ArticleLiterature Review

Breech vaginal delivery at or near term

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Abstract

Three percent to 4% of term fetuses will be breech at delivery. Evidence from randomized controlled trials has found a policy of planned cesarean section to be significantly better for the singleton fetus in breech presentation at term compared to a policy of planned vaginal birth. However, some women may wish to avoid cesarean section and for others, cesarean section may not be possible. We undertook this review to identify factors associated with higher and lower risk of adverse fetal or neonatal outcome at term during vaginal breech delivery. We searched MEDLINE from 1966 to 2002 using the search terms vaginal breech delivery and breech presentation and retrieved all relevant articles. We also reviewed personal references and reference lists of articles retrieved. Women who are older or who have a fetus that is either in footling presentation, has a hyperextended head or is estimated to weigh <2500 g or >4000 g may be at higher risk of adverse fetal outcome. Prolonged labor or not having an experienced clinician at vaginal breech birth may also increase the risk. Women with a fetus in breech presentation at term should be offered the option of delivery by planned cesarean section and should be informed that this will reduce their risk of adverse fetal or neonatal outcome. Practitioners should develop and maintain skills at vaginal breech delivery for those women not wishing or not able to be delivered by cesarean section.

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... Another risk factor for breech deliveries, whether for twins or singletons, is head entrapment, the failure of the infant's cranium to negotiate the birth canal following its body. The occurrence of entrapment among breech births today is in the range of 5.6-9.3 per cent, being somewhat more frequent among pre-term fetuses because of the larger size of their heads compared with their bodies (Van Eyk & Huisjes 1983;Anderson & Strong 1988;Robertson et al. 1995;Tunde-Byass & Hannah 2003). Whether the ultimate mechanism behind entrapment stems from the infant (e.g. ...
... contracted lower uterus, incompletely dilated cervix, pelvic tumours), fetal death can occur quite quickly due to compression of the umbilical cord (i.e. asphyxia) or trauma to the neural tissues (Anderson & Strong 1988;Dolea & AbouZahr 2003;Tunde-Byass & Hannah 2003). In fact, the relatively high likelihood of head entrapment, necessitating complex and sometimes risky obstetrical manoeuvres or surgical intervention to free the fetus, has prompted many modern medical practitioners to opt for planned Caesarean sections rather than vaginal deliveries of breech infants (Anderson & Strong 1988;Hannah et al. 2000;Tunde-Byass & Hannah 2003). ...
... asphyxia) or trauma to the neural tissues (Anderson & Strong 1988;Dolea & AbouZahr 2003;Tunde-Byass & Hannah 2003). In fact, the relatively high likelihood of head entrapment, necessitating complex and sometimes risky obstetrical manoeuvres or surgical intervention to free the fetus, has prompted many modern medical practitioners to opt for planned Caesarean sections rather than vaginal deliveries of breech infants (Anderson & Strong 1988;Hannah et al. 2000;Tunde-Byass & Hannah 2003). While this approach has not gone unchallenged (e.g. ...
Article
Death during childbirth was a significant risk for women in prehistoric and pre-modern societies, but it has rarely been documented by archaeology. The evidence for twins in the archaeological record has likewise been largely circumstantial, with few confirmed cases. Maternal mortality in childbirth is often obscured by the special ritual practices associated with this type of death. In the case of twin births that difficulty is compounded by past social attitudes to twins. The earliest confirmed evidence for obstructed labour comes from the burial of a young woman who died attempting to deliver twins in the middle Holocene hunter-gatherer cemetery at Lokomotiv in southern Siberia some 7000 to 8000 years ago.
... Approximately 3% to 5% of all pregnancies reach full term presenting with breech presentation. [1][2][3][4][5][6] The Webster technique is a chiropractic procedure that is believed to relieve the musculoskeletal cause of intrauterine constraint, with the goal of repositioning breech presentation to cephalic presentation. [7][8][9] The Webster technique is thought to promote cephalic presentation by treating sacroiliac joint dysfunction with sacral manipulation and lower abdominal tenderness, nodules, or adhesions with www.journalchiromed.com ...
... 14 When breech presentation persists to full term and cesarean delivery is performed instead of vaginal births, outcomes are improved; and the relative risk of neonatal death or serious morbidity is reduced by 33%. 2,13 These reductions in morbidity and mortality come at the expense of slightly increased maternal morbidity. 13 Although women demonstrating breech presentation at full term have been shown to prefer vaginal deliveries, 26 it is important to emphasize that patients must be fully informed of the potential risks and benefits surrounding both vaginal and cesarean delivery methods. ...
... 5 Observation of fetal lie has shown fetal malpresentation to decrease from 21% at the beginning of the third trimester to 5% at full term, 5 which is consistent with other reports. [1][2][3][4]6 It has been demonstrated that 75% of fetal malpresentations at 28 to 30 weeks' gestation spontaneously reposition into a cephalic presentation by full term. 5 In addition to the Webster technique, clinicians should acknowledge other management strategies for resolving breech presentation. ...
Article
The purpose of this report is to describe the results of a pregnant woman demonstrating breech fetal presentation who was managed with Webster technique in the presence of oligohydramnios. A 23-year-old primigravida woman sought chiropractic care for the management of breech presentation and bilateral sacroiliac arthralgia at 34 weeks' gestation. Sacral manipulation and abdominal effleurage (Webster Technique) was used to address breech presentation and sacroiliac arthralgia for a total of 7 treatments over a 3 1/2-week duration. The patient's sacroiliac pain reduced from 8/10 to 3/10. However, breech presentation was unchanged at each treatment. At a scheduled prenatal surveillance during the 37th week of gestation, the midwife detected vaginal bleeding and reduced fundal height, which resulted in hospitalization, diagnosis of oligohydramnios, and an emergency cesarean delivery. For this particular patient, the breech presentation was not corrected using the Webster technique. Clinicians who use the Webster technique to manage breech fetal presentation should be aware of undiagnosed comorbidities as a complicating factor in clinical presentation. Screening for previously undiagnosed comorbidities, such as oligohydramnios, must be considered.
... Approximately 3% to 5% of all pregnancies reach full term presenting with breech presentation. [1][2][3][4][5][6] The Webster technique is a chiropractic procedure that is believed to relieve the musculoskeletal cause of intrauterine constraint, with the goal of repositioning breech presentation to cephalic presentation. [7][8][9] The Webster technique is thought to promote cephalic presentation by treating sacroiliac joint dysfunction with sacral manipulation and lower abdominal tenderness, nodules, or adhesions with www.journalchiromed.com ...
... 14 When breech presentation persists to full term and cesarean delivery is performed instead of vaginal births, outcomes are improved; and the relative risk of neonatal death or serious morbidity is reduced by 33%. 2,13 These reductions in morbidity and mortality come at the expense of slightly increased maternal morbidity. 13 Although women demonstrating breech presentation at full term have been shown to prefer vaginal deliveries, 26 it is important to emphasize that patients must be fully informed of the potential risks and benefits surrounding both vaginal and cesarean delivery methods. ...
... 5 Observation of fetal lie has shown fetal malpresentation to decrease from 21% at the beginning of the third trimester to 5% at full term, 5 which is consistent with other reports. [1][2][3][4]6 It has been demonstrated that 75% of fetal malpresentations at 28 to 30 weeks' gestation spontaneously reposition into a cephalic presentation by full term. 5 In addition to the Webster technique, clinicians should acknowledge other management strategies for resolving breech presentation. ...
Article
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Objective: The purpose of this report is to describe the results of a pregnant woman demonstrating breech fetal presentation who was managed with Webster technique in the presence of oligohydramnios. Clinical Features: A 23-year-old primigravida woman sought chiropractic care for the management of breech presentation and bilateral sacroiliac arthralgia at 34 weeks' gestation. Intervention and Outcome: Sacral manipulation and abdominal effleurage (Webster Technique) was used to address breech presentation and sacroiliac arthralgia for a total of 7 treatments over a 3 1/2-week duration. The patient's sacroiliac pain reduced from 8/10 to 3/10. However, breech presentation was unchanged at each treatment. At a scheduled prenatal surveillance during the 37th week of gestation, the midwife detected vaginal bleeding and reduced fundal height, which resulted in hospitalization, diagnosis of oligohydramnios, and an emergency cesarean delivery. Conclusion: For this particular patient, the breech presentation was not corrected using the Webster technique. Clinicians who use the Webster technique to manage breech fetal presentation should be aware of undiagnosed comorbidities as a complicating factor in clinical presentation. Screening for previously undiagnosed comorbidities, such as oligohydramnios, must be considered.
