Vaginal Breech Delivery Research Articles

Implementation of the external cephalic version in breech delivery. Dutch national implementation study of external cephalic version

BackgroundBreech presentation occurs in 3 to 4% of all term pregnancies. External cephalic version (ECV) is proven effective to prevent vaginal breech deliveries and therefore it is recommended by clinical guidelines of the Royal Dutch Organisation for Midwives (KNOV) and the Dutch Society for Obstetrics and Gynaecology (NVOG). Implementation of ECV does not exceed 50 to 60% and probably less.We aim to improve the implementation of ECV to decrease maternal and neonatal morbidity and mortality due to breech presentations. This will be done by defining barriers and facilitators of implementation of ECV in the Netherlands. An innovative implementation strategy will be developed based on improved patient counselling and thorough instructions of health care providers for counselling.Method/designThe ultimate purpose of this implementation study is to improve counselling of pregnant women and information of clinicians to realize a better implementation of ECV.The first phase of the project is to detect the barriers and facilitators of ECV. The next step is to develop an implementation strategy to inform and counsel pregnant women with a breech presentation, and to inform and educate care providers. In the third phase, the effectiveness of the developed implementation strategy will be evaluated in a randomised trial. The study population is a random selection of midwives and gynaecologists from 60 to 100 hospitals and practices. Primary endpoints are number of counselled women. Secondary endpoints are process indicators, the amount of fetes in cephalic presentation at birth, complications due to ECV, the number of caesarean sections and perinatal condition of mother and child. Cost effectiveness of the implementation strategy will be measured.DiscussionThis study will provide evidence for the cost effectiveness of a structural implementation of external cephalic versions to reduce the number of breech presentations at term.Trial RegistrationDutch Trial Register (NTR): 1878

Evolving Evidence Since the Term Breech Trial: Canadian Response, European Dissent, and Potential Solutions

ObjectivesWe wished to gain insight into Canadian hospital policy changes between 2000 and 2007 in response to (1) the initial results of the Term Breech Trial suggesting delivery by Caesarean section was preferable for term breech presentation, and (2) the trial’s two-year follow-up and other research and commentary suggesting that risks associated with vaginal breech delivery and delivery by Caesarean section were similar. We also wished to determine the availability of vaginal breech delivery and the feasibility of establishing breech clinics and on-call squads, and whether these could include midwives. MethodsIn 2006, we sent surveys to the 30 largest maternity centres in Canada asking about their changes in practice in response to results of the initial Term Breech Trial and the subsequent two-year follow-up and the possibility of establishing breech clinics and on-call delivery squads and whether they could include midwives. ResultsOf the 30 surveys sent, responses were received from 20 maternity centres in six provinces. Hospitals were almost five times more likely to adopt a policy of requiring Caesarean section for breech delivery when current evidence suggested that it decreased risk for the neonate than they were to reintroduce the option of vaginal breech delivery when it did not. A breech clinic was considered possible, feasible, and desirable by only one centre, and forming a breech squad was similarly regarded by only two hospitals; 70% of respondents, however, did not entirely dismiss either possibility. ConclusionsThe weight of epidemiologic evidence does not support the practice developed in Canadian hospitals since the Term Breech Trial that recommends delivery by Caesarean section for all breech presentations. Obstetric and midwifery bodies will require creative strategies to make clinical practice consistent with current national and international evidence.

Singleton Breech at Term: Two Continents Two Approaches

Breech presentation is a complication in 3% to 4% of singleton pregnancies at term. On the strength of a large study published in the early 2000s, the American College of Obstetricians and Gynecologists (ACOG) recommended Caesarean section be routinely performed in such cases. However, French gynaecologists continue to perform vaginal breech deliveries. Through various observational studies, they have shown that their management approach, although different from the one used in North America, is safe. In 2006, the ACOG declared that vaginal delivery of a breech presentation may be acceptable under specific circumstances. In this analysis, we compare North American and French practices and present a protocol of care for the management of term breech presentation based on French recommendations.

