Caesarean Section For Breech Presentation Research Articles

The breech effect: is previous caesarean section for breech presentation an independent favourable factor in vaginal birth after caesarean section

Increasing proportion of births by Caesarean section (CS) is a widespread concern to the general public and health professionals. Evidence suggests that vaginal birth after Caesarean (VBAC) may be more...

Audit of external cephalic version

BackgroundBreech presentation complicates 3–4% of all term deliveries. The term breech trial, a multi-centre trial across 121 centres in 26 countries during 1997–2000, randomising 2088 women to ‘planned Caesarean section’...

Global report on preterm birth and stillbirth (3 of 7): evidence for effectiveness of interventions.

IntroductionInterventions directed toward mothers before and during pregnancy and childbirth may help reduce preterm births and stillbirths. Survival of preterm newborns may also be improved with interventions given during these times or soon after birth. This comprehensive review assesses existing interventions for low- and middle-income countries (LMICs).MethodsApproximately 2,000 intervention studies were systematically evaluated through December 31, 2008. They addressed preterm birth or low birth weight; stillbirth or perinatal mortality; and management of preterm newborns. Out of 82 identified interventions, 49 were relevant to LMICs and had reasonable amounts of evidence, and therefore selected for in-depth reviews. Each was classified and assessed by the quality of available evidence and its potential to treat or prevent preterm birth and stillbirth. Impacts on other maternal, fetal, newborn or child health outcomes were also considered. Assessments were based on an adaptation of the Grades of Recommendation Assessment, Development and Evaluation criteria.ResultsMost interventions require additional research to improve the quality of evidence. Others had little evidence of benefit and should be discontinued. The following are supported by moderate- to high-quality evidence and strongly recommended for LMICs:• Two interventions prevent preterm births—smoking cessation and progesterone• Eight interventions prevent stillbirths—balanced protein energy supplementation, screening and treatment of syphilis, intermittant presumptive treatment for malaria during pregnancy, insecticide-treated mosquito nets, birth preparedness, emergency obstetric care, cesarean section for breech presentation, and elective induction for post-term delivery• Eleven interventions improve survival of preterm newborns—prophylactic steroids in preterm labor, antibiotics for PROM, vitamin K supplementation at delivery, case management of neonatal sepsis and pneumonia, delayed cord clamping, room air (vs. 100% oxygen) for resuscitation, hospital-based kangaroo mother care, early breastfeeding, thermal care, and surfactant therapy and application of continued distending pressure to the lungs for respiratory distress syndromeConclusionThe research paradigm for discovery science and intervention development must be balanced to address prevention as well as improve morbidity and mortality in all settings. This review also reveals significant gaps in current knowledge of interventions spanning the continuum of maternal and fetal outcomes, and the critical need to generate further high-quality evidence for promising interventions.

Bilateral humerus fracture in a neonate after cesarean delivery

Humerus fractures in neonates are rare, but can occur during cesarean section and bilateral humerus fracture has not been reported yet. This case represents a newborn delivered by cesarean section for breech presentation which resulted in bilateral humerus fracture.

Fetal laceration injury during cesarean section and its long-term sequelae: a case report

This case report illustrates the cosmetic outcome of a scalpel-related laceration injury sustained to a newborn infant that occurred during the course of an elective cesarean section for breech presentation. This buttock laceration was noted to be 2 cm in length at the time of birth. Twelve years later, the same scar had migrated in a cephalad direction and had increased to 10 cm in length.

Évaluation des protocoles de décision de voie d’accouchement en cas de présentation du siège dans 19 CHU en France

Recently, a Belgo-French study led by PREMODA group showed that there was no significant difference between caesarean and vaginal delivery for neonatal outcome. To study protocols and rate of vaginal delivery of single breech in 2006 in the 30 French teaching hospitals that participated to the PREMODA study. Postal survey. Nineteen university hospitals answered (63%). Eighteen used a written protocol and three of them underwent systematic prophylactic caesarean section for breech presentation. Among 15 others, the decision criteria for the way of delivery included pelvimetry, absence of primary cephalic deflexion and foetal measurements. Some centres required additional restrictions. The rates of vaginal delivery varied from 1.7 to 49.7% depending on the centre with very different policies concerning decisional elements. Protocols with restrictions less than three were associated with higher percentages of vaginal delivery (28.9% vs. 21.6%, p<0.001). Most of teaching centres use a written protocol for breech delivery. Huge variations exist between vaginal delivery rates which seems partially linked to the number of restrictions of the protocol. However, criteria used to accept vaginal delivery in breech presentation are variable between centres and do not lie on objective findings.