... By thirty weeks gestation the vast majority (86%) of fetuses would have attained the cephalic presentation. Beyond 40 weeks gestation only a minority (less than 3 %) present by the breech (Tunde-Byass 2003). ...
... By thirty weeks gestation the vast majority (86%) of fetuses would have attained the cephalic presentation. Beyond 40 weeks gestation only a minority (less than 3 %) present by the breech (Tunde-Byass 2003).Delivery by the breech has also been found to be a risk factor for epilepsy (OR: 1.2[95% CI: 1.1, 1.3]). Moreover breech delivered babies with epilepsy were more often small for gestational age (9.7%) than breech infants without epilepsy (4.7%). ...
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Vol. 31-n. 4 (229-236)-2016 HUMAN EVOLUTION Bipedalism and a high encephalization quotient are unique characteristics of the human species. It is plausible that these characteristics are connected through the evolutionary process of the homo genus and may have influenced each other's development. The connection between bipedalism and a high encephalization quotient may have been conferred through to gravity's effect on the blood supply to the brain, both in utero and in the first year of life. The enlarged human brain initiates at birth whereby the neona-tal brain weighs 350-400g compared to P. troclodytes (chimpanzee) neonatal brain weight of 155g. After a progressive reduction in breech presentation throughout pregnancy, more than 97% of human fetuses present cephalically at the end of pregnancy. Adverse outcomes for the fetus are known to occur for breech presentation, prematurity and postdates delivery. The appropriately adjusted gestational age in the homo genus, possibly under evolutionary pressures, encouraged cephalic presentation. Gravity would have assisted blood supply, nutrition and cerebral metabolism of the growing brain. Another ob-stetric surrogate is that both body weight and brain volume in multiple pregnancies are significantly larger in the lower, first born twin, compared to the higher second born twin. The gravitational effect of brain blood supply persists beyond birth. Human babies only become fully bipedal at the age of 1-1.3 years. During the first year the greatest growth in brain weight is registered when it increases to 900g-1kg. The combination of Obstetric and Paediatric surrogates suggest that grav-ity's influence, through the evolution of human bipedalism, on blood supply may be responsible for the high encephalization quotient in the Homo sapiens species.
... Should ECV be declined or fail, generally women are offered delivery by planned (elective) cesarean section, as there is level 1 evidence of reduced risk of perinatal death and severe morbidity compared with attempting vaginal breech birth, and it is also associated with lower costs [3,12,13]. However, some women may still opt for an attempt at vaginal breech birth if they prioritise nonintervention over managing the relatively small absolute risks of a severe adverse event [1,14]. ...
Article
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Background: Despite the relative ease with which breech presentation can be identified through ultrasound screening, the assessment of foetal presentation at term is often based on clinical examination only. Due to limitations in this approach, many women present in labour with an undiagnosed breech presentation, with increased risk of foetal morbidity and mortality. This study sought to determine the cost effectiveness of universal ultrasound scanning for breech presentation near term (36 weeks of gestational age [wkGA]) in nulliparous women. Methods and findings: The Pregnancy Outcome Prediction (POP) study was a prospective cohort study between January 14, 2008 and July 31, 2012, including 3,879 nulliparous women who attended for a research screening ultrasound examination at 36 wkGA. Foetal presentation was assessed and compared for the groups with and without a clinically indicated ultrasound. Where breech presentation was detected, an external cephalic version (ECV) was routinely offered. If the ECV was unsuccessful or not performed, the women were offered either planned cesarean section at 39 weeks or attempted vaginal breech delivery. To compare the likelihood of different mode of deliveries and associated long-term health outcomes for universal ultrasound to current practice, a probabilistic economic simulation model was constructed. Parameter values were obtained from the POP study, and costs were mainly obtained from the English National Health Service (NHS). One hundred seventy-nine out of 3,879 women (4.6%) were diagnosed with breech presentation at 36 weeks. For most women (96), there had been no prior suspicion of noncephalic presentation. ECV was attempted for 84 (46.9%) women and was successful in 12 (success rate: 14.3%). Overall, 19 of the 179 women delivered vaginally (10.6%), 110 delivered by elective cesarean section (ELCS) (61.5%) and 50 delivered by emergency cesarean section (EMCS) (27.9%). There were no women with undiagnosed breech presentation in labour in the entire cohort. On average, 40 scans were needed per detection of a previously undiagnosed breech presentation. The economic analysis indicated that, compared to current practice, universal late-pregnancy ultrasound would identify around 14,826 otherwise undiagnosed breech presentations across England annually. It would also reduce EMCS and vaginal breech deliveries by 0.7 and 1.0 percentage points, respectively: around 4,196 and 6,061 deliveries across England annually. Universal ultrasound would also prevent 7.89 neonatal mortalities annually. The strategy would be cost effective if foetal presentation could be assessed for £19.80 or less per woman. Limitations to this study included that foetal presentation was revealed to all women and that the health economic analysis may be altered by parity. Conclusions: According to our estimates, universal late pregnancy ultrasound in nulliparous women (1) would virtually eliminate undiagnosed breech presentation, (2) would be expected to reduce foetal mortality in breech presentation, and (3) would be cost effective if foetal presentation could be assessed for less than £19.80 per woman.
... In vaginal breech delivery, there is a risk of intrapartum asphyxia due to cord compression and decreased circulation during the second stage of labor. The risk of asphyxia depends on the length of the second stage of labor, and is especially high after the fetal umbilicus has past the perineum [12,17]. A retrospective observational study from Helsinki examining risk factors and outcomes in "well-selected" vaginal breech deliveries, demonstrated that a second stage of labor <40 min protected against adverse neonatal outcomes [18]. ...
Article
Introduction: The routine to deliver almost all term breech cases by elective cesarean section (CS) has continued to be debated due to the risk of maternal and neonatal complications. The aims of the study were 1) to investigate if mode of delivery impacts on the risk of morbidity and mortality among term infants in breech presentation and 2) to compare the rates of severe neonatal complications and mortality in relation to presentation and mode of delivery. Methods: This population-based cohort study used data from the Swedish Medical Birth Register. All women (and their newborn infants) with singleton pregnancies who gave birth at term to an infant in breech (n = 27 357) or cephalic presentation (n = 837 494) between 2001 and 2012 were included. Births with vacuum extraction and induced labors were excluded, as well as antepartum stillbirths, births with infants diagnosed with congenital malformations and multiple births. Results: The rates of neonatal complications and mortality were higher among infants born in vaginal breech compared to the vaginal cephalic group. On the other hand, after CS the rates of all neonatal complications under study and neonatal mortality were lower among infants in breech presentation than in those in cephalic presentation. After adjustment for confounders, infants delivered in vaginal breech had 23.8 times higher odds AOR (ratio) for brachial plexus injury, 13.3 times higher odds ratio for Apgar score < 7 at 5 min, 6.7 times higher odds of intracranial hemorrhage (ICH) or convulsions and 7.6 higher odds ratio for perinatal mortality than those delivered by elective CS. Conclusion: Despite a probable selection of women who before-hand were considered at low risk and therefore could be recommended vaginal breech delivery, infants delivered in vaginal breech faced substantially increased risks of severe neonatal complications compared with infants in breech presentations delivered by elective CS.
... Likewise, Roman et al. examined 2478 women with breech presentation at term and found that significant risk factors were nulliparity, complete breech, membrane rupture before labour, neonatal weight higher than 3800 g, and biparietal diameters more than 95 mm [17]. Furthermore, a review by Tunde-Byass et al., which included four randomized trials and 21 retrospective studies between 1966 and 2002, showed a higher risk of CS when the fetus was in a footling presentation, the fetus' head was large, the estimated neonatal weight was above 4000 g, as well in nulliparous women, unknown pelvimetry, women of advanced age, and if breech presentation was diagnosed prior to labour [18]. Although in our study higher maternal weight was associated with an unplanned CS in the group of women who planned to have a vaginal delivery, this risk factor was no longer significant using multivariate analyses. ...