Accouchement du siège par voie basse : l’expérience des internes en gynécologie obstétrique français

To evaluate French trainees in Obstetrics and Gynaecology's (OG) training and clinical practice of vaginal breech delivery (VBD). A national survey was conducted among the 993 French trainees undergoing a 5-years training program in OG. Respondents were invited to specify whether they had received theoretical teaching in the management of VBD, whether they had used training mannequins, and the number of VBD they had performed. Answers were analyzed according to the seniority: trainees in years 1 to 3 were considered as juniors, and those in years 4 and 5 as seniors. Response rate was 45.5%. Overall, 41.6% of trainees had never been taught the management of a VBD. Seniors were significantly more likely than juniors to have received such a theoretical training: 67.7% vs 51.4%, respectively (p=0.001). Mannequin was used by 45.6% of trainees without influence of seniority. Overall, 49.1% of trainees had performed less than five VBD. This rate was 28.7% among seniors vs 64.8% among juniors (p<0,001). The level of theoretical training and practice in the management of VBD is restricted and should be improved.

Autism Spectrum Disorders in Extremely Preterm Children

To investigate the prevalence, correlates, and antecedents of autism spectrum disorders (ASD) in extremely preterm children. We conducted a prospective study of all births <26 weeks gestation in the United Kingdom and Ireland in 1995. Of 307 survivors at 11 years, 219 (71%) were assessed and compared with 153 term-born classmates. Parents completed the Social Communication Questionnaire (SCQ) to assess autism spectrum symptoms, and ASD were diagnosed by using a psychiatric evaluation. An IQ test and clinical evaluation were also administered. Longitudinal outcome data were available for extremely preterm children. Extremely preterm children had significantly higher SCQ scores than classmates (mean difference, 4.6 points; 95% CI, 3.4-5.8). Sixteen extremely preterm children (8%) were assigned an ASD diagnosis, compared with none of the classmates. By hospital discharge, male sex, lower gestation, vaginal breech delivery, abnormal cerebral ultrasound scanning results, and not having had breast milk were independently associated with autism spectrum symptoms. By 6 years, independent associates were cognitive impairment, inattention and peer problems, withdrawn behavior at 2.5 years, and not having had breast milk. Extremely preterm children are at increased risk for autism spectrum symptoms and ASD in middle childhood. These symptoms and disorders were associated with neurocognitive outcomes, suggesting that ASD may result from abnormal brain development in this population.

Perinatal outcomes of singleton term breech deliveries in Basra

This study aimed to assess the perinatal morbidity and mortality in breech deliveries, to study the correlation of parity and birth weight with perinatal mortality by mode of delivery. Of 210 women in labour in Basra maternity and child hospital, 97 underwent vaginal breech deliveries and 113 delivered by caesarean section. Birth trauma was restricted to vaginal deliveries. The perinatal mortality was significantly higher in vaginal deliveries (8.2%) compared with caesarean deliveries (0.9%). A higher perinatal mortality was recorded among infants > 3500-4000 g birth weight in vaginal deliveries. Caesarean section reduced the perinatal mortality in both nulliparous and parous women in term breech infants.

