Delivery For Breech Presentation Research Articles

Case Report: Inevitable Caesarean Myomectomy

A 25-year-old woman having an elective caesarean delivery for breech presentation, after a previous caesarean section for fetal distress, developed severe intra-operative haemorrhage from a large fundal sub-serosal leiomyoma with a ruptured false capsule. After the delivery of the baby and repair of the uterine incision, myomectomy was done to prevent further blood loss. Key Words: Myomectomy, Caesarean Section, Haemorrhage [Trop J Obstet Gynaecol, 2003, 20: 159-160]

Breech birth at term: vaginal delivery or elective cesarean section? A systematic review of the literature by a Norwegian review team

Breech birth at term: vaginal delivery or elective cesarean section? A systematic review of the literature by a Norwegian review team

Vaginal versus cesarean delivery for breech presentation in California: a population-based study

Objective To examine the population-based pregnancy outcomes associated with vaginal breech delivery. Methods A retrospective, population-based cohort study of all term (greater than 37 weeks' gestation), normal birth weight (2.5–3.8 kg), nonanomalous newborns in California, from January 1, 1991 to December 31, 1999 was performed. Neonatal mortality and major neonatal morbidity were compared by route of delivery for cephalic (3,271,092) and breech (100,730) presentations. Results More than 3.2 million singleton term newborns were identified during the study period, with 100,667 (3%) in breech presentation at the time of delivery. Of these, 4952 women (4.9%) had vaginal breech delivery, whereas 60,418 women delivered by cesarean without labor, and 35,297 women underwent cesarean in labor. Breech vaginal delivery in nulliparous women was associated with increased neonatal mortality (odds ratio [OR] 9.2, 95% confidence interval [CI] 3.3, 25.6) and morbidity (asphyxia: OR 5.7, 95% CI 4.5, 7.3; brachial plexus injury: OR 33.9, 95% CI 15.2, 76.1; and birth trauma: OR 5.8, 95% CI 4.7, 7.1) compared with breech delivery by prelabor cesarean in nulliparous women. In breech-presenting women with one prior vaginal delivery, neonatal mortality was not different between groups, but morbidities (asphyxia: OR 3.9, 95% CI 3.0, 5.1; brachial plexus injury: OR 22.4, 95% CI 9.9, 50.5; and birth trauma: OR 4.2, 95% CI 3.4, 5.3) remained increased for vaginal compared with cesarean delivery. Conclusion The “normal” term breech fetus, when delivered vaginally, had significantly increased neonatal mortality (in nulliparous women) and morbidity (all breech deliveries), when compared with the breech fetus delivered by cesarean, which suggests that these patients might best be delivered by cesarean to avoid these adverse outcomes.

Vaginal Versus Cesarean Delivery for Breech Presentation in California

In Brief OBJECTIVE To examine the population-based pregnancy outcomes associated with vaginal breech delivery. METHODS A retrospective, population-based cohort study of all term (greater than 37 weeks' gestation), normal birth weight (2.5–3.8 kg), nonanomalous newborns in California, from January 1, 1991 to December 31, 1999 was performed. Neonatal mortality and major neonatal morbidity were compared by route of delivery for cephalic (3,271,092) and breech (100,730) presentations. RESULTS More than 3.2 million singleton term newborns were identified during the study period, with 100,667 (3%) in breech presentation at the time of delivery. Of these, 4952 women (4.9%) had vaginal breech delivery, whereas 60,418 women delivered by cesarean without labor, and 35,297 women underwent cesarean in labor. Breech vaginal delivery in nulliparous women was associated with increased neonatal mortality (odds ratio [OR] 9.2, 95% confidence interval [CI] 3.3, 25.6) and morbidity (asphyxia: OR 5.7, 95% CI 4.5, 7.3; brachial plexus injury: OR 33.9, 95% CI 15.2, 76.1; and birth trauma: OR 5.8, 95% CI 4.7, 7.1) compared with breech delivery by prelabor cesarean in nulliparous women. In breech-presenting women with one prior vaginal delivery, neonatal mortality was not different between groups, but morbidities (asphyxia: OR 3.9, 95% CI 3.0, 5.1; brachial plexus injury: OR 22.4, 95% CI 9.9, 50.5; and birth trauma: OR 4.2, 95% CI 3.4, 5.3) remained increased for vaginal compared with cesarean delivery. CONCLUSION The “normal” term breech fetus, when delivered vaginally, had significantly increased neonatal mortality (in nulliparous women) and morbidity (all breech deliveries), when compared with the breech fetus delivered by cesarean, which suggests that these patients might best be delivered by cesarean to avoid these adverse outcomes. Normal, term, nonanomalous breech fetuses delivered vaginally have increased neonatal morbidity and, in nulliparous women, increased mortality compared with breech cesarean delivery.