Article
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PurposeTo identify risk factors for emergency caesarean section in women attempting a vaginal breech delivery at term. Methods Data from 1092 breech deliveries performed between 1998 and 2013 at a Swiss cantonal hospital were extracted from an electronic database. Of the 866 women with a singleton, full term pregnancy, 464 planned a vaginal breech delivery. Fifty-seven percent (265/464) were successful in delivering vaginally. Multivariate regression analyses of risk factors were performed, and neonatal and maternal complications were compared. ResultsRisk factors for failed vaginal delivery were peridural anaesthesia (OR 2.05; 95 % CI 1.09–3.84; p = 0.025), nulliparity (OR 2.82; 95 % CI 1.87–4.25; p < 0.001), high birth weight (OR 1.17; 95 % CI 1.04–1.30; p = 0.006) and induction of labour (OR 1.56; 95 % CI 1.003–2.44; p = 0.048). Maternal age, height and weight; gestational age; or newborn length and head circumference were not associated with an unplanned caesarean section. The rate of successful vaginal delivery in the low risk sub-group (multiparous women without induction of labour) was 58–83 %, depending on birth weight category. The likelihood of success for the high risk sub-group (nulliparous women with induction of labour) fell below a third at neonatal birth weights >3250 g. Complication rates were low in the cohort. Conclusions Use of peridural anaesthesia, nulliparity, high birth weight and induction of labour were risk factors for unsuccessful vaginal breech delivery requiring an unplanned caesarean section. Awareness of these risk factors is useful when counselling women who are considering a vaginal breech delivery.
... Algunos estudios afirman que el parto de nalgas vaginal solo debe asistirse en pacientes multíparas, porque parece existir una mayor morbimortalidad en nulíparas 18 . Sin embargo, los estudios más recientes dicen que es correcta la asistencia tanto en nulíparas como en multíparas 1, 3,11,15,27 . Lo que sí que queda reflejado es que el parto en multíparas es más rápido y puede ser más sencillo 1,3,4 . ...
Article
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Objective To analyze the perinatal results in our hospital comparing vaginal delivery and cesarean section in breech presentation singleton pregnancies at term. Material and Methods All live ante-partum singleton fetuses in breech presentation, at 37 to 41+6 weeks and days who delivered between July 2006 and August 2010 were included in the study. We compared perinatal results between cesarean section and vaginal delivery. Results There were no differences in Apgar score at 5 minutes < 7, pH umbilical cord < 7, base deficits and lactate, neonatal intensive care unit admission or perinatal mortality. Conclusions With appropriate maternal and fetal conditions and a qualified medical team, a breech vaginal delivery could be propose obtaining good perinatal outcomes.
... In 1 wild breech birth that resulted in a live born infant, the birth phase was described as relatively long, at 5 min (Moreno et al. 1991) versus the usual 1–2 min (Sekulic 1982); however, this birth was still rapid compared to the breech birth we observed and others reported in the literature. In the nonhuman primate examples, the longer birth phase associated with breech presentations, in which the infant is often partially outside the mother, likely creates the same circumstances for hypoxia and stillbirth described in humans (Byass and Hannah 2003), emphasizing the selection for a short birth phase. As is expected for macaques, the 3 free-ranging infants all emerged in vertex occiput posterior position (Table II), a position that allows the mother to assist manually in the birth of her infant (Trevathan 1988), by pulling on, supporting, and guiding the infant head first out of the birth canal. ...
Article
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The birth process is an integral part of reproductive success in mammals, yet detailed, quantitative descriptions of parturition in nonhuman primates are still rare. Observations of free-ranging births can help to elucidate factors involved in this critical event, to contribute to our understanding of how maternal and infant behaviors during parturition affect infant survival and to explain the evolution of human birth. We provide data on the parturition behavior of 4 multiparous Japanese macaques: 2 daytime live births that we photographed and video recorded at the Awajishima Monkey Center (AMC), Awaji Island, Japan in 2006; a daytime live birth video recorded in 1993 at the AMC; and a nocturnal breech stillbirth of a captive Macaca fuscata, video recorded at the Kyoto Primate Research Institute in 2006. Certain behaviors were similar among the females, such as touching of the vulva followed by licking of fingers, squatting during contractions, and average contraction durations. Parturient females facilitated the birth manually by guiding the emerging infant. There were also dissimilarities in the duration of the labor and birth stages, condition of the infant at birth, and the mother’s behavior immediately postpartum. The mother’s postpartum behavior ranged from almost entirely infant-focused to predominantly related to the consumption of the placenta. The 3 free-ranging females all showed considerable social tolerance during labor and birth. We argue that social proximity at parturition is more common in nonhuman primates than previously emphasized, and has potential adaptive advantages.
... Сем пре мату ри те та, по сто ји још раз ло га по ста вља ња фе ту са у тај по ло жај, а то су: пре те ра но опуште на ма те ри ца, по ли хи др ам нион, ано мали је ма те ри це, ви ше плод на труд но ћа, ми оми, фун ду сна пла цен та ци ја. Нај че шћа је једно став на кар лич на пре зен та ци ја (око 65%), за тим пот пу на и не пот пу на кар лич на, док су пот пу на и не пот пу на пре зен та ци ја ко ле нима и но жи ца ма ре ђе [1]. ...
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Term breech presentation occurs in 3-4% of all deliveries. Most obstetricians are completely sure how to end delivery when the foetus is in breech presentation, by caesarean section as the only option. The main goal of the paper was to present the method of delivery for term breech presentation analyzed at the Hospital of Gynaecology and Obstetrics and Clinical Centre in Kragujevac, and parameters that influenced the decision on the method of choice to perform delivery with the foetus in breech position. During a three-year prospective study, the course and outcome of all term breech deliveries were under followup. The study involved only deliveries in breech presentation, with a trial of labour ending by vaginal delivery, while elective caesarean section due to breech presentation of the foetus was not included in the study. The following parameters were compared: body mass, newborn's first minute Apgar score and head circumference, gestational maturity, gestational age, delivery duration, maternal level of education and maternal parity. Of total 6,470 deliveries, 653 (10.10%) were finalized by caesarean section. Of these, there were 202 (3.12%) term breech presentations, of which 72 (35.64%) women had caesarean and 130 (64.36%) vaginal delivery. A difference was detected in newborn's body mass and head circumference, delivery duration, maternal level of education and parity between pregnancies terminated surgically in comparison to vaginal delivery, while pregnancy duration, maternal age, first minute Apgar score, and most significantly, perinatal morbidity did not show any difference regardless of the method of delivery for term breech presentation. With respect of all known parameters, vaginal delivery in breech presentation is also accepted.
Article
Breech deliveries are the most common form of fetal malpresentations and are associated with significant risk for morbidity and mortality to mother and infant. There is an increased chance that emergency physicians may encounter breech deliveries as more women with known breech presentations are given the option for a trial of labor in lieu of mandatory caesarean section. Emergency physicians should be prepared for the complications that are associated with breech delivery and recognize the different maneuvers required to successfully deliver a breech infant.
Article
Breech presentation occurs at term in approximately 3% to 4% of singleton gestations. This presentation is associated with a variety of maternal and fetal conditions including preterm labor, abnormal amniotic fluid volume, hydrocephaly, anencephaly, mullerian anomalies, abnormal placentation, and multifetal gestation. Cesarean delivery has been associated with increased risk of subsequent accreta, placenta previa, hemorrhage, and hysterectomy. The Term Breech Trial initially suggested that planned vaginal breech delivery is associated with increased neonatal morbidity and mortality compared with planned cesarean delivery. Long-term follow-up of these vaginally delivered infants contradict the initial findings. Current debate surrounds the dilemma of whether the untoward complications of cesarean delivery are warranted given uncertain minimal increases in neonatal survival and improvement in neurologic outcome with planned cesarean.
Article
Patient-choice cesarean delivery is increasing in the United States. The American College of Obstetricians and Gynecologists supports this option, citing ethical premises of autonomy and informed consent, despite a lack of evidence for its safety. This increase in patient-choice cesarean delivery occurs during a time when women with a breech-presenting fetus or a previous cesarean section have fewer choices as to vaginal birth. Patient-choice cesarean delivery may become widely disseminated before the potential risks to women and their children have been well analyzed. The growing pressure for cesarean delivery in the absence of a medical indication may ultimately result in a decrease of women's childbirth options. Advocacy of patient-choice requires preserving vaginal birth options as well as cesarean delivery.