Vaginal delivery versus cesarean section for term breech delivery

The optimal method of delivery for breech presentation at term still remains a matter of controversy. This is probably due to the fact that the skills of vaginal breech delivery are being lost. The aim of this study was to examine risk factors: mother's age, parity, labor's duration, estimated neonatal birth weight for the mode of breech presentation delivery at term as well as the influence of the delivery mode on neonatal outcome. A retrospective study of 401 terms (more than 37 week's gestation) breech deliveries at the Institute of Gynecology and Obstetrics, Belgrade, from 2007 to 2008 was made. The following groups with respect to mode of delivery were included: the group I - vaginal delivery (VD) in 139 patients; the group II - urgent cesarean section (UCS) in 128 patients; and the group III - elective cesarean section (ECS) in 134 patients. Mother's age, parity, duration of VD, neonatal birth weight (BW), the Apgar score at 5th minute, and duration of stay in a neonatal intensive care unit (NICU) were determined. Neonatal mortality and major neonatal morbidity were compared according to the route of delivery. Fetuses and neonates with hemolytic disease and fetal and neonatal anomalies were excluded from the study. For statistical analyses we performed Student's t test, Chi2 likelihood ratio, Kruskall-Wallis test, Mann Whitney test, and ANOVA. The mean age of patients in the group I was 28.29 +/- 4.97 years, in the group II 29.68 +/- 5.92 years and in the group III 30.06 +/- 5.41 years. Difference in mother's age between the group I and III was significant (p = 0.022). In the group III there were 73.9% nuliparous similarly to the group II (73.4%). We performed ECS in 54.6% of the nuliparous older than 35 years, and 54.4% multiparous younger than 35 years were delivered by VD. The use of oxytocin for stimulation of vaginal labor was not associated with its duration (p = 0.706). Lowset maneuver was performed in 88.5% of the VD. Mean BW of neonates was 3189.93 +/- 399.42 g in the VD group, 3218.59 +/- 517.71 g in the UCS and 3427.99 +/- 460.04 g in the ECS group. Neonates of the estimated BW below 2500 g were delivered by UCS in 5.5% cases, vaginally in 3.6% cases and by ECS in 2.2% cases. Neonates of the estimated BW above 3 500 g were delivered by ECS in 44.8% cases, vaginally in 23.0% cases and by UCS in 30.5% cases. There was a statistically significant difference between the VD and UCS groups (p = 0.004). Neonatal well-being was diagnosed in 75.5% of the neonates in the VD group, in 72.4% of the neonates in the ECS group, and in 65.5% of the neonates in the UCS group. The Apgar score at 5th min > 8 was observed in 96% of the neonates in the VD group, in 97.5% of the neonantes in the ECS group and in 94.5% of the neonates in the UCS group. In breech presentation, perinatal asphyxia remained increased in the VD group by 9.4% as compared with the UCS group, 5.5% (p = 0.001) and the ECS group, 3.0% (p = 0.016). Neonates stayed in NICU significantly longer after UCS compared with VD or ECS (7.21 +/- 10.74 days vs 3.99 +/- 1.33 days and 5.34 +/- 2.88 days, respectively; p = 0.001 and p = 0.037, respectively). There was no diagnosed intracranial hemorrhage, brachial plexus injury and birth trauma in any groups. Also, there was no early neonatal death. For breech presentation elective cesarean section remains the major delivery method in nuliparous older than 35 years, while vaginal delivery is considered to be the method of choice in younger multiparous with ultrasonographically estimated neonatal birth weight 2500-3500 grams.

Liver Laceration A Very Rare Form Of Birth Trauma: A Case Report

A case of haemoperitoneum in a neonate secondary to liver laceration following birth trauma is presented. The neonate was in a state of shock. The patient required an exploratory laparotomy & did very well postoperatively. It is a very rare form of birth trauma following assisted vaginal breech delivery. CASE A 36 weeks gestation baby was delivered at a district health facility by assisted breech delivery with grade 2 meconium & APGAR score 3, 4 & 7 . After initial resuscitation & subsequent nasotracheal intubation baby was referred to neonatal unit at our hospital. On examination the baby was 2.28 kg wt , pink in colour, no obvious congenital anomalies, swollen & decreased movement of left upper limb, right cephal haematoma, mild oozing from mouth from torn frenulum & considerable bruising noticed around the body. Radiological examination revealed fracture left clavicle. Patients Hgb was-14.gm/dl,WBC-40.3 x10 / , PLT115 x10 / μl Fourteen hours after admission to baby developed sudden pallor, was noted to be very lethargic with mild to moderate abdominal distension. Intra abdominal bleeding was suspected, baby was then electively ventilated by endotracheal tube, an urgent USS was done & referred to Paediatric Surgery. Hgb was then 5.7gm /dl, PLT-71 x10 / , WBC-24.5 x10 / μl USS of abdomen revealed 2.7cm x 2.3cm x2.3cm heterogeneous lesion noted in the posterior segments of right lobe of liver with free fluid in pelvis & around the liver. Diagnostic peritoneal aspiration revealed haemoperitoneum. Informed consent was obtained from parents & an emergency exploratory laparotomy was performed-due to sudden & severe decompensation –findings were :50ml blood around the liver, with a 2.5cm x 2cm sub-capsular hematoma on the inferior surface of right lobe of liver, the rest of abdominal findings were normal. The liver was packed with gel foam.

