during labor: two with spontaneous onset of labor and one with induced labor. All three were extremely preterm: two were delivered in week 23 and one in week 25. We did not observe any significant trend in induction rates in either parous or nulliparous women. The induction rates were stable during the study period. We did not observe any significant difference in intrapartum cesarean section rates, in the frequency of pH <7.0 in the umbilical artery, or in the frequency of metabolic acidosis when comparing induced and spontaneous breech deliveries.

Risk factors for adverse outcomes in vaginal preterm breech labor

PurposeTo assess the risk factors for adverse outcomes in attempted vaginal preterm breech deliveries.MethodsA retrospective case–control study, including 2312 preterm breech deliveries (24 + 0 to 36 + 6 gestational weeks) from 2004 to 2018 in Finland. The preterm breech fetuses with adverse outcomes born vaginally or by emergency cesarean section were compared with the fetuses without adverse outcomes with the same gestational age. A multivariable logistic regression analysis was used to calculate the risk factors for adverse outcomes (umbilical arterial pH below 7, 5-min Apgar score below 4, intrapartum stillbirth and neonatal death < 28 days of age).ResultsAdverse outcome in vaginal preterm breech delivery was associated with maternal obesity (aOR 32.19, CI 2.97–348.65), smoking (aOR 2.29, CI 1.12–4.72), congenital anomalies (aOR 4.50, 1.56–12.96), preterm premature rupture of membranes (aOR 1.87, CI 1.00–3.49), oligohydramnios (28–32 weeks of gestation: aOR 6.50, CI 2.00–21.11, 33–36 weeks of gestation: aOR 19.06, CI 7.15–50.85), epidural anesthesia in vaginal birth (aOR 2.44, CI 1.19–5.01), and fetal growth below the second standard deviation (28–32 weeks of gestation: aOR 5.89, CI 1.00–34.74, 33–36 weeks of gestation: aOR 12.27, CI 2.81–53.66).ConclusionThe study shows that for each subcategory of preterm birth, there are different risk factors for adverse neonatal outcomes in planned vaginal breech delivery. Due to the extraordinary increased risk of adverse outcomes, we would recommend a planned cesarean section in very preterm breech presentation (28 + 0 to 32 + 6 weeks) with severe maternal obesity, oligohydramnios, or fetal growth restriction and in moderate to late preterm breech presentation (33 + 0 to 36 + 6 weeks) with oligohydramnios or fetal growth restriction.

Outcome of small for gestational age-fetuses in breech presentation at term according to mode of delivery: a nationwide, population-based record linkage study.

To evaluate whether a trial of planned vaginal labor is associated with adverse perinatal outcome in singleton, small for gestational agefetuses in breech presentation at term. This is a Finnish nationwide, population-based record linkage study. The studied population included all small for gestational age breech labors from January 1, 2004 to December 31, 2014. "Small for gestational age" was defined as birth weight below the 10th percentile according to gestational age. An odds ratio with 95% confidence intervals was used to estimate the relative risk for perinatal mortality and morbidity in a trial of vaginal labor. The reference group included all small for gestational age infants born in breech presentation by planned cesarean section. During the study period of eleven years, 1841 small for gestational age infants were delivered in breech position at term. A trial of vaginal breech labor is associated with a higher rate of neonates with an umbilical pH below seven [odds ratio 7.82 (1-61.21)], a lower 5-min Apgar score <7 [adjusted odds ratio 6.39 (1.43-28.46)] and <4 [adjusted odds ratio 6.39 (1.43-28.46)], a higher rate of postpartum neonatal intubations [adjusted odds ratio 6.52 (1.93-22)], an increased rate of neonatal antibiotic therapy [adjusted odds ratio 3.31 (1.85-5.93)], and with a higher rate of combined severe adverse perinatal outcome [adjusted odds ratio 4.24 (1.43-12.61)]. A trial of vaginal breech labor in SGA fetuses is associated with adverse perinatal outcome and should be avoided.