Article
The Term Breech Trial (TBT), a well-known study conducted by Hannah and published in the Lancet, revealed a better outcome for neonates after primary caesarean section compared with attempted vaginal delivery. The aim of the present study was to determine whether the results of TBT have to be taken into account when counseling pregnant women in central Europe. We investigated 882 women who had delivered infants in breech presentation over a period of 11 years. The neonates had a birthweight of >2500 g and no malformations. We compared mortality and serious neonatal morbidity after attempted vaginal delivery and after primary caesarean section. No infant or maternal mortality was registered in either group. Serious neonatal morbidity was higher (0.5%; n = 2) for attempted vaginal delivery than for primary caesarean section; in the latter group, no child fulfilled the criteria for serious neonatal morbidity. However, the difference was not statistically significant. As expected, after attempted vaginal delivery, the base excess, and 5-min APGAR scores were indicative of more markedly depressed children. After careful exclusion of risk factors and informing the patient in detail about the risks and possible complications, vaginal delivery from breech presentation is still warrantable.
Chapter
This chapter includes several simulation scenarios with learning objectives that focus on obstetric/gynecologic emergencies. The three cases focus on varied scenarios that incorporate the management of postpartum hemorrhage, shoulder dystocia, and breech delivery.
Article
In the Term Breech Trial, the risk of adverse perinatal outcome was lower with planned cesarean section versus planned vaginal birth. We undertook secondary analyses to determine factors associated with adverse perinatal outcome. By using multiple logistic regression analyses, we determined the effect of prelabor cesarean section, cesarean section during early labor, cesarean section during active labor versus vaginal birth, and other factors, on adverse perinatal outcome. For 1384 fetuses delivered after labor, we determined the effect of variables associated with labor on adverse perinatal outcome. The risk of adverse perinatal outcome was lowest with prelabor cesarean section (odds ratio [OR]=0.13) and highest with vaginal birth. For those delivered after labor, labor augmentation (P=.007), birth weight less than 2.8 kg (P=.003), and longer time between pushing and delivery (P<.001) increased the risk, whereas the presence of an experienced clinician at delivery (P=.004) reduced the risk of adverse perinatal outcome. Breech infants at term are best delivered by prelabor cesarean section.
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OBJETIVO: avaliar os resultados obstétricos e perinatais em casos de fetos em apresentação pélvica, de termo, nascidos de pacientes com partos vaginais prévios, comparando-os a fetos de termo, em apresentação cefálica. PACIENTES E MÉTODOS: foram analisados retrospectivamente 8.350 nascimentos ocorridos no período de março de 1998 a julho de 2003. Ocorreram 419 partos (5,1%) em apresentação pélvica, dos quais selecionaram-se 58 casos (grupo pélvico), que deveriam ter as seguintes características: antecedentes de um ou mais filhos nascidos pela via transpélvica, idade gestacional igual ou superior a 37 semanas, ausência de malformações fetais, inexistência de intercorrências durante a gestação, peso do recém-nascido no nascimento igual ou superior a 2.500 g e inferior a 3.750 g, e sem cesárea anterior. Esse grupo foi comparado a outro formado por 1.327 fetos com características semelhantes, em apresentação cefálica, de gestantes sem cesárea prévia (grupo cefálico). Analisaram-se a idade materna, paridade, idade gestacional, via de parto, peso do recém-nascido, presença de mecônio, índice de Apgar no primeiro e quinto minutos, necessidade de internação na unidade de tratamento intensivo neonatal e ocorrência de recém-nascidos pequenos e grandes para a idade gestacional. Os dados obstétricos e perinatais foram analisados pelo chi² e teste t de Student. Considerou-se como significante p
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PURPOSE: to assess the obstetric and perinatal outcomes in cases of term newborns in breech presentation, in patients with previous vaginal deliveries, comparing them to term newborns in vertex presentation. METHODS: 8,350 deliveries retrospectively from March 1998 to July 2003 were analysed. Of 419 deliveries (5.1%) in breech presentation, 58 cases were selected for the study (breech group), according to the following criteria: patients who had had one or more babies through vaginal delivery, gestational age ³37 weeks, no fetal malformation, no complications in the current pregnancy, birth weight between 2,500 and 3,750 g, and no previous cesarean section. The breech group was matched to 1,327 newborns in vertex position from pregnant women with no previous cesarean section (vertex group). Maternal age, parity, gestational age, delivery way, birth weight, meconium-stained amniotic fluid, 1- and 5-min Apgar score, need of neonatal intensive care unit, and small- and big-for-gestational age newborns were analyzed. Statistical analysis was performed by the c2 test and by Student's t test, with the level of significance set at p<0.05. RESULTS: when breech and vertex groups were compared, they showed significant differences regarding the following variables: birth weight (3,091±538 g vs 3,250±497 g; p<0.01), vaginal delivery (63.8 vs 95.0%; p<0.0001), cesarean section (36.2 vs 5.0%; p<0,0001), and 1-min Apgar score (p<0.0001), respectively. CONCLUSIONS: we conclude that in term fetuses in breech position from pregnant women with previous vaginal deliveries, birth weight, delivery way, and 1-min Apgar score were different compared to fetuses in vertex position from women with the same characteristics.
Article
Objective: To asses the impact of external cephalic version (ECV) on the mode of delivery of the uncomplicated term, singleton breech at teaching hospital. Material and Methods: This observational study was conducted in Obstetrics and Gynecology department, Hayatabad Medical Complex, Peshawar from 1st December 2003 to 31st January 2005 on all singleton term breech presentations from 37 to 41 weeks of gestation. Results: Out of 265 women presenting with breech presentation at 37 completed weeks or more at our unit during the study period, 188 patients met the selection criteria. Of these only 40 patients (21.3%) had ECV. Twenty seven of these were successful (67%). A total of 161 patients continued their pregnancies as breech. Of these the mode of the delivery was: Vaginal Breech Delivery in 97 cases (60.24%) and CSection in 64 (39.76%). Reasons for failure to offer ECV included; 129 (80.12%) cases were unbooked and admitted in emergency when ECV services were not available. 145 (90%) were admitted in labour, and majority of these were in active and advanced labour. Conclusion: ECV was not found to decrease significantly the number of non-cephalic presentation at term. The reasons were that in spite of good success rates it was not feasible to perform enough ECV to have an impact on mode of delivery of singleton term breeches.
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Free access to the first 50 readers available here: http://www.tandfonline.com/eprint/VDZpjBt4xXtJbzw8KiQv/full This article traces how scarcities characteristic of health systems in low-income countries (LICs), and increasing popular interest in Global Health, have inadvertently contributed to the popularisation of a specific Global Health business: international clinical volunteering through private volunteer placement organisations (VPOs). VPOs market neglected health facilities as sites where foreigners can ‘make a difference’, regardless of their skill set. Drawing on online investigation and ethnographic research in Tanzania over four field seasons from 2011 to 2015, including qualitative interviews with 41 foreign volunteers and 90 Tanzanian health workers, this article offers a postcolonial analysis of VPO marketing and volunteer action in health facilities of LICs. Two prevalent postcolonial racialised tropes inform both VPO marketing and foreign volunteers’ discourses and practices in Tanzania. The first trope discounts Tanzanian expertise in order to envision volunteers in expert roles despite lacking training, expertise, or contextual knowledge. The second trope envisions Tanzanian patients as so impoverished that insufficiently trained volunteer help is ‘better than nothing at all’. These two postcolonial racialised tropes inform the conceptual work undertaken by VPO marketing schemes and foreign volunteers in order to remake Tanzanian health professionals and patients into appropriate and justifiable sites for foreign volunteer intervention.
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Health care practitioners and researchers commonly call for greater reliance on evidence as a means to achieve improvement in quality of care. Systematic reviews provide a means to accelerate the use of evidence-based clinical interventions and public health practices. The extent to which these time- and resource-intensive systematic reviews currently address critical maternal health priorities in the intrapartum period is unclear. This analysis summarises key maternal health and research priorities, maps these priorities to existing reviews, identifies gaps in the literature that can be addressed with systematic reviews, and highlights key methodological concerns in conducting systematic reviews. The analysis draws on published data on maternal morbidities and an overview of 108 systematic reviews in Medline in the past 5 years using the MeSH terms ‘Delivery, Obstetric,’ to draw the links between health priorities, research priorities, existing evidence and missing evidence. Key causes of morbidity during labour and delivery in the United States include haemorrhage, pre-eclampsia and eclampsia, obstetric trauma and infection. Analyses of maternal morbidity and mortality suggest that key concerns include racial and ethnic disparities in health outcomes and the prevention of adverse events. Systematic reviews, however, generally tend to focus on the reduction of harms associated with interventions, are frequently limited to randomised designs, and do not address issues of health disparities. The results suggest that advances in evidence-based care in maternal health require that systematic reviews address issues of prevention of adverse events, include a larger variety of study designs when necessary and pay closer attention to health disparities.