Perinatal Outcome of Babies Delivered to Eclamptic Mothers: A Prospective Study from a Nigerian Tertiary Hospital

Background: Eclampsia is a leading cause of maternal and perinatal mortality in Nigeria. Preventive and interventional measures have been shown to reduce maternal mortality and morbidity with no significant beneficial effect on neonatal outcomes. The aim of this study is to assess the perinatal outcome of eclampsia at the University of Port-Harcourt Teaching Hospital (UPTH). Materials and methods: This prospective, cross-sectional study was conducted on 88 consecutive patients presenting with antepartum eclampsia at the UPTH between 1st January 2007 and 31st December 2008. A protocol was developed and used to collect information about socio-demographic characteristics, mode of delivery, perinatal complications and outcome. Data collected was entered into a spread sheet using SPSS 15.0 for Windows® statistical software which was also used for analysis. Chi square was used to test relationship between variables. P value&lt;0.05 was considered statistically significant. Results: There were a total of 5488 deliveries at the University of Port-Harcourt Teaching Hospital from January 2007 to December 2008. Of these, 5,310 were live births while 404 were perinatal deaths giving perinatal mortality rate of 73.6 per 1000 live births. Eighty eight (1.6%) of the mothers were eclamptic. Eight (9.1%) were booked, 80 (90.1%) were unbooked. The mean gestational age at delivery was 35.1 ± 4.2 weeks. The main mode of delivery was by emergency caesarian section in 49 (55.7%) of the patients. Others were spontaneous vertex delivery (34.1%), assisted vaginal breech delivery (6.8%) and instrumental vaginal delivery (3.4%). Fifty four babies (61.4%) were admitted into the Special Care Baby Unit. Indications for admission include prematurity (n=23), low birth weight (n=10), severe birth asphyxia (n=12), neonatal jaundice (n=4) and neonatal sepsis (n=5). There were 37 perinatal deaths giving a perinatal mortality rate of 411 per 1000 live births. Of the mortalities, 19 were intrauterine foetal deaths, while 18 were early neonatal deaths. Causes of death include severe birth asphyxia (n=6), respiratory distress syndrome (n=4), prematurity (n=4), neonatal jaundice (n=1) and sepsis (n=3). Conclusion: Eclampsia is a major contributor of perinatal mortality and morbidity in Nigeria. Detection and appropriate management of preeclampsia is critical to reduce the risk of eclampsia.

Prevalence Of HIV Infection Among Antenatal Attendees At Uyo Teaching Hospital, Akwa Ibom State, South-South Nigeria

This retrospective study was conducted at the maternity unit of the University of Uyo Teaching Hospital Uyo. The aim was to determine the prevalence of HIV infection among pregnant women receiving antenatal care in the center. The voluntary counselling and testing register, the partner notification and antenatal clinic registers of all patients that booked for antenatal care between 1st July 2005 and 31st December 2007 were reviewed. There were 5,635 new antenatal clients during the study period out of which 464 were confirmed HIV positive resulting in a prevalence of 8.2%. Most of the patients were between 21-30 years (70.0%). About 59.4% of the patients were multiparous while 49.4% booked for antenatal care in the third trimester of pregnancy. HIV was diagnosed in the antenatal clinic in 408 (87.9%) of the patients and 182 (39.2%) received antiretroviral drugs during pregnancy. Only 38.8% of the patients accepted to notify their partners. One hundred and eighty eight patients delivered in the hospital. One hundred and twenty (63.8%) had spontaneous vaginal delivery, 63 (33.5%) were delivered by caesarean section, 3 (1.7%) had assisted vaginal breech delivery and 2 (1.1%) had ventouse delivery. The high prevalence of HIV infection among women pregnant women who have antenatal care in our hospital is highlighted. The intensification of strategies aimed at primary prevention of HIV infection in the community, encouraging all pregnant women to avail themselves of orthodox antenatal care, and the need to emphasize the advantages of self disclosure of serostatus to partners during counselling sessions in the antenatal clinic are advocated. KEY WORDS: HIV Positive women, antenatal attendees, Uyo

