Term Breech Presentation Research Articles

Evidence-based changes in term breech delivery practice in Sweden

Objective. Medical documentation on term breech delivery (TBD) advocates planned abdominal delivery based on evidence. The aim of the present study was to describe a change in TBD practice in Sweden following evidence-based documentation arguing in favor of TBD by cesarean section (CS). Materials and methods. The study was a population-based observational study based on data from the Swedish Medical Birth Register. Eligible subjects were all mothers with singleton children in term breech (TB) presentation born between 1999 and 2001 at > 36 weeks' gestational age. Data were processed, and subjects were subdivided into groups, according to mode of delivery. Results. The CS rate increased from 75.3% in 1999 to 86.0% in 2001, due to an increase in planned abdominal deliveries. The change towards abdominal deliveries was more obvious for hospitals with fewer deliveries. While today, an increasing number of hospitals clearly have a non-selective CS policy, with a > 95% CS rate, others still deliver 30% of TB babies vaginally. Conclusion. In conclusion, the evidence-based recommendation for TBD has so far had considerable impact on Swedish obstetric practice.

Cord Blood Acid-Base Status at Delivery After Successful External Cephalic Version

Pregnancies after successful external cephalic version (ECV) are generally regarded as being normal. Nevertheless, increased levels of thyroid-stimulating hormone, an indicator of perinatal stress, recently were reported in cord blood in infants delivered vaginally after successful ECV. This retrospective study was an attempt to learn whether such infants are compromised, in particular, whether there are abnormalities of acid-base balance in cord blood. The 89 study cases were singleton deliveries at or after 37 weeks gestation that followed successful version. The same number of pregnancies with spontaneous cephalic presentation made up the control group. Women in the ECV group were significantly older, but there were no significant differences in birth weights or Apgar scores. Women in the ECV group had significantly more emergency cesarean deliveries than did control women. Cord blood arterial and venous acid-base parameters were similar in the 2 groups, as were the proportions of fetuses with a cord blood pH less than 7.20. Even after adjusting for maternal age, gestational age at delivery, mode of delivery, birth weight, spontaneous or induced labor, and duration of labor, differences in cord blood pH between the ECV and control groups were not significant. These findings support the use of ECV for term breech presentation. These infants may be more vulnerable biologically to the stress of labor, but with adequate intrapartum care, they should not be at increased risk of being acidotic at the time of birth. ECV may entail more emergency section deliveries, but it does lessen the incidence of cesarean deliveries for breech pregnancies.

Tocolysis in term breech external cephalic version

Objectives To study the effect of ritodrine tocolysis on the success of external cephalic version (ECV) and to assess the role of ECV in breech presentation at our centre. Material and methods A prospective randomized double-blind-controlled trial comparing ritodrine and placebo in ECV of singleton term breech pregnancy at a tertiary hospital. Results Among the 60 patients who were recruited, there was a success rate of 36.7%. Ritodrine tocolysis significantly improved the success rate of ECV (50% vs. 23%; P=0.032). There was a marked effect of ritodrine tocolysis on the ECV success in nulliparae (36.4% vs. 13.0%) and multiparae (87.5% vs. 57.1%). External cephalic version has shown to reduce the rate of cesarean section for breech presentation by 33.5% in our unit. Conclusion External cephalic version significantly reduced the rate of cesarean section in breech presentation, and ritodrine tocolysis improved the success of ECV and should be offered to both nulliparous and parous women in the case of term breech presentation.

Mode d’accouchement des femmes avec une présentation du siège à terme dans l’étude PREMODA (PREsentation et MODe d’accouchement)

The purpose of this work was to report labor and birth management practices for term breech presentation in France and Belgium in 2001-2002 and to describe indications for cesarean sections (before labor, emergency situations) in breech presentations. The PREMODA cohort is a survey population which included 19408 deliveries, 8108 of which were term breech presentations. Infants were delivered by cesarean section before labor (59.1%), emergency cesarean section during labor (18.4%) or vaginally (22.5%). The decision for cesarean section before labor was empirical (breech presentation) in 44.3% of the cases. Half of the cesarean sections performed during labor (n=704, 49.3%) were planned C-sections. Overall, 67.8% of the breech presentations were delivered during planned cesarean sections (before or during labor). When vaginal delivery was attempted, the rate of vaginal birth was 70%. These early results reveal a high rate of cesarean section as well as differences in inter-regional practices. Considering all cesarean sections performed before labor, the most frequent indication was an empirical decision because of the breech presentation. An increased rate of planned cesarean section does not reduce the rate of vaginal delivery when attempted.

