Non-cephalic Births Research Articles

187 Racial/ethnic disparities in malpresentation at term

Malpresentation at term has a multifactorial origin. We set out to explore maternal and perinatal factors associated with malpresentation at term. Retrospective analysis of the Center for Disease Controls’ Natality Live Birth database (2016-2018). The study group was comprised of all term singleton non-cephalic births and cephalic births following a successful external cephalic version (malpresentation group) and was compared to all other cephalic singleton births (control group). Maternal and neonatal characteristics were compared between the two groups using Pearson’s chi-square test with Bonferroni adjustment. Multivariate logistic regression was used to adjust outcomes for potential confounders. Results were presented as adjusted odds ratios (aOR) with 95% confidence intervals (CI), and statistical significance was set as P value < 0.05. The cohort included 9,692,203 term singleton births, of which, 354,689 (3.7%) were malpresenting. The odds of malpresentation for various maternal and perinatal factors are shown in tables 1 and 2. Non-Hispanic Whites had the highest odds of malpresentation while Non-Hispanic Blacks had the lowest (3.93% versus 2.81%; aOR 1.38, CI 1.36-1.39). Additional factors associated with increased odds include advancing maternal age and nulliparity (aOR 2.81, CI 2.74-2.88, and aOR 1.50, CI 1.48-1.51, for patients >40 years and nulliparous, respectively; Table 1), low birth weight (aOR 1.80, CI 1.77-1.83) and fetal anomalies (aOR 3.53, CI 3.06-4.06, and 2.32, CI 2.05-2.63, for malformations of the central nervous system and chromosomal anomalies; Table 2). To our knowledge, we report for the first time a small but significant racial/ethnic disparity in odds of malpresentation at term in a US population. We also identified several other maternal and perinatal factors increasing the odds of malpresentation at term consistent with prior reports. Our findings provide additional information to better understand malpresentation at term.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Perceptions, careseeking, and experiences pertaining to non-cephalic births in rural Sarlahi District, Nepal: a qualitative study

BackgroundIn low-resource settings, a significant proportion of fetal, neonatal, and maternal deaths can be attributed to intrapartum-related complications. Certain risk factors, such as non-cephalic presentation, have a particularly high risk of complications. This qualitative study describes experiences around non-cephalic births and highlights existing perceptions and care-seeking behavior specific to non-cephalic presentation in rural Sarlahi District, Nepal.MethodsWe conducted in-depth interviews with 34 individuals, including women who recently gave birth to a non-cephalic infant and female decision-makers in their households. We also conducted two focus groups with mothers (have two or more children, with at least one child under age five) and two focus groups with grandmothers in the community.ResultsSeveral women described scenes of obstructed labor and practices like provision of unspecified injections early in labor to assist with the delivery. There were reports of arduous care-seeking processes from primary health centers to tertiary facilities, and mixed quality of care among home birth attendants and facility-based health workers respectively. Very few women were aware of the fetal presentation prior to delivery, and we identified no consistent understanding among participants of the risks of and care strategies for non-cephalic births. Risk perception around non-cephalic presentation varied widely. Some participants were acutely aware of potential dangers, while others had not heard of non-cephalic birth. Many interviewees said that the position in which a pregnant woman sleeps could impact the fetal position. Several participants had either taken or heard of medication intended to rotate the fetus into the correct position.ConclusionsOur findings suggest the mixed quality of and access to care associated with non-cephalic birth and a lack of consistent understanding of the risk of and care for non-cephalic births in rural Nepal. The high risk of the condition and the recommended tertiary care present a dilemma in low-resource settings; the logistical difficulties and the mixed quality of care make care-seeking and referral decisions complex. While public health stakeholders strive to improve the quality of and access to the formal health system, those players must also be sensitive to the potential negative implications of promoting institutional care-seeking.

Cephalic version by postural management for breech presentation.

Babies with breech presentation (bottom first) are at increased risk of complications during birth, and are often delivered by caesarean section. The chance of breech presentation persisting at the time of delivery, and the risk of caesarean section, can be reduced by external cephalic version (ECV - turning the baby by manual manipulation through the mother's abdomen). It is also possible that maternal posture may influence fetal position. Many postural techniques have been used to promote cephalic version. The objective of this review was to assess the effects of postural management of breech presentation on measures of pregnancy outcome. We evaluated procedures in which the mother rests with her pelvis elevated. These include the knee-chest position, and a supine position with the pelvis elevated with a wedge-shaped cushion. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (22 August 2012). Randomised and quasi-randomised trials comparing postural management with pelvic elevation for breech presentation, with a control group. One or both review authors assessed eligibility and trial quality. We have included six studies involving a total of 417 women. The rates for non-cephalic births, Cesarean section and Apgar scores below 7 at one minute, regardless of whether ECV was attempted or not, were similar between the intervention and control groups (risk ratio (RR) 0.98; 95% confidence interval (CI) 0.84 to 1.15; RR 1.10; 95% CI 0.89 to 1.37; RR 0.88; 95% CI 0.50 to 1.55). There is insufficient evidence from well-controlled trials to support the use of postural management for breech presentation. The numbers of women studied to date remain relatively small. Further research is needed.