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A prospective trial was designed to study the effect of extradural analgesia on the management of breech delivery. From a study of 51 patients, it was concluded that the duration of labour was not lengthened, the frequency of breech extraction was decreased and the condition of the infant was improved, as shown by foetal blood sampling and Apgar scores. Therefore we recommend strongly that extradural analgesia should be used in the management of all breech deliveries.
Article
We present the case of a 26 weeks-three days gestation, singleton, frank breech vaginal delivery complicated by an entrapment of the fetal head. Upon diagnosis of this life-threatening situation, intravenous nitroglycerine was immediately administered and produced sufficient uterine and cervical dilatation to facilitate delivery. This is the first reported case of the use of intravenous nitroglycerine to facilitate vaginal delivery of an entrapped fetal head.
Article
To test the value of increasing the frequency of cesarean section and application of forceps to the aftercoming head, as means of lowering fetal mortality in breech delivery, two 5 year periods in one hospital were analyzed. The cesarean section rate rose from 12.2 per cent in the first period to 19.5 per cent in the second period; forceps application rose from 38 per cent to 77 per cent. With no other apparent cause, fetal deaths associated with breech delivery of infants weighing ≧ 2,500 grams fell from 1.4 per cent to 0.35 per cent. It is suggested that cesarean section be seriously considered in the management of footling presentation, an especially hazardous complication of delivery.
Article
A prospective study of 208 women in labor at term with singleton fetuses in a frank breech presentation was carried out. One hundred fifteen patients were randomized to a vaginal delivery group and 93 to an elective cesarean section group. Of the 93 women scheduled for cesarean section, 88 were delivered according to protocol. Five women progressed rapidly in labor and were delivered vaginally without complications. Of the 115 women scheduled for vaginal delivery, x-ray pelvimetry was obtained on 112. Three women were delivered vaginally without incident before x-ray pelvimetry could be obtained. One of these women was delivered of an infant who died shortly after birth of lethal congenital anomalies. Of the 112 women with x-ray pelvimetry, 52 had one or more inadequate pelvic measurements and were scheduled for indicated cesarean section. Three women, however, were delivered vaginally without incident before operation could be performed. Of the remaining 60 patients in this group, 49 were delivered vaginally without a perinatal death. Eleven women required cesarean section for difficulties during labor. There were no maternal deaths, but 73 (49.3%) of the 148 women who were delivered by cesarean section in this study experienced postpartum morbidity. Only four (6.7%) of the 60 women delivered vaginally had postpartum complications. Based on the data, it seems reasonable to allow vaginal delivery in carefully selected cases of term frank breech presentation.
Article
Objective: To assess subsequent pregnancy rates and recurrence of breech, as well as interpregnancy interval after a breech presentation. Methods: We conducted a national population registry-based study using data from 1967 to 1994, with maternal record linkage of sibships, comprising the first to the fourth birth of a mother. Results: The subsequent pregnancy rate after a surviving breech birth was lower than after a surviving nonbreech birth. Women with two births, of which one was a perinatal loss, had a higher subsequent pregnancy rate, compared with those who had surviving infants. The subsequent pregnancy rate was lower after a cesarean delivery irrespective of presentation. The interpregnancy interval was shorter if the previous infant died, whereas presentation did not influence the interval. The adjusted odds ratio of recurrence of breech increased from 4.32 (95% confidence interval [CI] 4.08, 4.59) after one previous breech delivery to 28.1 (95% CI 12.2, 64.8) after three. Conclusion: Breech and cesarean delivery lowered the subsequent pregnancy rate, probably because of the women's decision not to reproduce. Thus, preconceptional counseling with information, support, and reassurance regarding future pregnancies and deliveries might reduce the discouraging effect. A high odds ratio of recurrence of breech suggests effects of recurring specific causal factors of either genetic or more permanent environmental origin.
Article
Analysis of 340 term breech presentations in primigravidas showed a corrected perinatal mortality of 1.5%; the elective cesarean section rate was 15%. The incidence of complicated labour, defined in the study, was analyzed with regard to different parameters, e.g. X-ray pelvimetry data in all 340 cases. Complicated labour in vaginal deliveries markedly increased with increasing fetal weight (p>0.001) and decreasing pelvic capacity (p>0.001). In each case the fetal weight and smallest pelvimetry data were given score points and the sum of these was called the Feto Pelvic Breech Index, which was correlated to the incidence of complicated labour. By using this index the mortality and morbidity probably can be markedly reduced without the routine use of elective cesarean section. The prognostic methods available to detect feto-pelvic disproportion are discussed.
Article
We studied the effects of cesarean section on neonatal mortality for breech infants and low-birth weight vertex infants using data from the Georgia neonatal surveillance network on 392,241 singleton deliveries between 1974 and 1978. The risk of neonatal death for breech infants weighing 4,000 g or less delivered vaginally was significantly higher than the risk for those delivered by cesarean section. The lower the birth weight, the higher the risk for a vaginal breech delivery. For breech infants weighing 1,000 to 2,500 g, the risk was almost 2 1/2 times greater for a vaginal delivery v a cesarean delivery. The best outcome for high-risk vertex infants weighing 1,000 to 1,500 g was for those delivered by cesarean section in a tertiary perinatal center. An increase in the cesarean section rate may be associated with increased neonatal survival; however, the benefits must be weighed against the costs of an increased maternal mortality and morbidity. (JAMA 1983;250:2157-2159)
Article
Objective: To examine pregnancy outcome in nulliparous women with single term breech presentation. Methods: Two departments of Obstetrics and Gynecology at the same hospital used different approaches to deliver nulliparous women with singleton breech presentation at term. One department (A) delivered by trial of labor and the other (B) delivered by elective cesarean section. Prospectively and blinded to obstetric condition, parturients were assigned to either department in a systematic alternate fashion. The study period covered 8 years (1985-1992). The pregnancy outcome parameters examined were: Apgar score, intra- and post-partum death and maternal and neonatal morbidity. Neonatal morbidity was classified in three major categories: non-neurological trauma, neurological signs and respiratory problems. Results: The study included 264 women of whom 135 delivered in department A and 129 in department B. Department A had 35 vaginal and 100 cesarean births and department B 10 vaginal and 119 cesarean births. There was no intra-partum death and the only post-partum death occurred among vaginal deliveries. The Apgar score was significantly worse at 1 and 5 min in vaginally delivered babies of department B. Neonatal morbidity was significantly more frequent after vaginal births (P < 0.01). Maternal morbidity was significantly higher following cesarean sections (P < 0.01). Babies of vaginal deliveries had significantly higher non-neurological trauma (P < 0.01) and pathological neurological signs (P < 0.01) than those delivered by the abdominal route. Conclusion: The level of risk for mother and child in the nulliparous with term singleton breech, suggests cesarean section as the preferred route of delivery.
Article
The main hazards of vaginal breech delivery are perinatal mortality and neonatal morbidity, caused especially by trauma or asphyxia. The present study is an analysis of 366 consecutive term breech deliveries. The authors have been concerned with the evaluation of factors associated with early and late complications related to vaginal delivery. During the period of study, the cesarean section rate changed in their department from about 20 per cent of term breech presentations at the beginning to almost 50 per cent at the end. This change in the rate of cesarean section has occurred in spite of the fact that the strictly mechanical indication for abdominal delivery (i.e., feto-pelvic disproportion) has remained essentially unchanged during the period of the study. Consequently, the authors have been interested in evaluating the effects of different cesarean section rates on the incidence of significant fetal complications. (C) Williams & Wilkins 1982. All Rights Reserved.