Blue episodes in a neonate

In September, 2007, a 9-day-old baby girl presented to the emergency department with increased respiratory eff ort and weight loss. She was delivered by elective caesarean section for breech presentation. At birth, she was fl oppy, cyanosed, and bradycardic. Her Apgar score was 5 and 9 at 1 and 5 min, respectively. On examination she had a grade II systolic murmur. Blood pressure and oxygen saturation were normal. On day 3, she was noted to have some weight loss due to poor feeding. Following successful supervised feeding and some weight gain, she was discharged the following day, in good condition, with an echocardiogram planned for day 9. On day 6, however, the mother raised concerns about her baby’s rapid breathing and continuing feeding diffi culties but was reassured by the community midwife. When we saw the baby in the emergency department she was cyanosed (SaO2 88% on room air), with a respiratory rate of 30–40/min, intercostal recession, and grunting. She had noisy breathing with intermittent episodes of desaturation and bradycardia. Her nasal passages were patent. The rest of the clinical examination was unremarkable. Capillary blood gas showed respiratory acidosis (ph 7·28, PO2 6·5 kPa, PCO2 9·1 kPa, HCO3 31 mmol/L, and base excess +1·6 mmol/L). Septic screen was negative. Chest radiography showed a boot shaped heart, suggestive of congenital cyanotic heart disease. She was transferred immediately to a specialist unit for a cardiology opinion. Echocardiography showed a small posteromuscular ventricular septal defect which did not account for the clinical presentation. Her noisy breathing was attributed to inspiratory stridor, and subsequent microlaryngoscopy and bronchoscopy (MLB) showed a large cyst arising from the vallecula (fi gure A). Aspiration of the cyst failed because of the viscosity of the contents; the cyst was incised and de-roofed successfully (fi gure B). Histological examination showed a squamous epi thelium lined cyst with a smooth muscle-containing wall. She was discharged home on the 10th post-operative day with intermittent soft stridor, and on demand feeds. When the baby was reviewed 6 weeks later in clinic, she had gained weight and was well, with no stridor or breathing diffi culty, and feeding well. Congenital tumours of the oropharynx are rare. Laryngeal cysts are broadly classifi ed as ductal (75%) or saccular (25%). Ductal cysts arise because of obstruction in the collecting ducts; vallecular cysts are a form of ductal cyst. The vallecula is the groove between the epiglottis and the base of the tongue; during swallowing food enters the vallecula and passes around the epiglottis either side into the pyriform aperture and then into the oesophagus. Although vallecular cysts are benign, a mortality rate of 40% has been reported because of major airway obstruction. They arise because of obstruction in mucous glands at the base of the tongue. Vallecular cysts can be detected in pregnancy as early as 25 weeks’ gestation. They can present antenatally as polyhydramnios, tracheal compression, or compression of cervical vessels or hypoglossal nerve. Postnatally, they can present as respiratory distress. Other clinical features are intercostal recession, failure to thrive, cough, dysphonia, dysphagia, and cyanosis. MLB and rigid endoscopy are the mainstay of diagnosis. A fi bre-optic review of the upper airway and bronchus is mandatory to rule out laryngo/bronchomalacia. The defi nitive treatment of these cysts is marsupialisation with CO2 laser or electrocautery. The prognosis is generally good with no risk of recurrence. Cyanosis in neonates is often caused by congential heart problems or lung pathology; our case shows that investigating non-cardiac causes of cyanosis in neonates can be a life-saving measure.