Outcomes at 3 Months After Planned Cesarean vs. Planned Vaginal Delivery for Breech Presentation at Term: The International Randomized Breech Trial

Outcomes at 3 Months After Planned Cesarean vs. Planned Vaginal Delivery for Breech Presentation at Term: The International Randomized Breech Trial

Editor's Choice

Editor's Choice

Outcomes at 3 Months After Planned Cesarean vs Planned Vaginal Delivery for Breech Presentation at Term: The International Randomized Term Breech Trial

The Term Breech Trial, a randomized study of 2088 women, demonstrated a significant reduction in adverse perinatal outcomes when breech presentation was managed by planned cesarean delivery rather than planned vaginal delivery. Respective rates of adverse outcomes were 1.6% and 5%. At the same time, there was no greater risk of immediate maternal morbidity in the cesarean group. Other studies suggest that cesarean delivery may lead to problems with breast-feeding, postpartum depression, and negative feelings about childbirth. The present study is a 3-month postpartum follow-up of 1596 study participants, at 110 centers worldwide, who had a singleton fetus in breech presentation at term. Baseline data were similar for the 798 women randomly assigned to planned cesarean delivery and for the same number randomly assigned to planned vaginal birth. Cesarean delivery was carried out as planned in 91% of cases, but only 57% of women assigned to vaginal delivery were managed in this way. The commonest reasons for operative delivery were fetopelvic disproportion, failure to progress in labor, and fetal heart rate abnormality. Most women in both groups found it easy to care for their new infant and to be a new mother. Fewer women assigned to cesarean delivery breast-fed their infants starting shortly after birth. The planned delivery method did not influence sexual relations or women's relationships with their husband or partner. Pain in general was comparable in the two groups at 3-month follow-up, but women assigned to cesarean delivery more often had pain on the outside of the abdomen or deep inside the abdomen. Fewer women in this group had pain in the bottom or genital area. In addition, more women assigned to vaginal delivery reported having leaked or lost urine in the past week (7.3% vs. 4.5%). Very few women in either group reported losing or leaking feces, fluid, or mucus from their bowels. Postpartum depression was identified in 10% to 11% of both groups. Women assigned to cesarean delivery appreciated the fact that childbirth was not very painful and felt reassured about their infant's health. Women assigned to planned vaginal delivery liked the naturalness of the procedure and the opportunity to participate actively in their child's birth. They also felt that recovery was not difficult. The groups did not differ significantly in their view of the delivery method to which they were assigned. The investigators believe it reasonable to offer elective cesarean delivery to women with a breech presentation if there is a substantial risk that emergency cesarean will be necessary should vaginal delivery be planned. This policy has not been associated with higher rates of postpartum problems, and it may lessen the risk of urinary incontinence.

Neonatal survival rates in 860 singleton live births at 24 and 25 weeks gestational age. A Canadian multicentre study.

To determine the current survival rate of singleton living newborns born at gestational age of 24 and 25 weeks, using obstetric factors available to the physician before birth. Retrospective study of all live births in 13 of 17 Canadian tertiary centres. Population All singleton live births without congenital abnormalities. During the years 1991-1996, data were abstracted from clinical databases and charts of 860 live births, in 13 of the 17 tertiary centres in Canada, all with major neonatal intensive care units. Newborn survival was defined as alive at discharge from neonatal intensive care unit. Abstracted elements included gestational age, maternal antenatal corticosteroid treatment, birthweight, gender, fetal presentation and mode of delivery. Average survival rates increased from 56.1% at 24 weeks (n = 406) to 68.0% at 25 weeks (n = 454). Survival rates ranged from 53.1% at day 168 to 81.6% at day 181 (r = 0.802, P < 0.05). Steroid administration improved the survival rates at 24 and 25 weeks compared with that of unexposed fetuses, respectively (58.9% vs 41.8%; OR 1.70; 95% CI 1.03-2.08 and 74.2% vs 56.8%; OR 2.19; 95% CI 1.41-3.38). Caesarean delivery for breech presentation improved survival compared with vaginal delivery, both at 24 and 25 weeks (56.1% vs 36.0%; OR 2.19; 95% CI 1.10-4.34, and 68.7% vs 55.2% OR 1.78; 95% CI 0.093-3.43). Female neonates displayed better survival rates (59.6% vs 52.1% OR 1.36; 95% CI 0.92-2.01, and 72.6% vs 63.1% OR 1.51; 95% CI 1.02-2.25) at 24 and 25 weeks, respectively. Explanatory regression model confirmed these factors as prognostic variables associated with survival. This extensive collaborative study confirms that several prognostic factors, known before birth, including gestational age in days, steroid treatment, mode of presentation and fetal sex may help obstetricians, neonatologists and parents in their decision-making process at 24 and 25 weeks of pregnancy.