Article
Background. The present study was designed to determine neonatal mortality and morbidity in non-malformed singleton term infants delivered in breech presentation and identify a possible correlation between outcome on the one hand and mode of delivery, parity and birth weight on the other.Methods. Register-based cohort study of all (n=15718) singleton term breech deliveries of non-malformed infants in Denmark 1982–1990. Process and outcome measures: mode of delivery, gestational age, birth weight, congenital malformations, intrapartum death, Apgar scores and early neonatal death.Results. A total of 3247 (20.7%) term infants were delivered vaginally, 7106 (45.3%) by elective and 5356 (34.1%) by emergency cesarean section. Infants delivered vaginally and by emergency cesarean section had significantly higher rates of mortality (intrapartum and early neonatal death) and morbidity (low Apgar scores) when compared to those delivered by elective cesarean section. In vaginal deliveries, parity was not correlated with outcome, but infants with a birth weight above 4000 grams had significantly higher rates of low Apgar scores.Conclusions. Register data on singleton term breech deliveries imply that vaginal delivery is associated with increased mortality and morbidity. However, validation of data and additional information from the medical records are needed before a recommendation of whether selection of parturients, structure of perinatal care or professional skills need to be improved, or all singleton term infants in breech presentation should be delivered by cesarean section.
Article
To investigate whether sonographic examination of the fetal head extension, pelvic adequacy and fetal position, could replace the traditional x-ray method in the evaluation of the breech in labor. Seventy-two parturients admitted in labor with a breech presentation were prospectively evaluated by a newly proposed ultrasonographic approach. The head extension, obstetric conjugate and fetal attitude obtained were further compared to the gold standard radiologic measurements. A highly significant correlation between ultrasonic and x-ray measurements for the fetal head extension (r = 0.8696; p < 0.0001), obstetric conjugate (r = 0.8931; p < 0.0001), as well as high reliability (95.5%) in diagnosing the breech variant by ultrasound have been found. Ultrasonic evaluation of breech presentation, as performed by the proposed method, is simple, easy to perform and compares well with the standard radiologic studies. It is suggested that modern ultrasonic technique, which carries no risk of ionizing radiation, may replace traditional x-ray examination of the breech in labor.
Article
SummaryA consecutive series of 247 patients with a singleton fetus presenting by the breech (exclusive of instances of macerated stillbirth and of lethal congenital abnormality) is presented. The series includes 162 patients who had a vaginal delivery, lumbar epidural block analgesia having been provided for 56 of those. Examination of the “Apgar-minus-colour” scores and of the postnatal course of these infants strongly suggests that the provision of an epidural block reduces the incidence of Severe and of prolonged neonatal depression irrespective of the birthweight. The incidence of breech extraction was not increased by the provision of an epidural block, although the second stage was significantly (but not markedly) lengthened. It is suggested that a reduction in the morbidity and mortality associated with vaginal breech delivery could be attained by the provision of a regional block (epidural or spinal) which will obtund the bearing-down reflex and relax the perineum.
Article
Objective: To examine the relation between obstetric factors and the prevalence of urinary incontinence three months after delivery. Design: 2134 postal questionnaires sent between August 1989 and June 1991. Setting: Teaching hospital in Dunedin, New Zealand. Subjects: All women three months postpartum who were resident in the Dunedin area. Main outcome measure: Prevalence of urinary incontinence. Results: 1505 questionnaires were returned (70.5% response rate). At three months postpartum 34.3% of women admitted to some degree of urinary incontinence with 3.3% having daily or more frequent leakage. There was a significant reduction in the prevalence of incontinence for women having a caesarean section, in particular in primiparous women with a history of no previous incontinence (prevalence of incontinence following a vaginal delivery 24.5%, following a caesarean section 5.2% P = 0.002). There was little difference between elective caesarean sections and those carried out in the first and second stages of labour. The odds ratios for women having a caesarean section were 0.4 (95% confidence interval (CI) 0.2.-0.7) (all women and all primiparae) and 0.2 (95% CI 0.0-0.6) (primipara with no previous incontinence) in comparison with those having a normal vaginal delivery. The prevalence of incontinence was also significantly lower in women having had two caesarean sections (23.3%; P = 0.05) but similar in those women having three or more caesarean sections (38.9%) in comparison with those women who delivered vaginally (37.7%). Other significant independent odds rations were found for daily antenatal pelvic floor exercises (PFE) (0.6, 95% CI 0.4-0.9), parity > or = 5 (2.2, 95% CI 1.0-4.9) and pre-pregnancy body mass index (1.07, 95% CI 1.04-1.10). Conclusions: Adverse risk factors for urinary incontinence at three months postpartum are vaginal delivery, obesity and multiparity (> or = 5). Caesarean section and daily antenatal PFE appear to be protective, although not completely so.
Article
Objectives To study the incidence of undiagnosed breech and to compare the obstetric outcome with those diagnosed before the onset of labour in a local teaching hospital where external cephalic version at term is routinely offered.Design A retrospective casenote analysis.Setting Tsan Yuk Hospital, a teaching hospital in Hong Kong.Participants One hundred and thirty-one women with a singleton breech presentation at term, delivered in a local teaching hospital from 1 January 1997 to 31 December 1997. The group of 22 women who had successful external cephalic version performed was included.Results Breech presentation was diagnosed at the antenatal clinic in 103 women (79%). In the remaining 28 women (21%), breech presentation was diagnosed for the first time after the onset of labour. Undiagnosed breech presentations were more likely to deliver vaginally (42%) than those diagnosed at the antenatal clinic (1 1 %)(P < 0.001). Vaginal delivery was still more common in the undiagnosed group (46%) than the diagnosed group (26%), even when the group with successful external cephalic version was included (P < 0.05), although the difference became less obvious. The demographic characteristics, birthweight, type of breech and short term neonatal outcomes were comparable between the two groups.Conclusion It is important to include women who had successful external cephalic version when comparing the obstetric outcome of undiagnosed and diagnosed breeches. Careful assessment for vaginal delivery is still very useful even when breech presentations are first diagnosed after the onset of labour because the infants are even more likely to deliver vaginally with no great excess of neonatal morbidity.
Article
Objective To study the relation between various perinatal factors and the sequelae of very preterm birth, applying logistic regression analysis. Design In a nationwide collaborative study in the Netherlands, perinatal and follow up data were collected on 899 liveborn singleton nonmalformed infants with gestational age less than 32 weeks or birthweight less than 1500 g born in 1983. Main outcome measures Neonatal mortality rate and total handicap rates (minor and major) in surviving children at two years and five years of age. Results Comparing breech with vertex presentation, the odds ratio for neonatal mortality (adjusted for duration of pregnancy, birthweight, maternal hypertension and prolonged rupture of membranes) is 1.6 (P<0.05). Comparing abdominal versus vaginal delivery, the odds ratio indicates equal risks. When breech and vertex presentation are analysed separately it appears that breech presenting infants have a significantly lower mortality risk when born by caesarean section compared with vaginal delivery. However, comparing abdominal versus vaginal delivery in breech presentation, the odds ratio for handicap at five years (0.9) is not significantly different from 1. Conclusion The data presented suggest a reduced neonatal mortality rate in breech presenting infants born by caesarean section but because of the observational design of the study the statistical analysis described only identifies a possible trend and cannot prove the issue.
Article
EDITORIAL COMMENT: This is a scholarly clinical essay and we commend it to readers even if they feel symphysiotomy is not an option in their armamentarium — it will at the very least provide an excellent revision of the possible mechanisms of difficult breech extraction. This paper is a masterpiece with the right amount of repetition to make its central point. Summary: The most dreaded complication of vaginal breech delivery is entrapment of the aftercoming head. When this is due to disproportion, persistent attempts at vaginal extraction are likely to result in a dead or damaged baby. A largely unknown solution in this desperate predicament is to surgically enlarge the pelvis by means of a symphysiotomy. A review of the literature shows that symphysiotomy performed to free the trapped aftercoming head will save at least 80% of babies if the procedure is performed without delay. Every obstetrician should be prepared to perform a symphysiotomy if the aftercoming head is trapped.
Article
Objective To compare intrapartum related infant mortality in term (> 34 weeks) breech presentations in relation to vaginal delivery or delivery by caesarean section. Design Register based nationwide study. Setting Sweden from 1991 to 1992. Participants 6542 singleton fetuses born in the breech presentation. Main outcome measures Intrapartum and early neonatal deaths, stillbirths and congenital malformations, low Apgar score < 7 at 5 min, mode of delivery. Results After exclusion of antepartum stillbirths and congenital malformation, the intrapartum and early neonatal mortality rate was 2/2248 (0.09%) in the group delivered vaginally and 2/4029 (0.05%) in the group delivered by caesarean section. The relative risk was 1.81 (95% CI 0.26–12.84). Thus the difference was not statistically significant. This result was further supported after reviewing individual cases. Conclusions The intrapartum related mortality in the group delivered vaginally was low and the result could not verify an increased mortality in term breech presentations delivered vaginally compared with those delivered by caesarean section.