The Biological Characteristics of Human Third Trimester Amniotic Fluid Stem Cells

Third trimester amniotic fluid (AF)-derived human mesenchymal stem cells (MSCs) can be greatly expanded in vitro and induced to differentiate into multiple mesenchymal cell types. This study aimed to investigate the biological characteristics of MSCs from third trimester AF as a new source of therapeutic stem cells. Forty third trimester AF samples were obtained from healthy women who underwent elective caesarean section for breech presentation. A simple culture protocol for MSCs was used. A cell growth curve was drawn, and cell surface antigens and cytokines were analysed by immunofluorescent staining, reverse transcription-polymerase chain reaction and flow cytometry. MSCs from third-trimester AF were successfully isolated, cultured and enriched. MSCs expanded extensively without feeders, they were not tumourigenic and were induced to differentiate into osteocytes. Surface antigens were analysed and found to express the pluripotency marker Oct-4. Considering the great feasibility of biomedical engineering using MSCs, third trimester AF may provide a rich source for investigation of human MSCs.

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.

Femur fracture during abdominal breech delivery

While vaginal breech delivery, although rare, can cause femur fracture, abdominal breech delivery is not expected to cause it. A 2,490-g female infant was delivered at term by elective cesarean section for breech presentation. She sustained a fracture of the femur shaft. A simple splinting led to a complete healing of the fracture without sequelae. Although abdominal breech delivery reduces the risk of birth trauma, we must be aware that femur fracture can occur regardless of the mode of delivery.

Bilateral femur fracture in a newborn: an extreme complication of cesarean delivery

Bilateral femoral fracture due to birth trauma which is extremely rare, can occur during cesarean section. This case represents a newborn delivered by cesarean section for breech presentation who sustained bilateral subtrochanteric fracture of the femur. The newborn was treated with immobilization in pelvipedal cast. It has been concluded that performing accurate delivery technique and immediate evaluation-orthopedic consultation of the newborn in the presence of forced obstetrical maneuver are important.

Associated risk factors in children who had late presentation of developmental dysplasia of the hip

The purpose of this study was to assess the role of clinical examination, associated risk factors and plain radiograph of the pelvis in children who had late presentation of DDH. We report on a 7-year prospective study, in children who had late presentation of developmental dysplasia of the hip (DDH). For this purpose, 740 hips in 370 referred children, age range 3-7 months (mean 3.44 months) were clinically and radiologically assessed, and the associated risk factors recorded. Female sex, first born, positive family history and breech presentation were confirmed as risk factors for DDH. Significant findings were an increased risk for vaginal delivery over caesarean section for breech presentation (P = 0.002). There was an increased risk for caesarean section in the absence of breech presentation. Multiple births and preterm births had a reduced risk. For breech presentation, the risk of DDH was estimated to be at least 1.6% for girls and 3.4% for boys; a combination of factors increased the risk. Limitation of abduction (43.2%) and asymmetry of the groin skin folds (72.7%) were found to be the two most common clinical findings associated with DDH. Bilateral acetabular dysplasia is more common than unilateral dysplasia. Foot deformities were rarely encountered in children with acetabular dysplasia. The percentage of first-born babies who had DDH is lower than reported in the literature (34%), but still shows significant risk. We did find that bilateral acetabular dysplasia is more common than unilateral dysplasia. Torticollis and foot deformities are rarely found to be associated with DDH. All these findings needs further evaluation in children who had surgical treatment for DDH, to see if they are different from dysplastic groups. Limitation of abduction is an important clinical finding, but is not always associated with DDH. Asymmetry of the skin folds in the groin were found to be an important clinical finding associated with DDH for all age groups. As clinical examination depends on many factors, and most DDH cases are of the dysplastic type, it is mandatory to depend on further diagnostic tools for confirmation of DDH.