Neonatal survival rates in 860 singleton live births at 24 and 25 weeks gestational age. A Canadian multicentre study

Objective To determine the current survival rate of singleton living newborns born at gestational age of 24 and 25 weeks, using obstetric factors available to the physician before birth. Design Retrospective study of all live births in 13 of 17 Canadian tertiary centres. Population All singleton live births without congenital abnormalities. Methods During the years 1991–1996, data were abstracted from clinical databases and charts of 860 live births, in 13 of the 17 tertiary centres in Canada, all with major neonatal intensive care units. Newborn survival was defined as alive at discharge from neonatal intensive care unit. Abstracted elements included gestational age, maternal antenatal corticosteroid treatment, birthweight, gender, fetal presentation and mode of delivery. Results Average survival rates increased from 56.1% at 24 weeks ( n = 406) to 68.0% at 25 weeks ( n = 454). Survival rates ranged from 53.1% at day 168 to 81.6% at day 181 (r = 0.802, P < 0.05). Steroid administration improved the survival rates at 24 and 25 weeks compared with that of unexposed fetuses, respectively (58.9% vs 41.8%; OR 1.70; 95% CI 1.03–2.08 and 74.2% vs 56.8%; OR 2.19; 95% CI 1.41–3.38). Caesarean delivery for breech presentation improved survival compared with vaginal delivery, both at 24 and 25 weeks (56.1% vs 36.0%; OR 2.19; 95% CI 1.10–4.34, and 68.7% vs 55.2% OR 1.78; 95% CI 0.093–3.43). Female neonates displayed better survival rates (59.6% vs 52.1% OR 1.36; 95% CI 0.92–2.01, and 72.6% vs 63.1% OR 1.51; 95% CI 1.02–2.25) at 24 and 25 weeks, respectively. Explanatory regression model confirmed these factors as prognostic variables associated with survival. Conclusions This extensive collaborative study confirms that several prognostic factors, known before birth, including gestational age in days, steroid treatment, mode of presentation and fetal sex may help obstetricians, neonatologists and parents in their decision-making process at 24 and 25 weeks of pregnancy.

Breech presentation at term: morbidity and mortality according to the type of delivery at Port Royal Maternity hospital from 1993 through 1999

Objective: To compare neonatal morbidity and mortality at Port Royal Maternity between 1993 and 1999 for infants with a singleton breech presentation born after 37 weeks, according to planned mode of delivery. Study design: Retrospective study of 501 patients of whom vaginal delivery was planned in 322 (64%) or/and cesarean in 179 (36%). Results: Severe neonatal morbidity was similar in the two groups (13/322, 4.0% versus 8/179, 4.5%; P=0.82); severe trauma morbidity was not significantly higher in the “planned vaginal delivery” group (3/322, 0.9% versus 1/179, 0.06%; P=0.16); there were no long-term sequelae. Mortality was not higher when vaginal delivery was planned. Conclusion: We have not found in this series any excess of morbidity or mortality attributable to vaginal delivery of breech presentations. This work does not indicate that we should change our obstetrical practice in the light of other recently-published studies.

Caesarean delivery of breech babies is beneficial for infant health but has no impact on maternal health

Objective: To compare maternal and neonatal outcomes in elective cesarean vs. attempted vaginal delivery for breech presentation at or near term. Methods: We reviewed the maternal and neonatal charts of all singleton breech deliveries of at least 35 weeks’ gestation or 2000 g delivered between 1986 and 1997 at our institution. Patients delivered by elective cesarean were compared to those attempting a vaginal delivery. The neonatal outcomes analyzed were: corrected mortality; Apgar scores less than 7 at 5 min; abnormal umbilical cord blood gases; birth trauma; and admissions to the intensive care nursery. Maternal morbidity was also assessed and compared. Results: Of 848 women meeting criteria for evaluation, 576 were delivered by elective cesarean while 272 attempted a vaginal delivery. Of 272 women undergoing a trial of labor, 203 (74.6%) were delivered vaginally, while 69 (25.4%) failed an attempt at vaginal delivery and underwent a cesarean. When comparing patients delivered by elective cesarean with those attempting a vaginal delivery, no significant differences were noted in neonatal outcomes. However, maternal morbidity was higher among women delivered by cesarean, regardless of the indications for the procedure. Similar neonatal and maternal results were noted when nulliparous patients were analyzed separately. Conclusions: Cesarean delivery of selected near-term infants presenting as breech is associated with increased maternal morbidity without corresponding improvement in neonatal outcomes.