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

Safe Vaginal Breech Delivery: Possible in Selected Patients

In the U.S., fetuses in the breech position often are delivered by cesarean section, a practice motivated largely by poor data and the highly litigious climate. These Irish researchers challenged that strategy by retrospectively comparing obstetric and perinatal outcomes after cesarean delivery with those after vaginal delivery in highly selected patients with breech presentations at Dublin's National Maternity Hospital. In this hospital, standard management of term breech presentation avoids labor induction and …

Term breech presentation in The Netherlands from 1995 to 1999: mortality and morbidity in relation to the mode of delivery of 33,824 infants

To analyse neonatal mortality and morbidity in term infants born in breech presentation in relation to the mode of delivery (planned caesarean section, emergency caesarean section or vaginal delivery) and to compare these findings with those of the Term Breech Trial Collaborative Group [Hannah et al. Lancet 2000; October]. Retrospective observational study. The Netherlands. Infants (n = 33824) born at term in breech presentation in the Netherlands between 1995 and 1999. Multiple pregnancies, antenatal death and major congenital malformations were excluded. Data derived from the Dutch Perinatal Database were used to compare neonatal outcome of infants born in breech presentation in relation to the different modes of delivery (i.e. planned caesarean section, emergency caesarean section and vaginal delivery). Correction was made for differences in parity, duration of gestation and birthweight, using logistic regression. Intrapartum and first-week neonatal death, 5 minute Apgar score and birth trauma. Vaginal delivery and emergency caesarean section resulted in a sevenfold increase in low Apgar score, a threefold increase in birth trauma and a twofold increase in perinatal mortality when compared with the results of planned caesarean section. This study confirms the data found by Hannah et al. on an increase in early neonatal morbidity and mortality, following a trial of labour in cases of term breech presentation. These data require carefully weighed consideration against increased maternal (long term) risks due to a rise in caesarean sections.

Term breech presentation in The Netherlands from 1995 to 1999: mortality and morbidity in relation to the mode of delivery of 33,824 infants

Objective To analyse neonatal mortality and morbidity in term infants born in breech presentation in relation to the mode of delivery (planned caesarean section, emergency caesarean section or vaginal delivery) and to compare these findings with those of the Term Breech Trial Collaborative Group [Hannah et al. Lancet 2000; October]. Design Retrospective observational study. Setting The Netherlands. Population Infants ( n = 33,824) born at term in breech presentation in the Netherlands between 1995 and 1999. Multiple pregnancies, antenatal death and major congenital malformations were excluded. Methods Data derived from the Dutch Perinatal Database were used to compare neonatal outcome of infants born in breech presentation in relation to the different modes of delivery (i.e. planned caesarean section, emergency caesarean section and vaginal delivery). Correction was made for differences in parity, duration of gestation and birthweight, using logistic regression. Main outcome measures Intrapartum and first-week neonatal death, 5 minute Apgar score and birth trauma. Results Vaginal delivery and emergency caesarean section resulted in a sevenfold increase in low Apgar score, a threefold increase in birth trauma and a twofold increase in perinatal mortality when compared with the results of planned caesarean section. Conclusions This study confirms the data found by Hannah et al. on an increase in early neonatal morbidity and mortality, following a trial of labour in cases of term breech presentation. These data require carefully weighed consideration against increased maternal (long term) risks due to a rise in caesarean sections.

Mode of delivery and outcome of 699 term singleton breech deliveries at a single center

Objective: Elective cesarean delivery has been postulated to improve the outcome of term fetuses in breech presentation. We retrospectively compared the short- and long-term outcomes of term infants who were delivered from a breech presentation at a single center. Study Design: We reviewed 699 consecutive term breech presentations according to the intended mode of delivery at a single center between January 1993 and December 1999. The short-term outcome measures were perinatal death, neonatal death, or serious neonatal morbidity; the long-term outcome measures were developmental delay and spasticity. Results: The rate of serious perinatal morbidity in the trial-of-labor and cesarean delivery groups was 2.3% and 0.5%, respectively (P =.12). There was no perinatal or neonatal death in either group. With a median follow-up period of 57 months (range, 13-100 months), the rate of developmental delay was 1.9% and 0.5%, respectively (P =.29). Spasticity was not noted in any of the children. Conclusion: Our data suggest that planned vaginal delivery remains an option for selected term breech presentations. (Am J Obstet Gynecol 2002;187:1694-8.)