Impact of the mode of delivery on maternal and neonatal outcome in spontaneous-onset breech labor at 32+0–36+6 weeks of gestation: A retrospective cohort study

ObjectiveTo compare neonatal and maternal outcomes in spontaneously onset preterm breech deliveries after trial of labor (BTOL) and intended cesarean section (BCS), and between BTOL and vertex control deliveries, in singleton fetuses at 32+0–36+6 weeks of gestation. Study designRetrospective single center cohort study in a Finnish University Hospital including all spontaneous-onset preterm breech deliveries with 32 completed gestational weeks in 2003–2015. The study population comprised a total of 176 preterm breech and 103 vertex control deliveries, matched by gestational age and whether the mother had given birth vaginally before or not. Infants with severe malformations and antepartum fetal distress were excluded. Subgroup analyses were made in two cohorts according to gestational age. Main outcome measures were maternal and neonatal mortality and morbidity, low cord pH and Apgar score. ResultsNo mortality was observed, and severe morbidity was rare. No difference in incidence of low cord pH or five-minute Apgar score was observed between the groups. Apgar scores at the age of one minute were comparable in the breech groups but more often low in the BTOL group compared to the vertex control group. 16.5% of neonates in the BTOL group, 23.3% in the BCS group and 7.8% in the vertex group needed intensive care. In logistic regression analysis, lower gestational age and being small for gestational age were associated with the need for neonatal intensive care. Being allowed a trial of labor was not associated with the need for neonatal intensive care. Maternal morbidity was similar across the groups, but median blood loss was more pronounced in the BCS group compared to the BTOL group. ConclusionIn breech deliveries at 32+0–36+6 gestational weeks, trial of labor did not increase neonatal morbidity compared to intended cesarean delivery. Infants born after a trial of labor in breech presentation display low one-minute Apgar score and need intensive care more often compared to vertex controls.

Neurodevelopmental outcome at the age of 4 years according to the planned mode of delivery in term breech presentation: a nationwide, population-based record linkage study.

To evaluate whether a trial of planned vaginal breech labor affects neurologic development in children. This is a nationwide, Finnish, population-based record linkage study. An odds ratio with 95% confidence intervals was used to estimate the relative risk that a child delivered by planned vaginal breech labor would be diagnosed with adverse neurodevelopmental outcome (cerebral palsy, epilepsy, intellectual disability, sensor neural developmental outcome, hyperactivity, speech and language problems) at the age of 4 years. The reference group were children born by planned cesarean section. During a study period of 7 years, 8374 infants were delivered in breech position. Among them, 3907 (46.7%) had an attempted labor and 4467 (53.3%) infants were delivered by planned cesarean section. There were no differences in the neurodevelopmental outcome. In the planned vaginal labor group, 133 (3.4%) children had an abnormal neurodevelopmental outcome at the age of 4 years compared to 142 (3.2%) in the planned cesarean section group. The absolute risk of abnormal neurological outcome in breech deliveries at term was low, regardless of planned mode of birth. Planned vaginal breech labor did not increase the risk for abnormal neurological outcome compared to planned cesarean section.

Perspectives on risk: Assessment of risk profiles and outcomes among women planning community birth in the United States.

There is little agreement on who is a good candidate for community (home or birth center) birth in the United States. Data on n=47394 midwife-attended, planned community births come from the Midwives Alliance of North America Statistics Project. Logistic regression quantified the independent contribution of 10 risk factors to maternal and neonatal outcomes. Risk factors included: primiparity, advanced maternal age, obesity, gestational diabetes, preeclampsia, postterm pregnancy, twins, breech presentation, history of cesarean and vaginal birth, and history of cesarean without history of vaginal birth. Models controlled additionally for Medicaid, race/ethnicity, and education. The independent contributions of maternal age and obesity were quite modest, with adjusted odds ratios (AOR) less than 2.0 for all outcomes: hospital transfer, cesarean, perineal trauma, postpartum hemorrhage, low/very-low Apgar, maternal or neonatal hospitalization, NICU admission, and fetal/neonatal death. Breech was strongly associated with morbidity and fetal/neonatal mortality (AOR 8.2, 95% CI, 3.7-18.4). Women with a history of both cesarean and vaginal birth fared better than primiparas across all outcomes; however, women with a history of cesarean but no prior vaginal births had poor outcomes, most notably fetal/neonatal demise (AOR 10.4, 95% CI, 4.8-22.6). Cesarean births were most common in the breech (44.7%), preeclampsia (30.6%), history of cesarean without vaginal birth (22.1%), and primipara (11.0%) groups. The outcomes of labor after cesarean in women with previous vaginal deliveries indicates that guidelines uniformly prohibiting labor after cesarean should be reconsidered for this subgroup. Breech presentation has the highest rate of adverse outcomes supporting management of vaginal breech labor in a hospital setting.