Route of breech delivery and maternal and neonatal outcomes

Objective: To compare maternal and neonatal outcomes in elective cesarean vs. attempted vaginal delivery for breech presentation at or near term. Methods: We reviewed the maternal and neonatal charts of all singleton breech deliveries of at least 35 weeks’ gestation or 2000 g delivered between 1986 and 1997 at our institution. Patients delivered by elective cesarean were compared to those attempting a vaginal delivery. The neonatal outcomes analyzed were: corrected mortality; Apgar scores less than 7 at 5 min; abnormal umbilical cord blood gases; birth trauma; and admissions to the intensive care nursery. Maternal morbidity was also assessed and compared. Results: Of 848 women meeting criteria for evaluation, 576 were delivered by elective cesarean while 272 attempted a vaginal delivery. Of 272 women undergoing a trial of labor, 203 (74.6%) were delivered vaginally, while 69 (25.4%) failed an attempt at vaginal delivery and underwent a cesarean. When comparing patients delivered by elective cesarean with those attempting a vaginal delivery, no significant differences were noted in neonatal outcomes. However, maternal morbidity was higher among women delivered by cesarean, regardless of the indications for the procedure. Similar neonatal and maternal results were noted when nulliparous patients were analyzed separately. Conclusions: Cesarean delivery of selected near-term infants presenting as breech is associated with increased maternal morbidity without corresponding improvement in neonatal outcomes.

Mode of delivery in breech presentation at term: Increased neonatal morbidity with vaginal delivery

Mode of delivery in breech presentation at term: Increased neonatal morbidity with vaginal delivery

Delivery in breech presentation—a cause of hemorrhoids in a newborn

A term female bay, born to a 28-year-old healthy mother of one child at 38 weeks of pregnancy, was delivered by vaginal route in breech presentation. Birth weight was 2780 g. Primary examination revaeled a mild hematoma of the buttocks and right posterolateral external hemorrhoids in the anal region (Figure). Clinical course after delivery was uneventful. Complete spontaneous resolution of the hemorrhoids was observed within 48 hours. On the third day of life, the baby was discharged home.

Obstetric intervention and cerebral palsy

Obstetric intervention and cerebral palsy

Has pelvimetry a role in current obstetric practice?

Radiological pelvimetry is still requested in some centres before planned vaginal delivery for breech presentation or following a previous caesarean section. In a retrospective review of the utilisation of pelvimetry in 167 cases in our department, 103 (62%) and 64 (38%) had pelvimetry in the postnatal and antenatal periods respectively. Antero-posterior inlet and outlet diameters were inadequate in 19.2% and 16.2% respectively. Of those who had postnatal pelvimetry, only 36 (35%) returned to our unit for further confinement and the caesarean section rate in this group was 75%. The main indications for antenatal pelvimetry were breech presentation (28), previous caesarean section (23) and anticipated cephalopelvic disproportion (13). The caesarean section rates in these groups were 82%, 70% and 45% respectively. However, the emergency caesarean section rate in the breech presentation group was 28%. Nine patients (32%) of those who had breech presentation and delivered by elective caesarean section had normal pelvic measurements. Pelvimetry should only be performed if its results will influence the mode of delivery. Pelvimetry may be useful in selecting fetuses with breech presentation for vaginal delivery or elective caesarean section. However it would increase the likelihood of caesarean section in cephalic presentation.