Trends in the management of the breech presentation at term; experience in a District General hospital over a 10-year period.

The recent evidence from a randomised controlled study on the management of breech delivery has settled the argument, however, this has not been to everybody's satisfaction. Elective delivery of all full term breech babies has implications. However, the trend seems to have been set long before the recent evidence, which is bound to accelerate the changes. This is a retrospective observational study in a district general hospital. All planned term singleton (> or = 37 weeks gestation) breech deliveries between 1988 and 1997 were reviewed to assess changes in the management of the term breech delivery over a 10-year period. The main outcome measure was the trend of the intended mode of delivery correlated with the time period of the study and its effect on the neonatal and maternal outcome. There was a significant almost linear increase in the planned elective caesarean birth rate over the study period (OR = 1.25, 95% CI = 1.18-1.32). This was associated with a significant decline in neonatal intubation but no other effect on maternal or neonatal morbidity. There was no effect on perinatal mortality. Caesarean section has gradually become the preferred mode of delivery for the term breech presentation, despite prior lack of clinical evidence This change in trend may be influenced by maternal wishes. Reduced experience in the conduct of vaginal breech deliveries will have important implications for future obstetric specialists. A trial of vaginal delivery should be allowed in suitably selected cases before obstetricians lose the skills and confidence in performing an assisted vaginal breech delivery.

Obstetric outcome among women with unexplained infertility after IVF: a matched case-control study

Infertility itself and also assisted reproductive treatment increase the incidence of some obstetric complications. Women with unexplained infertility are reported to be at an increased risk of intrauterine growth restriction during pregnancy, but not for other perinatal complications. A matched case-control study was performed on care during pregnancy and delivery, obstetric complications and infant perinatal outcomes of 107 women with unexplained infertility, with 118 clinical pregnancies after IVF or ICSI treatment. These resulted in 90 deliveries; of these, 69 were singleton, 20 twin and one triplet. Two control groups were chosen from the Finnish Medical Birth Register, one group for spontaneous pregnancies (including 445 women and 545 children), matched according to maternal age, parity, year of birth, mother's residence and number of children at birth, and the other group for all pregnancies after IVF, ICSI or frozen embryo transfer treatment (FET) during the study period (including 2377 women and 2853 children). Among singletons, no difference was found in the mean birthweight, and the incidence of low birthweight (<2500 g) was comparable with that of the control groups. No differences were found in gestational duration, major congenital malformations or perinatal mortality among the groups studied. Among singletons in the study group, there were more term breech presentations (10.1%) compared with both spontaneously conceiving women and all IVF women (P < 0.01). The rate of pregnancy-induced hypertension was significantly lower among singletons in the study group (P < 0.05) compared with other IVF singletons. The multiple pregnancy rate was 23.3% in the study group. The obstetric outcome of the IVF twins was similar to both control groups. The overall obstetric outcome among couples with unexplained infertility treated with IVF was good, with similar outcome compared with spontaneous pregnancies and IVF pregnancies generally.

The term breech presentation. A retrospective study with regard to the planned mode of delivery.

To analyze retrospectively a large group of term breech and vertex deliveries, with regard to the influence of the mode of delivery on the frequency of fetal and maternal complications. All singleton breech deliveries after completed 36 weeks of pregnancy, with a live fetus, delivered at Rogaland Central Hospital, from September 1 1996 to the May 10 2001 were included (n = 575). Correspondingly as a control group, 582 cases in vertex presentation were analyzed. Planned vaginal delivery (VD) for the fetus in breech presentation (n = 448) in comparison with elective caesarean section (CS) (n = 127) increased early neonatal morbidity (3.6% vs. 0%). The frequency of Apgar scores < 7 at 5 min also increased (4.2% vs. 0.8%), as well as umbilical artery pH < 7.0 (4.4% vs. 0%), and referrals to the neonatal intensive care unit (NICU) (15.8% vs. 6.3%). Corresponding figures for planned VD of the fetus in vertex presentation were: 0.5% neonatal morbidity, 0.2% Apgar scores < 7 at 5 min, 8.1% admissions to NICU and 1.5% pH < 7.0 in umbilical arteries. Results comparing maternal morbidity in the different breech groups were inconclusive, but there were more maternal complications in the breech group planned for VD than in the corresponding vertex group (5.1% vs. 1.9%). Elective CS for breech presentation will significantly decrease the risks for the fetus in comparison with planned VD.