Article
Objective To examine the effect of epidural analgesia on the progress and outcome of spontaneous labour in women with a singleton breech presentation at term (3=37 weeks). Design A retrospective study. Setting Data Bank, Aberdeen Maternity Hospital. Subjects 643 women (273 primiparae and 370 multiparae) with a singleton breech presentation and spontaneous onset of labour at term. Outcome measures Duration of labour; augmentation of labour with oxytocin infusion; caesarean section rates. Results Epidural analgesia was associated with a significantly increased need for augmentation of labour with oxytocin infusion (P<0.001) and longer duration of labour (P<0.001), irrespective of parity. Comparing women who had epidural analgesia with those who did not, there was no significant difference in caesarean section rates in the first stage of labour in primiparae (odds ratio 1.79; 95% CI0.88–3.63) or multiparae (odds ratio 0.97; 95% CI 0.48–1.96). Epidural analgesia was associated with a significantly increased likelihood of caesarean section in the second stage of labour, both in primiparae (odds ratio 5.43; 95% CI 2.46–11.95) and multiparae (odds ratio 5.37; 95% CI 2.07–13.87). The increased likelihood of caesarean section in the second stage in primiparae with epidurals was independent of the extent of cervical dilatation (<3 cm or ≥3 cm) on admission. However, in multiparae with epidurals, the difference in second stage caesarean section rate was significant only when initial cervical dilatation was <3 cm (odds ratio 3.65; 95% CI 1.14–11.65). Conclusion Epidural analgesia was associated with longer duration of labour, increased need for augmentation of labour with oxytocin infusion and a significantly higher caesarean section rate in the second stage of labour.
Article
This study was undertaken to determine whether planned vaginal or elective cesarean delivery is better for singleton term breech infants and their mothers. We studied deliveries of 388 singleton term breech infants that were born in our teaching hospital in Vienna. We follow well defined criteria for vaginal delivery versus cesarean section of term breech fetuses. We thus compared 280 (72%) cases scheduled for vaginal delivery with 108 (28%) scheduled cesarean sections with regard to neonatal mortality and morbidity, including Apgar score, umbilical artery pH, and postpartum maternal morbidity. Vaginally delivered fetuses of primiparas had lower five-minute Apgar scores (5% < Apgar 7) and a lower umbilical artery pH (39% below 7.2). This is significantly different from the abdominally delivered primiparas (no Apgar below 7, only 11% with an artery pH below 7.2). Multiparas did not show significantly different results with regard to Apgar scores and umbilical artery pH between the different modes of delivery. Postpartum maternal morbidity was not different between the two groups. The results suggest that planned vaginal delivery of singleton breech infants of primiparas result in newborns with lower Apgar-scores, a lower umbilical artery pH and a poorer fetal outcome. On the other hand, it seems that singleton term infants of multiparas do not profit from cesarean delivery.
Article
Over a 3-year period a retrospective audit was performed of all uncomplicated singleton breech presentations at term to assess the role of X-ray pelvimetry. The review included 267 term breech presentations. Seventy-seven women (Group A) delivered in a consultant unit where X-ray pelvimetry was not used for decision making regarding the mode of delivery; 125 women (Group B) delivered in 2 consultant units where X-ray pelvimetry was always used, and 65 women (Group C) delivered in a fourth consultant unit where X-ray pelvimetry was used selectively. Obstetric outcome was measured in terms of mode of delivery. Short-term neonatal outcome was assessed by Apgar score at 5 minutes, evidence of birth trauma and admission to the neonatal special care unit for more than 24 hours. Significantly fewer women (12.9%) had an elective Caesarean section in group A compared with the other 2 groups (27.2% in group B and 33.8% in group C; p<0.05). The vaginal delivery rates following a trial of labour were not significantly different (79.1% for group A, 65.9% for group B and 65.1% for group C) and neonatal outcome was similar in all groups. It is concluded that fewer Caesarean sections were done, without adversely affecting the neonatal outcome, when X-ray pelvimetry was not used to select the mode of delivery of uncomplicated singleton breech presentation at term. Satisfactory progress in labour is the best indicator of pelvic adequacy.
Article
Objective To measure the prevalence and severity of postpartum faecal incontinence, especially new incontinence, and to identify obstetric risk factors. Design A cohort study with information on symptoms collected in home-based interviews and obstetric data from hospital casenotes. Setting Deliveries from a maternity hospital in Birmingham. Participants Nine hundred and six women interviewed a mean of 10 months after delivery. Main outcome measures New faecal incontinence starting after the birth, including frank incontinence, soiling and urgency. Results Thirty-six women (4%) developed new faecal incontinence after the index birth, 22 of whom had unresolved symptoms. Twenty-seven had symptoms several times a week, yet only five consulted a doctor. Among vaginal deliveries, forceps and vacuum extraction were the only independent risk factors: 12 (33%) of those with new incontinence had an instrumental delivery compared with 114 (14%) of the 847 women who had never had faecal incontinence. Six of those with incontinence had an emergency caesarean section but none became incontinent after elective sections. Conclusions Faecal incontinence as an immediate consequence of childbirth is more common than previously realised, and medical attention is rarely sought. Forceps and vacuum extraction deliveries are risk factors, with no protection demonstrated from emergency caesarean section. Identification and treatment is a priority.
Article
We conducted a meta-analysis of the mortality and morbidity of the breech presentation according to the method of delivery. Using the term 'breech', we used the Medline data base to search the English and French-language literature from 1978 to July 1995. Twenty-two studies (7239 deliveries) were found and analysed. The meta-analysis concerning perinatal mortality did not reveal a significant increased risk, when vaginal deliveries were compared with those delivered by a caesarean section (odds ratio: 1.90; confidence interval: 0.59-8.22) or when vaginal deliveries were compared with those done by planned caesarean section (odds ratio: 4.95; confidence interval: 0.44-80.06). The neonatal morbidity showed an increased risk with vaginal delivery. It is concluded that the practice of resorting to caesarean section for every breech presentation at term does not seem defensible.
Article
The study was conducted to compare the neonatal and maternal outcome of breech infants delivered vaginally at term with those delivered by cesarean section. All singleton term breech deliveries between January 1, 1992 and December 31, 1994 were reviewed (n = 496). Criteria for eligibility for vaginal trial of labor included: frank or complete breech presentation, estimated fetal weight of 2000-3800 g, no hyperextension of the fetal head and no history of uterine scar (group A, n = 283). Patients who did not fulfill these criteria, or had an abnormal pelvimetry, were delivered by cesarean section without a trial of labor (group B, n = 213). In group A, 226 patients (80%) delivered vaginally, and 57 (20%) patients underwent a cesarean section; 70% of the nulliparae and 89% of the multiparae delivered vaginally. No differences were observed between the groups in gestational week, number of nulliparae, pregnancy complications, and rates of epidural analgesia. However, maternal age and birth weight were significantly higher in group B. No maternal or perinatal mortality occurred. The incidences of 5-min Apgar score <7, birth trauma, neonatal complications, and neonatal intensive care unit admissions were similar between the groups and in the nulliparae and multiparae of each group. Maternal morbidity was significantly lower in patients who delivered vaginally. We conclude that a trial of labor in breech presentation based on appropriate selective criteria, and an active policy of labor management performed by experienced physicians, will facilitate safe delivery in most nulliparae and multiparae.
Article
A review of 186 cases of breech presentation with a corrected perinatal mortality rate of 0-54 per cent is presented. Details of paediatric follow-up are given. Careful selection of patients for vaginal delivery and the liberal use of Caesarean section are advocated. The importance of asphyxia as the main danger of breech delivery is emphasized and the use of fetal blood sampling as a practicable method of detecting early asphyxia is discussed.
Article
Between December 1970 and March 1973, 138 patients with a singleton fetus presenting by the breech after 36 weeks of pregnancy were deemed suitable for vaginal delivery under epidural analgesia; 130 were delivered vaginally, 10 of them by breech extraction. There was one stillbirth and no neonatal deaths. Epidural analgesia for vaginal breech delivery seemed beneficial. In 65 cases it was possible to compare the umbilical vein pH with the Apgar score at one minute. In 35 patients a continuous recording of the fetal heart rate was used to predict the Apgar score at one minute and the results are discussed.