Risk factors associated with adverse perinatal outcome in planned vaginal breech labors at term: a retrospective population-based case-control study

BackgroundVaginal breech delivery is associated with adverse perinatal outcome. The aim of this study was to identify factors associated with adverse perinatal outcome in term breech pregnancies, and to provide clinicians an aid in selecting women for a trial of vaginal labor with the fetus in breech position.MethodsWe conducted a retrospective, nationwide, Finnish population-based case-control study. All planned singleton vaginal deliveries at term with the fetus in breech position between the years 2005 and 2014 were analyzed. The study’s end point was a composite set of adverse perinatal outcomes. All infants with an adverse outcome were compared to the infants with normal outcomes. A multivariate logistic regression model was used to analyze the data.ResultsAn adverse perinatal outcome was recorded for 73 (1.5%) infants. According to the study results fetal growth restriction (adjusted odds ratio, 2.94; 95% CI, 1.30–6.67), oligohydramnios (adjusted odds ratio, 2.94; 95% CI, 1.15–7.18), a history of cesarean section (adjusted odds ratio, 2.94; 95% CI, 1.28–6.77, gestational diabetes (adjusted odds ratio, 2.89; 95% CI, 1.54–5.40), epidural anesthesia (adjusted odds ratio, 2.20; 95% CI, 1.29–3.75) and nulliparity (adjusted odds ratio, 1.84; 95% CI, 1.10–3.08) were associated with adverse perinatal outcome.ConclusionsAdverse perinatal outcome in planned vaginal breech labor at term is associated with fetal growth restriction, oligohydramnios, previous cesarean delivery, gestational diabetes, nulliparity and epidural anesthesia.

Management of Breech Presentation: Green-top Guideline No. 20b.

Management of Breech Presentation: Green-top Guideline No. 20b.

Cesarean Delivery Prevention

INTRODUCTION: Reducing the cesarean delivery rate is a national priority and performing vaginal breech deliveries can be one component of a cesarean delivery reduction strategy. Scientific evidence, professional recommendations, and consumer demand have all shifted to support vaginal breech delivery as an option to routine cesarean delivery for breech presentations. However, health care provider comfort and skill in this area are limited. At the George Washington University Hospital, we have established a Vaginal Breech Initiative to increase access to, and training in, the process of vaginal breech delivery. The Vaginal Breech Team, a collaborative care team composed of physicians and nurse–midwives experienced in vaginal breech, leads the Vaginal Breech Initiative. Components of the Vaginal Breech Initiative are careful antenatal screening and diagnosis, strict inclusion and exclusion criteria, rigorous informed consent, established delivery guidelines, and regular simulation training. METHODS: This is an observational report and data analysis of the vaginal breech labors and deliveries managed by a Breech Vaginal Team from 2011 to 2014. RESULTS: Preliminary outcome data from our first 18 patients attempting a vaginal breech delivery in the context of the Vaginal Breech Initiative demonstrate an 89% vaginal breech rate. CONCLUSION: Improving access to, and training in, vaginal breech at the George Washington University Hospital has contributed to reducing our cesarean delivery rate, increased patient satisfaction, and provided critical training and skills for our health care providers. Through careful diagnosis, patient selection, counseling, and collaboration, breech vaginal deliveries performed in the context of a Breech Vaginal Initiative are feasible in an academic medical center.

Breech labour is not a particular indication for STAN monitoring.

Breech labour is not a particular indication for STAN monitoring.