Focal Myometrial Defect and Partial Placenta Accreta in a Pregnancy following Bilateral Uterine Artery Embolization

A 29-year-old nulliparous patient was treated with uterine artery embolization (UAE) for a large symptomatic uterine fibroid, resulting in a marked reduction of the tumor volume. She subsequently conceived and progressed through pregnancy uneventfully. At cesarean section for breech presentation at term, a large fundal myometrial defect was encountered. In addition, the patient presented with unexpected partial placenta accreta, which resulted in massive atonic uterine bleeding. It is suggested that UAE was implicated in the pathogenesis of myometrial damage and abnormal placentation. It is proposed that the antenatal care of pregnancies after UAE include careful imaging of the placenta, its vasculature, and the thickness of overlying uterine wall so peripartum management can be appropriately planned.

Labor analgesia and cesarean section in women affected by tuberous sclerosis: report of two cases

Tuberous sclerosis is a multi-system disease characterized by the presence of benign growths in many tissues, mostly localized in skin, brain, kidney and lungs. Epileptic seizures and renal hemorrhage are frequent in such patients. Apart from life-threatening hemorrhage after rupture of angiomyolipomatoma, few data are available about anesthetic considerations during pregnancy. We report two cases of pregnant patients with tuberous sclerosis, one scheduled for medical termination of pregnancy at 27 weeks of gestational, the other a cesarean section for breech presentation under general anesthesia. We review and discuss the ability to perform regional anesthesia in each case.

The end of vaginal breech delivery

Sir, G Burke1 asks: ‘Is it worth doing 60 or 160 more caesareans, which nowadays cost nothing in terms of maternal mortality, morbidity or economically, to avoid one baby’s death?’ Regarding the Netherlands for the 5 years after the Breech Trial (2001–05), the answer is as follows: • Three hundred and twenty extra planned caesarean sections are needed to ‘save’ one extra child (short term)2 and even more in the long term because of uterine rupture, placenta praevia and an increased stillbirth rate before term associated with previous caesarean sections.3 The ‘costs’ were the following:3 • Four maternal deaths as a result of elective caesarean section for breech presentation (1:2200). These women would not have had an elective caesarean section when the child was in cephalic presentation.4 • Potentially life-threatening complications from uterine scars during future pregnancies can be expected. In a nationwide survey of serious maternal morbidity in the Netherlands from August 2004 to August 2006, 78 women with a previous elective caesarean section for breech were registered because of vital obstetric haemorrhage of >3000 ml (n = 39) and uterine scar rupture (n = 39). • In future pregnancies, four children with brain damage after uterine rupture can be expected. • 35 million Euros were spend on the 7500 extra caesarean sections. Out of 2.154 children born after vaginal breech delivery, 2.114 (98.1%) were alive and without ‘severe’ morbidity as compared with 5.515 (99.8%) of 5.524 elective caesarean sections for breech only and 2.088 (99.3%) after emergency caesarean section during a trial of vaginal breech delivery.2 Vaginal breech delivery thus has a slightly worse outcome than elective caesarean section, but this is not a new fact. Adverse outcome of vaginal breech delivery in the Term Breech Trial, however, was much higher (5.1%), but no other study has ever reported such high adverse outcome. The conclusion is that mode of breech delivery does not matter for 98 out of 100 children. The use of short-term combined end-point, mortality and ‘severe’ birth injury, overstates the true risk of planned vaginal delivery. This ‘severe’ birth injury results mainly in short-term morbidity. Twenty-nine ‘severe’ infant morbidities occurred after vaginal breech delivery: 9 clavicle fractures, very likely to heal without permanent injury, and 15 brachial plexus injuries, which are known to result in permanent damage in 10% (n = 2). Furthermore, one should take into account that the pulmonary morbidities were not included in the numbers of ‘severe’ injury, and these are much more frequent in elective caesarean section. In our risk-averse society, the crucial question is: which standard is reasonable to apply? Considering maternal risks, should 997 of 1000 women have a ‘superfluous’ elective caesarean section to ‘save’ the life of 3 out of 1000 babies?