The vexed issue of cerebral palsy and breech presentation

The investigation of the association between breech presentation and cerebral palsy (CP) presents a major challenge because of the rarity of the outcome in a sub-population that only accounts for 3 to 4% of term deliveries. Randomized studies such as the Term Breech Trial1 are unlikely to ever recruit enough cases to gain sufficient power to examine such rare outcomes. Cohort studies remain our best source of data to establish associations, although they are unable to demonstrate causality. Using data from a national CP registry and the Medical Birth Registry of Norway, Andersen et al. tested the hypothesis that breech presentation is an independent risk factor for CP and whether this relates to mode of delivery. They also aimed to assess if breech presentation is associated with low Apgar scores, and severity and sub-type of CP.2 This study demonstrates a significant association between breech delivery and CP. No particular pattern of CP was associated with breech births. However, the study also demonstrates many of the difficulties inherent in the use of large data banks to test hypotheses. The first problem is that although there were initially 374 cases of CP diagnosed in the study population of over 170 000 births, only 245 were available with sufficient information to be included in the study. This degree of exclusion will always put significant limitations on the conclusions that can be drawn since it is not possible to know that missing data is not in some way a systematic error. Even in CP cases where information was considered sufficient for inclusion, information as basic as gestation (term or preterm) was missing in 3 out of 29 breech and 23 out of 216 vertex live births. Term breech infants had a relative risk of CP of 2.98 compared with term vertex infants. When considering all breech births the relative risk was just over 4 and this remained significant when controlled for gestational age, assisted conception, small for gestational age, and sex. The elements of this association remain unclear.3 To clarify how mode of delivery affects CP in breech presenting infants would require a larger sample size, comparisons including Caesarean section and vaginal birth in breech, breakdown by elective and emergency Caesarean section, and comparison of CP rates between breech and vertex infants delivered at term in the same way (e.g. emergency/elective Caesarean section term vertex compared with emergency/elective Caesarean section term breech). This would help to control for the factors that lead to choice of delivery mode. With so few cases of breech CP these breakdowns are difficult. Birth defects were nearly three times as common in infants presenting by the breech as in those presenting by the vertex. This association is well described. Antenatal diagnosis of a birth defect may well have an impact on planned mode of delivery. Knowledge antenatally, for instance, that an infant has a serious malformation is likely to influence whether a mother chooses a Caesarean section performed in the fetal interest. The strong association between birth defects and newborn encephalopathy,4 as well as CP,5 has the capacity to confound findings if adjustment for the presence of birth defects is not included in the analysis. This remains a difficulty with the Andersen et al. study. The authors have attempted to address the issue of CP alone as an outcome. When it comes to consideration of the impact of mode of delivery, CP alone is an inadequate endpoint since the risk to the fetus is of death or damage. Not only is death a crucial endpoint, but it is very possible that some of those who died might have gone on to develop CP should they have survived. The picture of outcomes is, therefore, incomplete and might lead to false assumptions about the usefulness or otherwise of Caesarean section in preventing CP among singletons presenting by the breech. Birth complications in breech presentation, e.g. cord prolapse or a trapped head, have severe consequences, including perinatal death, and need to be carefully considered along with CP in assessing the safety of a proposed mode of delivery. Consideration of CP alone may lead to a false impression of the safety of one mode over another. Following the Term Breech Trial very few vaginal breech deliveries are undertaken in developed countries. Between 1996 and 2005 the rate of vaginal delivery of breech presenting infants halved from over 20% to only 10%,6 most of whom were probably second twins. De-skilling of the obstetric workforce is a growing problem. A proportion of singletons who present by the breech will still either arrive at hospital too late to receive a Caesarean section or have mothers who choose not to have one. It could be argued that, soon, breech delivery will be beyond the experience of most obstetricians and midwives.

P269 Vaginal breech delivery and early neonatal outcome

P269 Vaginal breech delivery and early neonatal outcome

I168 Where facilities for safe caesarean section exist, there is no role for term breech vaginal delivery

I168 Where facilities for safe caesarean section exist, there is no role for term breech vaginal delivery

Peut-on concilier autonomie maternelle et responsabilité médicale dans les décisions de voies d’accouchement des fœtus en siège ? Rôle de l’information

As far as breech vaginal delivery remains an acceptable option, each case has to be evaluated in order to determine whether in that particular situation it is medically relevant. When vaginal delivery is to be envisaged, maternal consent is needed. This implies seeking medical information that allows women to express their autonomy and to be part of the decision regarding their delivery. This article concerns a physicians reflection on medical information and on connections between the obstetrician's responsibility, that of the future mother, and autonomy. Understanding information as necessarily arising from an exchange between the care giver and the future mother is the condition that allows the coexistence of maternal autonomy and medical responsibility.