Breech labor on the WHO partograph

Objectives: To assess the impact of breech labor management using the WHO partograph on fetal and maternal outcomes of labor. Method: All 1,740 breech presentations in a larger multicentre hospital-based study in South East Asia of the use of the WHO partograph in labor management were studied. The partograph was introduced into each hospital during the study and a before and after analysis of various outcomes was conducted. Results: There were 923 breech presentations prior to implementation of the partograph and 817 after. The overall Cesarean section rate was 29.7% (21.6% emergency and 7.6% elective). Introducing the partograph reduced Cesarean sections for multigravida from 27.1% to 19.3% (non-significant) but had no impact on the rate for primigravida (38.5% to 38.7%). Prolonged labor (>18 hours) was reduced significantly among multigravida and primigravida ( P<0.05), despite a reduced use of oxytocin. Intrapartum stillbirths fell (non-significantly) from 1.9% to 11.1% (all parties combined). Fetal outcome, as measured by intrapartum deaths and Apgar scores <7 at 1 minute, was significantly better ( P<0.05) when delivery was by Cesarean section rather than vaginally, regardless of use of the partograph. Conclusion: The use of the WHO partograph in the management of breech labor reduces prolonged labor and (among multigravida) Cesarean sections and improves fetal outcome. In this study, however, Casarean section was a safer method of delivery for the baby, regardless of use of the partograph.

Emergency symphysiotomy for the trapped head in breech delivery: indications, limitations and method.

Careful case selection can avoid most obstetrical emergencies. However, even with optimum management of breech labour, the fetal head may become trapped. Since doctors in developing nations must be prepared for this dire situation, this article reviews breech case selection and outlines the steps in breech delivery, illustrating symphysiotomy for the entrapped head. The limitations and precautions associated with symphysiotomy are stressed.

462 CT Pelvimetry in Managing Breech Labor

462 CT Pelvimetry in Managing Breech Labor

Cryptorchidism, and epidemiologic study with emphasis on the relationship to central nervous system dysfunction.

This case-control study examines the relation of cryptorchidism to central nervous system dysfunction. Elevated odd ratios were found for cerebral palsy (RR = 34), low IQ (RR = 2.7), and low motor function measured by the Bayley test (RR = 3.6). Low IQ and cerebral palsy were independent risk factors for cryptorchidism. Breech labor (RR = 2.6), a gestation less than 34 weeks (RR = 2.0), and being a twin (RR = 4.1) were also independent risks. Other risk factors were estrogen use by the mother (RR = 3.3) and a maternal Quetelet index less than 24 (RR = 1.6). All of these risks were statistically significant. These factors suggest that cryptorchidism may be caused either by sex steroid action directly on the testes or by CNS damage, which in turn causes suppression of pituitary gonadotropins. The increased occurrence of cryptorchidism in twins and small babies indicates that retarded general fetal development can be another mechanism for maldescent of the testes.

Umbilical Cord Acid-Base State and Apgar Score in Term Breech Neonates

Umbilical cord acid—base state and Apgar score were compared in neonates after breech and vertex term birth. The breech group comprised 149 consecutive new-borns, 91 born vaginally and 58 by cesarean section. The control group consisted of a random sample of 150 new-borns in vertex presentation: 100 born vaginally and 50 by cesarean section. Among vaginally born babies, the 1-min Apgar score was more often depressed in the breech presentation group than in the vertex group; after 5 min the Apgar scores were comparable in both groups. No difference was found in umbilical cord values of pH and base excess between the breech and the vertex groups when comparison was made within each delivery mode. In both greups, umbilical cord values were lower after vaginal than after abdominal delivery. It is concluded that in selected cases, uneventful vaginal breech labor and delivery at term is not associated with an increased risk of asphyxia.

Umbilical Cord Acid‐Base State and Apgar Score in Term Breech Neonates

Umbilical cord acid-base state and Apgar score were compared in neonates after breech and vertex term birth. The breech group comprised 149 consecutive newborns, 91 born vaginally and 58 by cesarean section. The control group consisted of a random sample of 150 newborns in vertex presentation: 100 born vaginally and 50 by cesarean section. Among vaginally born babies, the 1-min Apgar score was more often depressed in the breech presentation group than in the vertex group; after 5 min the Apgar scores were comparable in both groups. No difference was found in umbilical cord values of pH and base excess between the breech and the vertex groups when comparison was made within each delivery mode. In both groups, umbilical cord values were lower after vaginal than after abdominal delivery. It is concluded that in selected cases, uneventful vaginal breech labor and delivery at term is not associated with an increased risk of asphyxia.