Maternal deaths after elective cesarean section for breech presentation in the Netherlands

The cesarean section rate for term singleton breech babies in the Netherlands rose from 57 to 81% after the Term Breech Trial in 2000. The Dutch Maternal Mortality Committee registered and evaluated maternal mortality due to elective cesarean section for breech. Four maternal deaths after elective cesarean section for breech presentation, from 2000 to 2002 inclusive, were registered, 7% of total direct maternal mortality in that period. Two women died due to massive pulmonary embolism, both were obese, and thromboprophylaxis was not adjusted to their weight. The other two women died from sepsis, one had not receive perioperative prophylactic antibiotics. The case fatality rate for elective cesarean section for breech presentation was 0.47/1,000 operations. No death after emergency cesarean section for breech presentation was registered at the committee. Elective cesarean section does not guarantee the improved outcome of the child, but may increase risks for the mother, compared to vaginal delivery.

Comparison between the use of the Joel-Cohen incision and its modification during Stark's cesarean section

Objective. A comparative evaluation between the Joel-Cohen incision and its modification for the Stark's cesarean section (CS).Materials and methods. In a retrospective study, 477 women who underwent a Stark's CS were evaluated: 204 with the Joel-Cohen incision (JC) and 273 with a modified Joel-Cohen incision (MJC). All patients were checked for the following parameters: febrile morbidity, the need for painkillers, duration of hospital stay, and ultrasound examination for blood collection (BC) on the third postoperative day. The collections, when diagnosed were divided into three groups: (1) in the abdominal wall, (2) in the pouch of Douglas, and (3) in the lower uterine segment (LUS). Those included in the study were low-risk primiparae at term, presenting for CS for breech presentation, macrosomia, and on demand, and who had combined spinal–epidural anesthesia. Statistical evaluation was performed using SAS/V12 software.Results. There were no statistical differences between the two groups with regard to febrile morbidity, duration of need for painkillers, and hospital stay. Statistically more blood collections were found in the MJC incision group (5.4% in the abdominal wall, 12.4% in the pouch of Douglas, and 11.7% in the LUS) than in the classical JC incision group (3.9% in the abdominal wall, 10.2% in the pouch of Douglas, and 8.8% in the LUS), however without any clinical significance.Conclusions. The routine use of the classical JC incision during the Stark's CS seems to be more rational, and causes fewer blood collections.

The end of vaginal breech delivery

Sir, G Burke1 asks: ‘Is it worth doing 60 or 160 more caesareans, which nowadays cost nothing in terms of maternal mortality, morbidity or economically, to avoid one baby’s death?’ Regarding the Netherlands for the 5 years after the Breech Trial (2001–05), the answer is as follows: • Three hundred and twenty extra planned caesarean sections are needed to ‘save’ one extra child (short term)2 and even more in the long term because of uterine rupture, placenta praevia and an increased stillbirth rate before term associated with previous caesarean sections.3 The ‘costs’ were the following:3 • Four maternal deaths as a result of elective caesarean section for breech presentation (1:2200). These women would not have had an elective caesarean section when the child was in cephalic presentation.4 • Potentially life-threatening complications from uterine scars during future pregnancies can be expected. In a nationwide survey of serious maternal morbidity in the Netherlands from August 2004 to August 2006, 78 women with a previous elective caesarean section for breech were registered because of vital obstetric haemorrhage of >3000 ml (n = 39) and uterine scar rupture (n = 39). • In future pregnancies, four children with brain damage after uterine rupture can be expected. • 35 million Euros were spend on the 7500 extra caesarean sections. Out of 2.154 children born after vaginal breech delivery, 2.114 (98.1%) were alive and without ‘severe’ morbidity as compared with 5.515 (99.8%) of 5.524 elective caesarean sections for breech only and 2.088 (99.3%) after emergency caesarean section during a trial of vaginal breech delivery.2 Vaginal breech delivery thus has a slightly worse outcome than elective caesarean section, but this is not a new fact. Adverse outcome of vaginal breech delivery in the Term Breech Trial, however, was much higher (5.1%), but no other study has ever reported such high adverse outcome. The conclusion is that mode of breech delivery does not matter for 98 out of 100 children. The use of short-term combined end-point, mortality and ‘severe’ birth injury, overstates the true risk of planned vaginal delivery. This ‘severe’ birth injury results mainly in short-term morbidity. Twenty-nine ‘severe’ infant morbidities occurred after vaginal breech delivery: 9 clavicle fractures, very likely to heal without permanent injury, and 15 brachial plexus injuries, which are known to result in permanent damage in 10% (n = 2). Furthermore, one should take into account that the pulmonary morbidities were not included in the numbers of ‘severe’ injury, and these are much more frequent in elective caesarean section. In our risk-averse society, the crucial question is: which standard is reasonable to apply? Considering maternal risks, should 997 of 1000 women have a ‘superfluous’ elective caesarean section to ‘save’ the life of 3 out of 1000 babies?