Successful but Limited Use of External Cephalic Version in Auckland

The possibility of a noncephalic (breech) presentation at birth can be markedly reduced by the use of external cephalic version (ECV). Using ECV, practitioners place their hands on the woman's abdomen and gently turn the baby from the breech to cephalic position. A major review reported that ECV at or near term (≥36 weeks) reduced the occurrence of noncephalic births by 62% and the rate of cesarean section by 45%. In New Zealand and in many other countries, ECV is now recommended to all eligible women presenting with breech presentation at birth. This prospective study assessed: (1) the success rate for ECV at a tertiary teaching hospital in New Zealand, (2) the factors predicting success, (3) perinatal outcomes among women who underwent ECV, and (4) the percentage of women with term breech presentation who attempted the procedure. From 2002 to 2006, a prospective audit was conducted in all women with singleton breech presentation ≥36 weeks who attended the ECV clinic. Of the 255 women presenting for ECV, the procedure was successful in 150 (59%). Multivariate analysis showed that an unengaged presenting part was the strongest predictor of success; the adjusted relative risk (aRR) was 3.3, with a 95% confidence interval (CI) of 2.2 to 5.1. Other predictors of success were multiparity (aRR, 1.2; 95% CI, 1.0-1.4), and a lateral spine position (aRR, 1.5; 95% CI, 1.1-2.0). Among the 150 women with successful ECV, 100 (67%) had a vaginal birth; of the 105 women with unsuccessful ECV, only 1 had a virginal birth. To prevent 1 caesarean birth, 3 women had to attempt ECV. The rate of referral was low; only 26% of women with singleton term breech presentation attempted ECV. The success rate of ECV in reducing beech presentation at term in this study is consistent with that reported in previous studies. The procedure restored the rate of cesarean section to that of a cephalic singleton pregnancy at term. Further study is needed to address the low rate of referral and barriers to use of ECV in this population.

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.

Tocolysis for repeat external cephalic version in breech presentation at term: a randomised, double‐blinded, placebo‐controlled trial

External cephalic version (ECV) reduces the incidence of breech presentation at term and caesarean section for non-cephalic births. Tocolytics may improve success rates, but are time consuming, may cause side effects and have not been proven to alter caesarean section rates. The aim of this trial was to determine whether tocolysis should be used if ECV is being re-attempted after a failed attempt. To determine whether tocolysis should be used if ECV is being re-attempted after a failed attempt. Randomised, double-blinded, placebo-controlled trial. UK teaching hospital. One hundred and twenty-four women with a breech presentation at term who had undergone an unsuccessful attempt at ECV. Relative risks with 95% confidence intervals for categorical variables and a t test for continuous variables. Analysis was by intention to treat. Incidence of cephalic presentation at delivery. Secondary outcomes were caesarean section and measures of neonatal and maternal morbidity. The use of tocolysis for a repeat attempt at ECV significantly increases the incidence of cephalic presentation at delivery (RR 3.21; 95% CI 1.23-8.39) and reduces the incidence of caesarean section (RR 0.33; 95% CI 0.14-0.80). The effects were most marked in multiparous women (RR for cephalic presentation at delivery 9.38; 95% CI 1.64-53.62). Maternal and neonatal morbidity remain unchanged. The use of tocolysis increases the success rate of repeat ECV and reduces the incidence of caesarean section. A policy of only using tocolysis where an initial attempt has failed leads to a relatively high success rate with minimum usage of tocolysis.

The Management of Breech Pregnancies in Australia and New Zealand

The Term Breech Trial (TBT), a large-scale international randomized study, concluded that planned cesarean section at term provides the best perinatal outcomes in breech presentations. Most women prefer vaginal delivery,however, and a Cochrane review suggests that external cephalic version (ECV) at term lowers the rates of both noncephalic births and cesarean section. This survey, mailed to all members and fellows of the Royal Australian and New Zealand College of Obstetrics and Gynecology, was an attempt to document current obstetric practice in managing term singleton breech pregnancies. A total of 696 obstetric practitioners responded. Their average age was 49 years and they had practiced obstetrics for 120 years. Most respondents practiced in a tertiary or community/district hospital setting. Before becoming aware of the TBT, 72% of obstetricians had recommended attempted vaginal breech birth, but subsequently only 20% continued to do so. More practitioners with less than 20 years experience stopped recommending vaginal breech birth. ECV was recommended by 67% of obstetricians, and more than 80% performed the procedure themselves. The proportion of practitioners with at least 10 years experience who recommended ECV was significantly lower than those having less experience. ECV is done before 37 weeks gestation by 42% of obstetricians using the procedure. More than half of obstetricians reported using tocolytics for at least some versions. A minority of 28% reported usually doing ECV outside the hospital. Very few respondents ever used analgesia. The median self-estimated success rate for ECV in nulliparous women was 40%, and for multiparous women, 60%. Those using tocolytics reported significantly higher success rates in both nulliparas and multiparas. ECV is an effective approach to breech presentations, but more needs to be learned about why version-and tocolytic agents-are not used more frequently and about the most appropriate timing of the procedure.