Relationship of cesarean delivery to lower birth weight–specific neonatal mortality in singleton breech infants in the United States

Objective: The preferred route of delivery for breech presentation has been controversial. We compared the birth weight-specific neonatal mortality of vaginal births to cesarean births in singleton births with breech presentation. Methods: A total of 371,692 singleton live births with breech presentation were selected for the study from the United States birth cohorts for the years 1989–1991. Differences in birth weight specific mortality were compared using a z-statistic for differences in proportions and by logistic regression. Results: Compared to primary vaginal births, primary cesarean births had significantly lower neonatal mortality for all birth weight groups, despite increased prevalence of fetal malformations in the cesarean as compared with vaginally delivered group. This mortality difference was greatest in the first hour of life. Difference in overall neonatal (less than 28 days) mortality rate ranged from a low of 1.6-fold in the 500–749 g group (726.6 per 1000 vaginal births compared with 456.3 per 1000 cesarean births, P < .001) to as high as about three-fold in the 1250–1499 g group (232.9 per 1000 vaginal births compared to 72.5 per 1000 cesarean births, P < .001). In the group with birth weights over 2500 g, neonatal mortality in the primary vaginal births was 5.3 per 1000 and in the primary cesarean births, 3.2 per 1000 ( P < .001). Similarly, repeat cesarean births had significantly lower birth weight-specific neonatal mortality, compared with vaginal births after previous cesarean. Conclusion: Singleton live births with breech presentation delivered by cesarean had lower birth weight-specific neonatal mortality as compared with vaginal births.

Grazer Frühgeborenenanalyse: Vaginalgeburt versus Sektio

Purpose and Method: The aim of the study was to analyse the impact of Caesarean section on the neonatal outcome of 328 premature infants delivered before 32 weeks' gestation. Results: The total neonatal mortality rate was 46/328 (14%). After the exclusion of patients with confounding factors (malformation, abortion, admission during the third stage of labour, emergency Caesarean section) 277 deliveries were evaluated further (140 vaginal, 137 Caesarean sections). The mortality rate was 12/277 (4.3%). Vaginal and Caesarean deliveries showed no difference in neonatal mortality (4.3% vs. 4.4%), intraventricular haemorrhage (25% vs. 23.4%), and trauma (7.8% ; vs. 12.4%). Subependydimal haemorrhage (19.3% vs. 31.4%; p <0.03), low Apgar scores (≤7) at 5 minutes (7.9% vs. 16.1%; p <0.05), severe respiratory distress syndrome (RDS III-IV: 17.8% vs. 43.8%; p <0.001) and ensuing artificial ventilation (50.6% vs. 61.7%; p <0.05) was significantly more common after Caesarean section than after vaginal delivery. Conclusion: We conclude that Caesarean section per se provides no benefit for premature infants at < 32 weeks' gestation. Accordingly, the indications for the procedure should be strict. For judging the mode of delivery in breech presentation this study is not appropriate since only 3 such cases at 24, 29, and 31 weeks were delivered vaginally. All three offspring were doing well.

Mode of delivery for breech presentation: Lindqvist A, Nordén-Lindeberg S, Hanson U. Perinatal mortality and route of delivery in term breech presentations. Br J Obstet Gynaecol 1997;104:1288–91

Mode of delivery for breech presentation: Lindqvist A, Nordén-Lindeberg S, Hanson U. Perinatal mortality and route of delivery in term breech presentations. Br J Obstet Gynaecol 1997;104:1288–91

Outcome of 1040 consecutive breech deliveries: clinical experience of a maternity hospital in Turkey

Objective: To determine the optimal route of delivery in breech presentation. Method: One-thousand and forty singleton breech deliveries among a total of 41 785 deliveries that occurred at Zübeyde Hanim Maternity Hospital between 1990 and 1994 were analyzed. Result: The breech deliveries accounted for 2.4% of all deliveries. Of the patients, 572 (56.3%) were delivered vaginally and 468 (43.7%) were delivered by cesarean section. The mean ages of vaginal and cesarean delivery groups were 25.2 and 24.6 years, respectively. Forty-one (3.9%) of the fetuses had congenital anomaly. The leading congenital anomalies were meningocele in seven and hydrocephalus in six patients. Mullerian anomalies were encountered in 29 (6.1%) patients at cesarean section. Fetal morbidity observed in cesarean deliveries were fracture of the humerus in one and fracture of the femur in one and soft tissue injury in four cases. Fracture of the humerus was observed in two, Erb's paralysis in four, facial paralysis in one and soft tissue injury in 43 fetuses delivered vaginally. The leading causes of puerperal maternal morbidity were genital tract lacerations in vaginal delivery group and wound infection in cesarean delivery group. The overall perinatal mortality of this series was 54.8/1000 (57/1040). The corrected figures for cesarean delivery and vaginal delivery groups were 8.5/1000 (4/467) and 57.9/1000 (32/552), respectively. Conclusion: We favor a selective approach for mode of delivery in patients with breech presentation in order to balance the fetal morbidity associated with vaginal delivery and maternal morbidity and cost associated with cesarean delivery.