The term breech presentation. A retrospective study with regard to the planned mode of delivery

Background. To analyze retrospectively a large group of term breech and vertex deliveries, with regard to the influence of the mode of delivery on the frequency of fetal and maternal complications. Methods. All singleton breech deliveries after completed 36 weeks of pregnancy, with a live fetus, delivered at Rogaland Central Hospital, from September 1 1996 to the May 10 2001 were included (n = 575). Correspondingly as a control group, 582 cases in vertex presentation were analyzed. Results. Planned vaginal delivery (VD) for the fetus in breech presentation (n = 448) in comparison with elective caesarean section (CS) (n = 127) increased early neonatal morbidity (3.6% vs. 0%). The frequency of Apgar scores < 7 at 5 min also increased (4.2% vs. 0.8%), as well as umbilical artery pH < 7.0 (4.4% vs. 0%), and referrals to the neonatal intensive care unit (NICU) (15.8% vs. 6.3%). Corresponding figures for planned VD of the fetus in vertex presentation were: 0.5% neonatal morbidity, 0.2% Apgar scores < 7 at 5 min, 8.1% admissions to NICU and 1.5% pH < 7.0 in umbilical arteries. Results comparing maternal morbidity in the different breech groups were inconclusive, but there were more maternal complications in the breech group planned for VD than in the corresponding vertex group (5.1% vs. 1.9%). Conclusions. Elective CS for breech presentation will significantly decrease the risks for the fetus in comparison with planned VD.

Best evidence in anesthetic practice: Prevention: planned Cesarean delivery reduces early perinatal and neonatal complications for term breech presentations.

Question For the fetus that presents as breech at term, does a planned Cesarean birth reduce perinatal or neonatal mortality or serious neonatal morbidity compared to vaginal planned birth?

Planned vaginal delivery versus elective caesarean section in singleton term breech presentation: a study of 1116 cases

Objective: To compare neonatal and maternal morbidity and mortality between planned vaginal delivery and elective cesarean section for singleton term breech presentation. Study design: We studied retrospectively all deliveries of singleton breech presentations at term in the public Hospitals of Lyon between 1 January 1991 and 31 December 1995. To take only the effect of delivery on the fetus into account, we eliminated high risk pregnancies and fetal malformations. Fetal parameters were corrected perinatal mortality, Apgar score<7 at 1 and 5min, umbilical cord arterial pH<7.15, neurological disorders, trauma and need for neonatal intensive care. Maternal parameters were mild, moderate and severe complications. Results: Of the 1116 breech presentations, 702 (62.9%) underwent an elective caesarean section and 414 (37.1%) a planned vaginal delivery. In the latter group, 342 (30.6%) had a vaginal delivery and 72 (6.5%) a non-elective caesarean section. Infants for whom the vaginal route was planned were at higher risk of mortality and morbidity. There were 2 deaths in this group and none in the elective caesarean section group and all fetal parameters were poorer: more Apgar<7 at 5min (RR: relative risk=3.05; 1.03–9.05), arterial pH<7.15 (RR=1.64; 1.11–2.43), intubations (RR=7.35; 2.10–25.6), neurological disorders, trauma (RR=4.24; 1.66–10.8), transfer to intensive care units (RR=3.23; 1.57–6.64). The overall maternal morbidity was lower in the planned vaginal delivery group (RR=0.65; 0.44–0.94) but this was only because of less mild complications. The moderate and severe complications were the same in the two groups (RR=0.97; 0.59–1.57). Conclusions: Planned vaginal delivery in singleton term breech presentation increases the risk of death and of neonatal complications. Elective caesarean section increases the risk of only mild maternal complications. For these reasons, elective caesarean section should be preferred for singleton term breech presentations.

Is Breech Presentation in Nulliparous Women at Term an Absolute Indication for Cesarean Section?