Intravenous nitroglycerin: a potent uterine relaxant for internal podalic version: case

Dear Editor, The uterine-muscle relaxation required for complicated obstetric situations traditionally has been achieved by use of a potent inhalation anesthetic. However, this procedure exposes the obstetric patient with full stomach to unnecessary general anesthesia, with the attendant risk and potentially lethal complications. Emergent uterine relaxation may be required for conditions such as retained placenta, uterine inversion, internal podalic version (IPV), and breech extraction. EVective on smooth muscle tissue and a venodilator, nitroglycerin is a short-acting and a potent uterine relaxant [1, 2]. Safety, predictability, and ease of intravenous (IV) administration of this drug have been established, and it has attracted the attention of obstetricians. Nitroglycerin is primarily indicated for the treatment or prevention of angina pectoris. Nitroglycerin has been used during manual extraction of retained placenta without clinically signiWcant hemodynamic eVects [1] and during replacement of a contracted, completely prolapsed uterus [1, 2]. Its use as a tocolytic has been reported in cesarean delivery of twins performed under spinal anesthesia: two cases of intrapartum external cephalic version, internal intrapartum podalic version of the second twin, and for the fetal head entrapment during vaginal breech delivery [1]. We report a case of IPV of intrauterine fetal demise (IUFD) in which relaxation of the uterus was accomplished quickly and safely with the use of IV nitroglycerin. A 30-year-old gravida 4 para 3 at 38 weeks gestation presented in active labor with antepartum hemorrhage since 2 h. Ultrasound conWrmed transverse lie, abruption placentae and IUFD; and examination revealed 4 cm dilated cervix. Her vitals were stable, hematocrit was 28% and coagulation proWle was normal. She made good progress, reaching 8 cm cervical dilatation over the next 4 h after which she started having hematuria so the decision was taken immediately to deliver the fetus by IPV. Uterine relaxation was achieved by direct IV nitroglycerin bolus 50 mcg along with ketamine hydrochloride 30 mg IV for sedation. Infusion of nitroglycerin at the rate of 50 mcg/min was started after 1 min of loading dose. When the uterus was relaxed (conWrmed with manual palpation), approximately 45 s after bolus, the obstetrician performed IPV and breech extraction. The procedure was completed in 4 min and 30 s. The total dose of nitroglycerin was 250 mcg. The placenta delivered spontaneously with no unusual cord traction. Transabdominal massage of the uterus and oxytocin infusion improved uterine tone. The hematocrit had decreased from 28 to 22%. One unit blood transfusion was given and she remained stable in the postpartum period. Hematuria was cleared in 2 h postpartum. Monitoring consisted of electrocardiogram, SpO2 and non-invasive blood pressure measurement. Hypotension occurred 1 min after nitroglycerin injection, which was normalized within 50 s with rapid infusion of crystalloids. The heart rate increased at the same time to 130 bpm. Side M. N. Gandhi · H. R. Iyer Department of Anaesthesiology, B. Y. L. Nair Charitable Hospital, T. N. Medical College, Dr. A. L. Nair road, Bombay 400008, Maharashtra, India

Is there a place for selective vaginal breech delivery in Malaysian hospitals: experiences from the Ipoh hospital

Background. The ‘Term Breech Trial’ (TBT) results of 2001 have impacted on the mode of delivery of breech with a low threshold for caesarean delivery (CD) worldwide.Aims. The trends in mode of delivery in developing countries have also changed. The aims of this retrospective analysis of all breech presentation was to see if similar trends are seen in Ipoh Hospital in Malaysia and if perinatal outcome is affected by mode of delivery.Methods. All breech pregnancies presenting in the labour at the Ipoh Hospital, Malaysia, irrespective of gestation or booking status were analysed with respect to mode of delivery, fetal outcome and maternal mortality.Results. Out of 4886 breech presentation between 1992 and 2004, 3725 cases were evaluable. The prevalence of breech at birth was 3%. Vaginal breech deliveries decreased from 70.4% in 1994 to 13.1% in 2004. Consequently, CDs rose to 86.9% in CDs. There were 107 perinatal deaths (1994–2004) in the series and the crude perinatal mortality rate (PNMR) was four times higher than the hospital PNMR (11.4/1000 in 2004).Conclusion. Although the CD rates rose exponentially with the release of the ‘TBT’, the mode of delivery did not impact on better PNMR in breech cases in this hospital. The need for selective vaginal births for breech, increased use of external cephalic version and the long implications of a uterine scar in future pregnancies in the ‘shared antenatal care in the local context in a developing country is discussed.