First cesarean birth and subsequent fertility

To determine whether cesarean delivery is independently associated with later subfertility. Retrospective cohort study. Maternity records kept for Scotland, 1980-1999. The study included 109,991 women who had first births between 1980 and 1984, excluding multiple or preterm births and perinatal deaths. Exposures studied were spontaneous vaginal birth, operative vaginal birth, planned cesarean delivery for breach presentation, planned cesarean delivery for other indications, and emergency cesarean delivery. The relative risk of not having a second pregnancy over the following 15 years, the interpregnancy interval, and the number of spontaneous early pregnancy losses between the first and second birth. Women who delivered by planned cesarean section for breech presentation had an increased risk of not having a second birth compared with women whose first birth was a spontaneous vertex delivery (relative risk [RR]: 1.21, 95% confidence interval [CI]: 1.14 to 1.29). However, after adjustment for maternal and obstetric characteristics, there was no longer a strong association (adjusted RR: 1.07, 95% CI: 1.00 to 1.15). Operative vaginal delivery (forceps and vacuum extraction) and all types of cesarean delivery were associated with longer interpregnancy intervals. There was no relationship between mode of delivery and the number of spontaneous early pregnancy losses between the first and second birth. It is unlikely that delivering by cesarean section in a first pregnancy decreases a woman's likelihood of having a second viable pregnancy.

Tocolysis for Repeat External Cephalic Version in Breech Presentation at Term: A Randomized, Double-Blind, Placebo-Controlled Trial

External cephalic version (ECV) lowers the incidence of breech presentation at term and limits the need for cesarean section in noncephalic births. Although tocolytic agents may improve success rates, they are time-consuming, may cause side effects, and have not been documented to lower rates of section delivery. The investigators attempted to determine whether tocolysis is helpful when ECV is tried again after an initial failed attempt. Using a randomized, double-blind, placebo-controlled design, 124 women with breech presentation at term were enrolled in the study. All of them had undergone attempted ECV without tocolysis but had failed to respond. None of them had an abnormal cardiotocograph after the attempt and none had heart disease, diabetes, or hypertension. Participants were randomly assigned to receive either tocolysis with ritodrine or placebo during a repeat attempt at ECV. Ritodrine at a concentration of 3 mg/mL was administered by syringe pump, starting at 1 mL/hour and increasing up to a maximum of 5 mL/hour. The mother's pulse was kept below 120 beats/min. A decrease in the need for elective cesarean section for breech presentation was the major reason for a decrease in operative deliveries. The frequency of cephalic presentation at delivery was significantly increased after tocolysis (relative risk [RR], 3.21; 95% confidence interval [CI], 1.23-8.39). The incidence of cesarean section declined (RR, 0.33; 95% CI, 0.14-0.80). For multiparous women, the RR for cephalic presentation at delivery was 9.38 (95% CI, 1.64-53.62). No significant effect of tocolysis was evident in nulliparous women. There were no changes in maternal or neonatal morbidity. Although pain scores did not differ between the active treatment and placebo groups, only one woman remained totally free of pain and approximately three fourths of women experienced discomfort. A second attempt at ECV for breech presentation will be substantially more effective if tocolysis is used, and fewer cesarean sections will be necessary. Using tocolysis only after a first attempt at ECV has failed, rather than in all nulliparous women, may well produce higher overall success rates with fewer side effects.