Article
The perinatal mortality associated with breech presentation at the Royal Women's Hospital, Melbourne, between 1974 and 1976 was 10.4%, or almost 5 times the overall hospital figure. Nine of 487 infants (1.8%) weighing greater than or equal to 2500 g died in the perinatal period, but 7 were already dead at the onset of labor or had congenital abnormalities incompatible with life. Sixty of 177 infants (33.9%) weighing 1000-2499 g died in the perinatal period, but 28 of these died due to prematurity alone or from complications of intrauterine hypoxia or birth trauma. Although elective cesarean section for breech presentation could not be justified for infants weighing greater than or equal to 2500 g, this procedure may well reduce the perinatal loss of premature infants by reducing the incidence of intrauterine hypoxia and preventing birth trauma.
Article
A total of 150 term uncomplicated breech deliveries were selected for a prospective study. Although 223 women were selected for analysis, subsequent complications required that 73 women be excluded. A predetermined protocol was utilized for the management of 81 women, while 69 women qualified for the control group. Analysis of the results clearly demonstrated the value of a well-defined management program.
Article
A feto-pelvic scoring system comprising maternal pelvimetric data, estimated fetal weight, type of breech presentation and previous obstetric history was used in selecting patients for cesarean section of vaginal delivery. A maximum score of 20 points was possible. Twelve points or less indicated cesarean section. During 1973-1975 224 singleton breech deliveries were evaluated. In 29.5% cesarean section was performed and in 83% of these it could be planned in advance. In 70.5% of cases, patients were allowed to deliver vaginally under continuous electronic monitoring of the fetal heart rate. There was one intrapartum death and only one early neonatal death of a small premature child. In two cases intrauterine death had occurred already in the antepartum period. The uncorrected perinatal mortality was 17.9 per 1000 but not significantly different from the uncorrected perinatal mortality of 8.0 per 1000 for all patients delivered at the Danderyd's Hospital during the period 1972-1975 (12832 births). The corrected mortality resulting from breech presentation was 8.9 per 1000. The infants exhibited similar and excellent 5 min Apgar scores whether delivered vaginally or by cesarean section or matched with a randomized control series of 1000 cephalic presentations.
Article
A review of 12 years' experience with term breech delivery at Overlake Memorial Hospital, Bellevue, Washington, was undertaken to ascertain patterns of care as practiced in a suburban community hospital setting. A total of 402 term breech deliveries were managed by 34 family practitioners and 21 obstetricians. X-ray pelvimetry was found to correlate with clinical pelvimetry in two thirds of the cases when used. There were 314 patients delivered vaginally and 88 by cesarean section (an over-all cesarean section rate of 21.9%). There was a striking increase to 43.9% during the last 2 years of the review. This review indicates increasing utilization of consultation with breech presentation, an increasing percentage managed by obstetricians, increasing use of x-ray pelvimetry, decreasing frequency of prolonged labor, a sharp increase in use of cesarean section, and a decline in perinatal morbidity.
Article
Utilizing the Zatuchni-Andros Breech Scoring Index a prospective study of 290 consecutive term breech deliveries occurring at Evanston Hospital from Jan. 1, 1968, to Jan. 1, 1974, is reported. This paper represents a direct continuation of a retrospective study of 500 consecutive term breech deliveries reported by the authorsin 1970. The results indicate that this breech assessment method is a valid method and it is recommended that patients whose breech score is 3 or less be submitted to immediate cesarean section and, conversely, those with a breech score of 4 or more be allowed to labor with meticulous observation with a high confidence level that successful vaginal delivery will result. Also, cautious stimulation with intravenous oxytocin can be safely undertaken when necessary in patients with a breech score of 4 or more. By employment of the Zatuchni-Andros Breech Scoring Index, the authors submit, fetal mortality and morbidity rates are markedly diminished.
Article
All cases referred for pelvimetry in 1970-1 and all breech presentations referred for pelvimetry in 1972-4 were reviewed. Indications for pelvimetry fell into four main categories: high head in the antenatal clinic (47-8%); high head in labour (13-9%); breech presentation (20-9%); and previous caesarean section (14-8%). In the first two categories pelvimetry rarely if ever influenced management, and it should not be performed routinely. In breech presentation and cases of caesarean section pelvimetry seemed to be of value, but in the latter group it should be performed puerperally to avoid the known radiation hazard to the fetus. A fairly close correlation between obstetric conjugate and pelvic capacity was shown, which suggested that a 3400-g baby might pass through a pelvis of obstetric conjugate of 10 cm as a cephalic trial of labour, but would need an obstetric conjugate of 11-7 cm for safe vaginal breech delivery.
Article
A retrospective study of 1423 liveborn breech deliveries occurring in one hospital from 1964 to 1973 inclusive showed that application of forceps to the aftercoming head of infants between 1 and 3 kg birth weight was associated with a significant reduction in neonatal mortality.
Article
An evaluation of the possible etiologic factors in hyperextension of the fetal head in breech presentation and a discussion of management are presented. Our seven cases plus a review of the literature led to the conclusion that hyperextension of the aftercoming head is a dangerous malpresentation that should not be underestimated. For this reason, we strongly suggest an x-ray of all breech presentations in early labor, not only to evaluate pelvic adequacy but also to determine the attitude of the head. In persistent hyperextension, cesarean section is the management of choice.
Article
Damage of the cervical cord is not rare in breech delivery with hyperextension of the fetal head. Among 57 cases from the literature and one of ours in which the angle of extension could be measured on X-ray films, 20 had an extension angle greater than 90 degrees. Of these, 11 were delivered vaginally and included 8 cases of damage to the cervical cord. It is recommended that elective Caesarean section be performed when the angle of extension exceeds 90 degrees.
Article
A retrospective study was made of the course and outcome of labour in 226 patients in whom a singleton fetus presented by the breech. Patients with macerated stillbirths or who were delivered before the 28th week of gestation had been excluded. Of the 226 patients, 101 received extradural analgesia, 79 received parenteral analgesia and 46 underwent elective Caesarean section. There was no difference in the incidence of breech extraction or emergency Caesarean section in the first two groups of patients. The length of both first and second stages of labour in multiparae was prolonged in the extradural group, but not markedly so. The Apgar scores of the infants delivered vaginally were not significantly different at one minute in both groups but the five minute Apgar score in the infants of primiparae was significantly higher in the extradural group. The Apgar score at one minute in the group delivered by emergency Caesarean section was significantly lower after extradural block but the difference was not significant at five minutes. This study suggests that the management and outcome of labour when the breech presents is not adversely affected by the provision of extradural analgesia.
Article
To examine the effect of epidural analgesia on the progress and outcome of spontaneous labour in women with a singleton breech presentation at term (greater than or equal to 37 weeks). A retrospective study. Data Bank, Aberdeen Maternity Hospital. 643 women (273 primiparae and 370 multiparae) with a singleton breech presentation and spontaneous onset of labour at term. Duration of labour; augmentation of labour with oxytocin infusion; caesarean section rates. Epidural analgesia was associated with a significantly increased need for augmentation of labour with oxytocin infusion (P less than 0.001) and longer duration of labour (P less than 0.001), irrespective of parity. Comparing women who had epidural analgesia with those who did not, there was no significant difference in caesarean section rates in the first stage of labour in primiparae (odds ratio 1.79; 95% CI 0.88-3.63) or multiparae (odds ratio 0.97; 95% CI 0.48-1.96). Epidural analgesia was associated with a significantly increased likelihood of caesarean section in the second stage of labour, both in primiparae (odds ratio 5.43; 95% CI 2.46-11.95) and multiparae (odds ratio 5.37; 95% CI 2.07-13.87). The increased likelihood of caesarean section in the second stage in primiparae with epidurals was independent of the extent of cervical dilatation (less than 3 cm or greater than or equal to 3 cm) on admission. However, in multiparae with epidurals, the difference in second stage caesarean section rate was significant only when initial cervical dilatation was less than 3 cm (odds ratio 3.65; 95% CI 1.14-11.65). Epidural analgesia was associated with longer duration of labour, increased need for augmentation of labour with oxytocin infusion and a significantly higher caesarean section rate in the second stage of labour.