The aim of this report was to study the perinatal outcome of singleton breech presentation in nulliparous women who delivered after 37 weeks, either vaginally or by cesarean section, and whether by elective surgery or emergency, and to identify the indications for cesarean sections. This is a retrospective study conducted at King Fahd Hospital of the University, AlKhobar, Saudi Arabia, to compare perinatal mortality and morbidity of singleton term breech infants delivered vaginally and by cesarean section in nulliparous women. There were 112 singleton term breech presentations, of which 96 (85.7%) were allowed to have a trial of labor. Of these, 67 (69.8%) had a successful vaginal delivery. Women who delivered by elective cesarean section were significantly older than those who delivered vaginally (P<0.0001), and those who delivered by emergency cesarean section (P<0.004). The infants delivered by cesarean section were heavier in weight than those delivered vaginally (P<0.0001). There were no significant differences in 5 minute Apgar scores and perinatal mortality between the groups. With proper selection of nulliparous women with breech presentation for vaginal delivery, cesarean section can be avoided in the majority of cases without compromising the perinatal outcome.

Patient Preference the Leading Indication for Elective Caesarean Section in Public Patients—Results of a 2-Year Prospective Audit in a Teaching Hospital

Because the rate of cesarean delivery has grown markedly in recent decades and recent research indicates that patient requests may be one of the strongest indications, a prospective study was undertaken to audit indications for operative delivery. A total of 9138 deliveries at an Australian teaching hospital in a 2-year period were reviewed. The cesarean delivery rate was 17.8 percent, and of the 1624 caesarean deliveries, 39 percent were elective. More than one fourth of elective cesarean deliveries (27 percent) were done solely because of the mother’s request, and this was the leading indication for elective surgery. In 103 of 170 cases, the woman had previously had a cesarean delivery, but the current pregnancy was otherwise suitable for a trial of labor. All 56 women with breech presentation also were otherwise suitable for attempted vaginal birth. Only five women presented no particular reason for requesting elective delivery. The most common medical indication for elective cesarean delivery was more than one previous cesarean delivery. Other medical indications included a previous complicated cesarean delivery, a term breech presentation in which a trial of labor was considered inadvisable, placenta previa, severe intrauterine growth retardation with abnormal placental function, transverse and unstable fetal lie, suspected cephalopelvic disproportion, and preeclampsia. Preterm breech presentation, active herpes simplex, multiple gestation, and abruptio placenta were other indications. Nonelective cesarean deliveries were most often done because of suspected fetal distress or failure to progress in labor. The investigators believe that current maternal decision-making may well be influenced by the modern emphasis on patient advocacy and consumer choice. Attempts to lower the cesarean delivery rate should focus on promoting a trial of vaginal delivery in cases of a history of past cesarean delivery and also in cases of breech presentation. It also would help to develop better means of detecting fetal acidosis during labor. Aust NZ J Obstet Gynaecol 1999;39:207–214

The relation of breech presentation at term to cerebral palsy.

To examine the relation between breech delivery and cerebral palsy, considering the influence of intrauterine growth, low Apgar score at birth, and mode of delivery. Register-based, case-control study. A cohort of infants with cerebral palsy born between 1979 and 1986 in East Denmark, identified by linkage of the cerebral palsy register with the national birth register. Discharge letters from births of breech infants with cerebral palsy were reviewed. Presentation, mode of delivery, gestational age, birthweight, Apgar score, type of cerebral palsy, severity of handicap. Breech presentation at term was associated with a borderline significantly higher risk of cerebral palsy than vertex presentation (OR 1.56; 95% CI 0.9-2.4). Breech presentation infants more often had a lower Apgar score (< 7 at 5 minutes) and were smaller for gestational age (SGA < 2 SD) than were those with vertex presentation; infants with a low Apgar score, or who were small for gestational age, had a higher risk of cerebral palsy. After stratification by being small for gestational age the risk of cerebral palsy was not related to presentation. There were no differences between breech and vertex infants with cerebral palsy in terms of low Apgar score, being small for gestational age, mode of delivery, and severity of the handicap. Breech presentation infants were more often classified as diplegic (77.8% versus 42.3% in cephalic infants). The risk of cerebral palsy among term breech presentation infants does not seem to be related to mode of delivery, but is more likely linked to a higher rate of being small for gestational age in breech infants.

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

Undetected breech presentation: impact on external version and cesarean rates.

The objective of this study was to determine the impact of undetected breech presentation on an external cephalic version program. We performed a retrospective analysis of all external cephalic versions attempted over a 1-year interval. We then analyzed all cesarean operations performed for the indication of breech presentation over the same interval. Cases involving twin gestations and premature births were excluded. We found that 21% of term breech presentations were not detected before the onset of labor and an additional 15% were not detected until after 38 weeks' gestation. Increased third-trimester screening for breech presentation could potentially decrease the need for cesarean delivery.