Evaluation of Clinicosocial Factors Associated with Antepartum and Intrapartum Stillbirths at Kathmandu Medical College Teaching Hospital

ABSTRACT Objective To assess the prevalence and biosocial and obstetric risk factors for antepartum and intrapartum stillbirths at a tertiary hospital in Kathmandu, Nepal. Study Design A prospective hospital based study during a one year period from 1st November 2007 to 30th October 2008. Results:18 stillbirths occurred out of the 790 deliveries that took place during the study period giving an overall stillbirth rate of 22.7 per 1000 births of which 22.2% occurred in the intrapartum period. The majority(89.9%) of patients were in the low risk age group, viz. 20-35 years. 62% were overweight, 16% obese and 22% had normal BMI. More than half (56%) were either illiterate or had only primary education and 33.3% were moderate smokers. 66.6% were nullipara and there were no grand multipara in the series. 72% had regular prenatal visits but only 33% presented with a history of loss of fetal movements. 50% delivered preterm and 22.2% were post-term while 66.6% had low birth weights. Hypertensive disorders of pregnancy and IUGR were the leading causes of stillbirths, others being prolonged PROM, cholestasis of pregnancy and congenital anomalies. 11.1% were unexplained and there was one case each of gestational diabetes, antepartum hemorrhage and vaginal breech delivery. Conclusion Avoidable intrapartum stillbirths continue to be quite high where timely and appropriate intrapartum intervention must be taken to prevent fetal loss. The identified antenatal risk factors should serve as potential targets for antenatal intervention and due importance of maternal fetal movement scoring must be stressed in the at risk patient.

Sheffield modified technique for external cephalic version

SummaryExternal cephalic version (ECV) is the manipulation of the fetus, through the maternal abdomen, to a cephalic presentation. The incidence of caesarean section for breech presentation has increased markedly in the last 20 years. External version has become more popular in the past 10 years because of the increasing evidence of risks from vaginal breech delivery, increasing demand on the reduction of caesarean sections, a strong safety record, and high success rate of ECV of up to 80%. The use of external cephalic version can produce considerable cost savings in the management of the breech presentation at term; however, there is a wide variation in the success rate, with a range between 30–80%. The ECV technique has remained unchanged for many generations without any modification. This paper provides the outcome of a small prospective study implementing a modified technique for ECV, which has a high success rate.

Iodine intake in pregnancy

doi:10.1016/j.ijgo.2008.09.019 breech and vertex neonates (7.25±0.69 vs 7.26±0.7 and 7.33±0.05 vs 7.33±0.06, respectively), and no difference in the base excess (−2.8±2 vs −2.9±2, respectively). Vaginal breech deliveries are associated with an increased risk of lower umbilical pH and adverse neonatal outcome [1,2]. This might be a direct effect of prolonged compression on the umbilical cord or some other feature during delivery [2]. Alternatively, there might be other undetermined in utero factors that have an impact on blood umbilical gases associated with breech presentation regardless of the route of delivery. We sought to eliminate the process of active labor as a factor that influences the umbilical acid base status by comparing umbilical gases and Apgar scores of neonates delivered by elective cesarean in breech or vertex presentation, which showed that there was no difference in pH levels. We speculate that lower Apgar scores and pH detected in term breech presentations should be attributed to the process of labor and delivery and not to other in utero factors.

Obstetric brachial plexus palsy: A birth injury not explained by the known risk factors

To determine the incidence and prognosis of obstetric brachial plexus injuries and analyze associated risk factors. Analysis of prospectively collected information comprising all births from 1991 to 2000, with complete follow-up of affected children. Setting. St Olav's University Hospital, a tertiary care hospital in the middle part of Norway. Thirty thousand five hundred and seventy-four children; all were examined within 24 hours of birth and 91 were diagnosed with brachial plexus injury. We reviewed the hospital records and analyzed the data submitted from our hospital to the Medical Birth Register of Norway. Risk factors are shoulder dystocia, macrosomy, diabetes, vacuum extraction and forceps delivery. The predictive power of these variables is poor. Almost half of the plexus injuries followed spontaneous vaginal deliveries with second stage of 30 minutes or less. Two newborns were delivered by cesarean section and two were vaginal breech deliveries. In 15 children (0.5/1,000) a permanent plexus injury has been diagnosed. Compared with transient plexus impairment, risk factors for a permanent injury were high maternal body mass index, shoulder dystocia, fractured humerus and fetal asphyxia. Fracture of the clavicle was significantly more frequent when the injury was transient, possibly reflecting a protective effect. The incidence of obstetric brachial plexus injury is 0.3% and the recovery rate is 84%, resulting in 0.5 permanent injuries per 1,000 births. Plexus injury is not well predicted by known risk factors. Other etiological factors should be sought.