Interventions to help external cephalic version for breech presentation at term.

Breech presentation places a fetus at increased risk. The outcome for the baby is improved by planned caesarean section compared with planned vaginal delivery. External cephalic version attempts to reduce the chances of breech presentation at birth, but is not always successful. Tocolytic drugs to relax the uterus as well as other methods have been used in an attempt to facilitate external cephalic version at term. To assess the effects of routine tocolysis, fetal acoustic stimulation, epidural or spinal analgesia and transabdominal amnioinfusion for external cephalic version at term on successful version and measures of pregnancy outcome. The Cochrane Pregnancy and Childbirth Group trials register (September 2003) and the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 3, 2003) were searched. Randomised and quasi-randomised trials comparing routine versus selective or no tocolysis; fetal acoustic stimulation in midline fetal spine positions versus dummy or no stimulation; epidural or spinal analgesia versus no regional analgesia; or transabdominal amnioinfusion versus no amnioinfusion for external cephalic version at term. The reviewer assessed eligibility and trial quality. In six trials, routine tocolysis with beta-stimulants was associated with fewer failures of external cephalic version (relative risk (RR) 0.74, 95% confidence interval (CI) 0.64 to 0.87). The reduction in non-cephalic presentations at birth was not statistically significant. Caesarean sections were reduced (RR 0.85, 95% CI 0.72 to 0.99). In four small trials, sublingual nitroglycerine used as a tocolytic was associated with significant side-effects, and was not found to be effective. Fetal acoustic stimulation in midline fetal spine positions was associated with fewer failures of external cephalic version at term (RR 0.17, 95% CI 0.05 to 0.60). With epidural or spinal analgesia, external cephalic version failure, non-cephalic births and caesarean sections were reduced in two trials but not the other. The overall differences were not statistically significant. No randomised trials of transabdominal amnioinfusion for external cephalic version at term were located. Routine tocolysis appears to reduce the failure rate of external cephalic version at term. There is not enough evidence to evaluate the use of fetal acoustic stimulation in midline fetal spine positions, nor of epidural or spinal analgesia. Large volume intravenous preloading may have contributed to the effectiveness demonstrated in two of the latter trials.

Cephalic version by postural management for breech presentation.

It is possible that maternal posture may influence fetal position. Many postural techniques have been used to promote cephalic version. The objective of this review was to assess the effects of postural management of breech presentation on measures of pregnancy outcome. The Cochrane Pregnancy and Childbirth trials register and Controlled Trials Register were searched. Date of last search: February 1999. Randomised and quasi-randomised trials comparing postural management with pelvic elevation for breech presentation, with a control group. Eligibility and trial quality were assessed by both reviewers. Three studies involving a total of 192 women were included. Postural management was associated with a non-significant trend towards fewer non-cephalic births (relative risk 0.90, 95% confidence interval 0. 73 to 1.12). No differences were detected for caesarean sections or Apgar scores below seven at one minute. There is not enough evidence to evaluate the use of postural management for breech presentation.

External cephalic version for breech presentation at term.

Management of breech presentation is controversial, both in regard to manipulation of the position of the fetus and the method of delivery. External cephalic version may reduce the number of breech presentations and caesarean sections, but there also have been reports of increased perinatal mortality with the procedure. The objective of this review was to assess the effects of external cephalic version at term on measures of pregnancy outcome. The Cochrane Pregnancy and Childbirth trials register was searched. Date of last search: October 1997. Randomised trials of external cephalic version at term (with or without tocolysis) compared with no attempt at external cephalic version in women with breech presentation. Eligibility and trial quality were assessed by GJH and checked by RK. Six studies were included. External cephalic version at term was associated with a significant reduction in non-cephalic births (relative risk 0.42, 95% confidence interval 0.35 to 0.50) and caesarean section (relative risk 0.52, 95% confidence interval 0.39 to 0.71). There was no significant effect on perinatal mortality (relative risk 0.44, 95% confidence interval 0.07 to 2.92). Attempting cephalic version at term appears to reduce the chance of non-cephalic births and caesarean section. There is not enough evidence to assess any risks of external cephalic version at term.